Habari Friends,

Impunity: exemption from punishment or loss or escape from fines…the impossibility of bringing the perpetrators of violations to account—whether in criminal, civil, administrative or disciplinary proceedings. (Wikipedia) In other words, No Consequences.

Impunity…a central word here in Kenya. One sees that word on nearly every page in the daily newspaper; impunity is rampant not only in high administrative circles but also among interactions with nurses on the ward. Several weeks ago, the Kenyan public was bombarded with the video of policemen summarily executing alleged criminals lying in surrender on Lang’ata Road in Nairobi (just hours before we drove along the same road). Just this week, a child in respiratory distress was ordered to have a chest xray at 11:45 am. The order was not “noted and handed over” until 9pm that day—the child did not have the xray until the next morning. Neither of these incidents is unusual. Neither provokes sustained or generalized outrage among the people here. It was very disturbing, in fact, to read so many letters to the editor praising the action of the police who shot the men lying face down on the tarmac through the head. I’m told that so many people have been brutalized by gangs of men who have broken into their homes, raped their wives and daughters and have escaped—with impunity. So people accept the brutality of the police, having no confidence in the justice of the courts. What they don’t think about is the possibility that one of them will be judged and executed by the police in a circumstance of mistaken identity. There is a move afoot to arm the traffic police—which also has prompted supportive letters to the editor. Yet nearly every time we drive, we see or hear of people who have been pulled over by the traffic police who have demanded bribes to avoid fines. One nurse anesthetist described refusing twice to pay bribes—she and her husband lost two days of work going to court to fight the tickets they were given (for speeding or not having the appropriate paperwork in the car)—both times having to pay a fine imposed by a court that supports the police. I drove to Nairobi on Thursday while Leland operated at Kijabe—though driving here is daunting, I am much more afraid of being stopped by the police checkpoints than of having a matatu plow into me—at least I have some control of where my car is on the road—I have no control over those policemen and their nightsticks. But God heard my cry, and spared me from being stopped. Quite honestly, that was serious prayer being sent up for two hours.

The nurses at Kijabe Hospital are very upset because the pay scale has been reconfigured to make it more “equitable.” Those nurses who have been working the longest have seen a decrease in their base pay with “allowances” for housing, education, etc that at least equal what the pay had been before restructuring. However, many of the longterm nurses are threatening to quit because they say they have taken a substantial cut in pay. It was explained to me by the Matron that the base pay is what banks consider when a person applies for a loan; it is also the basis for calculation of the pensions. Until this week, I had no idea how many Kenyans live on loaned money—the debts they accumulate are astounding—and are spread among family, friends, the hospital, and banks. It is also remarkable how freely hospital workers and patients ask us for loans—about two weeks ago, a patient’s mom stopped me in the hallway saying that her child had a cardiac defect and needed Ksh 14,000 for surgery—and could I give her that. When I said I could not give her the money, she looked incredulous and, laughing, asked, “Why not?” Quite honestly, the verse: “Ask and you shall receive” came to mind. There is a totally different philosophy here about asking for money, help, etc—and I’m coming to understand that people often don’t expect someone to give all that they’ve asked for—but the asker feels that he/she has nothing to lose by asking. Quite honestly, it takes a good deal of cultural awareness, understanding and wisdom to know what to do with all the requests for money, loans. Leland and I have responded to several requests—but obviously cannot help everyone who asks. It also can be quite disruptive to the local economy if missionaries overpay their help—it was explained that when that occurs, the Kenyans can’t afford to hire people to clean, cook, watch their children while they work.

We are again at Malu—the place of refuge and rest that we have found east of Lake Naivasha. There was a lull in workload following the holidays but the past two weeks we have again been inundated with patients—we had three mattresses on the floor in OPD and took out beds in one area so that more mattresses could be placed on the floor (we had one patient in “bed 11X” meaning 11 Extra). We had 8 emergency admissions last Friday and 4 new babies with spina bifida admitted on Tuesday. For the past two weeks, every patient who has arrived and is not emergent has been sent home (sometimes a 6-8 hour matatu ride) and rescheduled as an elective admission —including babies with hydrocephalus who are symptomatic but still feeding well. We had wondered if we had scheduled our R&R a bit too early, but after the past two weeks, we both needed the break. So here I sit on the wooden porch floor, writing and looking up at Tanga, the Rhodesian Ridgeback who alternates sleeping on the floor with chomping noisily on her toenails. The herd of horses just grazed through the “front yard.”

For the first time since we have been here, I have seen Leland grow angry with circumstances in the hospital as well as concerning the new apartment. Last week, during a craniotomy, he requested the microscissors to cut the arachnoid lining of the brain. Each of the three pairs of scissors that he brought had bent tips (from mishandling) and could not be used. Two of three cautery wires had damaged insulation, causing them to short out. The endoscope camera also malfunctioned and several cases of endoscopic third ventriculotomies had to be converted to shunts. Then, in our new apartment, an inspection by the architect, the contractor, the BKKH administrator (who will take “ownership” of the building once it is officially “done”) and the inhabitants revealed some deficiencies—like electric plugs that did not work, wet spots in the ceiling from defective roofing, pipes under the sink that leaked, windows with huge gaps allowing red dust to blow through the apartment). I’m afraid that our priorities (leaks, plugs,) are quite different from theirs (painting, smooth doors); I think this is one of those times where we will look at each other, shrug, and say, “TIA.” (This is Africa). We have requested that the resident from Vanderbilt who arrives next week bring more duct tape and weatherstripping to keep out the wind and dust.

In our work here, we continue to struggle with how best to treat the children with complex congenital brain deformities or those children who arrive at the OPD barely clinging to life. A 2 year old girl, Jebet, arrived in OPD from northwestern Kenya about a month ago with a history of one week of vomiting and diarrhea. She was severely dehydrated with a temperature of 41.7 C (107 F), heart rate of 200, respiratory rate of 68 and having a seizure of undetermined duration. She was blue; I left her to get oxygen (there was no one in OPD to help me); the tubing wasn’t available—once it was found, it wouldn’t fit on the adapter to the oxygen tank—which turned out to be empty anyway. Because she had had a shunt operation in November, I quickly aspirated fluid from her shunt for analysis and to prove that her shunt was working (her pupils were pinpoint so it didn’t look like a shunt malfunction problem). Then I called the pediatric service and they assumed management. However, because of her severe and prolonged dehydration, she clotted a major vein in her brain and sustained substantial brain damage. Leland examined her a few days later; she was still febrile and her condition was very grave. He recommended not aggressively treating her. However, she was aggressively treated and just yesterday, I was asked to explain to her very young and very poor mother why we could not “fix” Jebet. Once again, Pastor Mercy and I talked with her, explained that Jebet could not see, probably would never walk and talk. After the explanation, the mother asked if the paperwork could be completed that day so that she could pay the bill and take Jebet home—the complicating factor is that Jebet’s father told his wife, “Don’t bring her home; I don’t want a disabled child in my home.” So, now that we have salvaged this very ill child, she and her mother have no home to which to return. So, when Pastor Mercy asked me to lead the prayer, my request was for God to provide a home for Mama Jebet and Jebet. I am not sure that Jebet wouldn’t be better off now if she were in the arms of Jesus. We have at least two babies right now with very severe brain deformities in addition to severe spina bifida and hydrocephalus. It is hard to have the family spend precious resources on these babies who are unlikely to see their first birthdays with the best, most aggressive care.

We were told on Thursday that we are ordering “too many scans” on the children. Since we treat children with brain tumors, complex hydrocephalus, severe spinal deformities, it is exasperating to hear that we have ordered “too many scans”—especially when the vast majority of children go to surgery with only an ultrasound, not a CT or MRI. Ultrasound is readily available at Kijabe and is relatively inexpensive. CTs and MRIs are available only in Nairobi. Often, we order a CT without contrast when in the US, the child would get an MRI with contrast. The concern about “too many scans” reflects a lack of understanding of the kinds of abnormalities we are treating. However the concern also reflects the limited budget for the neurosurgical program

So that brings me to my requests. I’ll list them in no special order but I’ll ask you to prayerfully consider how you might be able to help. I think of that mama asking me for money—if she keeps asking, someone may feel led to help.

1. We ask that you pray for us to have strength, compassion, and wisdom so that we make good decisions in giving care in a place of very limited resources.

2. Pray for us to maintain a good sense of humor, flexibility, and reasonable expectations so that we are better at rolling with the punches.

3. Please prayerfully consider contributing to the BKKH fund that is established to pay for scans that children need for surgical planning. Many parents cannot afford the $200-400 cost of a scan here.

4. Pray for the leadership of Kijabe Hospital and BKKH. There have been and are soon to be complete changes of leadership at both entities. Change is always difficult and threatening—even when it is positive.

We thank you for your prayers, your monetary support of the neurosurgical program through BKKH, and for keeping in touch through email. We are grateful for each one of you—you sustain us.

As I’ve written this sitting on a chair under a tree in the open area in front of the cottage, I’ve watched several birds come to drink out of a concrete bird bath on the ground. The water level is quite low; each bird has perched on the side and carefully, tentatively tried to dip down to reach the water—but each has been unable to drink. It has been fascinating to watch each one finally “take the plunge” and get its feet wet by hopping off the the side to the floor—there drinking deeply and being refreshed. It teaches me that we all will come up dry unless we commit our entire beings to God’s purpose—that committing to the unknown can refresh us and give us sustenance. As Craig Barnes says in An Extravagant Mercy, “Receiving God’s grace shakes the very foundation of our carefully constructed lives…We even have to lose our interest in carefully constructed lives because, well, that may be the greatest sin of all.”

Take care, God bless.

Susan

Neurosurgery Patient Subsidy Fund

Bethany Kids @ Kijabe Hospital

PO Box 1297

Abingdon VA 24212-1297