the problem of pain

I was the substitute eye doctor last week as I covered for our executive
director when he got called away into town for a meeting. We ended up
seeing around 200 patients in the two days that we went out into the
community clinics, and most of the time there wasn't much help in
translating, so I was amazed at how 200 people could really pretty much
manage to sum up their complaints in about 5 ways: 1) my eyes hurt, 2)
my eyes feel like there is dust in them, 3) I can only see smoke and
blackness, 4) I can see far away but I get a headache when I read, and
5) People in the distance are blurry but when they get closer I can see
them okay. Maybe that was limited some by my language skills, but
honestly, that managed to sum up close to 190 patients (the other 10
were more fun -- my favorite was the 10 year old girl who was brought in
because she couldn't see when it was dark at night, but when they turned
the lights on she could see okay -- exactly what's the problem there?).
Most people when they present to the hospital don't even describe what's
wrong, they just name the body part -- ie "What's wrong?" "Eyes." (as
if I couldn't have guessed since they were coming to the EYE clinic).
Sometimes this gets pretty funny as you get a list of body parts from
some of the older patients, like learning anatomy: "How are you
today?" "Eyes, neck, chest, stomach, back, legs, arms, head." And when
you see them the next day, it's the same: "How are you feeling today?"
"Eyes." This can be frustrating when you're trying to work out whether
they feel better or worse.
It's funny that the vocabulary to express problems is so limited,
however. At home we're taught to elicit all the parts of someone's pain
-- is it stabbing? burning? like shocks? crampy? and so forth -- but
here there's really just one word for pain and it pretty much sums up
everything. Complaining is not so much of a right. I wonder if like
the Eskimos with their 82-odd words for snow if our vocabulary points
out our fixation on pain in the states, and also being pain-free, where
here the expectation is that pain is part of life, not something to be
dwelt upon.

Bupe

Bupe means 'gift' in Kaonde, which is somewhat appropriate as she's now become quite adept at finding little gifts for herself from our soft-hearted staff on peds 2, the malnutrition ward. Bupe and her family have basically moved to Mukinge over the past year as they've spent more time in the hospital than at home; one of the difficulties with treating malnutrition is that the children often require 1-2 months in the hospital to get better, but then the family can't do the farming at home, so they don't plant their crops and the cycle continues.
Families like Bupe's are part of the reason that we're doing our community intervention to reach families at home, teach them about farming for protein-rich foods (beans and peanuts and soy beans) and hopefully break the cycle before they get to the hospital. We're moving forward -- we've got around 230 families so far, and hope to be able to provide seed for all those families in October.
Projects like this make me worried, although they are good, because of the amount of control that you have to turn over to the community and families and overworked hospital staff now and after I go as well. But the opportunity outweighs the risks, and we're hoping for some miraculous changes in the years to come!

okavango

okavango, originally uploaded by mattcotham.

okavango

okavango, originally uploaded by mattcotham.

okavango

okavango, originally uploaded by mattcotham.

delinquency

delinquency, originally uploaded by mattcotham.

Not to rub it in, but here's a sample of what I've been doing recently:

back again

Blogging is bad when it's too introspective; I've had a hard time find
things worth blogging about the past few weeks after getting back from
vacation with my family. I've started thinking about where I'll be in
December and what life will look like after two years at Mukinge, but at
the same time I seem to find my responsibilities here continuing to
expand -- now spearheading our nutrition outreach, filling in for Jairos
in the mobile eye clinics, helping to orient pharmacists and lab
technicians, neither of which I have much of a clue about -- and so
forth. It's been a relief to have a full complement of doctors around
to take some of the burden of clinical work from me, but it's changed my
day-to-day routine quite a bit. Today and tomorrow we will go to the
villages to teach the community about nutrition, how to make a balanced
diet for their children, and suspend dozens of screaming children from
our scales as we monitor malnutrition in the various areas.

traveling man

This month has been a little bit unusual for me as I take a little
detour from my usual duties of doctoring, seeing patients in the
hospital, doing surgeries, teaching, etc. I've spent most days this
month away from the inpatient duties as we've been going out into the
community to get the community buy-in for nutrition outreaches and
educational programs (more to come soon), I was doing the music for our
SIM retreat, and now am going to head off for a little break with my
folks down to Botswana. Tomorrow I'm off with our executive director to
visit one of our referral hospitals to examine some monetary issues and
get perspective on the medical care they give there. It's good to leave
the hospital because it gives perspective on why I'm working there, but
it always brings up some guilty feelings as you know the people who are
left behind have to work harder to cover for your absence. No decisions
get made in that independent vacuum that we like to fool ourselves into
thinking exists in America; we can do what we like and the only one it
affects is us. That's an unusual perspective compared to most of the
majority world and one that most Zambians have a hard time understanding.

Zamcowboys

Had an unexpected encounter with my visiting neighbor the other day who
styles himself as the 'only Zambian cowboy'. We were able to swap
horseback riding stories (me: trail riding experiences at camp, him:
working in a stable in Lusaka), compared cowboy boots, and discussed the
merits of straw versus felt cowboy hats (me: pro-straw hats in hot
climates; him: pro-felt hat durability). I have to say, I figured when
I came to Mukinge that I would encounter some different cultures, but I
fully did not expect to encounter Texan culture half a world away. He's
gone back to Lusaka now to finish his course in lab technology, at which
point I am completely sure he will be the only Zambian Cowboy Lab Tech
in the country.

Mukinge...and one string

I was reading about and anecdote this week about Paganini giving a
concert where first one, then two, then three of his strings on his
violin broke. He reportedly finished the concert, and then played the
encore on the single remaining string.
Whether the story is true or not, it resonated with what we do here at
the hospital; despite no phones, our water coming and going and often
full of black sludge, intermittent electricity, overflowing toilets,
lack of funding, absence of IV's and syringes and tape and so forth, we
continue to play our concert for the people around us, and hopefully
most days it still sounds, perhaps not Paganini-esque, but like a simple
song of love and care for the people in the hospital, their families,
friends, and relatives. I'm constantly touched when a patient
unexpectedly reminds me that they can hear that song too, even on days
when I feel like the concert has to grind to a halt because too many
strings are broken.
So, here's to Mukinge....on one string!

the three 'selfs'

I've been reading a lot about cross-cultural relationships and service
recently. One of the new watchwords for any overseas mission are the
three 'selfs': self-governing, self-sustaining, and self-propagating.
These principles I think came about as an attempt to learn from previous
mistakes (yes, it can actually happen!) of neo-colonialism and
superiority complexes often brought in the past (and still brought some
by visitors, aid relief, and so forth) with devastating consequences.
Despite how things turned out, no one had a vision to come to Africa and
create dependency, unsustainable solutions, and destroy the local fabric
of society. I think these three 'selfs' provide important safeguards to
ensure that those models of developmental change don't happen again.
I can't help but remain uncomfortable with the three 'self' model,
however, on some fundamental levels. One comes from the nationals
themselves, some of whom have viewed this movement as an abandonment
that they neither asked for or particularly wanted. Is a forced
abandonment such a good thing? On many levels, it ignores the reality
of the economy of poverty in many of the places where these ministries
work. When a family subsists on 1-2 dollars/day, it is ludicrous to
expect any ministry to that area to ever be 'self-sustaining' without
significant economic and infrastructural changes occurring first. This
simple fact is obvious to the nationals who live and work in these
areas, but in an emphasis on 'self-sustaining' and 'self-propagating'
these concerns are swept aside. Jeffrey Sachs makes the point that
poverty has a threshold below which all interventions eventually lead to
nought because they lack the necessary impetus to grow. If that
threshold level has not been reached, a premature transition to
self-sufficiency will result in the ultimate destruction of the services
and ministry in the area. One could ask that very question of the
hospital where I work -- in the rural areas in our province there is
currently ONE Zambian doctor working in the whole province (at our
hospital already, I might add). Most of our patients total income for
the year will likely be between 200-300,000K (around 90-100 USD). Is
that a situation where the local populace can be expected to support a
hospital?
Although perhaps well-intentioned, I feel that the three-self principles
are an attempt to provide a somewhat easy solution to what is a
difficult problem, requiring humility and sensitivity -- how to be
willing to put yourself at the disposal of your Zambian/national
colleagues and trusting them to spend you wisely. How risky is that --
to open your own resources, money, time, professional gifts, and let
someone else in the community decide how they will be spent instead of
you deciding yourself? Such a concept is almost anathema to someone
from the individualistic cultures of the West where donations should be
ear-marked, reported on, and tightly controlled even after the money has
been given. Such a concept leaves you vulnerable to the people from the
other culture perhaps using more of your resources than you intended
them to, or spending them on different priorities, or even perhaps
'wasting' them, at least from your perspective.
I think that kind of partnership, however, is the one that we are
modeled in the Bible (see the Corinthians giving to the Jerusalem
church, for example), and is one that ultimately shows love and trust
for each other in ways that the 'self' model misses.
Self-sustainability is not a realistic goal; even self-propagation is
almost impossible to contemplate. I think we need to abandon that
thinking and instead look for a servant-partnership role for overseas
missions. I think we have a responsibility to continue to be involved
and supportive to the same levels that we were before, even if we are
not 'in charge' in places like Mukinge anymore. I hope that people
haven't chosen to leave places like Mukinge because that was too hard --
a statement something like 'if I can't be in charge of my things, then I
think I'll just take them and go somewhere where I can'. I don't think
that was the case in the past, but the fact remains that Mukinge (and
many other places like it) have been slowly abandoned by their brothers
and sisters in the West.

petty theft

I've become increasingly challenged recently by how I should be handling
theft from my home. The week I left Denver to start to come out here I
had a garage sale where people came by at 6am to steal my stuff before I
could get up; maybe that was preparation for what I've seen out here.
There's a fair amount of it; I've had 4 pairs of shoes, socks, a cell
phone, a water purifier, bungee cords, cement, wire, sprinklers,
shovels, hoes, candles, knives, sunglasses, books, DVDs, and bananas
stolen from my place over the past few months. Most of the stuff was
gifts, or extra things, and I have tried to maintain an attitude of
'enforced generosity -- I probably should have given that stuff away
anyway' to those donations to someone's pocketbook or feet. As Gwen,
who's lived here all her life, points out, people here are very poor.
And she's right, they are. I have an abundance of things, especially in
comparison to the villagers, and most of the things that have been
stolen have not been essentials. But it can be difficult when you're
expecting a phone call to find that your cell phone has been stolen
(especially now that there is no other way of communicating here at
Mukinge with the internet and landline phone systems not working), or to
go play basketball to find your shoes have been stolen so you have to
play barefoot, or to strap something on your bike to find your bungee
cords have been stolen so you have to make 2 trips to carry the things
you needed, or to water the garden to find your sprinkler missing so you
have to water by hand. And it's frustrating when you know they won't
have the batteries to run the purifier, or the charger to recharge the
cell phone, so those things will become useless to them in about a week
as well, doing no one any profit at all. At least I can be comforted
that my shoes, or knives, or candles are probably going to good use
somewhere. So I range between annoyance to acceptance and back again,
and try to hold possessions a little bit more loosely, and try to
remember in between thefts to continue to be generous to people who come
asking for help or money.

cash flow

I find myself in relative penury this past few weeks, although I wince
even as I write that as I look at the people around who are truly in
need while I sit here writing on my laptop with my collection of DVD's
and books in the other room, a freezer full of donated coffee from
overseas, and a pile of blankets on my floor to be given away. That
being said, I've been down to about $10 of cash for about 2 weeks, which
has forced me to make some interesting sacrifices (do I really need
butter on my toast? does the scooter really need to have its chain
repaired? what can I make for Easter dinner out of some potatoes and
evaporated milk?) and also forced me to have some hard conversations
with people when they come asking for assistance, loans, etc. which is
pretty common. I tend to respond to the needs that I have laid in front
of me, which when combined with extra expense for the labor on the
tennis court and lack of transport to the capital from whence all money
flows has put me in a bind.
I'm reminded that 'blessed are the poor' (not that I'm one of the poor,
as is very clear to me here) as per Ms. Hellwig:
- the poor know they are in urgent need of redemption
- the poor know not only their dependence on God but also their
interdependence on other people
- the poor rest their security on people, not things
- the poor have no exaggerated sense of their own importance
- the poor can distinguish between luxuries and necessities
- the poor can wait, because they have acquired patience in waiting for
needs to be filled
- the fears of the poor are more realistic and less exaggerated
- to the poor, the gospel sounds like good news and not like a threat
or scolding
These things are brought home to me right now in ways that I don't
usually feel in the states.

isn't it ironic

isn't it ironic, originally uploaded by mattcotham.

Who would have thought that perhaps one of the least sporty guys in
high-school would be the driving force to construct a tennis and
basketball court in a African town? It's been a bit silly, and a bit
frustrating, and not exactly NBA or Wimbelton standards (although it's
close to a clay court -- eat your heart out, Roland Garros) but it was
finally finished this weekend and christened with a rousing game of
tennis followed by a pickup game of H-O-R-S-E. I'm hoping that it
brings people together and provides some extra life to the community
here. It was really fun to see the kids shrieking in pleasure and
chasing tennis balls around the grass.

Lenten updates

Hey there from Kaonde-land!

It's been a good couple of months for us here at Mukinge, made possible by the fruition of some of the plans that we put together at the beginning of the last year.  Since the last time I wrote back around Christmas time, we've begun construction on the new nursing dormitory, rehabilitation of the administration block, repair of two of the staff houses, construction of a garage for our hospital vehicles, and building of the new HIV counseling center.  At the same time, the weather has caused some problems as we've had issues with lightning resulting in the burnout of our phone system, intermittent power surges, the downfall of our internet system, so we've been back to communicating by written notes carried by hand around the hospital.  It feels pretty good to not be at the mercy of the phone sometimes while on call, I must admit, despite the inefficiency of the current system.  As I remind myself on a daily basis, however, efficiency is not the goal here, but rather the relationships that you cultivate.

We're also in a transition period for staffing as two of our docs have left.  We have been lucky to enjoy the presence of a Canadian surgeon to help ease the transition and the hospital hasn't been too busy recently, so we've been managing well.  We are still facing some shortages at the end of the year when my term finishes at the hospital, especially in regards to surgical coverage and nursing supervisors/teachers.  If you know people interested in coming, let us know!

Mostly, though, I feel grateful for the progress that we've been able to achieve over the past year.  We've bought 7 oxygen concentrators for the hospital, upgraded our maternity care with ultrasounds and fetal monitors, increased our available staff housing by a total of 10 units, began much needed rehabs of different parts of the hospital, and so forth.  You have been generous to help the work go forward here, not to mention the many care packages, encouraging emails, prayers, and postcards I have received over the year.  We are continuing to look forward to exciting projects in the next few months, especially with a nutrition project that is currently in the planning stages to increase our community presence, provide much needed seed to local farmers to grow protein-rich foods like beans and peanuts, and provide education to the area.  I am also trying to raise enough funds to purchase a much needed anesthesia machine which costs around $28,000.  Seems like a big goal, but we'll see what we can do.  We've managed maybe a third of the cost so far!

Despite the comings and goings of people here on the station (mostly goings), I continue to try to strengthen my friendships with my Zambian colleagues, even despite some cultural issues.  We had a good cultural awareness seminar this past weekend which was pretty amusing as I continued to see in black and white how far away I am in my cultural expectations from Zambian culture.  I think across 12 of 13 different cultural attitudes that we quizzed ourselves on, I and the typical Zambian were exactly on opposite ends of the spectrum.  It actually amazes me that I am able to get any work done at all without immense frustrations on both sides, and it's shown me how much I am able to adjust despite ingrained cultural ideas.  It also makes you realize how much unspoken grace you are being shown by the people who work with that you are probably unconsciously offending right and left.  I had the opportunity to work at a nearby mission hospital in January and came away with a profound sense of gratitude for the more graceful way that we have dealt with those cross-cultural issues here at Mukinge over the years.

Thanks to you all.  If I can give any more details on work or things at the hospital, let me know.  We've recently been in the process of updating our website, so you might google 'Mukinge' and see what you get these days!  Don't forget to check the blog at www.mattcotham.blogspot.com. 

Best to you all,
Matt

the smell of progress

I'm surrounded by the smell of progress these days, but progress in
Africa isn't such a great smell all the time. One of my aromatherapy
candles quit quickly and the other was stolen from my coffee table,
leaving behind the tangy ammoniac smell of partially cured goat hide on
my new stool mixed with the turpentine of the varnish on the door which
I commissioned to serve as a basketball backboard. I'm inordinately
proud of this altered dwarf-sized door (short and fat) which may
represent the first major work I have ever knowingly ordered from
anyone, but the smell of varnish is particularly overpowering,
especially when I'm laying on my concrete floor already partially
overcome by the paint fumes of the Brilliant Green for the tennis court
that shredded 6 pairs of gloves and made my hands look like the
Incredible Hulk. I've been trying to scrub off this green hue with my
recent purchase of soap from the BOMA (the grocery store burned down
last month, remember, so everything's local purchases these days) which
is colored black and smells like cough drops. There's little more
disheartening than trying to scrub off green paint with black lather,
which leaves behind a disgusting black soap ring around the bathtub and
a smell of pharmacies without much improvement in the green cracks of my
knuckles or fingernails. But progress is progress, the dead-goat smell
is fading, and the tennis court is (mostly) rain-proof and ready for the
re-inaugural match next weekend.

aromatherapy

I got some aromatherapy candles in the mail today (thank you, Stacy!)
and am currently imbibing the manufactured smell of Vitality, which I
figured I needed after a 2 hour walk back from where my bike got a flat
tire on the way to meet the man who could sell me a door to build the
backboard for the basketball court, turning a 10 minute project into an
afternoon affair. Africa does provide its own aromatherapy much of the
time, from the smell of human sweat (maybe not your idea of
aromatherapy), the smell of burning rubber that we get in the dry season
from the hospital trash pit, or the smell of automobile exhaust that
seems to pervade third world cities. On the other hand, there's the
smell of frangipani (reminds me of the smell of a newly opened pack of
SweetTarts), or maybe fresh basil in my garden, or the smell of overripe
mangoes sitting underneath the trees. I was reading an article about
'smellscapes', where you hire someone to come decorate your home and
suggest smell 'palettes' for each room, or for special occasions, and so
forth. I can't help but think that we've divorced ourselves a little
bit too much from reality at that point. But I'll enjoy the extra dose
of Vitality here while I can.

strings and paper cups

That's about the level of communications these days at Mukinge,
Hopefully our phone system will be up and running soon, the internet
guys coming tomorrow will be able to solve our internet problems, and
the lightning will lay off for a day or two to allow the electrical
system to stabilize.

the keeper of the balls

No, not another off-color reference to the cat neutering....

John Griffiths (and family) left yesterday, appointing me the de facto
sports czar for Mukinge. While we are still working on getting the
tennis court surface finished -- a difficult task given the amount of
rain we've had -- I'm now the proud owner of more sports equipment than
I've probably ever had in my life: basketball, soccerball, rugby ball
(!), volleyball, and several frisbees, not to mention the volleyball and
tennis court net. I say owner, although I'm merely the regulator of all
things sports now, since I have no intention of ever keeping any of
these things. Anyway, I got a little bit of insight into the shifting
world of playground politics as I lent the soccerball to some kids,
expecting to have it returned. No such thing happened, and the next day
some more kids came asking for another ball. I, with visions of an
incipient runaway ball orgy centered around my garden shed, asked for
the first ball to be returned before further balls would be lent out.
This led to a 30 minute discussion with the various tribes of kids on my
doorstep as they accused each other of various things like selling off
the balls, hiding them in their gardens, promises from the departed
Griffiths family to bequeath various balls to different kids, and so
forth. I felt especially bad for some kid named Mpungo, who was
actually the lucky recipient of a soccerball, but who was now disowned
by all of the kids as being no-one's friend, therefore meaning that
no-one could play with his ball, so they needed another one. I'm sure
that just one day ago poor Mpungo had a few friends, but now I'm
picturing him in some lonely front yard kicking his ball to himself.

Well, if the first day is any indication, it will be a short-lived
tenure as the sports czar, except for maybe the basketball and tennis
net. We'll see....

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.