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.