Conversations and Journeys in Africa

Ashiah - (reposting)

2011-08-10T12:30:00.000-07:00

(Still) My favorite Pidgin word. It cannot be translated exactly into English, but the nearest approximation I have heard so far is that Ashiah = “I share,” or “I empathize with you.” It can be used when walking by someone working in a field, as an acknowledgement of their effort. It can be used as a general greeting and will be received as a gesture of kindness and good will. Patients say it to me when I go on rounds. I have taken to saying it everyday to the nurses, chaplains, caretakers, and patients.

The long-termers here tell me that most people passing through like this word. One MK (missionary kid) expressed to me how much she actually disliked the word, from hearing all the short-term-visitors talk about how much they liked it. In either case, I know when I leave Cameroon I will miss having such a beautiful verbal expression of empathy.

Compare & Contrast

2011-08-10T12:12:00.000-07:00

I'm back in Cameroon! 3 years later! My wonderful residency program not only allows me to come to Africa for a month rotation, but also pays part of my way! Samaritan's Purse and my wonderful friends and family have supported me and my new husband Bryan the rest of the way. It is fun to see old friends, hike old trails, and listen to the familiar sound of rain on the Cameroonian-tin-roofs.

I have now been back at Mbingo for one week. The rain and mountains are still beautiful. The hospital and it's residency training programs are still an amazing advance compared to much of the country. The word "Ashiah" (see previous post) is still my all-time favorite word. Yet communication issues still abound. The system is still working out major kinks. And patients still die, sometimes needlessly, other times inevitably, still others appropriately - and all with the soberingly-loud wail of grief that sends chills up and down my spine every time.

At first I was not planning on blogging again. My first stay I was just out of medical school; now I am in my third year of residency; before I was single, now I am married. Before I was naive and fresh to overseas travel, medicine, life and death; now I am further down the one-way-street of residency and it's experiences, knowledge, and insight, as well as cynicism, stress, apathy, and burn-out. Last time I cried often. So far I have yet to cry.

There. I have done it. One week of comparing and contrasting - a lifetime to go, I hope?

Endings

2009-05-11T13:25:00.000-07:00

When was the last time you read the last chapter of a book first? Maybe never? For me, it was last week. Having the end in mind frees me, somehow, to observe how the author crafts and weaves the narrative along the way. Before you diagnose me with having broken the eleventh commandment (thou shalt not ruin a suspense-filled-plot(?!?)), I beg you to humor me and read on…

Happy Endings…
Yesterday I received an email from Dr. Louise King in Rwanda informing me that one of my patients and friends, Fulaha, had recently received two prosthetic legs and is now able to walk with crutches. Happy ending! For those of you who weren’t able to keep up with my verbose blog, Fulaha was a young woman and an orphan unable to walk due to a congenital leg malformation. She had been staying at Shyira Hospital for the past nine months after a bilateral AKA (Above the Knee Amputation), sitting in an old wheelchair with two flat tires, making baskets, and waiting for her prostheses. Her name, pronounced “foo-LAW-haw,” means “Joy” or “Joyful” – and that she was! Whenever I approached, she would loudly proclaim “Mar-EEEEEEE-ya!” and throw her arms wide open for a hug.

Only once did I see Fulaha sad. On the day she was scheduled to go to the capital, Kigali, I found her still lying in bed with the sheet pulled over her tear-stained face. Her legs had not been completed on time and her trip was canceled. When I took my leave of Shyira Hospital in rural Rwanda, I departed wondering if my ‘inshuti Fulaha’ (literally: ‘Joyful friend’) would ever walk. A cliff-hanger to be sure…but, like my reading style, you already know the ending.

Fulaha, upon arrival

After her bilateral above-the-knee amputation:
April 2009, after her prosthesis installation surgery:

…Juxtaposed With…
Happy endings make great newsletter-stories, to be sure. I could fill pages about my six months in Africa with stories about the patients that went home well, the lessons I learned, the ways and places I saw God working and moving, the fun and adventures I had, the friends I made, etc., etc. Africa was and is a kind of second home for me. Though I can’t presume to understand even a fraction of the cultural nuances and climate, I look forward (hopefully and prayerfully) to returning after residency.

In medical school they taught us that, when in the position of giving bad news to a patient, it is best to fire a warning shot. Studies have shown that inserting the phrase “I’m afraid I have bad news...” helps most people brace themselves for the ensuing blow. Could this be another form, perhaps, of “reading the last chapter of a book first?” In either case, consider this to be your warning-shot: for every “happy ending” I saw in Africa, ten sad ones soberingly come to mind as well. I would be remiss to gloss over this crude reality.

…Sad Endings
Two weeks after arriving in Rwanda, I got an email from a doctor friend in Cameroon informing me that Mispah, a patient we had cared for together, had died. Despite her recovery from bacterial meningitis. Mispah was so depressed that she couldn’t eat the small amount of food her family could afford for her and consequently I saw her waste away from malnutrition. I brought her food and spoon-fed her. I checked on her ten times a day. I knew her family members by name. You know the ending. Maria, my nineteen-year-old patient in Cameroon who survived meningitis and recovered successfully from half-paralysis returned to the hospital the day after discharge. Unconscious and with a mysterious heart murmur, we helplessly watched her die the next day. I could fill pages about my six months in Cameroon and Rwanda with similar stories about the patients that died, the indescribable suffering, the appearingly hopeless circumstances and politics, the pervading corruption, the seemingly infinite poverty, etc., etc. These are the real-life cliff-hangers, with all their accompanying uncertainty and angst. Some of the bad endings are not in our power to prevent; some of them are, yet we do not. Overall, a sense of powerlessness pervades.

To be continued…
“Bagarira yose ntuzi irizera niri zarumba.” This is a Rwandan saying that can be literally translated as: “Treat every plant well because you do not know which will bear fruit.” My language teacher paraphrased it by saying “You don’t know yet who will be good or bad. God only knows.” Perhaps powerlessness and uncertainty are part of being alive. As much as I would like to read the last chapter of this book now to see how all of this will end, I cannot. However, just because I cannot see the end does not mean that the author Himself cannot. And just because much of this suffering and injustice seems to fly in the face of a loving and just God, doesn’t mean that He has given up on us or that He won’t explain it all in the last chapter. He has the end-goal in mind; He is still crafting and weaving this narrative along.

I’ve quoted Yancey once before, and I will end by quoting him again (from Where is God When it Hurts, Philip Yancey)

“The record of Jesus' life on earth should forever answer the question, "How does God feel about our pain?" In reply, God did not give words for theories on the problem of pain. He gave us himself. A philosophy may explain difficult things, but has no power to change them. The gospel, the story of Jesus' life, promises change…There is one central symbol by which we remember Jesus. Today that image is coated in gold and worn around the necks of athletes and beautiful woman, an example of how we can gloss over the crude reality of history. The cross was, of course, a mode of execution. It would be no more bizarre if we made jewelry in the shape of tiny electric chairs, gas chambers, and hypodermic needles, the preferred modern modes of execution. The cross, the most universal image in the Christian religion, offers proof that God cares about our suffering and pain. He died of it. That symbol stands unique among all the religions of the world. Many of them have gods, but only one has a God who cared enough to become a man and to die...”

" He who did not spare his own Son, but gave him up for us all—how will
he not also, along with him, graciously give us all things?" (Romans 8:31-32)

For more stories and/or pictures, please visit my blog at http://marybuckler139.blogspot, email marybuckler139@gmail.com, or call 414-839-8299. I’d love to hear from you. On June 22nd, 2009, I will enter the next stage of my medical training at my top choice residency program, a five-year combined Family Medicine/Psychiatry residency at the University Hospital & Christ Hospital in Cincinnati, Ohio. Thanks for all of your support and prayers!

An evening at Shyira with the Kings

2008-12-30T02:44:00.000-08:00

Imagine you have found your way to the living room of the King’s house in rural Rwanda. It is 7:30 P.M. The sun went down at 6:00 P.M., and after 15 minutes of darkness and flashlights, the electricity came on at 6:15. Dr. Caleb is on the porch chatting with his visitor (though the visit was surprise, having surprise visitors is, actually, a matter of course around here). He is likely needing a signature for some official hospital business. Dr. Louise sits nearby, checking her email at the kitchen table, while two short-termers sit at the school-room table (just adjacent) surfing the web and checking their email. (The King’s have a satallite and therefore the best internet connection on the hill. Graciously, they allow visitors to come and sit in their living room most nights of the week to take advantage of their wireless.)

“Vrrmm! Vrrrmmm!!“ Caleb Jr. runs in with three paper-airplanes and making appropriate airplane noises. “No, mom, I haven’t brushed my teeth yet,” he says. Hannah King, his older sister, sits down beside one of the short-termers, browsing her Facebook account. “Who’s that? How do you know them? What other pictures do you have?” she asks, a better question-asker than most journalists. “Yes, mom, I already brushed my teeth. And flossed.” Dr. Caleb comes in and sits on the couch. The littliest King child, golden-curly-haired Lydia, crawls into his lap for the evening bedtime story.

“I’ve gotten an email from Sara!” Louise exclaims. “She’s wondering what to pack for her trip home next week.” Sara, the oldest King child, is currently a middle-schooler at a boarding school in Kenya. She will soon be coming home for a much anticipated visit. As the three children snuggle up next to their father on the sofa, you wander over to the packed bookcase and browse a few of the titles:

Storey’s Guide to Raising Dairy Goats…
Mountains Beyond Mountains, biography of Paul Farmer…
Pilgrim’s Progress…
Field Guide to the Birds of East Africa…
Looking After a Donkey…
Harrison’s textbook of Internal Medicine…
Biography of Gladys Aylward…
Mere Christianity C.S.Lewis…

Storytime over, Caleb Jr. begins running around in circles with his paper airplanes and a blimp made out of a balloon. Equally as inquisitive as Hannah, he ignores the ’BEDTIME!’ announcement and begins peppering you with questions: “Which do you like better? The blimp or the airplanes?…What’s your favorite mythical creature?…If you had a Greek god for your parent, which one would you choose?…Will you play capture the flag tomorrow? Pleeeeeeeease!?”

Suddenly, the lights fade and the short-termers expel involuntary sighs of disappointment at a last email not quite having finished sending or a Skype-conversation with a sister being cut short. The electricity goes off at 8:30 every night, along with the electricity-powered satellite connection. Laptops are packed up, thank-yous said, fully-charged lanterns gradually illumine in the hands of the King children, and everyone shuffles off to their respective houses, rooms, and beds. A final “Sqawk sqawk!” emerges from the porch-dwelling parrot…

* * *

The above is an example of a typical evening here at Shyira Hospital. Before I arrived, I could hardly imagine what living at a mission hospital in rural Rwanda would look like. One short-termer, arriving a month after me, exclaimed surprisedly, “But where’s the pit latrine?” after he was shown to his personal apartment complete with shower, flush-toilet, and kitchen help. Certainly everyone on “the hill” does not have a flush toilet, but this is one of the many technological advancements (another being the satellite internet connection) that have come to Shyira thanks to Dr.Caleb and his family.

Even without these modern-day luxuries, however, I suspect that most people would be surprised at the comfort and family-atmosphere of Shyira. I myself, having never met the King family before, was hoping to get to spend maybe a few hours a week with them and perhaps to win the trust of their children gradually. Quite to my surprise, from the first day the King family and their children included me in their daily life, from afternoon games to flute lessons to nightly internet and watching movies cuddled on the couch – Thank you, King family, for your seemingly natural and endless hospitality, joy, and love!

Left To Tell...the Truth? (Christmas Eve Reflections)

2008-12-30T01:25:00.000-08:00

Last night I attended a Christmas Eve service with my friend Violette, a middle-aged Rwandan woman who teaches trauma-counseling workshops in churches around the country. I have utmost respect, appreciation, trust, and enjoyment of her, and often have said that I wish I could come back to follow her around, listen to her stories, and transcribe them into a book.

A few of you have read the book "Left To Tell," about one of the survivors of the genocide. Last night Violette confided in me that the pastor in the book who hid Immaculee was actually her [Violette's] father, that the woman weren't actually in the bathroom for more than a few hours (they were in another small but slightly larger room), and that there were many other fabricated, novel-esque, and manipulative details included in the book. Her father (who for many years never knew the derogatory content of the book since he only speaks Kinyarwandan) was very hurt when he found out. The examples Violette used were convincing. After parting, I was reflecting on the seemingly-inappropriate nature of this conversation for Christmas Eve, but yet at the same time on how central *truth* is to everything we celebrate. What, afterall, is the truth of all these events and histories? How can reconciliation occur if both sides sincerely (or insincerely) insist on different versions of reality? Regardless of the truth of either one of their accounts, I am amazed at how, despite the webs of lies and deception and manipulations and lack of insight we are entwined in, God still humbled Himself in order to RECONCILE us to himself, us who do not recognize or acknowledge half of the depth of our sin. His appearance of weakness as a baby allows now for His Strength to be made perfect in Our weakness. Grace.

Merry Christmas (Neheri inziza)
~Mary
Solace Ministries
Rwanda

* * *

A relevent excerpt from With What Remains: A Widow’s Quest for Truth in Rwanda, Lesley Belinda

“…Could I trust them? Was their version true? Were they intentionally missing out certain facts, or exaggerating others? Not knowing who to believe was torment…Was there perhaps some cultural element in the interpretation of truth? Coming from a western culture with a heritage of Greek dichotomy, my understanding of truth tends to be relatively clear cut, black and white. But to my understanding the African concept of truth seems much more fluid and relative. Much more important than absolute truth is the maintenance of community and relationship. Fostering harmony and peace --even if it means missing out or embellishing some of the facts --would always be more important than speaking out the full story, if that might cause hurt or offence…But betrayal is much more profound than just a different approach to truth. How hard it is ever to trust again when betrayal has been so deep. Yet this is the current experience of most Rwandans. If those with whom for years you have lived, worked and worshipped then betray you and murder members of your family, how do you ever trust anyone again?” (196).

“Discovering the truth can be shocking, but it can also be freeing. I realized this was part of the message the government in Rwanda was trying to impart to the population in relation to the Gacaca courts. ‘Ukuri kurakira’ proclaimed huge Gacaca posters along the roadside all over the country. ‘Truth heals.’ On the one hand I could endorse that now, having realized its impact in my own life. But on the other hand, when it came to searching for the truth about Charles’ murder, I knew full well that the process necessary to get there can itself be unbearably traumatic. Hundreds of thousands of Rwandans were having to make that choice in these days. Could they face putting themselves through such torment by reawakening the horrors of the genocide months? If discovering the truth could be the guaranteed end result, it might be worth the agony. But when the pathway to search for truth is strewn with lies and silence, intimidation and dead ends, and the reawakening of pain with no resolution, who would choose to follow it? Remarkably many have and still do, and for them the Gacaca courts have revealed details of the deaths of their loved ones, enabling them to unearth their remains and give them a dignified burial. Some kills have confessed to their crimes and there have been remarkable instances of reconciliation….But, for others, truth remains buried with their families…The resilience and courage of the vast numbers of women and children widowed and orphaned by the genocide humbles me to the core…” (132-3).

Kigali genocide memorial

2008-12-14T13:59:00.000-08:00

A week ago, Natalie and I found our way to the Kigali genocide memorial. Free to the public, it includes outside mass graves containing over 250,000 bodies, an indoor exhibit detailing to history of the 1994 genocide in Rwanda, a memorial to children killed, and an exhibit describing a few of the other well-known genocides. Despite the many books, stories, and accounts I have read and listened to regarding the events of 1994, I still cried my way through the tri-lingual exhibit.

There have been many books written on genocide. There have been many memorials built, many classes taught, and many “never again” resolutions made. This entry is in no way comprehensive. Rather, it is a scattering of quotes and/or historical points I jotted down as I cried my way through the exhibit…

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Igiti kigororwa kikirigito
Un arbe ne peut etre redresse que lorsqu’il est jeune.
A tree can only be straightened when it is young
-traditional proverb
(I saw this saying posted on signs around the city and had been told it was referred to HIV prevention education. Seeing it prominently displayed in the exhibit and knowing that the youth played a prominent role in the slaughters made me ponder another possible application.)

Ukijije ubuzima bw’umwe aba akijije isi yose.
Qui sauve une seule vie sauve le monde entire.
He who saves a single life saves the world entire.
-Talmud

Igihe bavugaga ngo ‘ntibizasubira’ nyuma ya jenoside yakorewe abayabudi, bashakaga kuvuga ko bireba abantu bamwe gusa abandi bikabirengagiza.
Quand on disait “plus jamais” après l”holocauste, cela concenait a certaines personnes et pas d’autres?
When they said ‘Never again’ after the Holocauste was it meant for some people and not for others?”
-Apollon Kabatici

Ntabumuntu Buzabaho budatanga imbabazi ata mbabazi zizatangwa hatabayeho ubutabera ariko na none ubutabera ntibuzashoboka ubumuntu butariho.
Il n’aura pas d’humanite sans pardon. It n’y aura pas de pardon sans
justice. Main la justice sera impossible sans humanite.
There will be no humanity without forgiveness, there will be no forgiveness without
justice. But justice will be impossible without humanity.
-Yolande Mukagasu.

I yo uza kwimenya nianje uk ntagengwa feres iyani.
Sit u me connaissais et sit u te connaissais vraiment, tu ne m’aurais pas tue.
If you knew me and you really knew yourself, you would not have killed me.
-Felicien Ntagengwa

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-26,338 kilometres squares, 8 million people killed.
-300,000 orphans, 85,000 of which are heads of households.
-500,000 women rape victims (many now HIV positive)

-“There was no ethnic war. There was a civil war. But the genocide happened, and it was something different.” (a significant comment in that some politicians and/or history textbooks have chosen to refer to the events of 1994 as a “war” instead of a genocide. From my readings and research, the correct term is actually “genocide.”)

-Other genocides (not a comprehensive list):
Armenians 1915-1918 15 million (75% of their population
the Hereros 1904-1904 65,000 Herero people killed (80% of their population)
10,000 Nama killed (50%)
the Holocauste 1939-1945 6,000,000 Jews killed, 10,000,000 people forced labor
Cambodia 1975-1979 2,000,000 Cambodian Vietnamese, Buddhist monks, Chinese, Trais, Cham,
Muslims, the Kola (30% of the population), 95% of Buddhist temples
the Balkans 1992-1999 ethnic Muslims and Croatians
Bosnia 2,200,000 displaced persons. 200,000 Bosnian Muslims killed,
10,000 Kosovar Albanians, 1000s of Croations

Pictures were not allowed inside.
Here are some of the mass graves surrounding the memorial

Natalie looking at one of the mass graves with an open-view-window.
Notice the sign: "Please do not step on the mass graves."

Goodbye, Shyira!

2008-12-13T09:05:00.000-08:00

Things I will miss most about Shyira:
-waking up to fresh Rwandan mountain air from our porch every morning
-sleeping in my mosquito net/tent (yes, it was a little romantic somehow)
-Rwandan hymns flitting through the air at random times throughout the day
-teaching “Medical English” to the hospital staff (they are SO motivated to learn English, it’s quite humbling)
-practicing my (poor) French (Excusemoi pour ma Francais trais faible!)
-Carina, the Kings, the Kohls, and the close ex-pat community
-Clementine, our cook and friend, and our constant game of charades to communicate. The day I left, she gave me a sweet present: a handwoven tapestry that said (in English, which she doesn’t speak): “We wirr be together in Heoven.” (In Rwanda they frequently confuse their “L”s with their “R”s, which made it even MORE special.)
-Walking forty-five minutes to the nearest market on market days
-Fresh fruit everyday, an infinite supply of mini-bananas, and the smell of fresh-baked-bread three times weekly
-the children

Things I (so far) have not missed:
-rounding on patients who still hadn’t gotten the medication I ordered on them three days before
-asking the lab about lab results that were supposed to have been finished days earlier
-struggling to communicate with the nurses about life-or-death patient issues
-unreliable internet connection (although it was freeing)
-“The man with the key has gone.” Self-explanatory, I think? (Also supposedly the name of a book about Africa (Ian Clarke - author). I will be buying it promptly upon my return home.)

Some Rwandan History

2008-12-13T09:03:00.000-08:00

For those of you who aren’t aware, fourteen years ago in 1984 Rwanda underwent a massive scale genocide. While American television was discussing the OJ Simpson scandel, Monica Lewinski, etc., 800,000 Rwandans (in particular the Tutsis, one of the three ethnic groups in Rwanda) were slaughtered over a mere one hundred days. What some people are not aware of, also, is that both before and after the genocide, there were various other fightings and killings, from both sides of course. Many people I have talked to have listed parents, spouses, children, and friends killed at various times. Because the majority population in the region of Shyira is Hutu, many of them have had family members killed in the years after 1984.

Since coming here, I have discovered that now in Rwanda, people rarely if ever say the names “Hutu” or “Tutsi” out loud. They say “Rwandan.” On the day of my arrivalI was advised that, if I must refer to the two main ethnic groups, it is best to say “the majority group” or “the minority group.” Otherwise when I talk people will hear only a foreign language (English) with these two very loaded words occasionally thrown in, and they can start to think I am saying something derogative. It is better to not give the wrong impression. Indeed, since arriving here I have felt like I talked more about the genocide at home before I came then I have here in Rwanda. Once, in the middle of a conversation, a nurse replied in answer to a question from me, almost in passing: “Well you know we had a genocide here, and after that…” blah blah blah. I was a bit shocked (and relieved) to hear someone say the word.

I’ve been told that this seeming-silence is not a year-around-mandate. Every April (April 1984 was the beginning of the “100 days of terror,” during which 10,000 people were killed everyday), the country goes into “100 days of mourning.” The “events” of 1984 are supposed to be a fairly open discussion topic in schools and in public, for the purpose of mourning for those who died and, hopefully, prevention of any sort of recurrence. Unfortunately I will not be in the country this coming April. I wish I could be.

"Why should I help this one person?...I can't believe I just said that." ~from Blood diamond (the movie

2008-12-13T09:00:00.000-08:00

"My donkey stepped on someone and I have to check on them!" With that, Dr.Louise raced out of the patient consultation room, leaving me with the patient, nurse, and Dr. R, one of the better English-speaking doctors here at Shyira Hospital. "Does this happen often?" I asked, hoping to break the silence. "No," replied Dr. R unconcernedly, "most people wouldn't do that. It's just because Dr. Louise is, well, how do I say…Dr. Louise is nice." "Ahh, I see" I said, smiling to myself. Though I still knew nothing about the statistics of donkey-induced injuries in rural Rwanda, the answer I got was just as interesting.

Drs. Caleb and Louise King value individuals. An HIV-positive boy used to return repeatedly to the malnutrition center after continual relapses. The Kings got to know him, took him home, and now he is part of the King family and thriving. A few years ago, they got a phone-call from a woman desperate to get rid of an unwanted child; now "Moses" is 6 years old, included in every King family activity, and on the verge of adoption by their cook. Many short-term visitors (like myself) come for one, two, or three month sojourns at Shyira Hospital; they are issued a standing invitation to dinner most-nights and are welcomed into almost every family event or game. And one morning a man is stepped on by a donkey; within the hour, he is personally attended to by the donkey's "Umuzungu" (white man) owner. What do all these anecdotes have in common? Drs. Caleb and Louise King value individuals.

This dialogue touches on a larger public health issue – in a world with limited resources and multiple problems, how do we choose what to spend our limited money on and what to not spend money on? In my medical school ethics class, public health was often used to discuss the opposition between advocating for the anonymous masses vs. the pleading individual. Of course, the so-called "anonymous masses" are made up of pleading individuals in desperate need. But if one person has limited resources, say $1000 - should they spend it on vaccinations for 100 children to prevent deadly childhood infections? Or should they spend it on keeping one premature baby with a heart defect alive in the ICU for 2 weeks, after which point chances are high that he would die anyway?

Certainly there is no simply or easy answer to this question. Many people focus on the suffering premie but seem unable to comprehend the delayed ramifications of non-vaccinated children. Other people advocate passionately for public health policies while appearing cold to such individual cases. I hope, were we able to analyze the hearts and motives of people belonging to both groups, that they would both be motivated by compassion, desire to relieve suffering, etc. Personally, I tend to lean more toward the "public health" mindset (the greatest good for the greatest number so to speak). I am frustrated when my fellow pro-lifers focus only on the "unborn" without acknowledging the suffering homeless living under the bridges, the malnourished in Africa, or even (dare-I-include?) the recalcitrant alcoholic that few doctors or people enjoy treating. Certainly we must 'choose our battles.' But how much of our "battle-choosing" is based on prejudices and biases we can't even begin to fathom? (As a side-note, this was certainly that the case in Rwanda - because the colonial powers preferred the nose and face shape of the Tutsis, they began planting the seeds that eventually led to genocide.)

All that being said, I have had various patients both at home and during these few months in Africa that I found myself caring more about and, therefore, going the "extra mile" for. As a surgeon may be drawn to a traumatic injury requiring sutures, I found myself drawn to a malnourished women with depression, a new-onset schizophrenia, a woman with post-partum depression, etc. Does the fact that I find myself naturally caring more about them make them more valuable? Certainly not. Several of my pediatrician friends tell me that they enjoy pediatrics more than adult medicine because, while most adults seemed to have problems of their own making (smoking, alcoholism, obesity, etc), children are rarely culpable in their diseases. Superficially this seems reasonable - I have certainly beat my head against many walls for all of the times I saw adult patients return again and again to the hospital for problems of behavior. Certainly the unborn baby is more innocent of all the things that most annoy and offend us about the alcoholic - it has not drained societies resources, it has not spent time in prison from some alcohol-encourage crime or in the hospital from the fifteenth episode of D.T.s. Yes, an unborn baby is more attractive and even more innocent. But is the unborn baby somehow intrinsically more valuable then the adult alcoholic?

I do not think the value of a human being comes from his or her skills, abilities, expenses, or even whether it does good or evil. I believe our value comes from how God sees us, and since He wants all of us as His sons and daughters and friends, He sees us all as infinitely valuable. But of course God also does not have the issue of limited resources that we tend to have. Even if I see every person as being equally and infinitely valuable, how do I choose to help some and not others?

And on a macroscopic level, what motivates health policy— Quality of life? Expense? The "Greatest good for the greatest people?" Value? Or perhaps it more practical than philosophical – limited resources? Immediate gratification? Acute care issues? Supply & demand (i.e. the people with the most money give to their personal interests and not to others)? Is that so wrong? Is that, afterall, any different than my having certain patients I am more drawn to than others, or the Kings taking special care for certain patients that would never be feasible for everyone?

There are no easy answers to any of these things. It is encouraging to me, however, that missionaries and medical workers in Africa are able to somehow balance the two. I hope personally that I can be, as much as possible, an advocate for those who are unable to advocate for themselves. I want to value the individual and not be afraid to go above and beyond for individuals, while still advocating and focusing on the needs and suffering of the multitudes. Jeremiah, a Hebrew writer, prophet, and poet wrote a beautiful description several thousand years ago, connecting knowing God with helping the oppressed.

He defended the cause of the poor and needy, and so all went well.
Is that not what it means to know me?" declares the LORD. (Jeremiah 22:16)

Books! from a bookworm...

2008-12-01T08:24:00.000-08:00

My top three favorite books about Rwanda that I have read (see rest of blog for excerpts and quotations):

Beauty from Ashes: Journeys of Recovery from the Rwandan Genocide by Callum Henderson
Personal stories of experiences in the genocide, along with insightful philosophical commentary on forgiveness and reconciliation from peope who were there. I've read it a couple times while being here. (blurb: "After outlining the background to the genocide and the church in Rwanda, author Callum Henderson of Comfort Rwanda, takes the reader through the horror and hope of 1994 and the subsequent years of recovery. The stories are intensely personal and deeply moving and give an insight, through the lives of those who lived through the genocide, of what life then and now is really like and the difference God is making to survivors.") Available online at http://www.solaceusa.org/usa_beauty_from_ashes.htm

Left to Tell: Discovering God Amidst the Rwandan Holocaust by Immaculee Ilibagiza
I suspect the most widely read book about Rwanda. Great bedtime read, reads like a novel (except it really happened). (Dustjacket blurb: In 1994 Immaculee was 22 years old and home from college to spend Easter with her family when the death of Rwanda’s Hutu president sparked a three-month slaughter of nearly one million ethnic Tutsis. She survived by hiding in a Hutu pastor’s tiny bathroom with seven other starving women for 91 cramped, terrifying days. This searing firsthand accound of Ilibagiza’s experience cuts two ways: her description of the evil that was perpetrated, including the brutal murders of her family members, is soul-numbingly devastating, yet the story of her unquenchable faith and connection to God throughout the ordeal uplifts and inspires. This book is a precious addition to the literature that tries to make sense of humankind’s seemingly bottomless depravity and counterbalancing hope in an all-powerful, loving God.)

We Wish To Inform You That Tomorrow We Will Be Killed With Our Families: Stories from Rwanda by Philip Gourevitch
(blurb: "Hutus kill Tutsis, then Tutsis kill Hutus--if that's really all there is to it, then no wonder we can't be bothered with it," Philip Gourevitch writes, imagining the response of somebody in a country far from the ethnic strife and mass killings of Rwanda. But the situation is not so simple, and in this complex and wrenching book, he explains why the Rwandan genocide should not be written off as just another tribal dispute. The "stories" in this book's subtitle are both the author's, as he repeatedly visits this tiny country in an attempt to make sense of what has happened, and those of the people he interviews. These include a Tutsi doctor who has seen much of her family killed over decades of Tutsi oppression, a Schindleresque hotel manager who hid hundreds of refugees from certain death, and a Rwandan bishop who has been accused of supporting the slaughter of Tutsi schoolchildren, and can only answer these charges by saying, "What could I do?" Gourevitch, a staff writer for the New Yorker, describes Rwanda's history with remarkable clarity and documents the experience of tragedy with a sober grace. The reader will ask along with the author: Why does this happen? And why don't we bother to stop it?")

Other books about Rwanda and/or Africa in general that I have read and enjoyed:

African Friends and Money Matters: Observations from Africa by David Maranz (for anyone who's ever felt ripped off or turned off by bartering and money stuff in Africa, or any third world country for that matter. Great cultural tidbits and insights!)
Product Description:African Friends and Money Matters grew out of frustrations that Westerners experience when they travel and work in Africa. Africans have just as many frustrations relating to the Westerners in their midst. Each uses and manages money and other resources in very different ways, and these differences create many misunderstandings and frictions. The author deals with everyday life in Africa. He first introduces the very different goals of African and Western economic systems and then presents ninety observations of African behaviors related to money matters. Explanatory comments are given that show how each one works out in real life. He illustrates his and others' experiences with anecdotes from across the continent. Drawings by two African artists add further clarity to the text as they capture Africans and Westerners in authentic situations. The result is that the reader is able to make sense of customs that at first seem incomprehensible. This book will be of interest to Westerners living, working, or traveling in sub-Saharan Africa: business, government, diplomatic, and NGO personnel, religious workers, journalists, development sociologists, and tourists. The audience also includes professors and students in African studies. Africans will also be interested for what it reveals about Western culture and many of the significant ways Westerners react to Africa.

Conflict Mediation Across Cultures: Pathways and Patterns by David Augsberger.
Believing not only that conflict is inevitable in human life but that it is essential and can be quite constructive, Augsburger proposes a shift to an "international" approach in resolving conflict. Augsburger focuses on interpersonal and group conflicts and provides a comparison of conflict patterns within and among various cultures. Includes numerous stories and fables from different cultures on the various conflicts- myths which are highly illuminating, teaching about cultures and about the nature of conflict, as only parables can. Interspersed in each chapter are many other stories and sharings from real life.

Shake Hands with the Devil: the Failure of Humanity in Rwanda, Romeo Dallaire, UN Peace Keeping Mission Force Commander during the genocide. From Publishers Weekly:As former head of the late 1993 U.N. peacekeeping mission in Rwanda, Canadian general Dallaire's initial proposal called for 5,000 soldiers to permit orderly elections and the return of the refugees. Nothing like this number was supplied, and the result was an outright attempt at genocide against the Tutsis that nearly succeeded, with 800,000 dead over three months. The failure of the U.N.'s wealthier members to act as the tragedy unfolded obliged the author to leave military service to recover from PTSD (as well as the near breakdown of his family). While much of the account is a thickly described I-went-here, I went-there, I-met-X, I-said-this, one learns much more about the author's emotional states when making decisions than in a conventional military history, making this an important document of service—one that has been awarded Canada's Governor General's Award. And his descriptions of Rwanda's unraveling are disturbing, to say the least ("I then noticed large piles of blue-black bodies heaped on the creek banks"). Dallaire's argument that Rwanda-like situations are fires that can be put out with a small force if caught early enough will certainly draw debate, but the book documents in horrifying detail what happens when no serious effort is made.

With What Remains: A Widow’s Quest for Truth in Rwanda, Lesley Belinda (author of The Colour of Darkness). “In 1994 Scottish health worker Lesley Bilinda lost her Rwandan husband Charles in the horrific genocide which swept the country with little warning. Since then she has lived with no knowledge of how or where he died, or the identity of his killers. Over a decade later, she returned to Rwanda to uncover the truth. But over the course of a traumatic emotional journey, a very different truth emerged…”

After the Locusts: How costly forgiveness is restoring Rwanda’s stolen years. Meg Guilleband (haven't actually read it but it looked great)

Left To Tell

2008-12-01T08:18:00.000-08:00

Excerpt from Left To Tell: Discovering God Admist the Rwandan Holocaust
by Immaculee Ilibagiza

Seven weeks in the bathroom left us all frighteningly gaunt--our bones pushed into our flesh, and our skin sagged. Sitting on the hard floor became increasingly uncomfortable as our muscle and fat disappeared, leaving us with no padding on our bottoms. Despite having two additional women with us, the bathroom grew roomier every day. We were shrinking, and our starvation diet left us weak and light-headed much of the time. I could tell by my clothes that I’d lost at least 40 pounds (and I was only 115 pounds to begin with). Our skin was pale, our lips were cracked, and our gums were swollen and sore. To make matters worse, since we hadn’t showered or changed clothes since we arrived, we were plagued by a vicious infestation of body lice. Sometimes the tiny bugs grew so engorged with our blood that we could see them marching across our faces…

I found a place in the bathroom to call my own: a small corner of my heart. I retreated there as soon as I awoke, and stayed there until I slept. It was my sacred garden, where I spoke with God, meditated on His words, and nurtured my spiritual self…I spent hours contemplating the meaning of a single word, such as forgiveness, faith or hope. I spent days with the word surrender, and I came to understand what it meant to surrender one’s self to a Higher Power. I gave myself over completely to God…

In the distance I could hear the killers singing their hunting song as they approached the house…I wanted to cry, but no tears came. My heart wa shardening to the constant onslaught of sorrows. I didn’t even feel anger towards the pastor…I once again asked Him for a sign that He was watching over us. The pastor opened the door and, without saying a word, handed me the Bible I’d asked for earlier. I opened it immediately and looked down at Psalm 91:

This I declare, that He alone is my refuge, my place of safety; He is my God, and I am trusting Him. For He rescues you from every trap and protects you from the fatal plague. He will shield you with His wings! They will shelter you. His faithful promises are your armor. Now you don’t need to be afraid of the dark any more, nor fear the dangers of the day; nor dread the plagues of darkness, nor disasters in the morning.
Though a thousand fall at my side, though ten thousand are dying around me, the evil will not touch me.

(Dustjacket blurb: In 1994 Immaculee was 22 years old and home from college to spend Easter with her family when the death of Rwanda’s Hutu president sparked a three-month slaughter of nearly one million ethnic Tutsis. She survived by hiding in a Hutu pastor’s tiny bathroom with seven other starving women for 91 cramped, terrifying days. This searing firsthand accound of Ilibagiza’s experience cuts two ways: her description of the evil that was perpetrated, including the brutal murders of her family members, is soul-numbingly devastating, yet the story of her unquenchable faith and connection to God throughout the ordeal uplifts and inspires. This book is a precious addition to the literature that tries to make sense of humankind’s seemingly bottomless depravity and counterbalancing hope in an all-powerful, loving God.)

Hospice Uganda

2008-11-30T13:04:00.000-08:00

If one takes a public taxi-bus from downtown Kampala, the capital of Uganda, to a certain outer section, disembarks halfway up a certain Mackindee Road, and walks a little way along the dusty street, they will come upon a pleasant little compound containing a few inviting brick buildings and some charmingly landscaped, simple gardens. Like most African compounds, there is a man employed to open and close the gate for vehicles as well as guard the entrance at night. A sign stands erect outside the entrance:

Hospice Uganda Africa:
Palliative Medicine Home Care and Training Services
Website: www.hospiceafrica.or.ug

If it so happens to be around eight-o-clock on a Thursday morning, you might wander into the larger brick building and follow the sound of singing to a conference room where black and white people are together singing a morning hymn. Following a prayer, the group will condense into the first few rows and case presentations from the past week’s home-visits will begin:

“38 year old single female, has five children, her main care-giver is an 11year-old daughter who is unaware of some medical issues so not using gloves. Born-again by religion, history of being Muslim. Cervical cancer, HIV/AIDS, Kaposi’s Sarcoma, pulmonary tuberculosis. Received radiotherapy Aug 2008 for 2 months  many times with no improvement  then found to be HIV+. Receiving Cotrimoxazol, ARVs, TB treatment. Has Vulva pain 5 out of 5 worse with sitting, better with standing…”

After finishing the case presentation and history, the group discusses various issues pertaining to palliative care for this woman, especially focusing on pain control and assistance for her child(ren) after their mother’s death. A physician from the UK takes this opportunity to talk about the proper titration of morphine. Another member of the audience asks about the child’s risk for contracting TB while her mom is on treatment...

-------------------------------------------

You have just sat in on one of the weekly case discussions at the headquarters for Hospice Uganda, the leading deliverer of Palliative care in all of Africa. Started less than 20 years ago by Dr.Anne Merriman with an original staff of three, Hospice Uganda is now comprised of hundreds of employees and volunteers working at multiple sites in Uganda. In addition to providing quality palliative care for the poor of Uganda (refusing care to nobody, a rare thing in 3rd world medicine), they also emphasize education and are constantly holding seminars, courses, and presentations. They have been invited to teach and install similar palliative care programs in numerous hospitals in the surrounding African countries.

Natalie and I traveled to Uganda at the beginning of November this year to visit their program and renew my Rwandan visitor's visa. Cynically I was somehow expecting another African program, partially organized, running on a meager-budget, the slim-staff with a poor work-ethic... In no way was I prepared for what I found. After the two days I was able to spend attending discussions and going on home-visits with a doctor and nurse, I was thoroughly awed and amazed by their high standard of care, quality of education (the best I’ve seen since coming to Africa!), and organizational structure. One visiting palliative care nurse from the U.S. passing through commented to me: “The UK is light-years ahead of the U.S. in regard to Palliative medicine – and it really shows here. This is amazing!”

If anyone is interested in learning more about their services, their website is wonderfully organized. They publish a pocketbook of "Palliative Care in Africa" (known as the "Blue Book") which I purchased. Uganda is the only African country where it is legal for nurses to prescribe oral morphine (thanks to the hard work and advocacy of Dr.Merriman), and only those nurses that have been trained by their program. Equally amazing is their simple but effective means of distributing the morphine to their dying cancer and AIDS patients: water bottles of the mixture, color-coded to indicate concentration.

If I am ever working long-term in Africa in the future, I hope to be able to draw on the excellent teaching of Hospice Uganda as well as network with them to other medical establishments. Hospice Uganda – I salute you!

Postscript: What is palliative care?
From the Hospice Uganda Strategic Plan/website: "Palliative care is defined as an approach that improves the quality of life of patients and their families facin life-threatening illness through prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems. Palliative care is much more than just pain relief! It is a holistic approach to the relief of pain and symptoms built on a foundation of personal care for the patient and support for the family..."

HIV - personal reflections

2008-11-30T08:35:00.001-08:00

It is easy to be caught up in all the medical jargon, statistics, drug regimens, and protocols necessary to provide care for people with HIV/AIDS. But after spending six months in Africa, seeing hundreds of people with HIV, many of whom died under my care --after all of this, what does “HIV” mean to me? A lecture I had in my medical school pathology course? A case-discussion on FUO (Fever of Unknown Origin) in an ID (Immunodeficient) patient I had with the Froedtert Hospital Infectious Disease team? A lab value and CD4 number to check every three months? A microscopic organism swimming around in millions of peoples’ blood streams? A list of symptoms and check boxes? What does HIV mean to me?

Before I came to Africa, I could look in a book to study the pathology, virology, symptom otology, treatment protocols, etc. What I could never find in a book was the patient - no, rather the people I have gotten to know as a result of being here. One woman had cerebral toxo (a very serious brain infection); after three days in a coma, she woke up; after six weeks, her left hemi paresis had improved dramatically and she walked out the door. Another woman with cerebral toxo never woke up. One woman had Stephen-Johnson’s Syndrome, a relatively rare but frequently deadly kind of allergic reaction to one of the more common ARV drugs; after three weeks of fluctuating clinical course, she improved, began eating, and went home. Another women with Stephen-Johnson’s Syndrome had severe swelling in her throat and died (drowned, rather) of acute airway obstruction the night of admission.

Perhaps my most ingrained memory will be of one particular woman. Well-known at the Shyira HIV clinic, it was noticed on one particular visit that her husband is HIV negative. When asked what methods they use to prevent transmission of the virus, she responded seemingly-casually (though, I thought, a bit quietly): “Oh, he has another wife.”

HIV - some medical talk (for the courageous few)

2008-11-30T08:32:00.000-08:00

HIV. AIDS. SIDA. SRV. PVV. All of these acronyms are different names names for the biggest public health crisis of the last twenty-years. One I.D. doctor I worked with back in Milwaukee explained to me that, “Not only is HIV potentially one of the greatest public health disasters of the century, but it also has been handled completely inappropriately from day one. In any other disease/infection, some very particular public health protocols would have been put into effect almost immediately, thus potentially limiting its spread dramatically. Somehow, however, the “public health” response was superseded by the political issues and agendas surrounding the populations that first acquired the virus. We still have not caught up. And the results have already been disastrous for the entire globe…”

In medical school, we learned repeatedly about HIV/AIDS - the virology, epidemiology, statistics, and various public health projects and approaches. In my last months at the medical college, in an attempt to be somewhat prepared (at least mentally) for some of the infectious diseases I would be seeing here in Africa, I rotated through a month working with the Froedtert Infectious Disease (I.D.) team. Whenever anyone with HIV is admitted to the hospital with an acute illness, it is likely that the I.D. team will be consulted that same day. There I saw a few cases of “advanced AIDS” - but it was nothing compared to what I have seen here.

There are many acronyms that are associated with HIV. Let me explain a few. HIV (Human Immunodeficiency Virus) refers to the virus itself. Having HIV does not necessarily mean you have AIDS (Autoimmune Deficiency Syndrome). Many people are walking around on the street, having no idea that the HIV is swimming around in their blood stream. Often people get it from sexual intercourse. Some have gotten it from transfusions (before they knew to screen for it - now this mode of transfusion is very unlikely). A few people have acquired it from needle-sticks on the job. The bottom line? Never assume the reasons why a person has it. You never know - and anyway, it doesn’t help you be a better physician, nurse, or friend.

A few years after contracting the virus a person’s CD4 (Number of WBCS (White Blood Cells,) the body’s immune system) slowly starts to weaken and deteriorate. They may start losing weight. They may begin to get sick more frequently. The confusing thing is that, at least in the U.S., HIV presents most commonly as a “flu-like” syndrome. Amidst all the other patients presenting with runny-nose, headache, and fever, how are doctors supposed to suspect this? Better safe than sorry will be my policy.

Once someone’s CD4 is low enough, they can be started on the ARV (Anti-Retroviral) Drugs that are the main and only weapon we have against this blood-born virus. The drugs cannot kill the virus entirely. Rather, they attack the way the virus multiplies and reproduces, slowing it down and allowing the body‘s natural immune system to rebuild itself to a healthy level. If a friend tells you he or she is taking ARVs, this usually means they are taking three or four drugs. This “multi-drug therapy“ decreases the chances of developing a resistant strain of the virus. Beginning ARVs is for-life. If once you stop, the your particular strain of the virus could now become resistant to one or all of the drugs you had been taking. The next time you begin ARVs, then, you often must begin on an entirely new regimen. There are only so many regimens. Even during my brief month at on the Froedtert I.D. team, I met a few people who had exhausted virtually all the available regimens. And that was in America. Here in Africa, there are less drugs available, and therefore less available regimens.

Imagine you are a doctor, and someone comes in with a low CD4 count (meaning their immune system is badly weakened). You start them on the first-line regimen of ARVs and send them home. A few weeks later, they come back looking very bad - fever, headache, cough, you name it. What’s going on, you say? Turns out that, during the first few months of ARV treatment, these people are at risk of IRIS (Immune Reconstitution Inflammatory Syndrome).

To understand IRIS, you have to understand another acronym - OIs. OI stands for Opportunistic Infection, and refers to all of the infectious diseases that a person with a healthy immune system will normally never have trouble with in their entire lifetime. To a person with a weak immune system (low CD4), however, they can be deadly. There are many OIs; the ones I have seen most commonly here in Africa in the setting of IRIS have been things like toxoplasmosis, cryptococcal menengitis (a fungus), or tuberculosis. If someone’s immune system is weak enough, they could be infected with one (or several) of these diseases and their immune system wouldn’t even be able to react enough to produce the symptoms we normally associate with being ill (for example, fever). Once the ARVs are in their system, however, the HIV is now suppressed and the immune system is allowed to recover. In patients with underlying OIs, the immune system suddenly recovers enough to start fighting these underlying, previously hidden infections and mounts an immune response against them. This response can be quite violent and occurs classically within 3-8 weeks of a patient staring ART. Sometimes the body’s immune reaction to the infections can be as dangerous as the infection itself (i.e.remotely comparable to an allergy, where the body attacks itself).

Back to your patient. Turns out that he at some point acquired tuberculosis (or a fungal infection, or any other OI - that’s why they’re called “opportunistic”), and now his body was finally reacting to it and showing the “symptoms” that you, the doctor, normally require to make the diagnosis. With HIV, absence of a symptom does not necessarily mean absence of a disease. Rules don’t apply anymore. Sounds dramatic? Well, it is.

In the U.S., if someone is admitted to the hospital with severe AIDS (low CD4) and some rare OI, likely every doctor in the building will want to come and see. Although it may be disruptive and disturbing to that patient to see so many white coats in and out of his or her room, it is a symptom of a health system that, despite its problems, functions much better than those I have seen here in Africa. Here, if a doctor doesn’t know how to recognize an OI in AIDS, it means he hasn’t been trained in Africa. I like to remind my African physician friends that they have seen hundreds of cases of things some doctors in America will only read about. On the flip side, for many diseases here there is no way to definitively diagnose things due to limited laboratory facilities; and even if they can diagnose some rare OI (or other tropical disease for that matter), the treatment options are often even slimmer.

Yes, HIV and AIDS are very serious. Yes, there is a high disease burden. Yes, many of these patients die (many of them have died before my eyes). On the flip side, however, both Dr.Palmer in Cameroon and now, Dr.Caleb here, have commented on how their HIV programs are the best funded part of the entire hospital. Foreign-aid programs are so enthusiastic to give money to treating and preventing HIV/AIDS that oftentimes they forget that not everyone in Africa has HIV/AIDS and there are other diseases that desparetely need treatment as well. However, the general conclusion seems to be that if people are willing to support HIV/AIDS programs, we can try and build a greater health care infrastructure can be built on the backs of these programs. Perhaps in an indirect way, the “HIV/AIDS crisis” will do for health-care infrastructure in developing countries what nothing has been able to do before.

*SIDA = Syndrome of Immune Deficiency Acquired (French syntax), SRV = Syndrome of Retroviral (again French syntax), PVV = Person vive con la virus (person living with the virus, excuse my bad French spellings)

Fulaha (pronounced “foo-LAW-haw”)

2008-11-30T08:28:00.000-08:00

Fulaha is a teen-age girl who was born without femurs. At least, that’s how the story goes. I don’t really know how much I trust any of the medical histories I am given around here. However, it does become more plausible when one sees how her legs extend to just below the knees and then stop (like a post-war amputee). Many patients stay at Shyira while they are waiting for their appointments at other hospitals. (for example, children with osteomyelitis receive antibiotics here until they are ready for surgery at Gahini, one of the best surgical and rehab facilities in Rwanda and a five hour drive away). The rumour about Fulaha is that there is someone in Kigali making artificial legs for her. She is waiting here until they are made. She has been here as long as I’ve been here (two and a half months so far) and I suspect she may still be here when I leave.

I made Fulaha’s acquaintance my first week here at Shyira. Everyday she sits outside the pediatrics ward in her wheelchair, watching people and traffic and working on her baskets. At first I was drawn to her by the brightly colored basket-weaving that was going on in her lap. Jeanne, my nurse friend, told me her name was “Fulaha,” which means “Joy” or “Joyful” --and that she is! Now whenever I pass in eyesight of her station, I hear a loud “Mariiiiiiiiiiiiiiiiiiiiia!” followed by giggling and ear-to-ear grinning. Of course I shout back “Fulaaaaaaaaaaaaaaaha!” which triggers giggling among most of the other chronic pediatric patients that have by this time emerged from the ward to see what the commotion is. Whenever I approach, she says “Mar-EEEEEE-YA!” and throws her arms wide open, giving me no choice but to give her a big hug. During the first few weeks when I missed Cameroon and still felt out of place here, her daily greetings were one of the things I most looked forward to.

The basket she is currently working on is one I commissioned. After a few days where I hadn’t seen her working on her basket, I went to visit her with Theogene (my trusty translator) to see what the matter was. After a five-minute-long discussion in Kinywarwanda, he turned to me and said simply “Her needle broke.” “Oh,” I said. The next day at market, Carina and I tackled the challenge of finding needles. Without knowing the Kinyarwandan word for ‘needle,’ this can be somewhat of a challenge. The first four “shops” didn’t have them, but the fifth one did. I bought her ten (for only $.75 total!). I wish you could’ve seen the look on Fulaha’s face.

Last weekend, Natalie asked why Fulaha doesn’t come to our Sunday morning Bible study. Coming up with no good answer, we marched over there, loaded her on one of our backs (much to her nervous excitement and delight) and tromped piggy-back-style the three minute walk to our back porch. She had put on her best outfit for the occasion, and was (as always) grinning ear-to-ear.

Only once have I seen Fulaha sad. It was the day she was scheduled to go to Kigali to take measurements for her legs. Walking into the ward later that morning, I was surprised to find her still lying in bed with the sheet pulled over her face. Sitting down on her bed, I said my usual greetings (Mwaramutse, Amakuru?). She murmured a response, pulling back the covers just enough for me to see tears glistening on her cheeks. We just sat together like that for a few minutes. Later that afternoon, she was back at her usual post with her usual grin.

Fulaha’s name means “Joy” or “Joyful.” I have always liked discussing the difference between “pleasure,” “happiness,” and “joy.” (As a side-note, I have decided that if I have two daughters their names will be “Hannah Joy” and “Rachel Leah.” If my future-husband is not okay with that, it might just be a deal-breaker.) I love the idea that although pleasure and/or happiness is a feeling, emotion, or experience, joy is a gift from God that we desperately long for and yet cannot acquire on our own. C.S.Lewis (my favorite theologian) was agnostic for the first years of his life. Later he wrote the story of how he discovered Christ. The title? Surprised By Joy. Some forty-fifty years later, he was married to a woman a year before she died of leukemia. Her name? You guessed it. Joy. The following are a few of my favorite Lewis quotes about the subject.

What does not satisfy us when we find it was not the thing we were desiring…I sometimes wonder whether all pleasures are a substitute for joy…But then joy is never in our power, and pleasure often is…Our best havings are wantings.

If there lurks in most modern minds the notion that to desire our own good and earnestly to hope for the enjoyment of it is a bad thing, I submit that this notion has crept in from Kant and the stoics and is no part of the Christian faith. INDEED, if we consider the unblushing promises of reward and the staggering nature of the rewards promised in the Gospels, it would seem that Our Lord finds our desires, not too strong, but too weak. We are half-hearted creatures, fooling about with drink and sex and ambition when infinite joy is offered us, like an ignorant child who wants to go on making mud pies in a slum because he cannot imagine what is meant by the offer of a holiday at the sea. We are far too easily pleased.

There’s more to communicating than having a set of vocal chords…

2008-11-30T08:25:00.000-08:00

Living and doing medicine in a country where I don’t speak the language has been hard.

Getting the correct story from each patient about the history of their illness has been hard. Communicating to the nurses when and why to give each medicine has been hard. Communicating to a Rwandan doctor the danger of giving a high dose of digitalis (a potentially dangerous heart medicine) to a child who had no heart problem was hard. Talking to a woman who saw her ten children being killed was hard; doing it through a translator, harder. Gaining only the smallest pieces of insight into the dynamics, issues, and politics of a developing hospital in a remote part of a post-genocide country has been hard.

Living and doing medicine in a country where I don’t speak the language has been challenging and rewarding.

Seeing my patients smile (and say “yego or oya”(yes or no)) after I spit out my few basic medical questions in Kinyarwanda (Umezute?(How are you feeling?), Urakorora?(Do you cough?), Uraruka?(Do you vomit?), Urahitwa?(Do you have diarrhea?)) never ceases be rewarding. Describing the frequency and purpose of a medication in my American-accented-beginner-French is a daily source of amusement (always to the nurses and, usually, to me as well). Being able to speak more and more French everyday to the Rwandan doctors as well as communicate how much respect and admiration I have for them is incredibly motivating. Realizing how much a person can find out about another person through a translator has fueled my future interest in cross-cultural psychiatry and counseling. Watching and being part of the struggles, challenges, and victories of a developing hospital in a remote part of a post-genocide country has been challenging, inspiring, and rewarding.

The verdict? I would do it again in a heartbeat!

It probably goes without saying (but I will anyway) that until coming to Rwanda, I took the ability to communicate for granted. Iris Kohl made a comment the other day that stuck with me: “In Germany, we learn two or three languages for very practical reasons --we will likely have to use them someday. In America, however, if a student studies a foreign language it is usually for more intellectual rather than practical reasons.” Before coming here I realized, in theory, that effective medicine requires speaking the heart-language of one’s patients. Being in a situation where I am unable to understand and respond to the concerns of my patients in situations of physical and emotional vulnerability, however, brought home to me the importance of learning-languages in a way that no “cross-cultural” textbook could have. When I am suddenly faced with a woman whose sister has just died, how do I communicate compassion and empathy in a culturally appropriate manner when the “I’m sorry” verb has multiple layers of meaning that I don’t yet understand? How do I have an “end-of-life” conversation with a woman with intractable, inoperable, untreateable cancer in a cultural where instead of saying “you are going to die” you are supposed to say “you are not improving?” How do I have a genuine discussion about philosophy, religion, life, and the God I love so dearly with someone when I can barely say “hello,” “how are you,” and “where’s the bathroom(pit latrine)?”

While we were walking the two minute walk to the hospital one day, Dr. Caleb made an offhand comment that stuck with me. He was telling me about how in the colonial era (and even recently), many of the foreigners in Rwanda never bothered to learn the native language. They were here for trading purposes and trading only. Instead, the Rwandans all learned French (now the second national language of Rwanda). “They could have been sitting around a table, the French talking in French and the Rwandans nodding and smiling and agreeing with them in French, meanwhile discussing something entirely different in Kinyarwandan. The French people would never have known.” Although I certainly don’t mean to defend some of the French people’s behaviors surrounding the 1994 genocide in Rwanda, I do wonder how much this sort of scenario could have been a contributing factor.

All of this to say…to say…TO SAY that I am very grateful to have so many friends at home who speak my same language, know me and understand me. But I am also greatful for the challenge of getting to know people when none of that is available.

Medical records and the human beings they contain

2008-11-14T10:05:00.002-08:00

In Rwanda, like Cameroon, the patients carry their medical records around with them in a small “cahier” (French for “exercise book”). Whenever they are seen by a doctor, he or she makes notes in the book, writes the diagnosis, indicates lab tests to be done, and finally writes the medication prescription(s). Sometimes all of this is fit onto the same page. Although it does eliminate a lot of the paperwork I am used to from the U.S., it is very difficult to assertain a patient’s exact medical history when they’ve lost their cahier or have a different one for each health center or hospital they’ve visited. Having doctor’s notes written in two or three different languages doesn’t simplify things, either. Frequently I have paused to offer thanks for our own medical record systems at home, however cumbersome.

“Ufite Cahier?” (Do you have your medical-record-book?) is a phrase I quickly learned to ask. Some people’s cahiers arrive in a state of disaray, folded into tiny wrinkled blobs, rain-soaked and mud-stained. Other people’s cahiers, however, are treated like a precious possession, pristinely clean and with barely a wrinkle. One woman, well-known in our HIV clinic, stored her cahier inside a folded piece of paper nested in an envelope and completely enveloped by multiple layers of brightly colored cloth in a fashion that permitted her to carry it around her waist at all times. It took five minutes to unbury it from its layers of protection. Coming from a people who have close-to-nothing as far as physical possessions are concerned, I couldn’t help but be touched by this display of ownership and care. I found myself wishing I could care for her --a human being infinitely for precious and valuable than a few bits of paper-- to the same manner and degree. But then, as I find myself frequently telling my patients (invoking a knowing smile from Theogene, my translator), “I am not God. I am a doctor, but I am not God…

“Are not five sparrows sold for two pennies? Yet not one of them is forgotten by God. Indeed, the very hairs of your hair are all numbered. Don’t be afraid; you are worth more than many sparrows” ~Jesus (Luke 12:6-7)

“Of COURSE I recognize you!…who are you, again?”

2008-11-14T10:05:00.001-08:00

I’ve never been good at remembering names. Or faces, for that matter. This becomes a problem when those people remember me. In Cameroon, I was mostly able to recognize women by their great variety of hair styles, weaves, braids, etc. Here at Shyira, however, many of the women have the same hair cut - a short boy-ish crop (Aloys explained that it is a matter of principle, especially among the Christian women. They dress simply, wear minimal jewelry, and cut their hair short to communicate that they are happy with themselves the way they are. It’s also a response to the common perception (usually true) of western materialism and focus on external appearance.) Although I do admire their philosophical approach to appearances, it does make it difficult to identify someone whose name you don’t know. After the first few weeks, I noticed myself recognizing women by their clothes - “the one with the orange skirt,” etc. Works well most of them time. Except when the women have purchased the same bolt of fabric from the market…

Expired Medications - CAUTION?!?!?!

2008-11-14T10:02:00.001-08:00

One of my favorite Cameroon discussions was with the pharmacists regarding medication expiration dates. “How long after a medication’s expiration date do you use them?” I queried, expecting a shrug and a wave indicating that such things didn’t bother them. To my surprise, my pharmacist friend answered, “Oh we don’t. It’s very dangerous. You should know that!” Shocked, I attempted to explain how the pharmaceutical companies assign arbitrary expiration dates both for liability reasons but also to encourage people to buy more of their medication before they need to. It saves them a lot of money from actually having to do extended studies on each medication for half-life-degradation time, etc. When he still shook his head and looked at me gravely, I decided to throw in a personal example: “My dad is a doctor, and we use expired Ibuprofen all the time! In fact he bought me a big bottle 8 years ago and I’m still using it. I’ve never gotten sick.” He laughed and nodded, but still looked unconvinced.

Later, in talking with Dr.Palmer, I learned that this was one of his biggest pet peeves about health care in Cameroon - “They know just enough to be dangerous & suspicious,” he said, “but not enough to back up all of their convictions. There’s really only one medication that has ever been shown to have negative side-effects when used past it’s expiration date, and we don’t even use it here. I tried a few times to put antibiotics in bottles without expiration dates, but then they get even more suspicious…” Although at the time this sounded amusing to me, it was no laughing matter when a certain medication was “out of stock” and a patient died because of it.

Upon arriving in Rwanda, I asked Dr.Louise if they had the same problem. “Oh yes,” she said matter-of-factly,” Caleb and I routinely sequester medicines in our room, to keep them from being thrown out.” I habit I can look forward to developing, I guess, if/when I return to Africa after my residency!?

Witwande? (What's your name?)

2008-11-14T09:59:00.000-08:00

Many people in Rwanda have names that, when translated, have meanings as long as a sentence. Some have Christian or religious significance: “God is my salvation” or “Prayed for,” for example. Emmanuel means “God with us,“ Dieu donne means “God gives.” Another boy‘s name was a bit different, with the meaning, “I have few enemies.” Hearing the meanings behind names makes me want to ask their parents for the story behind them. One woman patient’s name in particular will always stay with me. In the middle of rounding, my nurse had been carrying on a conversation with her for at least five minutes. Finally, I asked him what they were talking about. “Oh,” he replied nonchalantly, “her name means ‘I was grabbed and handled early.’ I was just asking her why she was named that.” “Oh” I replied.”He didn’t explain further. I didn’t ask.

Informal survey (according to me, Natalie, and Carina):

Top 5 Rwandan female names
1.Clemintine
2.Beatrice
3.Odette
4.Claudine
5. Jeanne/Jeannette/Janine

Top 5 Rwandan male names
1.Emmanuel
2.Theogene/Theophil/Theonest
3.John/John-Pierre/John-d’Amore/etc.
4.Samuel
5.Adrien

Anthropologist-wanna-be in Rwanda

2008-11-14T09:52:00.000-08:00

As part of the “mental status exam,” many doctors in the U.S. ask their patients to interpret a well-known phrase or saying. For instance, your doctor might ask you some day “What does the following phrase mean: ’Don’t put all of your eggs in one basket.’?” You might then answer “Don’t spend all your money in one place” or “Be careful with your investments,” for example. There is usually no one right answer - rather it helps yours doctor judge whether you are a concrete or abstract thinker, whether you are developing dementia, etc.

Curious to see if I could find an equivalent phrase in Kinyarwandan, I asked Aloys, my French/Kinyarwandan teacher, to teach a lesson on phrases and sayings. Excluding the French phrases, here’s what he gave me!

Phrase/Saying = “Literal translation.” (Aloys’ explanation, transcribed as best I could)

Inzira ntibwira umugenzi. = “The path doesn’t talk to the passenger.” (You can go and be lost and the road doesn’t say anything to help.)

Bagarira yose ntuzi irizera niri zarumba. = “Treat well every plant because you don’t know which will bear fruit.” (for example, you have a father who beats his children and mistreats them. People shouldn’t say the children will turn out all bad. You don’t know yet who will be good or bad, God only know.)

Ubwenge bw’umwe burayobera. “The wisdom of one has no sense.” (like the French saying “L’union fait le force,”=“The Union makes the force”, Together we can do many things.)

Umutwe umwe wifasha gusara ntiwifasha gutekeneza. = “One head helps itself in being crazy/mad/foolish, but not in thinking.” (we need other people)

Iyihuse yabyaya ibihumye. = ‘The cow who has been quick to give birth gave birth to the babies who have not yet opened their eyes.” (like “slowly but surely,” don’t be in a hurry)

Amatwi arimo urupfu ntu umva. = “The ears in which there is death don’t hear/listen.” (for instance, someone who doesn’t listen to advice.)

Igikenya nticyumva ihoni. = “Someone who is not afraid of death cannot hear the (car)horn.” (has no fear, but can suffer the consequences)

Uburana urubanza rw’inda ntatsindwa. = “He who is judged for his belly is not guilty/cannot be punished.” (everyone must eat)

Umwanzi agucira akobo Imana igucira akanzu. = “The enemies prepare the hole for you but God is preparing your refuge.”

Miritonze akamainhashi. = “If you are attentive, you will get the female cow’s milk.” (go slowly)

Ushaka inka aryama nkazo. = “He who wants to the cows must lie like the cows.” (If you want something, you must try to simplify yourself/give up things/stop many things.)

Kora ndebe iruta vuga numve. = “Work-and-I-see is more than say-and-I-see.” (similar to “actions speak louder than words”)

Inzira ebyiri zahaniye impyisi. = “Two ways are not possible for the hyena” (even a dangerous animal cannot catch two animals at once.)

Umwanze kumva ntiyanze no kubona. = “He who refused to understand will not refuse to see the consequences.”

Uniformly uniforms

2008-10-30T02:53:00.000-07:00

Africans like uniforms. Actually I can’t say that as a general statement. In the two African countries I have been in, they like uniforms. Children are seen on their way to school in various conglomerations of royal blue dresses, tan pants/shirts, black skirts with white shirts, etc. Choirs at church often have the same skirt or shirt (often made out of some wonderfully bright African fabric).

In Cameroon, all of the hospital staff worse some sort of uniform. The gutter cleaners wore royal blue jumpsuits, sometimes with big rubber boots. The cooks, if seen around mealtimes, sported aprons. The social workers wore long white coats with blue-colored waistbands; chaplains had black waistbands; and physicians, nurses, and pharmacists solid-white. As opposed to the often yellowish/brown/splattered coats of U.S. hospitals I am used to, these coats were always sparklingly clean. Even in the rainy season, when it is hard to find a dry day on which to air-dry your laundry, I still never saw a single spot on anyone’s coat. My white coat, on the other hand, quickly became dirty and despite the obvious cultural norm, I was in no hurry to clean it. One day my chaplain friend, Gennette, said “Mary, I want to take your coat home today and wash it. Please let me!” Feeling embarrassed, I thanked her perfusely, mumbled something about my mother being ashamed of me, and went home promptly to put it to soak in bleach.

In Rwanda, it is much to the same. The hospital-cleaners wear royal blue jumpsuits with big black or white rubber boots, which they tromp around in all day long with their mops, brooms, and buckets in hand. The social workers here have long coats made from blue and white checkered material. The chaplains (“evangelists” as they are called here) have long white coats with green waist and sleeve bands. The medical staff all have white coats - with one difference: they are used. As with much of the clothing in Rwanda, they are second-hand, shipped over from some aspiringly altruistic European or American doner. At least three of the staff here have a long white coat with the inscription “Carol T. Adams” above its left pocket, a donation from some Family Medicine residency in Florida. A few weeks ago I gave one of my old medical school coats to the Kings to distribute. This week I have seen it being worn around by one of the HIV nurses.

a little more "light reading" for all you internet browsing folks

2008-10-21T10:23:00.000-07:00

If you're interested in more of what's been going on here at Shyira since I've arrived, check out the newly-instigated King family blog. Dr.Louise is an excellent engaging writer - and it's especially fun for me to read, since I know most to all of these patients/people/events, firsthand!

http://thekingsatshyira.wordpress.com/

African woman...

2008-10-21T09:58:00.000-07:00

Dr.Louise King likes reading books. Books in general; but especially books about Africa. One such book she recommended to me for its beautiful descriptions, was The Shadow of the Sun by Ryszard Kapuscinski. Although a friend of mine from Nigeria (hi Jessica!) says she doesn’t agree with everything in it (and I tend to trust her opinions), I do enjoy the gorgeous imagery. Here is one of my favorite excerpts, that I think describes very well a common sight:

“…Every now and then our bus stops along the side of the road. Someone wants to get off. If it’s a young woman with a child or two (a young woman without a child is a rare sight), there unfolds a scene of extraordinary agility and grace. First, the woman will secure the child to her body with a calico scarf (her small charge sleeping the entire time, not reacting). Next, she will squat down and place the bowl from which she is never separated, full of food and goods of all kinds, on her head. Then, straightening up, she will execute that maneuver of a tightrope walker taking his first step above the abyss: carefully, she finds her equilibrium. With her left hand she now clutches a woven sleeping mat, and with her right the hand of a second child. And this way--stepping at once with a very smooth, even gait--they enter a forest path leading to a world I do not know and perhaps will never understand…”

A Typical Day for me at Shyira Hospital

2008-10-21T09:46:00.000-07:00

5:00am - “beep beep beep!“ (alarm clock goes off)

5:15am - the sun is barely rising as I head out for a morning run. I like to leave early, as there are less children to cry “umuzungu! (white person!)” and run after me. Although I have the goal of running everyday, the hilly terrain of Shyira makes every run either down hill or up hill, and some mornings I can‘t muster the energy or motivation. Even my favorite path has a steep rocky downhill section that requires a slower-than-running-pace. Grand total of times I have fallen during these morning escapades? = three. (Note: I DID ask if it was appropriate to go running in this area/culture - Dr.Louise said it was no problem, and that she herself used to go when they first moved here.) Despite the occasional “perils,“ I have had quite a few wonderful interactions and conversations with “random” people on my morning jaunts. My favorite was when a group of children along with two women decided to run down the hill with me on their way to fill their water jugs (dirty yellow former-gas-cans). Feeling bad that I was the only one not carrying something, I grabbed one of the woman’s gas can (empty at the time) and backpack and ran down the rest of the hill with them. The children were laughing at me the whole way. If you can’t talk to people, there’s more than one way to “befriend” them!

6:50am - The front door of the “Shyira Chalet” (“Sheer-ah Shaw-lay”) opens and closes with much squeaking, signaling that Clementine has arrived for the day. Clementine is the woman employed by the Kings to cook, clean, garden, and generally watch over the chalet, my residence during my three months here at Shyira (“Sheer-ah“). She is in her 20s and speaks only Kinyarwandan. At least, she did when I arrived. Since then Carina, Frank, and I decided to pay for her and the “other Clementine” to have English lessons together. That together with the Kinyarwandan “helpful-phrases” sheets that Iris Kohl typed up a few years ago for the chalet, we manage to have semi-conversations. When Frank and I began translating our “medical Kinyarwandan,” we had a lot of fun practicing the various phrases on Clementine: “Do you have stomachache?” “Do you have diarrhea?,” and our favorite for its literal-translation “Do you suffer when you stool?” Although Clementine is usually rather reserved compared to some of the other Rwandans here at Shyira, these medical questions never fail to get at least a smile and at best a loud laugh followed by giggling. If we can’t talk to each other, at least we can laugh together!

7:30 - Two minute walk to the hospital for the morning meeting. First comes a sermon/devotions-of-a-sort (not quite sure since I don’t understand the language), during which the half-empty wooden-benches in the meeting room fill to overflowing. Next comes the “sign-out” from the three overnight nurses. By this point, Dr.Caleb King’s cell phone has rung it’s tune (well-known to ALL of the hospital staff). His administrative phone-call ends just in time for him to contribute his “staff salary update” to the “announcements” portion of the meeting. Questions are asked. Other announcements are made. An occasional “firey discussion” may ensue (“Always about money,” Dr.Mark, a Rwandan doctor, translates for me.). I focus on grabbing as much French as I can, but after 10 minutes inevitably lose my attention and spend the rest of them time practicing various handshakes with a man sitting next to me, text messaging my nurse-friend Jeanne sitting three rows ahead of me about how-long-the-meeting-is-this-morning, or looking up medication doses on my PDA. Someone prays and then all of the staff head off to their various stations and jobs. The doctors stay behind for their “doctor-meeting,” giving the nurses time to take vital signs before they show up on the wards to round. Depending on the various matters of business, announcements, concerns, etc, a morning meeting can finish anywhere between 8am and 9:30am (once it went as late as 10).

Rest of the morning: Rounds!
What wards do they have here at Shyira? The almost-always full-to-overflowing female ward (20-30 women), the much-less-full men’s ward (5-10patients tops), the pediatric ward (5-15 patients), and the center for malnutrition (zero to 10 patients at any one time). My first few weeks I spent with Dr.Louise on female ward, getting used to ordering labs, medications, dressing changes, etc, in French, as well as building a small collection of useful medical Kinyarwandan phrases. It’s amazing how much I am able to “figure out” by just asking a few basic phrases: “How do you feel?,“ “Where is your pain?,” “Sit up,” “Open your mouth,” “Hang in there”(the Kinyarwandan phrase for offering sympathy), “Little by Little,” and “Let’s pray” (a phrase I don’t use yet since I can’t quite form a whole prayer in the language). Although the official languages of Rwanda are Kinyarwandan and French, 95% of the patients speak only Kinyarwandan.

12:00pm - Lunch back at the chalet with whatever short-termers are around as well as Carina, my housemate from Germany here to help home-school the Kohl children and and teach in the kindergarten. At nineteen years old, she says she wanted to “give a year to God” and enjoys being around children, although teaching is not her ideal future career. She is taking lessons in Kinyarwanda and is looking forward to being able to converse more fluently with Clementine. Living here with Carina has been wonderful these last weeks. In addition to having a spunky sense of humor and seemingly infinite patience with having to speak English to her non-German-or-French-speaking roommate (me), we both enjoy having people over for dinner, exploring new places, practicing Kinyarwanda at lunch to make Clementine laugh, going to bed early and staying up later than we planned having “girl-talk.”

Afternoons are flexible. For the first month, I used the afternoons to take French lessons (much cheaper here than at home), give tri-weekly flute lessons to the astoundingly motivated Hannah King (the year old second daughter of the Kings), type up the too-large “medical Kinya-rwanda” translation project Frank and I launched, and occasionally be talked into playing capture the flag with Caleb King (the third oldest King child. Caleb Jr.’s daily games of capture the flag fill the surrounding country-side with shouts and screams of playing children and involve half-a-dozen Rwandan boys, a handful of “muzungus” (usually the short-termers who haven’t gotten tired of the game yet), and occasionally a few adults.

6:00pm - the sun has set and we are in the dark.

6:15pm - the hospital generator turns on for our nightly two-hours of electricity. As the lights go on, a joyous murmur can usually be heard from various houses around the Shyira “hill.”

8:15pm - the hospital generator turns off along with all the lights. Soon thereafter, we retire to bed. Every other week we watch a movie on someone’s laptop computer. Recently I’ve started heading over to the hospital to practice my French whenever Jeanne has the night shift. (Jeanne is a young nurse who wants to practice her English in hopes of joining her sister in Canada someday.).

Miscellaneous: After church on Sunday is a King/Kohl/shorttermer potluck. Wednesday nights are taco/devotions night at the Kings. Friday nights are “pizza night.” Other evenings we spend quietly at home reading or studying languages or over at the Kings checking our email. Wednesday and Saturday are market days. “Vunga market” is a 30minute walk down a sometimes very steep hill path. Going-up on the way back is, of course, the hard part. But we can’t complain to much, when we see women taking the same route with a baby strapped to their back, another child holding their hand, and a sack of potatoes settled securely on their head.

AIDS Prevention Messages

2008-08-30T13:15:00.000-07:00

These are written on the inside front cover of everyone's consultation book. Hopefully they are effective!? I copied spelling errors too, for more of the "full effect."

1. There is no vaccine and no cure for AIDS. Prevention is the answer.
2. Everybody consider any person who is not your spouse who makes advances towards you for self as a potential HIV carrier.
3. Remember, alcohol consumption gives you false courage to make sexual advances and reduces your ability to control your sexual behavior thus exposing you to HIV infection.
4. Better stay at home with your families after work. This will enhance understanding in your families, reduce impulse spending and reduce your exposure to HIV infection.
5. Men, revise cultures that expose people to HIV infection such as succession rites, "inheriting wives or husbands.
6. Men, do not abandone your wives for a long time to go out in search of money or do not send home your wives when they are pregnant or nusing as this promotes flirting thus accelerating the spread of HIV.
7. Parents, enure that your sons and daughters and their would be spouses undergo pre-marital HIV screening twice before contracting, marriages. The second screening test should be done six months after the first one for confirmation.
8. Parents, do not force your daughters into marriages with persons of your choice because such marriages do not always make provision for pre-marital checks for HIV. Children, listen to your parents' advice.
9. Women, if you are already infected, undergo prenatal screening for HIV and reduce the chances of transmitting HIV to your unborn babies.
10. Please, stop accusing and persecuting innocent members of your families or neighbors for bewitching your relatives who die of AIDS.
11. Please, commit yourselves to the fight against the spread of HIV in our society. Cameroon is dying slowly from AIDS.
12. Please, acquire advice on reproductive health from the nearest health facility to enable you continue with sexual activites during lactation. This will reduce the beliefs that women cannot make love when they are breast feeding.
13. Watch your morals and sex behavior. This will cure the spread of AIDS.

FAQs

2008-08-28T17:13:00.000-07:00

I depart Cameroon on September 1st and arrive in Kigali, Rwanda on September 2nd. Shyira clinic is a 3-4 hour drive from Kigali, outside of Ruhengeri. They tell me the only internet access is on top of a hill and unreliable at best, so this may be the last blog for a while.

I thought I’d close my time in Cameroon by answering a few questions my future-dentist-brother (hi Philip!) sent me at the beginning of my trip:

Q. So where are you and Mbong (and how do you say a silent "mmmm" sound?) staying now?

A. In the hostel/rest house. Along with having a few rooms dedicated full-time to the optometry students, this the main housing for visiting medical students, doctors, researchers (there is a very successful Burkitt’s lymphoma treatment program), and some missionaries. The walls are thin, and my first week here I kept thinking people talking outside were right here in the room with me. The floors are concrete, and all in all it’s a bit drab, but Mbong and I had some fun decorating by making collages with the airplane magazines. Definetely better than the 20 year old calender-pictures that were encrusted to the wall!

Q. How are the toilet and laundry facilities?

A. Didn’t have hot water for the first few weeks. Toilet is fine. Laundry means hand-wash and line-dry outside. When the weather has been thunder-stormy (as happens here often in the rainy season), we had clothes strewn all over our room for a few days to dry. I enjoy the line-drying-thing, although I had to get used to my clothes smelling like all the hospital linens (same soap, yuck!). After one particular load with a certain orange-skirt (ahem, Mbong) we both had quite a few “newly” peach/orange colored socks etc.

Q.How do you get around most of the time? Bus? Car? Bike?

A. Most of the time I don’t, since I live right next to the hospital – very similar to a college dorm. When I go into Bamenda, the nearest biggish city that is a 30-45minute drive, I catch a ride with a hospital vehicle or cram into a taxi (see photo album for answer to the question “How many people can fit into a taxi?”)

Q. What's the typical diet?

A. Fu-fu and N’jama-jama are eaten with the thumb and first three fingers of your dominant hand. Fu-fu is made from ground-up corn, and N’jama-jama is a dark-green leafy vegetable (full of vitamin K and why, incidently, the surgeons here have to use crazy amount of anticoagulant before their surgeries). Bananas and plantanes are abundant, and peanuts are the snack-food-of-choice that every child carries around on their head in a large tray to sell for the equivalent of 5cents per bag. Fried fish with onions and pepe (a VERY hot spice) is another meal option that I love. And of course there is abundant pineapple, guava, popo (like mango but in the rainy season), and other fruits I haven’t yet learned to identify. Sounds exotic to write it, but really it's everyday life for the people here. They laugh at my "fruit excitement."

Q. Have you met any biting insects yet?

A. Nothing exciting. Just a few mosquitos. Yay for malaria-prophylaxis (although I’ve been told that Mbingo is at an altitude that does not get many mosquitoes).

Q.What's the frequency of diseases seen compared to the US?

A. All I have is personal anecdotes from my two months here, which is hardly a randomized-controlled-trial or statistical-report, but according to the WHO there's a lot of malaria, TB, and HIV/AIDS. Mortality is still due mostly to diarrheal diseases among other things.

Q. Do you get a lot of the typical US problems like diabetes or HTN?

A. Yes and yes. Mbingo JUST last week got the machine to determine Hemoglobin-A1C, without which it is almost impossible to track diabetes. (Dr.Palmer says that trying to follow diabetes without an A1C is like following HIV without a CD4 count.) As for high blood pressure, I have switched quite a few patients off of their calcium-channel-blocker (Nifedipine) to the current recommendations of HCTZ and an ACE-I, both cheap here. As far as inpatient HTN is concerned, many times the nurse will call me over to report a BP of 160/90 as being vitally concerning. I have watched Dr.Palmer explain numerous times that HTN is a chronic disease 99% of the time and an isolated high blood pressure does not constitute an emergency. But they still call me over.

Q. Do you see more protozoal-type diseases?

A. Umm…I can’t say. E.histolytica comes back from many of the stool-exams I send to the lab (Flagyl (Metronidazole) for 10 days), but I really can’t comment on anything else. Although there may be a patient in female ward right now with Elephantiasis…but that’s a bit different.

Q. How's the paperwork, comparatively?

A. WONDERFUL! Surgery notes are about the same length as in the US (vitals stable, afebrile, good urine output, abdoment soft, incision clean.). My medicine notes are the longest of anyone’s, and they really don’t go beyond a few paragraphs. Everything I write down is mostly for communication with other doctors. As far as charts are concerned, there are none. The patient carries around a little book that all the doctors write down complaints and meds (and occasionally a diagnosis or lab result, if I’m lucky). Many patients will have a different book for each clinic or hospital they’ve visited, and they’ll only bring the one book to each appointment, making it very difficult to track past medical history. Occasionally (like with Lilian, my pt with schizophrenia) I have written a “physician’s discharge note” in their book to increase the likelihood of good followup; oftentimes I’ll recommend what the doctor at the next visit will do. For instance, if Lilian develops extrapyramidal side-effects of Haldol, will the next doctor be able to recognize them, much less know how to treat them?

Q. What's the most common language there? (Your e-mail suggested language wasn't much of a barrier to communication.)

A. Cameroon has ten provinces, 8 are French speaking and Mbingo is in one of the two English-speaking provinces. Most people speak “Pidgin English.” Evidently at some universities or schools, there are “no Pidgin allowed” signs but I haven’t seen any yet. It’s amazing how I can take a fairly comprehensive patient history with just a few phrases. When Cameroonians ask me if I’ve learned pidgin yet, I share with them my few hospital-phrases (see previous blog) and they all start to nod and laugh and altogether seem to find it quite humerous.

The phrasing's the thing

2008-08-24T06:48:00.000-07:00

Some people here call me "white-man." For example, in the market: "hello white man," "white man come look at this," or "white-man come marry me." My response, if I'm not ignoring them, is to turn and say "White-WOman, white-WOman" which will inevitably bring some rousing laughter and leave them laughingly discussing it while I have slipped away.

Mbong was frequently referred to as "black-white-man-girl," since she looks like the people here but talks like someone from the U.S.

Descriptions took a bit of adjusting to at first, as well. People are not afraid to call someone "Fat here," but unlike in the U.S. it's not usually meant as a derogatory term. Rather, like "white-man," it is a descriptor. For instance, they might refer to "that fat woman over there" or that "fat-fat-man in B ward." Many people here actually see being "Fat" as desirable. Although when they talk about some of the Americans they have seen on T.V. that are 'fat-fat,' I do detect an element of humor in their voices.

Once I saw the wife and daughterof one of the surgery-residents walking by. As I knew both of them, I said "good evening, cherie cocoas, two beautiful women together!" They both laughed but the mother quickly said, "no just one" as she pointed to her daughter. I know that she attends the aerobics class and "is not reducing" (according to her husband who rounds with me in female ward), and was disturbed by her response a bit because it reminded me of the way so many women (myself included) respond to comments about beauty and weight back home. I hope that Cameroon will be able to encourage a more healthy perspective on these things, but am afraid that this commonly-struggled-with-issue is present in some forms, even here.

2008-08-24T06:43:00.000-07:00

For anyone interested in the physical therapy side of things here, check out Mbong's blog at Mbong.easyjournal.com. Here's an excerpt (unrelated to PT, but amusing):

"...As mentioned previously, language is extremely important to the people here and now that I have ‘mastered’ the basic greetings in a few different dialects shows them I care. The ‘name calling’ is all in good fun, Africans can be very blunt at times, particularly the ones in the more rural areas, so if you are fat they’ll let you know or if you are white they’ll be sure to remind you.

Earlier this week I mentioned to a coworker that I would like to learn the Kom dialect. “You know what would be the best way for you to learn to language?” my coworker asked. When I suggested that maybe reading the bible translated in Kom would be helpful, he responded with a very serious and emphatic: “no. You need to marry a Kom man.” No pressure. Right..."

Mbong had many propositions while she was here, which we had quite a few laughs over (not that she would be propositioned, but the way they would do it). I had a couple market encounters myself: "Kate, come and marry me" or "Kate let me give you this ring so I can marry you." (Someone told me that some men call all white women Kate here, anyone know why?). I decided to take my friend Bree's advice and answer sarcastically. so far the response that gets the most laughs is "I have nine husbands already, but would you like to be #10?" Thanks, Bree!

"We are not alone..."

2008-08-24T06:29:00.001-07:00

On a hike a few weeks ago, we stumbled upon some unexpected visitors and Mbong commented rather omminisely: "We are not alone..."

She wasn't talking about the waterfall, either... (I decided NOT to capture on film the various sized brown-clumps littering the entire hillside). She then proceeded to teach me the difference between cow-pies, horse-poop, and goat droppings. Begs the question - where did SHE learn all this? I still don't know...

After treking for a few minutes, we found some of "the culprits"...

Lilian (discovering mental illness in Cameroon)

2008-08-24T05:54:00.001-07:00

“Eeeeeiiioooeeeeee!” Wailing reached my ears just as I turned to walk out of the outpatient department. The source, a young woman bending over to hold her left leg as she shuffled to a seat, looked to be in much pain. As a new arrival, she had a long wait ahead of her in the clinic’s first-come-first-served no-appointment policy. Her wailing continued and, as I turned to watch, the man accompanying her tried half-heartedly to quiet her. There was little effect and he soon quit trying altogether.

Curiously concerned, I continued to watch. In the middle of a bout of hysterical sobbing, the woman suddenly burst into loud laughter, causing the few remaining heads not looking in her direction to turn and blatantly stare. Soon the laughter subsided and she began to mutter a few phrases over-and-over: “Have mercy on my soul, have mercy on my soul...” Eyes welling with tears, she then began again to cry, this time silently.

Deciding to take advantage of her temporary stillness, I sat down next to her companion and began to get her story. Her name was Lilian, and the man who had accompanied her here to the hospital was her junior brother, Roland. How long has her foot been paining her? “For one week.” What happened? “It just started swelling one day…” I sped through the usual questions and then finally asked the question I’d been yearning to ask – have you noticed her behaving differently or oddly? “Umm, yes yes,” Roland responded, eagerly and hesitatingly at the same time. “She acts very strangely. Sometimes she walks around the house, touching things and talking.” Does she ever talk to people who aren’t there? “Yes, yes!” he answered emphatically, “she talks to people that we don’t see. It is very strange…”

Just then, Lilian jumped up, wailing hysterically, and ran out of the waiting area. Roland and I followed and found her out by the front of the hospital. Lifting up her dress, she was pointing to her groin and saying “Wound! Wound! I have a wound!” Her brother, looking embarrassed, told her very sternly to “put your dress down and be quiet.” After a few minutes I was able to convince Lilian to come with me into an examination room, where I got more of her history from her and her brother.

She had been “acting strangely” for the past month. Although the family was very embarrassed by her behavior, if it hadn’t been for her foot swelling up they would not have brought her to the hospital. She had acted like this about four months before. After being at a different hospital for three days, however, her mother (who is separated from her father) came and took her out of the hospital against medical advice. Lilian herself wanted me to know she had HIV. Roland then told me that although she had tested negative a few years ago, she had lately begun expressing her desire to have the deadly and stigmatized virus. Lilian’s father, also present, wanted me to know that “it’s her wickedness, doctor, her wickedness that is causing this. She talks of old things, terrible things, and is wicked.”

That was a long story, I know, but I wanted to “show” instead of “tell” how the experience of identifying mental illness is more similar to that in the U.S. than I expected. Of course there are cultural differences in the ways it manifests and the “screening” questions to use. I won’t get into the discussion about the difference between “mental illness” and “spiritual illness” (though I’ve enjoyed having such discussions with various chaplains here) except to say that Lilian fits the clinical presentation, diagnostic criteria, and age-group for the onset of schizophrenia. After two weeks on Haldol (one of the two antipsychotic drugs available here), she stopped hearing voices, her emotional lability resolved, she stopped accusing her father and brother of being “demons,” and she began talking and smiling “normally.” It is amazing what adjusting the dopamine levels in someone’s brain can do! Too little dopamine equals Parkinson’s disease; too much, and people tend, like Lilian, to begin showing signs of psychosis (hallucinations, delusions, bizarre behavior, emotional lability, etc.).

In addition to watching her slowly improve and getting to know her (as opposed to her illness), one of the highlights of Lilian’s two-week stay in female ward was meeting Reverend Ndongnde. My first week here, a few people told me I ought to go and talk to him about his interest in mental illness. I never did, however, getting caught up in the everyday hustle-and-bustle of the busy wards. Now that Lilian arrived, however, I began seeing his daily notes on the chart: “stopped by, patient asleep, reviewed chart and recommend psychotherapy and possible family meeting in the future,” or “Patient seen and denying auditory hallucinations at this time, family meeting scheduled for Monday…” One day I caught him in the act: “So YOU’re the one who’s been writing these wonderful notes!” I said exhurberantly. “Doctor, doctor” he said, shaking my hand vigourously, “at last we meet, I am glad to work with you…I was hoping you would come to the family meeting, as you are the expert…” I couldn’t help but notice how he reminded me of my psychiatrist-father, that is if my father was a mildly plumpish African man of medium-height dressed in a suit and tie (Cameroonians like to dress up). I answered that I would love to come to the family meeting, but that I was sure he is more of an expert than I and in either case he could explain things to them in their own language which is more important than anything else I would do.

Walking into his office with the family, my eyes were immediately drawn to the large and small versions of the DSM-IV lying on his coffee-table (the manual of psychiatric diagnoses according to the American Psychiatric Association) along-side a book entitled “Schizophrenia: what a family needs to know.” His slightly cluttered bookshelves were filled with volumes on everything from psychotherapeutic techniques to “family counseling from a Christian perspective,” “how to teach counseling,” and “Boundaries” by Cloud and Townsend. For the next hour, I sat trying to hide my delight at the entire situation (as the topic under discussion was, for the family, an understandably sober matter). Rev. Ndongnde described, in Pidgin, the four different types of Schizophrenia (disorganized, atypical, catatonic, paranoid). The family began nodding in agreement as he described people with the “paranoid” subtype : “they di get suspicious plenty plenty of everybody, for example they go for say that their chop (“food”) it be poison, or they di say that people they bi following them…” etc etc. The family all agreed that Lilian sounded most like the paranoid type. The father and step-mother speculated that perhaps her biological mother had some paranoid behaviors as well (i.e. pulling her out of the hospital, or jumping from country-doctor to country-doctor), giving us a perfect opportunity to explain how commonly schizophrenia runs in families. Rev Ndongnde emphasized that, although some people have speculated in the past that schizophrenia was made worse by unstable family situations, people do not think that very much anymore and that they should not think that this is Lilian’s, her mother’s, or any of their own faults. The relief on their faces were evident. Her father shared how he appreciated learning about the disease (in general people are good at giving positive feedback, when sincere, here) and that it wasn’t anyone’s fault or the family’s fault that she is this way.

Rev. Ndongnde has quite a few patients come to his office on a monthly basis for what he calls “psychotherapy” or “psychoeducation.” He occasionally will have a psychology student from the US or UK come to spend a month with him, and he is enthusiastic about having visiting psychiatrists come and teach. All in all, this is one of the most exciting discoveries I have made here in Cameroon – an inroad into the subset of people who are interested in and intrinsically motivated to take care of the mentally ilil. Of course this is no easy-matter, especially when even in the U.S. the mentally ill are still frequently a marginalized community. At the same time, it would be interesting to see how, in this “culture of hospitality” where taking care of family is one of the greatest moral values, the communities may react to the possibility of effectively carrying for these people.

(As a sidenote, from these two months in Cameroon I am now 99% certain and committed to a combined residency in Family Medicine & Psychiatry. Were I to practice soley in the U.S. I would be completely content to be a practicing psychiatrist. However, because I would like to practice possibly full-time in the developing world, I see the benefits of encouraging development of a mental health treatment program from within an already established primary-care infrastructure. That and I am finding how much I enjoy treating diabetes, hypertension, snake bites, and HIV all in one day.)

Postscript: Before leaving, I am hoping to spend a few hours with a psychiatrist in Bamenda, yet another connection thanks to the wonderful Ngong family (Mbong’s relatives that have adopted me as their own). I also hope to visit a psychiatric hospital in the capital city of Yaounde.

Crickets, part two

2008-08-21T14:34:00.000-07:00

"You di eat cricket?" (translation: "Do you eat crickets?")

Dr.Nkesha has been asking this all week to our patients, while assessing the amount of protein in their diet. Many of them nod affirmatively. The woman this morning, however, denied eating crickets. Instead she told us how she likes to eat caterpillars (or the Cameroonian equivalent) - fried, on a stick. Mmmmm, now this I will HAVE to try!

"Country med-cine"

2008-08-16T13:47:00.000-07:00

Two weeks ago marked the end of the hardest week so far. I was in charge of running the 28 bed female-ward by myself, and there were some very sick patients, six of whom died over the course of the week. Nicknamed the “HIV/AIDS” and “meningitis” ward, female-ward has recently received an influx of meningitis cases. I maintained a relative amount of composure all week until Saturday morning. I had left the ward finally at 10:30pm the night before after checking on a few patients in particularly critical condition.

One of them, Stella, was a 25 year old HIV+ woman who had been advised to start antiretroviral treatment three months ago and instead had consulted one of the traditional doctors (a common course of action here). When she was admitted for acute abdominal pain earlier in the week, her caregiver-brother handed me two big sacks. The first one contained an assortment of medicines I was familiar with (two different antacids, various antibiotics with a few pills missing from each packet, some bisacodyl for constipation, and paracetamol (the Cameroonian version of Tylenol)). The other sac contained five unlabeled bags of various sizes that contained a mixture of things that looked like dirt, herbs, tea, and who-knows-what else. These were the “country med-cin” she had been taking. The nurses took one look at it, advised me not to touch it, and proceeded to scold the patient and caregivers about using “country med-cine.” The style of conversation here is generally more harsh-sounding then in the U.S., and I am still learning how to tell the difference between bluntness and actual anger/frustration. However, the family did not look particularly appreciative of the scolding, and I made sure to come back a bit later to explain to them why we really recommend she stop taking these medicines, especially while in the hospital. Stella and her brothers agreed to stop taking them and seemed to be appreciative of the conversation.

Over the next few days, her abdominal pain resolved but her mental status gradually deteriorated for no apparent reason. All of our tests came back negative, and despite all of our efforts, she became unresponsive and comatose. Her CD4 count came back showing advanced AIDS. By Friday evening, she had improved a bit and was actually taking food by mouth and murmured a few words – a huge improvement! The family seemed very happy. Imagine my surprise, then, when I walked into the ward the next morning to find am empty bed and sobbing family. An empty bed means two things – discharge home, or death. I went straight to the nurses to ask what happened. Evidently she had developed respiratory distress at 5:30AM that morning and quickly ceased breathing. The nurse then informed me that the previous afternoon a traditional-medicine-man had been observed by two-staff members in the ward administering various “traditional” treatments. We still don’t know the direct cause of Stella’s death. Certainly advanced AIDS itself can predispose to OIs (opportunistic infections) that could be deadly. Very high on our list, however, is intoxication from some unknown drug.

In the six weeks I have been here, I have learned a bit about what is referred to as “country” or “traditional medicine.” From my very-outsider’s perspective, these terms may refer to anonymously marked bags full of what looks like dirt, powder, tea, or other unknown substances that patients bring with them to the hospital. It may refer to small collections of needle marks on a patient’s skin – I have seen these clusters of black-marks on foreheads, backs, abdomens, feet, and even genitalia. These are the manifestations of “country medicine” I can see directly on physical exam.

Other manifestations are less obvious. One elderly woman in a coma for nine days, now presents to the hospital only after trying traditional methods first. What might have been a treatable illness at its start – meningitis – now presents in its last stages and is deadly. Another young woman presents complaining of dizziness. She has epilepsy and has been on treatment (Phenytoin and Carbemazepine) for four years. Because she recently began having one seizure a month (in my estimation, due to too low dosages of her seizure prophylaxis medications), she sought help from traditional doctors three days ago and now presents with dizziness, requesting to stop her seizure meds as she thinks they are the cause. I try to explain to her that her meds are unlikely to be the culprits as she has been taking the same meds for four years with no dizziness symptoms – the likely culprit is the country-medicine. She left looking less than convinced.

I have never spoken with one of these traditional practitioners, and do not have enough experience in the culture to necessarily make a judgment on my own. Good excuse, I decided, to ask questions of those who have!

Dr. Sob, a native Cameroonian doctor, explained to me that, in her estimation, the main issue is their lack of documentation. “These country doctors, the thing is that they don’t write anything down. If something works, or doesn’t work, you have to write it down so that the next person will know and can use that knowledge. Even Chinese medicine at least has been written down and documented for thousands of years. That is the problem with these African traditional healers – they don’t write anything down. That and that oftentimes they are just someone trying to make some money. The problem then is that patient’s spend all their money on these healers, and then don’t have any money left for when they come here to the hospital.”

Dr. Palmer’s wife, Nancy, has a PhD in cultural anthropology and spent many years talking with many of these traditional healers. “My main issue with it,” Dr. Palmer explained to me this morning, “is the animistic/spiritist philosophies that underlie most of what they do. It isn’t just trying a medicine that you don’t know. It’s buying into a whole philosophical and spiritual worldview. For your knee pain, they will tell you who you have offended that is now making your knees hurt. For your headache, they will tell you who you should apologize to and pay money to so that the curse will be removed from your head. For your HIV, they will tell you who you have to take revenge against for doing voodoo against you…”

Dr.Nkwenti is a pharmacist Ph.D. that trained at Oregon State University (the arch-rival of my undergrad-alma-mater) and then returned to his home in Cameroon to teach and work on diabetes education, prevention, and treatment. As a pharmacist trained in the U.S. but with in many ways a Cameroonian worldview, I asked his opinion. “You see, this is the thing,” he said over his lunch of fu-fu- and n’jama-jama. “I have some “traditional medicines” that I take everyday. And I’ve known people who were unhelped by the hospitals that then were helped immensely by these things. They just go out in the jungle and find some herbs, that’s all it is.” “Do they know what the different herbs are, then?” I asked. “Of course.They know. Most of them do, anyway. Thing thing is, there’s a different between “country/traditional medicine” and the animistic rites or ceremonies…”

Later this morning, we were interviewing a new patient who had been having total body pains on-and-off for 27 years. She told us that she had gone to “many hospitals,” but they could not help her and so she then went to traditional healers. After some time the pains left for a few years at a time, but they have always returned. Dr.Nkesha (another native Cameroonian doctor) asked her, “so did they tell you who did it? The country doctors, did they tell you who you must make amends with?” “Yes,” she said, “But I did not agree that I had done anything to that person and so I left.” She is, evidently, the minority.

Certainly I hope no one will blame her for seeking help for her chronic pain. When the “medical” and “scientific” hospitals fail, where are people to go? In the U.S. I am not opposed to all of the eastern or even homeopathic remedies – as long as it works, it deserves at least a second look by. Certainly I want to be respectful of other people’s cultures and worldviews. I appreciate Dr.Nkwenti’s distinction between “country medicine” as opposed to “animistic rites.” At the same time, I am not sure I can rule out entirely the many Cameroonians (at least in the hospital culture I am working in) who themselves refer to such country doctors as “charlatans” and crooks. Different cultures have much beauty. But not all in a culture is necessarily good or just or even healthy. Tolerance is good much of the time but it is not a universal virtue. Surely we ought not to “tolerate” thievery, abuse, and injustice?

In sum: I will wear my Cameroonian wrappa (wrap skirt), I will tie fabric around my head, I will learn as much of the language as I can, eat fu-fu- and n’jama-jama with my fingers, and do my best not to offend people in matters of manner and gesture; I will do all these things, but I will not, for the sake of being culturally-sensitive, tell people it is okay to go to a “country doctor” if I know he is taking their money, blaming their illness on another person, and giving them, at worst poison and at best, dirt.

As he went along, he saw a man blind from birth. His disciples asked him, “Rabbi,
who sinned, this man or his parents, that he was born blind?”
“Neither this man nor his parents sinned,” said Jesus, “but this happened
so that the work of God might be displayed in his life…” John 9

more Yancey

2008-08-16T13:44:00.000-07:00

What helps most (Philip Yancey, “Where is God When It Hurts,” fromChapter 13):

"...What can we do to help those who hurt? And who can help us when we suffer?

I begin with some discouraging news. The discouraging aspect is that I cannot give you a magic formula. There is nothing much you can say to help suffering people. Some of the brightest minds in history have explored every angle of the problem of pain, asking why people hurt, yet we still find ourselves stammering out the same questions, unanswered.

As I’ve mentioned, not even God attempted an explanation of cause or a rationale for suffering in his reply to Job. The great king David, the righteous man Job, and finally even the Son of God reacted to pain much the same way we do. They recoiled from it, thought it horrible, did their best to alleviate it, and finally cried out to God in despair because of it. Personally, I find it discouraging that we can come up with no final, satisfying answer for people in pain.

And yet viewed in another way that nonanswer is surprisingly good news. When I have asked suffering people, “Who helped you?” not one person has mentioned a Ph.D. from Yale Divinity School or a famous philosopher. The kingdom of suffering is a democracy, and we all stand in it or alongside with nothing but our naked humanity. All of us have the same capacity to help, and that is good news.

No one can package or bottle “the appropriate response to suffering.” And words intended for everyone will almost always prove worthless for one individual person. If you go to the sufferers themselves and ask for helpful words, you may find discord. Some recall a friend who cheerily helped distract them from the illness, while others think such an approach insulting. Some want honest, straightforward confrontation; others find such discussion unbearably depressing.

In short, there is no magic cure for a person in pain. Mainly, such a person needs love, for love instinctively detects what is needed. Jean Vaier, founder of l’Arche movement, says it well: “Wounded people who have been broken by suffering and sickness ask only for one thing: a heart that loves and commits itself to them, a heart full of hope for them.”

In fact, the answer to the question, “How do I help those who hurt?” is exactly the same as the answer to the question, “How do I love?” If you asked me for a Bible passage to teach you how to help suffering people, I would point to 1 Corinthians 13 and its eloquent depiction of love. That is what a suffering person needs: love, and not knowledge and wisdom. As is so often his pattern, God uses very ordinary people to bring about healing…”

"…deafened by the clanking chains of mortality." (Augustine)

2008-08-16T13:41:00.000-07:00

I am up late in the hospital library, reading up on congestive heart failure. This common disease takes on a new "mysterious" flavor here, where EKGs are few and far between and cardiac echoes are untrustworthy at best. We have three patients with CHF currently diuresing on the ward, each with distinctly different body habitus and each with different responses to the diuretics. How does one tell the different causes apart? Can my stethoscope be somehow transformed into an echo-machine, and myself into a highly trained cardiologist?

A few of the residents and doctors have passed in and out before retiring. My friend Dr. Anna is on call, and stops by to see what I am reading and tell me about the latest admission she has just tucked into bed before heading there herself. How very familiar and even comfortable this all is. Surely not so different from back home?

Trying to focus back on my cardiology textbook, my right hand lies unthinkingly over my left radial artery and I notice my own pulse. Regular rate and rhythm. Just a few hours earlier, that same hand rested on a different wrist, one whose pulse was irregular, thready…skipping beats…pulse…pulse…pulse…and finally…still. Twenty-two years old. HIV-positive. Unknown cause of death. What diagnosis do I write on the chart? "40% of the stage-four AIDS cases that present to the hospital will never be discharged." A statistic that Dr. Palmer quotes almost daily. Oft-quoted, one might say, because there is some measure of comfort provided by realizing the larger-perspective within which we work. Oft-quoted, I suspect, because he is frequently reminded.

In medical school, one of my supervising-interns taught me the criteria for declaring a patient dead: fixed dilated pupils, no respirations on chest auscultation, and no palpable pulse for longer than one minute. Here there is no such official criteria to speak of. If I do not document these exact physical findings, no one will question my "diagnosis." No one will review the chart. No one will bring a malpractice case against me. If I do not write a cause of death, no one will call me on it. And yet I still write it.

"Time of death: 5:20P.M., 13 August 2008. Called to bedside by nursing staff for blood pressure of 60/40, five minutes prior the patient was sitting up asking for food, oxygen-sats = 50%. Nasal canula switched to face-mask for oxygen delivery and sats increased to 70%. Nursing unable to obtain IV line since pt pulled it out this morning, cut-down not done due to inability to reach surgeon-on-call, attempted to place line myself but unable to visualize any vessels, while attempting a blind-placement, pt ceased breathing. Pupils fixed and dilated. No respirations present on anterior auscultation. Pulse absent for > 1 minute. Pt was a known case of HIV, likely HIV encephalopathy, acute cause of death unknown."

And then the wailing begins. What orginates as a body-wracking sob accelerates into a wail and then a piercing shriek that alerts the entire hospital-compound of the recent death. Some bodies convulse and shake so much that they fall to the ground and are escorted outside by other caregivers. Others cry out accusations to God, and questions ("Jesus, where are you? Where are you Jesus!?!") over-and-over. Once a newly bereaved mother began the grieving process by singing a fifteen-minute heartrending lament, a song so-beautiful in its poignancy and tender in its agony that even the nursing staff, so practiced at continuing on with their other duties come-what-may, paused for a few moments to listen with downcast eyes.

When it happens that a patient dies – as it so happens almost everyday on my ward – then I say "Ashiah" (a term expressing empathy and, sadly, not present in the English language) to the grieving family and go to the chart to record what happened. No one will read it, I am almost certain. But with no cardiac monitor, no defribrillator, no intensive-care-unit, and in the young girl above, not even an intravenous line through which to push fluids in a desparate attempt to raise her blood pressure— with none of these things and therefore none of the usual illusion of control I am trained to have, all I can do is tell what happened. These "discharge summaries (reason for discharge: death)" are the part of my personal journal that will forever be included in the medical records of Mbingo Hospital in Cameroon.

In the states, documentation is a burden and annoyance, slowing down patient care and requiring physicians to stay late into the night finishing dictations from the week before's patient-load. Not so here. Documentation is so scanty, medical-histories so scarce, that oftentimes I find myself digging through the too-thin-charts looking for something – anything – that can give a clue to why a patient is sick, why a certain thing happens, why a person dies.

Except – I am then reminded that no physiologic mechanism or diagnosis will tell me "why." My cardiology textbook may tell me "how" it is that CHF develops. A book on HIV/AIDS may explain to me the "how" of my patients' deaths, the physical mechanisms by which the various fragile organs stopped working, or even the historical events that lead up to my patient's eventual state of "asystole." Science can explain the "hows"; but one has to look elsewhere to explain the "whys." I am certainly not the first person to have seen death up-close; many have seen it closer than I. Neither am I the first person to speculate and contemplate the meaning behind it. "It is hard to have patience," C.S.Lewis said upon the death of his wife, "with people who say, "There is no death," or "Death doesn't matter." There is death. And whatever is matters. And whatever happens has consequences, and they are irrevocable and irreversible. You might as well say that birth doesn't matter. I look up at the night sky. Is anything more certain than that in all those vast times and spaces, if were allowed to search them, I should nowhere find her face, her voice, her touch? She died. She is dead. Is the word so difficult to learn?"

I like quotes; I read them, write them on flashcards, take them on runs with me, and memorize them, whether I agree with them or not. One of the biggest things I've missed here in Africa is ready access to quotations. I do have a few books with me, including Philip Yancey's "Where is God Where it Hurts" which in one section uses quotes to introduce different people's reaction to death, pain, and suffering.

"I have seen the moment of my greatness flicker,
And I have seen the eternal Footman hold my coat,
And snicker,
And in short, I was afraid."
T.S. Eliot, The Love Song of J.Alfred Prufrock
(Fear.)

"The doctor said: this-and-that indicated that this-and-that is wrong with you, but if
an analysis of this-and-that does not confirm our diagnosis, we must suspect you of having
this-and-that, then…and so on. There was only question Ivan Ilyich wanted answered: was
his condition dangerous or not? But the doctor ignored that question as irrelevant.
Leo Tolstoy, The Death of Ivan Ilyich
(Helplessness.)

"It is not so much the suffering as the senselessness of it that is unendurable."
Friedrich Nietzschie
(Search for Meaning.)

"All that the downtrodden can do is go on hoping. After every disappointment they must find fresh reason for hope."
Alexander Solzhenitsyn
(Looking for Hope.)

Even C.S.Lewis questioned, like my patient's grieving family, the role of God in death and suffering after the death of his wife:
"Not that I am (I think) in much danger of ceasing to believe in God. The real danger is of coming
to believe such dreadful things about Him. The conclusion I dread is not "So there's no God afterall,"
but "So this is what God's really like. Deceive yourself no longer."

Death and suffering are two of the most-discussed philosophical and theological topics. And yet, even here where daily I am at the bedside of people who are suffering and dying for reasons sometimes known and frequently not known –even here, I am at risk of uttering opinions and "true-isms" about something I have not experienced directly. "Those who have known pain profoundly are the ones most wary of uttering clichés about suffering…" (John Howard Griffen). Instead of attempting to condense some hundred-thousands of philosophical/theogical theses into a few paragraphs in a too-long-already-email, instead I'm going to end with a page out of Yancey's book that has recently taken on new depth of meaning.

From Philip Yancey's "Where is God When it Hurts":

...The fact that Jesus came to earth where he suffered and died does not remove pain from our lives. But it does show that God does not sit idly by and watch us suffer in isolation. He became one of us…Not once did he say "Endure your hunger! Swallow your grief!" When Jesus' friend Lazarus died, he wept. Very often, every time he was directly asked, he healed the pain. Sometimes he broke deep-rooted customs to do so, as when he touched a woman with a hemorrhage of blood, or when he touched outcasts, ignoring their cried of "Unclean!"

The pattern of Jesus response should convince us that God is not a God who enjoys seeing us suffer. I doubt that Jesus' disciples tormented themselves with questions like "Does God care?" They had visible evidence of his concern every day: they simply looked at Jesus' face.

And when Jesus himself faced suffering, he reacted much like any of us would. He recoiled from it, asking three times if there was any other way. There was no other way, and then Jesus experienced, perhaps for the first time, that most human sense of abandonment: "My God, my God, why have you forsaken me?"…The record of Jesus' life on earth should forever answer the question, "How does God feel about our pain?" In reply, God did not give words for theories on the problem of pain. He gave us himself. A philosophy may explain difficult things, but has no power to change them. The gospel, the story of Jesus' life, promises change.

Love's as hard as nails
Love is nails:
Blunt, thick, hammered through
the medial nerves of One
Who, having made us, knew
The thing He had done,
Seeing (with all that is)
Our cross and his.
(C.S.Lewis, "Love's as Warm as Tears")

There is one central symbol by which we remember Jesus. Today that image is coated in gold and worn around the necks of athletes and beautiful woman, an example of how we can gloss over the crude reality of history. The cross was, of course, a mode of execution. It would be no more bizarre if we made jewelry in the shape of tiny electric chairs, gas chambers, and hypodermic needles, the preferred modern modes of execution.

The cross, the most universal image in the Christian religion, offers proof that God cares about our suffering and pain. He died of it. That symbol stands unique among all the religions of the world. Many of them have gods, but only one has a God who cared enough to become a man and to die...
"If God is for us, who can be against us? He who did not spare his own Son,
but gave him up for us all—how will he not also, along with him,
graciously give us all things?" (Romans 8:31-32)

In some incomprehensible way, because of Jesus, God hears our cries differently. The author of Hebrews marvels that whatever we are going through, God has himself gone through. "For we do not have a high priest who is unable to sympathize with our weaknesses, but we have one who has been tempted in every way, just as we are—yet was without sin" (4:15)….T.S.Eliot wrote in one of his Four Quartets:
The wounded surgeon plies the steel
That questions the distempered part;
Beneath the bleeding hands we feel
The sharp compassion of the healer's art
Resolving the enigma of the fever chart.
The surgery of life hurts. It helps me, though, to know that the surgeon himself, the Wounded Surgeon, has felt every stab of pain and every sorrow...

Meningitis...STAT!

2008-08-08T13:07:00.001-07:00

Fever and stiff neck means meningitis until proven otherwise. There are many flavors of meningitis, and so far I have seen a wide selection here (my apologies to non-medical folks for the medical-eese-lingo):
-run-of-the-mill-bacterial-meningitis
-an elderly woman who didn’t improve until we added antibiotic coverage for Lysteria
-an HIV+ woman with left hemiparesis and a fixed pupil who turned out to have toxoplasmosis
-a young HIV+ woman with Cryptococcus in her CSF
-a woman with mental status changes and a positive malaria smear

One of the only ways to distinguish between these various mengitis “flavors” is to perform a lumbar puncture. This procedure consists of inserting a long needle into a patient’s lower back, penetrating the space where the CSF (cerebrospinal-fluid, the fluid that nourishes the brain) flows and withdraw a few mLs for laboratory analysis.

Although I have never seen a case of meningitis in the U.S., I do remember learning that anyone with fever and a stiff neck needs an LP immediately. The first few times I wrote “stat LP” on a chart here, the nurses laughed at me. I soon realized that, short of doing it myself, “stat” means it will be done within the next 24-48 hours and not a minute sooner. Although in the U.S. most doctors will do their own LPs, here they usually refer them to the nurse anesthetists who are less than excited to leave their busy OR obligations during the day. With the start of the new residency program, Dr. Palmer wants the residents to start doing all of their own LPs, and so last week I went on a mission to find someone to give me a refresher lesson. That’s how I met David.

David is one of the three nurse anesthetists working in the hospital. There are no anesthesiologists here, so David and his three colleagues are what makes it possible for the three operating rooms to be running most days of the week. They are very overworked, and often-times are up for more than 30 hours after being called in overnight for an emergent c-section or other procedure. David is the most senior nurse anesthetist, has been here for 17 years, and is as it turns out a very excellent and patient teacher. After watching him do one LP, I performed the next one and left feeling optimistically elated. A few days after the lesson, however, I attempted another LP by myself and failed dismally. Later that day, I passed David in the corridor and he said “they called me to redo a failed LP, what happened?” Before I knew it, we had set up another “lesson” for later that afternoon. I brought one of the new residents, Dr. Anna, along, and soon we had both successfully filled a syringe with the precious-spinal-fluid. While walking the sample over to the lab, he said "So what did you learn this time that you will do better for next time?" People here like awards and certificates, so I joked a few days later I was going to make him a certificate as the "official LP-instructor of the internal medicine residency program." He laughed but looked pleased.

Billy Bank’s Bootcamp – sustainability model?

2008-08-08T13:03:00.000-07:00

Nine months ago one of the missionary wives began inviting women in the community to do “aerobics” home-videos with her. After two months, she went home to the states on furlough. The women still meet three times weekly for an hour, one of them in charge of bringing the video, and visitors (such as myself) are enthusiastically invited and made to feel welcome. Beautiful example of a “Felt Need” being met in a sustainable way! (Not to mention how my abs still feel a bit sore…)

"Doctor Mary"

2008-08-08T12:48:00.000-07:00

In addition to the ulcer and surgical wards, there are four medical wards at Mbingo Hospital - mens, womens, childrens, and maternity. During my first few weeks at Mbingo, I mostly followed the ward doctor (Dr.Sob) around female-ward on rounds and in OPD (outpatient department). Before the start of the new Internal Medicine Residency on August 1^st, however, there was a one-week period where the old doctors were gone and the new residents were yet to arrive. Even though I officially graduated medical school in May, I didn’t bother to buy the longer-white coat that doctors are allowed to wear and have instead been wearing my shorter-medical-student-version. All of the patients and nurses have called me “Dr. Mary” from the first day, however. What used to be a foreign-sounding title is now familiar and even fun, and I enjoy the challenge of increased responsibilty. “Dr. Mary, Dr. Mary!” is a sound that I frequently hear across the ward or from down a walkway from a patient with some question or complaint, and warrants a response of “I am coming” or “Ashiah.”

“You’re running female ward for the week” Dr. Palmer said, a few days before Dr. Sob and the others were to leave for their new postings. “I’ll be around if you have any questions.” As much as I’ve been wanting more of an active role, the thought of being soley in charge of the care and treatment for the 27-bed-ward was rather daunting. The first day took me six hours to round on all 20 patients. The nurses, used to rounding in one-two hours at the most, were growing rather impatient by the end. By the second and third days, however, I knew all of the patients, was finished in only a few hours, and had the ward down to 12 patients. (Many patients needed to be either sent home with palliative care or more proactively managed.)

One of the most difficult things about patient care here is obtaining a complete history. Often the doctor’s admission note is skimpy, and the daily follow-up notes two lines or less and illegible. Some patients are very good at explaining. Others, however, have a very tangential way of answering questions even to the nurses who can speak pidgin fluently. Here is an example of a typical dialogue:

Me or Nurse: “When did it start?”
Patient: “It di hurt PLENTY plenty!”
Me/Nurse: “How long it di hurt for?”
Patient: “Doctor, it di hurt SO much, for many days.”
Nurse (getting frustrated): “The doctor di ask for HOW LONG it di hurt. You need for answer the question, for how long it di hurt? One week? One month?”
Patient: “One week my belly di hurt, then it di stop, then I di cough and have fever, oh I di have plenty PLENTY fever.”

Eventually we’re usually able to get a rough estimate of the chronicity of their illness. From my time shadowing Dr Sob I picked up some useful pidgin phrases. Although the nurses chuckle sometimes when my pronunciation is off, they have cut down my history-taking time by quite a bit. For example:

“You di shit fine?” = Are you stooling normally?
“You di piss fine?” = Are you urinating normally?
“You di breath fine?” = Are you breathing normally?
“You di choppa fine?” = Are you eating normally?
“You di walka fine?” = Are you walking normally?

If any of the above questions get a “no, doctor, I NO di shit/piss/choppa fine” then I would follow up with a “How you no di shit/piss/choppa fine?” The first few days of saying “shit” and “piss” to all my patients I felt a bit uncomfortable, but after seeing how they didn’t batt-an-eyelash and even understood me better than if I were to say “stool” or “urinate,” I stopped worrying about it. The nurses laughed when I told them how, in the U.S., the big debate was whether to ask “did you stool” or “did you poop,” and how “shit” would be considered rather vulgar coming from a doctor in a hospital-setting.

Overall I am enjoying being directly responsible for patient care and am learning more than I could ever have imagined. I also wish could be hear longer to learn the language more fully.

The Albino

2008-08-08T12:28:00.000-07:00

I got auburn corn-row braids done a few weeks ago in the market. From a distance, Dr. Palmer confused me for an albino. Next time I’ll ask for a darker color.

(footnote: some people might suppose that sitting in one place for the three-hours it took to braid my hair was a waste of time. In my opinion, however, it was a great excuse to have a three-hour conversation with the two women involved in the “procedure.” At one point the braider (“Beck-ee”) said (in Pidgin English) “You di very strong, very strong! The other white woman, she di cry the whole time.” The other woman helping laughed and said “it’s because she di sociable.” Turns out she's Catholic, and we ended up exchanging our favorite verses (mine Ps139, hers Ps24). Should I ever live in Africa long-term, I think I would strongely consider finding a hair-braider that I would go back to every few months – in addition to getting a better bartering-price, it seems like a great way to make a friend. There’s nothing that builds relationships and allows for conversations like having someone stuck to your head for three-plus hours!)

Empathetically injured

2008-08-08T12:27:00.001-07:00

Mbingo Hospital has “chaplains” that round in each ward and are around to provide spiritual and emotional counseling and support as patients request. Today the female-ward chaplain-in-training showed up to morning rounds with an oversized-trauma-neck-stabilizing-collar around her neck, looking fairly uncomfortable. At the inquisitive looks on our faces, she explained: “This is our day to learn what it feels like to be a patient – I have to wear this for the next twenty-four hours. So when I say “Ashiah” to the patients, I can REALLY empathize.” The chaplain-instructor then proceded to tell a story of how, last year, the chaplain-in-training who had the full-led-cast for a day got stuck in a bathroom stall and had to call for help getting out. THAT, I think, is a level of empathy that few health-care workers attain. Ashiah.

Ashiah

2008-08-08T12:21:00.000-07:00

My favorite Pidgin word. It cannot be translated exactly into English, but the nearest approximation I have heard so far is that Ashiah = “I share,” or “I empathize with you.” It can be used when walking by someone working in a field, as an acknowledgement of their effort. It can be used as a general greeting and will be received as a gesture of kindness and good will. Patients say it to me when I go on rounds. I have taken to saying it everyday to the nurses, chaplains, caretakers, and patients.

The long-termers here tell me that most people passing through like this word. One MK (missionary kid) expressed to me how much she actually disliked the word, from hearing all the short-term-visitors talk about how much they liked it. In either case, I know when I leave Cameroon I will miss having such a beautiful verbal expression of empathy.

Pidgin

2008-08-08T12:03:00.000-07:00

I am no linguist, but I think most people would agree that the African dialect known as "Pidgin English" is an interesting linguistic phenomenon. Most languages may sound amusing to outsiders who do not speak it very well; to the native speaker, however, the various sound-combinations are usually not intrinsically humerous. Not so, however, with Pidgin! Those who understand and speak Pidgin fluently laugh at it as much if not more-so than the foreigners who are first introduced to it, perhaps like I might smile at a gangster’s slang or a thick southern accent. Perhaps it is because people here can turn it on-and-off. In either case, because of this insight into the humorous-ness of their own language I have decided that African culture, at least linguistically, has much to teach us about having a healthy ability to laugh-at-oneself.

For the linguistically inclined, here is a page from Joy’s “cultural orientation” packet:

A Simple Guide to Pidgin English

Verb tenses
Present, “di”
"I di go" = I go, "I di sing" = I sing

Past, “done”
"I done go" = I went, "I done sing " = I sang

Future, “go”
"I go go" = I will go, "I go sing" = I will sing

Far Past, “bi” or "I bi go", "I bi done” or "I bi done go", Used in telling history or Bible stories

Helpful Pidgin Words & Phrases
Ashiah = Sorry; shows empathy
Dash = Small gift. “Dash me something” = Give me a present
Pekin = Child
Sabi = to know or understand something. ‘No sabi’ = I don’t know
Na whati? = What?
For saka whati? =Why?

Prepositions: “For” is commonly used for nearly all prepositions. “Carry dis book for table.”

Expressions of feeling may be followed by “say.” “Think say” = think; “He done talk say…” = He said; “feel say” = feel.
Expressions of distance of nonspecific, going from “near plenty” to “near,” “far small” to “far” to “far plenty.”
Medical personnel will soon learn that “four-letter words” related to bodily functions are not vulgar in Pidgin; they are normal. “You di shit wata-wata?” = Do you have diarrhea?
Some English words have different meanings. “Skin” means body. “my skin no well.” = I am not well. “Find” = look for. “I di find my shoe” = I am looking for my shoe.
To make a word plural, add “dem.” “Pekin dem” = children. (Frequently in church they mention “di pekin for God” = Son of God, or “we di be pekin-dem of God” = we are children of God.
There is no “th” sound in most of the vernacular languages, and in Pidgin. “This” sounds like “dis.”
“Done” sounds almost like “don’t” without the “t."

Walking tour of Mbingo

2008-08-08T11:23:00.000-07:00

My first night here at Mbingo, I found myself locked out of my room for a few hours. While waiting for my room key, I decided to stroll the walkways of the hospital. I call them walkways instead of “corridors” because the concrete pathways connecting the various wards and building are all outside (under tin roofs, a construction for which in the current rainy season I have frequently been greatful). Outside the various wards are many mats and foam-pads and on them lay sprawled various men and women. Some are eating fu-fu and “njama-jama” with their thumb and forefingers (the traditional method of eating which I am becoming fairly adept at). Others are sitting in circles chatting or playing card. A few are sleeping, supine forms covered with sheets or “wrappas” (the one-or-two-yard blocks of fabric that the women use as wrap skirts). One pair of men is playing checkers with a few onlookers.

Who are these sprawlers? Sometimes they are newly-discharged patients, loitering for a few days until their family brings money to pay their bill. In the afternoon a few of the less critical patients may be seen out-and-about on the lawn. But the vast majority of these persons can be identified as the “caregivers,” those family members or friends required by the hospital to stay with each patient. They are the functional CNAs of the hospital. It is their job to prepare all the meals for the patient, assist them with toileting, help with washing and clothes-changes, and sometimes alert the nurses to things that would otherwise go unnoticed. As a general rule, no patient will be admitted to the hospital without a caregiver. Oftentimes different family members will take turns every few days. Some people have to take off work for weeks or months at a time.

Coming from the western approach to inpatient-hospital-care, I am more familiar with a scenario where a family drops off the patient at the doors of the emergency room, sometimes not to return for a few hours or a few days. It was not uncommon during my medical-school clinical years to round on a patient everyday without ever speaking with or interacting with their family. Being familiar with all of the problems of this model, therefore, I was at first enthralled with this African way of providing hospital care in a way that not only includes family in the treatment plan, but actually requires it. Since then, I have of course seen a few problems or “kinks” that have resulted from the required-caregiver policy, but overall I admire and appreciate the approach.

That first night I met many such “caregivers,” shaking hands with them as I passed and sitting to chat with a few who were more interested. Cameroon has ten provinces, eight of which are French speaking. Mbingo Hospital is in one of the two English-speaking provinces, on the border of Nigeria, a fact that I have been very greatful for as I know next-to-no-French. As long as I do not “rap” (the Pidgin English word for talking quickly in straight-English), most people understand my English and are amused at the few pidgin phrases I am able to throw in. One woman I met that first night, Vera, proceded to greet me everyday whenever I passed by her mat: “Hello, my friend!,” “Dr. Mary good morning!” or “Hello Mary, mother of Jesus,” to which I would respond with the friendly-right-hand-shake and “Hello, my friend!,” “Good morning Vera,” or “I love Jesus, but I am not his mother!” (the last phrase of which usually brought about a few hearty laughs from surrounding loungers). Although she spoke only Pidgin, I was able to elicit from Vera that she is Catholic and had been there for three months taking care of her sister who was finally discharged two weeks after my arrival.

Next to woman’s ward (where I spend most of my time) is the ulcer ward. It contains 50-60 beds, most of whose residents have been there for many months and have many more to go while their chronic wounds gradually heal. There is almost always a game of checkers going on outside, with bandaged-footed-men taking turns to push the rough-hewn-plastic-fragments around. Whenever I walk by, I slow down my fast-clip to ask “who is winning?” to which they usually respond with a shrug or a pointing finger. One checkers-regular was very excited to hear I had lived in Wisconsin, as his son is a doctor in Minnesota and he has other family living in Maryland and California.

Continuing past the ulcer ward and then children’s ward, I reach the xray department which consists of two main rooms, one for xrays and one for ultrasound. The xrays dry on a rack outside on the walkway (check out the right lung in the front, below!) There is no CT scanner, a diagnostic tool I am getting used to living without. A few hosptals in the capital city have one, but oftentimes they don’t know what to do with their findings and send the patients to us, CT scan in hand.

Next we pass children’s ward and men’s ward and come to the pharmacy and lab. I am getting more familiar with the available drugs on the formulary, as well as what to substitute when I see the “O/S” (out-of-stock) written in the chart next to my orders. I am getting to know a few of the pharmacists, and most mornings one tries to round with the doctors on every ward. I was surprised to find that they function very much like pharmacists do in the U.S. – checking our orders and doses and offering recommendations. Some of their recommendations are helpful, and I appreciate their “why” questions (keeps us doctors on track), but Dr. Palmer cautioned me the first week to always double-check things with my own resources.

Laboratory here is limited but does a good job with basic electrolytes and WBCs with diffs, as well as CSF fluid analysis, LFTs, urine analyses, etc. In a few weeks we are supposed to get some sort of machine that will radically expand our lab’s capabilities and enable us to check TSH (thyroid hormone) and other endocrine hormone levels.

From lab we go to OPD (out-patient-department), the clinic part of the hospital. There are no appointments, so oftentimes a patient may wait the better part of a day before being seen. Mondays are the worst days, and the usual disorganization is drastically worsened with the increased patient load.

Past OPD is maternity, the orthopedic “accident” ward (with its assortment of traction beds), the new private ward (where only the more wealthy patients can afford to have their own rooms like we all do in the states), and the “theater” and surgery-wards. All in all, the hospitals has around 200-250 beds in addition to an eye-department and opthamologist training program, the PAACS program (Pan-African-Academy-of-Christian-Surgeons) residency program with seven residents currently, a Physical Therapy department, and the “GoodHope village” for lepers a few miles down the road.

There is no E.R. or ICU (“yet,” says Dr.P). If you were a patient arriving to the hospital in a critical state, you would pull into the turn-around, be placed on the stretcher (stored outside by the map), and brought into OPD to be assessed. There is a reception-room off the turn-around that is open 24-hours, there is someone in the pharmacy 24hrs a day, and someone from radiology and/or lab can be called in in the middle of the night if necessary (though, just like in the U.S., they are not very happy about it.).

:"Please don't put that in in your mouth!"

2008-07-21T04:21:00.000-07:00

When a nurse picked a cricket off the back of my white coat, I didn't think anything of it. Since then, however, Mbong and I have noticed that our room has become a sort of "hostel-for-crickets." Neither Mbong nor I are especially squeamish around bugs, and the following dialogue was amusing to both of us:

Mary: "Oh look, another cricket."
Mbong: "Hmm. You know, some people here eat crickets."
Mary (moving as if to pick it up): "Hmm. Let's try it! Got any chocolate to dip it in?"
Mbong: "Please don't put that in your mouth!"

First Blog!

2008-07-21T04:15:00.002-07:00

The year is 1952. You are in the African country of Cameroon, in search of a piece of land on which to build a hospital for the care of people with leprosy. After being turned down many times, you finally acquire a piece of undeveloped bush property in the northeastern province, an hours drive from the nearest major city. The remote location is, in fact, ideal to isolate this dread disease from the rest of society.

Now, more than fifty years later, what originally began at a Leprosy Settlement is now one of the largest hospitals and referral centers in Cameroon and the West-African Sub-Region. Once, 150-200 people with leprosy were pushed far away from the rest of society to be unsuccessfully treated and to die. Now, with successful treatments for this once-dreaded disease easily available, there are only approximately 20 "lepers" still on site, living in their own independent community with services and care-providers allocated to them as needed.

Greetings, all! I type this on a borrowed laptop, from the African country of Cameroon. This weekend was the three week anniversary of my being at Mbingo Baptist Hospital as well as the three week anniversary of my first time overseas. I have not written sooner since it is rainy season and internet time has been unreliable ann few-and-far-between. The above "narrative" was part of my orientation to the hospital…

"Of course we have a new leprosy, you know," Dr. Dennis Palmer said to me the afternoon I arrived. "HIV & AIDS." Dr. Palmer is the director of the new Internal Medicine residency program beginning here next month, and he and his wife (a cultural anthropologist and mother of three grown sons) have spent much of their lives working to help craft and empower a sustainable Cameroonian-run-system here. Even before I saw their huge book collection (complete with "The Quotable Lewis" which I must admit I had been missing already), I had developed an enormous admiration and respect for these two people. (I'll be writing more about them but, for now, I'll just point out that, "incidently," Dr.Palmer is co-writer of the "Handbook of Medicine in Developing Countries" along with Dr. Catherine Wolf in Haiti, with whom some may be familiar.) I apologize ahead of time for the length of this email, and hope to keep it shorter in the future.

Medically:
There are many "sensational" and "tropical" presentations that would be much-acclaimed in the U.S., but here are run-of-the-mill. One man came in with a red, swollen left hand and forearm, palpable epitrochlear lymph nodes, and what he soon informed us was a "viper-tooth" remnant sticking out of a puncture wound in his second finger. In this country where (as I learned later from Dr. Palmer) over 90% of vipers are venomous, this man had been bitten, decided to first pursue "country-medicine", and finally presented to us five days after the "event." Since the first 12 hours are the most deadly as far as viper-venom is concerned, there wasn't actually much for us to do other than give antibiotics for the ensuing cellulitis. I recommended removing the viper-tooth (the "remove the source of infection" mantra I remember from med school), but am not sure if it was ever done. The Cameroonian doctor I was working with did give him a lecture about how he "should not use country medicine," but like in many of the doctor-patient lectures I have heard given in the U.S., the patient looked neither apologetic nor persuaded.

HIV is indeed as common as they say, and opportunistic infections ("OIs") abound. I feel confident in diagnosing by sight Kaposi's sarcoma in an AIDS patient, can recognize the fever curve of typhoid fever, and am comfortable including "Cryptococcus" and "toxoplasmosis" on a typical meningitis differential. I have been directly coughed on by a patient who was later found to have TB (positive AFB in sputum), and look forward to seeing whether or not my PPD will convert upon my return to the U.S. in six months. I was a bit surprised by the lack of malnutrition in this part of Africa, but my roommate, Mbong, tells me that Cameroonians will go without many things before they will go without food. Equally surprising, however, was the incidence of newly diagnosed leprosy – though effective treatments have been around for a few decades, there are still some people who put off coming to the hospital until after they have already lost several fingers and/or toes. Sensational though these things may sound, they seem to be as normal to the doctors here as diabetes and hypertension are in the U.S.

Other things, however, are surprisingly close to home. Antibiotics are as overprescribed here as in the states. Unneccessary lab tests that have no effect on the treatment plan are ordered in abundance – another familiar frustration. Philosophical conversations on the value and ethics of placebo treatments pop up from time to time. Women present for infertility workups without their husband, though they have had children by other men and the husband has not (and yes, just like in the states, the woman's workup is ten-times more expensive). And, from the little time I have spent so far in this culture, I have come to the conclusion that physician-patient communication is a challenge that spans all cultures.

Day-to-day:
I love being here! I feel in many ways more rested than I have in the last four-years of med-school. People get up early (4 or 5am), go to bed early (8pm), and walk slowly (something I may never be good at). It is not uncommon to hear a staff-member or patient spontaneously "bursting into song," followed soon by the entire ward joining in – in full, glorious harmony! It is rainy-season, so five out of seven days we have rain that is so loud on the tin-roofs that we have to shout to have conversations. I love falling asleep to the rain (reminds me of home in Portland, Oregon). I love waking up to the exotically melodious birds that sing so loudly they could be in the room with me. Outside my door is a panoramic view of the Cameroonian cloud-covered mountains. And you will hardly believe I'm writing from Africa when I tell you that the temp hasn't gone above 70degrees.

My first week I had a room to myself, and was actually thankful that my luggage hadn't arrived yet. There's nothing like being vulnerable to help you get to know people, and "where could I find some _____(insert any awkward personal-hygiene item)" is a line that, now from personal-experience, I can guarantee will secure even the most socially-anxious person some instant Cameroonian friends (people here love to help).

With the start of my second week, came my luggage…and a roommate! Mbong (prounounced like "mmmmm-bong" with the "mmmm" being silent) is a Physical Therapy student from Boston, here for one month. Her parents are both from Cameroon, so although Mbong was born and grew up in the U.S., she has many relatives here, some of whom I've gotten to meet. We have many things in common, including our age, having big feet, a love of hiking, exploring, and ice-cream, not being afraid of getting wet and muddy, and enjoying getting to know the people here as well as the various visiting doctors and missionaries that pass through. I am so surprised and thankful for her presence here for this first month, both as a sister in faith and as a friend with whom to share the everyday experiences, struggles, and joys!

Personally:
I love being here, am enjoying becoming friends with some of the Cameroonian physicians, am getting the hang of the hospital system somewhat, am developing an intense admiration and respect for the docs already here, and am constantly amazed at the conversations that come up and how "at home" I feel in so many ways. So far there has been minimal culture shock, and I am glad to know that people are people everywhere – humanity is a constant, no matter what the culture. Reminds me of a quote I once heard--"it may be a third-world country, but they are first-world people." There have been a few lonely moments, but they are surprisingly minimal – and it's hard to be lonely in a culture where everyone knows my name, and would even if I WASN'T one of the few "whites" on the premises.

Many things are sad and angering, but many other things are amazing and joyful. Some things about the "system" here appear wrong, unjust, and uncompassionate to me, but there are other things I have a great admiration and respect for (more details to come). Many things are different than at home in the U.S., but many things are surprisingly similar. Mbong is wonderful at reminding me to not "pass judgement" too quickly. Above all else, there is one constant that has stuck with me -- from the moment I stepped off the plane into the humid air of rainy-season in West/Central Africa, I was filled by the sense of having "come home." At first I diagnosed this as part of the "honeymoon/infatuation phase" of culture shock. But later, as the sense of "coming home" persisted even when I have felt some of the classic "culture shock" symptoms (withdrawn, angry, lonely, etc.), I have begun to wonder if it may not be a more permanent condition, and one that is healthy instead of pathological.

Culturally:
Upon arrival, I was given an orientation by a 30-ish-year-old woman named Joy. Joy has a degree in cultural anthropology. When I asked why, she said "because people have reasons for doing what they do. We may not always know why they do it – but there is usually a reason." Poof—Instant friend! Other Joy quotes: "People like promises here. If you say you're going back to visit someone, then do it!" and "We consider visitors to be a blessing, like rain…(on the importance of hospitality)."

From day one I have seen how people in Cameroon are more people-oriented than task-oriented. Even the most focused among them are quick to stop whatever they are doing to greet a visitor ("good morning!" or "good afternoon!" or "good evening!) and extend their right-hand. On the flip side of this hospitality-emphasis, many of the missionaries have commented how difficult it can be to have privacy. Even Joy mentioned that privacy is not necessarily an "African" concept. We then proceeded to have a discussion around the terms "introvert" and "extrovert," and whether or not they are even applicable or relavent in this culture…I suspect many of you may have more insight into this than I.

"For I was hungry and you gave me something to eat,
I was thirsty and you gave me something to drink,
I was a stranger and you invited me in,
I needed clothes and you clothed me,
I was sick and you looked after me,
I was in prison and you came to visit me…
whatever you did for one of the least of these brothers of mine, you did for me."

(Latest theological discussion passage with Dr.Palmer, on the famous topic of the interaction between works and faith, from Matthew 25...thoughts?)

Bon Voyage!

2008-06-27T09:19:00.000-07:00

Tomorrow (Saturday, June 28th) I depart out of the O'Hare airport bound for Cameroon. As this is my first trip overseas, I am getting a crash-course in packing light for extended periods of time. As you brush your teeth tonight, try pondering how much dental floss you will need to use over the next six months. (I considered not bringing any, but my dentist-ally-inclined brother wouldn't let me get away with that.)

Africa 2008 - letter

2008-05-18T18:05:00.000-07:00

A Medical Mission to Rwanda & Cameroon, Africa
____________________________________________________________________________________
July thru December, 2008

March, 2008
To my friends and family,

A STORY
Brought up as one of nine children, Diane was twenty years old at the time of the genocide. When the killing began she fled to a nearby field of sorghum. Her mother, father, and eight brothers and sisters never made it that far. They were hacked to death, along with the other one-million victims slaughtered over a mere three months in Rwanda’s 1994 genocide. For five days Diane hid among the sorghum, listening to the screams and cries of victims. She was eventually caught by the interahamwe (youth militia responsible for most of the organized killing) who beat her around the head and broke her leg. She was not far from death when suddenly the group’s chief decided to spare her life: at twenty years old she could make the interahamwe a captive wife.

They put her up for sale, to be auctioned to the highest bidder. The bids are still clear in her memory, and she was bought for 7,000 francs (£10 then). The winner’s prize was to rape her in front of the crowd. Diane longed for death to overtake her. Brought up a charismatic Catholic, her faith in God was shattered, and the possibility that God could exist disappeared in the nightmare she was living.

Eventually Diane was rescued, pregnant with her captor’s child. Despite the manner of its conception, Diane hoped for some solace in her child’s birth. But even this was denied her, as the child was stillborn. Left disabled, she had no home and no strength to plow her field and produce food. Night-time brought insomnia and nightmares; she wanted to cry continually. “I had fear and sorrow, and kept to myself…I hated everyone,” she remembers, “and I hated God.”

RAPE, TRAUMA, & PTSD
Rape was not an individual man’s obscene choice, but a tool of genocide used against the Tutsi women and girls. Men with HIV/AIDS were especially prominent; if a woman was not raped to death she was often told by infected men as they raped her that she would die the slow death of AIDS. Others had their breasts and sexual organs mutilated, and horrific atrocities were carried out with sharp implements, sticks, knives, spears, broken bottles and gun barrels. Many women were left with injuries to the vertebrae, complete loss of functioning female organs, persistent infections, severe headaches, and a sense of shame and guilt. No one knows for sure how many women were raped during the genocide, as many rape survivors have never reported it to any authorities for fear of the stigma attached. The outcome is that a large proportion of the surviving women are forced to deal not only with the horrific killings of their families, but also with their own personal battles against the trauma of brutal rape. One journalist and survivor says “Rape is not an event that happens on a single day. For the survivor it is a recurrent nightmare for the rest of her life.”

In my third year of medical school, I learned that nightmares and flashbacks after trauma are one of the criteria for a diagnosis of PTSD (Post-Traumatic Stress Disorder). Many Rwandan survivors do not pass a night without bad dreams or insomnia. Some are unable to even lie down in bed. One survivor was still spending the night in bushes ten years after her traumatic experiences. Another woman tells how, while looking at her husband’s photograph, she suddenly found him standing in front of her, a shocking hallucination. Many children after the genocide would cry hysterically for fear in broad daylight, seeing attackers coming to kill them and their families. The men who survived and were forced to watch what their wives went through are now traumatized and afraid to remarry. For many survivors, the nightmare that replays endlessly night after night is a dreadful recurring chase in which they struggle to flee machete-wielding interahamwe and from which they wake up, exhausted. Drug abuse, depression, anxiety and behavioral problems are common.

INJUSTICE…AND GOD?
Why, on the eve of celebrating my graduation from medical school, am I going into depth telling you these tragic stories? Don’t we have enough of our own trauma, discrimination, and injustice here in the United States? Hasn’t Africa been in the midst of war for centuries? What can we possibly do to help? And what does God have to do with any of it? If God does exist, isn’t it His fault for letting these atrocities happen in the first place? Indeed, it is a sad fact that some of the most brutal slaughtering during the Rwandan genocide occurred when pastors and priests turned over their own congregations to the interahamwe, and this in a country that claimed to be 90% Christian! Such news could make any of us say, along with Gandhi, that “I like your Christ, I do not like your Christians. Your Christians are so unlike your Christ.”

A few years ago, as I was bemoaning the sadness, tragedies, and injustices of the world, a best friend said to me: “Mary, some people think they have more compassion than God.” However much my own heart is broken by these injustices, God’s heart is broken infinitely more. Jesus’ model for love, a nameless Samaritan, messed up his clothes and his schedule by picking up a stranger who lay wounded and beaten in a ditch (Luke 10). Acts of love like this are so important to God that when the Israelites couldn’t be bothered with the practicalities of what it takes “to loose the chains of injustice” and “to set the oppressed free,” God stopped listening to their prayers (Isaiah 58:1-6). Sometimes referred to as the social-justice book of the Bible, Isaiah is full of God’s hatred for injustice as well as for the hypocritical church:
Learn to do right! Seek justice, encourage the oppressed.
Defend the cause of the fatherless, plead the cause of the widow.
Come, now, let us reason together, says the Lord. (Isaiah 40)

MEDICAL MISSION TRIP
Some of you I know well, others hardly at all; some of you I speak with every week, others I have been out of touch with for a while; some of you probably hate news-letters in masse. Although I can’t hope to know where each of you is coming from, I am writing to invite you to follow along with me as I journey to Africa this year. After graduating with my M.D. from the Medical College of Wisconsin this June, I am delaying a residency in Psychiatry & Family Medicine for a year to pursue medical missions. During July & August I will be working through INMED at the Banso and Mbingo Hospitals in Cameroon (http://inmed.us/training/banso.asp). For September through November, I will be working at Shyira Hospital in rural Rwanda with Drs. Caleb & Louise King (http://www.shyira.org/shyirahospital.htm). And finally, during December, I will be working with Solace Ministries (www.solaceusa.org) in Kigali, Rwanda’s capital city, in the areas of trauma counseling and with their clinic for community health and HIV/AIDS prevention and treatment.

Come with me! …as I learn medicine in the context of hospitals and community health programs with limited supplies in the midst of rampant disease and suffering. Come with me…as I take this next step on the path to discovering whether God is calling me to be a career missionary. Come with me…as I discuss these eternally significant questions about injustice and suffering with people who are face-to-face with these things everyday. Come with me…as I listen to the stories of people who have lived through trauma and tragedies and, like Job, somehow still desire to praise God, full of joy. Come with me!

SOLACE RWANDA
Solace Ministries was founded by a genocide survivor, Jean Gakwandi, who saw many widows and orphans who were stripped of their relatives and property, deeply traumatized, and tortured by feelings of guilt, anger, resentment, sorrow, and hatred. On asking God what he should do, the answer came through Isaiah 40:1 “Comfort, comfort my people, says your God” and 2 Cor 1:3 “We are comforted so that we can comfort others.” Today, Solace ministries has expanded their ministry to include the HIV/AIDS pandemic, demonstration farms, child-headed households, and youth camps in addition to its trauma counseling and support of widows and orphans. Jean Gakwandi, a man so familiar with the shattered lives and stories of thousands, says: “The tragedy of 1994 has shown us that we believe in a living and loving God.”
Eight years after the genocide, Diane was still in shock. One of the woman leaders of Solace Ministries began to comfort her and brought her into their community where she was astonished to find people who care for her and love her. Many afflictions experienced by survivors are clearly injuries or diseases with no spiritual cause, but some survivors associate their pain with unforgiveness, anger or bitterness. Above all else, those who have been horrifically raped and abused need the genuine, unconditional love of God for their healing. Along with personal counseling and prayer, women at Solace are encouraged to come to the fellowship meetings where a combination of worship and praise, preaching and testimony helps the women to share their experiences, discover they are not alone in their trauma, open up to the healing of the cross and begin to trust again. In a society where even speaking of the genocide is discouraged and rape-victims are stigmatized, these meetings are a vital source of support for both men and women in their recovery. For those who knew Diane before she was healed, it is hard to recognize her. She sleeps at peace for the first time. Although memories are never completely eradicated, their power is broken. Her faith returns as she sees God to be ‘the solution and not the reason’ for her pain. Diane is not shaken when other women begin to talk of their own rapes, and she listens and counsels them effectively. She now feels she has a hope and a future and is determined to share it with as many people as she can.

HOW YOU CAN HELP
Most of all I need people who will commit to praying for me and for these ministries from July through December. I would love to send you email updates while I’m in Africa, as internet-service allows. If you would like to receive periodic newsletters and prayer-requests by email, email me at marybuckler139@gmail.com and I’ll add you to the list!

Thanks for reading! And thanks for being in my life.

Mary Buckler (MD graduation ceremony at MCW, 5/16/08)
2524 N. 57th St.
Milwaukee, WI 53210

Women of Solace Ministries

If you are called to give financially (tax deductible) to either Solace Rwanda or my mission trip, you may give online at http://www.solaceusa.org or make out checks to “Solace USA, Inc” with my name in the subject line and send to: Solace USA, Inc · W164 N9703 Water St · Germantown, WI 53022. I am pursuing scholarship funds but am in need of an estimated total of $6500 for airfare and living expenses for the six months abroad. Excess funds will be donated to Solace Ministries.

(Stories taken from the following books: Beauty from Ashes: Journeys of Recovery from the Rwandan Genocide & Good News About Injustice: A Witness of Courage in a Hurting World)