Chiulo

In the dim, flickering evening hospital lights, I sit on a patient’s steel cot in the cement block women’s ward, performing an ultrasound on a pregnant woman with abdominal pain who I find to have a healthy baby at fourteen weeks gestation.  I watch the roaches climb over the next bed as I listen to the wailing and screaming of family members of a 42 year old man who died only an hour or so after I sat with him on his cot, discussing his medical condition (which didn’t at all to me appear life-threatening).  It was our third death of the day, all unexpected.  The other two were an adult with epiglottis after a successful operation for Ludwig’s Angina (a severe oral infection originating in an infected tooth) and a newborn.

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This is Chiulo, a government hospital that previously was a Catholic Mission Hospital, about a 4 hour drive south from Lubango, in the desert southwest of Angola, near the Namibia border.  The last two hours are off-road.  I’m in my second week of helping here, as they are facing a physician shortage.  The hospital was established in 1948 and is located in the Cunene province, which is estimated to be 80% illiterate and perhaps the poorest in Angola.  The hospital is located in the middle of nowhere, and has about 250 beds.  The census was nearly 300 last week as they fill up the verandas with people on mattresses and on the cement.  No one is turned away.  Every bed that empties from a discharge or a death is filled immediately, and malaria season hasn’t yet begun (though there are still many cases of severe malaria).  I can’t imagine this place next month when the rains begin.

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I’ve spent my days dividing the workload with the two beautiful, Italian physicians who are currently covering the hospital.  They work seven days/week, are always on call and are quite spent.  Paula is a FP who committed to Chiulo for a year and is going home after three months.  She said that, although she has much experience working in Africa, she cried every night for her first two weeks and simply cannot keep up the pace required for a year.  She so obviously loves the kids and does so well with the more than 100 inpatient children.  Pedro is a 5th year surgical resident who, here for six months, is in his last month.  Both treat every patient with such care, practice excellent medicine, and give their very best to a situation that is simply incredible.  This place has them completely spent, with its poor nursing labor (more on that below), limited (and broken) equipment, small pharmacy, no chance to get away, etc.  For me, it’s been like stepping into a place of my dreams.  It (or a place like it) would be such a great place to serve these beautiful rural Angolans who have so little, who deal with so much, and whom our Father loves as He loves me.  There are no replacement physicians currently scheduled from October forward.  The hospital has been staffed for ten years by an Italian NGO called CUAMM.

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It’s been a step up in acuity (severity of illness) from Lubango and the volume is almost suffocating.  A high percentage of people in this region have HIV, so there is much AIDS related illness.  Another major learning curve for me.  TB is much more rampant here as we see several new cases/day.  The Maternity Ward averages 3-4 deliveries/day and a Cesarean is alway lingering (several/week).  I did a Cesarean on my first day here and there was no water and the OR lights, the suction, and the cautery didn’t work.  The surgery took a little extra time but baby and Mom recuperated well.

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Our work day begins at 8:30a, we take lunch when we finish rounds (usually from 3:00p-4:00p), work again until a dinner break (about 7:00p), and do evening rounds from 9:00p-11:00p.  The work is a non-stop sprint because there are always several very ill people waiting to be seen (broken bones, fever, stitches, etc).  More than 30% of the inpatients are unstable and would be in an ICU in the States.  There is usually more than one death each day.

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The wailing and screaming as I write indicate another death (a beautiful six month old girl with several days of diarrhea).  It continues for several hours and is passionate, heart-wrenching, and so loud.

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On the men’s ward, many are young, rail thin, with sunken eyes, and are HIV+.  The HIV prevalence in the region is high and it is usually innocently and ignorantly contracted heterosexually.

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One day we had four cases of TB empyema, each needing their chest cavity drained with a chest tube.

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When I arrived, there were 20-30 very sick kids with measles.  The majority of kids admitted have some degree of significant malnutrition.  We treated three cases of meningitis in one week, had several cases of cerebral malaria and coma.  There are several kids here with awful burns from falling in the fire.

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The majority of these rural folks prepare simple meals with cooking fires.  After dark (6:30p) most activity centers around the fire and inevitably the unthinkable happens… often.  Many here are scarred from these major, innocent childhood burns and the kids here this week are so beautiful and courageous during their daily, unimaginably painful dressing changes (sugar and vaseline).  We have one child with epilepsy who seized and fell into the fire (also common, because people with epilepsy, like everyone else, stay near the fire in the desert night to stay warm).

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Most cases of epilepsy here (there are many) are caused by either meningitis or by a pork tapeworm which burrows anywhere in the body but is devastating when burrowing and forming inflammatory cysts in the brain (Neurocysticercosis).  It is picked up by drinking water or eating vegetables contaminated with the feces of infected animals (or people).  It is a common, debilitating disease in the developing world.  Fences (to keep animals out of the garden) and outhouses (to keep human waste out of the garden) are uncommon here, and life-saving,   Is it no wonder that their loving Father prohibited the Israelites from eating pork?

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Before work one morning, we went to the market, about a ten minute drive from the hospital.  I’ll try to post some pictures.  There were perhaps 40-50 “shops” set up with goods placed on a table of laid out tree limbs and some sort of covering (wood, grass, cardboard) for shade.  Most of the shops sold a great variety of alcohol and many of the men at the market at 8:00a were stumble drunk.  One could buy the basics: Peppers, potatoes, sugar, salt, onions, tomatoes, garlic, spaghetti, rice, chickens, beef (hanging outdoors), raw beans, raw peanuts, etc.  There was no refrigeration or frozen food.  One could buy simple tools, basic clothes, shoes and blankets, etc.  There were candies and simple toys.  It was outdoors in the desert sun, so third world, and such a neat place.

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I’m ever trying to understand the culture.  The hospital workers are in perpetual slow motion.  Although these physicians treat the nurses with great respect and patience, so many of the physician orders are simply not carried out.  There are plenty of nurses and most of the time you can’t find them, though so much is undone.  I had a very sick woman with an overwhelming infection take a turn for the worse and I ordered a powerful antibiotic and, despite multiple respectful reminders of how this is what she desperately and immediately needed, she didn’t receive the medication for more than 48 hours as she teetered on the brink of death (she died).  X-rays can be taken only on Tuesday and Saturday so you can imagine how imperative it is to get chest films on critical patients.  Many simply have not been taken to X-ray by the nursing staff on the appointed day and we have to then wait another several days (if they survive), to see, for example, if they have a collapsed lung or fluid in their chest or both.  This week we ran out of X-ray film (no prior warning that we were getting low, etc) and there were no films done.

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We put a tracheostomy in a young man whose airway swelled shut from Diptheria and he died during the night with no one notifying us of his deteriorating condition.  The nurses where likely sleeping.  He was doing so well, resting comfortably and completely stable, when we left him at midnight.  Another man came in with difficulty breathing.  With ultrasound, we saw that he had fluid around his heart, but because he had no difficulty breathing at rest, and because it was late, we decided to observe him through the night and treat his TB pericardial effusion with medication (corticosteroids) and not yet put him through a needle aspiration.  He died during the night, surely worsening over hours, and we were never called.  We could have performed the aspiration as he worsened…

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There seems to be such apathy, such lack of concern for those ill.  It appears (by both their demeanor and their work ethic) that they simply don’t care.  I’m not sure, philosophically (according to their belief system), if they feel responsibility for their work and for the patient’s welfare; that their work affects outcomes.  Have they become fatalistic and hard in light of so much suffering and death?  Do they believe that God or fate is in such complete control of outcomes that they have no role?

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They are in need of encouragement, respectful instruction and role models of love and good medical care.  I would love to see what might happen if they were honored and thanked and embraced daily.  Is the attitude here cultural or spiritual?  Is lack of love evidence of lack of Light?  What if they could know participating in God’s work, that they could be His hands, His instruments?  I wonder what might happen if Jesus introduced His love to this place through one of His own?

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There is much made in today’s American churches about drawing close to Jesus.  Millions are spent on musical equipments to create an atmosphere where we can “feel” His presence.  Yet Jesus told us how to draw close to him, to touch Him, to love Him, and to feel His presence (Mt 25:35).

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Jesus’ new commandment was not to love Him more, to know His word more, to worship more…  How do we treasure His kingdom, “make a difference”, “give all” for Jesus, become “holy”, worship the King of Kings or find His “presence” (all common phrases in churches today)?  Jesus told us clearly that these don’t happen primarily at a church service.  They happen through our time, our resources, and our sweat, as we seek out the hurting, the lonely, and the hungry, and “touch” Him in the “least”.

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Thank you for touching the rural people of Angola through our work.  There are so many opportunities around the world (outside the rich man’s house), where Lazarus suffers.  That is where Jesus is, among those without adequate clothes and shelter, those malnourished, those without potable water, those sick, lonely, forgotten…

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Jesus was clear in that we can know the Bible, worship to beautiful music, preach to others, attend great conferences and church services… and miss Him. Let’s remember today where we find Him.

6 comments

  1. Tim,I’m praying for you and all your patients. I’ve only seen a few Ludwigs and don’t care to see anymore.I’m still praying that we can teach Angolan believers basic dentistry to prevent some of the dental complications. Mark told me he had bible study at your house and really is excited to return to Angola. In His Name,Jim

  2. I have some idea of how frustrating it is to work in such conditions, even though CEML is a step up in the conditions for treating people and usually a step down in the condition of the patients we usually had there (although we always had one or a few who needed intensive care). I also had a hard time trying to balance the respect and understanding for what the nurses were doing, with what it seemed to be a lack of heart and responsibility for their such important work. Many days all I wanted was to find a place to cry for a while, and receive extra strength and encouragement from the Lord. May the Lord always grant you much strength and courage as you do represent His love to these “little ones”. I am glad that you did more than replace my work there. I honestly think it was an upgrade in many ways for the patients and the hospital. May the Lord always bless you and protect you and your family from every kind of harm.

  3. Thanks for your posts, Tim. You do an excellent job of painting word pictures so we can better “see” what you are doing and more knowledgeably pray for you and the other medical providers.

    May God’s love continue to shine strongly through you…and through your family…to these hurting children of His.

  4. We miss having you and your family close, but I see how the Lord is using you to help meet an overwhelming need in that area. Praying for you. You are a great example of sacrifice and a light of God’s love to those people.

  5. Tim – thanks so much for your heart and God-given ability to write/communicate as you do. I often read your posts with tears in my eyes remembering all too well the many faces I have seen and treated over the years – both abroad and home, trying to love as Jesus would. Praying for you all and those you serve daily.

  6. Tim, Boy if YOU think the Angolans are in slow motion, i probably wouldn’t even notice that they had moved at all! oh boy, reading your posts i want to come and assist in any way i can. i asked the boys if we should move over there,, they are not as interested…i laughed when you wrote about the two physicians leaving early and that you had found your “paradise” Please Lord give him strength, health and endurance. How do you stay uninfected with so much contagion? Give me a ballpark of what we would need to put together for Rob and i to come for a few weeks? Bless you brother, sure miss you and Bets, but are happy in our hearts you have found some rest for your soul! Ter

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