Rumors…  Every population, community, and individual must consistently deal with unsubstantiated information.  We must determine both the truth and significance of each message that we hear/see.  Most of what we hear doesn’t require a response or judgment on our part, while a small portion does.  In most conflicts and issues there is no reason for us to have an opinion or choose a side, as it is truly “none of our business”.  Some people think they must have an opinion about every matter and every person, and this is simply not true, though we often hear and repeat a matter without filtering it for truth and/or significance.

 

When we were in the US on Home Assignment, two things happened simultaneously that were potentially damaging to our work in Cavango.  Firstly, rumors circulated about the “high” and “unfair” prices at our clinic, some of which were propagated by a church pastor whom we had served multiple times at the clinic (resulting in healing each time) and he had previously voiced offense (to others and not to us) that he had to pay for his care.  Secondly, we didn’t have enough money in our clinic accounts to purchase meds (we have set up the clinic to operate financially with no outside help).  This is simply not possible because we sell our meds for the same prices that we are charged when we make our purchases at the pharmacy warehouses in the cities.  I considered the possibility of theft, but I’ve worked with few men anywhere with more integrity than our local head nurse/clinic director and he’s really the only one with access to the money.  The other issue that could contribute to account discrepancy and money loss, is giving out meds using “dividas” or credit (it is sadly a commonly exploited cultural norm).  Even though I had encouraged our staff over the years to issue credit only in dire circumstances, after a couple of staff meetings it became clear that we were giving medications more and more with a “promise to pay”.  As any five-year-old could predict, most of these “promises” went unfulfilled, and it soon became evident that this was clearly the source of our financial shortfall.  I had observed this practice over the years but didn’t realize its extent, until our books revealed the deficit in recent months.

 

I decided to confront both issues directly with the leaders of all of the communities that benefit from the services we provide.  I sent out notices to about twenty principal villages and towns within about 60km of our hospital, inviting the village leaders to a meeting at the clinic to discuss the hospital finances.  All of the leaders arrived the next afternoon (I don’t believe a single village was unrepresented and the presence of so many leaders on such short notice was quite encouraging as an indication of their interest in our work) and we discussed for three hours the work of the clinic, some of our challenges, and our prices and the reason behind them.  I explained that the consultation charge (about $5.00US) pays for salaries (our salaries are a fraction of those at the government hospitals) and the money collected for pharmaceuticals (each medication has a different price) is used only for the purchase of more medications.  They asked the question I am commonly asked (because we always charge a small fee for our services), “What do you do when someone arrives without money?”  I always respond similarly, by acknowledging that this situation is indeed difficult because the patient is ill, he/she cannot afford the care and the care cannot be given unless people pay for the service (workers) and for the product (meds).  I explained that our clinic is truly a community clinic in the sense that one person’s payment allows the purchase of medications for another.  If one doesn’t pay, then there isn’t money to purchase medication for the next…

 

I explained further that the workers who staff the clinic obviously cannot work in their fields when they are working at the clinic and, for this reason, must receive monetary compensation for their work (this culture lives and dies by how their fields produce), in order to buy food (that they cannot grow) for their families.  I also explained that the medications are not ours, but that we simply transport them from the city and pass them on to the person who uses them, at cost.  Straightforward, truthful, face to face conflict resolution is interpersonal and builds or destroys trust, whereas rumors cause harm outside of relationship with the subjects of the gossip.  This direct explanation at this meeting brought clarity, and these men arrived with questions and doubts (they are advocates for their people), we addressed them directly with honor and respect, and they left enthusiastic supporters of our work (most already had been, but they’d heard the rumors…).

 

I also told them that we refuse no one, but that we treat the sick person on the day of arrival and simply require payment before further treatment the following day.  This was an introduction of a new policy because of the money loss associated with credit, and they received it well.  I told them that we would have to close our doors within the next month or two if we continued to operate as we had been.  These leaders, many of whom own simple businesses, voiced understanding and supported this necessary policy.  Interestingly, one of these men collapsed on the road the next day and was brought to us in a coma, with cerebral malaria, and without money.  We followed our new policy and he walked home several days later healed, paying for his (inexpensive) services completely prior to discharge.

 

I asked these leaders for their opinion re our prices and our service, and several voiced passionately that they knew of no clinic anywhere with lower prices or better service.  They told many stories of amazement of people leaving their village near death and returning well.  Many of these seasoned men said they had never seen this happen in this region.  Several shared about experiences of traveling to the city and paying prices from three to ten times higher.  It was clear that these men were not behind the rumors, which is normally the case, as people without knowledge (or with an agenda) tend to spread lies.  My explanation was well received and the Q&A session lasted almost an hour, building trust and solidifying the important relationship between our clinic and the people we serve…

 

Two brothers brought in their 23-year-old brother with an acute mental status change.  A week prior, he had begun to speak “foolishly” and, at times, he didn’t make sense at all.   He hadn’t had a fever or trauma (no street drugs here) and had never experienced anything like this previously.  A patient with this presentation is a challenging work up anywhere, but in rural Angola (no testing, electricity, etc) more so.  We explained the situation to the family and that they would serve him best by taking him to a city hospital (CEML) where they could get some good testing because the history and exam were concerning, yet yielded little direction for me as to cause.  They said they wanted us to treat him and I explained that we would certainly do what we could in beginning to treat some possible causes. while considering others.  Among other things, psychosis, diabetes, toxin exposure (from the unknown ingredients of “traditional medicine”), and various types of infection and parasitic disease could cause his symptoms. We began treatment and after two days of little improvement (too little time to see if our treatments would have an effect), the family told us they were taking their brother to a traditional medicine doctor.  A traditional medicine “healer” is a man who mixes “all-natural” products (plant parts, animal parts/secretions, moth balls, etc) in a concoction and either injects it, gives it orally, rubs it on the skin, or gives it in the form of an enema (the more violating, foul (moth balls, enema) or painful a remedy, the more likely it will help, according to the typical rural Angolan mindset).  He/she will also create wounds on the skin in the area of the pain/problem (via burning and cutting) and chant or sing various incantations.  Of course, he/she has an untested mixture for any/every ailment.

 

Our enemy and many people in the world seek to harm another and/or seek personal gain by counterfeit and deception (lies that appear true, worthless products “dressed up” with bells and whistles, etc).  “Sales” can benefit the client, the seller, or both and counterfeit services or products usually benefit the seller.  I, of course, practice evidence-based medicine, which is tested and reproducible, I receive no compensation for my service, and I pray to the only hearing, responsive and all-powerful Author and Sustainer of life.  The counterfeit (traditional medicine) provides unmeasured and untested mixtures, makes a great profit for their service, promotes their products with anecdotal stories (vs tested evidence) and invokes help from the unseen world (which everyone here acknowledges), “praying” to unknown gods.

 

“There is nothing new under the sun”.  The selling points used by the Shamans are 1) the “all-natural” label (which is attractive in the US, as well, and is crackers because many all-natural products are deadly – hemlock, gasoline, ricin, botulinum, strychnine, tobacco, Black Mamba venom, etc), 2) anecdotal stories of improvement (secondary exclusively to the placebo effect), and 3) relational trust within a community (a salesman who is highly relational will always sell more product).  They also commonly malign evidence-based medicine (their highly effective competition).  We see the same scenario play out everywhere in the world, where unproven remedies (unknown benefit, unknown risk) compete in the health care market with those proven (known benefit, known risk).  Remember that, with the right sales person, the placebo effect is sufficient to generate a profit.  If one sells a product and 20-40% of the clients feel improved (as in massage therapy, which changes nothing but feels good) and are vocal advocates, and few clients feel worse, one has a profitable business.  We also see the western media, and those in the alternative health care market, highlight (ad nauseam) the apparent damage caused by medical errors and adverse reactions to medications, yet we never see publications about how many people are healed via evidence-based medicine, or even a comparison of the two.  This leads to the prevalent misperception that evidence-based medicine is dangerous and this misperception sadly kills more people than the actual errors themselves, because people who would benefit from evidence-based medicine fear the same and seek out the pretty, counterfeit, “safe” remedy at the “health store” (the modernized version of the potion-peddler).

 

I try to patiently explain the difference between the counterfeit remedies on the market (here and everywhere) and those we have at our disposal (tested, proven) and leave the decision to the patient and/or his/her family.  Evaluation of risk/cost/benefit must be the focus in these decisions as, with each proposed remedy, there is variability of the known vs unknown risks/benefits.  The issue really comes down to trust in the one giving counsel and offering the remedy, or trust in the remedy itself, whether misguided, informed or otherwise.

 

The sad addition in Angola is that the “all-natural” remedy often kills.  We have at least one or two people in our hospital every day with varying degrees of liver failure from “traditional medicine” and some recover and some die.  They receive traditional medicine for a “cold”, irregular periods, or another minor problem and suffer a long, painful death from liver failure.  Many people today pay for unknown and unstudied risk/benefit rather than that which is tested and proven.  I’ll never understand…

 

I faced this same trust issue this past month when confronted with personal health challenges.  I had a bad case of malaria that caused lung inflammation, diminishing the oxygen level in my system, and that stressed my heart to the point of causing frequent angina (heart pain) with little exertion.  After debating for over a week, I made the difficult decision to travel to South Africa for evaluation and the physicians there found (through evidence-based medicine) the inflammation in my lungs (on x-ray), the low oxygen level (86% sat, PaO2-60 mmHg), and narrowing of three arteries that serve my heart (via angiogram).  They, then, proposed and/or performed remedies for each.  I joked with each how unpleasantly differently the world looked from the other side of the stethoscope as I was faced with many decisions over the course of a week in the arena of trust, based on my impression of the doctor/hospital, his/her explanation of the tests and remedies, and their breaking down the cost/risk/benefit of each step.  The rural Angolan faces the same process (with less knowledge) when confronted with illness and it has been healthy for me, as a physician, to remember what these decisions look like from the perspective of the person ill.

 

My lungs should heal over the next month or two (ARDS from malaria) and my heart vessels are likely serving my heart better than they have been in years.  It was a wise decision to go and I’m grateful for the excellent care, for the results, for the encouragement and support of so many of you, and for all the lessons learned in the process.

 

I awoke the morning after the heart procedure experiencing a severe emotional heaviness and “saw” a scene from one of my favorite movies, the classic, “Chariots of Fire”.  This is my memory of the scene and may not be entirely accurate.  Harold Abrahams had just won the Olympic gold medal in the 100-yard dash, the fulfillment of his life-long pursuit.  His teammate, Aubrey, was about to burst into the locker room with enthusiastic congratulations when a perceptive colleague (Lord Andrew) stopped Aubrey and explained to him that Harold would best be left alone in this sober and quiet moment after his victory because, “though losing can be hard to bear, my dear Aubrey, winning can be quite difficult to process, as well.”  The “vision” identified perfectly the emotions I was experiencing and, I believe, was a gift from my Father to help me process the totality of my experience.

 

I felt myself in a similar place, having sober difficulty processing the incredible “miracle” that had just been performed on my heart.  Not one of my (many) heart patients in Cavango (hundreds of square miles and hundreds of towns and villages) would ever be in a position to receive the procedure that I had just received.  Well over half the people living on the earth today (including the entire population of Angola) and the great majority of those living throughout history (billions of people) would never have the “privilege” of experiencing three of their (life-threatening) obstructed coronary arteries mechanically opened, of enduring the pain of multiple needle sticks in the wrist for an ABG, of experiencing the discovery of low oxygen levels in their system, of suffering a grossly swollen and tender arm from a thrombosed vein (secondary to an IV catheter), and of “suffering” through the night hooked up to many wires and tubes and being pestered by too many (truly) concerned nurses to allow for rest.

 

Tragedy, loss, and pain are difficult to bear.  In a world filled with the same, their absence and/or the presence of privilege or undeserved favor is also difficult to process.   Jesus’ kingdom, however, readily acknowledges the former, while promising the latter, as His invitation is especially to those experiencing the former (the hurting, abused, undeserved, forsaken, forgotten, marginalized…) to live for eternity in the presence of the One who favored them so passionately that He left all of the privilege of His kingdom to experience all the indignities of human existence (not to mention the inhumane suffering), and to rescue them from the lies and deception of this present confusion and darkness.

 

During our 6 week stay in Cavango in May, I remember thinking one evening that our time seemed relatively light compared to some of the challenges of the past year.  And then (smile) I fell from a ladder and began to ache all over…

 

A phrase that has meant much to me during my recent uphill journey, “I will remember today, and trust in, both my Father’s goodness and my own ignorance.”