Counsel and advice are received if the the source is trusted and the receiver has the humility to desire input. The wisest counsel has no value if these foundations aren’t realized. Trust takes time to develop (there’s no such thing as instant trust), and this is especially true as a physician seeking to develop trust in a culture with little exposure to good medical care and much exposure to care lacking resources and knowledge. Humility is a choice. We have a woman in our village with two albino children (complete lack of skin pigment) under the age of five. She has been in to see me with her kids perhaps five times over the two years that we’ve been here and I’ve kindly counseled her each time that if she doesn’t cover her kids with clothing and a hat, the sun will kill them at a young age, explaining the reason as simply and respectfully as possible. I saw them again this week for malaria and her kids had short sleeves and no hats and their scalps were covered in scabs from healing burns from sun exposure. Her disregard for my counsel stems from either lack of trust in the foreign doctor or lack of humility, but the kids will die young. There are many albino folks in this region and they are accepted without discrimination. Few live into adulthood because of exposure to the intense Angolan sun at a mile elevation.
The nurse director of our clinic in Cavango is a beautiful man with a great gift of service. He has enjoyed for years the status of “doctor” in the village, even though he has had little exposure to good medical practice. He has one year of minimal training (in 1996) and his experience consists of seeing a few people each week for years and trying to treat these patients with essentially empty shelves. He has learned much since my arrival and puts into practice what he sees in my work, but there is often an obvious battle within him to submit to the foreign doctor’s methods (new medicines vs the outdated, inadequate meds on which he was trained). He has enthusiastically admitted that over these two years he’s seen more medical success than he ever thought possible in a rural clinic (through appropriate diagnosis, effective medicines which I purchase and use, and asking our Father to help with each case), and yet he often lacks the humility necessary to submit to my experience and knowledge, especially in front of others.
It’s been my philosophy to enter a new culture as a learner, to ask questions, and to focus on honoring the local people and their customs. I also try to lead by serving/example/humility (as demonstrated by the One I follow) and, unfortunately, these methods of learning and leading are counter-cultural here (and in most cultures) and are often perceived as weakness. With the best of intentions, too often cross-cultural/missionary doctors arrive and start changing everything for the “better” (short-term results are gratifying!), forgetting about the importance of listening, respect, honor and the necessity of building trust over time.
In this culture, leaders are served and relationship with those led is beneath them. Strict paternal obedience, status, empty promises and short-term results are valued, while long-term results are rarely prioritized. In my clinic director, this cultural norm is combined with complete ignorance regarding medical studies, research, and how I’ve gained (and still gain) my medical knowledge. How could he ever imagine the medical practice/knowledge/training of the west? His inner conflict (trusting and submitting to the doctor or trusting another lesser-trained person from the past?) often manifests itself in ineffective or outright poor treatment (when he tries to authoritatively treat according to his antiquated training), leading to conflict and difficult discussions with the doctor, where this doctor must again remember that respect, honor and the long term are more important than any medical error or oversight. This reality in cross-cultural medicine is often unrealized until experienced…
The thick malaria season this year combined with the now-sixteen-month economic crisis, which has left the country with very few affordable medications, has significantly raised the patient volume at our little hospital/clinic in Cavango (where medication is always available at cost). For those interested in numbers, we are averaging about 60 consultations/day, divided into about 40 new patient visits and 20 in-patient visits, with about 40% of each currently involving malaria. The most common reason for admitting a person with malaria is coma from cerebral malaria, mostly in kids less than 5 years of age. Our average in-patient stay is about 4 days, with most going home completely well after treatment.
We have 6 individual rooms in a building set apart for TB patients and we currently have 11 patients with TB (8 with extra-pulmonary TB). We have three male nurses (most nurses in Angola are men, and historically there have been few doctors, male or female), each with one year of training in the 90s, and one of the three is “on call” each night, sleeping at the hospital. All three work seven days/week and two split night call, alternating weeks. So for seven days, one nurse is “on” day and night and gets the next week “off”, only working 12-14 hour days. The third nurse is our beautiful director (above), who responds to all urgencies, day and night, and works seven days per week. We average about 3-4 patients arriving during the night with an urgent concern (most commonly coma). Last night, for example. we had four kids arrive in a coma and two died within an hour of arrival and the other two are doing well. We also had a 16-year-old, pregnant woman in severe heart failure, a young man with a tibia fracture from a motor bike accident, and three others with severe malaria. The people of this culture are so tough, unfortunately often waiting until death is imminent before seeking help.
These tireless nurses absolutely refuse to not treat all who arrive, whenever they arrive, because they say they know what it’s like to have a sick child and have nowhere to go for help. They’ve each lost several children to malaria during the war, when no medications or health care workers were available anywhere. They are some of the most beautiful people I’ve met (including the director) and this missionary is challenged daily by their hearts for the hurting.
I’ve tried to suggest boundaries/guidelines like no new registrations for consultations after noon (it takes us until dark to see those who arrive before noon) and on weekends, unless the problem is urgent. My “rules” are agreed upon, then violated whenever someone arrives sick or injured, because no one travels for hours (usually on foot) to the hospital until there is an urgency! I’m concerned for the nurses’ children and families and for their own health (one recently had malaria, followed by pneumonia, and we were short a nurse for a week). He saw me today and his pneumonia is back and he was working with a winter coat on in 85F heat. They smile at my concern, because in their world view, one simply does not turn away someone who needs help. So many days, they are glassy-eyed and even nod off during a conversation, but they are up again at night, caring for another child with cerebral malaria.
In our morning discussions with the patients these days, I appeal to the in-patients and their families to respect these nurses and their need for rest and to only call on them if the situation is dire. I encourage these people to express gratitude to the nurses for their tireless effort and to communicate our guidelines to their villages when they return home. We are in the process of sending a document to every village in the area with our (“limited”) hours of service.
The clinic day begins at 6a for the nurses, distributing meds to the in-patients for about two hours. We have a “technician” who begins registering new patients at about 7a (people begin arriving before sunrise (6a). This technician is in training and will begin nursing school next year. Our technician from last year is currently in nursing school and will finish in three years and his tuition (about $1000/year) is being paid for by our beautiful supporters. These are two beautiful young men, who will each return home after training and serve the people of this region for many years.
My day begins at 8a with a brief (30min) discussion with our in-patients and their families, along with the new arrivals, on how they can improve their physical and spiritual health. There are usually between 50-200 adults who hear practical information on physical health and a message on the kingdom of Jesus, that they can then take back with them to their village and friends. I then make “rounds” on our in-patients until about 10a, at which time I begin seeing new patients. The days usually last until about 6p (we must quit at dark or work with candles/flashlights), unless we have new “urgencies”. The nurses do a good job of calling me after hours only when they can’t treat someone and I “usually” don’t work during the night.
I am in Cavango for the first two weeks of each month and the nurses do all the consultations during the last two weeks monthly, when I am traveling and doing clinics in other remote areas with MAF. This past month we traveled about 14hr by air with MAF along with a combined 10hr driving on oxcart paths in the rural province of Cuando Cubango in the region of Mavinga. With all of this travel, we saw about 350 patients, perhaps half with malaria, mostly kids (the adults simply don’t seek treatment). The region of Mavinga has no malaria meds (or any meds, for that matter) and without our presence, none of these would have received treatment, resulting in many deaths. It was a rich, dark and overwhelming 10 days, as the needs were far beyond what we could meet.
We spoke at each location with the health care workers and emphasized that we cannot see everyone, but that we wanted them to treat the straightforward cases and save the complicated or difficult cases for us. They responded by saying that they had no meds, so every illness (and every case of malaria) was an illness that they could not treat. In the heart of malaria season, this region is facing a crisis of great proportions. We charge the equivalent of $1.50US for medications and many could not afford it.
When I arrive back in Cavango on the first of the month, any “complicated” patients (pretty much all of them) from the previous two weeks are waiting to see the doctor, along with those who arrive for consults on those days. The first few days of each month are crazy, as you might imagine. It’s not unusual to arrive on the 1st of the month to several hundred people camping around the hospital awaiting my arrival. It’s quite a sight to arrive to all of these people milling around the cooking fires on the hospital grounds on the last day of the month.
It’s quite a pleasure to be able to participate in all of the good outcomes (so many) and quite a challenge to face the few people that we simply cannot help, but the pace is unrelenting. So many nights I arrive home and think, “There is no way I can repeat another day like today” only to wake up the next morning ready and enthusiastic to see how my Father might use me that day. I wish everyone could experience the joy of serving hurting people who have no other means of help.
Our team of supporters is beautiful, and none of our work is possible without them. This month we had a men’s group from Columbus send us $5000 to purchase malaria meds because of the crisis we are facing with medication shortage/cost. We had a fellow missionary couple (who live on so little) give us $300 to help purchase malaria medications. Even a security guard from the US Embassy in Angola (when he learned of our dire need for meds) sent us cash to purchase a month of malaria meds! This is combined with the money contributed by so many of you (we have a faithful team contributing $3000 monthly for meds and MAF’s airplane fuel – combined with MAF’s extravagant supporters) will help me always have medication to treat these people who have no other means of treatment. If you are interested in helping, see “Contributions” above on our site. It is such an incredible privilege to be a hand connected to such a beautiful body of people that is reaching so many people who will never know of the body behind the hand that is touching them! The flaws of the body of Jesus (the church) receive much attention in today’s world (and media), but His body is also incredibly beautiful, indeed!
Every religion/movement other than authentic Christianity focuses on “me”. Only Jesus puts the focus outward and on “other”. One of the saddest “developments” in Christianity is the modern emphasis on how following Jesus benefits “me”. When Jesus’ feet were covered with Judean sand, His focus was always on the glory/love of His Father and His love and concern for others. He repeatedly said that “life” was only found in a focus on the Father and a preoccupation with the good of others.
Our next post will highlight some of the wondrous stories that unfold every day in our work among these beautiful rural Angolan people…
The Kubackis in Angola 