By hand-delivered notes and word of mouth, we invited the community leaders from about a fifty-mile radius to attend a meeting at our clinic on a recent Saturday morning. More than forty leaders arrived by foot or by motorbike and enthusiastically participated in two hours of discussion about the state of health in our region. Our clinic numbers are down (in the heart of malaria season) and I called the meeting to try to find out why. The discussion was animated and enthusiastic and they gave many reasons, primarily focusing on the cost of our care. They said that our prices were difficult for the rural people ($5 US and meds at cost) but became too much when the price of corn halved in 2017. It was an excellent rainy season last year and corn (the country’s main staple) became abundant and, therefore, inexpensive. For the rural Angolan, this was as bad as when the global oil prices halved several years ago and caused the cutting of all infrastructure and social programs in the country (oil is Angola’s main source of revenue), including health care. The rural Angolan now has no means to earn enough cash to pay for a consultation (their main income is selling sacks of corn in the cities) and they emphasized that at the current price they can’t even afford the transportation into the city to sell their corn, so they are cashless. This is why, they said, our patient numbers have decreased. Children are dying in villages without seeking help, because they simply have no money. One kilogram of corn is now sold for 40 kwanzas (a dime in the US), from last year’s price of 100kz, so they would have to sell 50kg (over 100lb) for a consultation! The meeting gave me an opportunity to listen to these leaders, as this is has been a very difficult season for them and for those they lead. They care and their concern was obvious, which was good for me to see. We also took the opportunity to share again (we call a couple meetings/year like this one) with them our concern, our heart to serve, how we operate, the fact that the clinic makes no profit from our charges and that I receive nothing for my service. They need to hear this often to continue to gain trust in our work/word, as many of them still, after five years, wonder why I am really here.
There was great interaction and much gratitude expressed for our work. In an effort to respond to their concerns, we lowered our charges for consultations for children (resulting in our pediatric malaria patients doubling this week). There is such benefit to face-to-face interaction in this culture and likely in any culture (with people) and these leaders, like leaders anywhere, need to see and hear that they are respected and appreciated!
I get angry, most days, when I see injustice and the fruit of man treating man poorly. Jesus did, as well, when He entered temple/market and when confronting those who abused their position of authority over the people He loved. Perhaps it isn’t so with you, but injustice and the consequences of man-treating-man-poorly are in my face every day and often steals my sleep as I think over the people and circumstances from the day (the stories below illustrate just a few cases from this week). I was angry most of this night, couldn’t sleep (again) and finally got out of bed at 4a and wrote the following. The ugliness of this world can be overwhelming, at times.
Five-year-old Madalena came in with malaria and the worst case of scabies I’ve seen, and I’ve seen a few. Every single part of her body was covered, and she’d been this way for months. Scabies is easily treated if one has access to someone who can make an accurate diagnosis (not difficult) and has access to the medication and has the minimal resources available to purchase the same. Her father (who had access to none of the above until he arrived at our clinic), his other kids and his wife have had this infestation for years. I’ve had small patches of scabies a couple times for a couple weeks (from contact with those who have it) and it itches worse than poison ivy. Is this Father neglecting his children? Without a doubt, but he also had to walk almost a full day and pay about two weeks wages to get an opinion from someone he doesn’t automatically trust because he has initials after his name. More years of education (like that of a doctor) to these folks is understood as more years in a building with a dirt floor, no chairs and maybe a chalk board, with a teacher showing up perhaps half of the time… Scabies is not something I have to worry about because of where I was born, my socioeconomic standing and the nonmedical common sense that I’ve learned over the years about hygiene.
One-year-old Tiago had two holes in his buttocks (see photo), exposing muscle, where he had received dirty injections in his village, which abscessed and caused severe illness (it was persistent vomiting which caused his mother to bring him to the clinic). Who is to blame? The man who gave the injections, certainly. From his perspective, he was helping (as best he knows) a baby with malaria with medicine he had purchased at an outdoor market and trying to use the few syringes he could afford to help as many babies as possible…
Claudia hadn’t gotten pregnant for a year and was taken, willingly, to the village “doctor” who boiled up some animal products (you don’t want to know) and some roots and leaves over a fire, and gave it to her rectally, as an enema. Two months later, her belly began to swell but she continued having periods. Her feet swelled and her abdomen became so tight that she couldn’t breath when she walked or tried to sleep. She came to us and was easily diagnosed with acute cirrhosis (destroyed liver) from liver toxins in the plants. She will likely survive only a few months, at best. This “doctor” treats many patients and placebo plus self-limited diseases give him better than a 30% “success” rate (symptoms resolve). Only a few of his “patients” develop this “complication”. He learned his craft as an apprentice and treats people in this way because there has never been another method of treatment in this region (modern medicine is only now arriving with any consistency) and because he wants to help those hurting. I almost never see a patient who hasn’t been to the “traditional doctor” first. At our hospital, we have about one new arrival/week with this deadly “complication”.
Three-year-old Pedro arrived with swollen abdomen, feet and face and difficulty breathing. He had malaria, but was also severely malnourished and his heart valves were incompetent because in the last year he had suffered strep throat which went untreated and the bacterial toxins caused inflammation on his heart valves, after which they couldn’t close properly with each heart beat and the inefficiency of the “pump” caused liquid back-up in his body, which his mother recognized as edema and which he felt each night as suffocating fluid in his lungs, which caused him to sleep sitting up. A low-risk valve-replacement surgery in the US would give this little guy a normal life, while we will use medication to try to give him a few more years of childhood. There is no such surgery available in Angola and it is available in every major city a continent away. Strep throat is never treated here, the rash of Scarlet Fever is difficult to appreciate on black skin, and in our area 1/15 kids has valvular abnormalities from Rheumatic Heart Disease that will kill him/her. How can there possibly be a place in this world where strep throat can’t be treated?
Nine-month-old Maria arrived having coughing fits and difficulty breathing for two weeks. Her caring mother walked about 4hr to the clinic as soon as she could scrape up the fee. This same caring mother has taken all of her kids to our vaccination clinic and all of their vaccinations are up to date. Her daughter, however, has severe pertussis and may not survive. Pertussis is one of the vaccinations that her daughter has received, supplied by the government of Angola. The vaccinations in Angola, however, are virtually never kept cold and they lose their efficacy long before they are injected into a child’s arm. The “trained” man in charge of the vaccine program over our region of the country told me once that I could substitute one vaccine for another if we ran out because they are all the same thing.
24-year-old Domingas, who we knew well, arrived at our clinic every month for a prenatal visit for her first and cherished pregnancy of eight months. No women here do regular prenatal visits and virtually all births occur in one-room homes, with 10-12 older women shouting instructions. We knew Domingas well because several years ago she tripped while walking around the nightly cooking fire and fell, hands-first, into the coals. We treated her whole right side and severely deformed hand for months and she lived at our clinic because of her frequent dressing changes, which she tolerated remarkably well, and she survived. She arrived one day last week with severe abdominal pain all night with severe vaginal hemorrhaging. The ultrasound, which two weeks prior had shown a thriving baby, now revealed that the baby had died. Her uterus was rock hard and had only begun to open by mid-day (2cm). We had severe storms and could not fly her out. We did a few things to try to help her placental abruption (separation of the placenta from the uterus) stop hemorrhaging, but she continued to bleed severely and died before evening. We have no blood for transfusion (would have saved her life) here and we cannot do a Cesarean, so we were pretty much observers of her final hours. Domingas would have survived this relatively rare complication of pregnancy easily in any developed world setting and likely would have gone home the following day after receiving some blood (giving her time) and allowing the abruption to run its course through a vaginal delivery.
Six-month old Francisco had fever for 5-6 days but continued to nurse and the parents simply didn’t have the money to take him to the clinic. Then, during the night he became short of breath, stopped nursing and had seizures, so they brought him to us. We began anti-malarial medicine, gave him medicine to stop his seizures and he began tolerating liquids, before dying of profound anemia the following day. We could treat his malaria (no health posts in the country have malaria medicine this year) but we are not set up to safely receive and give blood. Such a small amount of good blood products would have saved his life. Malaria kills very few in the first three days. Those who die from this disease do so because they don’t have access to care during these early days of fever, they don’t have resources to purchase the (inexpensive) medication, and/or they are vulnerable to severe disease from malnutrition or bites from multiple infected mosquitos in the same period (no mosquito net and/or adequate clothing).
64-year-old Sara had difficulty breathing for over a week. We had seen her last year for a very stable chronic cough and told her she had TB and eight months of treatment would likely provide a cure. She returned this week profoundly edematous with oxygen levels below 50% and breathing more than 50x/minute. She had Cor Pulmonale, or right heart failure secondary to high pulmonary pressures from extensive lung scarring from the tuberculosis. We began medications for heart failure which usually work well, but we needed time. Only supplemental oxygen could buy her time, because until the TB in her lung was treated and the inflammation decreased, the rest of her body would remain oxygen-starved, and she died two days later. In the US, people carry oxygen canisters around in a purse… This year, we hope to have solar power, which will allow limited electricity and make such options available.
70-year-old Domingo returned to our clinic after a month. How many times can I say that he and his wife are likely the kindest people I’ve ever met? He came in a month ago having not urinated for almost a week before arriving, and urinating drops for weeks prior. His kidneys were severely inflamed (acute renal failure), he was delirious and couldn’t walk or eat (because of vomiting). We were able to insert a urinary catheter and over several days his renal function normalized and eventually he went home. He came back today asking to have the catheter removed and we explained the risk of it all happening again and he went home with the catheter. His options are a permanent suprapubic catheter or prostate removal surgery and he can’t afford either. How many 70-year-old men are walking around in the US with catheter connected to a bag of urine strapped to their leg? We have many just at our little rural clinic. Sometimes pretty simple measures are life-saving…
53y/o Fernando had become increasingly confused over several days and complained of arm pain and fever. He had difficulty walking and talking. He had a severely stiff neck, a negative malaria test, and no evidence of a stroke. He likely has meningitis and, at his age, the cause is probably tuberculosis. Without a lab (we hope to have a simple lab this year when we get some limited electricity) we are unable to pull off a little spinal fluid to accurately diagnose which type of meningitis he has. We will treat him for a couple days for bacterial meningitis (more acutely dangerous) and, if he doesn’t improve quickly, will begin TB medications.
Twelve-year-old Elisabeth has a spleen that touches her left hip bone. This is likely from sickle anemia, a treatable, inherited disorder that causes her to have crises of intolerable pain several times/year because of the funky (medical term) shape of her red blood cells, causing organ ischemia because of blocked blood flow. She needs her spleen removed and/or early treatment for her frequent bouts of malaria (several times/year, including the cause of the fever that brought her to us), which add to the scarring and enlargement of her spleen. The spleen is an organ easily damaged by trauma and normally protected by the ribs. A simple fall could be deadly for this girl. Consistent, early treatment for malaria will never happen when the closest treatment center is almost a two-day walk…
This life is ugly, unjust, painful and confusing for so many people. What is my response (besides anger and insomnia) to the injustice (and resulting suffering) confronting me every day?
Man hurting/abusing/neglecting man is our response to the freedom granted us by our Creator, which can obviously be used to benefit others at a cost to self or benefit self at a cost to others. We were created in love and love – prioritizing another over oneself – invites relationship and reciprocation, but never demands the same because the beloved’s desires/decisions are honored above those of the lover. Freedom. Love is not honoring, humble, or true without granting freedom to the beloved and, therefore, when God says He loves us, He does so granting to us freedom to respond to His love as we will. As illustrated above, this freedom is horribly abused, causing untold suffering throughout the world.
Jesus left His Kingdom to visit this arena of injustice and pain (and personally experience more injustice than I ever will) and offered to us an invitation to eternal relationship with Him, in no way minimizing the reality of the suffering known by those He visited. He temporarily healed some (His miracles validated His promises) while He emphasized that eternity must be our priority, that He had designed an eternity without injustice/pain/loss, and that the way into this eternal life (in His home) was relationship with Him.
Eternity is the equalizer! The pleasant and unpleasant circumstances of this life will matter little to any of us in 10,000 years, and Jesus communicated that we were created not for a few earthly years, but for eternity… I must see both earthly suffering and pleasure with eternal eyes or the anger I feel every day (re the unequal distribution of the two) will drive me to despair. My choice. Jesus’ resurrection means His words were not of a lunatic, a politician or a wishful thinker, but of a witness, based in reality.
It is for this reason, as well, that we, as Jesus’ followers, must go (as He did) to those harmed by injustice, with encouragement, an embrace, and an eternal perspective. Our message, our work and our hope is not earthly resolution to all of the pain and despair, but life and justice beyond the pain!
We become no less angry about the illnesses of neglect mentioned above or the beating received by the bleeding man in the ditch on the road to Jericho, but we put soothing balm on his wounds, give him some cool water to drink and lead him to our Father for rest and healing, one person at a time…