exam time

exam time, originally uploaded by mattcotham.

Right now are the grade 12 exams here in Zambia, which make the ER oral
boards pale in comparison to the amount of stress that these engender.
Try to imagine that your SAT score would be one of the primary deciding
factors for every school you ever applied to and every job you ever took
and you'd understand a bit better. Maybe 10 staff members of the
hospital are studying and retaking their exams to improve their scores,
even at the age of 40 (imagine taking your SAT again at the age of
40!). Just to give you an example of how serious people are, we had a
girl come in from the secondary school with what turned out to be a
ruptured tubal pregnancy -- heart rate in the 140's, pale, dizzy. She
took her grade 12 history exam this morning before she'd let us do the
tests this afternoon to figure out what's going on or operate on her.
Surely that deserves one or two extra credit points on the exam?

how the grinch stole homecoming

how the grinch stole homecoming, originally uploaded by mattcotham.

Well, we made it back yesterday after a long trip where I nearly got
bumped from my flight to Johannesburg, my luggage was deliberately left
behind by United in Washington so that we wouldn't have too much weight
on the plane (they told us about that decision when we landed 13 hours
later), and about $1000 of gifts/equipment got stolen out of my bags
along the way. I'm struggling with thoughts of wishing plagues of
hemorrhoids and ingrown toenails (that would be revenge for us doctors)
on the perpetrator of that deed, since these were things that I had
planned for months to get and some of the stuff were things that people
here had given me money to buy for them. I was feeling a little bit
like Santa Claus bringing it back for people, and now I feel a bit like
the Grinch came and stole our Christmas, and there won't be any little
dog with a large bone tied on his head bringing it back. But like the
Grinch points out, stuff is stuff, and although not always replaceable,
it's not the end of the world when it goes away.

I'm trying to get more photos on the blog; they are not always related
to the stories (I'm not picturing feeding this guy to the crocs,
although come to think of it....)

October updates

I see that it's been close to two months since my last group email -- time flies when you're trying to get ready for ER boards, I guess.  I am currently back in the states for a brief time for my oral boards and then will be heading back to Zambia on Tuesday.  I get a lot of questions about whether I'm struggling with culture shock; coming back to the US, even for a brief time, has its advantages -- I feel like I'm getting a years' worth of shopping done in a week -- but also brings you up hard against American materialism and excess.  Although I don't deny that I think salad in a bag is a modern miracle, especially after the 5 step process of washing and disinfecting that I'm required to do, we spend a lot of energy on activities which are of little profit, I think.

I guess the two biggest questions I get when I'm back are 1)"What's it like over there?" and 2)"How can we help out?"  I find myself wishing I was more charismatic to go out and 'sell' a project or need for the hospital, but the bottom line is that both questions are problematic at best.

What's it like in Zambia?  It depends on what aspect you look at.  I would say overall that it's just more extreme than life over here; I think I've said this before.  In terms of work, it's more satisfying in many ways, because it allows me to be more holistic as a doctor, incorporating who I am into what I do, and the patients are more grateful and more engaged with their doctor.  It's a throwback to the trusting nature that people used to have with their doctors here before the age of the internet and information overload where they depended on their doc to do the right thing and know what was best.  At the same time, work is much less satisfying, as patients die or you can't help, and they are often very young.  I can give many examples of patients who were just tragically cut short, and it's difficult to care for them and feel very helpless.  Life outside of work is better, more simple, more fulfilling than the American pursuit of entertainment and so forth, but it's also more frustrating, more boring, and more difficult to get things done.  I blogged about this recently in 'native soil', if you want to read more. 
Anyway, you want to put a 'positive spin' on things so that your parents don't get too worried :), supporters don't get discouraged, and you don't give the impression that Zambia is falling apart and incredibly frustrating, because it's not.  Many stories end up sounding that way, however, and it's sometimes difficult to find a balance.

How can you help out?  After my friends Hilary and Tay came to visit, I was struck again by how many things go on outside of work that need help as well.  People want to help with 'the kids', but that's a very nebulous term -- the kid patients in the hospital, the local kids of the hospital staff, some of the nearby village kids, AIDS orphans, local schoolkids -- all have different advantages and disadvantages when it comes to ministry.  I am probably too focused on the hospital needs, because that's where I serve and spend my energy.  All of those needs -- housing, electrical transformers, drugs and supplies, incoming personnel -- are ongoing and there are no guarantees that interventions to help will have the desired effect.  For example, we have recently purchased some new kitchen pots and are renovating the kitchen for about $20,000, but our electrician sometimes makes mistakes and there's a real chance that there will be mistakes in installation which could cause lots of damage.  But he's the only electrician around, so we may have to trust him and hope for the best.  We've raised the money for a water pump so that around 20 people can have running water, but we were swindled by the guys who ordered it and so still haven't managed to get the proper pump installed, now two months later.  Projects all seem to have those sort of hang-ups, but you need to get them done, so you do the best you can.  I definitely feel that while I'm over there I can help facilitate things getting done properly.
So how to help?  I guess from a capitalistic perspective, it's a risky investment: no guarantee of success.  Don't be fooled by these NGO's who promise that 'every dollar will be spent on something' because Africa doesn't and can't work that way.  But there are a lot of really positive things.  I'm encouraged by the lack of graft and good accountability on the part of the people that I work with to do the best they can in a tough situation.  And I'm also struck by the huge upside when things do turn out well -- getting water to people, providing good healthcare, giving comfort to patients and families, supporting people in their need -- these are things that we should be a part of as Christians and citizens of the global community.  Because there are so many different ways to get involved -- education, financial projects, nutrition, infrastructure, medical care -- let me know if you have a heart for something and I'll see how I can make it work.

It's really encouraging to know that people are interested and engaged with what's going on out at Mukinge.  That's easily been the best part of this brief sojourn at home.  I'll be headed back in less than a week to Zambia for round 2 of my two-year commitment.  What happens after next November is still up in the air, and I'm pretty content to leave it that way, with the understanding that God will show me the answer to those decisions when they press upon me.

Thanks for your prayers and support.  Looking forward to talking and hearing from each of you.

Talk to you all soon.
Matt

modernization

Not exactly sure that changing the font qualifies as modernization, but
it seems to at least eliminate the irritating page breaks. Hope you all
can still read it -- as my dad's eyes get worse, I get more sensitive to
these things. I've not been blogging much this week since I figured few
people want to hear about my studying habits, and some of you I've
managed to talk with in person. Suffice it to say, I should be ready
for exams on Sunday, I've managed to find most of my gift ideas (anyone
know where I can find a hammock?), and have enjoyed spending time with
family and friends. I'll catch you guys up once I reach Lusaka again!

native soil

It feels pretty good to be back on American soil, even if it was the product of a 17 hour flight from Jo-burg to NYC and I still have about another 12 hours in lay-overs, transfers, and flights to come. I love the fact that the US citizens line in customs looks as diverse as the visitors to the US line in JFK. And, I'll admit it, my triple-shot latte also tastes pretty good after 4 hours of sleep and 11 months delay. These are mid-terms for me, a chance to step back and figure out what the last year has been about, where I'm headed to in the future, and where I am being led from here. We're conditioned to pursue happiness in America. I wish I could say that I was ecstatically happy all the time in Zambia, and I would have to say that I'm pretty content most of the time. But it's a complex place. Let me try to outline some of those ways.

Friendships: Mukinge has been an amazing place for friendships with some really wonderful people who I have grown close to because of all our shared experiences, but also because of who they are. There are people that are really worth spending the time to get to know -- Zambian and ex-pat alike. At the same time, Mukinge is a place where many people are there for a short time and then gone. And cross-cultural friendships are difficult because of expectations of financial/material gain that are often placed on them, differences in cultural backgrounds, family structures. So it can be lonely at times as well.

Work: Work can be really fulfilling. I put together a slide show of pictures of just a fraction of people who've we've helped -- the man who slit his throat in an attempt to kill himself and came back to his family and to Christ after we sewed him up, the woman with the massive hemopytsis holding her baby after her C-section a week later, the man fitted with his wooden peg-leg after his traumatic amputation of his leg, smiling and sticking his thumb up at the camera. I'm reminded of people's lives that I've saved over the year, people who are grateful for a gentle touch or kind word, and families who were strengthened in their faith and love for each other because of work that we did. At the same time, the slide slow reminded me of all our failures -- the immigration officer staring at the camera like he can see his own death in the lens (he died two weeks later), Josua reaching out to the camera and then laying in the high-care area of pediatrics 3 months later, dead from malnutrition, Tom sitting in his wheelchair gradually losing his smile over a few weeks as he's forced to grow up unexpectedly by the tragedy of unexplained paralysis. Some days are really good, but some days I find myself losing hope that what I'm doing makes a difference as well. I find that rationalizations that 'what would it be like if you weren't here' to ring hollow when you know about how much more effective medical care could be if you could bring the funds and personnel to bear.

Cultural adaptation: I mentioned above that we pursue happiness in America; it's in the Declaration of Independence, which in itself is so foreign to many people from other cultures, who live by the Declaration of Interdependence: on friends, on family, on the rest of the world. That transition for a bachelor who's practiced being independent for around 10 years to a culture of interdependence has been rocky at times. Part of the reason is that coming from a position of power, interdependence can very easily become just dependence, a one-way street, especially if you don't take the time to appreciate the non-quantifiable gifts that many Zambians have to offer, and Zambians don't take the time to learn about your non-material gifts as well. I was transitioning from a pluralistic society to a monolithic society, which has its own adjustments in terms of voluntarily giving up your freedoms in order to have cultural relevance. Rural Mukinge is not the cultural melting pot, something which is hard for us to understand when we go because it seems so foreign, such a great 'exchange of ideas'. When I arrived, however, I quickly realized that to make a difference I would have to change myself in order to make the differences that I can't change less obtrusive. Giving up your freedoms to be relevant -- giving up deep friendships with women because of the misconstructions that are placed on them here, changing the way you greet people, structure your day, deal with interruptions -- it's obviously the reason you go, and the lessons you learn are awesome, but it's also a painful process of subjugating yourself in ways where you're taught as an American that you should be able to pick how you're going to live your life.

I think this is going on too long for a blog -- probably half of you tuned out after the first paragraph -- so I'll stop it here, despite the adrenaline that only a triple shot latte can give you after 11 months of abstinence. Hope to talk to some of you in person, or at least by phone while I'm home.

full circle

I am back in the guesthouse in Chamba Valley where I started this trip
ten and a half months ago. In a lot of ways, things haven't changed much
since I was here then; it's still hot, and full of mosquitoes, and I am
fully expecting to have another night spent sitting up and swatting bugs against
the wall. This has been made more challenging since the last time I was
here by the addition of regular power outages, so that you are
trying to swat bugs by sounds and feel alone, which is a distinctly
dicier proposition.

Despite similarities, a lot of things are really different than before, too. My computer is now full of beautiful pictures and also with emails about water pumps and visiting medical students. There is now a separate Zambia folder with funding proposals, memorandum,
minutes from various meetings, and medical protocols.

In a moment of pique last week as my insomnia kicked in and my frustration level was
high, I made a list of all the things I'd had to learn while I've been
here for 10 months. At the time I was mad because I'd been forced to learn so much in such a short period of time; now I'm feeling kind of proud of myself. Here's the abbreviated list:

How to plant and fertilize maize and a garden

WHO recommendations for malnutrition, setting up a malnutrition
protocol, components of mineral supplementation, whether commercial
mineral supplies are adequate for human consumption, price of skim milk
powder, how to purchase and deliver milk powder, where to buy peanuts,
soy, how long peanuts can be stored, where to find containers for peanuts

Basic Kaonde

How to deworm a cat

Where to hire someone to shovel off the tennis court

How to get out of trouble when you're over your head in a C-section

Dosing and monitoring of chemotherapy for cancer, HIV drugs

African vernacular songs on the piano

How to distill water, where to find distilled water for lab and OR use
(the air conditioner, rainwater)

How to sterilize surgical instruments

How to fix a tire on a motorbike

Tennis forehands

A variety of medical conditions: Madura foot, eosinophilic folliculitis,
lymphoblastic lymphoma, leprosy, nephrotic syndrome, acute rheumatic
fever, cerebral malaria, ecclampsia, uterine rupture, snake bite,
organophosphate poisoning, tropical ulcer, pin placement for skeletal
traction, typhoid fever, skin grafting, hydrocoele repair, ultrasound
diagnosis of DVT, VSD, and ectopic pregnancy

30 or so African choruses

How to dispose of medical waste

How to make nshima

Charitable organization legal proceedings

About 200 people's names

The Evangelical Church of Zambia organization and the hospitals' role
with ECZ

How to set up a computer network (well, how to fail to set up a computer network, really)

ER medicine for my ER boards

What SIM stands for, who runs SIM, how to get things done through SIM,
how to request funding from SIM, how to recruit personnel via SIM, old
SIM projects that have been conducted at Mukinge, SIM future goals for
the hospital

Pharmacy ordering systems, contacts of about 5 pharmacy delivery
suppliers in Zambia, methods of delivery, goods received vouchers

Where to find sources of lab supplies, drugs, and stores in Zambia.

The government supplier of pharmaceuticals system, ordering timetables

What is an electrical transformer, how much voltage requirement is
needed to run a hospital

How to dig a VIP toilet

Mukinge history of severe illnesses, malnutrition, malaria, history of
relationships with the local health board

Antibiotic resistance patterns for Mukinge for the last 6 years

How to put someone on the Zambian government payroll, how to find out
how many people they expect us to have on staff

Installing and troubleshooting cellphone modems, wireless cards, and
internet access on 10 different computers

It's a long list, and I edited out a fair number of things. It feels like almost everything on that list I had to figure out on my own when I got here because of the lack of long-term docs to do a
proper handoff. Like I said before, I was peeved at the time I wrote the list because I was feeling that it was unfair to have to study for my boards on top of the rest of the
things that were going on. But now, I'm kind of just proud of myself for
managing all those things. Who knows what the next 14 months will bring?

off we go

Travelling is always a bit of a production when you live out in the
bush; the current crisis is a fuel shortage throughout the middle of the
country, so that one of our doctors is stuck 2 hours away by road and
can't get back. That played a little havoc with my travel plans as
well, and there's the usual last minute changes (my flight time out of
Mukinge has changed 4 times in the last 48 hours). And of course
there's just the amount of time it takes to get anywhere; I will leave
Mukinge today on the 6th, yet not arrive in the US until the 11th.
Looking forward to seeing everyone in the states at the end of the road,
though!

do we all speak English here?

My head cold has made it even more difficult than usual for people to
understand my American accent here; even my Kaonde seems to be more
difficult to understand. It works both ways, though, when I had to go
over the pharmacy orders for the month and was trying to figure out why
we were ordering 'cold cramps'. Alas, the Zambian 'l' and 'r' switch
got me again (you pronounce them the same), and what we really needed
were 'cord clamps', for umbilical cords. I do sort of enjoy the idea of
ordering up a bunch of cold cramps, however, and seeing what happens....