Morning rounds are where a physician daily evaluates the patients in the hospital and tweaks treatment, as necessary. It is typically such a joyful part of my day, as the improvement in each is often obvious and the pleasure in the patient or parent is nice to see. These days it’s common to have small kids walk into the room and receive a sucker after arriving in a coma one to several days earlier. Many die, but so many recuperate fully after I was convinced they wouldn’t make it when they arrived. Our hospitalized are typically critical, as there simply isn’t the space to admit many. We have about 20 beds for the acutely ill and they fill up fast. We often have about 30 in-patients, so rounds can take a while, until about 10a. The most enjoyable part of my job is seeing the sickest recover. Our chief nurse, Florindo, will soon see the minor illnesses and reserve the sickest for me, which has been my goal since my arrival. Having him do consults will make the most of his abilities (he’s been learning from me now for almost two years) and will make the most of mine. It will also divide up the volume and allow us to serve better, with less rush, and give us more opportunity to spend time with the patients and allow us more time for teaching about improving both physical and spiritual health.
I put forth a proposal to the village council this past Saturday morning re hiring some people to work in the hospital in non-medical capacities. This will free up our nurses greatly (they laugh when I tell them that they are trying to wear too many hats). We will hire someone to work in our pharmacy, our cantina (where we sell simple foods for the patients and their families), in cleaning, in keeping statistics, and in organizing/equipping the clinic rooms. We also need guards at night (to keep dogs, pigs, cows and thieves off of the hospital grounds), someone to help register the patients and someone to help with our vaccine program.
We face the challenge of growth with its involved adjustments and risks, which seems pretty straightforward to me but, as you can imagine, in a culture that operates much as it did when Jesus walked with His Father in the Judean hills, made meals for His followers and built tables, change is unfamiliar. The council meeting went well, though, and extravagant praise was voiced for our work and how it has benefitted so many people in the region, because people have somewhere reliable to go when they are ill, medicines are available, and so many have recovered. Also, one of our best nurses from the past, Rodé, returned after being away for two years caring for her sick husband. He recently died and she is returning this month. She is quite talented, has integrity and is a genuine Jesus-lover. She will develop a maternity practice, emphasizing prenatal care, which is nonexistent in the region.
Integrity is such an important quality in our staff, and is often lacking in this very poor culture, where stealing is commonly seen as necessary rather than wrong and where “what is yours is ours” (there is little real ownership). For example, we can always and easily buy government meds on the street in the cities for reduced prices (we don’t). These meds arrive in the health posts from the government and are sold by nurses and clinic workers to people who then sell them on the street. It’s quite a business. If we are not diligent, the same will happen at our clinic, as well, as medicines will “walk out the door” through the hands of our staff to sick people who say they can’t pay, but need meds. Most private clinics have money and meds disappear regularly, and we operate on much too tight of a budget to allow for this. All of the clinic workers are asked continually for meds, as a favor, from a friend. Relationships are so significant here that, culturally, it is very difficult for the clinic workers to say no, especially when the worker owes a favor to the one asking. This impoverished, cashless rural culture is driven by favors. Everyone owes everyone favors. We need to hire people who will say no to these requests, and they are not easy to find. Our council and Florindo both emphasized this challenge at our recent meeting.
Moises, the young man we sent to Lubango for nursing school, is doing well and we will soon be sending a young man away for six months of lab tech training, which will allow us to test for malaria, TB and parasites. This will be a big help as to accurate diagnoses, especially when I’m traveling.
Some of the challenges we face where modern medicine has yet to develop (or be trusted) are illustrated in the following stories. We often offer young women with vaginal fistulas free transport (by air or car), free surgery and free care in Lubango through two beautiful foundations from the US, “The Fistula Foundation” and “Hope for our Sisters” that finance the care of these women. The hospital in Lubango does great surgical work on these women who, essentially, have a hole (fistula) develop from their bladder to their vagina during an abnormally long labor, caused by the inability of the baby to fit through the pelvis of the mother. The surgical repair gives them back their lives. I’m currently in Lubango, but Bets told me that last night a woman came to our hospital in Cavango with a dead baby after three days of hard labor. We see this so much… no doubt another fistula patient…
We’ve sent perhaps 6 women with this problem to Lubango from our clinic this year. Two to five million women in the world have fistulas, 90% can be repaired surgically, they occur where C-sections aren’t available (most of rural Angola) and the women are often ostracized in their family/community because of their smell (the urine flow virtually never stops). We recently offered a free trip in the small plane, free treatment, etc, to three young women and none showed up. The reason they passed on this incredible opportunity is unknown to me, but could be lack of trust, fear of the unknown, fear of the city, fear of the plane (most have never been in a car, let alone a plane), etc. Then, as I was driving to Lubango a few days ago and going through a small village about 2hr from home, a woman runs out to the road, stops me, and asks when she can go to Lubango for the same surgery. Some accept and trust our care, many still don’t.
A very fit, 60-year-old man arrived in Cavango in excruciating pain after a two-hour motorbike ride. He is a Soba, or village chief, and very articulate and bright. He told his story. He fell on his motor bike and injured his hip and was unable to walk (or ride the motor bike) and he was taken to a local health clinic where he stayed in bed for 3 weeks without diagnosis or treatment. He finally asked his son to take him to our clinic, where we were able to easily make a clinical diagnosis of a hip fracture and confirm it with ultrasound. Because it had been 3 weeks and he was still not ambulatory, I suggested that he likely needed surgery, but that we needed an x-ray to confirm that surgery was indeed necessary (if the fracture was displaced), as ultrasound can identify the fracture but the degree of displacement is difficult to assess. We could transfer him to our hospital in Lubango for the x-ray and likely surgery (my suggestion) or he could obtain the x-ray “locally” and “free”, which would allow us to make the decision re surgery.
He chose the latter. So we took this man, who groaned or cried out at each bump (about 20-30/minute on these roads), by car an hour to Chinhama, where they (sometimes) have an ambulance. The ambulance was there but broken, but they said they would call the closest city (Cachiungo) and an ambulance would come and pick him up within the week. He would then be transported 3-5hr (on dirt with innumerable bumps and jolts) in this ambulance to the closest city (Cachiungo), where he would switch to another ambulance (if available) and be transported an hour to the hospital in Huambo where he would finally be x-rayed, after which he would return to me with the x-ray. The whole process (to get a simple x-ray) will likely take this man about two weeks, and then the return trip could take as long! This all within the “free” Angola health care system. On the way to where we dropped him off, he showed us where he fell and it was a treacherous, severely rutted road on a steep decline. He endured a sleepless, 50-degree night with no blankets and in severe discomfort. A friend found him the next day (unable to move) and took him to the health post, where he stayed until he came to us. This is a nice illustration of why no one goes anywhere in rural Angola alone.
I rarely meet a woman in her thirties or older who hasn’t had at least three children die before the age of five, usually from Malaria. The loss of a young child is a unique and devastating tragedy in the US, but here normal life. And children are every bit as precious in this culture as they are in the US…
We currently have more than 12 adults in our practice with huge bellies filled with fluid, called ascites. There is a long list of possible causes but, in Angola, many cases are caused by traditional medicine, the name given to the “natural” medicine received by virtually everyone as a first course during an illness. We see very few patients in our clinic who haven’t visited the local “traditional medicine” practitioner for a cocktail, an enema, or an injection. The mixtures given by the traditional “doctor” vary and some mixtures or quantities cause liver failure and ascites. Tuberculosis, cancer, cirrhosis, a common parasite here called Schistosomiasis, as well as Hepatitis B (all common) also can cause ascites, so the diagnosis can be challenging, especially in a setting with no laboratory or electricity. We sometimes drain off as much as 3-4 gallons of fluid (for their comfort), only to see it re-accumulate in a few days.
These “doctors” are usually well-intentioned, place a huge emphasis on “natural” and “herbal” remedies (even in this culture these labels are attractive), and know nothing of studies that verify the value of particular treatments for certain diagnoses (evidence-based medicine). All knowledge is anecdotal (like the friend who says that they tried a certain remedy for a certain problem and it helped) and no mixtures have specifically measured dosages (measuring cups, teaspoons, etc are rarely seen in rural Angola). I’m told that the remedies (roots, leaves, juices – think Granny from Beverly Hillbillies) are mixed with about the same precision as soup ingredients… a little of this, a pinch of that… a bit more of this might help this time…
Obviously, the “all-natural” marketing scheme (sound familiar?) has been popular for a long time and in many cultural settings… In the US, we sell our “natural” remedies in modern pills in artistically designed bottles, or in fragrant oils, creams or gels, etc, and studies will verify that they have the actual value of water, but the felt value of placebo. Studies show as much as 50% of people will improve from placebo medication in various forms – enough for a good marketer to make a lot of money. Here, though, people die from liver failure and never suspect that the “all-natural” remedies, given to them by someone they trust, could be the cause. Even here, the label, “all-natural” gives one the impression of no risk and all benefit, which is simply not true, as illustrated by these people who went to the traditionalist with a cold and left with liver failure.
I can’t blame these wholly uneducated people for using these traditional “healers”. Trust in the science and reliability of modern medicine will take time, because the only modern medicine in the rural areas for the last 50+ years has been in government health posts, which historically stock few good medicines, and these are administered by poorly trained, well-intentioned “nurses”. We daily have people come to our clinic with prescriptions from health posts as the practitioners write prescriptions when they are out of medicine – commonly the case for the last year and a half of a severe national economic crisis – and I am constantly explaining to our staff that these medicines are outdated and prescribed as part of a long list (commonly an anti-parasitic, an antibiotic, a vitamin, Tylenol among others) that the practitioner hopes will help in a shotgun-type treatment method, because he rarely is able to identify a specific diagnosis. The prescribed antibiotic and vitamin are invariably given as an injection because Angolans believe that injections are more potent than pills (this was the case 50 years ago). I insist that our staff sells no medicine in this manner and that the people see me to obtain a definitive diagnosis and proper treatment. Accurate diagnosis and treatment via a history (questions and answers) and a simple exam is virtually unheard of in this culture because of lack of solid, evidence-based training. Often a patient asks why I am asking so many questions because their typical experience in visiting a health post is to state their symptom and receive their prescription, without any further interaction or exam.
Communication in a country with many languages (and almost nothing communicated in writing) can be a trial. No one wears watches, so punctuality is impossible. In rural Angola, the most specific one gets is the hour. Time is given by the hour and never by the minute. The 10th hour literally means between 10:00 and 11:00, and this is for people with watches. When I ask the time of someone wearing a watch, they will say it is the 10th hour, whether it is 10:10 or 10:50. To them, it is the same time. Most, however, use the sun. Punctuality is important, however, when one has a 2-3hr trip by car to a village with no electricity and 100+ people waiting. Work must therefore end at dark, usually 6p, so it’s best to begin early (we like to be set up and ready to begin between 7a and 8a, the earliest that people will arrive at the local health post). We communicate that we would like to leave the town where we stay, at 4-5a, but the watch-less/clock-less driver gets up with the sun (maybe a little earlier – no alarm clocks), takes his time arriving, and we depart at 7a instead of 5a.
The “telephone game” you played as a child is accurate no matter the culture, in that information is always lost or changed over time and communication transfers. Villages often think we are arriving on a different day/week and everyone is in their fields before we arrive. We have a team in each place consisting of local men and women who often would rather we work in their (large) town than in the small villages where we would prefer to work (more remote is better for us as this is where those with the greatest needs live). Messages aren’t sent and then we are “stuck” holding a clinic in their town for the day. Churches, for example, begin their services with someone verbalizing the date (repeated several times), as sometimes this is the only reliable calendar one has as to day and month. So when we send a message about arriving on a particular day, the day of the week may be communicated or understood errantly and people are expecting us on a different day.
Communication… When we see someone in Cavango for a repeat visit because they haven’t improved, the first question we ask them is how they took their medication. Almost 100% of the time, there was an issue with communication. They didn’t understand (rural folks are sensitive to appearing simple if they say they don’t understand) or the dosing was communicated errantly. Everything must be repeated 3-4 times and still instructions are often forgotten or misunderstood.
The challenges, both obvious and not so, are great and can be overwhelming. All of the missionary doctors here are tired and it’s easy to become discouraged by the overwhelming number of people suffering and dying at young ages. If one succumbs to the temptation to see only the forest, rather than the individual trees, our work seems futile. When one focuses on each individual and only on the task at hand, one can work with a degree of joy, because so many are helped through our simple work. This is, of course, easier said than done, especially when one doesn’t see a day off for a while. It’s not easy to rest when someone presents their seriously ill child to you…
We (missionaries involved in our rural outreach) have some meetings this week to strategize as to addressing the rising health care needs around us (the economic crisis deepens monthly), our own health, and the wisdom/humility necessary to run this race well. We want to both trust our Father’s sovereignty, and be maximally spent by Him in this difficult place at this difficult time for these beautiful people… Please pray for us.
The Kubackis in Angola 