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Maasai, medicine and a life with meaning

December 3, 2012

Dr. Bacon bottle feeds a rather hungry giraffe.

Editor’s note: This is the second installment of Colville physician Dr. Barry Bacon’s travelogue/report from the African continent and his ongoing work there.

McGiver
One of my jobs here is to find stuff that doesn’t work and see if I can make it work. Mostly things on the car: a door that needs adjusting, a choke that needs reattaching, a glove compartment that flops open, a seat that won’t adjust. In the house there are a few items as well---a toilet that won’t flush, an oven door that won’t close, a washing machine that isn’t hooked up, a water heater that doesn’t work. The young physicians I work with all laughed when I told them I brought a pipe wrench and a hammer, among other things. They wondered what that was all about. I told them the story of the trip across South Africa, Zimbabwe, and Mozambique to Malawi when we had a fire in the engine compartment with nothing to put it out except a serving of tomato juice, and two blown shocks. Since the accelerator cable had burned up, I had to rig a hanger through the firewall connecting the carburetor linkage to the hanger wire. I could pull on the other end of the hanger and rev the engine. I drove for 100 miles like this until we reached a spot where the “refurbished” ambulance could be fixed. I had forgotten my tools. I didn’t want that to happen again. Once my colleagues began to see that a few things around the place were being fixed, they were happy for the tools.
Since we have fixed a few things at home and in the car, we heard about a list at the hospital that needs help. Jeff left a list for me with one thing in particular that was close to his heart. The oxygen concentrator isn’t working. That is our project for today. I plug it in and it sounds fine. But try as I might, I can’t get any oxygen out of it. I decide to tear into this project. Perhaps it is something easy, a hose that has come unhooked or has a crack in it. I pull the machine apart into pieces. I pull off the vacuum hose. No problem with suction. I pull off the outflow tracts. NO problem there. I trace the hoses around the serpentine routes through the machine to their various destinations. Everything is hooked up. I pull off one of the end hoses. I blow into the end. It is completely plugged up. I chase it down a bit more. I am embarrassed to say it, but the end of the connection is plugged up with mud. The fix is as easy as taking a needle and running it through the orifice. I place the connector back on and turn on the machine. It runs like a charm.
I call the nursing supervisor. I am delighted to tell him that the machine works fine, and that it can be used immediately. He is ecstatic. He explains that the machine has been sitting in a back storage room for a year, since it stopped working. I pull off the end connector and explain how it can be checked and fixed if this happens again. I smile at myself that the solution was so simple, but my method of finding it was so convoluted. On the other hand, I wonder how many more years the machine would have sat in the back closet losing its useful life and wasting the resources of whoever donated it to the patients of Sagam. I wonder how many other pieces of equipment we will uncover in our investigation of the hospital.

The Maasai people were so moved that they decided to give the people of the United States a gift.

Maasai Gift
Paula told us a story about the Maasai that I thought was worth repeating. Paula is a young internal medicine physician who practices hospitalist work in New York City. She has been accepted for the fellowship program here at Sagam, but will still work part time in New York.
There was a Kenyan living in New York City during the Sept. 11, 2001 terrorist attack on the World Trade Center. He returned to his home shortly afterward and had the opportunity to tell the story to a group of Maasai people who lived near his home. As he explained the loss of lives, the destruction of the buildings, people leaping to their deaths, the Maasai people were so moved that they decided to give the people of the United States a gift. They wanted to give something from their very heart. They decided to give the people of the United States of America a gift of ten cows.
In order to understand the significance of this gift, you have to understand the Maasai worldview. The Maasai believe in one creator God. They call Him Enkai. Enkai’s favorite animal is the cow. He has entrusted all of the cows in the world to the Maasai, His chosen people. The Maasai believe that all of the cows in the world belong to them, since God gave them to the Maasai people. So their gift of ten cows was something of deep significance to them.
The U.S. ambassador to Kenya was told of the gift of the Maasai. He went to visit with them and to accept the gift. The ambassador explained how grateful the people of the United States were to receive this gift, and how much it meant that the Maasai people had sacrificed for them. However, he explained, America could not accept the gift because it was too far away and the way was too difficult.
On the other hand, would it be possible to sell the cows and take the money to buy beads? If the Maasai women were willing, they could make some of their beautiful beadwork. This would be brought to America and displayed at the memorial to Sept. 11. Then all of the Americans could come and see the compassion the Maasai felt for those who suffered and could enjoy the beauty of the gift they had made. The Maasai agreed.
So it is that when the Memorial to Sept. 11 is opened in New York City, you can see the beautiful beadwork the Maasai women have made to comfort the people of the United States. You have heard of the gift of the Magi. Now you have heard of the gift of the Maasai.
Oct. 14
Our weekend plans have taken a bit of a left hand turn. We had the incredibly great idea of traveling from Kenya through Uganda to Rwanda to pick up my motorcycle and bring it back. I would then leave it here in Kenya as a backup vehicle for emergencies. Things got messy.
We didn’t know about the need for the original logbook for a vehicle crossing into Uganda. So we had to spend some extra time at the border promising to come back, check with the officials personally on the way back, pay a fine, buy some extra insurance, etc. Uganda is deceptively large. I knew this, but my friends had an idea of when we would be across Uganda, and it turned out that all of us were optimistic. We got to Kampala and traffic was at a standstill. After waiting for an hour without moving, the group decided that getting the motorcycle wasn’t such a necessity after all. We would reconfigure our trip and head to Jinja instead.
Jinja is the headwaters for the Nile River, flowing out of Lake Victoria. It is a common tourist destination with quite a bit of outside money flowing into Uganda. The Nile is beautiful here, with a tremendous volume of water right from its beginning. Tourists often raft the Nile, bungee jump over the Nile, fly or parasail over the Nile, or kayak the Nile. We were going to raft the Nile.
The first rapids are a 10-foot waterfall. That’s your introduction to rafting the Nile. The Nile is not as continuous an adventure as some of the other rivers I have been on, but except for the Amazon, it is definitely the largest volume of water I have been on. The rapids are spectacular, incredibly powerful, and being thrown into the Nile like a wet t-shirt into a washing machine (one of the rapids is called “the washing machine”) and held under for a few seconds, only to come up and realize that the Nile River is residing in your trachea is definitely a memorable experience.
There is a tremendous variety of bird life along the Nile. Inexpensive places to stay if you don’t mind a tent or camping experience. Some are very fine guides and some delight in dumping visitors into the water as often as possible. But some of the best memories are the ones you don’t expect and couldn’t have predicted.
The Flower
When we reached the river, we were divided into three groups. There were three groups of five, one group of four, and a smattering of ones and twos, 19 total. We had to divide ourselves into three boats, 6, 6, and 7 in each of the boats. The director decided that one of the larger groups needed to be split up in order to make it work, so he chose ours. Our group of five would be divided between the three boats. Godfrey and Luke would go into one boat with a group of four Americans from Minnesota; Paula would go with a group of British guys; wouldn’t you know it, Jennifer and I would be stuck in the boat with a group of young women from Sweden, Austria and Germany. (OK, I’ve had worse fates.) The truth is, they were very focused young ladies, and they were a blast. For most this was their first rafting trip, but they did very well. Well, all except that one time when Maya, seeing the rapids coming up, ignored the guide’s command to “paddle hard straight ahead”. “Oh-oh”, she said and dove into the bottom of the raft. We were thrown into the Nile more than once together, and floated down the river on our backs looking up at the fish eagles, hornbills and cormorants sunning themselves along the banks.
One of the girls in particular caught my eye. She was from Sweden and spoke the language well, but her olive brown skin color, black hair and solid body build looked more Mayan Native American than her Swedish friends. Jennifer asked about the meaning of the tattoo on her left shoulder. She explained that it was a reminder of her ancestral home in Chile. I had a chance to ask her a bit more of her story.
Joyce’s family moved to Sweden when she was very young. They moved there, she explained, because they had family in Sweden already. She carried the stoic facial expression so common among Native Americans as she spoke. I asked if they had moved because of political unrest. Yes, she nodded. I stopped at that. Political refugee. I didn’t want to pry further. Probably a lot of pain behind that story.

She mentions the children who, for Christmas, ask only for a chance to go to school.

We stopped for a lunch of biscuits, pineapple and juice on the banks above the Nile. I talked with Anika, the girl from Austria for a while over lunch. Her story was fascinating. She seemed eager to tell it to someone, anyone who would hear it and understand.
She has been in the country of Uganda for the past three months. Now her time is winding down. She has a couple of weeks to herself, so she and some friends are here rafting the Nile. She is having a great time, as I am, but she can’t stop thinking about the experience she has had.
She is a social work student and is here on a bit of a whim. Her Mom didn’t want her to come, thought it was too dangerous. (She hasn’t written home about floating down the river in croc-infested waters yet.) She was plugged into the poorest, most destitute part of the slums surrounding the capital city of Kampala. She is a changed person.
She has made a lot of mistakes in her life, she confesses. But this experience, she can’t forget it. She is so different now. Her attitudes toward the things that she has, the things she takes for granted, she sees that so many of the things we “need” in our materialistic culture aren’t important.
She writes to her friends at home and they don’t believe her. “No,” they write back, “you are lying. Things can’t be that bad.” She mentions the children who, for Christmas, ask only for a chance to go to school.
“I can’t help but think of all the things children back home ask for. Everyone needs to have an i-pod,” she muses.
She describes a family of five who slept together in a space of about two meters by two meters. Yet they offered her a place to stay for the night. And the woman who knelt before her to thank her for the medicine she bought for her skin condition. It was a small amount of money, but unreachable for the woman. She didn’t know how to thank Anika, so she knelt in front of her and tried to express what she felt.
Anika is overwhelmed at this point of the conversation. Her voice is choking and her eyes are tearing up. Her skin is visibly changing; the hairs on her arms are standing on edge. She is profoundly, physiologically moved by what she has experienced here. She came on a whim to further her education. But she was overwhelmed by joy, by compassion for these people.
“I told them last week that it was my last day with them,” she chokes a bit as she speaks. “But the next day they still came looking for me. ‘Where is Nachimuli?’ they were asking. That’s the name they gave me. It means ‘a flower’.” The flower of the Nile.
Beautiful things show up in the strangest places. This girl standing before me is nothing special. She is plain looking, straw colored hair, average height and weight, working on a social work degree. But at this moment, I see how beautiful she is becoming. She is being changed from the inside.
I offer a few words of encouragement. I warn her of the difficulty of transitioning back to the West, where people want to talk about what you have experienced for, say, 30 seconds or so, and then they want to move to important concerns in the “real world” such as the latest theory on what Michael Jackson’s doctor is doing now. I offer to correspond with her if she finds this frustration too much, or if she just wants to talk to someone who might understand. We talk for a bit longer. She doesn’t want to stop just yet. I ask her to remember to carve out time in her life for the poor of this world. I urge her not to allow the busy-ness of life crowd out the people she has met. Give them a seat at her table, invite them into her life, put them on her budget and find a way to do what she can. It is a good life, I assure her, a life worth living.
We are off again, rampaging down the Nile River in a raft, rowing, leaning, laughing, falling in, choking, and screaming. I can’t forget the flower that I met. I wonder to myself, what if life was more like that. Meeting people who are changed, moved by this world to live differently, a life of significance, and taking the opportunity to give them a nudge, encourage them, affirm them, give them value, reward them for making a different choice from the usual materialistic self gratifying culture of the world we live in. It reminds me of what a young preacher once said, “I was hungry, naked, thirsty, imprisoned, and you fed, clothed, quenched, visited me.” It’s the criteria for the judgment. It’s what separates the righteous from the wicked. Nachimuli may not know it yet. She has discovered the secret to everlasting life.
CD4 Count of One
By all accounts, she shouldn’t be alive. By my brief glance, she doesn’t look like she is.
We are on rounds again at Siaya Hospital. We are looking over the devastation of the past week, patients with HIV, TB, diabetes, stroke, liver failure, meningitis, and malaria. We are trying to find out what happened to the child we attempted to resuscitate last week, but no one seems to know.
We are making rounds on the adult wards. The new attending physician just started today. He has been in Kenyatta Hospital recently. He is committed to excellence and sets a high standard for the 35 or so students that are trailing him today. He grills them on a number of topics and expects them to know their patients well. He won’t tolerate sloppiness. I like this guy.
We finish in the male ward and move to the female ward. It is already afternoon. The attending physician is trying desperately in this first day with the students to impress them with the importance of taking their work seriously. By the looks on their faces, they are taking him seriously. He tells them they have until Friday to learn the whole of knowledge about tuberculosis and HIV. He adds to that malaria. Oh yes, and anemia. He wants to make physicians of them yet.
The study of medicine in Africa is never easy. Lack of equipment, limited resources, limited tools and overwhelmed systems, satisfaction with mediocrity and crummy attitudes can drive you crazy. This physician seems to be on a one-man crusade to change all that.
There is a woman sitting on the edge of her bed struggling for air, and we don’t know why. There is a woman with diabetes and hypertension who has suffered a stroke, but we don’t know if we should treat her or not because we don’t have a ct scanner. There is the woman who came in with hemoglobin of 2.4 (normal is 12) who can’t get blood because it is too expensive and there is no blood bank here and the blood must be obtained by family members from Kisumu 2 hours away and no one has taken the trouble to change the system to actually save lives. There is the woman with HIV sitting in the ward with a CD4 count of 1. 1. The doctor draws in a deep breath and looks at her. It’s not compatible with life, but here she is. All 87 lbs of her. At first glance it is hard to tell whether or not there is anyone there. She is alone. We learn that everyone in her family has died from this disease. The group moves on.
CD4 count is a way of measuring what is left of the immune system, at least the part of the immune system that gets hammered by HIV. Normal CD4 counts hover around 800. Patients below 400 need special treatment. Those below 200 are at risk for a variety of dreadful diseases. Those below 100 need to be propped up with all kinds of medicines.
I don’t know that I have ever seen a human with a CD4 count this low. As I stand at the back of the mob of students surrounding the attending physician who has found another hole in their knowledge and is trying to plug it, I can’t help but steal a curious glance at this woman. I wonder at her life, what were her dreams, her goals, her plans to be a mother. I wonder what was lost with her lying here in a hospital bed. I look over at her. She is staring back at me, her eyes sunken, hollow, curious, questioning. No doubt she is wondering at my life as well. What am I doing here? What brings this strange white man to this hospital? Do I have a family? Is my life a good one? Do I love my wife, perhaps more than she was loved?
I smile at her. She manages a weak attempt in return. I walk slowly to her bedside and take her hand in mine. I don’t speak her language, but I smile at her eyes. I take her x-rays and look them over. I sit beside her and feel her sunken face, peer into her eyes, her dry coated tongue, check her lymph nodes, listen to her lungs and her heart, check her abdomen, feel her enlarged liver and spleen, the doctor sort of thing. I’m trying to tell her something else. I am hoping that she senses through my hands what she cannot understand from my words. She watches me, curious, wondering, too polite to protest, perhaps grateful for human touch, if only by a physician. I grasp her hand again, and she squeezes mine with her thin leathery palm. I smile at her again, the kind of reassuring smile that a physician gives to his patient that says all will be well. But I think my eyes cannot lie to her. I fear that she sees the sadness that is there, that says I know I will not likely see you again. She cannot live long like this. She represents all of the wasted talent and motherhood and vibrancy of 25 million Africans who are on their way to the same place she is going, into nothingness. I want to wish her peace for her journey. I want to give her courage for the days ahead. I want her to travel into this unknown place with the sense that her life mattered, that she was loved, that she could rest without fear.
Fish Ponds
I wanted to see some fishponds, because one of the things the Pokot people have requested for their development project is to raise fish. Their water supply is so seasonal that the water runs through with a fury and then dries up. We have to find a way to slow the runoff and capture the water in ponds, then raise fish for sale and for personal use. This will give the people another stable source of protein in their diet.
We have tried for several days to connect with Dorothy, one of the hospital workers who have offered to show us to the fishponds near her house, just about 200 yards from the hospital. Every day we have to postpone the field trip due to rain or some other issue. Today, the rain was brief, so we are going. Just before leaving, the rest of the team sends a message. There is no water at the house and they need me to bring some. Also, could I bring Luke’s lab results? Luke had fluid splash in his eyes while trying to care for a child in shock. He will be taking a drug regimen to prevent HIV transmission for a month. He feels sick from the medicine and had some labs done to make sure he is ok. From the looks of Luke, I can understand why people stop taking their medicine. We look at the treatment of HIV as miraculous and life saving, but the truth is it is wretched. You feel like a floppy, angry, depressed, arthritic egg noodle.
Godfrey and I accompany Dorothy down toward the fishponds. We walk down a small hill where she points out her water supply. It is gravity fed protected spring, water coming out of the ground through a perpetual pipe. The excess water runs down the hill into the ponds, about six in number, terraced into the hillside. We find a woman working beside the ponds. She is about 60 years old, friendly and helpful, but embarrassed at seeing a white person down by her ponds. She is cheerfully whacking at some sweet potatoes that grow along the side of her pond. I ask a few questions through Dorothy.
The woman seems happy enough to take a break from her sweet potato harvest. She explains that each pond, about 25 yards by 50 yards can hold 2000 fish. The fish crops are rotated about every three months so that harvesting takes place year round. These fish, catfish and tilapia, take about 6 months to mature. When ready to sell, the water is drained from one pond into the next, recycling the water. Pipes flow in and out of the pond so that water and flooding can be controlled. The shallow end of the pond is ankle deep. The deep end is 4.5 ft deep. Fish stir up the mud as we talk. She feeds the fish a mix of flour, dry grass and dry minnows, stuff that floats. Fish are prone to being eaten by birds, dogs, and the neighbors who sneak around at night, she continues. How much does she make at harvest. It depends, she explains, on how many fish are eaten by the dogs, birds, and neighbors. A heron flies overhead as we talk. Besides, she continues, there are widows and orphans who come. She can’t charge market price to them. Can she give us an average? She thinks for a moment. About 1500 shillings, she estimates. $18 for three months work. I swallow. I’ll have to rethink this fish thing. I want it to be a source of income for someone. It’s a lot of work and a lot of vigilance.
We walk back up the hill. Dorothy has offered to let us borrow a couple of jerry cans for the water problem. We travel to her modest house a block away. We shimmy through a crooked heavy gate into her yard. Turns out she lives in a pasture. “Watch out for these cows,” she warns, “they are wild.” I look at the cows. Aside from the impressive horns, the scrawny beasts look pretty safe. We step gingerly to Dorothy’s house, balance on the narrow walkway around the perimeter to her front door. Just inside, she has stored several buckets and jerry cans. Her laundry hangs just inside the front door. “You know, you have to watch these cows,” she explains. “They like the taste of soapy water. If you leave your laundry out on the line, they will eat your clothes. You come back and you find your shirt is half gone.”
We carry the buckets down to the spring by the fishponds and slowly fill them the African way, rinsing, washing, and shaking before filling them. We watch children nearby curiously looking at us. “You have to fight with the school children sometimes for water,” Dorothy explains. She goes on to advise us about carrying water on our heads, jerry cans, and cows. These are the African way of life.
We purchase two jerry cans for Dorothy in exchange for the two she is giving us. We load up the water and drive back to her place. We help her get her buckets back inside the fence, and she is satisfied that she can take it from there. “I am safe now,” she explains, “although these cows look thirsty. I have to watch them or they will get my water.” I look over the fence. She is surrounded by a herd of big horned beasts, all staring at her. We thank her for her kindness and close the crooked gate behind us. “Otherwise these cows will get out,” she shouts after us. I smile to myself. The hospital receptionist lives a simple African life in a humble cement home with a tin roof with her laundry hanging inside the front door to protect it from the cows that prowl outside hoping to drink soapy water drawn from a spring down the path that leads to the fish ponds tended by the friendly lady who chops sweet potatoes while watching for herons, dogs and neighbors in order to make $18 and still finds a way to help the widows and orphans who live nearby. I shake my head at the thought. It is the mystery and majesty and honor and frustration and generosity and poverty and loveliness of Africa. We bounce along the road home in our rickety Pajero with two jerry cans filled with spring water.

Find your life of usefulness, a life that is beyond belief…

Inventory
One of my jobs here at Sagam Community Hospital is to look over the inventory of what we have available to us. We are doing this with the thought in mind that we want to move things in the direction to provide a higher level of care necessary to train family physicians. We are missing some pieces, both in equipment and in training.
I have been asked to begin in the operating theatre, or operating room. I pulled down some packs to review the contents. Looks like the last sterilization for some of the sets was ten years ago. The c/section pack is complete; that’s good news. The #1 general set could be used for multiple purposes, including a backup for c/sections, hysterectomy, probably some abdominal cases. The #2 laparotomy set is missing a few pieces. It could use a couple of retractors and an operating scissors. The sets for dilation and curettage are fine, except they are missing the dilators and curettes. I scour around the operating room, but for the life of me, I can’t find those vital pieces. I’ll put them on my shopping list.
I peruse the various boxes lying around the room. Some look promising, some contain garbage. Some have never been opened since 1963. I pull out a couple of the packages. American Medical Instrument Company, Columbus GA. Date of packaging: January 1963. I realize that these instruments, deaver retractors and malleable retractors, are nearing their 50th birthday, having never found their usefulness.
I think I can make use of some of these instruments, so I opened a deaver retractor. It is carefully wrapped in plastic. Inside, the instrument has a tight foil wrapping. I open the foil and breathe in the scent of the 1960’s factory in Georgia where it was packaged. The grease protection has long since turned to sticky molasses. I turn it over carefully, admiring its brilliance, shape, and I wonder at the person who painstakingly packaged this instrument. What was she like? Was she a mother? Working hard to support her family? Did she have dreams for this instrument? Did she hope that the hard work of the factory and her own hands would help to save someone’s life? I determine that the 50th birthday of this instrument will not be spent like the last 49, sitting in a box in an obscure corner of a dusty operating room.
I grabbed some soap and water and scoured away the glued on grease covering. The stainless steel still shone like the day it was made. I smiled as I admired its design and grace. I dried the instrument and laid it carefully in the set alongside the babcocks, allises, metzenbaums, and kellies. At last it had found its place in the world, after only 50 years. I know that the factory worker who packed this deaver away all those years ago is likely long gone, but I’d like to think that I honored her memory in some way. If someone reading this happened to work at the American Medical Instrument Company in Columbus Georgia in 1963, I just want you to know, you did your job well. The instrument you wrapped so carefully looks gorgeous alongside all of its colleagues in the operating set at Sagam Community Hospital. At last, it has found its life.
Maybe this is a parable. No matter what the age, a life sitting on a shelf without purpose or direction can still find all of this and more. I just want to encourage you, pull off the wrapper, clean up the grease and find your life of usefulness, a life that is beyond belief.
Oct. 19
Sinaga A:
It’s early Friday morning. The car died again last night, the latest in a string of near death experiences for the Pajero. This time the hydraulic clutch breathed its last. I called the mechanic early this morning and asked him to replace the hydraulic cylinder that pushes the clutch plates apart. Who knows how long that is going to take, since he will have to locate a similar piece from another Pajero? I am walking to the hospital to catch the ride to the “outreach clinic” at 7 a.m.
We climb into the “ambulance”. It is a four-speed shift on the column minivan. It looks like someone ate the armrest on the driver’s side. Bare metal spans part of the dashboard. A vent window is shattered. The sliding door is so dry from lack of lubrication that it has to be slammed with considerable force. The same door doesn’t open from the outside, so someone has to open the window to open the door from the inside. The dear driver dutifully grinds the worn starter against the worn flywheel again and again. He stops when the starter doesn’t engage and pumps the gas a few times hoping that will help. Finally the starter kicks in, and the engine roars to life.
We drive a couple of blocks and stop to pick up Dorothy, the one who lives in the pasture with the cows, and another lady, one of the community health workers. The two community health workers who accompany us today are of the traditional African build, kind, generous sized women whose job it is to communicate health to the villagers and organize them for health projects like todays. One of the women has a face so gentle, she reminds me of an African female Buddha.
We continue on for ½ mile until we reach a trail alongside the road and follow it down to a field. The community health worker directs the driver across the field to a home on the other side. A cow with a large hump is tied to the house. We bump around to the front of the house where two more cows watch us curiously from where they are tied. This is where we will hold clinic.
Our supplies for the day consist of containers of paracetamol (Tylenol), cough syrup, ibuprofen, and amoxicillin. Also a bp cuff, some paper, a notebook, and a large thermos of tea and five cups. The team sets up two tables and some chairs under the eaves of the house where we will be seeing patients.
Dorothy invites me to investigate the local guava trees.
“Here we have so many guavas,” she begins to extol one of the many virtues of life in western Kenya. “You know, in Nairobi, these will cost 10 shillings! (About 12 cents) But here, they fall off the trees.” She selects two from the tree. “This one is not good,” she explains. She refers to a ripe one. “These are the best.” She points to a green one. I ask how we should peel them. “You eat the whole thing,” she replies.
I watch her as she takes a generous bite out of the green exterior. I wipe off the outside and try to navigate my mouth around the tough exterior. My lips are pretty well toast, having not recovered from the Nile expedition. I take a bite and notice that it tastes like, well, a really green, unripe thing. I glare at Dorothy. She doesn’t notice. She is busy explaining that some guava trees are taller than others, some have better fruits, some ripen sooner, some she doesn’t like. “I think they are different species,” she muses. She turns to me. “What do these have?” she asks. Vitamin C, vitamin A, I reply thoughtfully. I keep chewing. And chewing. Also lots of fiber, I conclude. “Oh,” she ponders the meaning of this. I carry the second guava to the workstation for later.
We begin with an elderly man wearing a Special Olympics t-shirt from Maryland. He has several issues he wishes to address today. A couple of kids are seen. Evan is a four year old with a fever. All of the children today have enlarged spleens, one of the common signs of chronic malaria. Many are pale, malnourished, distended bellies, cheerful, fun loving, curious. Evan spies my guava, and reaches out his hand. He looks up at me with guilty four-year-old eyes. I give it to him. He is delighted.
An elderly man with a Las Vegas shirt wants some help with his arthritis. An 87 year old with dark glasses and a fishing hat wants to know about his hernia. We explain that he needs surgery. He says he was told that if he had surgery, he would die. We explain that he could die if he doesn’t have the surgery. He seems comforted by this news. A one year old has a respiratory infection. Several more have malaria. An elderly woman has hypertension and arthritis. A three-year-old boy has had a stroke, likely due to sickle cell disease. Two older women look like they have TB. Everyone is listening intently to each other’s medical problems, HIPPA be hanged. Between patients, I watch malachite kingfishers, pied wagtails, mouse birds, an indescribable sky blue bird, brown kites flying, soaring nearby. The Buddha lady is lying on her stomach on the grass in the shade.
The hospital calls. They need the ambulance to pick up someone. “We are nearly done,” replies the nurse who accompanies me. 45 patients for the morning. We head back just as a vehicle from the hospital comes looking for us. “They were going to take the ambulance and leave us stranded,” explains Dorothy. Amazingly, the vehicle that came to get us is the Pajero. The mechanic found a replacement hydraulic cylinder and has it back on the road. We head back to the hospital with a handful of patients for admission. The empty medicine bottles bounce across the dashboard on the way. It’s been a good start to the day.

Signs off the wall at Siaya Hospital
“Suture removal- 50 shillings (about 60 cents)
Admission- no charge”

At Sagam Hospital
“Sagam Community Hospital: We offer at reasonable cost: 1. Hearse 2. Coffins 3. Lowering gear 4. Tents.”

To be continued…

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Cusick—again in Spokane Friday Quarterback Aaron Fritts and the twins—seniors Alex and Angelo...

 

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