Gates in Kenya

Crossing the Great Rift

2010-05-20T08:06:00.000-07:00

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

2010-05-15T11:45:00.000-07:00

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

2010-05-14T08:30:00.000-07:00

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

2010-05-10T09:20:00.000-07:00

"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

2010-05-08T08:02:00.001-07:00

“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.

2010-05-02T07:41:00.000-07:00

Banana Man.

2010-05-02T07:29:00.000-07:00

"Salamia" (Greetings)

2010-05-02T07:16:00.000-07:00

Liz, Grace, and two of her

daughters.

Another Kenya

2010-05-02T06:37:00.000-07:00

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.

2010-05-02T00:44:00.000-07:00

Tom Making rounds.

Mothers and Babies

2010-04-29T06:39:00.000-07:00

The last ten days have been memorable for two reasons: first, in the aftermath of Dr. Serrem's appendectomy, a lot of call (4 of the last 5 nights, so I can be off this weekend); and second, some challenging cases on the maternity ward.

Ten days ago we had unexpected twins, born more than two months premature. We were able in the middle of the night to figure out the modern-appearing incubator (it appeared to have never been used) and, after a rough first night as they struggled to breath, both seemed to settle down and by the next day had begun breastfeeding. I was hopeful that they would both survive, but on the third day, the smaller one developed massive bleeding and quickly succumbed. She probably died because in all the excitement with the incubator, the midwife neglected to give a shot of Vitamin K (routine around the world) and, as preemies are prone to do, developed hemorrhagic disease of the newborn. I had not seen this in my 30 years in medicine. The second twin received her shot belatedly, and went home apparently doing well.

A week ago tonight (was it only a week ago? See last post...) I was up with first one and then a second c-section, both came in from home with obstructed labor of many hours duration.

But the most challenging was still to come. Late Sunday we admitted Christine, a woman who had a six year old at home, but had lost her second pregnancy at 7 months with an eclamptic seizure (the most severe form of toxemia). Now, still several weeks from her due date, she had been found at a dispensary to have high blood pressure and all the other signs of recurrent toxemia, and been instructed to go immediately to the District Hospital. Instead, she waited five days, and then came to Lugulu.

I worried about how small her baby was, and wanted to see if her blood pressure would settle down overnight. She had had two previous c-sections, so would need a third, and her husband was making noises from afar that it was too expensive here and he wanted her to go to the District Hospital.

By the next morning her blood pressure was worse, and she was having signs of an impending seizure. What had been concerning had now become a life-threatening emergency, but we managed to do what was necessary in a relatively expeditious manner: hydrazine for her blood pressure, magnesium injections to prevent a seizure, and (once her husband agreed) preparation for surgery. Amidst all this excitement, the nurse announced that no one had heard the baby's heart beat for two hours. Although we don't like doing a cesarean when the baby is dead, in this case I felt it gave the best chance for the mother to survive.

At surgery, the baby was limp and blue, but I thought I detected a weak pulse in the cord. I passed her off to the resuscitation nurse and concentrated on finishing the surgery. But five minutes later, from the far corner, the baby let out a lusty cry. God is good, and life is very resilient.

The mother's toxemia resolved quickly after delivery, and somehow that scrawny baby (severely growth restricted because of the mother's high blood pressure) has started to feed and appears to have a fighting chance to survive.

Later that morning, another woman came from home, with a retained placenta and post-partum hemorrhage. I discovered we had only a half unit of O+ blood in the hospital, and she was third in line, behind a man with acute leukemia who probably had less than two weeks to live, and a man with advanced HIV, to weak from anemia to even stand. I started asking some questions about how it was that we could be out of blood. It seems that a couple of years ago blood banking was regionalized, so that all our blood comes from Eldoret, an hour and a half away. (The old system was that if you received blood from our blood bank, you couldn't leave the hospital until one of your relatives donated a replacement unit. It was quite effective.) In theory, regionalization is a good idea, but it turns out that the regional blood bank relies on blood drives at colleges and secondary schools. So, three times a year, when all the schools are on vacation, we run out of blood for two or three weeks at a time.

So, some statistics. Of all the measures of health we have (infant mortality, life expectancy, etc.), the one that shows the greatest gulf between the developed world and places like Africa is maternal mortality. Infant mortality is about 20-fold higher here than in the U.S., but maternal mortality is probably a hundred-fold higher. We used to say that 500,000 women a year died of the kind of pregnancy and childbirth complications that I have described (about one per minute). Very recently, there has been a report suggesting substantial progress over the last couple of years in decreasing that number. The key to continued progress are things like better access to timely c-sections, availability of blood for transfusion, and attendance of trained medical personnel at births (usually midwives). We know here in our local area (based on a demographic survey of 70,000) that 72% of births are at home, almost all without any trained attendant. So what we see here at the hospital are the complications of those home births.

The World Health Organization has made one of its major "millennium goals" the reduction of maternal deaths by two thirds, by 2015. Until this recent report, there had been little evidence of progress, and we still have a long way to go. Pray for all the mothers around the world who face the daunting prospect of giving birth in a system where their basic needs are so often unmet; and pray that governments around the world may see their way clear to dedicate the needed resources, so that they may build on this initial progress.

What is new is old; what is old is new

2010-04-26T10:02:00.000-07:00

Tom asked me to take a turn as “guest blogger” and talk a bit about what is it like being back in Lugulu after thirteen years away. The last time I was here was 1997, the year we pulled Matt and Nathan out of school for two months and all four of us returned. Since then Tom has been back several times, but I have not.

So much is exactly as I left it – most notably our house. The pictures I cut out of Mary Azarian’s A Farmer’s Alphabet are still on the wall above our bed. Most of the furniture and dishes are exactly the same, down to the brown teapot I used (and am using still) to make tea. Because no one lives here full-time, there aren’t as many books and other things, so it doesn’t feel quite as homey as it used to, but I know where all the light switches are and feel completely comfortable. There is water in the taps right now, but there wasn’t when I arrived and I don’t think it will last. Someone installed a shower in the bathroom - but of course parts are missing and it doesn’t work. Bathing is still in a black plastic tub, the warm water heated in an electric kettle in the kitchen, very much the same.

Grace, our housekeeper all those years ago, is still here and taking care of us. Today is laundry day and she is washing our clothes by hand; they’ll dry in the sun on the clothesline in our yard. She is doing well, despite many challenges. Several years ago her husband Daniel passed away, so she is a widow raising her family on her own. She works at the hospital in the kitchen preparing meals for the private pay patients – she is an excellent cook. She also has a small business making mango juice, which she sells to anyone who wants to buy. Her youngest, Elizabeth (named for me), is now in Form 1 in secondary school; the oldest, Catherine, is married and expecting her first child. Her mother-in-law lives with her - she is in poor health and probably has alzheimers. In many ways her life is like my own – working and caring for and worrying about children and parents. In most other ways it is so very different. She is struggling to put up a new house – the roof in her present house leaks badly; the mud walls are crumbling. She still gets her water from a dug well in her compound, still doesn’t know month-to-month whether or not she will have the income she needs to survive. Yet she is someone who greets each day with gladness.

A huge change is the fact that just about everyone (Grace included) has a cell phone. There was never the infrastructure here for people to have landlines and many people do not have electricity, so they have moved directly to cell phone technology. There are kiosks everywhere advertising “charging services”, so it is easy to get your phone charged. No one has a cell phone “plan”, you simply buy minutes at a kiosk if you need them. One of our friends explained m-Pesa, to us, a way to send money securely via cell phone to anyone you like. In the past, if you needed to get money to someone, say your mother, you had to travel to her home and hand-deliver the funds. Now you pay money into your m-Pesa account then “flash” the funds to your mother’s phone and she can collect at her local m-Pesa kiosk. Amazing.

Public transport seems a bit safer – the matatus are no longer small pick-up trucks with covered cabs where passengers ride squashed inside or hanging onto the back. Now the matatus are mostly mini-buses with regular seats for all the passengers. My trip from Kisumu to Lugulu involved three matatus, and they were reasonably comfortable. (On one leg of the trip, I was seated next to a woman carrying a briefcase and a live chicken - no question that I was in Kenya!) The roads have deteriorated badly, though, so the ride is very rough. For shorter trips, it’s fun to ride the boda-bodas – bicycle taxis. I have not tried the motorcycle taxis – there is a limit to the risks I’m willing to take! Bicycles still ply the road carrying amazing loads – huge bags of potatoes, cans full of water, stems of bananas. Much of the economy still runs on human muscle power.

It’s the people who touch me the most. Some of the hospital staff members we knew and loved are still here and it is a joy to see them, to hear how their families have grown and flourished, to share a meal with them. The staff who are new to us are also welcoming and friendly, so I don’t feel like a stranger.

What is very different for me is not having Matthew and Nathan here – I feel a bit lost without them. A huge part of my role and day-to-day life in the 90's was caring for them and teaching them at home – I’m not quite sure where I fit now. I’ve made my own way and life in Lancaster; bookbinding doesn’t really fit here. Everyone has made it clear they wish I could stay longer – a lot longer – but I just don’t know what I would do or how I would fit. Even so, I’m glad to me here, glad to reconnect.

Liz

Unstuck in Time

2010-04-22T08:04:00.000-07:00

Billy Pilgrim, the protagonist in Kurt Vonnegut's Slaughterhouse Five, described his random bouncing back and forth from past to future as being "unstuck in time."

April 20 marks my half way point here (my flight from Philadelphia was March 20, and our return flight from Nairobi is May 20), and I too am beginning to feel unstuck in time, although in a different sense. For me, every day is so intense with new (and often emotionally draining) experiences, that time has a very different quality here. Events of yesterday (was it only yesterday I gave Grand Rounds at the district hospital?) seem like a week ago; events of last week (was it only last week that Liz arrived?) seem like a month ago; and at times my life in Lancaster seems very distant indeed, as though I have been here for much longer than a month.

[ Interrupted for an emergency cesarean section]

People say that "time flies when you are having fun", but it has never seemed that way to me. My experience is that when life is at its fullest and most intense, time somehow slows down, or at least takes on a different quality. Thomas Kelly, in his essay The Eternal Now, talks about living simultaneously in two dimensions, the temporal and the eternal. And Jesus alludes to "life more abundant". Perhaps both of these get at what I am truing to describe.

At any rate, it is good that I am here... Today my colleague Dr. Serrem was taken to surgery, for an emergency appendectomy (done by the outside surgeon). So, life promises to be even more intense while he recuperates.

Malaria

2010-04-17T04:03:00.000-07:00

"Pole sana, mama. Mtoto amekufa." My kiswahili was never very good, and has deteriorated, but this phrase is burned into my mind. "I am very sorry, mama. The child has died."

I was called to the children's ward at 6 a.m., with the message that a child had "changed condition." I know from experience what that is likely to mean, and indeed by the time I arrive, the child is pulseless and obviously dead. There is no reaction from his mother until I pronounce these words, but as soon as I speak, it lets lose a torrent of tears and quiet wailing.

Emanuel was a chubby and apparently healthy three year old, admitted by me the afternoon before, yet another child with high fever, convulsions, and malaria parasites in his blood smear. He was put on the usual treatment (IV quinine, the standard treatment for severe malaria since the Jesuits discovered the bark of the "fever tree" in South America in the 17th century). There was no reason to believe that he was one who would not survive.

This week I have been responsible for (among other things) the pediatric ward, and each day for the first three days, a child died. It is sobering to look around at the end of morning rounds at the ten or fifteen children, and wonder which one might die today.

Sometimes, the death is unexpected, like Emanuel's. Other times, it is more predictable. Brian was 5 and appeared malnourished. He continued to have seizures for several hours after admission and never woke up, before dying the next day. And sometimes, malaria is just one contributing factor, as with Gideon, age 8, admitted moribund from the HIV clinic. We were able to resuscitate him, only to lose him several hours later.

Children with complications of malaria make up the bulk of our admissions to the pediatric ward. Often they are either having seizures, or comatose. Still, most do in fact recover remarkably fast. Often after a few doses of quinine, followed by the more modern and effective oral medications, and they are ready to go home after just 3 or 4 days.

And sometimes we have memorable success. Faith is 12, newly diagnosed with HIV (her father died of AIDS several years ago, and her mother is ill). She was admitted from an outlying dispensary, in a coma for 3 days. Because of her already advance AIDS, we worried about all the unusual infections (cryptococcal meningitis, tuberculosis meningitis) but in the end she seemed to have cerebral malaria, woke up after three days of quinine, and walked out of here after a week. She has been enrolled in the HIV clinic and will start her medicines in a couple of weeks, and she should do well, for at least a few years and possibly for decades.

We used to say that malaria kills more than a million people a year, 90% of them African children under age 5. However, over the last 2 to 3 years, remarkable progress has been made, and deaths in Africa are down. The reason for this is probably two-fold: the ready availability of a new drug (derived from a Chinese shrub), and the widespread use of insecticide-impregnated bed nets, to keep the mosquitoes from biting while children sleep. The progress has provoked enough optimism that experts are once again talking about "eradicating malaria" (as they did in the 1950's).

Still, this week's experience reminds us that that goal is still far off. The reality here in rural western Kenya is that all children will have several bouts of malaria during their first few years of life -- and any episode can be fatal.

The Kindness of Strangers

2010-04-13T08:59:00.000-07:00

Several years ago, our younger son Nathan took a bike trip, along the Blue Ridge Parkway from Virginia to Koinonia in Georgia. Getting started he had some weather and mechanical issues, and there were a couple of panicked phone calls. But he was able to find help when he needed it , persevered, and ended up having a grand adventure. During his trip, when friends would ask how he was doing, my stock reply was, "He is learning what it is like to be totally dependent on the kindness of strangers."

Monday, after a tiring weekend on call at the hospital, I wanted to get away, and so thought it would be a good opportunity to go visit Hezron Soita (the retired hospital chaplain, a good friend from previous trips) at his shamba. I walked the half mile or so to the market, then hired a piki piki (a motorbike taxi); Hezron had assured me everyone knew where he lived, so just tell the taxi to take me to Pastor Soita's house. By the time we started out, the sky was looking ominous and it had started to sprinkle. After about four miles, the wind was picking up and it was clear that we were going to get a big storm (which is good because it hadn't rained in 9 days, and this is supposed to be the time of planting). The driver pulled over and told me we had arrived. I had been to his house years ago, and nothing looked familiar, but I also remembered that Hezron's house was a few hundred meters off the main road, so I assumed that I was left with a short walk. I paid him and he was off, and I asked directions at the little roadside hoteli where he had stopped . There ensued a big discussion which I couldn't understand, someone pointed, and I started off. But just then, the skies opened and they came running and gesticulating, motioning for me to come in out of the rain. A hoteli turns out not to be a place to stay, but just a mud hut with a couple of tables, some chairs, and a place to get a cup of tea. So I sat inside for most of an hour while the rain came down in torrents. Mostly it was too dark to see much, but there were 7 or 8 men, animated conversation in Bukusu, and frequent boisterous laughing, no doubt at my expense, but I was grateful to be dry, and to be able to speak with the one person who seemed to know some English, a high school student named Amos.

When the rain stopped, Amos offered (without my asking) to walk me to Hezron's, and as we started off, a couple of his older friends (or perhaps relatives) joined us. We walked and walked down various dirt paths, past mud houses with barefoot children; I had the distinct impression that it had been several years since a mzungu had passed by these parts. We passed by Amos's house, and he asked me to take a picture of him and his siblings. At another point, he stopped in the path and asked if we could trade "contact information" (mobile phone numbers), which seems to be the Kenyan equivalent to asking someone to be your Facebook friend. He was inpatient at how slow I was to enter his number, so I handed him my phone and had him put it in.

At one point, it briefly entered my mind that I had only the haziest idea of where I was, and I had no idea who these three young men were or where they were taking me. That thought was not so much frightening as a cause to marvel, that here I was, half way around the world, lost in inclement weather, and these three strangers had taken it upon themselves to help me find my way.

Eventually, after a 2 or 3 kilometers of walking through "the real Kenya", we came to Hezron's shamba. One of Amos's friends asked me if I would give them sodas; under the circumstances it seemed a reasonable request, but I had to explain that neither Hezron nor I had any soda. Hezron invited them into his very modest mud home, chatted with them for a while in Bukusu (I got the impression he didn't know them personally, but knew their families), and then sent them on their way, with many thanks.

After all this, I had just an hour to tour Hezron's crops, share a cup of tea, and meet his new wife (Hezron is 75, twice widowed, now married a third time; he still puts in several hours of work every day in his fields). Then, as darkness started to fall, Hezron wheeled out his motor bike and gave me a ride back to Lugulu.

Tonight I saw on my mobile phone that I had missed a call from Amos. I called him back, thanked him again for his help yesterday, and invited him to stop by the hospital so I could buy him the soda I owed him. Seems the least I can do.

Resurrection

2010-04-10T06:22:00.000-07:00

I am aware of a certain tendency I have to write about "bad" things, suffering and death and things that go wrong. So, in this Easter season, here is a story about a kind of resurrection.

Jackson is 76 and a man of few words. He was brought to the hospital a couple of weeks ago, and all I could get out of him was, "Sina nguvu" ("I have no strength"). The full story took several days to emerge, perhaps slowed by my lack of language skills, but eventually helped by Jackson's advocate, one of our pharmacists who comes from his village. It seems that he had been getting noticeably weaker over the last 3 months, with a gradual but definite decline. More recently, he had been stumbling and even falling, becoming forgetful, and then incontinent. I couldn't find anything on exam or basic labs, and my first thought was this is just what happens when you hit 76 (the prejudice of the young against the old). However, during the several days it took for the full story to emerge, he was getting day-by-day visibly worse, until finally he couldn't get out of bed or even talk. At this point I suggested to the family that if we really wanted to know the cause, he would have to get a CAT scan, which could only be done Eldoret (an hour and a half away) and would cost about $60. And of course even if we knew the cause, there was no guarantee that we could do anything about it. I thought their answer would be no, but to my surprise they were able to raise the money over the next couple of days, and off he went.

He returned with the CAT scan showing the largest sub-dural hematoma (a blood clot between the skull and the surface of the brain) that I have ever seen. The treatment is to drill "burr holes" in his skull, removing the clot, and relieving the pressure on his brain. Now what?

It turns out that one of the things that has changed dramatically for the better is the availability of surgery. Dr. Legeyo, the government district surgeon (a general surgeon, there are no neurosurgeons outside of Nairobi), was here the next morning to "do the necessary". By the next day, Jackson was sitting up, starting to talk and, by the following day, even starting to walk.

This contrasts with a patient we had in 1994, still vivid in my mind. He was a young man who had hit his head in a workplace accident, and had the same type of problem but much more rapidly progressive. Over the next 48 hours, he went through all the textbook stages of excess pressure on the brain from a hematoma. But in those days, there was no CAT scan, and no possibility for referral. I had even resolved that it was better to attempt the burr holes myself (my do-it-yourself surgery book said they are easy) than to watch him die, but without the proper equipment it was not possible. And so he died...

Of course, for Jackson this is not really a resurrection, but (with luck and rehabilitation) simply a return to his previous level of 76 year-old function. Still, a modest success, and an illustration of how some things have changed for the better over the last 15 years.

"To Do the Necessary..."

2010-04-07T09:01:00.000-07:00

English as spoken in Kenya has many interesting and sometimes confusing phrases (or at least confusing to American ears), but more often than not, these "Kenyanisms" are right on target.

A couple of days ago Dr. Serrem was musing out loud about a certain patient and whether we would "do the necessary" (as opposed to an alternative course of action). Sounds like another version of Kant's categorical imperative, which in a way I suppose it is.

The context was this: "unknown African female" in her twenties, admitted after the motor bike she was riding (along with two others) crashed. (I am told these kinds of accidents have become distressingly common in recent years.) She suffered a broken femur, multiple facial fractures, as well as a head injury which rendered her unconscious. Eventually, she woke up, but still could not tell us her name; the families of the other two victims claimed to have no idea who she was.

So when Dr. Serrem was wanting to "do the necessary" he was talking about surgery to properly repair her fractured femur. Just the needed hardware (a K nail) would cost more than $200, and then another $200 for the surgeon's fee. Her total bill could easily end up being $700 or $800, with no guarantee that the hospital would ever get paid. Hence the dilemma: "do the necessary" for the patient and accept the likely financial hit to the hospital; or find some alternative.

In my many years as chairman of our hospital ethics committee in the U.S, we have sometimes faced difficult dilemmas; but in a large hospital with a healthy bottom line, I can honestly say that financial issues have never played more than a peripheral role in those decisions. In the U.S., we have the great luxury of being able to divorce ethics from finances. (Perhaps it would be more accurate to say that our wealth has allowed us to pretend that the two could be divorced, but with the Medicare trust fund due run out of money in seven years, perhaps we have only postponed our own day of financial reckoning.)

But this is not an abstract issue here. Several years ago, the Friends Lugulu Hospital was in financial extremis, unable to even pay its staff for several months running. Even now, the finances are strictly month-to-month. We cannot afford to take too many chances on patients being unable to pay. As I have often said, Lugulu is a mission hospital, but it is not a charity institution. It gets no outside support for day-to-day operating expenses, but depends entirely on fees paid by patients to keep operating. True, many patients are for legitimate reasons unable to pay in full, and their bill will be adjusted accordingly. But to put it bluntly, too much free or charity care could easily sink the hospital. And although the amounts in terms of dollars seem small to us, in the context of the local economy, fees like this can be the equivalent of several months income for many families.

The end of the story: the doctor and the administrator went back and forth over the weekend (they both were undecided), before the family was finally located on the fifth day. They paid some but not all of her $100 bill, and insisted on taking her to the nearby government hospital in town, where the daily charge will be considerably less -- but where she is very unlikely to get the needed surgery for her leg. The family's decision saved the hospital from having to make the difficult choice, but unfortunately the woman is likely to suffer more as a result.

"Why do you look for the living among the dead?"

2010-04-04T09:17:00.000-07:00

Easter Sunday: I had no responsibility at the hospital, so traveled with Jotham Simiyu (on the back of his motorbike) to Malaha Monthly Meeting for Easter services. From previous experience, I knew this would be an all-day event, and that I would likely be asked to "bring the message" (or at least one of the messages). When traveling among Friends in Kenya, I have learned to take Peter's advice to heart: "Always be ready to explain to others the hope that is in you, yet do it with gentleness and respect (I Pet 3:15)

By way of explanation, I feel like I have heard quite a bit over the last week, building up to Easter, about the crucifixion, so this was my attempt to shift the focus a bit. What follows is an abbreviated and de-Kenyanized summary of what I said, or what I think I said... I spoke without notes. I was grateful to be forced to pause frequently for the translation, because it gives one time to thing what to say next. Another thing I have learned is that you can say most anything and talk about most anything, as long as you anchor it in Scripture. Also, I have left out the various Bukusu and Kiswahili greetings that are obligatory to begin with.

"Today is Easter, the day we celebrate, and remember that our story does not end with the crucifixion, but continues to the resurrection. In the end, we are people of the resurrection...

"When I read through the accounts of the first Easter from our four gospels, what strikes me is that the first reaction of the women who find the tomb empty was not joy, but confusion. They came to anoint Jesus' body with spices, and finding the tomb empty, all they could think of seemed to be, "What happened to the body?" But the angel redirects them: "Why do you look for the living among the dead?" (Luke 24:5)

I want to talk this morning about my own favorite Easter story, from Luke 24: 13-33, the story of the road to Emmaus. Someone once said that a Quaker is defined not so much but what he or she believes, or by what he or she does. Rather, a Quaker first and foremost is someone who has met the Inward Christ. I like this story because it about meeting Christ in an unexpected way.

[Scripure reading in two languages.]

Why are these two disciples traveling away from Jerusalem? By their own admission, they (like the women at the tomb) are confused, but it also seems not too much of a stretch to say they are frightened, frightened that what happened to Jesus might also happen to his followers. They were, quite reasonably, fleeing from Jerusalem.

What surprises in the account is that, in this long and involved conversation between Jesus and the two disciples, they don't recognize him. What are we to make of this? Sometimes, it seems, the risen Christ is indeed hard to recognize; even Mary Magdalene mistook him for the gardener. Beyond that, these disciples had certain expectations: "We had hoped that he was the one to redeem Israel..." God's ways are not our ways, and when we bring our human expectations of what and who Christ is and should be, he may remain unrecognized.

Even more surprising, when they finally do recognize him in the breaking of the bread, what happens? He vanishes... I prefer to think this is not because he is abandoning them; but rather, once Christ is recognized, he is confident that his disciples will do what is necessary -- and he is off to somewhere else. And indeed, once he is recognized, these disciples go back to Jerusalem, from where they had just been fleeing. They were tranformed, from confused and frightened, to bold and confident. "Were not our hearts burning within us while he was talking to us on the road, and opening the scriptures?"

One other thing stands out: what the risen Christ did on the road was to teach. This story is one of the places where early Friends came to use the phrase Inward Teacher to refer to the Light of Christ. Remember Fox's often repeated refrain: "Christ has come to teach his people himself."

Another passage that beautifully expresses this idea of the Inward Teacher is from the Hebrew Scriptures, Isaiah 30:20-21: ""Though the Lord may give you the bread of adversity and the water of affliction, yet your Teacher will not hide himself any more, but your eyes shall see your Teacher. And when you turn to the right and when you turn to the left, your ears shall hear a word behind, saying, "This is the way; walk in it."

There is much for us to ponder in this little story. On the road that is our life, the risen Christ may come to us in unexpected ways, ways that are difficult to recognize. Will we recognize him? Will we heed the word from behind us, encouraging us and teaching us: "This is the way; walk in it." And as we are walking, will we receive those who are sent to us by Christ? Jesus said (John 13:22) "whoever receives one whom I send receives me, and whoever receives me receives the one who sent me." Who might Christ send to us on this road? Might it be "one of the least of these?" Will we receive them in His name? Will we perhaps even recognize Christ in that person? And recognizing Christ, will we, like the disciples in our story, be transformed?

May it be so.

Thoughts on the seed of the poppy

2010-04-02T09:12:00.000-07:00

I had my first opportunity yesterday to meet with "the registrars", the family physician residents in training at the government district hospital 5 miles down the road. It was supposed to happen two days prior, but Jan had called me that morning to say don't come; all the registrars had been suspended without pay by Moi University, and told to go to Nairobi and camp out at the Ministry of Health until the Ministry promised to pay the university the tuition that was owed to it, going back over a year. As they say they say here, "TIA" (this is Africa...)

My assignment with the registrars was to introduce the topic of palliative care and hospice. In my trips back to Kenya over the years, I had begun to feel very strongly that this was sorely needed here. People can die horrible deaths, with inadequate pain control and no attention to their psychological needs. This is especially true with cancer patients, but can also happen with AIDS, heart disease, and really any chronic incurable disease.

In the meantime, I had been able to make contact with the Kenya Hospice and Palliative Care Association (through their contact with Hospice of Lancaster County); their major purpose is to assist communities in starting their own hospice programs.

The session with the registrars went well, had two hours to explain the rationale of what we do in hospice, i.e., when a disease is incurable and progressing toward a predictable outcome, the attention turns to quality of life and relief of symptoms. All this made intuitive sense, and they were easily able to come up with examples from their own recent experience of patients who would benefit.

The sticking point was the use of morphine and other strong opioids for the relief of pain. There is a great fear of morphine here among physicians; it is hard to know what it is based on, since few have any experience at all. It is not easy to get (and in fact the first task of a new hospice here is always to secure the supply of morphine), but it is possible. I think I was able to allay many of their fears and speak from experience how necessary it is to the function of hospice. (In the U.S., morphine would be just one of several alternatives available; but those alternatives are absolutely unavailable here, hence the importance of morphine).

Sometimes, in advocating for this, I find myself thinking almost theologically. We each have in the cells of our brain finely-tuned opiate receptors, which allow the brain to turn down pain signals. It just so happens that a certain compound purified from the seed of the poppy plant, originally growing in central Asia, exactly fits those opiate receptors, and with this compound we are able to greatly ease the pain of suffering patients. What a wonderful example of the bounty and mystery of God's creation! And also a tribute to human ingenuity, which was able to discover all this.

Creation is good; but creation is also fallen. Human ingenuity has also learned how to make use of the seed of the opium poppy for unhealthy and destructive purposes, and this has led directly to the fear of doctors here.

Creation is good, creation is fallen, and creation can be redeemed. Could it be that the proper use of morphine is part of that redemption?

HIV: The Good and the Bad (Take 4)

2010-03-29T08:13:00.000-07:00

NB: I wrote this 3 days ago and have spent hours trying to figure out how to transfer it to the blog, and in the end have to just retype it. Sorry for the delay; my postings may be infrequent given the problems I am having.

3/26: Dr Serrem, the acting medical officer in charge, gave me the new call schedule yesterday, which had me on call that night (my second day here). Perhaps he thought being on call would help me get over jet lag. But I am not about to complain: he has been here alone over most of the last 3 months. (He was joined the week before I arrived by Dr. Mark Waithaka, who just finished his internship at a nearby district hospital and was posted here by the government; he is the age of my sons...)

One of my admissions during the day was Jacob, a 42 year old policeman, admitted with shortness of breath and difficulty swallowing, worsening over 3 weeks. A look in his mouth showed the telltale thick white crust of oral thrush, a certain marker of advanced HIV. His chest x-ray was suggestive of PCP pneumonia, a complication that used to be common in the U.S. but is now rarely seen. The nurse whose job it is to counsel patients about HIV testing found out that in fact he had known that he was HIV positive for over a year, but had resisted the pleas of his wife to seek treatment. So despite the now readily available and free treatment for HIV (which his wife is on), the results for this man were distressingly familiar from my previous time here: inability to swallow pills, worsening respiratory status overnight; and then today delirium (probably from low oxygen in his blood), increasing air hunger, coma, and death just 24 hours after admission. This despite the availability of medicine to treat his thrush and pneumonia; he had simply delayed too long.

A welcome contrast to this was an invitation from the HIV clinic to come greet a group of 15 or so preschool and primary school children, along with their mothers (or grandmothers, as many were orphaned), members of a "Children Living with HIV Support Group". These are some of the 400 or so children (and 2500 adults) receiving HIV care through Friends Lugulu Hospital's Comprehensive Care Clinic. The care is free, and ultimately funded through PEPFAR by your tax dollars. Whatever disagreements we may have had with George W. Bush, this is his legacy in much of Africa.

The good and the bad; hope and despair; the promise of life and the specter of death: seems it's all here, everyday.

HIV: The Good and the Bad

2010-03-29T03:31:00.000-07:00

testing testing testing.Having trouble with internet connection, so far have not figured out how to post. This is a test.

Arrival

2010-03-24T22:47:00.000-07:00

Arrived safely in Lugulu late in the afternoon of March 23, after an 8 hour bus ride from Nairobi. I am still not adjusted to the 7 hour time difference, so am wide awake at 3 a.m. writing this.
The journey here involved an overnight flight from Philadelphia to London, then a 3 hour layover and an eight hour flight to Nairobi. I stayed 2 nights and one day in Nairobi with my friend Bruce Dahlman, a family physician from Minnesota who has been living in Nairobi while working to support family medicine training programs throughout East Africa. I had just a few errands to do in Nairobi, including a brief stop at Friends International Centre, where Nairobi Yearly Meeting and FWCC are both headquartered.
The rains have started just in the past few days; an hour of heavy rain this afternoon just as I was arriving, and then on and off all through the night. After two dry years and poor crops, everyone is happy to see the rains start. The fields have been prepared, and soon farmers will be planting. The rains bring the vegetation back to life and allow the crops to grow, but of course the rains will also bring more malaria. My friend Jan (who along with her husband Ray replaced us in Lugulu in 1995, but now works at the government hospital down the road in Webuye) says that at the government hospital they have 95 children in their 40 bed children’s ward. The government heavily subsidizes hospital care for children under 5, so Lugulu will not have many children here, as it would be much more expensive for families.
Some things seem new and different: in Nairobi, lots of big new shiny buildings; cell phones everywhere; and at least here in the hospital, many computers. But other things stay the same: the power was out overnight and much of the morning; and even though it has started to rain, there is no running water in the house (hard to know why, but I suspect the water table dropped enough during the prolonged dry period that the borehole that was drilled when we were here in 1994 is not longer reliable).
Today was taken up largely with meeting new people and renewing old acquaintances; tomorrow I start work in earnest.

Nenda na Mungu

2010-03-20T10:11:00.000-07:00

Waiting to depart for the airport: This is a story I have told dozens of times over the years, mostly for the benefit of people preparing to travel to far-off places where they will be without the conveniences of home, and perhaps into situations where they may find themselves totally dependent on the kindness of strangers. Today I tell it for my benefit.

Twenty years ago, I heard Gordon Browne (who died this past year) give a plenary address to New England YM, on the occasion of his retirement after many years of service as the executive secretary of FWCC / Section of the Americas. In that position, he would from time to time travel to visit Friends in out-of-the-way places, like the Alto Plano of Peru and Bolivia. He observed that when he was preparing for such a journey, his Anglo friends would invariably say to him, “Gordon, be careful.” But his Latino friends would say, “Gordon, vaya con Dios” -- “Go with God”.

Perhaps we can generalize to say that those with much to lose think in terms of being careful, while those with less to lose know from whence their protection comes. Or, to quote Friend Bill Kreidler, “Protection comes from God; security is from the devil.” Traveling can involve giving up some of our security; but in turn we may gain that experience of protection. May it be so.

So, vaya con Dios. Or, rendered into Swahili: Nenda na Mungu.

2010-02-25T14:33:00.000-08:00

Mount Elgon from

Hospital grounds

2010-02-25T13:56:00.000-08:00

Hospital
Guest House
(our 1991-94
residence)

Testing

2010-02-13T15:02:00.000-08:00

Setting up blog... all new to me; when we lived in Kenya, and even when we returned in 1997, there was no e-mail. Hakuna, as they say in Swahili. So please bear with me as I try to learn new technology.