Who's who II

The second installment of the who's who for the hospital: mostly our
nursing staff here.

Liz Bennett -- usually introduces herself as 'they call me bossy
Bennett' for reasons that I don't quite understand; not actually that
bossy at all. Has a love/hate relationship with her computer which I
have become embroiled in, and has a huge heart for our nursing students
here at the hospital. Also has a HUGE cat named Tinker who I think
could probably eat my cat in one gulp if he wanted to.

Jan Matthews -- described as a 'real pot of gold' by one of the visiting
doctors, she's approaching the retirement age but still manages to
giggle like she's 16. She has the ability to put on a semi-miraculous
spread of food at her house with seemingly no effort and is the
instigator of many of the cakes that we eat during tea time. She's been
in Zambia for almost as long as Zambia has been a country. A real
prayer warrior with who knows how many notebooks filled with prayer
requests that go back years.

Michelle Proctor -- everyone's favorite pediatric nurse, with a
fantastically happy black lab named Bouncer because he shares a
Tigger-like enthusiasm for chasing such delicacies as small rocks and
pebbles. Amazing gifts of hospitality. Comes from the land of Beatrix
Potter, who's biography we were (forced) to watch one Friday evening.
She braves the spider-filled cavern of our storage area more than anyone
else. Despite being an excellent nurse and friend, I think she'd quit
the whole shebang to open up a Starbucks branch in Kasempa, if the
opportunity were to arise.

Ruth Green -- assumed the role of youngest medical staff ex-pat from me
when she arrived this summer; from Northern Ireland yet is brave enough
to at least consider going to a Catholic church for services every now
and then. Has an unfortunate lack of knowledge for cooking Irish
delicacies, however, so we're having to remedy that little by little
(taught by non-Irish folks). Willing to help me out by putting feminine
hygiene products that I was asked to buy into her own shopping basket.

Kate Stimson -- a Londoner transplanted to rural Africa; spent the last
two years as a nanny in England while taking a break from her nursing
duties. A good source of British slang like 'brilliant' and 'mental'.
The primary tutor for Ruth's Irish baking deficiencies. Also just
arrived this summer.

Alfonsina Tembo -- one of our dedicated locals who's passing up fame and
fortune to work at a place like Mukinge. Full of sensible ideas and
willing to call you out if you're doing something wrong (ie, drinking
your Coke before you eat your meal). My neighbor and fellow gardener,
along with her duplex-mate Susan. A brilliant laugh.

I could continue to go on for the pharmacy staff, lab staff, business
office, maintenance staff, ZEN's, and so forth, but I'm getting tired.
I think you get the picture that it's very much a team effort here.
Even now as we are putting together this planning document for the
coming year we've had so many different people with different expertise
lend a hand. As John said, it's a good feeling when you're able to
pitch in and help out a bit, even in places that aren't your
'responsibility'. Without everyone, we wouldn't be able to do what we
do on a day-to-day basis.

control freak

One of the interesting things I've noticed about myself is that as I get
more involved with the management at the hospital, I find myself feeling
that things which I used to just shrug off now bother me a bit more. I
think this is because of the illusion of control that doing stuff with
management gives me. For instance, when the power went off for three
days when I first arrived, it didn't bother me very much. We've had a
lot of problems with the power recently as they try to fix some of the
power grid infrastructure, but there's an illusion that I can do
something about it by deciding to run the generator, or call the power
company. Even now that I'm in the communication loop so that I hear
that the power will be switched off and back on at a certain time, when
it goes three hours later, I find myself getting frustrated, when I
think if I didn't know anything I would care less. It's an strange
phenomenon, and I need to learn to let go of things that I have the
illusion of control over, but actually have the exact same amount of
control over that I had in January.

the devil you know

I've got a patient right now with a big white spot on his lung, coughing
up blood, and losing weight. He's been gradually getting worse over the
past few weeks. We are having fairly regular doctors' rounds every
Friday where we discuss cases that we're not sure what to do; one of the
things that we find is that we often make decisions not on necessarily
what we think is going on, but what we think we can treat. So the man
with the spot on his Xray; could be cancer, could be TB, but we can
treat the latter and not the former, so we give him a diagnosis of TB
and treat him as such. Same with the woman with the swollen lymph nodes
in her leg. Or the man with blood in his CSF -- could be a bleed, or
could be encephalitis, but we can only treat the second one.
This obviously leads to overuse of some resources on patients that don't
have the diseases that we are treating them for, and skews our success
rates for treatment of certain diseases. It also makes explaining
prognosis to patients and families difficult (e.g. "I'm going to start
you on some medicine, but I don't really think it will help, since I
don't think you actually have TB"). I struggle with the right way to
approach these patients, however, because I think that false hope and
wastage of resources aren't really good things, but missed diagnosis of
treatable disease is also a bad thing. So we usually err on the side of
treating them.

who's who part 1

As people here at Mukinge get on the internet and take a peek at this
blog, I'm reminded of how often I don't mention the people that I work
with. Part of that is intentional, because I always found it to be very
boring hearing stories about people I'd never met and would likely never
meet. However, it does a disservice to the amount of work everyone puts
in and makes it seem like I'm working in a vacuum, which I assure you
that I'm not. So, at the risk of causing trouble with my brief
portraits of the people that I work with, here's the brief bios of the
admin people and doctors I work with:
Jairos Fumpa: the man in charge, although he refuses to be called the
man in charge, but rather the 'acting' man in charge. That probably
gives you an idea of the kind of man he is: humble, hard-working. He's
been here for a long time now, and is the glue that holds the place
together, the man with the memory of why we decided to do things that
way from 10 years ago. Be careful, though, or he'll whisk that cataract
out of your eye before you can blink. Has about the most outgoing 5
year old son you could ever imagine, who loves his bright yellow
Nigerian outfit.
Kingsley Kuwema: the man trying to keep up with the onslaught of HIV in
the area -- a race against time and before the west gets tired of
funding the effort here in Africa. He runs a math course for adult
education on the side of his house. If you think your building project
was bad, he has been building a house now for ten years in a nearby town
and still hasn't finished -- but he's a man with vision like that. Good
thing for our HIV program, too.
Lynn Hacker: our jack-of-all-trades administrator, nursing supervisor,
OR coordinator, and anesthetist. She's from Wisconsin but her accent
places her someplace between Norway and New Zealand after living out
here for so long. Makes her own bread and seems to have a miraculous
supply of things like decaf coffee which she shares liberally. She
hosts a rather rag-tag group of us every Friday for videos which range
the gamut from a little cheesy to very moving. I'm not sure exactly
where Spy Game fits on that spectrum, though.
David Friend: more African medical experience than the rest of the
doctor staff put together (including our Zambian doctor!). A man with
the ability to make the word 'hmmm" express a thousand different
emotions. Gets big and strong by eating nshima (Zambian corn meal mush)
every day. Somewhat of a health nut (of course, by my standards running
50 feet is a health nut) by getting up around 5:30 every day to go
running in the 40 degree weather. He's the deputy pool director while
he's here.
Edgar Mutimushi: my closest match in terms of experience and medical
training; finished his medical internship last year and reported here in
January out of that. Always with a chuckle and a smile, and a maniac
UNO player (okay, perhaps I exaggerate a bit). Has a very sweet wife
who shares my love for How To Cook Everything.
John Griffiths: you won't see a pair of bushier eyebrows around, but I
should speak softly lest he trounce me even more thoroughly than normal
on the tennis court. I was toying with the idea of making a John
Griffiths day of the week calendar featuring a different button missing
on his shirt daily; the practice of getting them all buttoned in the
morning is difficult for him. Easily the most analytical of us and
well-read; always tracking down answers and challenging you (in a
friendly way) to defend your decisions. Perhaps has a little bit of
poor judgment, however, as he engaged in a American poetry trivia
contest with me, an American and English major. Adopted 2 children from
Russia for a total of 5.

Next week: part 2: the RN's and other folks around the area.

VIP treatment

We had the national police commissioner in the hospital this week after
he arrived after a stroke on Monday. Like most places in the world,
stroke care here is never very satisfying, once the deficits have begun
there's little that you can do, except make sure that it doesn't get
worse. Certainly the lack of CAT scanning makes neurological medicine
feel like you're trying to use an axe to remove a splinter; the tools
you've got just aren't sophisticated enough for the detail that you need
to treat properly.

Certainly we see a fair amount of neurological issues -- right now I've
got 4 women on female ward with various neurological complaints -- one
with high fevers and left arm/leg weakness who we suspect may have a
brain abscess, one with pleasant dementia, not talking, and left leg
weakness who we think may have PML, and two with garden-variety strokes
due to poorly controlled blood pressure. One particularly difficult
situation is the mother whose daughter and mother are both in the
hospital, lying in beds next to each other, one with the suspected brain
abscess and one with a stroke. Her life will change dramatically as she
struggles to care for two invalids at home.

But what was remarkable about the police commissioner was the amount of
people that came by to visit, call, text message, or otherwise inquire
about his status. I'm constantly amazed at the power systems and the
deference given to people of position; from a western perspective it
sometimes seems like toadying, but it's really a different flavor and
emphasis than having a bunch of people come by to see the boss in the
hospital would have at home. It's hard to define, but it's a more
relational concern, and merely marks the co-mingling in so many African
relationships of business and friendship to a degree that we don't have
at home.

Fortunately for me, I survived the onslaught of attention from the
government offices checking up on us (at least I hope that I acquitted
us okay) and he was transferred back to the capital two days ago, where
I hope he arrived well. I'm sure I will hear more follow-up in the days
to come.

the $200,000 patient

Sometimes working in the hospital is like pulling a string out from my
grandmother's crocheted afghan (which I'm missing with the cold weather
right now): you think you're just picking out a loose thread and all of
a sudden whole sections are coming unraveled. Part of the problem of
constantly being underbudgeted (our budget for all the drugs, lab
supplies, X-ray films, and medical stores like IV's, tape, gauze etc. is
$500 this month) is that things are deferred until they can't wait
anymore and then are patched together with whatever solution you can
afford. But later when you try to solve problems, you find that the
problem was actually part of a solution to another problem, so then you
have to fix that one as well, etc.

Case in point: we have trouble keeping our oxygen concentrators working
properly (if anyone knows of a biomedical servicing company that would
be willing to come or that we could send someone to train at, the info
would be appreciated), so back in February I tried to buy three more for
the hospital. One of the nurses that works here, Liz, got her church to
donate another one and pay for the transport. Unfortunately, the
customs clearing house here has a backlog of around two years of
packages that had been sent to the hospital, the local girls school, and
the now-defunct services department, all of which were lumped together
in the same boxes and we owed them around 360 pounds (there's a way to
do the fancy pound sign but I don't know it). So we had to sort out the
different things people owed, much like sorting out a restaurant check
with a bunch of cheapskates who are divving out their 10% for the waitress.

At the same time, we had to get the hospital truck working again so
that we could pick up the boxes; it has two bad tires so we created a
income-generating project to use the truck to raise money for the
tires. At the same time, the battery has gone dead for the truck so
that was borrowed from the generator, but we've had power outages
because the local grass fires have been burning some of the electrical
line poles, so we've needed to use the generator some recently. And of
course, you can't run an oxygen concentrator without electricity, so
we've made it full circle in trying to get the oxygen concentrators here.

Tracing through those threads is difficult even when you've been part of
the decisions to make them; trying to trace through someone else's
decision-making process is nearly impossible. Needless to say, trying
to take care of a small need for one patient often ends up costing much
more and taking a lot longer than you hoped -- I ordered the
concentrators in February, and we will hopefully get them this weekend.

hungry hungry hippos

I took the initiative to expand my language training this week by
scheduling regular meetings with one of the local elders who has taught
several previous 'muzungus' to speak better Kaonde. Steve and Heather,
our local Peace Corps workers, think that it may be effort better spent
elsewhere as there are almost always translators available, and learning
Kikaonde is like learning Icelandic, or Latin -- you're unlikely to ever
find someone to speak with outside of the local area. Even in Zambia,
when I travel to Lusaka I can't really communicate very well. But you
notice a big difference in the way patients see you when you learn the
language; even a few words provokes laughter throughout the ward
(good-natured laughter that you're speaking Kaonde, not laughing because
it's so bad) and smiles and a torrent of information that you just don't
get when you use the translators.

Anyway, I started meeting with Mr. Kapanza this week, and enjoyed my
time immensely. One of the things he's struggling with this year is a
very poor maize crop; although he worked really hard and planted a lot
of maize, about February 3 hippos came and stayed for a week in his
fields, eating all of his hard work, so that he only ended up with maybe
1/10 of what his crop would have been. It's illegal to kill hippos,
although the game wardens are supposed to do it for you if a situation
like that happens. Unfortunately, the wardens didn't show up until even
a week after the hippos had left, obviously at which time the damage had
been done. The hippos returned again 2 weeks ago, a fact which amazes
me since our river isn't that big (maybe 15-20 feet across at the
widest), but the harvest had been finished at that time. The game
wardens once again arrived to late to chase the hippos, so they are
still roaming at large. Maybe they'll show up again if they get hungry
enough....

Holiday time

Hello again to all of you out there in America and far-flung parts of the world!

I realize it's only been a month since I last wrote, and I hope that these emails aren't becoming annoying.  I've been sitting around eating bon-bons this month as I elected to have a vacation and see some of the sights of Zambia with two friends of mine that came out to visit from Denver.  It's holiday season in Zambia as this Friday marks the end of school for 6 weeks until September.  Taking a holiday from work was a good thing just to get a break from the grind of suffering and sickness.  We had our breath taken away by several scenes in the game park and at Victoria Falls, but I won't try to overburden the email server with too many pictures in this email.  Zambia (and Botswana) can be incredibly beautiful, sometimes something you forget when the hospital trash pit smells like burning rubber and you've seen another leg covered in warts, or pus, or burned down to the bone.

That being said, I've been glad to be back at the hospital.  I had missed seeing several of the young teenagers who I had been caring for the past few weeks, and managed to get a few good pictures before they flew the coop.  Hospital life continues to have its share of frustrations -- our water pumps (2 of 3) have broken, so that part of the compound has no water at all, and the rest of us are on water restrictions.  We're trying to get these problems fixed but when things have to come from Lusaka, it moves slowly.  Meanwhile, the people you work with are having trouble even cooking or taking a bath.  I find it difficult to know what the proper response should be -- should I invite 20 people over to my house every day to take a shower?  I think I probably don't end up doing enough for my co-workers.

One of the difficult (maybe the most difficult) part of becoming a government hospital is our requirement to be landlords and provide free housing for all the government staff that work at the hospital, around 100 or so workers.  I feel like I spend a lot of my time trying to solve community living problems rather than medical problems and a lot of our funds are spent on problems like the water pump or fixing toilets, instead of on medicines, etc.  On the other hand, if we are going to make a difference here in Kasempa, one of the major impacts will be how we treat the people that work at the hospital and show them love, provide jobs, allow for fulfilling vocations, and so forth.  You shouldn't run a hospital without first taking care of your nurses, lab technicians, radiographers, doctors, etc, so things like housing are important as well.  But it's a problem that western hospitals don't have to face, and it's frustrating for us, because we don't have the funds to treat all of our workers the way we think they should be treated and we'd like to be treated ourselves.

I've decompressed my clinical workload so that I have more time to spend learning some surgical techniques and so forth.  I'm okay now with skin grafting and closed orthopedic things.  I still need lots of practice with hernias and hydrocoeles, and obviously anything bigger than that is still a little ways off.  But I'm becoming more of a jack-of-all-trades doctor (a 'bush' doctor, as they like to be called) in addition to just becoming a jack-of-all-trades person -- learning some more Kaonde, figuring out the nuts and bolts of computer networks, tinkering with some motorcycle maintenance, doing a bit of gardening, figuring out how to de-worm the cat, learning some African-style hymns to play on piano, and so forth.  I find it difficult to always want to be flexible -- it's nice to be able to define your job and say 'this is what I do', so that you don't get overwhelmed with requests to do other things -- but that approach doesn't work here and you have to be cheerful when something unexpected comes your way (like it does almost every day).

Thanks for your prayers and support.  We are still working on the Friends of Mukinge non-profit donation conduit, thanks to all of you who've been asking.  I will be sure to send out an update when that comes online.  Keep praying for our patients; we have so many for whom we can only do very little. 

I'll close with my GQ shot of me leaning against the frame of the picture with our newly purchased bags of maize.  We are buying up all of our maize for the coming year right now; our cups overflow with corn!  (note the Chuck Taylors)

Love,
Matt

the rumor mill, part deux

I hear today that perhaps the rumors of Judith's death were premature; I
certainly hope so. It made me think about how often I don't really get
follow-up on a lot of the patients that I see; because they live in
rural areas, many times the parents or family won't bring them back to
the hospital if we've told them it's an incurable illness. So then we
only hear through the grapevine that 'that child with X died' from
someone passing through. And with the way communications sometimes work
at Mukinge, even that information might be garbled or not passed on at
all. Anyway, I hope that she's doing fine.

what to do, what to do

Warren Cooper, the visiting surgeon that we had out in February, said
that he dislikes the weekends the most when he goes to visit places,
because he gets bored too easily. I've been filling my time this
weekend watching M*A*S*H on DVD, where they complain about how little
there is to do in Korea and invent little farces to keep themselves
busy. They seem to spend the rest of their time staying up all night to
sit at the bedside of a patient who's sick or operating '17 hours
straight'. I feel a little bit guilty spending my Saturday watching a
70's TV show when I'm supposed to be 'doing something' with my time
here; the simple fact of the matter, however, is that a day to sleep in
until 8am and not be hounded by folks asking for money or favors can be
a real blessing at times here. I'm certainly not cut out to stay up all
night multiple times during the week; even this week after spending just
part of 4 nights up doing anesthesia I was tired. Even though I'm on
call and have to stay close to home, the difference psychologically
between going into work and not going in can be very important. I try
not to feel too guilty that I don't measure up to the standards of the
TV doctors or even some of the missionary doctors you read about, at
least the way that their biographers would like to make you think they
worked. Certainly most days I enjoy the visitors and kids playing and
the work and the patients, but you do need a break. So here's to BJ and
Trapper and Hawkeye for another weekend or two.

just couldn't resist

just couldn't resist, originally uploaded by mattcotham.

A few of the patients that I've taken care of recently. This is Judith,

who had severe nephrotic syndrome. She died a few weeks after this picture.

a few more

a few more, originally uploaded by mattcotham.

I sent a picture of Tom a few weeks ago; he was affected paralysis of

unclear cause. Despite a lot of prayers and exploratory surgery, he

never got much better, although remained cheerful throughout it all. He

went home today.

Maize collection

Maize collection, originally uploaded by mattcotham.

We are currently in the process of buying the 400 odd bags of maize that

we will use for the coming year to feed our patients. Here's a few of

the bags.

the spectacular sunsets continue

the spectacular sunsets continue, originally uploaded by mattcotham.

Still getting beautiful sunsets nearly everyday. This is my backyard again.

Coming soon....bungee jumping video!

maternal death

We had our first maternal death in close to two years in the hospital
yesterday, a fact which is remarkable in itself, although we did have a
second case about three months ago of a woman who died en route to the
hospital. Most hospitals in Zambia have maternal deaths approximately
every 2-3 months, so a stretch of 24 months is really exceptional and a
testament to good medical care over the past two years by our maternity
staff. Our case yesterday was a difficult one where the woman came in
talking and in labor; Dr. John was discussing tubal ligation with her,
turned away for a few minutes, and when he came back she was not
breathing and had no pulse. I got a call while working in the theater
that they needed a laryngoscope and someone to help, so I grabbed the
equipment to find John doing CPR on a blue patient in the dim light of a
60 watt bulb with about a dozen of the nursing students and nursing
staff standing around looking frightened and unsure of themselves. I
tried to intubate her without suction and was unable to see the cords, I
asked for a scalpel and after a couple of minutes was brought one; a
minute later we delivered the baby but it was dead as well. We managed
to get the suction working and intubated her and continued CPR for a few
minutes, but didn't manage to bring her back. I stitched up her wounds
while John went to talk to the family and the nursing staff helped to
clean up the mess of blood on the bed.
Today John and I had a discussion about doing the peri-mortem C-section
on the patient; it's one of the heroic measures that I've been taught in
emergency medicine but I had to admit that I had the thought about
whether it was the right thing to do -- possibly deliver the ninth baby
to a father without a mother, little funds for infant formula, probably
limited family support, and so forth. But I just couldn't be that
utilitarian in the situation without more information.
The father is a local elder in a nearby church; he was remarkably
phlegmatic about his wife and child's death. We will have a lot of
processing to do as a hospital staff about how we feel and if we could
have done anything differently.

the magnitude of the task

Having Hilary and Tay out here for a visit gave me the opportunity to
reflect on the way things are at Mukinge. Working in a hospital like
Mukinge is a challenge, because in order to stay sane and not completely
frustrated with things, you have to be willing to accept things as they
are. Otherwise, you get this mounting frustration which is compounded
daily by the way things are done or not done. Everywhere you look at a
place like Mukinge there's room for improvement -- better screening for
our HIV infected mothers, better management of seizure disorders, better
referral systems for people that are too sick for us to take care of,
better nursing care of paralyzed people, better education of our student
nurses, better use of our pharmacy and stores equipment, better upkeep
of our infrastructure, better records keeping for our patients, better
educational programs for our clinical staff. And you can pick one
project and try to make it work, and make little progress, and then get
distracted or put onto another project which seems more urgent. A great
example of this is the reform of the records system which I tried to
help out back in February (see the blog 'computer seances'); we had a
computer donated and tried to put together an electronic register.
However, there was a feeling by the clerks that they didn't have enough
time to do it, there was little supervision of the project because I was
too busy, the computer started to malfunction, and eventually it was let
to die a quiet death as I got caught up in trying to improve our airway
management skills, and so forth. Now we have hired a new stores manager
to help manage our inventory and help plan for shortages, something we
desperately need at the hospital; he was sent for a course by one of the
departed missionaries to help him learn. However, the quality of
education in Zambia is such that he learned little useful for working in
Mukinge in his course, so we have to redo the education that he went
through. Now, I could choose to help him learn his job, but it would
mean the neglect of the rest of my duties at the hospital to a certain
extent. So instead I choose to meet with him for an hour or two per
week, which is not nearly enough to get the job done, but is the most I
can spare for now. You pick your battles, and hope they don't pick you.

back to the grind

Back in the hospital after my respite. Had some magical moments with
Tay and Hilary, some of which were captured on film and some of which
will remain only in my head, and then packed them back on the mission
plane and headed back to the hospital. We're changing things up again
in terms of assignments (the ER doc in me can't stay in one place too
long) so my workload should get more interesting and more varied
starting tomorrow; not as much inpatient work, more surgery, and more
time in the outpatient department. I've got it structured so I can
spend an afternoon a week doing a little language study as well. I'd
like to continue to improve my Kikaonde, although it feels a little like
learning cuneiform or something like that at times; useful in a small
set of circumstances, but not exactly generally applicable.

Having vacation has reminded me of a lot of the things that I love about
this place; I need to work to enjoy those things more while I'm here and
back off a little on the work, I think. Zambia is full of incredible
moments like dancing with the kids in the village to the radio of the
truck, seeing the sunset over the Chobe river, or picking my lettuce and
snap peas out of my garden while my cat chases the chickens. I think a
little healthy balance is good.

trip photos, part 2

trip photos, part 2, originally uploaded by mattcotham.

vacation photos, part 4

vacation photos, part 4, originally uploaded by mattcotham.

vacation shots, part 6

vacation shots, part 6, originally uploaded by mattcotham.

Vacation shots, part 1

Vacation shots, part 1, originally uploaded by mattcotham.

Despite the risk of making you think that I've got it too easy here, I'm

sending on a few photos of my recent trip to Victoria Falls and Chobe

National Park in Botswana. Pretty spectacular trip.

vacation photos, part 5

vacation photos, part 5, originally uploaded by mattcotham.

zambian solidarity

zambian solidarity, originally uploaded by mattcotham.

Bought a new Zambian hat like lots of the guys wear around here.

Nothing like rubbing shoulders with a Zambian for 7 hours in the bus to

make you feel connected with him.

vacation photos, part 3

vacation photos, part 3, originally uploaded by mattcotham.

bungee

bungee, originally uploaded by mattcotham.

if I can ever figure out to post video, will send this one on. That

would be me.

7/7/7

An auspicious day for a 16 hour bus ride, if any day could be an
auspicious day to sit on a bus for so long. When you travel via bus to
Lusaka, you get up at 3:30 to catch the 4am bus to the nearby city,
Solwezi. This is the same bus I took back in March, which has to be the
most maddening bus ever because it picks you up at 4, but doesn't leave
until 6. You may ask, 'Matt, why don't you just catch it at 6, then',
but it drives 5km away and sits there for the 2 hours, so that it's not
really practical to go find it at 6am. Anyway, I made it onto Mark's
Motors (pronounced Max Motors, don't ask me why) at 8:30, managed to
score the seat on the back row that faced the aisle so I could stretch
out my legs, and settled in with my iPod for the trip.
Travelling by bus is one of the best ways to get a sense of the country;
you see Africa 1st-hand, sometimes really close-up, like when I was
holding the baby of the woman sitting next to me, or reading about the
uncle who wanted to marry his niece on my next-door neighbor's paper
(the lead article for the day). But nevertheless, I was ready for a
break from Africa at the end of all that time, so I was glad to see the
smog and lights of Lusaka in the distance.
Now I'm back at the first place I saw when I came to Zambia. It's not
quite full circle, but it is an opportunity for reflection, remembering
the days of sweating and swatting mosquitoes. Hard to remember all
those too hot days when it's 40 degrees outside now and I've got only
two sweaters to my name. I nearly was down to one after a woman in the
hospital got pretty angry with me this week when I declined to give the
one I was wearing to her. I feel much more comfortable and more
uncomfortable than I did 6 months ago; just having some Zambian Kwacha
and a basic grasp of the language goes a long way to feeling
comfortable. I don't feel nearly as much out of place as I did, and
there are few places that I could go where I wouldn't know anyone
around. On the other hand, I get more uncomfortable with the limits of
what I can provide for the patients at the hospital, more uncomfortable
with the sense of entitlement that I get from some Zambians, and
uncomfortable with how some of the ex-pats have responded to their
Zambian brothers and sisters.
Although there's no more marathon bus rides in the future, I guess my
journey in Zambia still has a long way to go.

vacation time

I left for vacation yesterday for 10 days to clear my head and get away
from Mukinge. As such a small place, it's good to take a break every
now and then; the life gets a bit claustrophobic at times. We had an
extended weekend last weekend; I asked one of the Zambian nurses what
she did for the weekend and she somewhat grumpily replied 'there's
nothing to do here'. Certainly there's more opportunities for
entertainment for me with DVD's and the computer age and the advent of
the internet these days. But it's still good to take a break from
personalities and the grind of work and the depressing nature of the
patients that you can't do much for and don't get better.
At the same time, vacation feels a little bit guilty, just because you
spend a fair amount on yourself. This is magnified by the opportunity
to come to Lusaka where there are well-stocked stores; I've been
accumulating a list of things to get for the past 6 months, so you end
up doing 6 months worth of shopping in one day, which makes me feel
frivolous and like I'm spending too much on myself. It's a lot easier
to buy things here and there; the psychological impact of all that money
that you spend on yourself is lessened and you don't feel nearly as
guilty about it all. And all the stuff is not essentials -- you can buy
flour and cabbage and corn at home -- but the little extras that make
things nice; a mixing bowl so that I don't have to use my stewpot, or
some olive oil, or toys for the cat so he doesn't shred my ironing
board. My biggest guilty pleasure will be a mattress if I can figure
out how to arrange it. It's a tough balance between being comfortable
and being a good steward of your money, especially when there are needs
for people to go to school, or to buy blankets for their kids when it's
cold, or requests for loans to put a door on their house.

burning days/burning haze

Hello to all my friends and supporters out there!

It's been some time since I last wrote; since then the days have gotten shorter and colder (it gets down to 40 degrees at night!) and now that the rains have been finished for about 3 months the burning season has begun.  Burning season is marked by the advent of small children running around with flaming sticks and setting the grass and fields on fire.  Ostensibly this is to prepare the fields for next year, but as I remember from my days as a Boy Scout where we burned down part of someone's ranch, small boys need little excuse to go around burning things.  This season has its good and bad points -- beautiful sunsets at the hospital, but accompanied by the smell of burning rubber.

Work has continued to be a source of challenge and satisfaction for me out here.  As you may well imagine, with limited entertainment and diversionary activities, I spend a fair amount of time obsessing about various cases and what to do, with some successes and failures.  We've diagnosed a case of leprosy, which was good since we can treat it, and lots of cases of cancer, which are challenging because people often present to the hospital so late that we could do little for them even if we had the treatment.  Tragically, in the era of AIDS, many of these cases occur in young men and women who are 30 or below -- lymphoma, parotid tumors, cervical cancer, KS -- and there is a lot of life left to be lived for many of them.  As one of the doctors here says, "There's not many fairy-tale endings in Africa", which is very true for most of our patients, despite the lucky few who we can diagnose with a problem that we can fix.

We continue to try to shake things up clinically, so I've been back in charge of the male and female wards and the TB ward, which for the most part I've enjoyed.  I've also had a few stints as the acting executive director since the current ED has been away on trips out of the country; it's given me the chance to meet with some of my counterparts at the district and provincial levels, which has been eye-opening for me and also a good source of contacts and information for things that could help out our patients.  The meetings themselves are intensely frustrating for me on a personal level, as it seems that very little actually gets accomplished despite a lot of people talking, and also some of the attitudes of the Zambians in charge can be disheartening (the last meeting I was at one mentioned that he'd like to get a scholarship to do some training overseas, so that 'he could get some rest and maybe come home with a car".)  That's in contrast, however, with the people that I work with who go very much beyond what is reasonable in dedication to their projects and patients, spending time away from their families, spending personal resources, and extra time on the job here to get things done.

We're at the beginning of planning for the coming year, which is a unique time and I'm glad that I can be a part of that, although who knows whether the promised funding from the government will come through.  Finances, as usual, are an issue at the hospital, but fund-raising efforts from home continue to go well and my charitable organization should be off the ground soon.  Thanks for all your generous support!  We're still progressing towards our goal of around $30,000 for capital projects here at the hospital.  We are continuing in need of manpower, especially nurses, a laboratory supervisor, and soon to come, a pharmacist.

I'll cut it short there.  If you want more thoughts, etc, don't forget the blog at www.mattcotham.blogspot.com.  It's got pictures now.  You can also see an aerial view of the hospital on google earth if you look up Kasempa -- we're just a few km south where the airstrip makes a big 'X'.  The satellite email system is here, but in a limited capacity; hopefully to be expanded soon.

Talk to you all soon.  I'll end with a picture of David, our surgeon, and a man who we constructed a prosthesis for after he got an amputation when he was involved in a motor vehicle crash.  It's maybe not that pretty, but he was very happy.

Matt

travelling mercies

A lot of our management team was away this week, so I had the privilege of attending the organizational meeting for the local measles vaccination campaign that will happen next month.  It was an interesting meeting as we try to sort through logistics of getting vaccines that need to be refrigerated out to rural health clinics without power, much less refrigerators, often 40-50 miles away down roads that take several hours to traverse.  We also have to try to recruit staff for the administration of the vaccine, even when we don't have staff to run the hospital or local clinics.
Anyway, as many Zambian meetings do, this one started an hour late and ran over into the lunch hour.  I am still without my motorbike and so was walking back the 3 miles from town back to the hospital, and was a little hungry.  As I walked through the charred stubble that is most of our fields, trying to avoid the clouds of dust that get whipped around by our cold season winds, with my stomach rumbling a bit, I couldn't help but think again about all of our patients who often have to walk or bike those miles when sick, or in labor, or anemic, or with HIV wasting.  Many of our HIV patients are around 60-80lbs.  A few months ago, I took care of a woman who had been referred to us by Mufumbwe hospital, a local district hospital even more rural than us without a doctor that works there.  She was too sick for them to take care of, so they wanted to send her to us.  However, they didn't have transport available, so she was discharged from the hospital, placed on the back of a bicycle, and forced to cycle for three days to reach us with her family.  Keep in mind that this was a woman who was too sick to stay there.  Anyway, they made it to us, and eventually recovered.  That's in contrast to the women who our student nurses took care of at a local clinic, pregnant and with malaria, but there was no malaria medications at the clinic, the ambulance was broken down, and she died before it could be fixed and come and get her.  In keeping with local custom, the husband cut out the baby from the dead woman so that it could be buried separately. 

Tom

Tom, originally uploaded by mattcotham.

This is a picture of Tom, who I blogged about on Monday