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

Christmas in Kijabe

Dear Friends and Family,

I wrote a blog posting on 12/13/10 but an electrical surge blew my surge protector strip for the American plugs on the computers. The battery on my computer died and could not be resurrected until we had purchased new strips. Then, the internet connection failed so I could not post the blog even with a fully charged computer. Perhaps that is “providential” as my Dad would have said—the blog I wrote then was a bit down.

As I explained in the last blog, I had reached the end of my rope so I flew to Vienna on 12/2/10 (at 12:25 am) to meet Kelly, Joe, and my granddaughter Evelyn. My temporary Kenyan visa expired on 12/1/10 which was duly noted by the customs agent in Nairobi; he said it is fairly easy to renew—I told him, No! I HAD to leave Kenya!! Upon reaching Vienna I found a winter wonderland—it snowed for two days. It was good to be back where traffic signals are strictly obeyed, no one leaps from barriers between lanes and matatus are not heading directly toward you at breakneck speeds IN YOUR LANE! Crossing the street was so...pedestrian—no suspense at all. I gained 4 pounds in 5 days (schnitzel will do that). What was really helpful (besides playing with my granddaughter) was to talk with Joe and Kelly about their experiences in Syria. Joe has spent a good deal of time working with the Syrian guards who patrol the outside of the embassy. Over his 15 months there, he has significantly improved morale among them—mostly by treating them with respect and having clear directives about performance. Although his and my roles are dissimilar, he had some ideas that I will try since morale and performance are important issues here in Kijabe.

I have to admit that I had trouble returning--not simply because I missed my connecting flight to Nairobi in Zurich, had to detour through Istanbul arriving in Nairobi at 02:10 am—and did not find the driver hired to meet my plane until 05:45 am. The sidetrip gave me the opportunity to see Istanbul from the air and to cross off another country on my mental map of the world. My attitude remained less than stellar—until one of the moms approached me for help—then my heart melted with love for these women and their babies. I realized then that it has always been the patients that have saved me, fed me, ministered to me at least as much as I have to them. It is the Erics and Megans and Chanons, and Mr. Moseleys, and Sarahs and Marks and Davids, and Danelles of Madison, Portland, Pittsburgh who have been my best teachers, my strongest supports, and sources of greatest joy in my work. So, as in the past, these Kenyans ladies and their babies drew me back to the place where God has most certainly brought me.

We’ve continued to be busy at work. In November, Leland did 72 operations (his previous all time high was 30/month in Pittsburgh; so far in December he has done 81). Our Pediatric Neurosurgery fellow, Humphrey Okechi, has been a wonderful addition to our team. Humphrey has a gift for organization as well as technical skill in the operating room, so our rounds are concise and mercifully shorter each morning. He also has learned a good deal of Swahili during his first 6 weeks (I guess if one can learn Chinese, as he did in a year, one can learn any language) so is able to have more than rudimentary conversations with the moms. Leland and I are consigned to saying “nyumbani, kesho” which means “home, tomorrow.” We do cause some giggles among the moms as we try to properly pronounce words—asking the staff to spell the word causes some consternation, as the spelling is fluid and depends on one’s native tribal language. Babies admitted as Fatih Jepkemoi become Faith Chepkemoi sometime during the hospitalization. Athan becomes Aden, Iynoam becomes Ahinoam. Also, people don’t get caught up in such things as spelling: our clinic secretary Veronicah sometimes leaves the “h” off her name—she says she doesn’t much care how it is spelled. It reminds me of Ellis Island where names of immigrants were changed because the staff processing them didn’t understand the language and assigned phonetic spelling.

Leland and I spent one afternoon reviewing the complications of the past 20 children treated for myelomeningocele. We are dismayed at the number of spinal fluid leaks, wound infections, instances of incisions falling apart (up to 20 days after surgery). We talked recently with two of the pediatric surgeons here—there are so many factors that impede healing here—intraoperative temperature (the babies get cold during surgery), nutritional status and vitamin/mineral deficiency, skin preparation (we don’t have chlorhexidine prep here—it has been shown to significantly decrease surgical site infections), even oxygen supply to the tissues. At altitude, the air is “thinner.” Most people here increase their hemoglobin levels in compensation—that happens within 120 days of acclimating. However, so many of our babies are significantly anemic—they arrive preoperatively with hemoglobins of 7-9 (normal at sea level is 11-16). We have decided on some interventions that we can fairly easily institute; Leland will change the way he prepares the skin before surgery; we will start each child on multivitamins when they are admitted and send them home with a one month supply. Intraoperatively, the temperature will be monitored and recorded every 15 minutes. I need to talk with a nutritionist in the States of ways to supplement the mom’s nutrition so that the breastmilk is of better quality. Long term, we’ll need to work with the Kenyan staff to teach moms to cook more nutritious foods, refrain from feeding cows milk before the age of one year (one 3 week old baby was being fed cow’s milk last week).

We have so many discouraging stories—Leland asked that I tell you about a different outcome. Early this week, he saw a 26 year old Somali lady who had been struck by a stray bullet—which lodged at the end of her spinal cord causing complete paralysis of her legs. She had sustained the wound December 2nd; Leland told her that he thought there was a 20% chance of improvement after surgery. The surgical procedure went well; the following day, she had movement in one leg. Two days later, she had normal movement of her right leg and antigravity movement of some muscles in her left leg. We have seen many Somali patients; Dick Bransford says that arguments will never sway them, but caring for them compassionately in Christ’s name is the best way to minister to them. One Somali mom told the translator that she wanted to hear about this Jesus because she saw Him in Leland and me. That, quite honestly, is why we are here.

Two weeks ago I gave a 15 minute talk to the nursing staff on how to do wet to dry dressings—despite our telling and showing many of the nurses, we found every morning that the dressings were done incorrectly. After the talk, we were astounded to find that the dressings were correctly done….for the next 5 days—then a lapse back to the old way. When I asked about that, the nurse said that they’d been doing the dressings their way for years and she didn’t understand why we should change. Another thing I’ve recently discovered is that the nurses have as much trouble understanding our accents as we do theirs. So, they “seem” to understand what we say but really don’t. Other nurses are really not fluent in either spoken or written English—so once again, they say they understand but don’t follow the order that has been written. Today a very sick child was not given antibiotics for 24 hours--the nurses didn't see the new order until during the night (it was written yesterday at 0645 am) and then the antibiotics were locked in a cupboard, so could not be given until the person with the keys arrived for work this morning.

We are thrilled to report that we moved into our new home—a 768 square foot apartment on the third (gasp!!) floor of the new building on the downside of the mountain from the hospital. We have the furniture that we ordered (delivered 5 days early—that’s when they were delivering to Kijabe—take it or leave it). We have drapes that I chose and were made to order on Biashara Street in Nairobi—they were done in two days!! I finally have a stove that doesn’t make bread into nuclear waste—we feel like we are in heaven. There are a few glitches—they made ventilation screens at the top of each window—so each night a roof rattling gale blows through our apartment, flapping the draperies, showering that wonderful red dust on everything. Believe it or not, the wind wakes ME up at night!! (I’m deaf!!) The showers are remarkable—we love them; but in every other tap the water comes out in a pitiful trickle. And we have solar hot water—which so far has been solar tepid water. Every time I think about complaining, though, I remember that most of the staff at the hospital—and nearly all the patients—bathe in basins with cold water or water heated over a charcoal stove. Even with the imperfections, we both feel like we are now at home.

It was a strange Christmas in Kenya. The chaplain decorated the ward 3 days before Christmas. By Christmas day, each area had a small tree. But, there was no celebration of Advent (the sermons were from the book of Esther), and other than in mid-November, no carols or advent songs were sung. Leland and I finally went to the Uhuru Highway Lutheran Cathedral in Nairobi on the Sunday before Christmas—both of us remarked that we were able to worship for the first time since leaving Madison. We had dearly missed the liturgy, the readings, the recitation of the Creed, the Lord’s Prayer—as well as the hymns. I think that we will try hard to drive to Nairobi each Sunday to worship there. Despite the identification as a “cathedral”, the church is small so should allow us to get to know the members. It has a good mix of Kenyans and wuzunga—and has both a German and a Kenyan pastor. Otherwise, Christmas was quite low key here—a few of the staff exchanged gifts—like cabbage, etc. In a way, it was good to see a lack of commercialism and greed. It is a little disorienting to see life-sized replicas of Frosty the snowman and Rudolph in the Nairobi mall—2 degrees south of the equator.

In the last blog, we asked for ideas for how to ship the operating microscope. Eric Hanson, the new pediatric surgeon who arrived, told us he has room in his crate in Boone, NC for the microscope. So, we will need to ship it to Boone, but then the problem is solved. We hear that people are passing the blog along to fellow coworkers, etc, and welcome any new followers. If anyone has thoughts about ways we can improve nutrition, please send them.

Most of all, we ask for and thank you for your prayers for us. Even when we have very hard days, we remember that so many people are lifting us up to the Lord in prayer. We are part of a very large community—not just here in Kijabe but extending all over the world—people who care deeply about the poor, the sick, the helpless. “..for I was hungry and you gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me, I was naked and you gave me clothing, I was sick and you took care of me, I was in prison and you visited me. Then the righteous will answer him, “Lord, when was it that we saw you hungry and gave you food, or thirsty and gave you something to drink? And when was it that we saw you a stranger and welcomed you, or naked and gave you clothing? And when was it that we saw you sick or in prison and visited you.” And the king will answer them, ‘Truly I tell you, just as you did it to one of the least of these who are members of my family, you did it to me.’”

Take care, God bless.
We wish you a Merry Christmas and a new year full of joy, peace, and health.
Susan

Hello, folks!

As of today, we are 2 days shy of being in Kenya for 3 months. Time being time, it seems like anywhere between 1 and 9 months—depending on the day, my mood, etc. I’m afraid that I “hit the wall” recently; until about 2 weeks ago, I felt upbeat, content, patient, kind, really inspired to be here. Well, I have to confess that those feelings have vanished over these past two weeks. Despite knowing in my head that change takes time—that is true anywhere—I guess I had hoped that the small changes we have tried to make in taking care of patients would be well-received. What I saw as “small changes” are quantum leaps here—and so, understandably, we’ve met resistance. In return, I can say that my response to the resistance hasn’t been particularly productive—I tend to become quiet and remote—and that isn’t well understood here. So, I’d say that I have a lot of work to do on my attitude.

Leland has a gift of good timing and incredible intuition—he arranged for us to take this weekend (Friday after rounds until Sunday afternoon) at Malu, a sort of bed-and-breakfast-lunch-and-dinner place in the hills north of Lake Naivasha. The food was outstanding (African interpretation of rustic Italian—absolutely delicious), the cottage was heated by a crackling cedar wood fire lit each night by Biden (pronounced Beedin) or Njeri. We rode beautiful and responsive horses in the forest above the camp, and read and rested, refreshing our souls and spirits. The birds were spectacular—large and loud ibis feeding in the pastures, sparrow sized black birds with iridescent heads, robin sized birds in shimmering emerald/turquoise hues, African eagles soaring silently overhead. What impressed us most was the quiet—the absence of the ubiquitous Kijabe winds. Getting away from Kijabe is, we’ve found, absolutely necessary to maintain our perspective and emotional, psychological, and spiritual health.

We continue to see patients die—four babies last weekend. Because there are no autopsies, we most often don’t know what caused the death. We don’t have ability to do EEGs so we can’t always tell if children are having seizures. The lab is unreliable, so we can’t count that the calcium level is really low (one child had a calcium level of 5.6—very low—and 4 hours later, without any treatment, the level was 9.6). We have checked sodium levels and have gotten results of 101 and 194 (both are probably incompatible with life—or nearly so) in children who really didn’t look too bad. There are no tallies of intake and output—the children for the most part don’t have diapers (in US hospitals, disposable diapers can be weighed before and after use, and calculations of urine output can be made)—they urinate in cloths which are then washed by the moms and hung out on the line. So determining fluid and electrolyte balance—something fairly simple in the US becomes quite complicated.

We also see incisions that won’t heal; 10-14 days after surgery, many just fall apart. After watching the nutritional status of the moms, seeing the diet they are served in the hospital (which is probably in many cases better than what they might receive at home) and seeing two month old breast-fed babies with rickets, I am convinced that some of the wound healing problems are nutritional. We talked about supplementing the mom’s and the babies with vitamins—sounds simple, huh? Except, that is an expensive undertaking, we don’t know for sure if that will translate into better wound healing, we don’t know how long to supplement, and that won’t address the problem after discharge. One missionary who has been a midwife in Uganda (and has been quite encouraging to me in my recent funk) suggested that we start having “food parties” to teach the moms how to prepare nutritious food from readily available sources—like cooking and eating the greens of the sweet potatoes to enrich their diet. So, I am on the lookout for an available person to coordinate that undertaking—but we’ll need a Kenyan to take charge of the actual teaching.

Despite the above complaints, we do continue to feel led to be here—and grateful for the opportunity to serve here. There are so many opportunites to show God’s love—last week, we had a 2 month old baby boy, Victor, with a large myelomeningocele (open spinal cord) that caused him to have no leg function. His head was 53 cm (about 5 cms larger than my granddaughter’s head at 16 months). We obtained a head ultrasound and there was very little brain tissue—mostly spinal fluid. So, we recommended that he be taken home without surgical intervention. Pastor Mercy and I talked with the mother—she was a young single mom who came from the displaced person’s refugee camp and had no family supports at all. After I explained that even with surgical intervention (which would cause him pain), he would not be able to think, play, walk, even urinate or empty his bowels normally, we prayed together, thanking God for the gift of this child and asking God’s strength for his mother, to care for him and love him as long as he lived. These are not easy decisions or discussions or prayers—and we don’t presume to know what is best or “right” to do in cases like these. But we occasionally see children for whom it seems most appropriate to not intervene surgically but provide love and emotional support to their moms. Whenever it has been possible in these situations, we’ve asked that the bill be paid through our indigent patient fund so that the mom does not have the added burden of a bill that she can’t pay.

It is sobering to see so many women who have waited to get treatment for their babies’ hydrocephalus because they can’t pay for treatment—they have waited so long that the heads are the size of basketballs—and they don’t understand that we can’t make those heads normal—ever. So much here is related to lack of basic resources—food, transportation, adequate shelter, family support, basic medical care including prenatal visits, immunizations.

Some of you have written asking what you can contribute. We have not answered these questions—not because we haven’t appreciated your asking, but because we have not known how you can best help. While sending toys or clothes for the children for Christmas is appealing, it is probably not what they most need. We have thought about asking for donations toward supplying disposable diapers for the babies after surgery—to better keep incisions clean, aid in keeping track of urine output. However, we will need to address the problem of waste disposal, storage of diapers, and how to fairly supply each mom with a daily allotment. We need more information about how to best enrich the nutritional status of the moms and babies before we can ask for your help in that effort. So, we would appreciate your patience while we gather more information. Any contributions to the indigent patient fund go toward paying the bills of those who otherwise would not be able to afford treatment. We also pay for CT or MRI scans on those patients who otherwise would not be able to afford them and in whom Leland would not be able to operate without a scan. Contributions toward those endeavors can be directed to:

The Neurosurgery Patient Subsidy Fund

Bethany Kids at Kijabe Hospital

PO Box 1297

Abingdon, VA 24212-1297

Another need just recently arose: an operating microscope, so desperately needed for tumor cases, has been acquired and is sitting in a crate in Madison, Wisconsin, awaiting shipment. Our usual means of shipping, through Africa Inland Mission (AIM), is no longer available (they are no longer shipping equipment overseas) and so, we will need to establish new means of having equipment shipped to Africa. Ideas and/or contributions toward that are welcome.

Please continue to keep us in your prayers—that we not become so discouraged by setbacks that we fail to care for the children, their moms, the hospital staff. Thank you also for your words of encouragement through email. They mean more than you can imagine.

Take care, God bless.

Susan

Habari friends, family, others who have stumbled across the blog,

Two weeks have flown by since the last blog post. It is hard for us to fathom that we’ve been in Kenya two and a half months. We’ve been too busy to be homesick, yet we’ve missed the color change and fall of the leaves in Wisconsin, we’ve missed the first snow fall. Last week in church, I had an acute attack of longing for Luther Memorial—for the worshipful, quiet, reverent awe-filled liturgy, the familiar (and formal) hymns, the wonderful complex harmonies of the choir and Bruce Bengtson’s masterful leadership. I cried silently while the prayer was hollered (definitely not a Lutheran pray-er). After the service (and a thoughtful sermon by Pastor Muhota), we had our communion of bread cubes and grape juice—and yet—yet God was there in that service and in that communion every bit as much as at Luther Memorial.

Over the past two weeks, we’ve seen about 4 children who have big heads and essentially no brain tissue—it is so hard to make decisions about treatment for them when so many other children need operations—and will have benefit from them. We have been inundated with sick children—there are beds lining the corridor; still Bethany Kids at Kijabe Hospital (BKKH) has had to turn away hypoxic children because of lack of bed space. Probably 2/3 of the children are on the neurosurgery service, the rest are on the paediatric or general surgery service. On Monday, a child came in to OPD pulseless and not breathing---we started CPR but we had no working oxygen or suction—not to mention any medications; it was unsuccessful. The baby’s name was Pollyanne and she was 4 days younger than my granddaughter Evelyn. She had hydrocephalus and spina bifida—we will never know why she died—maybe seizures, maybe a shunt malfunction, maybe something else. I sat with the RN, Chaplain Mercy, and Pollyanne’s mum while we told her that the baby had died. It’s hard for me because Mercy believes fervently that spina bifida, death, illness, all are part of God’s will and we need to accept that. I sit silently through these explanations—I admire and respect Mercy but I adamantly disagree—I don’t believe any of this is God’s will. Later, I stood with the baby’s father while he held Pollyanne’s hand and wept. He finally said something—Agnes the RN translated it for me. “He says, ‘Why did God let this happen?’” Then everyone waited for my response. Finally, I said, “I don’t know why God allows these things to happen. I do know that God stays with us through every terrible time.” I had nothing more to say—I still don’t know the answer to his question.

We were blessed this week by a visit from Scott Ward and David Etzwiler, two gentlemen (and I mean that literally) who are leaders of Medtronic Foundation, the charitable arm of a medical device company that is very generously supporting our work here. Through them, Medtronic Foundation has donated funds for wireless/highspeed internet to be developed at Kijabe Hospital. The company has also been instrumental in funding the pediatric neurosurgery fellowship that Leland is offering here. It was good to talk with people whose accent I can easily “read.” (They are from Min-ne-soh-ta). They spent 3 days in the OR with Leland—and were a bit blown away when they arrived in the OPD—the cacophony of languages, babies crying, the SHEER NOISE just amazed them. On Wednesday, we drove with them to Mary and Stephen Njenga’s ministry in Ebburu north of Naivasha. There they have established a school for 125 children—most of whom are “functional” orphans with little effective parenting. As soon as we got out of the car, we were overrun with little hands reaching out for us—most of the children had never touched a muzungu before—I had about 5 children on each arm (some of whom were trying hard to see if my white color would rub off). Leland made the mistake of putting a small child on the roof of the car and suddenly had about 30 children to lift up and down. Scott acquired instant friends by taking everyone’s picture; David made a great hit with the kids by using a rugby ball as a missile to shoot the well-ensconced soccer ball out of a tree (made more exciting by the presence of a very active beehive in said tree.)

Mary and Stephen have a dream--to have a ministry to the children and families in that small town on a mountaintop. They have bought some acreage and have built the school. A dormitory for boarding students is nearing completion. Mary works 6 days a week at Kijabe Hospital (she is head nurse of the OR) and then goes up to cook for the children—they realized early on that the children needed nutritious food in order to learn in school. Mary also has a clinic nearby—and they are farming on the land—planning to add 997 more goats to the 3 that they already have. Their vision is to be self-sustaining in 9 more years. The land formerly belonged to a British “Baron” who used Italian POWs to build a Tuscan villa overlooking the Abedere mountains and Lake Naivasha. As we toured the ruins of the house, Stephen reminded us of how futile it is to build treasures on earth, where rust and moth decay—instead of building treasure in heaven. It isn’t often one has such a stark reminder of that.

That is the impressive quality of so many of the Kenyans we have met here in Kijabe—they not only have dreams but they use the few resources they have to follow their dreams. If we look at the needs of Kenya with human eyes, we are tempted to throw up our hands and say the needs are too vast to even begin to address. Yet so many people are taking a small piece and saying, “yes, with God’s help, we CAN.” They are answering the call they hear. Can you imagine what the world would be like if we all did that?

Well, the electricity has just gone off for the third time in about 10 minutes—again reminding me of the quirks of living here. I drove for the first time yesterday—white knuckles all the way (for both me and Leland—he kept muttering something about falling off the side of the road). It was exhilarating (though we appreciated that more after getting home). The weather is downright Portlandesque—it changes from misty moisty morning to brilliant sunshine to driving rain to spectacular sunset. (The weather is the only thing that could remotely be called Portlandesque).

The most striking and wonderful facet of our lives here is the opportunity to minister to the mums and children—we have opportunities every day to show the love of Christ, to be his hands, voice. I talked with one young single mom whose baby has hydranencephaly—absence of the brain above the level of the brainstem. With Mercy’s help, I explained that the child (about 16 months) would never see or hear, would never speak, would always be like a newborn baby—and no surgery would change that fact. She cried—then on her way out of the hospital with her baby strapped to her back, she came to OPD—to thank me; we hugged. Those are the moments when I hope the people feel God’s arms, not mine, holding them.

Please continue to pray that we do the work that God wants done here—that we follow and not go our own way. We also pray for you—that God will lead you in your corner of his world—to be his hands, voice, feet, mind to the people to whom you minister.

Till next time…
The Lord bless you and keep you.
The Lord make his face shine on you and be gracious to you.
The Lord look upon you with favor and give you peace.

Susan

Habari!

I have tried to give you some idea of our lives here—and have shared some humorous anecdotes. Leland reminded me that I haven’t given you much information about how hard working here can be. So, with this installment of Updates from Kijabe, I’ll try to do that.

These past two weeks, we have seen two children die, and have had 4 intraoperative cardiac arrests. The old saying, the operation was a success and the patient died unfortunately applies. The first boy, Said, was 4 years old—he had a very large tumor in his cerebellum—much larger than his scan from July indicated. Toward the end of the 3 hour operation, Leland noticed that his blood was thin and asked that he be transfused. There was no blood available; despite Leland’s emergency donation directly from his vein to Said’s, the boy’s heart stopped, and he could not be revived. The tumor resection, though difficult, was complete—and Said died of a completely preventable cause. Two days later, a 15 year old girl, Lilian, had what we thought was an unusual and very serious reaction to anesthesia (malignant hyperthermia)—this was after a successful resection of an extensive spinal cord tumor. She also arrested on the operating table—and despite being resuscitated, later died in the ICU of brain damage. This Friday, a 3 year old girl with hydrocephalus had a cardiac arrest after being given anesthesia—even before her operation had started. Just afterward, a 73 year old man with an acute bleed in his brain also arrested just after Leland had successfully evacuated the blood from his brain. Both of these patients were successfully resuscitated and appear to have had no damage from their arrests. Because of these problems the anesthesia equipment was examined; it now appears that three of the four arrests may have been related to malfunction of the anesthesia equipment.

There are cultural differences that make working here hard. In the West, organization and planning ahead for potential problems are part of everyday life in hospitals. Here, they are, in many ways, foreign concepts. Little things like organizing supplies so that they are readily available when needed---don’t happen. Everyday, I spend valuable time searching for tape, going to the Central supply office for packs of gauze (none were available on Friday), locating scissors to cut bandages, finding sterile gloves for procedures. Something as simple as a dressing change becomes an hour-long process (hard when we have 30 children on the service). In the same way, staff here don’t plan for potential problems—like children having respiratory difficulties. I disagree with some missionaries who have said the staff doesn’t care—I really believe that many staff don’t recognize when children are in trouble and are at risk of dying. This is true not only on the ward but also in the ICU—intubated patients on ventilators have died with plugged endotracheal tubes. It can be difficult to get people to respond quickly when a child is unstable.

And we have so many very sick babies and children. I have never seen so many with severe anemia, such complex and extensive congenital defects. On Friday alone, we admitted four children with myelomeningoceles—a day old baby with both a cervical and lumbar defect, a three day old baby with a lumbar defect, a day old baby with a large, leaking thoracic defect, and an 11 month old boy with a bleeding and leaking cervical defect. This is unheard of in First World countries. Another one month old baby admitted this week has hydrocephalus, bilateral cleft lip and palate, a congenital absence of her left arm, and bilateral club feet. Her name is Rahama—her mother died when Rahama was 13 days old. Her older sister also has spina bifida that has never been repaired. Because of malaria, anemia, and other congenital anomalies, the risk of surgery is greater in these children. I am continually challenged to use every bit of my past education and experience as a pediatric nurse practitioner, former pediatric ICU nurse, as well as my neurosurgical experience in ministering to these children. Leland also acts as much more than a neurosurgeon—he evaluates abdomens, listens to chests—it takes everything we have ever learned to take good care of these children—and yet, some die. That is a very hard thing.

We know that we need to pace ourselves—and have tried to do that by taking breaks. Last Wednesday was one of the two Kenyan Independence Days (the other is in June). We drove down the worst road I have ever seen (worse than the one in Monument Valley, kids) and over to Mt. Longonot, a volcano in the valley. We spent about an hour climbing up to the rim (no switchbacks here—just straight up the side!). Unlike parks in the US, there are no guardrails, fences, or even rangers at the rim—just a sheer drop into the crater with a path along the rim. Unfortunately for us, a large group had arrived before us—they were having a loud prayer meeting along the rim. People were praying in Swahili (eyes shut), arms raised to God, walking around—it was terrifying to us because we had very little room to walk without fear of falling into the crater if one of them bumped into us. Obviously, that didn’t happen—we loped down (the dust was so slippery it was easier to lope than climb) and then drove into the valley to celebrate the climb the Kenyan way—by having roast goat. Then we tested our little car by driving back up the worst road I have ever seen—which entails an extensive ab workout just by maintaining an upright position, not to mention working off those calories. These excursions help us maintain perspective as well as refresh our spirits.

This morning we heard a wonderful sermon from Romans 14:1-23 by Pastor Muhota of the AIC church. He spoke of Paul’s exhortation that we not be critical of differences—in what we eat, in the way we worship, in whether we dance or stay rock still during songs. Yet on the walk home, another missionary criticized us quite severely for making rounds to see the children scheduled for tomorrow’s surgery instead of “honoring the Lord’s Day.” I wondered what she thinks of the nurses who work on Sunday taking care of the children. It is hard not to respond sharply (I appreciated having just read Craig Barnes’ sermon from 10/10/10 on not using our weapons (my sharp tongue) but trusting in God—thank you Craig).

Then there are the peculiarly Kenyan inconveniences that make our lives less predictable—some would say more humorous. This morning the electricity went out---about 6 times. It was interesting to have the lights and sound system go on and off during the church service—and getting a shower can be downright suspenseful since we have an electric showerhead that heats the water—or doesn’t as the case may be. Shampoos are especially tricky; I think I’ve gotten the shampoo/conditioner segment of the shower down to less than a minute. And cold water rinses are supposed to make hair shinier, right?

Whenever we feel discouraged, it seems that God sends us a gift. One morning it was the end of a rainbow over the valley; one evening a spectacular sunset over the Mau range. Last night, we were both too tired to cook; we had just checked on the progress on our new apartment being built (and to our dismay, found that it will have an electric stove—reread the above paragraph) and so we stopped by the hospital “cafeteria” for some mukimo, beef stew (Leland), and beans/maize and rice (Susan)—only to find they didn’t have most of that. However—Pastor Mercy was leading about 30 ladies to the wards—they were a women’s choir and they gave us an impromptu concert, including dancing and ululations. Those are the moments that feed our souls—and make us so grateful to God that He brought us here. It is a privilege to be here, to use what gifts God has given us to serve him. We have much joy here.

Until next time, take care, God bless. Please continue to pray that God will use us for his glory. Thank you for your prayers—we feel supported—and we need your prayers.

Susan

PS: I am having a lot of trouble importing photos--will try to solve the problem with the next post.

17 October 2010

Dear Friends,

Habari. So much has happened since the last update from Kijabe. The President, Mwai Kibaki, dedicated the new operating room suite at Kijabe Hospital on Friday, 8 October. Our hospital was given 4 days notice that he would attend, so in that time, the hospital was painted inside and out, the road from the highway was repaved, new curtains were hung in the wards, all the hedges and gardens were trimmed! We should have him visit more often. The hospital employees were so proud—at the ceremony the Maasai murans (warriors) danced, there was a brass band that curiously played The Star Spangled Banner along with God Save the Queen and the Kenyan anthem, and there were many speeches. I missed the dancing because ALL of the nursing staff left the wards to see the spectacle—leaving the patients with no staff. Ah, things are different here….

I am struck with the fluidity of things…time, dates, spelling, rules. Time is an approximation; if one starts rounds at 0630, that really means sometime between 0640 and 0715. Leland and I joke that church has a rolling start here—although the published “start” time is 0830, things are really underway in earnest by about 0850. Birthdays: in the US, one of the patient identifiers is the birthdate. In Kenya, most Muslim children have a birthdate of January 1 of the year in which they were born. Non-Muslim children may have a recorded birthdate that is somewhere in the month in which they were born—but that date may differ on successive admissions. Names also are fluid—sometimes Stacy is spelled Steicy, Josaphat morphs to Josphat and back again—last names also change spelling from day to day (Muthamni becomes Mutharimi)—making sure what patient is being discussed can be challenging. The nurses also switch patients from bed to bed—so that one day bed 71 is Maxwel, but later that day it is Hosea—Maxwel is now in Hosea’s former bed 81. If you are confused, imagine how we feel making rounds—especially when the staff insists on using only the bed number as the identifier—not the patient’s name. Rules: although there are traffic lights that turn red and green (only in Nairobi), no one pays the least bit of attention; if you see an opening you take it—or someone else will. On our death-defying drive to Nairobi yesterday we were a bit taken back when, on a divided 4 lane highway, we swerved violently to avoid a head-on collision with a matatu (almost always a Toyota van that carries people from town to town) driving in the wrong direction. On the way home, a huge traffic jam caused us to follow everyone else to the other side of the median barrier, so all four lanes were traveling in the outbound direction. It worked surprisingly well until we met the traffic headed toward Nairobi. I’m actually not entirely sure how we got out of that mess, but I do remember it involved frantic arm waving and driving over curbs.

I’ve wanted to share with you more about the children and moms here. You cannot imagine how dearly these children are loved by their moms. Despite having very damaged babies with devastating neurological problems, these moms play with, sing to, kiss, caress, and really delight in their babies. We have an annex with two large rooms containing 19 cots—the moms and babies sleep together (no Kenyan mom would think of using a crib). Although most of the children have had surgery, there is surprisingly little crying—if the baby fusses, he/she is nursed immediately. When a mom needs to use the toilet, another mom watches her baby—in fact, the older children in the ward, if not too sick, play with the younger ones. All the moms talk together and provide support to each other—it is quite different from the US where we are so concerned about privacy and confidentiality. I’m not sure but I think this system works better—at least in providing mutual support. I wish you could hear the moms sing; the chaplain, Mercy Nganga, led the moms in singing the other day—they broke into harmony; the beauty of it brought tears to my eyes.

We do find that we need to get away from Kijabe weekly for a few hours—last week we drove to Naivasha, seeing Maasai herding their cows and goats along the highway. Once there, we had lunch outside and then walked to the edge of the lake—where we saw a bird standing on a rock—which ascended until ears and eye were visible. Then a little farther out along the shore, we saw a group baptism with the hippo submerged about 50 yards away. Gives the term “trusting in Jesus” a new slant.

Kenya is also a study in contrasts—the almost indescribable beauty from the ridge at 8000 ft overlooking the Great Rift Valley with the volcano crater, Mt Longonot in the distance in a blue haze, the rich terra cotta color of the earth, the jacaranda trees covered in periwinkle blue blossoms…the abject poverty of the rural people living amid trash and scraps of plastic bags fluttering in the wind, the donkeys grazing by the highway (giving literal meaning to the term “being at the end of one’s rope”), the tin roofed shacks advertising Blessings Butchery, Susan’s Saloon, God’s Promise Tailoring and Beauty Shop, Gichiengo Omuja Hotel and Butchery, the men pulling carts heavily laden with 10 gallon water containers, women carrying huge bundles of wood on their backs, men handshaping the building stones for the new construction here at the hospital complex.

Some short stories:

Each patient, before surgery, is led in prayer by a surgical team member—sometimes Leland, sometimes Mary, the nurse anesthetist. On Friday, a 14 year old Muslim girl was ready to be put asleep for surgery and she agreed to a prayer. After Mary had prayed, the girl asked, “Why do you pray to your father?”

I traveled to Embu for a mobile clinic, a 3 hour drive (4.5 hour return—turns out Kenyan nurses like to shop too—though this was no mall; who knew people could get such joy out of vegetable shopping?). There I saw a 3 month old girl with a temperature of 42.9 C(it equals 109 F). She was limp, rolling her eyes. She had an unrepaired myelomeningocele and most likely end-stage meningitis. I felt quite helpless—her mother hadn’t money to take her earlier for care, and she would not survive a trip to Kijabe. I doubt she lived through the night.

We saw one boy in clinic—a 12 year old with a complex spinal deformity. Leland needed an MRI to safely plan surgery, and his mom agreed to get one. Fortunately she told a nurse that before she could pay for the MRI, she would have to sell her only goat. We were able to arrange for BKKH to pay for the scan out of the fund we established for just that reason.

We continue to be humbled, challenged, stretched, molded by our days here. We ask for your prayers that God will be glorified through the work of our minds and hands, that He will guide us each moment and give us wisdom, patience, cheerfulness, graciousness in our relationships with staff and patients.

Take care, God bless.

Susan and Leland

29/09/2010

Dear Friends,

Karibu! It is time for an update from Kijabe.

We are learning some Swahili words. Karibu means welcome—to which the polite response is Asante (thank you). Habari means hello/how are you; in Tanzania, the response is nzuri, but in Kenya (at least in this area), one responds mzuri. I was taught the phrase/response by a Tanzanian nurse who is visiting here (and who obviously believes I need to acclimate myself better to the community)—so when I replied nzuri, the Kenyans had a good chuckle.

Our weather here is quite unlike the common “picture” of Africa. Though we are just south of the equator, our altitude (7200 feet at Kijabe) causes cool nights—blanket weather (sometimes socks as well!) The days have been partly cloudy to brilliantly sunny. What is most amazing to me here is the wind—each late afternoon as the valley cools, the wind from the highlands at the top of our ridge sweeps down to the valley. It begins as a rustling of the trees; by dusk and for a few hours afterward it strengthens until at times it has the sound of a jet engine or continuous rumbling thunder. I am reminded of I Samuel 19 when Elijah looked for God in the wind, then the earthquake, then fire, but finally heard God in the silence. Perhaps my relative deafness is a blessing. J

Leland returned to the US for Julie and Art’s wedding on September 18. He had a wonderful time with family and long-time friends (we are careful not to use the term “old” at our ages). He loved seeing both the bride and groom so obviously cherishing each other and all the people who attended. After he left Pittsburgh, he flew to South Africa for lectures in Johannesburg and Cape Town, returning to Nairobi on 23/9/2010.

The matron of the hospital, Ann Ndungu, graciously hand carried my application for my Kenyan nursing license to the Nursing Council on 23/9/2010. She met with the committee members (having formerly been a Council member herself) and pled my case. She reported to me on Monday 27/9/10 that they wanted to meet with me for an interview—on Tuesday (28/9/10)! So, Leland and I made the trip to Nairobi yesterday morning, arriving at the Council building at 09:20. I was #20 on the list for interviews. I completed another application and paid an interview fee. At 12:40, they asked that I go upstairs—where there was another waiting room full of people. A lady waiting there said she was #10 on the list (having arrived at 07:50). So, it looked pretty bleak that we would be called before they went to lunch from 12:45 to 2 pm. They break for the day at 3:30, so I was envisioning having to drive back to Kijabe and come another day. However, soon after that lady was called, they called my name; Leland came in with me as my interpreter and we had a 30 minute interview, at the end of which I was given a registration number, allowed to pay $400 USD (that, I am told, is a month’s salary for a nurse), and given another application to get my actual license (after I pay yet another fee). From what we could gather, I will not need to do any supervised bedside nursing. So, I thank all of you who prayed about this—the results certainly exceeded my expectations and met my wildest hopes. There is no doubt to me (and to the Kijabe nurses) that God’s hand directed this process.

Humphrey Okechi, the hoped for pediatric neurosurgery fellow, is a step closer to starting—his medical papers have been received and forwarded to the National medical board for review and approval. We hope that he will be able to start in late October. Having had a taste of Kenyan bureaucracy, the word “hope” is chosen carefully.

Leland has started his full operating schedule this week; most children have some variant of spina bifida—but with much more complex features and infections of the open spinal cord and/or cerebrospinal fluid as well. One 2 month old baby has a completely formed finger and remnants of toes within the folds of a large mass covering her back. She has excellent leg function however, so with the needed operation, there is some risk of loss of function.

We have a growing Somali patient population who present language barriers but also some lack of trust in the providers here. One lady claims that her child’s kidney was removed and sold for profit (the child had a burn and so had a graft of skin taken from the lower abdomen). It is sad that there is almost no way to convince her otherwise—and there is some concern about her going back and reporting her beliefs in her community.

We have eaten well so far—many vegetables! However, buying vegetables here can be an incredibly intimidating experience; one has to deal with The Vegetable Ladies. They are a group of about 10 ladies, each of whom sits behind a card table in a concrete block building in the village and sells exactly the same vegetables. Fortunately, only 5 were there the day I shopped—but one has to buy about the same amount from each lady or some will seem angry. I announced loudly when I arrived that I was “just one” that week. I bought carrots, onions, tomatoes, broccoli, cucumber, and potatoes--and when one lady couldn’t make change, she just handed me another zucchini (making 5). I said, “I’m going to turn green!”—to which they all laughed. I hope to be friendly enough with them to get their picture by the time I post the next blog. Most of their vegetables are not home-grown as we had thought; we learned that they all go to the high road on Tuesdays and Saturdays to meet the trucks from Mombassa/Nairobi. It is no wonder then that all the produce is the same.

The new operating theatres are nearing completion; a formal dedication is scheduled for 8 October. Rumor has it that either the President or Prime Minister of Kenya is expected to attend. When the new theatres open, Leland will sometimes have 2 operating rooms, so should be able to accomplish more cases with much better efficiency than can be accommodated now. Construction of our apartment building is also progressing well—we climbed up again last Saturday to measure the rooms. On our way back from Nairobi last week, we bought some living room and dining room furniture which will be made over the next month and then held until we move into the new apartment. We are thrilled with the views overlooking the Rift Valley and will be happy to move to a quieter and less dusty location within the complex.

We appreciate the responses we’ve received from many of you—and are very thankful for your prayers. I cannot explain how much it means to us to know that you are praying for us.

Take care, God bless.

Susan and Leland