A day in the Life of a Visiting doc in Rwanda March 2005

Kibogora Pediatrics, PC

This is a ‘day in the life’ at Kibogora for a visiting American pediatrician.

6:10 AM: Another day in paradise. It is daylight. It is always daylight after 6AM and before 6PM. Kibogora is somewhat south of the equator but the days are almost identical in length. One can and does set one’s clock by the sun.
Step One: is there electricity? Most days there is and that makes life easier.
Step Two: is there water? Better by far to learn that the water is off before you flush the toilet (for what may be the last time is hours.)
Step Three: Unlock kitchen door for Simeone (pronounced Sim-e-OH-nee), our kitchen help. He will work most of the day but leaves in the early afternoon and will lock up, pushing the key under the door.
Step Four: A quick wash up before breakfast is on the table: Rwandan coffee (dark roasted and pungent), toast, local fruit (small bananas, pineapple and papaya) with yogurt and water (I never seem to be able to drink enough).
7:20AM Leave my laundry (to be done in a venerable Maytag complete with electric mangle) for the muganda, the outside worker cum launderer.

Start my commute to the hospital. The front gate of the hospital is within sight from the front of the house but actually getting there requires a walk over the ‘hump,’ up and down a hill that is the spine of the Kibogora peninsula. I lock the front door and keep the key to let myself back in after Simeone leaves. (Africa: the land of keys). As I go I see the small flock of greenbuls, robin-like birds with the attitude of blue jays. They have started their bickering at dawn and will continue except during the hottest time after noon. It is important to watch one’s step as the fallen guava or grenadilla (passion fruit) make the brick walkway hazardous for the unwary. I unbolt the gate as I go through. Our zamu (guards) have been up all night making their rounds among the several houses which make up the compound. The missionaries, their families and single female nurses live in housing within the compound. An attempted armed break-in at Dr. Belindwa’s home 2 weeks ago has people scandalized. His mother used this as an excuse to come from Congo to visit her son…and daughter-in-law of 2 weeks duration. At the hospital gate I will greet the guard with a “Muramutse”, as it is morning.

7:30AM Morning Prayers: At least one song (sung in Kinyarwanda) and a homily by one of the hospital chaplains or a visitor. This may be translated but usually not.
“Morning report” amounts to a reading of the admissions from a log…in French. There is no discussion.

8:00AM Rounds start. We have a full team today: Dr Thompson, a family practice resident from Orlando; Dr Archippes Belindwa, a recent graduate from Congo, a staff nurse, Martin, and myself. I usually start in Maternity, which is where they keep the premature infants, my major interest. I have been following a set of twins born 2 months early and weighing about 3 Ibs a piece. At two weeks old, they are doing well with their tube feedings every 2 hours. Mother is there to provide. There is no storage refrigerator. They are replaced into a wooden incubator powered by 2 lightbulbs (that is to say NOW 2 lightbulbs, as when I arrived there was only one working. Who knows for how long.) Since there has been electricity I believe they have been warm enough but I have yet to be sure that the idea has been accepted that these babies need to be warm EVEN IF the electricity goes out. It seems absurd that I am worried about temperature in the tropics but indeed that lesson is probably the most important one given.

I was asked to keep an eye on an adult patient who I have been feeding through a jejunal tube. He has been so poorly nourished that he does not heal his wounds after surgery. A feeding tube was placed directly into his intestine and I have been tasked with getting him nourished enough to heal some of his massive surgical wounds. We have been going at it a week and are just now getting into target range or 3000 calories a day. He is skin and bones, every rib standing out and looking like a scarecrow. He is complaining that he wants to walk around a little. I write the order.

Finally to Pediatrics, all the way at the bottom of the hill near the garbage fires and the latrine. Children are always give short shrift, even in third world countries. The ward consists of five rooms with about six beds placed down each side. There is a three feet clearance down the middle and 4-6 inches between the beds. This however can represent about 15-18 patients, as sometimes there are two patients (meaning 4 people) per bed. A parent and usually at least one sibling accompany each patient. Fortunately, at Kibogora there are no beds on the floor; unfortunately this is because there is not enough floor. The windows are unscreened but every bed has a mosquito net suspended above it, giving the appearance of a flock of blue hammocks roosting, suspended about 3 feet off the ground when “up” for rounds. Each room exits onto a wide, covered walkway with a view down the hill to the hospital gardens. Patients or their families may pay off some of the fees by working in the garden, which in turn supplies some of the food for the patients.

Rounds are conducted in an Anglo-Franco- kiSwahili-Kinyarwanda pidgin, which is a hoot. It can take a long time to get ideas exchanged. The ‘educated’ language is French and only occasional individuals have even a little schoolbook English. I find that if I am careful to use very precise English medical terms, they are frequently recognizably good French medical terms. When we each slip into slang, the troubles begin. I have learned to read enough medical French to get through a typical admission note, bad writing and all. The frustration levels were lowered once I learned to use the French terms. (Thank you Agatha Christie and Hercule Poirot.)

Most patients have malaria or have had it within the last six months. Quinine is the most common treatment for resistant “P. falciparum” malaria, the bad kind. I haven’t seen any of the good kind (P. ovale, P. malaria, or P. vivax) since arriving however. Most are therefore anemic. We don’t transfuse for any hemoglobin above 7 gm%. We have no blood available about 4 of 7 days on average. Last night a woman died because of its unavailability. Occasionally cerebral malaria is encountered. Very discouraging work, that. A six-year-old with convulsions was brought in. When I saw her 2 days later, the quinine had dropped the fever but she was comatose and rigid. I was more startled when I went to examine her. Every area of her body from head to legs was covered in cuts varying from 3-12 CMS. They are administered by a healer (what in less politically correct times we might have described as a witch doctor). He is obviously quite skilled. None of the cuts goes all the way through the dermis. By now I have seen any number of these wounds and they all seem to heal without infection. Since she has gotten over her malaria she has been unable to walk or talk or follow directions. Over last weekend she started eating, the day after we prayed with the family for her healing.

The pediatric wards have a huge variety of diseases once one gets beyond the malaria, intestinal parasites (of several persuasions) and occasion miocrofilariasis. Some of the severity of illness harkens back to my internship. A 12-year old has a cough, weight loss and night sweats and the consumptive demeanor to make a Mimi jealous. On exam she has all the auscultory signs of cavitary tuberculosis including egophony. Three days on quadruple therapy and her fever is gone, she is gaining weight and a smile has returned. She has 5 more weeks of isolation before she can go home. Another 11 year-old comes in with a mother who tells in voluminous detail how her cough keeps her up at night. She is blue, dyspneic and her hands are cold. She has a thready pulse and ascites, which throws her off balance as she walks. She has pneumonia of course but also rheumatic heart valve disease (PS, PI, MS). After 3 days of digoxin and amoxicillin she has lost about 9lbs (15% of her entire weight), reduced ascites, has opened up her right middle lobe and sleeps through the night.

Other diseases are familiar from my previous assignments to mission hospitals. Kwashiorkor, severe malnutrition causing red hair swelling, fluid retention, apathy and susceptibility to infection is sort of an old friend. I lost about 3 children a week to it when I was in Zambia in 2001. So far I haven’t lost any of my kwashiorkor patients. It is indeed nice to work in an affluent country. We haven’t run out of milk powder since I’ve been here.

Today however, was a red-letter day. I sent home “Mother Teresa.” She is a twelve year old girl who weighs about 15kg (33lbs). She was already in hospital since before I arrived. I would find her all over the hospital (climbing up and down the equivalent of 3-4 flights) dressed in the same dress with a shawl over her head. She kept losing weight. It developed into a bit of a cat and mouse game between us. I would forbid, coax, cajole, make funny faces, and pretend to cry when I directed her to squeeze my hands. She would reply that I was a grown man and she didn’t believe I should cry. I bribed her with toy balloons, bread from one of the waduka (shops), and when all else failed threatened her with a “sonde,” a naso-gastric tube. It took one experience and she knew she could not count on the crazy umuzungu to act civilized…so she started to eat. She has gained a kilo and a half since the showdown and smiles at me, walks with me and gives me hugs when I am near her rather diminutive height. I learned that her mother had abandoned her in hospital at the beginning of her stay. Mother showed up today. Teresa is to return in two weeks. I presented her with a throwaway camera to bring back with her. I have arranged with one of the national doctors to forward the film on to me.

AIDS is alive and well in Rwanda. The prevalence is about 30% and of my patients, about 10% are affected at any one time. Many are merely dwindling down and admitted for malnutrition. One little 6 month old has what I think to be a fungal infection. He was deteriorating daily before we took the potentially dangerous step of using Amphotericin even without a culture (not available here). He has been afebrile for the first time in a week and has started eating again.

We see each patient, discharge the willing and listen to the new admissions and to their mothers; the air is hot and moist, the children are all dressed for Michigan in February. After the two acute wards we do the gastroenteritis wards and finally Isolation. We averaged 65 patients/ day last week. This week the load is less and about half the time I can finish by noon. Some of the time rounds are interrupted by the huge rainstorms that sweep up from Burundi. It is impossible to hear enough to continue until the storm passes. At noon the resident and I are expected to have lunch at one of the houses. This is the major meal of the day and usually well worth the 7-8 flights of stairs to get to it. Today talapia, potatoes, carrots and green beans, carrot cake and tea. (“Go to Africa, Treat Malnutrition, Get Fat!”).

We will not restart rounds “until 14;” 2pm. I return to the house and try to be cool. The house is about 85F and the humidity is 60-70% until a storm comes by to cool things off briefly. I spend my time usually reading Manson’s Tropical Medicine or learning a little Kinyarwanda. Frank Ogden usually takes a siesta. Very civilized. By “14” the air is no cooler but lunch is well digested and we start again. We are almost always finished by 5PM in time for a short breather, shower and time to appreciate the sunset before dinner at 6:15PM.

Tonight I am to have supper at the Sudell’s, a family that has come for a year from Lancashire, UK. From thence they have brought a love of football (soccer) and table tennis as well as a profound distrust of things Scottish (at least on David’s part this having much to do with a disputed football match some years ago). It was he and his youngest, Emily (Ems) who picked me up in Kigali and got me here. The Sudell’s are tall and unrelentingly blond: John 16, Phillip 14, Ems (10) and Mary, the mother of them all. David has been involved with setting the “station to rights” and a building project among the Ba-Twa, the pygmy-oid indigenous people of the area.

Supper is light: soup & salad. After dinner we gamble…for who does the dishes. My losing streak is finally broken and David is elected. He has the good grace to grumble about it, which grumbling makes us all feel well out of it. Sunday and Thursday night we have a Bible study. Once or twice a week we will see (again) one of the recorded movies available. Tonight however, I must go back to the house.

The paths among the houses are quite dark and one of these announces “N’amakuru.” I call back to the zamu, “N’ mesa.” (“What’s the news?”… “It is good.”) There are a few fireflies in the grass and rather more toads of impressive dimensions trying to have them down for “light” dinner. I hear out over the lake the fishermen “singing to the fish” as the three-hulled fishing boats slowly seine Lake Kivu. There are drums on Ijwa tonight. The clouds over Congo are lit every few seconds with lightning but no thunder. Overhead the sky is clear. Jupiter is climbing, Orion is falling and the Southern Cross wheels about the Milky Way. I come in and sit down to write: “This is a ‘day in the life’ at Kibogora…”

Traveling home from Rwanda April 2005

The major problem with travelling home is the mindset one can get into. It is one thing to be ready to leave and quite another to have already left, except for the body, which lingers until your ride comes. It is best to ‘discover’ that you are scheduled to leave on the morrow and only then to bend your thoughts in that direction. The decisions regarding ‘what goes and what stays’ are probably only marginally poorer than that provided by deep deliberation.

Judging by the eclectic assemblage of clothes that adorn the population, many people appear to lighten their load by giving away t-shirts and sweatpants. A nice shirt I saw in church read “I’m too sexy for my hair …That’s why it’s not there.” I’m not sure she could read English. T-shirts with commercial appeals are the most common of course, followed closely by European football clubs and American supermarkets.

I was able to pack all that I had left in one of the two suitcases with which I had come primarily because I dropped off donated and requested items in Kibogora: blood pressure cuffs, used eyeglasses, drugs, DVD’s, ketchup and brown sugar.

I was scheduled to be taken to Butara from Kibogora the morning of the 26th April. This was done to allow me to catch a ride with the Ogden’s (Dr. Frank and Carol) who were coming up from Burundi on their way to Kigali to swap cars with David Sudell and bring back some building supplies and a Burundian surgeon, Dr. Kaganga, to work at Kibogora for a while. If this sounds complicated, it pales in comparison to the actuality. Travel in Africa is typically complicated enough to tax your logical capacities. In addition someone is always coming up with a last minute request or problem to add to your ‘to do’ list on arrival. I was to be ‘on the porch’ at the Hotel Ibis in Butara at 5:30PM. There was no plan “B.”

I was driven by the hospital’s driver, Innocent, the three hours from Kibogora to Butara, the old capitol of Rwana-Urundi colony prior to the 1963 independence. He speaks little English but we get by with an argot of several languages. We worked our way out of the Kiva Lake area, past Gataca Church (which has it’s new roof) up the road to N’amasheka and to the paved highway in about 45 minutes. From there we started to climb. This is the tea-growing area. Huge farms are seen with the typical green “cushions” of tea plants, row upon row, going up impossible hillsides. A man from N’amesheka was brought in Saturday after a tea branch he was pruning with his ‘ponga’ snapped back into his eye. He noted that his vision deteriorated for two days before coming in. He has a well-developed cataract now and is blind in that eye.

We rapidly enter the jungle at the top of the grade and run into several military patrols. They are said to be there to prevent poaching in the jungle. Rwanda has published the plan that they will turn the entire area into a tourist destination, limit access by road (thus adding about two hours to the six that it now takes to get to Kibogora), and build some tourist hotels. The reason most people think that they are there is to prevent infiltration from Hutu rebels in Congo. Whatever the reason, we enjoy it while we may. The temperature drops about twenty degrees and we stop for several troops of colobus monkeys, black and white along the road but not much taken with becoming photographic subjects. The two hours consists of good roads winding up to impressive overlooks before descending into a liana-choked forest. Gangs of men pile logs along the road. None of the logs shows the marks of anything but a ponga. We do see a couple of men gleaming with sweat in the morning coolness, at a makeshift saw-pit using the deep gully at the side of the road to take planks off a 3 foot wide mookwa log.

We still see people with huge head loads. Very different from rural Zambia or Kenya, both men and women carry on their heads. This leaves their hands free for other loads and balance. Some of these loads are huge bulky bundles of leaves or lumber. Some are just silly: a single umbrella or hoe. They are most usually carried on a head ring made by each person out of banana leaves. They are quick and easy to construct and frequently discarded on the road at the end of a trip. Not surprisingly, posture here is excellent. The next step-up in mass transportation is the wheelbarrow. This vehicle bears no relation to any similarly named item from Lowe’s. It is of home manufacture, with a solid wooden tire on a wheel scavenged from some vehicle. The bed is made of sticks, roughly shaped to make a platform that is canted slightly at the front end by about 10 degrees. It is used by typically two-men to carry wood, potatoes, charcoal or produce. One pulls and the other pushes. I saw a gang resting on the long hill going up to Tyavo last week and motioned that I would like to try to move it. The pusher, a very muscular young guy who was streaming in sweat and heaving huge breathes, gladly realized the “Tom Sawyer” potential and let me have at it. The handles are widely spaced and sturdy. With the help of the puller, I was able to get it up to trotting speed fairly quickly but it was quite unstable even so. I was able to get another hundred feet up the hill before quitting (to my own credit without tipping the poor thing over). We took pictures of each other to good-natured laughter from the spectators. (What will these bazungu do next?)

Travelling on Rwandan roads is enlivened by taxis…of the two-wheeled persuasion. Even very poor roads will have a bicycle or two with a plank seat behind the driver. These affairs may be quite gaudy with reflectors and whip-antennae. They are reminiscent of a Schwinn I lusted after in third grade. Paying passengers are expected to help push the taxi to get it up to speed before hopping on (sidesaddle in the case of women…how do they do that?).

All travel in Rwanda will bring you to a genocide memorial or three. These may be simple cross-marked slabs of concrete at ground level like in Kibogora or large affairs such as at Kigali. The most chilling I saw was up towards Kibuyi north of Kirambo. It consists of a concrete mausoleum built into the hillside and extended perhaps 50 feet. The front is about 15 feet wide and is glazed and barred. It is lined with shelves and skulls. The shelves behind the front recede into the darkness gleaming with stacks of femurs and an occasionally naturally preserved mummy. No accurate account has been made but the best estimate has been that about 1.4 million of the 8.3 million people of Rwanda died in the period from 1994-1998.

Eventually we got to Butare and I got a tour of the National Hospital, a typical rambling affair of covered walkways and ramps. I visited their Newborn Intensive Care and was interested to find a two-month-old who looked pretty good. She was however suffering from a narrowing of her aorta that will in time make her heart fail. There is no cardiac surgeon in Rwanda; much less a pediatric cardiac surgeon nor any of the infrastructure needed to accomplish the surgery.

I spent the rest of the afternoon walking the main street after going to the national museum. This however was a bit of a disappointment. As the power was off, the tour was thus by flashlight and the legends were in French. I had gotten a room at the Hotel Ibis, quite plush actually. Screens on the windows and electricity (at least from 6AM until 11PM) and everything. Frank, Carole and company showed up on time and we went to dinner. Carol observed to me that “TIA,” “This is Africa” and that in ordering food one needs to “ask for what you want and eat what you get.” We have a quite nice dinner of talapia and retire at about 9:30PM.

We start at 6AM sharp to get to Kigali. Frank has to pick up another doctor coming in, drop off two of us and swap cars with David Sudell. I catch the plane on time at 4PM. It will be 28 hours before I am in Atlanta, 22 hours of that in the air. My travelling companion is Nathan Thompson, the son of a Congolese / Rwandan/ Burundian missionary (depending on which country had not evicted him at the time). Nate is a senior med student at U. Washington and will be graduating in June after spending a six-week surgery rotation with Frank. He had been in Burundi for the week. We are able to share a flight to Nairobi and Amsterdam. We part after a prayer session in the airport. He still has a 12-hour flight leaving an hour after mine.

The rest of the trip is lot in sleep, reading and contemplation; this was a good trip indeed.

Trip to Narok July 2002

I had to fold my shoulders and duck my head to get through the door. Unfortunately, like a cork in a bottle, I now had no light to navigate. I had spent the day with the Kejeri family and their church, returning to Namunchka late in the day and had been invited for ‘chai,’ hot, sweet milk and tea. . I followed the instructions of my amused host, turned right and then immediately left into a slightly higher room and found my seat by touch on the “mens” side of the room. The atmosphere was hot, smoky, claustrophobic and somehow cozy. A small fire burned in a grate on the floor without benefit of a chimney. The only light and ventilation came through an irregular 4” X 8” hole high in the cow-dung and mud plastered wall of Jackson and Elizabeth Wejeri’s home. I tried to forget about breathing. It had been a long day.
Last week, I was invited to go along with a maternal-child clinic trip to Suswa, a Great Rift Valley town that on a clear day is actually in sight of Kijabe, about 8-10 miles by road. Suswa is a collection of stick and clapboard buildings placed at random sites generally around a large corral.
The clinic used to meet in the most substantial edifice in the town, the tavern, which by all reports made a tidy profit on “rufi” (Maasi moonshine). This despite several instances of blindness among the patrons thereof. The clinic was now meeting in a small clapboard building, The Suswa Baptist Church. We cleared the unpainted wooden pews and lectern and set to work. Four hours later, 150 babies had been weighed and immunized.
Saturday, I was talking with Drs. Gary Rourke and Bruce Dahlman and their wives Corrine and Kate. I asked the source of the baptist presence in Suswa. The story they shared made me again marvel at the working of the Holy Spirit in people’s lives. In 1990 a widowed Maasi matron came to a roadside preaching crusade, went in to listen, was saved and left with a Maasi Bible. She went home, read her Bible and, following the Word, brought her grown children to the Lord. They in turn evangelized their neighbors and started a church. This one group has gone on to start new churches all over the valley since 1993.
As it turned out the Rourkes and Dahlmans were helping another Maasi church in Namuncha, “out there past the pumping station.” The pastor of the church, Simon Wajeri, was graduating the next day from the Narok Bible College. They were taking two cars to transport the church choir which was performing. I was asked if I’d like to come along. I did.
The Maasi have been resistant, as a rule, to evangelical efforts since these started in the latter part of the 19th century. The Maasi were primarily nomadic warriors and herdsmen, holding a dominant position not only in the Great Rift Valley but south across the border to Tanzania and up to the highlands of Kenya well north of Kijabe.
The British occupation of the highlands of Kenya would most likely have been a rather bloody affair had not the Maasi suffered twin disasters just before the British arrived: a huge reduction in their herds due to rinderpest and bloody internecine warfare which reduced their numbers further. Due to this they were pushed out of the highlands into the Rift Valley floor where it is hotter and drier. They speak their own language and are much less likely to know Swahili. Martin, a Christian Kykuyu artist with whom I talked, commented that the Kikuyu and Maasi now intermarry frequently, “But we still don’t understand the Maasi.” Why he thought that husbands and wives necessarily understood each other was not explained.
The Maasi therefore have been isolated by geography, politics, language and religion for over a hundred years. Many continue a traditional life of herding cattle and goats. Their dress is colorful and distinctive. The men frequently wear kilts and a red plaid shawl and carry long sticks for herding and defense. They have no horses and only an occasional donkey. The women wear elaborate beaded necklaces and earrings. Both men and women have pierced ears that can be as long as 6 inches. (Some men, I note, must find this annoying and wear their redundant ear lobes wound over the top giving them a resemblance to Shrek).
The Maasi are looked upon by many Kenyans as quaint, backward, recalcitrant and not overly bright. “Hillbilly” comes to mind. The Maasi, on the other hand, think of themselves as the “real” people: brave, honorable but harsh if challenged.
We set out at 7:30 the next morning, drove down through Suswa again and then turned south until we came to a petroleum pumping station and forded a small stream. Navigation immediately became one of compass directions and distances. Imagine scrubland crossed by any number of cattle trails making foot deep dust, fine a talc. We came up on a small clapboard building and a rock pile (the building fund) and heard singing. After a few minutes of the inevitable greetings, introductions, and involved interrogation regarding the whereabouts and health of my family, we piled 13 people into each car and left. More would have boarded if we had allowed it. The trip out to Narok took about 2 hours but was made memorable by the presence of the Kenya International Safari Rally. We went out alternating between marveling at the zebra, gazelle and giraffe and being terrorized by racecars, dodging around trucks and cars on the pot-holed two-lane road. Half way there, Bruce’s land cruiser overheated and blew the radiator cap into hiding. Another 25 minutes were taken up with refilling the radiator and finding the cap.
When we arrived in Narok we were however only slightly late. The choir was able to sing and dance . The graduation ceremony itself was more reserved and quietly joyful than any I’ve seen lately in the USA. Simon received his divinity certificate, an associate degree. He expects to get his bachelor's in about a year. As anywhere in the world, the ceremony was followed by photos with the various relatives. Simon’s mother, all 4’ 11” of her, and brother, Jackson were wreathed in smiles. Dr. Bruce Dahlman presented a bible commentary from the mission group. After a celebratory meal at a local restaurant (we wazungu got silverware) we started back with now 14 in our Land Rover; Simon was now sharing the front seat with Gary, the stick shift and me.
The entire return trip was rather more exciting than the trip out. It became an evangelical travel-log by Simon. He would point to a little building and tell us that that was where he had done a week-long crusade the previous year. Twenty-six people were saved. The building holds 40. There was the road that takes you to Dukuleli where he spoke for 3 days and started a new church last month. Here was the house of one of the people whom he had led to the Lord…
On arriving back at Namunchka, we were invited into his brother’s home and listened to Simon as he gave an impromptu seminar in evangelism. He felt that the Maasi were now being brought to Christ for two reasons. One, that these days are the endtimes and the success among the Maasi is part of the final incoming harvest. Secondly, he believes that the Maasi needed only to be presented with the gospel in the right format, by Maasi in Maasi. He sees himself in the great traditions of evangelical efforts from Pentecost on. He is bringing an update to Paul’s assertions that to Jew he is a jew and to Greeks, a greek. We left, the cars laboring to climb out of the Valley. I felt it had been a mountaintop day nevertheless.

This week, please pray for Simon Wajeri, the Namuncha Church and unsaved Maasi in Maasiland.

Graves of Kijabe July 2002

Graves in Kenya
In America, I guess, it would be considered, at the very least, bad advertising to have a cemetery in close proximity to a hospital. Nevertheless, at Kijabe there is a quiet little burial ground about a 100 yards from the “business” entrance. I made a small detour to see it on my way back to my house last week. The whole area has been planted with orderly rows of trees that shade the entire cemetery. A dirt path lined with Poinsettia runs down the middle. The grass grows a bit rank in places despite the workers hacking back the weeds and bushes from time to time. It is a quiet place through which many of the hospital staff walk on their way to and from work.
I found the oldest grave with a readable stone back at a corner. It was quite a thing, covering the grave with a Mansard stone top. The inscription read that Reginald Singyng So-and-So had died here at Kijabe while hunting and that he was really from India and it almost seemed he was a bit embarrassed to be here. He died in 1922, a few years after the mission opened.
The next group of stones was several men and women in their thirties and forties who also died in the early 1920’s. These were some of the early missionaries who came out to Kenya to serve at Kijabe. They died at their station, bringing the news of Jesus to the Kykuyu.
Mixed in with these were small markers, level with the ground and taking up hardly any space at all. They all had dates of birth and death in the same year; some in the same month; some on the same day. One had the inscription: “The first face he saw was Jesus.” A stone nearby bore a woman’s name. It had the same name and date as one of the babies.
The next group of graves was a little more recent. These people died in their 60’s and seventies even. The stones frequently noted service at Kijabe for 10, 20 and even forty years. One stated: “Born in Kenya, Died at Kijabe, Will meet the Lord from Kijabe.”
I walked along a little further past a jumble of weathered wooden crosses and rock-bordered but marker-less graves. Some of these showed signs of recent visitation with faded flowers laid on the ground. As I moved along to the end of the path, I saw graves with stones in Swahili and Kykuyu. Here there were whitewashed crosses and Bible verses on the stones.
I met Joaichim Techand, a 52 y/o German missionary to Congo, on his deathbed. I never had the opportunity to talk to him; we were trying to get his heart started at the time. We failed. All the doctors on call at Kijabe had been paged to the hospital in the small hours of Saturday, the 13th. We worked on him for most of the next hour before we had his family come into the room, said a prayer committing him to his Lord and called the code. It was his first heart attack. He, his wife and 3 of their six kids were in Kijabe for the week to see Ruth, their oldest girl, graduate from high school. Graduation was at 10AM that day.
I don’t know where he will be buried but I’m sure he would be welcomed to spend the brief time from now until the rapture in the company of believers among Kijabe’s quiet rows of trees and tombstones.

Please, take some time over the next few weeks to prayer for Joachim’s family.

Broadcast letter from Kijabe, Kenya July 2002

Greetings from Kijabe Hospital, Kenya.
I arrived into Kenyatta International Airport on Tuesday July 2 without difficulty. I was collected and brought to Kijabe with two other doctors who will be working here during July also. We are staying in a house overlooking the Great Rift Valley, the other side of which I haven’t clearly seen yet. The area’s most notable landmark is Mt Longonot, and inactive (NOT dormant) volcano. The climate is quite cool as the elevation is 7000 feet. This is the beginning of the dry season and reminds me a good deal of Northern California in the fall. Those of you who are admiring my fortitude in braving the rigors of Equatorial Africa may now move on to other matters.
The hospital serves people from all over Kenya but primarily the Kykuyu and the Maasai. The Kykuyu a rather prominent in government as they are a large fraction of the country’s population and the first president, Jomo Kenyatta, was Kykuyu. The Maasi are more rural and isolated generally and thus more traditional. Most people speak a usable amount of Kiswahili (i.e. the language of the Swahili). Contrary to my stay in Zambia last year, there is very little malaria Burkett’s lymphoma or shistosomiasis. There is however a good deal of tuberculosis and AIDS (the local population has a prevalence of about 35% since it is on a heavily traveled truck route).
The medical supplies which I brought were fallen upon with glad cries! Children in this hospital, as in most general hospitals, are at the back of the queue as far as getting supplies. In a country which has limited resources, children frequently do without, medically.
This week a mother of a boy on the ward asked about Jesus and was led to Jesus by a Kykuyu layman. A mother in the next bed listened in and was also saved. Last night the 12 year-old boy was saved while his mother looked on. We serve a truly amazing God. His care is sufficient. I saw a sign today at the local school which said something like: “Our highest goal is not to do good works, succeed in accomplishments or even to see the working of God’s will in His creation but rather in the furtherance of our communion with God as his children in imitation of His Son.”

Sincerely yours,
Walt Boutwell

letter from Mukinge to a friend

Dear Jim (DiPisa a psychologist friend and fellow climber/ backpacker),

I remain alive and well! Some of my patients can also say the same. Today is Easter and it is something else to celebrate it in Africa. I was on call all night & finished a delivery (my 1st in 28 yrs) and then got up to go to a sunrise service. The nursing students singing going up the hill behind the hospital in the dark. On the horizon bright Venus, overhead the Moon and Mars and to the right the milky way and southern cross. Several of us stayed to have a bit of breakfast in the beautiful weather. I had a tour thru the Tb (read AIDS) ward this pm. So little I could do except ask what was bothering them, how well they ate and whether they slept or not. Leprosy, snake bites (spitting cobra, which are the short (4' vs 8') brown ones---> eye injuries.
I think your comments about being open with the experiences of faith is on the money. It is one thing to believe something; it is another to put all your weight on the one anchor. If you really don't weight that single anchor, it really wasn't there to begin with.

I'm tired. Me go bed.
Mesanta Awhanni (thanks and good bye)

letter from Mukinge to Cheryl

Dear One,
Them phone line was nonop over a few days last week and so mail got bunched.
I’m on call this weekend for the WHOLE hospital. YIKES. So far so good as I have yet to run into any major catastrophe. There has been a major premie epidemic since my arrival however. We are kicking a set of 2 day old twins out of their incubator (1.7 & 1.3 kg) in order to get two other Unrelated babies into a separate incubator each. NO IV’s just ng feeds. Gave a talk re NRP (newborn resuscitation) Thurs. It bore fruit this morning as a ZEN (Zambia educated nurse) bagged a kid for 30’ and got her back. I did rounds today and saw Burkitt’s (lymphoma), Kaposi’s (sarcoma), Hansen’s (leprosy) and a tree-felling accident (Newton's Disease??).
I sent an email yest for the 3-5 year old class. I hope it can get to them before I return. Walked into town yesterday and bought you two of the more fashionable kesapis about. It will make you proud. I spent a little over $5.
I am feeling remarkably fit, well rested and comfortable. The rains have stopped and nights are quite cool and crystal clear. The southern cross and alpha & beta Centauri are just over there. Saw the Coal Sack, Beehive, Large Magellanic cloud, Canopus and a bunch of constellations which are even less obvious than up Nawth. Orion is still very recognizable even if he has fallen on his front rather than his back.

Letter to a Christian sister from Mukinge 2001

Dear Lisa,
Thank you for the unexpected pleasure of your email. I really appreciate the letter here which is at times so different from home.
I can’t tell you how priveledged it feels to be here with these people. Today I was able to see a smile on a child’s face which is 1-3 Burkitt’s Lymphoma, to talk to a man about his Leprosy and to help a man with Kaposi’s Sarcoma (& almost undoubtedly AIDS) get some sleep. A little 1 day old girl who was seizuring all Sun & Monday is going to survive perhaps with my help.
But the greatest privledge is the amazing experience of coming so far and only to find myself in the middle of a Christian family. Cultural differences are real and language is a huge barrier but we are all just sinners who for no good reason have been forgiven and brought into the family. These subsistence farmers have a much better sense of who they are and what is important than many of us including me.
Tomorrow, the school here is going to climb the little hill behind the hospital for sunrise services. I am on-call this weekend but have traded off to get the time free for the service. I will have the joy of celebrating Easter a good 8 hours before you, the same time zone as Jerusalem, I find.
Your brother in Jesus our Living lord,
Walt B

Letter from Mukinge to a high school friend and believer 2001

Dear Nancy,
Sorry I havn’t written recently despite your long and interesting email. I have tried out some of the sites and they are most enlightening. But not alll yet! I havn’t even begun with your own pastors site, except for his opening discussion of the Talmud.
I am a little separated from web access at the moment. My most pressing problem are malaria (not mine) and trichuriasis (you don’t really want to know). I have been here over a week and it is quite liveable. The people are poor but wonderful and I enjoy worshiping with them. Rather to the point sermons also. I cannot believe the basic poverty. I see kwashiorkor (sever protein malnutrition, every poster kid you saw for Biafra in the early 70’s) kids and count them by the dozen. One died this AM. Overwhelming infections (another died this afternoon about 445P). But everyone younger than 40 has all their teeth and nobody smokes! Everyone smiles when I try to greet them with my misanta-mwanii and hand clapping. I am home on the 27th Keep me in your prayers.
Walt Boutwell

Excerpt from letter to brother from Mukinge 2001

Dear Joey,
It was so good to get your mail and to know that two way communication is not just a theoretical event!!
The seasons are cold then dry then rains then warm and dry. We are entering the latter which is from Apr. or May to July, a tropical Autumn…..
(about lecturing)…..However, it is fun to teach people who want to learn (and impossible to teach those who know they are well-informed). I usually start my own talk on infant feeding with the 1749 battle of Culloden (as all really good lectures do, you know), go on to the “Gin Epidemic” and then wing it! …..
Thank you for your prayers and kind words. However I can’t but help thinking that I should have been doing this with the fat of my life rather than the tail. Please keep praying for this mission.
I am well if a trifle punk about the edges at times. Sleeping under mosquito netting takes some getting used to.



Love ya,

W

Excerpt from a letter to David "Top" Moore, Mukinge 2001

I don’t feel that much of my training or experience is of use here. I have never seen malaria before and here literally everyone has it. For adults it means a nasty day of two with aches chills and fever. For kids under five it may kill, wreaks their nutrition and stunts their growth. Kids are weaned at 9m and the mother rapidly get pregnant again thereafter. The baby is breast fed (&therefore well nourished) but the older kid (now 1.5 years old) is fed slices of thick corn mush (called 'nsheema) almost exclusively; moderate calories and low quality, low amount protein. Picture the red-headed bloated belly, apathetic toddler. Many die.
As an experience it is astounding, as a service, I hope to be a little more help than trouble. In all humility, this is following the guidance I have been given. I don’t need to solve problems here, little or big. I have to be faithful

Letter to my sister from Mukinge 2001

Dear Bea,
Thanks for writing back. It seems like I should have a lot of free time but I always fill it. Today (sat the 7th) I had to iron my underwear as well as the rest of my kit. Had it washed yesterday & dried on the line (no dryers) and today I get to steam to death the mango fly eggs which were laid on it yesterday. It seems that if you don’t they hatch & mistake you for unripe fruit. Two rather painful instars later they emerge as maggots.
Went to the provincial capital yesterday, Solwezi. Luanda chief’s residence and all. He is Chief Solwezi, no less. Town looks like a clip from “A Girl like Alice” and your average western. Fewer horses and more people. Met a man who was starting a training school for older orphans, walked out to the site 2 miles away. He was a foster child of one of the missionaries at Mukinge. An interesting afternoon. Drove back with r hand drive. Only thing I couldn’t remember is to use the turn signal instead of the windscreen washer. Every time I forgot great peals of laughter from the 9 MH workers with me.
Zambia is a lot like one's prejudices suggest and not. A women in kesapis (1x2M brightly printed cloth, skirt cum baby-carrier, pot holder, table cloth, blanket, diaper (nappie here) carrying a load of wood on her head. Road side vendors selling corn on the cob roasted for 50Kwacha (about 1.5cents), beggars, piles of small dried fish, post polio paralytic limbs, cataracts, cobras (as road kill), lines of army ants (local name is pishuti), goats lying in the roadway, brilliant flowers, fruit on the trees, dust, bicylcles built for one but carrying three peddling the bare pegs in bare feet, malaria. It is also drinking a coke on an open veranda with painted disney characters wishing me a "cool yule" next to an advertisement for condoms. Wish Roz a happy bd.

Many Thanks

To those who were faithful in praying for me while I was away:

Cheryl Outland-Boutwell
Beatrice Boutwell Readel
Nancy Whitman Cyr
Lisa Cleland
Walt Lilley
Lawrence Phipps
Thomas Moore
Ann Boutwell Moore
Joshua Boutwell
Sarah Boutwell

Report to World Medical Mission on Mukinge

Report on
World Medical Missions
Trip to Mukinge Hospital
Kasempa, NW Province, Zambia
March 26 to April 26, 2001


The Locale and the People:
The Mukinge Hill area is a wide valley running down to a small river which eventually drains into the Zambezi. The hill area undergoes intensive rains during the wet season which was just ending in April. This leads to rutting and washout of the red dirt roads which then bake hard by the end of April. Many of the roads I was driven over, dwindled to foot paths in the further reaches of the district. Mukinge is located a few kilometers from Kasempa the local “Boma”. These were organized around tribal units and have become the government centers with independence. The Boma was about a 40 minute walk from Mukinge. During these trips we would pass about a dozen small villages immediately beside the major footpath. Each village consisted of a half dozen or so thatched mud huts which typically house several nuclear families and perhaps a “mother-in-law or two.” Large villages of several thousands which were the rule a hundred years ago have vanished as the threat of warfare and arab slavers have subsided. Each village appears to be furnished with at least one barking dog and a complementary gaggle of small boys. The later will begin to ask in unison and in severality “How are you?” on the approach of a any westerner. We rapidly learned to turn the tables and say “Moogia biepi?” Kikoande for “How are you?”
Kasempa includes a radio station, district government offices, several private schools of various stripes, a bus station and market. This later consists of a sloping rutted and weed-grown square with a public pump and rows of small shops on streets surrounding the square as well as leading away for a 100 yards or so at seemingly random directions. The shops all seem to offer an almost identical supply of notions, eggs, kesapis, biscuits and toiletries. An open-air market selling bread, dried fish and fresh vegetables adjoins the square. In addition, a clothing market is situated near the market. This consisted of stick-built booths to shield the sun and waist high tables, to display the wares. These consisted of newly made kesapis (1 by 2 meter cotton print material) and old clothes. Of the latter variety I saw near-new T-shirts for a midwest grocery chain among others.
The area around Kasempa and Mukinge Hill is intensely cultivated. Each village is situated among its fields. These are mostly field corn and raised rows of eggplant, okra, tomatoes and onions. During the rainy season vegetables become scarce and small. Very few domestic animals other than a rare goat are in evidence.

Nature of the Facility:
Mukinge Hospital is a 200+ bed hospital in rural Zambia serving the mostly subsistence farmers of the Kuanda tribe. The hospital is a collection of one-story buildings including seven wards, an operating theater, pharmacy, administration building and outbuildings. The wards include 2 pediatric, one male, one female/OB, one male TB, one female TB, one eye/ortho. The pediatrics wards were divided into two, each with approximately 35 patients. The acute ward, “Paeds I,” included mostly malaria which was unresponsive to the usual therapy (chloroquine), complicated or associated with other diseases. Other diagnoses included infections (mastitis, shoulder bursitis), burns, fractures, Burkitt’s Lymphoma and bacterial gastroenteritis. At times I had six patients on the floor waiting for beds.
Patients who were thought to have more chronic conditions were admitted to “Paeds II.” This was therefore the “kwashiorkor” ward. Kwashiorkor produces in the young child, swollen legs, pot-belly, paler skin and reddish hair which is due to a diet deficient in protein, vitamin and micronutirents. Any child with tuberculosis was treated here also. This disease is a cognate for HIV/AIDS. The incidence of HIV+ patients is about 20-24%. Due to this, serological studies for HIV are seldom done as no treatments is available.
Mukinge Hospital was started in 1953 by Dr. Robert Foster, the son of the original missionary couple who started the station through the (then) Sudanese Interior Mission (SIM). Zambia represents an example of a mission giving over authority to the indigenous church, the Evangelical Church of Zambia which it started. Both SIM and ECZ are administratively responsible for the facility. Since independence in 1963, the government has sought to have closer ties with Mukinge as it supplies needed health resources for a large area of rural countryside. For this reason, Mukinge has contracted to supply in-patient and out-patient care to the population under government support. However, the government hospitals are less well supplied than Mukinge, despite better access to transportation. While I was at Mukinge, a number of patients who had been seen in the provincial capital, Solwezi, came to Mukinge by foot or bus in order to see the doctors there.
One boy with Burkitt’s Lymphoma had been waiting for medication in Solwezi for several months. His huge tumor had eroded through his face in two places, closing his right eye. Five days of medication (Vincristine, Cytoxan, and prednisone) reduced his tumor size by twenty-five percent and allowed him to start eating again. Five more courses would most likely result in a cure (90% 5 year survival) if the medications could be obtained and given properly.
The nature of medical care changes dramatically in the third world. One young mother brought her 4 month old son to the hospital at night after a two day walk from her village. The infant evidenced severe respiratory distress, cyanosis and lethargy. He had been treated for pneumonia several times without benefit. He however, had a huge liver and large heart associated with a single loud S2, dramatic evidence of congestive heart failure. He also had the typical appearance of trisomy 21, Down Syndrome. By the next morning, diuretics and oxygen had helped his condition and a chest x-ray was consistent with my suspicions of a severe form of cyanotic congenital heart disease, Transposition of the Great Vessels. In the best of circumstances, this child had some chance of normal cardiac function in a good tertiary hospital immediately after birth. Even then, a substantial palliative procedure would have allowed continued growth for many years. But no intracardiac procedure was available either here or in Lusaka, the capital. Moreover, none would have been done for a child with so little potential for compete recovery. On reexamination of the baby, he now appeared to have gotten over the little honeymoon provided by the previous night’s treatment and was rapidly worsening, typical of this kind of heart defect; he was within hours of dying. I tried to explain this through a translator. It would have been unnecessarily cruel to try to bring this mother to a true understanding of her baby’s disease only to say we could do nothing. Instead, I said that the baby’s heart was not fully developed and that he would get sicker and die from this and that we had no treatments for it. We prayed at the bedside and the mother wanted to know if she and the baby could go home now. I told her that the baby would die during the two day walk and her response was that she wanted to be home to bury him. With all the other patients, I didn’t see her leave.

Insights
Inserting yourself into a foreign culture produces a huge number of insights from the trivial to the occasionally profound. I undoubtedly received more blessings from those I met than what little I provided. Nevertheless, I think the most profound insight was voiced by a medical student with whom I was traveling. He stated that he had discovered that “People live here.” This is no longer “Central Africa” to me but a few square miles of Kuanda homes and fields populated by people who are wise and foolish, strong and weak, saved and lost. They have no more essential spirituality nor veniality than suburban America. They still have to answer the same questions we all do. Their problems loom on their emotional horizon just as emphatically as ours. Their problems seen from afar seem overwhelming and inexorably triumphant. Seen from up close, the people will deal with them in some fashion. There are mature Christian brothers and sisters who are dealing with their own problems, making their lives, responding to the urgings of the Holy Spirit. If there is one regret that I had, it was the baseline presumption that as a Western doctor, I had peculiar and important expertise out of proportion to anything the Kuanda could produce. This served to separate me from those with whom I wished to fellowship.

Typical Day sent good friday 2001 from Mukinge

To:vfbc
From:
I have had a busy week so far but today is Good Friday, one of the 12 national holidays here and things should be at a slower pace. Yesterday we had a 10% 2degree scalding burn on the abd & legs, a huge Burkitt’s Lymphoma about the size of a volly ball on the face of a 6 year old, half a dozen malaria, a trisomy 21 with probable transposition of the great vessels (TGV) who I discharge to die at home, a Kwashiorkor who died after being discovered moribund in the morning. I started intraosseous fluids and got her to cry, start moving again and have pulses in her extremities again only to return in 90 minutes to find her all wrapped up in her shroud for delivery to the morgue, probably arrythmia. Gave a powerpoint presentation at 1400 on resuscitation. Sent home a kid after cleft lip surgery, sent home three malarias, treated scabies without wreaking the kids skin, took a picture of everyone in the ward and a little girl who was seizuring all Sun and Mon from sepsis will survive. Generally a pretty fair day.

Email from Mukinge, Zambia 4/4/01

Dear Vaughn Forest Family

Greetings from Mukinge, Kasempa District, NW province, Zambia. I have been here since Friday 30, March and am just beginning to see how I might get by. The 2 pediatrics wards are huge (this is the NON busy season) with 35 kids in each. Most have malaria, worms, anemia, burns, breaks and fevers. I have seen kwashiorkor like out of a news film. The first day here I lost a little girl to terminal starvation (& malaria, gastroenteritis and heavens knows what all). I don’t really know what I would do here if it were not for the staff. It is numerically mostly Zambian except for a few Aussies, North Irish, Canadian, English and (yes) Americans about. These folk are really dedicated, smart and tough, (e.g. a “short term” SIM missionary goes for a minimum of 3 years, most do not take malaria prophylaxis therefore) . Very discouraging work at times. AIDS is a piece of the landscape. The station is about half the size it was in the 60’s (30 now).
On the 31st I went to town, Kasempa which is “the Boma” meaning British office of military administration or something; quite a hold over from the colonial period, but I think it is aword hijacked from swahili. It was a radio station, a power plant (something of a episodic endeavor), an emigration office (I have to go tomorrow to prove that I have a ticket home) and a few dozen shops around a deeply gullied plaza littered with dogs, trash, bicycles and mothers in kesapis with babies on their backs. A small loaf of bread goes for 1510 Kwacha (about 50 cents).
The day is divided by a 2 hr lunch break so that the workers can walk home and cook their insheera (a rather bland thick maize porridge that is rolled into balls and eaten with the fingers, very efficient). Morning rounds are punctuated by tea and prayers at 10AM. Work continues to almost sun down (very little dusk this near the equator) so that you don’t need a “torch” to avoid the occasional snake, (all high test, no regular). Theatre (ie surgery) was delayed this afternoon as the chief (&only) surgeon had to extract a 7 ft cobra from his garden. They keep the ‘bushy mice” population in check donchaknow.
The weather is quite humid and warm into the low 80’s but nights are cool and damp(we’re at 4000ft). It is heading into winter and the dry season so that it only rains a few times a day now with bright sun in between. Tonight is one of the few nights which doesn’t have something I feel I must go to so I am trying to keep up with the mail. Please remember me in your prayers and write if you find time.