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.

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.