'Willing to take the risk'

Editor’s note: This is the fourth installment of Colville physician Dr. Barry Bacon’s travelogue/report from the African continent and his ongoing work there. This story picks up after the events described in “Widow Powered” which appeared in the 12-12-12 edition of the Statesman-Examiner.Rwanda Project Believe it or not, the people at Wright Medical Technologies have promised to send me ten sets for treatment of osteomyelitis for children in Rwanda. This is great news. I, of course, am not in Rwanda, but that’s ok. I have corresponded with one of the young doctors in our family medicine residency (just graduated this week) and he is very interested in continuing and leading out in this project. I believe that there is tremendous potential for not only effectively treating this devastating disease in east Africa, but for the African physicians to take the lead, and eventually for manufacturing to take place in Africa. The materials are less than $10 if manufactured locally. This is a very exciting moment for me. The problem of osteomyelitis, chronic infections in the bones of children, is region wide. We have the opportunity to stop the repeated failure of therapies for these kids and save their limbs, which now have to be amputated. We’ll have to do it with a bit of secrecy. We can introduce the therapy, get some successes and then publish our results once we have some experience. We’ll choose 10 eligible kids, treat their disease, then follow the kids for at least 3 months to make sure it works, then submit our results for publication. I may need to make a trip to Rwanda to get things off the ground, but I can handle that. Friday, October 26 Everyone else is still asleep. I am up early in order to get to the hospital on time for the 7 a.m. departure of the outreach clinic. The vehicle is still in Kisumu for our visitors’ use. Which means we get nothing. I’ll walk the 15 minutes to the hospital, braving the black rhinos and water buffaloes as I go. (Yes, I know there are no water buffaloes in Africa. Yes, I am about as likely to see a water buffalo as I am a black rhino). The morning is beautiful. The tree at the entrance to the hospital, full of black-faced weaverbirds, is alive with song and a flurry of nest building. Each male is desperately hoping that the next female to amble into the area will choose his specially constructed nest as her new mansion. Each female that flits through brings a cacophony of chirping, squawking, wing flapping and hanging upside down in display to attract her. The disappointment is apparent as the sounds die down and the nest building resumes. I climb into the ambulance that is to transport us to the small village a few minutes away where we will conduct a bush clinic. Dorothy is here and will accompany us. Since she is a local girl, she knows the Luo language, which many of the hospital workers do not speak, but rather speak Swahili. She will translate for us when necessary. The rest of the team includes three nurses and a driver. I look at my surroundings. A large gap is apparent under the back door, where someone smashed into the back of the ambulance. The seat ahead of me looks like a chew toy for a grizzly bear. The overhead light is wrecked, likely a casualty of the same bear. We are off to the clinic. Dorothy is two seats ahead of me. “I don’t like the dust in this vehicle,” she exclaims. “It is too dusty.” We putter along the rocky road for about five minutes, and then abruptly stop. The team sitting in front of me is discussing something in Swahili that required them to stop the vehicle. This is not good, though I don’t know what it means. We travel for about ten minutes more. I look out at the silent corn, houses of eroding mud brick, children in faded school uniforms watching curiously, goats nibbling the edges of the road from their staked pasture du jour. There is much of Africa that is wonderful and timeless and cannot change. There is the background of deep poverty, intense suffering and social injustice that must change. We stop near a small side trail where one of our team members jumps out and walks away from the vehicle. Good, I’m thinking, we must be here. The driver turns around. The nurse in front of me is extolling his great virtues as a practitioner, trying to convince me to get some money to sponsor him for further studies. Something is loudly dragging under the car. I fear the rear differential has broken, but realize, no, this is something else. The nurse drones on, unaware that I have switched gears and I am worried that our vehicle is falling apart and can’t hear a word he is saying. He is smiling at me as he explains his great giftedness. The driver notices the noise and opens the back door. I jump out and look at the damage. No big deal, just the cage that holds the spare tire under the van has fallen off. It turns out we have not arrived anywhere. We are lost. The community health worker, I am told, who was to accompany us and direct us to the right place didn’t show up this morning, so we don’t know where we are supposed to be. We back track along the road and ask for directions a couple more times. We decide travel in a different direction. Apparently people give better directions in another village where we will get lost a second time. Fifteen minutes later we pull into the green yard of a warm and welcoming lady in a housecoat. She is delighted to have us visit. She wonders why we are here. We explain that we are lost and that we are looking for someone who can give us directions to the place we are supposed to be. The driver of our ambulance attempts turning around in her yard, but the grass is slick so he burns out a big patch of turf instead. We stop for a moment and get out while our team leader runs down the path to find the man who knows directions. (Is that an oxymoron?) The very talented nurse opens the side door, but doesn’t realize that it is precariously mounted. He accidentally tears the side door off the van. He stands there holding it, not sure what to do next. The driver takes it from him and reassembles it. We are back on the road again and are directed to a small clearing just a minute from the hospital. We walk down a narrow path through a yard between houses down a hill and find the community health worker. She hasn’t told anyone we are coming, so no patients are ready. We decide to go back to the place where we found the direction man and see some people there. First, however, there is one lame woman that needs help. Would we be willing to do a home visit? We trudge down the hill further to her modest home. Inside, we find the woman sitting surrounded by three small children, the oldest of which is four years old. The children are pressing against her from three sides, nothing in their hands, no toys visible, no electronics, a simple mud floor that soaks in the urine and mud alike. From one corner a chicken with her chicks sounds an alarm as we enter. We take a seat on her modest furniture. The mud-plastered walls are bare except for a 2009 calendar. The smoke blackened roof sheets creak and stretch in the morning sun. One of the nurses checks the woman’s blood pressure as we get some basic information from her. She had a stroke 18 months ago. She has been unable to go to the clinic since that time for follow up because she has a great deal of trouble walking. Not only so, but the paths in every direction from her place are steep, difficult climbs. She is essentially house bound. She arises with great effort and struggles to keep her balance. Her left hand hangs loosely at her side. She explains that she has been in this condition since the stroke, and it is not likely that she will improve further. Her blood pressure we learn is 200/100. I examine her and find weakness in her leg, arm and face. She is 40 years old. I know that for the rest of her life, this will always be her condition. We cannot fix what has happened. We can only reduce her risk of having another such event. Children with runny noses and enlarged bellies from worms, enlarged spleens from malaria, anemia, malnutrition… We make arrangements to get her some help and we are off to the direction man’s house. We park on a level spot just across from where a frightened cow is tied to the hedge that crowds the road. We enter his small home, creatively constructed on the side of a hill with steep steps coming down into the back door where chickens investigate our presence through the sunlit doorway. A news article on President Obama hangs on his plastered wall. Western Kenya is home territory for his ancestors, who live about 20 miles from this place. We arrange our patient flow and begin to see patients, a total of 35 this morning, children with runny noses and enlarged bellies from worms, enlarged spleens from malaria, anemia, malnutrition, adults with hypertension, poor eyes, arthritis, respiratory infections, HIV. Children watch me curiously, but keep their distance, concerned that I might have something sharp to poke them. We finish around 12:30 and walk back up the hill to where the ambulance is parked by the frightened cow. We climb in and start down the road, happy to be finished with an exhausting, if crazy, morning. However, the driver is directed on a detour so that we can pick up another patient. We head down a road that becomes more constricted and narrow as we travel. A quarter mile down the way, the road becomes impassable. The deeply rutted path is so eroded; its bed is four feet below the surrounding fields. It hangs at a 45-degree angle. The head nurse asks me if we can make it. “No,” is my clear response. The driver decides to try anyway. He guns the shaky van and careens into the abyss. I am hanging on with a death grip to the side of my seat as we slam against each other. Sick patients behind me gasp, little old ladies with arthritic spines and difficulty breathing whom we are carefully transporting to our hospital to tenderly care for them. We jumble around like jellybeans. Fortunately, the van is two-wheel drive, so as one wheel is suspended in midair, we stop abruptly, wheels askew and spinning. The driver is unconvinced. He backs out of the muddy mess and decides to try once more. Neither rain nor hail nor common sense will stop this driver from getting us in a bigger mess than we have ever experienced in our lives. Finally, he gives up, turns the vehicle around and parks it while we wait for the patient to arrive on foot. I decide to get out and walk. I remember that I have some other work to attend to that requires some tools that are still stashed at the house, which is a short walk away. I excuse myself and walk out in the fresh air. I grab the tools, head to the hospital and console myself with doing a couple of ultrasounds, fixing a newborn warmer and checking out the operating room light. A film crew from the U.S. has arrived and they want to interview me. They want to document the mighty things we are accomplishing here at Sagam in order to make a documentary that MGH can use to promote their global health work. I would go and talk to them, but I don’t have time right now. A first time mother is in labor, but stuck at 4 cm for the past 8 hours. The nurses wonder if I can help. I examine her and find that she is not more than 3 cm. The head is well applied. My opinion is that she can successfully deliver vaginally, but I am concerned. I offer to rupture her bag of waters and she agrees. It’s really the only intervention I can offer her, since we don’t have an administration pump to safely use pitocin. I work with the nurses to make sure we have everything ready for a c/section, in case it is necessary. Just then the power goes off. It starts raining outside. The hospital director summons me to attend a meeting with insurance representatives and some business personnel. They want to meet me because my presence here means that a physician is available to provide a higher level of service. No one tells the insurance rep that I am only here for four more days. I smile at everyone and apologize for my delay, since I was caring for the lady in labor. I hope that it demonstrates a commitment to patient care, rather than that I was wandering around in the dark looking through a messy operating room for basic supplies to prepare for an emergency operation. I clean up a mess I made in the pediatric ward where I fixed the newborn warmer. I needed enough light to see what I was doing since the electricity is off. I sit for a few minutes in the hallway and watch the rain. I don’t want to leave until I know the patient in labor is safe. Meanwhile, the surgical instruments are being sterilized in a heavy metal cooker over a knee high charcoal stove. The ob nurse calls me for a consult. She needs me to cut an episiotomy for her. I look at the progress the patient has made. She is about to deliver. I look at the tools the nurse is using- a needle driver, a bandage scissors, and a weird round scissors that were donated by the Flintstones. That’s our tool kit. I use a small amount of local and give the nurse instruction about use of and timing of episiotomy. The patient delivers shortly afterward, a beautiful girl. We all cheer. The mother smiles, exhausted and happy from a long day. We repair the tear with a miniscule needle and no tissue forceps, just our fingers to grab the needle in the dark. I promise the nurses that I will bring them an extra tissue forceps from my stash at the house. “Only for maternity,” they declare protectively. Any small token for their use is guarded carefully. I look over the newborn carefully and hold her close. She snuggles against my chest, content to be warm and comforted. I congratulate the mother, give a few instructions to the nurses, and prepare to walk back to the house. I’m exhausted. I haven’t had enough to drink. I left the house this morning before 7 and it is now 8 p.m. I slip down the muddy path toward our place and reflect on the day. I feel safe, knowing that rhinos hate mud and aren’t out tonight. Fireflies flicker in the darkness along the roadside. Gentle human sounds rise from the valley below, sounds of the evening. A rare African passes me in the darkness. I realize from the look on their faces that I am the most frightening thing on the road tonight. I am tired, beat up, and I feel great. I ponder what I should say to the film crew that will convince the folks back home to change the way things are without destroying what is good.Then there is the hope of giving a better future to a young man because our paths have crossed. I am willing to take the risk. It is a good life.The Orphan This morning started with a walk up the slippery road to the hospital. The moment I exited the gate of our yard a call went up, “Mzungu!” It wasn’t the frightened call of a terrified pedestrian running away, nor was it the angry cry of an injured subject. Rather it was the happy welcoming call of a best friend. A boy of about six years old has sighted me and is calling his friends and family to come and join the wonderful, life-changing experience of holding the hand of an mzungu. The boy runs to me and grasps my hand in both of his own, with upturned face, bright eyes and sunlit smile. His peers are more timid, holding back until they are sure they are welcome. I greet him in Swahili. He is speaking Luo. With great animation he describes to his friends the feel of my skin, and the texture of my veins. He discovers the hair on my arm and rubs his hands up and down, detailing the wonderful experience as he walks with me. A girl about his size comes and takes my left hand. She is looking intently at my watch and is trying to outdo her friend on my right side in expressing the wonder of it all. The boy on my right is rubbing his cheek against my forearm and encourages another trailing behind us to do the same. The timid one rushes forward, snatches a quick cheek experience and dashes back a few steps. A man chopping at tree stumps in his yard ignores us as we walk past. We walk like this for a quarter of a mile, doing nothing else in particular but enjoying each other’s company. I am walking down the middle of the mucky road, my shoes getting heavier with each step. No matter. The children are on the edges with bare feet and shake off the mud that clings to them as we walk. Finally they tire and return home. They will greet me later as I pass again. Things are quiet at the hospital today (Sunday) so I say hello to the staff and invite the clinical officer on duty to call me if any disasters occur. He promises that he will. I head home to work on some lectures and household cleaning in the absence of the rest of our team who have gone to visit Masai Mara. It’s just Godfrey and me this weekend. I arrive to find the Internet down and electricity sputtering off and on. So much for my plans. Later in the day, Jane Rogo called and invited me to walk with her to visit one of the orphans in her program. Jane, Godfrey, the hospital coordinator Benson and I walk a mile or so to Fredrick’s home. Fredrick is 17, but in form 1, the equivalent of 9th grade. Jane explains along the way that when Fredrick was young, his mother died. She was a single parent. Fredrick’s mother suffered from mental illness in her early 20’s and died shortly after Fredrick’s birth. One can only imagine what situations mental illness creates in this environment. She may have been taken advantage of. She may have resorted to means of earning money that put her at great risk of disease. We don’t know. Fredrick was raised by his grandmother, and he lives with her now. He must get up at 5 a.m. and walk 5 km to the day school, returning about 7 p.m. He is also the caretaker for his now elderly, frail, blind, crippled grandmother. His uncle lives nearby, but doesn’t have a job. His uncle suffers from chronic wasting disease and TB. We enter the grandmother’s home now and introduce ourselves. The grandmother knows we are there but can’t see us and can’t hear us well. I sit beside Fredrick and talk to the family. I want to know what resources they have used from the family and what part they are willing to contribute in the future. Jane warns me later that the uncle is a good talker but doesn’t follow through. Jane also points out that the family has a good thing going with Fredrick staying here caring for the grandmother, in which case the family doesn’t have the expense of paying someone else to care for her. It really is too much for Fredrick to take on, and his studies have suffered. Another cousin enters the house. He is older than Fredrick and has finished secondary school a couple of years ago, but doesn’t have a job. It appears that there is help around and available if Fredrick must leave in order to be in a boarding school, for example. I talk to Fredrick in the presence of the others. I tell him pretty straight that I want to know what he will do with his education if the door is opened for him to attend. I want to know if he values the opportunity that education represents. I tell him that I know what it is to work hard. Though both my parents were living while I was going to school, they had to work hard because they believed in education, and I worked hard as well. This is what I expect of him. I ask him to write a letter of commitment that he will study hard, do his best, and get his best grades. But if he desires an education, likely I can find someone to support him. I need to hear from him. He nods his head. He understands. A load appears to be lifting from his frame. He can see a door opening before him to a future. I look at him. He is one African student in a sea of faces in need. The difference is that he is an orphan. Maybe I can level the playing field just a bit. Jane says he is a good student. Maybe if I give him a chance, he will change his world. Godfrey is nodding his head. He identifies with this young man. We take a picture and head out on the road. We pass the weathered mud frame house where the uncle stays, and the equally dilapidated house where the cousin stays, and talk things over as we go. Jane cautions me to make sure that we work together on this project, since she doesn’t have confidence in the uncle. I agree that we should have a local fund for the boy that she would access and keep a record of expenses. “How are you?” a young voice from the edge of the road calls out. Jane scolds the children for only noticing the Mzungu and not the rest of the group. Another child comes up and takes my hand. “You see?” asks Jane. “They only see you. They only greet you. They don’t even know the rest of us are here.” I tell the others of the experience from this morning with the boy rubbing his cheek against the hair on my arm. They laugh wildly. “I remember shaking the hands of the priest when I was a boy,” laughs Godfrey. “When I could do that, I was happy the whole day.” Such is the life of a mzungu. The reward at the beginning or the end of a long day is sharing not language but the simple joy of being together and holding the hand of a stranger. Then there is the hope of giving a better future to a young man because our paths have crossed. I am willing to take the risk. It is a good life. To learn more about the orphans of Kapedo and how to help, go to www.PokotTurkanaPeaceInitiative.com.