chicken wars

chicken wars, originally uploaded by mattcotham.

Small business enterprise is very common among most people that live in
the area. It's easy to see why a program like the World Bank's
microlending program could reap a lot of benefits around, especially
when local bank interest rates are in the 20% range and to just own a
bank account will cost something like $100/ year for a country that has
an average annual income of around double that. Anyway, one of the
most common things to do is to raise chickens. This started with just
one family a few years ago, but now there are around 5 staff members who
have a little business raising chickens to sell to people around the
area. That's all great, but when the hospital starts buying chickens
for the hospital to feed patients, it can become very dicey quickly
about who you're going to buy from, how many you will buy, and so on.
We've had to establish a 'chicken rotation' to make sure we keep the
peace, and everyone gets a chance to sell off their chickens. Of
course, chickens running wild are free game....

man in chains

I was rounding in the female ward this week when a man wandered in and
began singing a few hymns on the ward. It not being the usual visiting
hours, I was curious as to what he was doing there, but as the hymns
weren't particularly boisterous (no Onward, Christian Soldiers here) and
he left after just one song, I didn't really follow it up. Talking with
some of the other staff later in the day, I learned that he was one of
the locally known mentally disturbed patients that lives in the nearby
community. What's more, I was surprised to learn that he lives his life
with a manacle around his left leg. John, one of our docs here at the
hospital, assumed this was some sort of dramatic oversight and sent him
to the workshop to have it removed, but as it turns out, like Jacob
Marley he's condemned to live his life with a shackle around his leg
because the family refuses to have it taken off. They say that when he
gets more unbalanced, they need to be able to chain him up to one of the
trees in their front yard, where he is left for a few days until he
comes back to his senses. This rather byzantine arrangement is by no
means uncommon in the area, where people who are delusional or mentally
ill are routinely labeled as possessed by demons and locked away until
they 'get over it', at least for a little while.

fixing the cat

fixing the cat, originally uploaded by mattcotham.

I decided that it was time to change the cat's name back to Charlie from
Randy, so we decided to neuter him last week. David and I watched a 5
minute DVD of a vet in California castrating about 10 cats in under 5
minutes, and then I gave him an injection in his back, threw him in the
closet, and when he was out of it we strapped him down with a towel to
my ironing board and did the deed. It's about the simplest operation
you can imagine; it's easy to understand how those vets do 200 in a day
at the local animal shelters. Anyway, he recovered out back in the
shed, and the next day he's back purring and hanging around my door, so
I guess there's no hard feelings.

winds of change

It's been a pretty encouraging time here at Mukinge over the past few
weeks as we continue to improve the hospital and make some changes
here. Thanks to many donations from overseas, we've been able to finish
the expansion and rehab of one of our staff houses here and are starting
on two more in the next month. We're in the middle of building a new
dormitory for the nursing training college with funds from the Zambian
government. We have secured funds from the Churches Association of
Zambia and are building a gift shop to help bring in income for the
hospital and hopefully for local villagers as well. We have also
managed to find funds from the Biet Trust to build a new four-plex
apartment complex here at the hospital to improve our staff housing.
We've also been blessed to buy a new water pump thanks in part to
donations from home and finally install it after 9 months of struggling
so that around 20 of our staff members can have water and electricity
where they have been without for 9 months. I have managed to almost
finish the rehabilitation of the tennis court, which is looking
Wimbelton-worthy. We have purchased and installed a new internal
wireless phone which allows us to roam around the hospital and mission
station when on call, which is incredibly freeing and makes you feel
like you can get out and around without too much pain. We have also
managed to secure funding from Catholic Relief Services to finalize the
internet project here so that all of the staff homes at Mukinge will
have wireless access -- around 200 Zambians and ex-pats alike. Soon we
will embark on a rehabilitation of the administration block funded by
some donors of Lynn, our anesthetist nurse.
It's fun to be a part of things when they are moving forward. It feels
like we're able to make some headway on some projects that have been
maybe sitting dormant for too long. Thanks again for your support.

close to home

I suppose that after a year of working here, and having hundreds of
patients die under my care, I should be more used to the idea. I don't
go to the death scenes of my patients very often, simply because it's
too hard to do it over and over again. It's difficult to be in the room
with six wailing women, rolling around on the concrete floor, unable to
stand, staring up at you with questions in their eyes. I unfairly
interpret this as a kind of accusation, and I feel that every time
someone dies it undermines the work that we're trying to do here at the
hospital to provide hope and comfort to sick people. In fact, I was
told when I arrived that about a year prior to my arrival, when someone
died in the OR, the next day half the hospital got up and left, whether
they were finished with their treatment or not.
Yesterday I was forced to operate on a very sick 70 year-old man who
came in with signs of intestinal obstruction -- vomiting feces,
distended abdomen, no bowel movement for 3 days -- but when I made the
decision to go to the OR, we couldn't find a reversible cause and so we
closed him back up after rooting around for 30 minutes. This would be a
case where slightly more advanced imaging like a CAT scan would be
invaluable in preventing an unnecessary operation. He continued to get
worse and worse throughout the day and about 10 hours after going to the
OR he died. Like many of the cases I've seen here at Chitokoloki, he
was the family member of one of the staff here and it's very difficult
to go to church and see them the next day when you know that they died
under your care, whether you did something right or wrong in that care.
In a case like this where you're inexperienced and the usual doctor
isn't there, there's the questions of whether you know what you're doing
as well and whether the family member would have survived if the 'real'
doctor had been around.
I'll go to the funeral today and stand with the family of the people who
may or may not be harboring these thoughts about me. It's easier to not
go, knowing that people will probably forgive the omission as a white
man and a visitor from somewhere else, but it still seems like a
cowardly thing to do to avoid the family and the situation altogether.

Some people will do anything....

Some people will do anything...., originally uploaded by mattcotham.

Many of our patients don't like to take their medicine, which isn't
surprising when you taste most of the medication formulas used here --
very bitter, none of the candy coatings and flavorings like you get in
America. Today I went to see one of my post-op surgical patients and
when I examined the wound I found it smeared with a thick white paste.
I'm thinking to myself that he's brought some weird African medicine
from home, so I go and get the translator. Turns out he had been
chewing up his Tylenol, making into a white paste, and then smearing it
on the wound to make it hurt less. This is a similar approach to the
witch doctors whose remedies for most illnesses is to simply cut the
skin in small cuts over wherever it hurts. We explained the idea that
the medication needs to be swallowed, so we'll see how well we do tomorrow.

TB trouble

TB trouble, originally uploaded by mattcotham.

As many of you know, TB, HIV, and malaria have become the focus of
international attention and research over the last five years with the
advent of the global fund, emphasis on research, and increasing funding
sources from places like the US and the WHO. We are beginning to see
the tip of what will likely be a increasing scourge of MDR-TB, which
stands for 'multi-drug resistant' TB. Because TB is so common in places
like Zambia, we don't go around treating contacts of people with TB,
which means that occasionally we will see entire families, one by one,
as they come in and are diagnosed with TB in the hospital. This
particular lady was the wife of a man I treated 2 months previously, and
who's brother I also treated 2 months before that, and who I'm sure also
has several infected children running around their home, not to mention
neighbors, extended family, and so on. We are unfortunately
short-staffed in our ability to do community follow-up, which would be a
place I would like to increase hospital services out and about in the
area if we can find funding for a program like that. But I'm often
struck at how deep the iceberg goes when I scratch the surface in the
hospital.

TB trouble

TB trouble, originally uploaded by mattcotham.

As many of you know, TB, HIV, and malaria have become the focus of
international attention and research over the last five years with the
advent of the global fund, emphasis on research, and increasing funding
sources from places like the US and the WHO. We are beginning to see
the tip of what will likely be a increasing scourge of MDR-TB, which
stands for 'multi-drug resistant' TB. Because TB is so common in places
like Zambia, we don't go around treating contacts of people with TB,
which means that occasionally we will see entire families, one by one,
as they come in and are diagnosed with TB in the hospital. This
particular lady was the wife of a man I treated 2 months previously, and
who's brother I also treated 2 months before that, and who I'm sure also
has several infected children running around their home, not to mention
neighbors, extended family, and so on. We are unfortunately
short-staffed in our ability to do community follow-up, which would be a
place I would like to increase hospital services out and about in the
area if we can find funding for a program like that. But I'm often
struck at how deep the iceberg goes when I scratch the surface in the
hospital.

a stretch

It's been a hard experience playing at being the only doctor in town
here at Chitokoloki so far. One of the things I've been really grateful
for at Mukinge is the opportunity to do things as a team and bounce
ideas off the other doctors. I can call on the knowledge and experience
of the other ones working there, whether the nursing staff who has seen
so many things, the other doctors which draw from a wealth of different
medical experience than me, or the advice from people from home. One of
the really difficult things that I find about medical work in Africa is
that often times it feels like you're groping around in the dark without
much idea where you are going; this is a stressful experience when lots
is at stake but having other people's hands to hold while you wander
around in the dark makes it more bearable.
Up here, it feels like I'm on my own to screw up or do well, and I've
been faced with opportunities that are past my training. Some of it is
just the struggle of trying to find what you need in a hospital that you
are not familiar with; here they are more concerned with theft than we
need to be at Mukinge so lots of equipment is squirrel away in places
that are locked or hidden, making it difficult to find in an emergency.
I've also had some problems which I've never been asked to solve before
-- for example, the local Zambian hospital was doing a hernia operation
and ran into complications, so they asked me to fix the problem, which
turned out to be a large hole in the bladder. Considering I don't even
consider myself trained to do a routine hernia, trying to fix the
problems in someone else's complicated hernia was asking a bit much.
But I did my best, and the guy is doing well. Another case, a 6 month
old with a bone infection, I've been hesitating about taking to the OR,
but will probably have my hand forced soon.
Anyway, I've realized the crutch of having other people to lean on here
for the past few days. I think that this year will continue to be
tricky at times as people come and go and I lose a bit of that safety
net. I mostly need to take advantage of the opportunity to learn from
people when I can.

stranger in a strange land

After much debate with the mission agency and the church board, I
managed to get off to help up here at Chitokoloki. Perhaps more
beautiful than Mukinge (don't tell her I said that) it's a good
experience to see a different take on how a mission hospital could be
run. It's a very different approach to mission here; more focused on
outside help and working in spite of the government system as opposed to
our approach at Mukinge, to try to work within the system and build it
up. Both viewpoints have their advantages and disadvantages, I think.
But anyway, it will be a stretch as we try to push our way through some
cases and help take care of a few people.

What to say

Haven't had a lot of fodder for the blog recently. New Year has come
and gone, fairly uneventfully, with board games and a few visits into
the hospital after hours. Progress begins on the tennis court, hampered
by the rain, funerals, and would-be thieves trying to take my precious
cement. Today I have staked dogs near the cement to ward them off.
Zambians for the most part retain a large fear of domestic animals, dogs
and cats both, and the Griffiths' dogs are particularly vocal, making
them ideal guard dogs against most nighttime predations.

We had an unusual delivery tonight as the supply truck for medical
stores arrived, unannounced, at 9pm. I get a phone call from the
hospital asking me what they should do so I get out of my house to see
what the deal is. Obviously no one's available at 9 pm to unload
medical supplies or drugs, and I emerge from my front door to see a huge
18 wheeler truck parked outside the hospital, covered with a tarp and
obviously stacked with a fair number of boxes. I'm a little worried
what we're going to do with all that equipment that no one was expected
at such a late hour, but fortunately I don't have to worry long. I
stroll up to the truck to find two very tired drivers who had traveled
over 16 hours that day. Stacked next to them were two small boxes each
about the size of a large shoebox containing some ready-to-use formula
for our malnourished children. The conversation went something like this:

"Hey there, I'm Dr. Matt, can I help you?"
"Dr...?" I repeat my name, but it's clear that they aren't going to get
'Matt' correctly, so I let the matter drop quickly.
They press on: "We've come to deliver these to you."
Me, looking around, seeing the two boxes. "You mean these?"
"Yes."
I'm slightly puzzled at this point, given the size of the truck and the
size of the package, which would have taken up maybe 1/5 of a regular
car trunk, sitting next to this 18 wheeler truck that they've driven all
day. "You mean these? You drove this huge truck all this way to
deliver two boxes?" I ask again.
"Well, we have other places we need to visit, too."
"Umm, thanks very much, then." We look at each other. "Well, have a
safe trip." At which point they climb back into their truck and head
back up the road, and I grab the two boxes and carry them to the
malnutrition ward. I am glad at this moment that I am not a driver for
MSL. I can't help but imagine some UPS supervisor viewing this whole
process and simply shaking his head.

a few cultural observations

Any self-respecting anthropologist would look at this list and say
'duh', but considering I never took Anthro 101 in college, here's my
take on a few things which have stood out for me in the previous weeks:

PRIVACY: The western view of privacy and the Zambian view of privacy are
almost diametrically opposite. Most Americans I know value their
privacy, spend their time trying to move to free-standing houses, build
high fences, complain to the police if their neighbors make too much
noise, and would think very hard before inviting their parents to come
live with them. Zambians, on the other hand, find that kind of
existence weird, isolating, and tiring. They can't imagine even wanting
to spend that much time by yourself, or needing that kind of space, or
having to manage to cater for yourself all the time. Alone time is
mostly to be avoided, rather than cherished.

SICKNESS: Zambians can be hard to pin down here; they are much more
willing to suffer through horrible, disfiguring diseases at home for
months or years before they come to the hospital. On the other hand, we
have almost every week someone show up to the hospital 'comatose'
because they just don't feel well so to dramatize that they refuse to
speak, eat, or move. The next day they are almost universally fine.
Westerners generally avoid both extremes of the approach to sickness;
they wouldn't ignore a tumor growing on their cheek until it erodes into
their mouth, but neither do they embrace this exaggerated 'sick role'
that some Zambians feel the need to do.

EFFICIENCY: This would be one of the more obvious differences in culture
here; I've been struggling to try to pursue less efficiency in my daily
life. It's probably the most endearing and most frustrating part of
working with Zambian staff. Lack of efficiency gives priority to the
relationship instead of the schedule; it's lovely to have people drop
what they are doing to spend time with you, and it's very annoying when
things just don't get done for days on end.

I love the things which transcend culture however, but just take on
different forms in different areas -- kids playing hopscotch: at home
with sidewalk chalk, here with patterns drawn into the mud with sticks;
cottage industries: kids selling lemonade at home, kids selling mangoes
from their trees here. And of course Slinkys and balloons, which seem
to cross all cultural lines.

Christmas Time is Here

Merry Christmas!  Our version of poinsettas here -- the flame lily, or 'Doctor's Joy', as Gwen Amborski calls it (she should know, having lived here all her life).  Poinsettas actually bloom around Easter time, so we've got our lilies and Christmas flowers backwards.  These grow wild in the fields around the hospital, and my other Christmas colors are being supplied by the red and green of the gigantic watermelons growing in my garden, the green and gold of the mangoes, and the silver of the evening rain on the trees in the mornings.  (Thank goodness for our internet access, because otherwise no one seems to know when a watermelon is actually ripe.)  Other than that, I've got lots of recordings of Bing Crosby singing about a White Christmas and such to get me in the mood.

Last time I wrote to you all was back in October; we've now passed the one year anniversary of my Mukinge stay.  I got the news that I passed my ER boards, which was good, although a near thing, having momentarily forgotten about the presence of things like CT scanners during my test.  The tests here are still challenging as well, although of different natures, like what's the proper food to serve to a Chief, what is causing the raging fevers of a patient, how best to support the people who come knocking on my door asking for help, or what decision to make about my future that's coming up in now less than a year.

Christmas time for me is always a time to remember gifts that have been given to me; I cannot even believe how blessed and lucky I am to have so many of you thinking of me, giving me the gifts of packages, time, emails, and prayers.  Rarely a week goes by when I don't have some kind of package slip waiting for me in my mailbox here, and it's been a joy to share some of the things from home with the people here from Zambia and elsewhere.  My big load of kids toys is especially fun around Christmas time.  Many of you have supported the work out here financially as well, allowing us to buy a water pump to supply running water to over 30 houses here at Mukinge, several different purchases of much needed medications for the pharmacy, 4 oxygen concentrators, and to remodel an entire house to help retain needed nursing staff for the patients.  Coming up in the year to come we're hoping to remodel two more staff houses as well as the male ward of the hospital.  Potentially we may have found a donor to help us upgrade our operating room facilities as well.  And I think I may redo the tennis court as a Christmas gift to the mission complex as well.

A year has gone by quickly; I blogged a few months ago about lessons that I've learned in a year and I'm struck by how much I've learned and changed in just a short amount of time.  We continue to serve and help as best we can for the people here.  Thank you for your service to me and us over the year.

With much love,
Matt

hail to the chief

We've been having sermons the last few Sundays in chapel on
relationships in various parts in our lives -- with family, friends,
workplace, government -- and one of the things that keeps hitting home
is the importance of respect. I remember in college how my friends from
the East Coast would make comments about relationships in the south as
'fake' or superficial because they placed a emphasis on respect, even
when you don't necessarily like the person who you're dealing with. All
I can say is that the issues you might bring up with Southern culture
are magnified to the Nth degree here.
For example, two weeks ago on Wednesday one of the district chiefs from
north of here showed up to have eye surgery. Unfortunately, he hadn't
coordinated with anyone at the hospital, so the eye surgeon was gone on
a trip, the cell phone service was down, and he had not arranged for any
place to stay or any provision for food or shelter. So I go to meet him
in the reception area, crouch down to the ground, clap my hands, and ask
his entourage what I can do for him, to which I am told 'whatever you
think is appropriate'. I am thinking to myself that it would be fairly
inappropriate in America to show up unannounced and uninvited and expect
someone to take care of you for two weeks, but I remember our chapel
talks on respect and wisely keep these thoughts to myself. I ask them
if they would like to stay in the hospital or stay in the guesthouse in
town a few kilometers away, to which they say 'whatever you think is
appropriate'. I think to myself that probably making him walk the 5
kilometers to town will be seen as 'inappropriate, so I start working to
find a private room for him to stay in. We have two -- one on the labor
ward and one on the female ward. I decide that the female ward room
will be more 'appropriate' than screaming women on labor and delivery,
so we go there. I then ask if they need to eat, to which they say
'whatever you think is appropriate.' I now explain to them that a 33
year-old American male take on appropriate might be a little different
than a 60 year old , requesting a bit more clarification on
'appropriate' and find out that yes, he hasn't managed to pack lunch for
himself. It now being 3 o'clock, our evening meal won't be served for 2
hours, so I go home to find something to cook for the chief. My
refrigerator contains mustard, eggs, green peppers, and potatoes, so I
decide that eggs are probably the safest of those options and make some
scrambled eggs for the chief, with some peppers mixed in. I deliver the
eggs to the private room where he is settling in, thinking that I can
now possibly go see the other 200 patients in the hospital, when the
chief's staff comes out and says that he is not happy because there is
no table on which to eat his eggs. The nurse in charge of the ward and
I look at each other. I suggest the rolling trolley that the nurses
dispense medicine from, but that suggestion is rejected as not
respectful enough. Eventually we decide to move my doctor's office desk
into the room, where he then happily eats his eggs.
Two weeks later, after his eye surgery but not quite long enough for him
to arrange a ride back to where he came from, my desk still missing from
my office, we have needed to spray for cockroaches in the ward. We
arrange for the chief to move to another room so he won't asphyxiate
from the fumes, but again we are told that we are not being respectful.
Fortunately, in the two weeks since his arrival some of the senior
Zambian staff have returned from their meetings and the cell phones are
working again, so I can defer this discussion of respect to one of
them. I am sure that it was handled better than my initial attempts at
appeasement, and we did manage to avoid cultural crisis and still spray
for cockroaches.

cockroach trouble

We've embarked on a number of building projects/remodelling the past
year -- repainting the chapel, installing cooking pots and remodelling
the kitchen, renovation of the Mwilu house, building of an ARV center.
After the kitchen remodel was finished, we decided to use the small
amount of excess money left to conduct a spraying of the entire hospital
to try to cut down on the cockroach numbers. Unfortunately, in order to
spray properly, you have to move all of the patients out of the ward for
3-4 hours, which can be a little problematic for wards like maternity.
Anyway, this week was the turn of the TB ward and peds 2, our
malnutrition ward. The TB ward spraying went smoothly, but peds 2 was a
bit more of a problem -- we sprayed overnight but the cockroaches there,
perhaps stronger from all of the malnutrition food they've been feasting
on for years, merely got angry, starting literally coming out of the
woodwork, covering the walls, jumping out on you, so forth. It was like
a bad scene from Indiana Jones. After some emergency purchasing of
additional bug spray, we managed to collect a bit of cockroaches 2 feet
across and at least 6 inches high. Pretty impressive. This is the time
of year where the bugs rule -- flying termites littering my doorstep
every morning with the remnants of a thousand shed wings, mosquitoes
giving malaria to close to half the hospital, black ants boiling out of
the ground in huge trains, ready to devour anyone who is slow enough to
pause accidentally in their path. I guess the cockroaches were just
upset about being left out of the fun.

the truth is sharper...

We still fight the struggle of getting people to come to grips with HIV
here in Mukinge. This is very much a person-by-person struggle, as all
of the posters and advertisements in the world seem to do little to
convince the village wife that she could conceivably be HIV positive,
much less need treatment for it. We have mandatory offered HIV testing
for all of our TB patients because the co-infection rate is around 70%;
one of my patients today became very angry because we were drawing blood
from her on the ward. This was a blood draw to determine if she would
be healthy enough to start on anti-HIV meds; she'd already had her HIV
test last week. To our surprise, however, she got very angry, claiming
that she'd never given consent for an HIV test and had never been told
her test results. Now, we pretty clearly document our counseling
process, and there were notes from our HIV counsellor on the chart, so I
was pretty sure that she'd been told both about the first blood test and
the results. But she was very adamant, spitting out Kikaonde far too
rapidly for me to follow, so I brought in the HIV counselors to come
talk with her again. After some further questioning, it was pretty
clear that she had gone through the whole counseling process as usual,
but was in such denial about her positive test that she couldn't even
admit that she'd been told the results.

As I was standing there in the nursing station with her and our
counselor, I keep thinking about how I could 'force' her to hear her
test results simply by repeating them again there until I was sure she'd
heard. I really wanted to, to a certain extent. I mean, shouldn't her
husband and children have the option of being tested, even if she was in
denial? Plus, it just seemed like cowardice to run away from the truth
like that. But for her, the truth was really a weapon in the truest
sense of the word, and to wield it like that against her would probably
do irreparable damage to her, as well as to our doctor-patient-hospital
relationship. So we left it alone, with her in her denial.

a disaster in the making

We had our disaster/emergency drill yesterday at the hospital, where we
practice what to do with mass casualty incidents. I had asked one of
our visiting docs to help me plan it and so she had organized several of
the nursing students to come and help. We had notified the nurses to
let them know we would be practicing today so that they could be ready.
What I didn't anticipate was the acting skills of our nursing students.
We drove up a carload of them to our outpatient department, where they
started wailing and keening after having tangled themselves up and
squirting ketchup all over themselves. Our watchmen went into a panic,
as did the chaplains, carrying the students out of the back of the
truck. Someone said that they had seen them all gathering in the
nursing training school just a few minutes before and 'there must have
been some sort of electrocution' that happened there. People were
scurrying left and right, I later found out that the staff in the
business office stopped their work for 30 minutes to pray for the
injured nursing students, and we called a halt to the whole process
after about half an hour to discuss some of the issues that came up.
Note to self: make sure that EVERYONE knows there's a drill on before
conducting one again.

the life you save may be your own

Always wanted to have a Flannery O'Connor title in my blog. This week
has been exhausting, but also pretty satisfying. One of the problems
with medicine at home is the sheer distance of it -- your doctor
presence has to be mediated by white coats, scrubs, ultrasound machines,
tubes, oxygen and so forth. Most people's impression of going to the
hospital is of finding yourself or loved ones 'hooked up' to various
machines, pumps, IV's, catheters, and so forth. Here, some of those
barriers still exist, but often the distance is frightening close --
frightening because it remind you of your own mortality, and frightening
because as a doctor you are working with so little reserve. At home, we
think little of transfusing 5-10 units of blood in the ER, to be
followed by another 30-50 in the OR. Here, I donated blood on Monday
afternoon and transfused that unit of blood that evening while doing
anesthesia on a sick C-section patient, since it was the only unit of
type O blood that we had. On Tuesday I was called to obstetrics because
of a baby who was born who wasn't breathing -- we put a tube down into
his lungs and I spent my lunch break acting as a ventilator until he
picked up enough to breathe on his own. What happens when you're not
there to be the blood bank, or the ventilator, or the doctor to do the
C-section?

Flannery O'Connor was trying to say that our actions have a much bigger
impact on us than they do on other people; perhaps not a complicated
idea, but a profound one nevertheless. The corollary I think also holds
true, however -- if you don't save the lives that you can, you may lose
your own way in the process as well. I think that what I struggle with
here is how exhausting that process can be, especially when you are
stretched thin between work and life and interpersonal relationships
which sometimes take a lot of effort to keep smooth. I have to think
that the lives of others are worth it; what I don't often remember is
that truth that when I seems like I'm just spending myself to the limit,
I'm also saving myself from callousness or ineptitude as well.

email slowdown

Sorry if the blogging has been sparse -- we're having some trouble with
our internet these days, which means I have to travel to the airplane
hanger to do my email, something which is rarely convenient and often
impossible when you're on call, since no one can get in touch with you
there. So sorry if the communication hasn't been so prolific.

malnutrition miracles

We've recently had some opportunities to apply to increasing assistance
and funds to help with the malnutrition problem we see here at the
hospital. For various reasons -- farming patterns, soil deprivation,
cultural stubbornness, chronic diseases like HIV and TB -- there are few
protein sources in Kasempa with resultant rampant malnutrition and
malnutrition deaths. We've recently gotten some help via surprise
deliveries of things like Plumpy'Nut and have also been offered
additional assistance via some of the HIV programs in the area.
Previously I am told that we had been declared a 'malnutrition free'
area by the World Food Programme, so our food supplementation funds had
been cut off. Most of the external donations by private individuals for
the hospital are actually designated for food of some kind.

Our visiting nurse, Kate, who's currently in charge of the malnutrition
ward, and Edgar, the doc in charge, have been working extra hard to come
up with the measurements that they need to secure the funds. These are
things like arm circumference and heights on our adults. Thanks to
their hard work, we're getting closer to maybe getting some more of the
help that we need!

the normal is the weird

People usually ask me at home 'what the normal stuff that you see out there at the hospital?' to which I usually reply things like malaria, or HIV, or pneumonia, or diarrhea.  But in actuality the cases that consume a lot of your time and brainpower are the weird, where you're struck with something you've never had to deal with before and are not even exactly sure where to begin.  Those type of cases are the usual for us, each week having to puzzle through how to take care of a huge urinary mass, or whether you should remove the breasts on a hermaphrodite, or when to do the surgery for a 4 month abdominal gestation.  Those are the things that tropical medicine diplomas can't prepare you for: you rather rely on your ability to be resourceful, puzzle through things on your own, call on remote expert guidance from doctors overseas, and tackle things without knowing all the outcomes beforehand.  Obviously that kind of working without a net doesn't always work out well, but surprisingly it does quite a bit of the time, too.

working life

working life, originally uploaded by mattcotham.

Mukinge is a very out-of-doors kind of hospital; perhaps not as much as
the mud huts that David used to work in with MSF, but I enjoy the
exposure to the wind and rain and sun on my daily rounds. Most ER's at
home have few or no windows -- they were usually added on as
afterthoughts on the ground floors of hospitals and I suppose that the
presence of a window would make sick people uncomfortable, although I
never really understood the logic of that. But here, I can sit out on
the steps outside of ultrasound while I'm waiting for the nurses to
bring a patient for a scan and enjoy the sun on my face for a few
minutes in the middle of my day. Or I can dodge the drips on the
walkways when the rainstorms suddenly hit around 2pm, dancing around the
puddles on the walk and feeling the spray from the gutters on my arms.
It's nice, it keeps me in touch with the outdoors, and it gives some
variety to my day which is sorely lacking at home.

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....