Will the real healthcare crisis please stand up?

I can't decide which case is more troubling or unique,....is it the scrotal hematoma, ...or the roundworm impaction? Perhaps the adenoid hypertrophy or the circumcision that also resulted in injury to the ureter (which most certainly would be cause for a malpractice suit in the U.S.). The 16 year girl with Downs syndrome being treated for tuberculosis was interesting, but other than her Downs syndrome, not unique,... there's a lot of TB here. But I think the cases that most captured my attention were the Mother and two sons who had been sexually abused and consequent to "prophylactic" antibiotic treatment, developed gluteal necrosis, which is almost never seen in the U.S. Caused by injection techniques totally devoid of sterile measures, these infections were difficult for me to comprehend, but not for the rounding physician who I accompanied on this, my last day in Kenya at St. Mary's Missions Hospital. Dr. Johnson was well familiar with the unjustified horrors of the routine sexual abuse that occurs here. He understood that many face life difficulties here that have no basis of comparison in the U.S. He understood that for those without financial resources who face traumatic circumstances as a way of life, when medical services are needed, they can be found at St. Mary, provided by overworked, understaffed, yet caring physicians, nurses, pharmacists and others. St. Mary's will treat outpatients for 100Kes (Kenya shillings) (approximately $1.25) or inpatients for 350kes/day/bed ($5.00). Quite a bargain for health care, yet you will be seen, evaluated and treated for these prices. Its not Jefferson University or Einstein Medical Center, .... there may not be the latest medical technology or lab evaluations, but St. Mary's can be the difference between whether you live or die. Here, that's the very basic difference that counts. The very bottom line.

We've been in Kenya 42 days. During that time , we've established a solid and enduring relationship with the medical and pharmacy staffs of St. Mary's Missions Hospital, met with staff and faculty of the University of Nairobi, where I've lectured twice, and soon to be Drs. Cheam and Nguyen have collaborated with the U.O.N. pharmacy students, conducted five medical camps, toured Glaxo SmithKline Pharmaceuticals, M.E.D.S (Mission for Essential Supplies and Drugs),and met with individuals from KEMRI-Wellcome Trust to establish a method of database development for the hospital. So its been a busy time, and, an enjoyable time. Yet, I hadn't spent significant time in the medical clinics or the medical care areas, so as it turned out, when we asked who was doing rounds today and the response was 'no one', we did what any self-respecting physician and pharmacist would do, we started rounds. You see, St. Mary's is the sort of place where sometimes you work where you're needed. If you happen to be a physician and pharmacist team and no one has made rounds that day (for whatever reason), well,... you get the picture.

The pace is dizzying and exhausting, from the pedicatrics ward, to Women's Surgical and finally on to the Mens surgical,..with an array of disorders, discomforts, patients who have late-stage cancers, victims of road traffic accidents, those in need in skin grafts, and yes, those with necrotic tissue disorders consequent to inappropriate and incorrect use of antibiotics. We treat, order lab tests, correct orders, cancel some antibiotic use, discharge some patients, and overall, make sure that patients are receiving the appropriate care. Completing this, we move on to the outpatient clinic, where the pace is just as frenetic if not more so. St. Mary's sees more than 277,oo0 outpatients yearly, by the most recent estimation. Are there other hospitals in Nairobi? Yes, but none that serve the poor with the compassion and dedication seen at St. Mary's, and so, patients flock here. You can imagine that maintaining this pace on a daily basis, yields fatique, disconnection and often disillusionment. But those who keep this pace realize that the patient's need for care outweighs their need for rest (at least at the time). Its energizing but concerning to think about the over half-million people (patients plus those accompanying them) who come through these doors in need of physical and emotional healing. The goodnews is that, here, it can be found. The bad news is that the staff is overworked and 10 more St. Marys could maybe begin to quench the overwhelming medical needs of Kenyans. We finish for the day at St. Mary's,.. haven't eaten,.. we're drained emotionally, but excited about the child we were able to discharge because his adenoids were no longer swollen, or the women whose antibiotic burden was lessened because of the teachings from Drs. Cheam and Nguyen on pharmacokinetics, but saddened because of the 100 year old man who will die from prostate cancer because at this stage there's little to be done (his PSA was greater than 100).

But this happens everyday at St. Mary's,... a lot of patients are seen, yet only a small fraction of those who could be seen, ....if they could get here, ....if they had the $1.25 or $5.00/day for in patient treatment. The if's, like the why's, could fill this page...

We talk about the health care "crisis" in the U.S. But it begs the question,...even in the most desperate situations, will patients be denied care? Is there a way to treat all patients? Will medications be made available all, even to those who cannot afford them or are without health insurance? The truth is that even without the recent healthcare legislation, we all have access to healthcare. The question has been whether or not we're willing to create equality in order to erase the artificial boundaries to access. Are we, as a society, willing to do the work, up front, that will allow all of our neighbors the freedom to pursue our common human right for access to the state- of-the-art care. Too often, those without the time, without the resources, or,.. without the energy are forced to create their own access through avenues that are the birthrite of us all, but remain hidden in a thicket of bureaucracy and frustration. Too often, these potential patients lack access, not because the care is unavailable, but because of the inherent fatique, disconnection and disillusionment created by our system. So, maybe this is the biggest and most profound WHY. Perhaps one could understand, although not justify, inaccess to care, and resultant fatique, disconnection and disillusionment at an overworked Missions Hospital in a developing country, ..corrupt governments and all of that,... but then, maybe all of us are corrupt in our denial of the basic human right of healing for all. ..Hmm?!

Our collective blessings are many. Our collective challenge and our call is to insure equal access to all of those blessings. Perhaps its instructive to remember the universal implications of Martin Luther King's statements about the illusion of democracy, and that none are truly free until all have access to, and enjoy the freedoms.

Where has the time gone?. a few days to go

These weeks have flown by,... can't believe our 6 weeks is almost gone,...but time does fly when you're having fun,.... and this,.. has been fun. In the past two weeks alone we've traveled the breadth of Kenya. From Nairobi to Kisumu on the shores of Lake Victoria, back to Nairobi, on to Mombasa, and back to Nairobi again. All along, studying this vast and beautiful country, its healthcare system, its customs, its people, its poverty, its wealth. And, as if we hadn't traveled enough, we then left for a 2 day holiday in Masai Mara, ... safari, anyone? The five weeks of this clinical service learning experience has officially ended. Its been a blast.

The two clinic days we had this past week, were in Laikipia district in places known only to those who live there,.. Sipili and Donyloip. Anyone who finds these on a map has my admiration, if not my suspicion that they just fabricated these names. But they do exist,. ask anyone, again, anyone who lives there, that is. But Sipili and Doyloip are real. The people are extremely hospitable and genuine, desiring a quality of life similar to that which is desired by all places on this globe. Sipili and Donyloip are also dry and dusty, ...without any meaningful rainfall for the past four years,... that's right, four years,... but the rains have come recently, planting has begun and area farmers are looking towards a harvest in the next several months, as well as the resultant food and water.

No,.. we haven't gone the route of veterinary medicine,... but the medical camps were held not far from livestock, and our patients didn't come through a maze of shopping malls and
housing developments to reach us. Instead they traversed open fields of grazing cattle. Quite a difference from the areas to which we're accustomed. But this is daily living for these areas in almost desperate need of health care. Areas where upper respiratory and skin infections are commonplace as is gastrointestinal worm infestation. Malnutrition and dehydration are the norm. Cardiovascular and metabolic diseases aren't seen so much since these are diseases of aging, yet some of our patients were in their 10th decade, and even as you age here, you're more inclined toward prostate, esophageal and liver cancers. Although there was one patient who was under the care of her son who was managing her diabetes, but now, they were out of money with no prospects that the closest hospital would continue to provide her insulin or her oral diabetic medication (Glucomet) without charge,... Although we happened to have a three month supply of Glucomet, the insulin would have to wait,.... We were a well stocked pharmacy, but in this area, largely devoid of electricity, we had no refrigeration, and therefore no insulin, and for that matter, neither did the patient. This son, who had managed his Mother's diabetes thus far was limited in options, but that's not unusual here,... truly, the options available are either limited or,... none.

This has been a new and quite different experience for soon to be Doctors Saomony Cheam and Tam Nguyen from the University of the Sciences in Philadelphia. When we embarked on this adventure, even I who have praticed in similar settings on many occasions, had not envisioned that this trip would involve seeing approximately 300 patients over two days in places that appear on no maps and thus are located, literally, in the middle of nowhere. These Doctors of Pharmacy have opened themselves to rare opportuinities in global health and have, over the course of the last two weeks, provided much needed medications to over 450 patients including the clinic conducted in Mtwapa, Kenya. But its much more than this. The care, compassion and hope that Drs. Cheam and Nguyen have given along with the medications they've dispensed,... that care will be enduring in this community. Amid the herds of cattle and dry, dutsy environment, these pharmacists saw the need for administering the quenching balm of hope and love, and they have more than met this need.

But this has been a trip of opened opportunites. Medical students from the University of Cincinati joined us. Elihu Godshalk and Pam Stem, forth year medical students saw patients, touched patients, prescribed for patients and in this also administered love, compassion and hope. The human touch aspect is huge here. For it is through this human contact that we are providing others with the touch that we all need as part of the human family. Its through this touch that not only affects the patients seen but also forever changes us. Elihu, Pam, Saomony and Tam have changed this community, themselves and those of us who have done this before. These soon to be Doctors of Pharmacy and Medicine have been an inspiration to all of us. For this we are thankful.

So Dr. Michael Johnson has been here before,.... the people of Sipili and Donyloip know him, have worked with him,,,, know of his compassion and passion for inspiring hope for "The Least of These". Dr. Johnson has been in Kenya for 20 years, but will be leaving soon. Will a void be felt,.. absolutely,... Will God provide another who will adminster health care to this area,.... absolutely,.. For I believe that although the Bible refers to "The least of these, my bretheren", in God's view, these are not really the least these, rather they are indeed our bretheren....and in that, they are also God's children. Dr. Johnson and his familiy have sacrificed much, in love, to be here for the last 20 years, but they, like Abraham, know that God will provide. Even to this dry and dusty plain, God will provide,... maybe especially to this dry and dusty plain, God will provide.

Amos Ooga, also was a blessing, having only recently welcomed a newborn, he and his wife are meeting the challenges of any couple married for two years. But here was Amos, a specialist in orthopedic appliances, serving on the mission field,.. a blesssing to those served, and a blessing to those with whom he served. Thank you Amos.

Then there's Anthony,... who we really couldn't do without, since he was single-handedly responsibile for our arriving safely at Nayaharuru, Laikipia, Sipili and Donyloip, as well as returning us safely to Nairobi. Anthony, a zillion thanks, especially since some of the best photos of the clinic were taken by you.

I've improved my kiswahili, somewhat,... at least conversational at the prescription window, ...mbili mara mbili kwasiku... (two tablets twice daily), ... Enjoying my time with Tam, Saomony, Michael, Elihu, Pam, Amos and Anthony. Learning much about each one and especially learning about each one's passion for service. This team is serving with joy. In our eyes, serving our bretheren,... in God's eyes, serving His children.

But there's one thing more. This team is American, Kenyan, Vietnamese, Cambodian and Jewish.... five different heritage origins. Could this be the Body of Christ? Too often we tend to segregate ourselves without reconciling ourselves in Christ or to each other. Perhaps this is what John saw in Revelations when he talks about a gathering of people from every nation and every tribe standing before the throne of the Lamb. In this team we've begun to create an assembly of service composed of people from various ethnic backgrounds,... an unlikely team perhaps, but a team in which our service to God greatly overshadows any differences we may have. Yes, these weeks have flown past, ....we've done, seen and traveled much,.. an adventure to say the least, an awesome and wonderful experience to say the most.

Four days to go, but then, who's counting :>)

Glorious Victory Academy Clinic,.... a good day?

Well the announcements were made, ...the guy with the bull horn and motor scooter made his appointed rounds on a Friday afternoon. Four villages, north of Mombasa, Kenya,..Barani, Kanamai, Majengo and Porrini,.. were his areas. The medical camp was coming, 10:00 Saturday morning until 4 in the afternoon. He didn't say until the last patient was seen, because then we knew, we could be there all night (literally). But they came, mostly parents bringing sick children, some adults, but mostly children. They came,.. all 165 of them... iron deficiency anemias, upper respiratory infections, a lot of skin infections, eye infections, urinary tract infections,... they came and stayed, all of them, in the hot, humid area of this free medical camp set up by visitors from the U.S.,... a medical camp set up for those in these villages who don't see Doctors, either because they can't afford to see a Doctor or because getting to the Doctor is much too far and with a 15 or 20 kenya shilling Matatu ride out of their economic reach, access is a major problem. And so they came, with inquinal hernias, some malaria, many middle ear infections, one perforated ear drum,one schistosomiasis, and several ulcers in adults. They came because they were sick and needed care,... several patients were there who had prescriptions from governmental dispensaries, but they had no money. We treated them and provided similar medication, free of charge. Some were there because of visual difficulties,... had glasses before, .....broke them needed more,... we referred them. One patient who is HIV positive that I've been following for the past few years whose son is also HIV positive, ... both are doing well, maintaining medication regimens and visit schedules. It was a full day at what has turned into an annual event, this Glorious Victory Academy Medical Camp. The one where you can get medical examination, medication, treatment with dignity delivered with love,... and its free,... you know, ...sort of like salvation. But if people are hurting, its hard to get them to care about the saving grace of Christianity. So this clinic tries to ease their suffering with touch and care as well as examination and medicine.

Dr. Stephen Muhudhia, a close friend who often works these clinics with us, saw many of the patients. Whenever we're organizing the clinics, Dr. Steve, a pediatrician quickly agrees to assist and join in the planning. He describes the iron deficiency anemia he sees on this day,.. iron deficiany anemia caused by malnutrition. For those of us from the U.S., Steve talks about geophagia, the craving for soil, that our bodies begin to develop in situations of malnutrition. We listen and learn intently as he relates the stories he's heard,.. to us, alien stories,.. about children who literally eat dirt because they crave to do so as a result of malnutrition. We're learning, we're learning the sadness of existence in these four villages, where there is a scarity of clean drinking water, where mothers must decide which child is fed today. This is the world we're treating today.

The pharmacy students, soon to be Drs. Nguyen and Cheam, are learning too. This world is far
from the classroom they've habitated for the last six years, far even from the Native American reservations and other places of need where they've served during their recently past year of clinical rotations. But these Doctoral Candidates have sought a different plane of practice. Theirs is a mission of service to those who have severe health needs. Their vision is expanding on a daily basis, these health care professionals whose dedication to caring is becoming limitless. For me, it has been a priviledge to witness. Whereever they choose to practice, they will do so combining their professional knowledge with love and compassion. In this clinic, they operated the pharmacy under the supersion of my good friend Simon Tunje, the pharmaceutical technologist with whom I've worked for the past two years. Simon's participation in these clinics is critical since it allows me the freedom to consult with the school administration and others concerning health and educational issues pertaining to the general community.

So you could say yesterday was a good day,... we saw 165 patients, counselled many more on various life issues, distributed mosquito nets, trained pharmacy students and continued relationships within four area villages. Energized by the work, yes, you could say it was a good day. But good for whom... We get to feel good about ourselves, we who do a medical camp here once a year,.. we who get to see a Doctor whenever we want,.. we who get to go home to the U.S. Was this a good day for the many who suffer daily from malnutrition? Was this a good day for the mother who told me her daughter would like to transfer to another secondary school but can't for lack of school fees, or the mother whose mud dwelling that had been three rooms is now one room because of the severe rains. While our organization (Bibles, Books and Shovels) has an ongoing relationship with these communities, people continue to have daily struggles, but nonetheless seek good days. So we dispense our medicines, examine our patients and try to infuse some "goodness" into this day. But can we really? In an area where many days just aren't so good?

Steve Muhudhia once told me that those who think they're dispensing pills and cough syrups only, are missing the point. Dr. Muhudhia, a Kenyan well familiar with medical outreach ministries, explained that when medicines are brought and patients are seen and cared for with love, kindness and compassion, along the pills and cough syrup, is a giant dose of hope and knowledge, ...knowledge that there is someone who cares, hope that perhaps the children can aspire to a better life, hope that, although governments may not care or provide basic needs for their citizens, there are those who do (care), and will hold the governments accountable, even as they are dispensing pills and cough syrups.

John the Baptist, while in prison, enduring his own suffering that didn't feel so good, and knowing of others' continued struggles,..sent his disciples to ask Jesus if He was the one they had been waiting for,.. was He, in fact, the Christ,.. Jesus replied, ...you go tell John that the lame walk, the blind see, the good news has been preached to the poor..... I think he may have been saying that, yes, suffering still exists, and will continue to exist, but now there is a sense of hope because they've seen and heard the good news of physical and spiritual healing through compassion and love. Whatever it is that we do, our call is to be that good news, through our actions, as well as our words. If we do that, then everyone may be able to say "Yes, this has been a good day".

Dad

Ok, Ok, so I'm a bit nostalgic, some might say. Others might be a little less kind and say I'm hallucinating. Still others would say,... well, ... maybe,... a little,... But if you look closely at the picture to the left, this man who was kind enough to allow his picture to be taken by a stranger, and one with an American Accent at that, this man, bears a striking resemblance to my Dad. I've heard it said, although I don't know by whom, and I'm not sure I believe it, that all of us has someone in this universe that we can claim kinship with as a look-alike, not related by blood. I haven't found mine yet, but I'm in Kenya and I've found my father's look-alike,... Go on, take a close look, or maybe you don't have to look that hard. This man is a carbon copy of ..The man.

So you might say, Neil c'mon, you're way over the top on this, and I would say,.. look,... I was at a petrol station where we had stopped to have our radiator hose repaired on the aforemention State-of-The-Art Toyota (see previous post), walking along, minding my own business, when out of the corner of my eye, off to the left, I spy a gentleman, probably the owner of the petrol station, sitting in a chair, and sitting as only my Dad could sit,... those of you who knew him won't need an explanation,..those of you who didn't,.. well, its hard to explain anyway. So I walk closer, and he begins to rise from the chair as only my Dad could rise, and walk as only he could walk,... and, ...I'm not making this up,.. when I asked to take his picture, he sounded like,... that's right. And the most amazing thing,... when he posed for the picture leaning on a car parked outside the petrol station's bay,... he stood like The Man. Even had his shirt open at the collar,... I tell you it was uncanny and a bit spooky,.. don't know how else to describe it.


We live in a small world,... so small that I think we're connected by the tiniest of threads, the most stunning coincidences, the strangest circumstances, that at the most unexpected moments capture our attention and bind us together as the human family we really are. I saw this gentleman for the quickest of 15 minutes, and we were bound for that 15 minutes through his likeness of my father and willingness to have his picture taken because of that. He expressed flattery when asked for his picture and a silent joy when told that he looked like someone that I love. Eerily, the same type of silent joy my father often expressed in similar circumstances, and in that, we found relationship,... for a brief 15 minutes perhaps, but I'll remember those 15 minutes for quite awhile.

So, whenever you're out and about, minding your own business, be on the lookout for that strange set of circumstances that could provoke you to think about how you're linked to your neighbor in very real, yet unexpected ways. Of course some of us may not want to be linked to our neighbor,... but I'll save that one for later. As for me, .. I just felt like yelling, "Hey Dad,.. wait up" :>)

On the lighter side,.... roadside justice?

Cruising along on our way to Kisumu, me, my good friends Rose and Keith, their children, Rose's Mother and Brother, heading out of Nairobi for our next big city destination, Nakuru. The vehicle is rather dated, well, not so much dated as it is just out of shape. In fact, you might hear it blocks before you actually see it. Basically, its a minibus, seats 14 with pop-up roof intended for safari park excursions. It has a crack in the windshield, spews volumes and volumes of dark exhaust (and its passed emissions inspection, if that tells you anything about vehicular inspections in Kenya), the passenger seatbelt doesn't work and it has no shock absorbers (that I could detect anyway). Its a Toyota. But don't let any of these minor flaws mislead you. This car is sound. This car navigates pot holes and speed bumps that would make a lesser car, plead for mercy. Say what you will about Toyota, but I'm convinced that they manufacture vehicles specifically made for Kenyan roads. I've been on other road trips in Kenya where you just knew you were going to break an axle. But no way. These cars withstand the nastiest of road conditions and road deterioration and no roads, for that matter. My Highlander would have been trashed long ago. I'm a BIG fan of Toyota in Kenya. Not to mention that it takes its occupants to the brink and back (Kisumu) and they live to tell the tale. Thank you Toyota.

Anyway, we're cruising along when we're flagged down by the Roadside Police. One thing you have to know is that in Kenya, few police have cars. They'll flag you down, arrest you for some fictitious violation and then say, "Drive me to the police station." That is, if you're arrested. Most of the time, the'll inspect your car, at roadside, fine you and then collect the fine, at roadside. One stop shopping has a whole new meaning. So we were stopped, which, by the way is a routine occurrence in Kenya, fined 400 kenya shillings (a little over $5.00 U.S.) and then sent on our way. Keith says the infraction was the cracked windshield. Now, we could be stopped again and fined for the same cracked windshield (as it turns out we weren't but there are no guarentees). Bear in mind that, if we hadn't paid the "fine" at roadside, we would have received a summons to apear in court to receive an even heftier fine. So this is roadside justice,... its quick, usually painless, if somewhat annoying, and cheap compared to the alternative. Courtroom justice would have cost more in money and time. By the way, the word "justice" is purely incidental. It fills space, nothing more,.. though it could easily be called roadside "hassle". How about roadside injustice? And of course, let's just say the 400 kenya shillings doesn't go to the municpal treasury. Its really very funny once you get used to it,... you just build the time into your day, and you have no worries. Its all about expectations (you should expect to be stopped). So the next time you're in Kenya, better be sure to carry around an extra 1000 bob,.. you never know when you'll need it, lest you hear the words,.."you're under arrest,... drive us to the police station."

The Lecture

So I gave a lecture at the University of Nairobi, College of Health Sciences. I was invited to talk on the issue of Clinical Pharmacy and the role of the clinical pharamcist as a member of the healthcare team. The title of my talk: Current and Emerging Trends in Clinical Pharmacy: Integration of the Pharmacist as Health Team Member. In the audience were professors from the various healthcare disciplines, noted names in their various fields in Kenya, including highly respected professors of pharmacy, representatives from the Kenyan Ministry of Health, and the Kenyan Poisons and Pharmacy Board (the Kenyan FDA equivalent), and what seemed to be the entire student body of the University of Nairobi school of pharmacy. All of these individuals want to make a difference in health care in Kenya and all strive to bring pharmacy to the forefront of that paradigm shift in Kenyan healthcare. Further, it seems to be the concensus that the University of Nairobi, College of Health Sciences should be among the leaders of advancing healthcare in this country, if not the leader. So there I was, presenting my views on where the profession of pharmacy could go in Kenya, and how the profession can bring about meaningful change in Kenyan healthcare. The Gospel according to Neil...:>). or maybe an Epistle, 21st century style, by powerpoint. Of course my tongue is planted firmly in my cheek; I was humbled by the experience.

In any case, Kenyan training in the healthsciences is, in many if not most cases, more advanced than some U.S. schools of the healthsciences. Their thinking is quite progressive, their attitudes are very positive, their overall position is that we, as healthcare scientists, particularly pharmacists, have a rightful place among the healthcare elite of this country, and it is our obligation to be the authors of change,.... for all Kenyans. But, in this country of approximately 40 million, there is rampant HIV/AIDS, epidemic malaria, particularly in coastal areas, nutritional problems abound, with hunger, starvation and dehydration leading the causes of death in children. The issues of poverty as the primary factor in all of these circumstances is huge with most working individuals livng on $1.00 per day. So why is it that in a country of such forward thinking health professionals, AIDS and its accompanying deaths, exists at record prevalance, dehydrated children die routinely, malaria still kills the most vulnerable, and in its most remote areas, there are no physicians, no pharmacists, no medications and almost nothing that bears the slightest resemblance to regularly administered modern healthcare.

Several years ago, while walking on a gravelly/dirt path towards the main road, in a small Kenyan village, I asked my host, "What happens when someone gets sick back here". He smiled the kind of smile usually given to someone who has asked the most nieve of questions,..and replied simply," they die." Over the years, in other remote areas of Kenya, I've asked the same question, and the answer has always been the same,...."they die,...,of the simplest malady,... "they die." Of the most uncomplicated respiratory or cardiovascular disorder,..."they die". But wait a minute,... we have forward thinking health professionals,.. people who boldly state their intention to innovatively treat disease. People with uncomplicated disease are not supposed to die prematurely.

The universal tragedy is that this is not a story unique to Kenya. In many of our "developed" countries, there are those who die, needlessly, because "innovative healthcare" is not synonomous with the term "equally available healthcare", and even with U.S. healthcare reform, and the availability of insurance for an additional 32 million individuals, we are left questioning if that insurance will provide innovative healthcare to all. My mother who may have been diagnosed with cancer may not be offered state of the art treatments without the appropriate insurance, and what's even more tragic, is that investigations required to render an accurate diagnosis, may not even be ordered until the cancer is in its late stages,... because my mother may not have an insurance program that will pay for state of the art diagnosis and treatment, ...y'know,... the treatments that are seen on Fox Chase Cancer Hospital commercials. Or, my mother, because of the color of her skin, or perceived social background, may be seen as not worthy of elite care that would be offered to others of higher social or economic background. So, I wouldn't get too overjoyed about the new U.S. healthcare proposals until we have a sense of how the new legislation incorporates, in very specific terms, the dignity that one human being affords another,... or until the newly enacted laws state how we should relate to each other as the community that we really are. So, of course, Kenya doesn't have a monoply on poorly and unequally disseminated healthcare. We all share pieces of this tragedy.

Nevertheless, I incorporated some of this in my talk last week, calling on those in the audience to truly advocate for adequate and evenly distributaed healthcare for all Kenyans (especially those in the slums where we've often treated patients). It seemed very well received, and judging from the optimistic views of the students, their overall idealism as well as ambitious thoughts on healthcare provision, there is abundant reason to be hopeful that in future generations this change will come about. These Kenyans seem more than committed to the meet the challenges and engage in the difficult work that change will require. Their dedication to this could allow them to make the difference in providing healthcare for all Kenyans, in a way that affords uplifting the human spirit, allowing human dignity to flourish and dispenses hope along with medication. Now if that hope and committment for equality in healthcare reaches the world, the term Universal Health Care could take on its true meaning. Archeologist have said that civilization began in East Africa. Maybe the rebirth we need for global equally disseminated healthcare will begin in East Africa as well.

But on the bright side,...

Our World Gospel Missions colleagues are in Malindi on retreat for the next week. Before leaving, Dr. Johnson was asked to admit a child from Imani orphange to St. Mary's Hospital. The transporter of the child had not yet arrived and so Michael provided a note to me to convey to the driver authorizing the child's admission. Upon leaving, Michael comments,
"Oh by the way, I've referred another child to you."
" Don't worry Michael, the driver has already been here and he has the note, so, he's on his way to the hospital"
"No, this is another child. Faith (from Imani), called me this morning and she's sending another child, I gave them your number so you could admit them, just sign the note for 'The Least of These' (his organization for providing care). "I told them Dr. Pitts would admit the child since I wouldn't be here."
"Oh thanks Michael, Now I have admitting privileges."
"Well, after you've been here two weeks, you're in charge"

Such is life at St. Mary's hospital, even visiting health care professionals lend a hand at providing care for those who may not have access either because of distance, finances or both. As it turns out, this child was the son of Faith's friend, Maureen, who had already gone to Kenyatta National Hospital because her child had been experiencing seizures every hour since 4:00 a.m. But because she is aware of the care and personal attention the child will receive at St. Mary's she called Dr. Johnson, and then, me.

Ian Josh, 3 1/2 years old, was seen almost immediately at St. Mary's and it was at first suspected that he had menningitis. Although he hadn't had a seizure for the last 2 hours and his temperature was normal at the time, menningitis is suspected in cases where the child doesn't have a history of convulsive activity. In addition to the mother and father, Ian is accompanied by his grandmother who happens to be a retired nurse and was tracking symptoms and current course of events well. The child had recently experienced pneumonia, had been hospitalized, treated and released from Kenyatta during the course of the past two weeks, had finished discharge meds, but now had a different problem,... these new onset convulsions, of seemingly unknown origin.

The pediatrician, Dr. Kimani was wise, patient and kind,.. a great combination of personal attributes when seeing patients at St. Mary's. Upon inquiring about the patient's history, it is determined that these current episodes may be due to high fever. Even in our country, children have seizures of this type. Nonetheless an EEG is ordered, phenobarital is prescribed and the child and family are sent home. When I called to follow-up that evening, Ian hadn't experienced further seizures and was sleeping, no surprise since he had had several doses of phenobarbital that day (for emergency and acute treatment of the seizures). When Ian's Mother, Maureen, called the next day, Ian was doing well, still experiencing no further symptoms.

So, there is a bright side and, for most situations, good outcomes for cases at St. Mary's,.. not all children remain in the hospital and not all children die. Although we still don't know whether or not Ian has epilepsy, the EEG will provide further information, we do know that he was seen with compassion and love, by all who attended him. Isn't this what we're supposed to do?

As for my admitting priviledges, I hope they're short lived,.... but then again,..whenever we're asked to 'stand in the gap' for 'The Least of These', we all have admitting priviledges to offer our neighbors a higher quality of life.

I have...only questions

Three young men, one physician and one pharmacist are gathered in an office in the physician's home in Nairobi, Kenya one afternnon in April. The three young men were looking for news, mostly good news, that their father, in the late stages of liver cancer could be offered some hope for a longer life. The 60 year old carpenter has become excessively weak in the past several days. The three young men are just the oldest of this man's progeny, and seemly, the spokesmen for the family. Alarmed at the deteriorating condition of the father, they come to the physician's house with a plea that something can be done to sustain the father's life.

There is hope in their eyes although a despair in their body language. Seated on benches and chairs in the office, they are bent with hands cupping faces, weighted by the burden of uncertainty, wondering what words of assurance will be provided. The physician has seen the father's X-rays and shows signs of internal struggle as he looks for words to express his truth. That the father will die from this cancer is certain... when?.. is less clear. How to tell these devoted sons is difficult and unclear. The words come slowly and with compassion, but they come. "The best course for your father at this point is hospice care. " Your father can be made comfortable in his final days. "This is time for refelction and reconcilliation with family members", says the physician. "There are no effective treatments".

When we hear those words, where do we turn? When you are told that your 60 year old father will not live much longer, how do you fit those words into your life. The sadness of Kenya is that 60 years old is beyond the average life expectancy by several years, and so, this father was living in excess of his allotted time. But isn't that still 18 years too short? Isn't that 10 years below our conception of a "normal" lifespan? I have no answers, only questions.

These young men, Daniel, Simon and Peter, will soon loose their father at the age of 60 years old. The physician and pharmacist, good friends and co-workers in missions, deliver the bad news with compassion and sympathy, tempered with an attempt at hope that at least the father's pain can be relieved. Through consultation with each other, the pharmacist and physician offer morphine as a way of mitigating the father's pain, ..but who will mitigate the pain of these sons? Who will offer relieve for the Mother who will soon loose her mate, or the twin sisters and youngest brother, who at 22, will be fatherless? It seems shallow at times to say that God relieves our suffering, although he does. It can sound insincere and empty to suggest that God lifts our fears of the unknown, although he has promised to do that. The morphine the pharmacist recommends will be unable to sooth the emptyness and the soon to appear void of the father's loss... What can we offer them, other than prayer,.. which we offer? I have no answers,....only questions.

Pasaka

At 4:00 a.m., Pasaka Imani died. He was 3 months old, we think. The cause of death: severe dehydration. He leaves to mourn, the hospital familiy that cared for him in his final hours. His Father: unknown. His mother: Unknown. He was pre-deceased by his "brother", Bonaventure Imani, also aged 3 months, we think. So maybe we did need lipid and high calorie fluids to save his life. Throw away lives,... no one to grieve. As I watched his empty bed Sunday morning, I could only think of what may have been had he lived. The story of his life is short though and we can only grieve for his extended human family that allowed Pasaka's death at 4:00 this morning. While we slept, he died. There is nothing left to say.

An ordinary circumstance...

The woman brought the tiny bundle into St. Mary's Hospital pediatric ward. The child was still,.. pale,... emaciated, ...but alive. Quickly he was given Lactated Ringers intravenous solution. Ordinarily, a child brought to an American hospital would have been given intravenous lipid emulsions and total parenteral nutrition, the life saving, calorie rendering nutrients we administer in the U.S. healthcare system. As a sterile products pharmacist, I've prepared many of these life giving fluids. I've seen the miracle these medications can deliver. Under ordinary circumstances this child would be in the nursery intensive care unit. Urgent action would have been taken to measure vital signs, to determine weight, nutritional needs and weather or not social worker intervention was needed. Under ordinary circumstances this child would have been placed in an incubator with all modern bio-technology available and ready for use to revitalize an infant who was near death. Under ordinary circumstances. But this wasn't an ordinary circumstance. This child brought in by a woman, not his mother, but a woman worker at Imani Orphanage. Only doing her job and just carrying and delivering a package given to her by yet another (anonymous) person delivering this package found abandoned somewhere in Nairobi. The package? ... a barely breathing tiny human being. A child destined for St. Mary's Missions Hospital Pediatric ward on this Good Friday evening. By our western, civilized standards, this is no ordinary circumstance. For East sub-saharan Africa, it is all too ordinary. A child abandoned, a child found, a child delivered to a missions hospital, a child who died. No, we don't know the mother, a woman who doesn't know the fate of her child. We only know that on this Good Friday Evening, this child, God's child, has left no one to mourn except a hospital staff who has Lactated Ringers and a small gurney for this child to spend his final moments. Oh, and we didn't know his name,.. but we do know he died on the same day that we commemorate the death of Jesus. So maybe we can envision Jesus, you know, the guy who said, "Today you will be with me in Paradise", receiving this infant child into His bosom, and in that, there is good fortune for this child at the end of this ordinary circumstance. So let's call him Bonaventure,... child of good fortune.

Then there is Pasaka, also nameless, but called Pasaka by Dr. Johnson the M.D. on call. Pasaka is kiswahi for Easter. Earlier in the day, Pasaka was also brought in from Imani orphanage after being found abandoned somewhere in Nairobi. Also given an electrolyte and salt solution, as was Bonaventure, but Pasaka has so far survived the torments of dehydration and malnourishment. Even without an incubator or high fat/high calorie fluids, Pasaka lives on this Easter eve,..as Jesus lives.

Life in any circumstance, in any environment, is tenuous. We all live by the day, if not the hour. In Kenya, life occurs sometimes in minutes. These two children were brought to St. Mary's Hospital hours apart,... one lives, the other dies. One child will return to a home, even if its an orphanage,... the other spent the night in a hospital mortuary. Jesus said "Suffer the little children to come unto me and forbid them not, for such is the Kingdom of Heaven. In Kenya, it seems that it is ordinary for children to suffer abandonment, dehydration and malnutrition, all products of extreme poverty, and in this we forbid them from coming into God's kingdom here on earth and life plays itself out sometimes in the hours and the minutes. Life is tenuous and random it seems. Its a matter of time and a matter of place, for if you were born in Kenya and don't arrive from the orphange in time, you could die.

So,... thus far in my most recent visit to Kenya (I've only been here for two weeks), we've seen two children die, unnecessarly,... a pleathora of assorted cancers and infections,... and untold numbers of suffering human beings that would not suffer,... under "ordinary" circumstances. During the Easter season, our ordinary circumstance is that traditionally, our children wear new suits and dresses to Church to sing praises to Jesus. Generally, we don't think about dying children. This Easter, as I sing praises to Jesus, Bonaventure and Pasaka have taught me about death and resurrected life in its real sense,... its close, and its personal. The way Jesus wants to relate to me. If we are open to God's lessons, the death of one infant on Good Friday, and the revitalization of another on Easter Sunday, can have profound,... and lasting impact. An ordinary circumstance at St. Mary's Hospital in Nairobi, Kenya,....A profound and extraordinary implication for how we live our Christianity.