Notes from the bush

finale

2008-11-21T07:08:00.003+02:00

Hey there to all you faithful readers....
I'm now officially back in the US, and as such, think that it's probably time for the blog to end. I was at the Global Health Missions Conference this past week and actually was stopped in the halls by a couple of people who I had never met except through the blog -- a funny experience, but also one that made me realize that more people than what I had pictured were reading the thing. So thanks to all of you.

They told me in my 'debrief' that most people will have about a 3 minute attention span for my stories about what my experience in Africa is like; that seems a little bit silly to try to condense it all into 3 minutes and I'm guessing that if you've made it through 200+ blogs then you're probably willing to stick out a bit more of my rambling. I've been trying to come up with some pithy insights, but a comment from one of the people at the conference has stuck with me: "the relationships that I have overseas are some of the most complicated relationships I've ever had in my life." I resonate with that comment as the experience has so many different layers to it.

I was reading Henri Nouwen before I left and he said "no one can help anyone without becoming involved, without entering with his whole person into the painful situation, without taking the risk of being hurt, wounded, or even destroyed in the process." Maybe I've been wounded some in my time overseas, but it's a beautiful scar, and one to treasure, not hide. Some scars open you up deeper.

I hope every one of you will pursue your call to be gloriously wounded that way someday. I am looking forward to connecting with each and every one of you.

Until then.

Matt

seed distribution continued

2008-10-08T20:53:00.001+02:00

seed distribution continued, originally uploaded by mattcotham.

One of our hospital chaplains, Daisy Munguya, sharing with the crowd
about Joseph and the famine in Egypt.

seed distribution continued

2008-10-08T20:52:00.001+02:00

seed distribution continued, originally uploaded by mattcotham.

Some of our ward attendants teaching everyone how to cook porridge with
peanuts mixed in....

more pictures

2008-10-08T20:51:00.001+02:00

more pictures, originally uploaded by mattcotham.

seed distribution

2008-10-08T20:50:00.001+02:00

seed distribution, originally uploaded by mattcotham.

These past two weeks have seen the distribution of all those seeds I
posted on the blog last week. It's been a great opportunity to spend
time with the communities, get other glimpses into local village life
(entertaining the local headmen, etc), and spread the love of God in the
places that we've been. I'm gonna post a few pictures so you get the
flavor....

The Glostavent

2008-10-01T19:01:00.001+02:00

The Glostavent, originally uploaded by mattcotham.

The Glostavent -- perhaps the sequel to The Groundnuts Project -- is the
name for our new anesthesia machine. It arrived about a week ago and we
had a visiting anesthesiologist come out to show us the ropes the first
part of this week. It's been great -- although a little bit expensive
it's perfect for our environment and will be fantastic for what we're
doing here. It should help us to give safer anesthesia and smoother
anesthesia as well, especially for some patients who are more ill and
can't withstand the usual drugs that we give. What a great gift to the
hospital -- thanks to all of you who helped contribute to make this happen!

out with a bang

2008-10-01T19:00:00.000+02:00

Haven't been writing all that much for a while -- perhaps it's best to
be winding down a little bit with the blogging and honestly after two
years I'm not sure that I have much more to say. The last few weeks
will be a tough transition for me -- transitions are always tough, I
think -- and I'm going 'flat out' as David likes to say trying to spend
time learning about our new anesthesia machine, get the restaurant
finally open, get all these seeds packed, transported, and distributed,
cover the 4 wards in the hospital that I'm responsible for, get the HIV
study off the ground, and manage to get my stuff distributed, packed and
on it's way. This week and next will be especially busy as the
groundnuts project finally draws close to the end, meaning that I will
just be remaining with a few things left on my list. I wouldn't have it
any other way, however.

The groundnuts project

2008-10-01T18:56:00.001+02:00

The groundnuts project, originally uploaded by mattcotham.

The Groundnuts Project -- sounds like a 60's band. I spent last Friday
traveling with the hospital truck to a nearby district to pick up around
4,000kg of seeds for peanuts and soybeans to bring back for seed
distribution this week. It's been kind of a madhouse with staying up
late to pack up seeds, leaving early in the morning the next day to
travel out to the villages and do the distribution ceremony, and cover
my inpatient duties at the hospital. We ended up moving around a total
of around 8,000kg of seeds, which has been developing my back and
stomach muscles -- Zambians have such good core strength, I think it
comes from hoeing and hauling around 50kg sacks of maize! You could
continue to pray that people feel the love of God through the work at
the hospital and through these gifts of seeds, and that there will be a
good harvest for the families that plant them.

fire on the mountain

2008-09-21T15:06:00.001+02:00

fire on the mountain, originally uploaded by mattcotham.

When I was a kid we accidentally burned down the neighbors yard by
putting some not-quite-extinguished coals in a bag of grass clippings.
I think I'm getting a little payback this week. It's a little late for
the burning season here -- it's usually in June-July -- but the last few
days we've had a couple of fires creep pretty close to the hospital.
This is the hill next to the hospital, and then the next day the field
behind my house was set on fire and burned to about 50 yards of my back
door. It makes me a little bit nervous when you realize there's no fire
department for about a 4 hour drive. But everything did fine, and
actually now I'm pretty safe since there's nothing left to burn....

jewish zambia

2008-09-15T20:33:00.000+02:00

We are cranking out the circumcisions these days at the hospital. Who
would have thought that adult circumcision would be such a popular
thing, especially since we aren't doing childrens' circumcisions very
much. There's a big push in the country because circumcision is thought
to decrease the HIV and sexually transmitted infection rates, so there's
funding to get these done. I honestly don't really understand the
popularity amongst the local populace, but we get lines of 10-15 young
men every Saturday outside of the OR to get the snipping done. Many of
our hospital staff has signed up at one point or another. Fortunately
I'm involved very peripherally -- only to give a few words of comfort as
they gingerly make their way around the hospital on Monday morning.
I won't put any pictures with this post. :)

Leaving home

2008-09-07T09:15:00.000+02:00

Hello again from Mukinge!

Time in Zambia is rapidly drawing short for me -- my departure date has officially been set for November 10th, which is just 10 weeks away from today as I write this. I had my end-of-term review this week with the director of the mission, which seemed maybe a little premature -- what if I set the hospital on fire next week? -- but has given me a chance to do some reflecting and thinking about what I've been learning over the last two years:

- community: except in a family, there's not many communities like a mission community, where you work, socialize, exercise, eat with, go to church, and in general never escape a small group of people from widely different backgrounds (Ireland, NZ, China, England, America, Canada, Zambia) and ages (2 weeks to >70 years old). Psalm 133 -- 'How wonderful, how beautiful, when brothers and sisters get along! -- expresses the idea that a vibrant community is one where every day brings a sense of expectancy to see what is being done in each others' lives and in your own. I've been growing in learning about forgiveness and refusing to 'close the door' on a relationship because of past issues or hurts; God's mercy is new every morning and I cannot deny the possibility that each day brings a transformation in each of our lives. (Read C.S. Lewis' "The Weight of Glory" for a more erudite exposition of that theme.) It's been a good journey to learn to live with that sense of possibility.

- transformative development: entire books, thesis, and international organizations have been dedicated to figuring out how to best help people in Africa. It seems to me that Africa itself has had more difficulties showing progress than other nations in the developing world, especially in the areas of poverty and disease. I've been struggling with these concepts as we've been working with the nutrition project, to try to bring some small amount of transformation in the farming practices in a way that doesn't foster dependence, shows the love of God for the people, and will make a change in the area. I've been learning from lots of different sources and experiences. One conclusion that I have come to, however, is the one that our western ideals of independence and self-sufficiency are neither biblical or practical for the region. We should be aiming for interdependence, where all of our gifts on both sides of the coin are freely offered and control is relinquished to achieve the greater purposes for the area. Of course, for true interdependence, each gift has to be honored, even the gifts that don't seem so important from a western perspective.

- hope: for many people, hope is at best a vague longing, a feeling in the pit of your stomach that things could be better, a dissatisfaction with the state of the world. Here I've been in touch with a more concrete definition of hope, however, that not only recognizes the dissatisfaction but also knows that a remedy is coming. Every day has the potential to be a depressing day in the hospital -- small kids with cancer, HIV and its consequences on individuals and families, neglect and malnutrition, inadequate health care being offered by referring institutions and by the hospital itself, witchcraft and shamanism, and death and disability in all of the patients at the hospital. Learning to have hope in a setting like this one has been difficult, but life-changing.

There's still a number of things going on in my last few months -- organizing 16,000kg of seeds to distribute to the surrounding communities, getting anesthesia machines and soft-serve ice cream installed at the restaurant that we built this year, working on a survey research project for children taking HIV medications, organizing a training for community malaria health-care workers, and of course just being a doctor in the hospital with all its usual challenges and joys. I have been so appreciative and blessed by your support and prayers over the past two years. I've mentioned it in previous emails but you have been so generous with money and time for the work here in Zambia. I think it's been a real picture of interdependence in my life to be here.

Thanks so much for all of you. I will be back in Fort Worth after Nov 19th and through the holidays, and then likely back to Denver sometime at the beginning of 2009 to start up work again (this is still in the air, so if you've got some job tips, I'm all ears!). I hope to have a chance to share with each of you what these last few years have been like and where I'm heading next.

All the best,
Matt

Captain and crew

2008-08-22T18:38:00.001+02:00

Captain and crew, originally uploaded by mattcotham.

Captain (the kid on the right) was in the hospital for about 3 months
last year; he came back today after not feeling very well for a while at
home. The man on the left is his brother, who's two years older than
him. Captain's 18 years old. He hasn't gained any weight since he was
7 years old -- he was 16 kg when he was admitted then, and he's still 16
kg today. We actually spent a lot of time with his family when he was
here in 2007, organized a meeting with everyone, sat them down, and so
forth, but they have basically said that he's on his own, despite his
chronic diseases. It's very sad to me.
For some strange reason on the bus today we got a mysterious package
from someone I don't know -- full of Twix bars. So I decided that they
must be (at least in part) Captain's Twix bars. Not that Twix is
exactly the nutritional answer for a kid that's malnourished, but part
of Captain's problem is the loss of hope and love in his life, too.
Maybe a gift of chocolate can help him remember that love.

a birth and a death

2008-08-20T13:39:00.000+02:00

The Tompkins welcomed Emelyn, their third child, into the world
yesterday morning at 9am. After a somewhat stressful week, she arrived
one week late and without any complications. I've blogged about this
before, but it's a little bit weird being expected to make the medical
decisions for your friends and people that you live with closely; it's
difficult to maintain a good perspective on things and still be
respectful to what other people want to do. Fortunately, my role was
basically as a remote observer, as two of our nurses did all of the work.

The president of Zambia, Mr. Mwanawasa, died yesterday after being in a
coma in France for over a month. Zambia has traditionally been a very
stable country, with orderly elections and a good democratic process.
Like during any crisis, at home or abroad, this democratic process will
be tested as new elections take place over the next few weeks.
Sometimes it's difficult to remember what it's like for a country to be
only 40 years old or so; the pull of inertia to keep the status quo may
not be as strong as a place like America.

I'm pretty optimistic that it will go pretty smoothly, however, in
contrast to the debacle in Zimbabwe just to the south of us.

chicken coops and generosity

2008-08-18T22:26:00.000+02:00

My neighbors, Pam and Menda, want to start an orphanage. In fact, they
are already supporting several orphans, but are currently working to
build an actual dormitory and house so they can have a stable place for
them to live. To do that, they raise and sell chickens in their
backyard. They are not the only ones. In fact, we have so many people
raising and selling chickens for various charitable causes around the
mission station that at one point it became quite tricky for me to
navigate the social circle of the 'chiken corner' when I was deciding
from which of my neighbors I would buy my next chicken.

That's pretty typical of my experience of African generosity. My host
family where I learned Kikaonde for 2 weeks not only farmed three entire
fields for their family, but also cultivated an additional 2 fields for
the support of orphans in the community. At our church, we all go and
hoe the hospital field so we will have maize to sell or give to hungry
people who come to the service. The Nurses Christian Fellowship
sponsors work days to buy clothes for their trips to the local prison.

I don't know many people at home who are volunteering to work an extra
job and donate the entire proceeds of that job to their local charity.
If they are out there, I'm certainly not one of them. I'm humbled by
how pale and flabby my giving is in comparison to that kind of 'sweat'
giving that so many people do here. Let me tell you, it's not easy to
hoe one extra field, much less two for the support of people around
you. That kind of exercise of love builds a strong Christian body.

I have benefited so much from being able to learn from people like the
Mendas and my neighbors. It also makes me want to help in whatever ways
that I can -- contribute some clothes to a yard sale, buy an extra
chicken here or there (at one point I was up to seven in my freezer --
not an easy fit in my rattling old fridge). Hopefully my love has
gotten stronger as well for the chance to work alongside people like them.

which is dirtier, the bath or me?

2008-08-14T15:15:00.002+02:00

which is dirtier, the bath or me?, originally uploaded by mattcotham.

I won't say that sometimes I don't become frustrated with the
difficulties of the basics of life (at least the basics for an American)
-- electricity outages (I had several pieces of equipment get fried this
weekend with various power surges, including my computer cable --
fortunately I have a backup) and water. This week the water has been
intermittent; this was my long-awaited bath today after two days with no
water in the morning. Perhaps I should have held out for one more day....

which is dirtier, the bath or me?

2008-08-14T15:12:00.001+02:00

which is dirtier, the bath or me?, originally uploaded by mattcotham.

kind of pretty, in a gross kind of way....

handovers

2008-08-11T17:56:00.000+02:00

This week marks the official handover of my job as the director of
clinical services at the hospital to one of the other docs who's
planning to stay longer than me. I've been nominally in charge for
about 18 months now (at times it seems like no one's in charge, but I do
my best) but since I'm planning to head back to the US in November we
wanted to try to do the transition a few months early to help work out
the bugs and make sure things go smoothly. So far, it has been less
than smooth, but we've got three more months to work it out.
How to hand things over well must be a recurring issue for missionaries
and aid workers all over the world. I haven't figured it out yet. So
many of us want developing countries to be 'self-sufficient'; this is a
more complicated issue than it seems on the face of it. So much more is
needed to keep a project running here than at home, and it's almost
impossible for the community to support these projects with the limited
resources that they have, even if the community has embraced the idea
and wants to make it work. I see projects that would have died for the
lack of the funds to buy 20 gallons of fuel (currently priced at around
$14/gallon in the town where I live). I see equipment in the hospital
which doesn't work because of lack of batteries, or the simple matter of
a UK-style plug (about $2, plus a 5 hour one-way bus ride to get to the
store that sells them).
But these small expenses, at least to me, loom larger for a community
that is chronically strapped for cash, living on the wages of
subsistence farming (on average $800-1000/family), or who has extended
themselves financially to buy into the 'American' dream of possessions,
comfort, and entertainment. Add to that the need to support large,
extended families -- the money order post at the post office must be the
busiest place in town -- and most of the time even small expenses can be
difficult to meet, and unfair for an institution to expect to be filled
from the pockets of the workers.
So I've been learning to let go, but it's difficult because I know the
road has been made much smoother for me by the gifts and resources that
I have at my disposal as a rich American with good support from home.
The road is more rocky for someone similar trying to do my job without
those resources. True 'self-sufficiency' is still a long way off. In an
ironic way, I'm beginning to see that a good handover actually means
that I continue to be involved, present, and available to help meet
needs even as I'm not the one in charge. Or to put it another way, to
not only hand over responsibility, but also to hand over my resources
and the control of those resources so that the job can continue to move
forward without me.

the power of prayer

2008-08-05T21:31:00.000+02:00

My friend Hilary has been out to visit me the past month (she's the one that has been guest blogging on the site) and she's been challenging me to improve my prayer life with the patients at the hospital. One of the beauties I've found about practicing medicine here in Africa is that I feel less self-conscious when I'm spending time with my patients (maybe because I feel so much more self-conscious everywhere else....) and often feel free to share the gospel or pray with them and their families. However, even though I pray for patients on my own, or in prayer meetings, or with the chaplains, I rarely do it with the patients themselves. Part of me gets nervous for my patients when I pray with them -- what if they don't get better? What will that do to their faith? And part of me just plain gets nervous for myself -- what does it mean to take a public step of faith, in the middle of a whole ward, with other patients looking on; God's reputation, so to speak, at stake? Can my faith survive another 'unanswered prayer'? It's a test of the strength of my relationship with God to see if it can withstand months and months of heartfelt prayers that often seem to end up being answered with deformity, or disability, or even death in my patients. Maybe it would be better just to ask for safe things -- God to 'bless them', or 'give them comfort', instead having the boldness to ask for what I really want to see happen -- my 7 year old patient Edward to wake up from his cerebral malaria coma and drink some water; my 16 year old patient Tom to get up from his mysterious paralysis and walk again, my 60 year old patient Vincent to fight off his drug resistant TB and go home after 120 days in the hospital.
Most of us have been faced with situations like that in our own lives -- the parent who died from cancer, the young person who died in a traffic accident, the young baby that died from SIDS -- and these things often test our faith. It can be difficult to work in a hospital where those crises of faith happen every day, several times a day, as you watch the hope fade away from some of your patients and their families until they become resigned. But Hilary reminded me that God's reputation is God's business, and it's not my job to pray the prayers and answer them too (a conundrum which sounds easy, but quickly becomes complicated when you're the doc caring for the patient that you're praying for). This has been freeing for me to keep praying for patients on the wards, in the hallways, sitting on the fence outside -- wherever I find them, and let God take the circumstances and use them for himself as he sees fit.

Back to usual

2008-08-05T21:02:00.000+02:00

I wanted to say thanks to Hilary for being willing to contribute to the
blog for the past few weeks. She's winging her way back to the US
today. I hope you've enjoyed it a little bit. Now you're back to just
boring old me....

Mukinge Hill Academy teaching staff

2008-08-04T22:22:00.002+02:00

Mukinge Hill Academy teaching staff, originally uploaded by mattcotham.

The fabulous teaching staff at Mukinge Hill Academy: from left to right
- me (Auntie Hilary Burg), Auntie Patricia Fungaloko, Auntie Grace,
Auntie Mabel Pollock, Auntie Brasselo, Uncle Humphrey, Mr. Fungaloko
(teaches at Mukinge Basic School). Normally everyone has beautiful
smiles - maybe we waited a little bit too long to take this picture :-)

last day of school

2008-08-04T19:03:00.002+02:00

last day of school, originally uploaded by mattcotham.

report card - end of term

2008-08-04T19:01:00.000+02:00

From Hilary: Hi, everyone! I'll be headed back toward the United States of America a little later this week…. I hope my guest blogging has provided a wider perspective on life here in Kasempa, Zambia. It's been a little hard to describe the differences between education in the United States and education in this part of Zambia in just a few entries. I think the general prevailing attitude is one of doing the best we can with the resources available. We haven't had running water in the school the entire time I've been here (there is a faucet in the classroom but nothing has ever come out of it), which makes science and art projects a bit challenging. There's no photocopy machine for the school, and there's only one math book for each grade level, so the kids take turns copying the problems out of the book then passing it on to the next student. As you can imagine, it takes several hours/days for all the kids in a particular grade level to complete the homework for the current math lesson. I've been amazed at the lack of wastefulness when it comes to paper. The kids typically have a small exercise book for each academic subject in which they write all the answers during their independent curriculum work. The kids are very careful to write on both sides of the paper, all the way across each line on the page. If a child leaves the school, his or her exercise books are=0 Acollected, and the remaining blank pages are torn out one by one to be used for taking tests, etc. It's quite a bit different from our throwaway society.

Things have been a little bit different instructionally as well. As I mentioned in a previous blog, the students spend most of their days working independently on the main academic subjects (social studies, science, mathematics, English, word building) with some whole/large group instruction for Zambian social studies, Kikaonde, art, and physical education. We had the students stop doing the independent curriculum work one week before the end of the term in order to allow enough time for grading and doing report cards, which meant that we were able to provide a little more creative instruction during the last week of school. Apparently the kids don't spend a lot of time writing in school; during this last week I gave a mini-lesson on writing a five sentence paragraph about their field trip to Mukinge Hospital (introductory sentence, three sentences with supporting details, concluding sentence), collected their first drafts and made corrections, then handed the corrected drafts back with instructions to write a final draft. The first drafts needed a lot of work, to say the least; the kids also told me that they had never done a final draft of their work before, so explaining the idea of fixing mistakes and turning in a second copy of their writing took a little bit of=2 0effort. Our second writing assignment was also a bit challenging but highly entertaining; I had the kids write a short script then create their characters with popsicle sticks, pipe cleaners, colored markers, and stickers. (One of my favorite scripts called Cat and Mouse went something like this: CAT – Look, I see a fat mouse that I can eat. MOUSE – I think I will go for a little walk. CAT – I think my dinner is in front of me. MOUSE – I think I can smell danger. I will run home. CAT – My dinner has disappeared.… pretty good for a first attempt!) Once again, the kids' creativity came to the forefront as they started making capes, hats, and all kinds of other decorations for their characters.

So all in all, being and teaching in Zambia has been a great experience. If anyone has the opportunity to teach or work in Africa or another foreign land, I highly recommend pursuing the adventure. And if you come to Mukinge Hill Academy in Zambia, bring lots of rubbers (erasers), high quality pencils, and paper – we would certainly appreciate the contributions! Please feel free to email me at hilaryburg@aol.com if you would like any further information or have any questions… and thanks for bearing with the sideways pictures, weird text appearance, and other blogging mishaps! Lots of love to all, H ilary (Twasanta, mwane – that means thank you in Kikaonde!)

It's time to go back to school! Get the latest trends and gadgets that make the grade on AOL Shopping.

still learning the languages

2008-08-04T18:58:00.001+02:00

From Hilary: Hi, everyone! Mabel and I celebrated the last day of school for the term this past Friday with the kids. The language lessons are still continuing…. from Mabel I've learned that "yunks and yunks" means years and years (for example, "I've lived in this house for yunks and yunks"), and that "She's a real gaig" means that someone is very funny. I've gotten used to the kids telling me that their stomachs hurt by saying, "My stomach's paining me," but it took me a while to figure out that my reminders to put a period at the end of each sentence weren't very effective because the kids refer to a period as a "full stop" (in addition, capital letters are officially known as big letters). Learning the form of English spoken by people from the United Kingdom like Mabel has been helpful for me; Zambia was a British colony (Northern Rhodesia) for some period of time, so I think Mabel's version of English is perhaps a little more familiar to the children. I didn't realize "quite" had so many variations of meaning until I saw the phrase "quite good" on the children's report cards and asked Mabel about it. I was trying to figure out the difference between good, quite good, very good, and excellent; I was mostly puzzled by the two phrases "quite good" and "very good" since to me these meant pretty=2 0much the same thing. Mabel explained that "quite good" means "almost good" or "less than good." Oops - I think I had tried to pay a few of the children a compliment earlier in the week by telling them that their work was quite good…. I hope my words didn't demoralize them but maybe inspired them to work a little harder.

It's time to go back to school! Get the latest trends and gadgets that make the grade on AOL Shopping.

village friends

2008-08-03T21:40:00.002+02:00

village friends, originally uploaded by mattcotham.

nutrition class

2008-08-01T23:25:00.003+02:00

nutrition class, originally uploaded by hilary.

In honor of Dr. Matt

2008-08-01T23:17:00.001+02:00

Hilary: My guess is that Dr. Matt will probably continue to be rather understated about the difference he's made during his time here in Africa, but it's clear that he's found his way into the hearts and lives of many individuals and families in this community. Here's a sampling of some of the things that Zambians and non-Zambians alike have shared about Matt:

Everyone says Dr. Matt is very hardworking.

People don't tell him thank you nearly enough.

I am so pleased with that young man.

You (Matt) are coming back, aren't you?

He's the best single (unmarried) cook.

I didn't know Dr. Matt was so talented (playing the piano, and so on)

Is there anything the man isn't good at?

Even his cat is intelligent.

His language (Kikaonde) skills are impressive.

Dr. Matt is a very good doctor.

He is a good brother in the Lord.

We will miss him very much.

Matt still has a little more than three months here in Zambia before he starts heading tow ard the United States of America, but his host family – the Yanjishas – have already expressed their sadness about the fact that he's headed away from Zambia. I think prayers for a wonderful transition for people on many continents who love and care about Matt would be warmly appreciated. With love to all, Hilary

Photo captions: Scenes from the community education class on nutrition that Dr. Matt has been teaching; giving a lift to a member of the Yanjisha family.

It's time to go back to school! Get the latest trends and gadgets that make the grade on AOL Shopping.

occupational hazards

2008-08-01T23:06:00.003+02:00

Hilary: I've been spending a few hours each week praying for the hospital patients with one of the chaplains, so I've had the opportunity to experience some of the joys and sadnesses that the medical staff here encounter on a regular basis. I think teaching and doctoring are not all that incredibly different; the specific job descriptions may vary, but doctors and educators are both essentially interested in helping people and making the world a better place, at least from my perspective. There are, however, a couple of specific differences about working in Zambia that stand out to me:

1. Matt's job is a lot less dusty than mine. By the time I walk the half mile to school on the dusty road being passed by multiple vehicles traveling far too quickly in my opinion, spend the day surrounded by lovable but dusty kids, then walk the dusty half mile back, I'm usually covered with a fine orange coating. Matt, on the other hand, comes back from the hospital looking just as clean and shiny as he did in the morning. It's a bit irritating :-).

2. Matt's patients don't spend most of their days rubbing their hands in his hair and attempting to braid it into little plaits. My hair naturally tends to be a bit on the voluminous side, but it seems to have reached new heights and widths with the help of my amateur classroom beauticians. (note from Matt: perhaps Hilary should shave her head like I did?)

Zambian social studies

2008-08-01T22:58:00.002+02:00

Hilary: Recently I had the chance to sit in on the Zambian social studies class that Auntie Fungaloko, the grade 1 instructor, teaches to our grades 4 and 5 students twice each week. The subject matter is a little bit heavier than the geography-focused social studies the kids work on during their independent curriculum time. Currently the kids are studying "Social and economic problems in Zambia" including HIV/AIDS, unemployment, and poverty. The kids' homework assignment for the week was the following:

1. Decide 3 ways in which to educate people in your neighbourhood about HIV/AIDS.

2. Interview your parents or grandparents about how life in Zambia has changed since they were young. Write down what they say.

3. Pick one social problem (HIV/AIDS, unemployment, poverty) studied in this unit and draw a picture story to show how the problem is being dealt with. Write good English to explain what is happening in your pictures.

The next unit in the social studies book focuses on human rights, including sections on the Law of Inheritance (passed in 1989, this law ensures that widows and children receive a substantial portion of their deceased husband's/father's estate; previously the estate often returned to the husband's original family) and violations of human rights.

It's time to go back to school! Get the latest trends and gadgets that make the grade on AOL Shopping.

secondhand best

2008-07-31T20:17:00.000+02:00

I'm told there used to be a concept called the 'missionary barrel';
instead of throwing something away or giving it to Goodwill, you instead
sent it overseas for a missionary to sort out and use. Thankfully, that
concept has largely died, but it still holds true from time to time when
it comes to medical supplies -- send the expired stuff, the odd-sized
things, the rehabilitated or too antiquated equipment out to the field.
(Before I came, I was reading that Africa now has a waste disposal
problem because of the sheer number of antiquated or even
non-functioning computers that are sent out; apparently they contain
some kind of hazardous chemical inside which my 2 foot deep trash pit in
the backyard isn't quite adequate for.) Unfortunately, our patients and
doctors aren't particularly odd-sized (or expired for that matter!) so
we have an entire shelf in the storeroom full of size 9.0 and 5.5
surgical gloves! (that's really big and really small if you're non-medical)
We've been blessed with recent donations to cover the purchase of a
brand-new anesthesia machine for the hospital which will allow us to
give safe gas anesthesia to our patients at the hospital; saving us
money, providing for a safer anesthesia, and allowing us to treat
patients more effectively that we used to be able to. It's unusual that
something brand-new comes from donations and it got me stirred up again
about why we settle for less than the best when it comes to the work
that we are doing here. Don't get me wrong, we do our absolute best
with what we are provided with -- work extra hours, fill in the gaps,
trust in God to make up the difference -- but you get demoralized
because you know that your 100% effort is limited to say, 70%
effectiveness, because of the circumstances that are around you.
I was reading about the miracle at Cana and the fact that the wine that
Jesus made was 'the best wine'. Even though it would be 'wasted' on the
already drunk guests, it was still worthwhile to produce something that
would be the best to him. The difference between offering what could be
the best wine instead of watered down grape juice often lies outside of
myself and my control -- on the supplies from the government, the
donations of strangers -- and it's been really beautiful when the church
has recognized that responsibility and stepped up to fill the
difference. It's been one of the joys of being here to see that gap
slowly closed, little by little, with help from outside ourselves here.
It's very good when we can truly offer 'the best' to those who come
looking for our help.

more cards

2008-07-27T15:27:00.003+02:00

more cards, originally uploaded by mattcotham.

hearts and chicken feet

2008-07-27T15:27:00.001+02:00

hearts and chicken feet, originally uploaded by mattcotham.

FROM MATT:
We had a gift from the academy this week as Hilary got the kids to draw
pictures for us and gave them to us at prayer meeting. Now in general,
I'm not a big kids' picture fan -- random scribblings don't inspire me
to clear off my refrigerator and proudly display them for everyone to
see. These were a bit more amusing than the usual run of the mill
cards, however, as the combination of memory verses, favorite pictures,
and words of encouragement didn't always match up so well....

So we've got the piranhas eating the smaller fish with the encouragement
to "be kind one to another" -- good advice there.
We've got "Dear Mr. Mat, how are you? are you fine? for all have
sinned and fall short of the glory of God" (that particular verse was
very popular for almost everyone, trying to keep us humble I bet.)
We've got "Thank you for coming, even young mens will fall" -- that was
sent to the Schuberts, with three teenage boys.

So maybe I'll keep these on display for a little while longer than average.

It's time for a field trip!

2008-07-25T15:50:00.002+02:00

It's time for a field trip!, originally uploaded by mattcotham.

Hilary: More kudos to the staff at Mukinge Hospital for
allowing us to bring the children for a “career day” field trip to the
hospital! Mabel and I walked the dusty half mile to the hospital with
our grades 3-5 students for a series of short presentations on the
different kinds of jobs found in the medical facility. Special thanks go to Dr. Edgar
Mutimushi, a Zambian physician who reminded the kids about the
importance of studying hard and showed the kids how to use a stethoscope; nurse James
Mesa, who has a winning smile and informed the kids that interior qualities
such as being kind and having a compassionate heart are important parts of
being a nurse; lab technician Paddy Chandalala who amazingly welcomed us into
the lab and let the kids look at slides through a microscope, many if not all
of them for the first time; and radiographer Kamfunte Kanyama who beautifully
explained what she does and brought along a sample X-ray for the kids to look at
firsthand.
In addition, Mr. Tantula invited us into the physiotherapy department
for a brief tour, and Uncle Gilbert explained what goes on in the outpatient
department. We also had the opportunity to walk by the pharmacy, tailor
shop, kitchen, optic shop, and nurses’ training college. Yippee for field
trips!

MHA Annual Concert and Sports Day

2008-07-25T15:43:00.000+02:00

The annual Concert and Sports Day at Mukinge Hill Academy held last Saturday, 19^th July was a success, in my humble opinion. "Concert" is perhaps a strong term, although this is the official title given to the event; the kids sang songs complete with plenty of body movement, recited poems and memory verses from the Bible, and acted out a play based on the story of Joseph and his brothers from the Old Testament (see picture posted last Sunday). The sports part of the day included running races, potato sack races, wheelbarrow races (plenty of crashes in this one), three legged races, long distance races (twice around the perimeter of the school grounds), and a long distance race for the children's mothers (somehow this race ended up being significantly shorter than the long distance race for the kids :-)). I think we had around 70 parents and community members in attendance in addition to all our students; it was great to see the local community including lots of staff members from Mukinge Hospital supporting what's going on at the academy.

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the namesake, part II

2008-07-20T17:42:00.001+02:00

the namesake, part II, originally uploaded by mattcotham.

I got a chance to meet the baby named after me last weekend when we went
out to visit my host family from the village. I don't really know why I
enjoy the fact so much that there's another kid running around out there
with my name -- it's not exactly as if Matthew is an uncommon name --
but it still makes me smile. As you can see from the picture here, he's
off to a healthy (read: fat) start! As we do more of our malnutrition
outreach, I'm grateful for the kids that do at least start out fat --
they've got a leg up on the rocky road of subsistence farming ahead of them.

Mukinge Hill Academy

2008-07-20T17:19:00.002+02:00

Mukinge Hill Academy, originally uploaded by mattcotham.

Our play: Joseph and his brothers

2008-07-20T16:42:00.002+02:00

Our play: The Story of Joseph, originally uploaded by mattcotham.

Three kinds of English

2008-07-18T16:18:00.001+02:00

Theoretically the schoolkids, Mabel, and I all speak English, but the number of differences between Irish-, Zambian- and American-English have been pretty amazing. From Mabel I've learned that rubbers are erasers, wool is yarn, lollipop sticks mean popsicle sticks, joined up writing is the same as cursive writing, and that anorak is a preferred term for jacket. Apparently people often refer to children as "pets" in Ireland; the schoolkids seemed to think Mabel was a "wee bit" funny for calling them animals in the beginning but they seem to have become accustomed to it.

For the first few hours in the school I thought I was having an easier time understanding the children than I was listening to Mabel until one of our young ladies asked, "Auntie Hilary, may I go to the room?" Now, we have two small rooms connected to the back of the classroom which we sometimes use for small group instruction, plus a few of the grade 3 students travel back and forth between our classroom and the grade 1 classroom since we're a little short on desk space, so I wasn't entirely sure which room this child wanted to go to. "The room?" I queried. "Yes, auntie, may I go to the room?" "Which room?" I asked. The somewhat frustrated child then quietly informed me, "Auntie, I need to go to the toilet." Ah yes, the roo m.

Lately I've started teaching the kids and Mabel how to say short phrases in Spanish. Maybe we'll all be able to understand each other soon :-). Hasta la vista, Hilary

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Multiplication mission

2008-07-18T16:14:00.001+02:00

Mathematics, or "maths" as people in Zambia refer to the subject, seems to be a bit of a challenge for many people in the country. One of the expatriate nurses shared with me that many of the Zambian nurses struggle with mathematical concepts, and this has caused some difficulty when it comes to administering the proper dosage of medication and other job responsibilities. In the classroom it's been frustrating watching the children calculate problems like "24 x 4" as "24 + 24 + 24 + 24" when they're supposed to be practicing their multiplication skills. It seems like they never learned their multiplication times tables, or at least the information never really sank in. So we have now embarked upon a "multiplication mission" for the next few weeks, focusing on memorizing the times tables. Many educators and others in the United States say that it's not necessary to spend much time memorizing mathematical facts since we have such tremendous access to technology, but I haven't seen a single calculator in our classroom and am fairly certain that most of the kids aren't using one at home, let alone other more advanced forms of technology. Plus, it seems to me that medical staff and other professionals don't exactly have time in the middle of a busy workday to find a calculator or a cell phone to determine the answer to a simple ma thematical problem. So, everyone, nine times four equals …? Mathematically yours, Hilary

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Zambian schoolhouse

2008-07-14T18:09:00.000+02:00

Hi, everyone! For those of you who are regular or occasional readers of Matt's "Notes from the bush" blog and may not know me, I'm a friend of Matt's and fellow parishioner from Colorado who's working at Mukinge Hill Academy about half a mile down the road from Mukinge Hospital for the next few weeks. Matt agreed to have me as a "guest blogger" for the time that I'll be here, so hopefully this will give everyone a grander perspective on what life in this part of Zambia is like.

Mukinge Hill Academy hosts about 70 students in grades 1-5 (British system of education), and many of the staff members at Matt's hospital choose to send their children to this academy. There are two classrooms in the building, with grade 1 in the first classroom and grades 3-5 in the other, while the grade 2 students and teacher meet in a room at the church across the road. At this current point in time, the regular headmistress/grades 3-5 teacher is on "home assignment" in the United Kingdom, so a lovely woman named Mabel from Ireland, myself until the end of this current school term, and the regular Zambian classroom assistants are handling affairs until Janet returns. I'm working mostly with the older children although we do combine all the students for some activities such as preparing for an upcoming concert/sports day.

I had seen the school last year when Tay and I had visited Matt during the summer of 2007, but working in it definitely provides a different experience. I'm still in the process of learning the children's names; David, Victor, and Success have been easy enough to pronounce and spell, but Chikumbutso, Kameya, and Kaumba make me think a little more. I had taught for several years in southern California before moving to Colorado a few years ago to begin a PhD program in education at the University of Denver and thought I'd seen a variety of educational arrangements in schools, but the format at Mukinge Hill Academy is new for me. The day normally begins around 7:45 am (the actual start time depends on when the keys arrive and with whom :-)), and the children typically begin working on individual workbooks in the areas of English, math, science, social studies, and word building. The students are basically using a home school curriculum, as it has been difficult to find teachers to serve in this part of Zambia and it was decided many years ago that a curriculum which encouraged students to function independently would be a good approach.

Anyway, the schedule itself is not terribly complicated: the students bring their goal sheets to Mabel and me at the beginning of the day for a checkover, spend most of the morning engaged with their workbooks, individually check in with me, Mabel, and the other assistants in the room as they finish each assignment, and take tests when they come to the end of a particular academic unit which Mabel and I then grade that same day. The students have an early-morning break, then continue the process of working on their individual assignments along with the continual checking and grading, have a late-morning break, then do something like art, religious education, or PE in the early afternoon until the end of the school day. There are other breaks during the week for assemblies and Kikaonde (language) lessons and occasional field trips, but that's the general idea.

Anyone who has ever worked with children knows that kids are an endless source of entertainment and creativity, and the children in Zambia are certainly no exception. For our art session on Friday, I told the kids that we were going to make friendship bracelets as do many children in the United States. The idea was to make a simple bracelet with two plastic "charms" or beads on it, but in no time the kids had moved on to friendship necklaces and triple wrap bracelets, along with extras to give to family members. It's all about sharing the love :-). We spent the afternoon practicing relay races, potato sack races, and three-legged races for the upcoming sports day and concert (more on this in the near future). Lots of love to all, Hilary Burg (aka "Auntie Hilary," as the children call me :-))

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Guest Blogger

2008-07-12T11:41:00.000+02:00

Hi there everyone -- for the next month or so, there will be some guest
blogging from Hilary Burg about life in the local elementary school,
Mukinge Hill Academy, where she's working for the month of July. So you
can check out blogs about about the local education scene as well!
We'll try to be fairly obvious about who's doing the blogging....

4th of July, Zambia style

2008-07-07T16:22:00.001+02:00

We celebrated July 4th this week along with the rest of you in America.
It's a pleasure to be able to get back to my boyhood days of playing
with dangerous fireworks. Firework season is in December in preparation
for New Years', so it's slim pickings these days. However, I've become
more resourceful after 18 months here, so I got my chess playing contact
from the BOMA to rustle around in the shop where he works and he
uncovered two stacks of fireworks buried beneath the cartons of mchuzi
mix and Colgate toothpaste. Zambia fireworks inspire even more
nervousness that the ones I remember from childhood that would chase you
around the yard emitting green sparks: the two cartons of fireworks that
we could find had a fuse that was about 2mm long (okay, maybe that's an
exaggeration -- it was really 1mm) and were shaped suspiciously like
bullets wrapped in paper. Not knowing exactly what to expect, we found
a fairly long stick with a live coal on the end from our bonfire and had
a go -- and were rewarded with a very satisfying amount of explosion and
flashing lights shooting up into the nearby tree. Despite the fact that
we've had no rain since April, there was not even one extra fire. And
nobody's eye got put out, so I guess we met the definition of 'fun and
games'.

snake attack

2008-07-07T16:22:00.000+02:00

Probably the number one question that I get asked by people interested
in coming to visit is "what about the snakes". I've had some close
encounters with snakes since I've been here -- the time I went to the
pool to find a 6-7 foot spitting cobra swimming in the deep end; the
time I was riding my motor bike and a HUGE snake appeared out of the
grass about 10 yards in front of me -- its head had disappeared in the
grass on one side of the road before the tail appeared on the other
side; the four snakes I found on my doorstep in two weeks last
December. Remarkably, though, even if you get bitten, most people do
pretty well -- they get a big huge swollen leg that takes about a month
to go away, but there's not a lot of lasting damage.

Issues of expired drugs, unfamiliar diagnoses, and fatal diseases come
up routinely in the hospital and are part of what makes the medicine
here so challenging. This past week, we had the first severe case of
snake bite I've seen in the hospital -- a guy who was bitten 24 hours
previously and sent from one of our referring hospitals. Usually with
these severe cases of neuro toxins you expect them to die within just a
few minutes; why this man had such a delayed presentation I don't really
know (it was a 'green snake with a black head' -- more descriptive than
the usual at least, if someone wants to take a stab at identifying it).
But when he arrived at the hospital he was barely breathing and the
muscles all over his body were twitching uncontrollably. He was rapidly
accumulating fluid in his lungs because his muscles were so weak, and I
knew we didn't have much time.

Unfortunately, time was not the only thing in short supply; we have very
little snake anti-venom in the hospital, because it's expensive for us
to stock. Usually to treat a severe case of snakebite you need around
10-15 vials of anti-venom. I knew we had a hidden stash in the bottom
of the pharmacy refrigerator -- it was expired from 2004, but I had
resisted throwing it away in the hopes that it could still be useful.
Anti-venom is made from horses serum, and can be potentially dangerous
or even fatal to give if the horse serum reacts with your body. So I'm
contemplating giving a potentially dangerous drug which when it's good
can be trouble -- my batch, though, was 4 years out of date and slippery
from the mold from the bottom of the refrigerator. I've never given
this drug, or even seen anyone give it to a patient. And there's always
the chance that my diagnosis of neurotoxic snake bite could be wrong as
well, since I've never seen one of those, either.

I was surprised by our pharmacist, who reported that we had 18 of these
expired vials, about 10 more than I remembered having on hand. The man
was clearly dying, so I called in the other docs who agreed with me and
we started with 8 vials. They helped a little bit, but he was still
twitching like an electrocuted fish, so we ended up continuing to give
and give extra vials, nervously noting his wheezing with some of the
doses as he reacted to the medicine he was given. At vial #16, his
twitching finally stopped, and we ended up giving the full 18 vials to
him to make sure his symptoms didn't come back.

The next day, he's sitting up in bed, smiling, and saying he's feeling
much better! And he went home the next day after that with a slightly
swollen leg but not much the worse for wear. He also met with the
chaplains and decided to dedicate his life to God on the day he was
discharged. I can't help but think that it was unusual for him to take
24 hours to develop symptoms, to arrive at the hospital at just the
right time (an hour later he would likely have been dead), to need 18
vials to get better which just happened to be the amount that we had,
left over from some order back in 2002 or 2003, and that maybe there had
been a plan for him made a long time ago that was difficult to see until
he came.

babies in the grass

2008-07-07T10:04:00.000+02:00

I had my first opportunity to deliver a baby on the side of the road
about a week ago -- this is an opportunity that everyone who works at
the hospital seems to get to enjoy at some point during their stay. I
was sitting in the maternity ward when the phone call from the girls
school came, saying someone was giving birth on the side of the road
about a kilometer away. The maternity nurse and I looked at each other,
and I offered to drive her out to the place on the back of my scooter,
so we hopped on board and zoomed at 20 kph down our rutted, dusty road
to the place where she was supposed to be. We found her sitting up in
the grass with a blanket pulled over her head and the baby on the dirt
at her feet. At this point, a small crowd had gathered, and I think she
was pretty embarrassed, so she wouldn't answer us or look out from
underneath the sheet. So we recruited about 7 women who had gathered
around to make a barrier by spreading out their skirts (the outer skirt,
not the inner one -- this isn't one of those risque stories) like a
fabric wall, at which point the young mother peeped out from underneath
her blanket and we were able to get the baby and her cleaned up. She
even agreed to be taken back to the hospital to sew up some small tears
(on the back of the motorbike, mind you -- people have to be tough here
to sit on the back of a motorcycle 20 minutes after giving birth)!

Fortunately, everyone did well and went home the next day.

the english cut

2008-07-02T17:23:00.001+02:00

the english cut, originally uploaded by mattcotham.

There's too many puns to be made on 'the first cut', but suffice it to
say that after mom and dad brought me a pair of electric clippers one of
the fun things we've been doing is offering free haircuts to the men on
male ward while they are in the hospital. I thought that maybe we'd get
one or two guys who wanted to get a shave, but it never fails that when
we do it the entire ward files up for a haircut and we're surrounded
with piles of curly hair next to the laundry lines outside. Usually I
leave the job to our capable ward assistants (Mr. Bazelel Munguya
pictured here) but I had a go at it today. The first person asked me
for an 'english cut', which I later found out was not to be confused
with an 'english bobee cut'. Actually, in my opinion pretty much any
haircut that I give is by definition an 'english cut', or at least a cut
in english. However, the actual english cut consists of shaving on the
sides and leaving it infinitesimally longer on the top (by about 1 mm
longer according to the clippers). I think I have a picture from
Livingstone last year that may illustrate the topic...coming next....

top right

2008-07-02T17:16:00.001+02:00

top right, originally uploaded by mattcotham.

So I think the actual english cut would be the top right. Perhaps with
a little practice I can manage the '$' in the back of the hair soon,
though?

the namesake

2008-06-16T08:30:00.000+02:00

Got to meet my first baby named after me last week -- a lady I did a
C-section on about a month ago. Unfortunately, I couldn't find my
camera and she was headed back to the village, so there's no pictures,
but you can rest assured that he was very handsome at one month. :) No
one names their babies before they are born -- or even for several days
afterwards, for that matter -- so there's some opportunity to make
suggestions if they are interested. We spend a lot of our call doing
obstetrics here; with the average family size around 7-9 people, you can
imagine how busy that can get at times. It's more fun when there's
these personal connections, though. Does anyone else want me to be
suggesting their names to potential mothers?

comfort zones

2008-06-03T08:54:00.000+02:00

Hello to all! It's been too long since I've been in touch from Mukinge! I admit that I've been playing a little bit of hooky over the past few months as I took some time out to visit with my parents and see some beautiful animals in Botswana. Those times are really hard to express well in an email -- the scale is just too big to get across with pictures or words. There's a comfort, or peace, to put it better, in time spent looking into a red sunset with your family as the tower of giraffes gracefully graze in the distance.

I've found my role at the hospital changing a little bit over the past few months as I try to get involved more with the local communities doing education and mobile clinics. In April as the result of brainstorming with the district health nutritionist, our nurses on the malnutrition ward, and some of the doctors, we decided to put together a community-based malnutrition project aiming to address barriers to growing protein-rich foods, and then to provide seed for protein-rich foods like beans and peanuts to the families that successfully completed the educational part of the program. So far we've had a lot of interest from the local community and we have had close to 300 families sign up -- could be quite a challenge providing food for that many families come October! Right now, we still don't know where the funds will come from to provide seed for that many people, but we are confident that we will be able to provide. It's been a stretch for me to do something like that without having all my 'ducks in a row' before I get started, but I've been changing what I feel comfortable with in the knowledge that we will be cared for, like we've been cared for 50 years. I don't really like the phrase 'out of my comfort zone' -- it seems overused these days, and maybe not all that applicable to a place like Africa where the entire continent is sort of one big 'uncomfortable zone' as you face issues of malaria and overwork and problems with things like water and electricity. But I've consistently found that the places where I need to be working are often just a little bit outside what I think I 'should' be doing. Gracefully, I also find that when I arrive at those places, they are just the place where I am supposed to be.

Last week I substituted for our executive director, Mr. Fumpa, in the hospital's mobile eye clinic. I drove off for two days to what was perhaps the center of the dust universe to see people complaining of 'smoke' and 'darkness' in their vision. After two days of peering through dust and smoke myself (it's now burning season in Zambia, when they burn all the fields) I could sympathize well with them and their vision problems. These community experiences have been a change for what's comfortable for me as well -- doing work in the hospital -- as I face life without the comforts of electricity or running water or the comfort of people who can help translate for me if I'm getting stuck with my Kaonde. One of the things weighing on me as I begin to contemplate what will happen after I leave is the general discomfort of needing to leave the programs behind in the hands of the local people, who may or may not be able to carry on after I've left. I'm starting to face the reality of my leaving more and more and am doing my best to encourage and identify local people to provide the impetus that most of these programs will continue to need. So much of development aid these days is focused on 'sustainability', which is a concept that falls well short of the mark in places as poor as rural Zambia. You often need outside resources to overcome barriers like transportation and communication that we take for granted at home. I think what we need is 'sustained interest' from the rest of the world, which is perhaps a concept that's even trickier than sustainability.

There's a lot more going on the hospital that I could tell you about -- the fruits of some of the seeds that we planted last year are coming ripe: a new restaurant, a rehab of the admin block, the new nursing student dormitory, a HIV counseling center, internet access in the hospital, completing the construction of two more staff houses, beginning on our apartment complex, and so forth. We've seen some miraculous recoveries that have had the docs scratching their heads and wondering how that person pulled through. I have enjoyed seeing the basketball/tennis court put to good use almost every single day by the local youths and kids of the community -- makes the effort worth it. My current goal is to find an ice cream machine for our new restaurant (a person can dream, huh?). And as always at Mukinge, for every up there is a down -- this week we had a 14 year old boy die from cancer after traveling 4 days to get to the hospital. I had a 1 year old boy die under my hands while doing my eye clinics because there were no IV cannulas to transfuse the patients with severe malaria at the clinic where we were at. And despite our overall infrastructure progress we've continued to have issues -- the telephone system is down, the electrical transformer is about to go and causing electrical fluctuations which have caused the burnout of two water pumps, leaving us with a tenuous water supply. Funds that we've raised have lost value as the dollar becomes weaker and the price of oil continues to rise, making transport in the rural areas even more expensive.

You all have been so generous with your support, emails, and finances to the hospital while I've been here, and I wanted to say thank you once again. My current goals are to be finishing up around 6 months from now and spend some time in the states working and thinking about my future, so hopefully I can catch up with all come next Christmas season!

All the best,
Matt

the problem of pain

2008-06-03T08:53:00.000+02:00

I was the substitute eye doctor last week as I covered for our executive
director when he got called away into town for a meeting. We ended up
seeing around 200 patients in the two days that we went out into the
community clinics, and most of the time there wasn't much help in
translating, so I was amazed at how 200 people could really pretty much
manage to sum up their complaints in about 5 ways: 1) my eyes hurt, 2)
my eyes feel like there is dust in them, 3) I can only see smoke and
blackness, 4) I can see far away but I get a headache when I read, and
5) People in the distance are blurry but when they get closer I can see
them okay. Maybe that was limited some by my language skills, but
honestly, that managed to sum up close to 190 patients (the other 10
were more fun -- my favorite was the 10 year old girl who was brought in
because she couldn't see when it was dark at night, but when they turned
the lights on she could see okay -- exactly what's the problem there?).
Most people when they present to the hospital don't even describe what's
wrong, they just name the body part -- ie "What's wrong?" "Eyes." (as
if I couldn't have guessed since they were coming to the EYE clinic).
Sometimes this gets pretty funny as you get a list of body parts from
some of the older patients, like learning anatomy: "How are you
today?" "Eyes, neck, chest, stomach, back, legs, arms, head." And when
you see them the next day, it's the same: "How are you feeling today?"
"Eyes." This can be frustrating when you're trying to work out whether
they feel better or worse.
It's funny that the vocabulary to express problems is so limited,
however. At home we're taught to elicit all the parts of someone's pain
-- is it stabbing? burning? like shocks? crampy? and so forth -- but
here there's really just one word for pain and it pretty much sums up
everything. Complaining is not so much of a right. I wonder if like
the Eskimos with their 82-odd words for snow if our vocabulary points
out our fixation on pain in the states, and also being pain-free, where
here the expectation is that pain is part of life, not something to be
dwelt upon.

Bupe

2008-05-26T11:57:00.004+02:00

Bupe means 'gift' in Kaonde, which is somewhat appropriate as she's now become quite adept at finding little gifts for herself from our soft-hearted staff on peds 2, the malnutrition ward. Bupe and her family have basically moved to Mukinge over the past year as they've spent more time in the hospital than at home; one of the difficulties with treating malnutrition is that the children often require 1-2 months in the hospital to get better, but then the family can't do the farming at home, so they don't plant their crops and the cycle continues.
Families like Bupe's are part of the reason that we're doing our community intervention to reach families at home, teach them about farming for protein-rich foods (beans and peanuts and soy beans) and hopefully break the cycle before they get to the hospital. We're moving forward -- we've got around 230 families so far, and hope to be able to provide seed for all those families in October.
Projects like this make me worried, although they are good, because of the amount of control that you have to turn over to the community and families and overworked hospital staff now and after I go as well. But the opportunity outweighs the risks, and we're hoping for some miraculous changes in the years to come!

okavango

2008-05-22T21:41:00.002+02:00

okavango, originally uploaded by mattcotham.

okavango

2008-05-22T21:38:00.002+02:00

okavango, originally uploaded by mattcotham.

okavango

2008-05-22T21:35:00.002+02:00

okavango, originally uploaded by mattcotham.

delinquency

2008-05-22T21:34:00.001+02:00

delinquency, originally uploaded by mattcotham.

Not to rub it in, but here's a sample of what I've been doing recently:

back again

2008-05-22T21:12:00.000+02:00

Blogging is bad when it's too introspective; I've had a hard time find
things worth blogging about the past few weeks after getting back from
vacation with my family. I've started thinking about where I'll be in
December and what life will look like after two years at Mukinge, but at
the same time I seem to find my responsibilities here continuing to
expand -- now spearheading our nutrition outreach, filling in for Jairos
in the mobile eye clinics, helping to orient pharmacists and lab
technicians, neither of which I have much of a clue about -- and so
forth. It's been a relief to have a full complement of doctors around
to take some of the burden of clinical work from me, but it's changed my
day-to-day routine quite a bit. Today and tomorrow we will go to the
villages to teach the community about nutrition, how to make a balanced
diet for their children, and suspend dozens of screaming children from
our scales as we monitor malnutrition in the various areas.

traveling man

2008-04-24T19:58:00.000+02:00

This month has been a little bit unusual for me as I take a little
detour from my usual duties of doctoring, seeing patients in the
hospital, doing surgeries, teaching, etc. I've spent most days this
month away from the inpatient duties as we've been going out into the
community to get the community buy-in for nutrition outreaches and
educational programs (more to come soon), I was doing the music for our
SIM retreat, and now am going to head off for a little break with my
folks down to Botswana. Tomorrow I'm off with our executive director to
visit one of our referral hospitals to examine some monetary issues and
get perspective on the medical care they give there. It's good to leave
the hospital because it gives perspective on why I'm working there, but
it always brings up some guilty feelings as you know the people who are
left behind have to work harder to cover for your absence. No decisions
get made in that independent vacuum that we like to fool ourselves into
thinking exists in America; we can do what we like and the only one it
affects is us. That's an unusual perspective compared to most of the
majority world and one that most Zambians have a hard time understanding.

Zamcowboys

2008-04-09T16:44:00.000+02:00

Had an unexpected encounter with my visiting neighbor the other day who
styles himself as the 'only Zambian cowboy'. We were able to swap
horseback riding stories (me: trail riding experiences at camp, him:
working in a stable in Lusaka), compared cowboy boots, and discussed the
merits of straw versus felt cowboy hats (me: pro-straw hats in hot
climates; him: pro-felt hat durability). I have to say, I figured when
I came to Mukinge that I would encounter some different cultures, but I
fully did not expect to encounter Texan culture half a world away. He's
gone back to Lusaka now to finish his course in lab technology, at which
point I am completely sure he will be the only Zambian Cowboy Lab Tech
in the country.

Mukinge...and one string

2008-04-03T14:07:00.001+02:00

I was reading about and anecdote this week about Paganini giving a
concert where first one, then two, then three of his strings on his
violin broke. He reportedly finished the concert, and then played the
encore on the single remaining string.
Whether the story is true or not, it resonated with what we do here at
the hospital; despite no phones, our water coming and going and often
full of black sludge, intermittent electricity, overflowing toilets,
lack of funding, absence of IV's and syringes and tape and so forth, we
continue to play our concert for the people around us, and hopefully
most days it still sounds, perhaps not Paganini-esque, but like a simple
song of love and care for the people in the hospital, their families,
friends, and relatives. I'm constantly touched when a patient
unexpectedly reminds me that they can hear that song too, even on days
when I feel like the concert has to grind to a halt because too many
strings are broken.
So, here's to Mukinge....on one string!

the three 'selfs'

2008-04-03T14:07:00.000+02:00

I've been reading a lot about cross-cultural relationships and service
recently. One of the new watchwords for any overseas mission are the
three 'selfs': self-governing, self-sustaining, and self-propagating.
These principles I think came about as an attempt to learn from previous
mistakes (yes, it can actually happen!) of neo-colonialism and
superiority complexes often brought in the past (and still brought some
by visitors, aid relief, and so forth) with devastating consequences.
Despite how things turned out, no one had a vision to come to Africa and
create dependency, unsustainable solutions, and destroy the local fabric
of society. I think these three 'selfs' provide important safeguards to
ensure that those models of developmental change don't happen again.
I can't help but remain uncomfortable with the three 'self' model,
however, on some fundamental levels. One comes from the nationals
themselves, some of whom have viewed this movement as an abandonment
that they neither asked for or particularly wanted. Is a forced
abandonment such a good thing? On many levels, it ignores the reality
of the economy of poverty in many of the places where these ministries
work. When a family subsists on 1-2 dollars/day, it is ludicrous to
expect any ministry to that area to ever be 'self-sustaining' without
significant economic and infrastructural changes occurring first. This
simple fact is obvious to the nationals who live and work in these
areas, but in an emphasis on 'self-sustaining' and 'self-propagating'
these concerns are swept aside. Jeffrey Sachs makes the point that
poverty has a threshold below which all interventions eventually lead to
nought because they lack the necessary impetus to grow. If that
threshold level has not been reached, a premature transition to
self-sufficiency will result in the ultimate destruction of the services
and ministry in the area. One could ask that very question of the
hospital where I work -- in the rural areas in our province there is
currently ONE Zambian doctor working in the whole province (at our
hospital already, I might add). Most of our patients total income for
the year will likely be between 200-300,000K (around 90-100 USD). Is
that a situation where the local populace can be expected to support a
hospital?
Although perhaps well-intentioned, I feel that the three-self principles
are an attempt to provide a somewhat easy solution to what is a
difficult problem, requiring humility and sensitivity -- how to be
willing to put yourself at the disposal of your Zambian/national
colleagues and trusting them to spend you wisely. How risky is that --
to open your own resources, money, time, professional gifts, and let
someone else in the community decide how they will be spent instead of
you deciding yourself? Such a concept is almost anathema to someone
from the individualistic cultures of the West where donations should be
ear-marked, reported on, and tightly controlled even after the money has
been given. Such a concept leaves you vulnerable to the people from the
other culture perhaps using more of your resources than you intended
them to, or spending them on different priorities, or even perhaps
'wasting' them, at least from your perspective.
I think that kind of partnership, however, is the one that we are
modeled in the Bible (see the Corinthians giving to the Jerusalem
church, for example), and is one that ultimately shows love and trust
for each other in ways that the 'self' model misses.
Self-sustainability is not a realistic goal; even self-propagation is
almost impossible to contemplate. I think we need to abandon that
thinking and instead look for a servant-partnership role for overseas
missions. I think we have a responsibility to continue to be involved
and supportive to the same levels that we were before, even if we are
not 'in charge' in places like Mukinge anymore. I hope that people
haven't chosen to leave places like Mukinge because that was too hard --
a statement something like 'if I can't be in charge of my things, then I
think I'll just take them and go somewhere where I can'. I don't think
that was the case in the past, but the fact remains that Mukinge (and
many other places like it) have been slowly abandoned by their brothers
and sisters in the West.

petty theft

2008-03-25T12:17:00.000+02:00

I've become increasingly challenged recently by how I should be handling
theft from my home. The week I left Denver to start to come out here I
had a garage sale where people came by at 6am to steal my stuff before I
could get up; maybe that was preparation for what I've seen out here.
There's a fair amount of it; I've had 4 pairs of shoes, socks, a cell
phone, a water purifier, bungee cords, cement, wire, sprinklers,
shovels, hoes, candles, knives, sunglasses, books, DVDs, and bananas
stolen from my place over the past few months. Most of the stuff was
gifts, or extra things, and I have tried to maintain an attitude of
'enforced generosity -- I probably should have given that stuff away
anyway' to those donations to someone's pocketbook or feet. As Gwen,
who's lived here all her life, points out, people here are very poor.
And she's right, they are. I have an abundance of things, especially in
comparison to the villagers, and most of the things that have been
stolen have not been essentials. But it can be difficult when you're
expecting a phone call to find that your cell phone has been stolen
(especially now that there is no other way of communicating here at
Mukinge with the internet and landline phone systems not working), or to
go play basketball to find your shoes have been stolen so you have to
play barefoot, or to strap something on your bike to find your bungee
cords have been stolen so you have to make 2 trips to carry the things
you needed, or to water the garden to find your sprinkler missing so you
have to water by hand. And it's frustrating when you know they won't
have the batteries to run the purifier, or the charger to recharge the
cell phone, so those things will become useless to them in about a week
as well, doing no one any profit at all. At least I can be comforted
that my shoes, or knives, or candles are probably going to good use
somewhere. So I range between annoyance to acceptance and back again,
and try to hold possessions a little bit more loosely, and try to
remember in between thefts to continue to be generous to people who come
asking for help or money.

cash flow

2008-03-25T12:16:00.000+02:00

I find myself in relative penury this past few weeks, although I wince
even as I write that as I look at the people around who are truly in
need while I sit here writing on my laptop with my collection of DVD's
and books in the other room, a freezer full of donated coffee from
overseas, and a pile of blankets on my floor to be given away. That
being said, I've been down to about $10 of cash for about 2 weeks, which
has forced me to make some interesting sacrifices (do I really need
butter on my toast? does the scooter really need to have its chain
repaired? what can I make for Easter dinner out of some potatoes and
evaporated milk?) and also forced me to have some hard conversations
with people when they come asking for assistance, loans, etc. which is
pretty common. I tend to respond to the needs that I have laid in front
of me, which when combined with extra expense for the labor on the
tennis court and lack of transport to the capital from whence all money
flows has put me in a bind.
I'm reminded that 'blessed are the poor' (not that I'm one of the poor,
as is very clear to me here) as per Ms. Hellwig:
- the poor know they are in urgent need of redemption
- the poor know not only their dependence on God but also their
interdependence on other people
- the poor rest their security on people, not things
- the poor have no exaggerated sense of their own importance
- the poor can distinguish between luxuries and necessities
- the poor can wait, because they have acquired patience in waiting for
needs to be filled
- the fears of the poor are more realistic and less exaggerated
- to the poor, the gospel sounds like good news and not like a threat
or scolding
These things are brought home to me right now in ways that I don't
usually feel in the states.

isn't it ironic

2008-03-19T14:28:00.001+02:00

isn't it ironic, originally uploaded by mattcotham.

Who would have thought that perhaps one of the least sporty guys in
high-school would be the driving force to construct a tennis and
basketball court in a African town? It's been a bit silly, and a bit
frustrating, and not exactly NBA or Wimbelton standards (although it's
close to a clay court -- eat your heart out, Roland Garros) but it was
finally finished this weekend and christened with a rousing game of
tennis followed by a pickup game of H-O-R-S-E. I'm hoping that it
brings people together and provides some extra life to the community
here. It was really fun to see the kids shrieking in pleasure and
chasing tennis balls around the grass.

Lenten updates

2008-03-04T15:06:00.000+02:00

Hey there from Kaonde-land!

It's been a good couple of months for us here at Mukinge, made possible by the fruition of some of the plans that we put together at the beginning of the last year. Since the last time I wrote back around Christmas time, we've begun construction on the new nursing dormitory, rehabilitation of the administration block, repair of two of the staff houses, construction of a garage for our hospital vehicles, and building of the new HIV counseling center. At the same time, the weather has caused some problems as we've had issues with lightning resulting in the burnout of our phone system, intermittent power surges, the downfall of our internet system, so we've been back to communicating by written notes carried by hand around the hospital. It feels pretty good to not be at the mercy of the phone sometimes while on call, I must admit, despite the inefficiency of the current system. As I remind myself on a daily basis, however, efficiency is not the goal here, but rather the relationships that you cultivate.

We're also in a transition period for staffing as two of our docs have left. We have been lucky to enjoy the presence of a Canadian surgeon to help ease the transition and the hospital hasn't been too busy recently, so we've been managing well. We are still facing some shortages at the end of the year when my term finishes at the hospital, especially in regards to surgical coverage and nursing supervisors/teachers. If you know people interested in coming, let us know!

Mostly, though, I feel grateful for the progress that we've been able to achieve over the past year. We've bought 7 oxygen concentrators for the hospital, upgraded our maternity care with ultrasounds and fetal monitors, increased our available staff housing by a total of 10 units, began much needed rehabs of different parts of the hospital, and so forth. You have been generous to help the work go forward here, not to mention the many care packages, encouraging emails, prayers, and postcards I have received over the year. We are continuing to look forward to exciting projects in the next few months, especially with a nutrition project that is currently in the planning stages to increase our community presence, provide much needed seed to local farmers to grow protein-rich foods like beans and peanuts, and provide education to the area. I am also trying to raise enough funds to purchase a much needed anesthesia machine which costs around $28,000. Seems like a big goal, but we'll see what we can do. We've managed maybe a third of the cost so far!

Despite the comings and goings of people here on the station (mostly goings), I continue to try to strengthen my friendships with my Zambian colleagues, even despite some cultural issues. We had a good cultural awareness seminar this past weekend which was pretty amusing as I continued to see in black and white how far away I am in my cultural expectations from Zambian culture. I think across 12 of 13 different cultural attitudes that we quizzed ourselves on, I and the typical Zambian were exactly on opposite ends of the spectrum. It actually amazes me that I am able to get any work done at all without immense frustrations on both sides, and it's shown me how much I am able to adjust despite ingrained cultural ideas. It also makes you realize how much unspoken grace you are being shown by the people who work with that you are probably unconsciously offending right and left. I had the opportunity to work at a nearby mission hospital in January and came away with a profound sense of gratitude for the more graceful way that we have dealt with those cross-cultural issues here at Mukinge over the years.

Thanks to you all. If I can give any more details on work or things at the hospital, let me know. We've recently been in the process of updating our website, so you might google 'Mukinge' and see what you get these days! Don't forget to check the blog at www.mattcotham.blogspot.com.

Best to you all,
Matt

the smell of progress

2008-03-04T15:05:00.000+02:00

I'm surrounded by the smell of progress these days, but progress in
Africa isn't such a great smell all the time. One of my aromatherapy
candles quit quickly and the other was stolen from my coffee table,
leaving behind the tangy ammoniac smell of partially cured goat hide on
my new stool mixed with the turpentine of the varnish on the door which
I commissioned to serve as a basketball backboard. I'm inordinately
proud of this altered dwarf-sized door (short and fat) which may
represent the first major work I have ever knowingly ordered from
anyone, but the smell of varnish is particularly overpowering,
especially when I'm laying on my concrete floor already partially
overcome by the paint fumes of the Brilliant Green for the tennis court
that shredded 6 pairs of gloves and made my hands look like the
Incredible Hulk. I've been trying to scrub off this green hue with my
recent purchase of soap from the BOMA (the grocery store burned down
last month, remember, so everything's local purchases these days) which
is colored black and smells like cough drops. There's little more
disheartening than trying to scrub off green paint with black lather,
which leaves behind a disgusting black soap ring around the bathtub and
a smell of pharmacies without much improvement in the green cracks of my
knuckles or fingernails. But progress is progress, the dead-goat smell
is fading, and the tennis court is (mostly) rain-proof and ready for the
re-inaugural match next weekend.

aromatherapy

2008-02-27T14:50:00.000+02:00

I got some aromatherapy candles in the mail today (thank you, Stacy!)
and am currently imbibing the manufactured smell of Vitality, which I
figured I needed after a 2 hour walk back from where my bike got a flat
tire on the way to meet the man who could sell me a door to build the
backboard for the basketball court, turning a 10 minute project into an
afternoon affair. Africa does provide its own aromatherapy much of the
time, from the smell of human sweat (maybe not your idea of
aromatherapy), the smell of burning rubber that we get in the dry season
from the hospital trash pit, or the smell of automobile exhaust that
seems to pervade third world cities. On the other hand, there's the
smell of frangipani (reminds me of the smell of a newly opened pack of
SweetTarts), or maybe fresh basil in my garden, or the smell of overripe
mangoes sitting underneath the trees. I was reading an article about
'smellscapes', where you hire someone to come decorate your home and
suggest smell 'palettes' for each room, or for special occasions, and so
forth. I can't help but think that we've divorced ourselves a little
bit too much from reality at that point. But I'll enjoy the extra dose
of Vitality here while I can.

strings and paper cups

2008-02-27T14:49:00.000+02:00

That's about the level of communications these days at Mukinge,
Hopefully our phone system will be up and running soon, the internet
guys coming tomorrow will be able to solve our internet problems, and
the lightning will lay off for a day or two to allow the electrical
system to stabilize.

the keeper of the balls

2008-02-11T21:16:00.000+02:00

No, not another off-color reference to the cat neutering....

John Griffiths (and family) left yesterday, appointing me the de facto
sports czar for Mukinge. While we are still working on getting the
tennis court surface finished -- a difficult task given the amount of
rain we've had -- I'm now the proud owner of more sports equipment than
I've probably ever had in my life: basketball, soccerball, rugby ball
(!), volleyball, and several frisbees, not to mention the volleyball and
tennis court net. I say owner, although I'm merely the regulator of all
things sports now, since I have no intention of ever keeping any of
these things. Anyway, I got a little bit of insight into the shifting
world of playground politics as I lent the soccerball to some kids,
expecting to have it returned. No such thing happened, and the next day
some more kids came asking for another ball. I, with visions of an
incipient runaway ball orgy centered around my garden shed, asked for
the first ball to be returned before further balls would be lent out.
This led to a 30 minute discussion with the various tribes of kids on my
doorstep as they accused each other of various things like selling off
the balls, hiding them in their gardens, promises from the departed
Griffiths family to bequeath various balls to different kids, and so
forth. I felt especially bad for some kid named Mpungo, who was
actually the lucky recipient of a soccerball, but who was now disowned
by all of the kids as being no-one's friend, therefore meaning that
no-one could play with his ball, so they needed another one. I'm sure
that just one day ago poor Mpungo had a few friends, but now I'm
picturing him in some lonely front yard kicking his ball to himself.

Well, if the first day is any indication, it will be a short-lived
tenure as the sports czar, except for maybe the basketball and tennis
net. We'll see....

chicken wars

2008-02-09T21:48:00.001+02:00

chicken wars, originally uploaded by mattcotham.

Small business enterprise is very common among most people that live in
the area. It's easy to see why a program like the World Bank's
microlending program could reap a lot of benefits around, especially
when local bank interest rates are in the 20% range and to just own a
bank account will cost something like $100/ year for a country that has
an average annual income of around double that. Anyway, one of the
most common things to do is to raise chickens. This started with just
one family a few years ago, but now there are around 5 staff members who
have a little business raising chickens to sell to people around the
area. That's all great, but when the hospital starts buying chickens
for the hospital to feed patients, it can become very dicey quickly
about who you're going to buy from, how many you will buy, and so on.
We've had to establish a 'chicken rotation' to make sure we keep the
peace, and everyone gets a chance to sell off their chickens. Of
course, chickens running wild are free game....

man in chains

2008-02-09T21:37:00.000+02:00

I was rounding in the female ward this week when a man wandered in and
began singing a few hymns on the ward. It not being the usual visiting
hours, I was curious as to what he was doing there, but as the hymns
weren't particularly boisterous (no Onward, Christian Soldiers here) and
he left after just one song, I didn't really follow it up. Talking with
some of the other staff later in the day, I learned that he was one of
the locally known mentally disturbed patients that lives in the nearby
community. What's more, I was surprised to learn that he lives his life
with a manacle around his left leg. John, one of our docs here at the
hospital, assumed this was some sort of dramatic oversight and sent him
to the workshop to have it removed, but as it turns out, like Jacob
Marley he's condemned to live his life with a shackle around his leg
because the family refuses to have it taken off. They say that when he
gets more unbalanced, they need to be able to chain him up to one of the
trees in their front yard, where he is left for a few days until he
comes back to his senses. This rather byzantine arrangement is by no
means uncommon in the area, where people who are delusional or mentally
ill are routinely labeled as possessed by demons and locked away until
they 'get over it', at least for a little while.

fixing the cat

2008-02-02T09:58:00.001+02:00

fixing the cat, originally uploaded by mattcotham.

I decided that it was time to change the cat's name back to Charlie from
Randy, so we decided to neuter him last week. David and I watched a 5
minute DVD of a vet in California castrating about 10 cats in under 5
minutes, and then I gave him an injection in his back, threw him in the
closet, and when he was out of it we strapped him down with a towel to
my ironing board and did the deed. It's about the simplest operation
you can imagine; it's easy to understand how those vets do 200 in a day
at the local animal shelters. Anyway, he recovered out back in the
shed, and the next day he's back purring and hanging around my door, so
I guess there's no hard feelings.

winds of change

2008-02-02T09:42:00.000+02:00

It's been a pretty encouraging time here at Mukinge over the past few
weeks as we continue to improve the hospital and make some changes
here. Thanks to many donations from overseas, we've been able to finish
the expansion and rehab of one of our staff houses here and are starting
on two more in the next month. We're in the middle of building a new
dormitory for the nursing training college with funds from the Zambian
government. We have secured funds from the Churches Association of
Zambia and are building a gift shop to help bring in income for the
hospital and hopefully for local villagers as well. We have also
managed to find funds from the Biet Trust to build a new four-plex
apartment complex here at the hospital to improve our staff housing.
We've also been blessed to buy a new water pump thanks in part to
donations from home and finally install it after 9 months of struggling
so that around 20 of our staff members can have water and electricity
where they have been without for 9 months. I have managed to almost
finish the rehabilitation of the tennis court, which is looking
Wimbelton-worthy. We have purchased and installed a new internal
wireless phone which allows us to roam around the hospital and mission
station when on call, which is incredibly freeing and makes you feel
like you can get out and around without too much pain. We have also
managed to secure funding from Catholic Relief Services to finalize the
internet project here so that all of the staff homes at Mukinge will
have wireless access -- around 200 Zambians and ex-pats alike. Soon we
will embark on a rehabilitation of the administration block funded by
some donors of Lynn, our anesthetist nurse.
It's fun to be a part of things when they are moving forward. It feels
like we're able to make some headway on some projects that have been
maybe sitting dormant for too long. Thanks again for your support.

close to home

2008-01-20T19:18:00.000+02:00

I suppose that after a year of working here, and having hundreds of
patients die under my care, I should be more used to the idea. I don't
go to the death scenes of my patients very often, simply because it's
too hard to do it over and over again. It's difficult to be in the room
with six wailing women, rolling around on the concrete floor, unable to
stand, staring up at you with questions in their eyes. I unfairly
interpret this as a kind of accusation, and I feel that every time
someone dies it undermines the work that we're trying to do here at the
hospital to provide hope and comfort to sick people. In fact, I was
told when I arrived that about a year prior to my arrival, when someone
died in the OR, the next day half the hospital got up and left, whether
they were finished with their treatment or not.
Yesterday I was forced to operate on a very sick 70 year-old man who
came in with signs of intestinal obstruction -- vomiting feces,
distended abdomen, no bowel movement for 3 days -- but when I made the
decision to go to the OR, we couldn't find a reversible cause and so we
closed him back up after rooting around for 30 minutes. This would be a
case where slightly more advanced imaging like a CAT scan would be
invaluable in preventing an unnecessary operation. He continued to get
worse and worse throughout the day and about 10 hours after going to the
OR he died. Like many of the cases I've seen here at Chitokoloki, he
was the family member of one of the staff here and it's very difficult
to go to church and see them the next day when you know that they died
under your care, whether you did something right or wrong in that care.
In a case like this where you're inexperienced and the usual doctor
isn't there, there's the questions of whether you know what you're doing
as well and whether the family member would have survived if the 'real'
doctor had been around.
I'll go to the funeral today and stand with the family of the people who
may or may not be harboring these thoughts about me. It's easier to not
go, knowing that people will probably forgive the omission as a white
man and a visitor from somewhere else, but it still seems like a
cowardly thing to do to avoid the family and the situation altogether.

Some people will do anything....

2008-01-15T19:19:00.001+02:00

Some people will do anything...., originally uploaded by mattcotham.

Many of our patients don't like to take their medicine, which isn't
surprising when you taste most of the medication formulas used here --
very bitter, none of the candy coatings and flavorings like you get in
America. Today I went to see one of my post-op surgical patients and
when I examined the wound I found it smeared with a thick white paste.
I'm thinking to myself that he's brought some weird African medicine
from home, so I go and get the translator. Turns out he had been
chewing up his Tylenol, making into a white paste, and then smearing it
on the wound to make it hurt less. This is a similar approach to the
witch doctors whose remedies for most illnesses is to simply cut the
skin in small cuts over wherever it hurts. We explained the idea that
the medication needs to be swallowed, so we'll see how well we do tomorrow.

TB trouble

2008-01-15T18:38:00.003+02:00

TB trouble, originally uploaded by mattcotham.

As many of you know, TB, HIV, and malaria have become the focus of
international attention and research over the last five years with the
advent of the global fund, emphasis on research, and increasing funding
sources from places like the US and the WHO. We are beginning to see
the tip of what will likely be a increasing scourge of MDR-TB, which
stands for 'multi-drug resistant' TB. Because TB is so common in places
like Zambia, we don't go around treating contacts of people with TB,
which means that occasionally we will see entire families, one by one,
as they come in and are diagnosed with TB in the hospital. This
particular lady was the wife of a man I treated 2 months previously, and
who's brother I also treated 2 months before that, and who I'm sure also
has several infected children running around their home, not to mention
neighbors, extended family, and so on. We are unfortunately
short-staffed in our ability to do community follow-up, which would be a
place I would like to increase hospital services out and about in the
area if we can find funding for a program like that. But I'm often
struck at how deep the iceberg goes when I scratch the surface in the
hospital.

TB trouble

2008-01-15T18:38:00.001+02:00

TB trouble, originally uploaded by mattcotham.

a stretch

2008-01-12T16:30:00.000+02:00

It's been a hard experience playing at being the only doctor in town
here at Chitokoloki so far. One of the things I've been really grateful
for at Mukinge is the opportunity to do things as a team and bounce
ideas off the other doctors. I can call on the knowledge and experience
of the other ones working there, whether the nursing staff who has seen
so many things, the other doctors which draw from a wealth of different
medical experience than me, or the advice from people from home. One of
the really difficult things that I find about medical work in Africa is
that often times it feels like you're groping around in the dark without
much idea where you are going; this is a stressful experience when lots
is at stake but having other people's hands to hold while you wander
around in the dark makes it more bearable.
Up here, it feels like I'm on my own to screw up or do well, and I've
been faced with opportunities that are past my training. Some of it is
just the struggle of trying to find what you need in a hospital that you
are not familiar with; here they are more concerned with theft than we
need to be at Mukinge so lots of equipment is squirrel away in places
that are locked or hidden, making it difficult to find in an emergency.
I've also had some problems which I've never been asked to solve before
-- for example, the local Zambian hospital was doing a hernia operation
and ran into complications, so they asked me to fix the problem, which
turned out to be a large hole in the bladder. Considering I don't even
consider myself trained to do a routine hernia, trying to fix the
problems in someone else's complicated hernia was asking a bit much.
But I did my best, and the guy is doing well. Another case, a 6 month
old with a bone infection, I've been hesitating about taking to the OR,
but will probably have my hand forced soon.
Anyway, I've realized the crutch of having other people to lean on here
for the past few days. I think that this year will continue to be
tricky at times as people come and go and I lose a bit of that safety
net. I mostly need to take advantage of the opportunity to learn from
people when I can.

stranger in a strange land

2008-01-06T15:54:00.000+02:00

After much debate with the mission agency and the church board, I
managed to get off to help up here at Chitokoloki. Perhaps more
beautiful than Mukinge (don't tell her I said that) it's a good
experience to see a different take on how a mission hospital could be
run. It's a very different approach to mission here; more focused on
outside help and working in spite of the government system as opposed to
our approach at Mukinge, to try to work within the system and build it
up. Both viewpoints have their advantages and disadvantages, I think.
But anyway, it will be a stretch as we try to push our way through some
cases and help take care of a few people.

What to say

2008-01-04T21:31:00.000+02:00

Haven't had a lot of fodder for the blog recently. New Year has come
and gone, fairly uneventfully, with board games and a few visits into
the hospital after hours. Progress begins on the tennis court, hampered
by the rain, funerals, and would-be thieves trying to take my precious
cement. Today I have staked dogs near the cement to ward them off.
Zambians for the most part retain a large fear of domestic animals, dogs
and cats both, and the Griffiths' dogs are particularly vocal, making
them ideal guard dogs against most nighttime predations.

We had an unusual delivery tonight as the supply truck for medical
stores arrived, unannounced, at 9pm. I get a phone call from the
hospital asking me what they should do so I get out of my house to see
what the deal is. Obviously no one's available at 9 pm to unload
medical supplies or drugs, and I emerge from my front door to see a huge
18 wheeler truck parked outside the hospital, covered with a tarp and
obviously stacked with a fair number of boxes. I'm a little worried
what we're going to do with all that equipment that no one was expected
at such a late hour, but fortunately I don't have to worry long. I
stroll up to the truck to find two very tired drivers who had traveled
over 16 hours that day. Stacked next to them were two small boxes each
about the size of a large shoebox containing some ready-to-use formula
for our malnourished children. The conversation went something like this:

"Hey there, I'm Dr. Matt, can I help you?"
"Dr...?" I repeat my name, but it's clear that they aren't going to get
'Matt' correctly, so I let the matter drop quickly.
They press on: "We've come to deliver these to you."
Me, looking around, seeing the two boxes. "You mean these?"
"Yes."
I'm slightly puzzled at this point, given the size of the truck and the
size of the package, which would have taken up maybe 1/5 of a regular
car trunk, sitting next to this 18 wheeler truck that they've driven all
day. "You mean these? You drove this huge truck all this way to
deliver two boxes?" I ask again.
"Well, we have other places we need to visit, too."
"Umm, thanks very much, then." We look at each other. "Well, have a
safe trip." At which point they climb back into their truck and head
back up the road, and I grab the two boxes and carry them to the
malnutrition ward. I am glad at this moment that I am not a driver for
MSL. I can't help but imagine some UPS supervisor viewing this whole
process and simply shaking his head.

a few cultural observations

2007-12-19T16:49:00.000+02:00

Any self-respecting anthropologist would look at this list and say
'duh', but considering I never took Anthro 101 in college, here's my
take on a few things which have stood out for me in the previous weeks:

PRIVACY: The western view of privacy and the Zambian view of privacy are
almost diametrically opposite. Most Americans I know value their
privacy, spend their time trying to move to free-standing houses, build
high fences, complain to the police if their neighbors make too much
noise, and would think very hard before inviting their parents to come
live with them. Zambians, on the other hand, find that kind of
existence weird, isolating, and tiring. They can't imagine even wanting
to spend that much time by yourself, or needing that kind of space, or
having to manage to cater for yourself all the time. Alone time is
mostly to be avoided, rather than cherished.

SICKNESS: Zambians can be hard to pin down here; they are much more
willing to suffer through horrible, disfiguring diseases at home for
months or years before they come to the hospital. On the other hand, we
have almost every week someone show up to the hospital 'comatose'
because they just don't feel well so to dramatize that they refuse to
speak, eat, or move. The next day they are almost universally fine.
Westerners generally avoid both extremes of the approach to sickness;
they wouldn't ignore a tumor growing on their cheek until it erodes into
their mouth, but neither do they embrace this exaggerated 'sick role'
that some Zambians feel the need to do.

EFFICIENCY: This would be one of the more obvious differences in culture
here; I've been struggling to try to pursue less efficiency in my daily
life. It's probably the most endearing and most frustrating part of
working with Zambian staff. Lack of efficiency gives priority to the
relationship instead of the schedule; it's lovely to have people drop
what they are doing to spend time with you, and it's very annoying when
things just don't get done for days on end.

I love the things which transcend culture however, but just take on
different forms in different areas -- kids playing hopscotch: at home
with sidewalk chalk, here with patterns drawn into the mud with sticks;
cottage industries: kids selling lemonade at home, kids selling mangoes
from their trees here. And of course Slinkys and balloons, which seem
to cross all cultural lines.

Christmas Time is Here

2007-12-13T16:42:00.000+02:00

Merry Christmas! Our version of poinsettas here -- the flame lily, or 'Doctor's Joy', as Gwen Amborski calls it (she should know, having lived here all her life). Poinsettas actually bloom around Easter time, so we've got our lilies and Christmas flowers backwards. These grow wild in the fields around the hospital, and my other Christmas colors are being supplied by the red and green of the gigantic watermelons growing in my garden, the green and gold of the mangoes, and the silver of the evening rain on the trees in the mornings. (Thank goodness for our internet access, because otherwise no one seems to know when a watermelon is actually ripe.) Other than that, I've got lots of recordings of Bing Crosby singing about a White Christmas and such to get me in the mood.

Last time I wrote to you all was back in October; we've now passed the one year anniversary of my Mukinge stay. I got the news that I passed my ER boards, which was good, although a near thing, having momentarily forgotten about the presence of things like CT scanners during my test. The tests here are still challenging as well, although of different natures, like what's the proper food to serve to a Chief, what is causing the raging fevers of a patient, how best to support the people who come knocking on my door asking for help, or what decision to make about my future that's coming up in now less than a year.

Christmas time for me is always a time to remember gifts that have been given to me; I cannot even believe how blessed and lucky I am to have so many of you thinking of me, giving me the gifts of packages, time, emails, and prayers. Rarely a week goes by when I don't have some kind of package slip waiting for me in my mailbox here, and it's been a joy to share some of the things from home with the people here from Zambia and elsewhere. My big load of kids toys is especially fun around Christmas time. Many of you have supported the work out here financially as well, allowing us to buy a water pump to supply running water to over 30 houses here at Mukinge, several different purchases of much needed medications for the pharmacy, 4 oxygen concentrators, and to remodel an entire house to help retain needed nursing staff for the patients. Coming up in the year to come we're hoping to remodel two more staff houses as well as the male ward of the hospital. Potentially we may have found a donor to help us upgrade our operating room facilities as well. And I think I may redo the tennis court as a Christmas gift to the mission complex as well.

A year has gone by quickly; I blogged a few months ago about lessons that I've learned in a year and I'm struck by how much I've learned and changed in just a short amount of time. We continue to serve and help as best we can for the people here. Thank you for your service to me and us over the year.

With much love,
Matt

hail to the chief

2007-12-11T20:35:00.000+02:00

We've been having sermons the last few Sundays in chapel on
relationships in various parts in our lives -- with family, friends,
workplace, government -- and one of the things that keeps hitting home
is the importance of respect. I remember in college how my friends from
the East Coast would make comments about relationships in the south as
'fake' or superficial because they placed a emphasis on respect, even
when you don't necessarily like the person who you're dealing with. All
I can say is that the issues you might bring up with Southern culture
are magnified to the Nth degree here.
For example, two weeks ago on Wednesday one of the district chiefs from
north of here showed up to have eye surgery. Unfortunately, he hadn't
coordinated with anyone at the hospital, so the eye surgeon was gone on
a trip, the cell phone service was down, and he had not arranged for any
place to stay or any provision for food or shelter. So I go to meet him
in the reception area, crouch down to the ground, clap my hands, and ask
his entourage what I can do for him, to which I am told 'whatever you
think is appropriate'. I am thinking to myself that it would be fairly
inappropriate in America to show up unannounced and uninvited and expect
someone to take care of you for two weeks, but I remember our chapel
talks on respect and wisely keep these thoughts to myself. I ask them
if they would like to stay in the hospital or stay in the guesthouse in
town a few kilometers away, to which they say 'whatever you think is
appropriate'. I think to myself that probably making him walk the 5
kilometers to town will be seen as 'inappropriate, so I start working to
find a private room for him to stay in. We have two -- one on the labor
ward and one on the female ward. I decide that the female ward room
will be more 'appropriate' than screaming women on labor and delivery,
so we go there. I then ask if they need to eat, to which they say
'whatever you think is appropriate.' I now explain to them that a 33
year-old American male take on appropriate might be a little different
than a 60 year old , requesting a bit more clarification on
'appropriate' and find out that yes, he hasn't managed to pack lunch for
himself. It now being 3 o'clock, our evening meal won't be served for 2
hours, so I go home to find something to cook for the chief. My
refrigerator contains mustard, eggs, green peppers, and potatoes, so I
decide that eggs are probably the safest of those options and make some
scrambled eggs for the chief, with some peppers mixed in. I deliver the
eggs to the private room where he is settling in, thinking that I can
now possibly go see the other 200 patients in the hospital, when the
chief's staff comes out and says that he is not happy because there is
no table on which to eat his eggs. The nurse in charge of the ward and
I look at each other. I suggest the rolling trolley that the nurses
dispense medicine from, but that suggestion is rejected as not
respectful enough. Eventually we decide to move my doctor's office desk
into the room, where he then happily eats his eggs.
Two weeks later, after his eye surgery but not quite long enough for him
to arrange a ride back to where he came from, my desk still missing from
my office, we have needed to spray for cockroaches in the ward. We
arrange for the chief to move to another room so he won't asphyxiate
from the fumes, but again we are told that we are not being respectful.
Fortunately, in the two weeks since his arrival some of the senior
Zambian staff have returned from their meetings and the cell phones are
working again, so I can defer this discussion of respect to one of
them. I am sure that it was handled better than my initial attempts at
appeasement, and we did manage to avoid cultural crisis and still spray
for cockroaches.

cockroach trouble

2007-12-09T14:02:00.000+02:00

We've embarked on a number of building projects/remodelling the past
year -- repainting the chapel, installing cooking pots and remodelling
the kitchen, renovation of the Mwilu house, building of an ARV center.
After the kitchen remodel was finished, we decided to use the small
amount of excess money left to conduct a spraying of the entire hospital
to try to cut down on the cockroach numbers. Unfortunately, in order to
spray properly, you have to move all of the patients out of the ward for
3-4 hours, which can be a little problematic for wards like maternity.
Anyway, this week was the turn of the TB ward and peds 2, our
malnutrition ward. The TB ward spraying went smoothly, but peds 2 was a
bit more of a problem -- we sprayed overnight but the cockroaches there,
perhaps stronger from all of the malnutrition food they've been feasting
on for years, merely got angry, starting literally coming out of the
woodwork, covering the walls, jumping out on you, so forth. It was like
a bad scene from Indiana Jones. After some emergency purchasing of
additional bug spray, we managed to collect a bit of cockroaches 2 feet
across and at least 6 inches high. Pretty impressive. This is the time
of year where the bugs rule -- flying termites littering my doorstep
every morning with the remnants of a thousand shed wings, mosquitoes
giving malaria to close to half the hospital, black ants boiling out of
the ground in huge trains, ready to devour anyone who is slow enough to
pause accidentally in their path. I guess the cockroaches were just
upset about being left out of the fun.

the truth is sharper...

2007-12-03T21:59:00.000+02:00

We still fight the struggle of getting people to come to grips with HIV
here in Mukinge. This is very much a person-by-person struggle, as all
of the posters and advertisements in the world seem to do little to
convince the village wife that she could conceivably be HIV positive,
much less need treatment for it. We have mandatory offered HIV testing
for all of our TB patients because the co-infection rate is around 70%;
one of my patients today became very angry because we were drawing blood
from her on the ward. This was a blood draw to determine if she would
be healthy enough to start on anti-HIV meds; she'd already had her HIV
test last week. To our surprise, however, she got very angry, claiming
that she'd never given consent for an HIV test and had never been told
her test results. Now, we pretty clearly document our counseling
process, and there were notes from our HIV counsellor on the chart, so I
was pretty sure that she'd been told both about the first blood test and
the results. But she was very adamant, spitting out Kikaonde far too
rapidly for me to follow, so I brought in the HIV counselors to come
talk with her again. After some further questioning, it was pretty
clear that she had gone through the whole counseling process as usual,
but was in such denial about her positive test that she couldn't even
admit that she'd been told the results.

As I was standing there in the nursing station with her and our
counselor, I keep thinking about how I could 'force' her to hear her
test results simply by repeating them again there until I was sure she'd
heard. I really wanted to, to a certain extent. I mean, shouldn't her
husband and children have the option of being tested, even if she was in
denial? Plus, it just seemed like cowardice to run away from the truth
like that. But for her, the truth was really a weapon in the truest
sense of the word, and to wield it like that against her would probably
do irreparable damage to her, as well as to our doctor-patient-hospital
relationship. So we left it alone, with her in her denial.

a disaster in the making

2007-12-01T08:47:00.000+02:00

We had our disaster/emergency drill yesterday at the hospital, where we
practice what to do with mass casualty incidents. I had asked one of
our visiting docs to help me plan it and so she had organized several of
the nursing students to come and help. We had notified the nurses to
let them know we would be practicing today so that they could be ready.
What I didn't anticipate was the acting skills of our nursing students.
We drove up a carload of them to our outpatient department, where they
started wailing and keening after having tangled themselves up and
squirting ketchup all over themselves. Our watchmen went into a panic,
as did the chaplains, carrying the students out of the back of the
truck. Someone said that they had seen them all gathering in the
nursing training school just a few minutes before and 'there must have
been some sort of electrocution' that happened there. People were
scurrying left and right, I later found out that the staff in the
business office stopped their work for 30 minutes to pray for the
injured nursing students, and we called a halt to the whole process
after about half an hour to discuss some of the issues that came up.
Note to self: make sure that EVERYONE knows there's a drill on before
conducting one again.

the life you save may be your own

2007-11-25T16:33:00.001+02:00

Always wanted to have a Flannery O'Connor title in my blog. This week
has been exhausting, but also pretty satisfying. One of the problems
with medicine at home is the sheer distance of it -- your doctor
presence has to be mediated by white coats, scrubs, ultrasound machines,
tubes, oxygen and so forth. Most people's impression of going to the
hospital is of finding yourself or loved ones 'hooked up' to various
machines, pumps, IV's, catheters, and so forth. Here, some of those
barriers still exist, but often the distance is frightening close --
frightening because it remind you of your own mortality, and frightening
because as a doctor you are working with so little reserve. At home, we
think little of transfusing 5-10 units of blood in the ER, to be
followed by another 30-50 in the OR. Here, I donated blood on Monday
afternoon and transfused that unit of blood that evening while doing
anesthesia on a sick C-section patient, since it was the only unit of
type O blood that we had. On Tuesday I was called to obstetrics because
of a baby who was born who wasn't breathing -- we put a tube down into
his lungs and I spent my lunch break acting as a ventilator until he
picked up enough to breathe on his own. What happens when you're not
there to be the blood bank, or the ventilator, or the doctor to do the
C-section?

Flannery O'Connor was trying to say that our actions have a much bigger
impact on us than they do on other people; perhaps not a complicated
idea, but a profound one nevertheless. The corollary I think also holds
true, however -- if you don't save the lives that you can, you may lose
your own way in the process as well. I think that what I struggle with
here is how exhausting that process can be, especially when you are
stretched thin between work and life and interpersonal relationships
which sometimes take a lot of effort to keep smooth. I have to think
that the lives of others are worth it; what I don't often remember is
that truth that when I seems like I'm just spending myself to the limit,
I'm also saving myself from callousness or ineptitude as well.

email slowdown

2007-11-25T16:33:00.000+02:00

Sorry if the blogging has been sparse -- we're having some trouble with
our internet these days, which means I have to travel to the airplane
hanger to do my email, something which is rarely convenient and often
impossible when you're on call, since no one can get in touch with you
there. So sorry if the communication hasn't been so prolific.

malnutrition miracles

2007-11-19T21:09:00.000+02:00

We've recently had some opportunities to apply to increasing assistance
and funds to help with the malnutrition problem we see here at the
hospital. For various reasons -- farming patterns, soil deprivation,
cultural stubbornness, chronic diseases like HIV and TB -- there are few
protein sources in Kasempa with resultant rampant malnutrition and
malnutrition deaths. We've recently gotten some help via surprise
deliveries of things like Plumpy'Nut and have also been offered
additional assistance via some of the HIV programs in the area.
Previously I am told that we had been declared a 'malnutrition free'
area by the World Food Programme, so our food supplementation funds had
been cut off. Most of the external donations by private individuals for
the hospital are actually designated for food of some kind.

Our visiting nurse, Kate, who's currently in charge of the malnutrition
ward, and Edgar, the doc in charge, have been working extra hard to come
up with the measurements that they need to secure the funds. These are
things like arm circumference and heights on our adults. Thanks to
their hard work, we're getting closer to maybe getting some more of the
help that we need!

the normal is the weird

2007-11-15T13:11:00.000+02:00

People usually ask me at home 'what the normal stuff that you see out there at the hospital?' to which I usually reply things like malaria, or HIV, or pneumonia, or diarrhea. But in actuality the cases that consume a lot of your time and brainpower are the weird, where you're struck with something you've never had to deal with before and are not even exactly sure where to begin. Those type of cases are the usual for us, each week having to puzzle through how to take care of a huge urinary mass, or whether you should remove the breasts on a hermaphrodite, or when to do the surgery for a 4 month abdominal gestation. Those are the things that tropical medicine diplomas can't prepare you for: you rather rely on your ability to be resourceful, puzzle through things on your own, call on remote expert guidance from doctors overseas, and tackle things without knowing all the outcomes beforehand. Obviously that kind of working without a net doesn't always work out well, but surprisingly it does quite a bit of the time, too.

working life

2007-11-11T13:51:00.001+02:00

working life, originally uploaded by mattcotham.

Mukinge is a very out-of-doors kind of hospital; perhaps not as much as
the mud huts that David used to work in with MSF, but I enjoy the
exposure to the wind and rain and sun on my daily rounds. Most ER's at
home have few or no windows -- they were usually added on as
afterthoughts on the ground floors of hospitals and I suppose that the
presence of a window would make sick people uncomfortable, although I
never really understood the logic of that. But here, I can sit out on
the steps outside of ultrasound while I'm waiting for the nurses to
bring a patient for a scan and enjoy the sun on my face for a few
minutes in the middle of my day. Or I can dodge the drips on the
walkways when the rainstorms suddenly hit around 2pm, dancing around the
puddles on the walk and feeling the spray from the gutters on my arms.
It's nice, it keeps me in touch with the outdoors, and it gives some
variety to my day which is sorely lacking at home.

exam time

2007-10-31T08:26:00.001+02:00

exam time, originally uploaded by mattcotham.

Right now are the grade 12 exams here in Zambia, which make the ER oral
boards pale in comparison to the amount of stress that these engender.
Try to imagine that your SAT score would be one of the primary deciding
factors for every school you ever applied to and every job you ever took
and you'd understand a bit better. Maybe 10 staff members of the
hospital are studying and retaking their exams to improve their scores,
even at the age of 40 (imagine taking your SAT again at the age of
40!). Just to give you an example of how serious people are, we had a
girl come in from the secondary school with what turned out to be a
ruptured tubal pregnancy -- heart rate in the 140's, pale, dizzy. She
took her grade 12 history exam this morning before she'd let us do the
tests this afternoon to figure out what's going on or operate on her.
Surely that deserves one or two extra credit points on the exam?

how the grinch stole homecoming

2007-10-27T17:21:00.001+02:00

how the grinch stole homecoming, originally uploaded by mattcotham.

Well, we made it back yesterday after a long trip where I nearly got
bumped from my flight to Johannesburg, my luggage was deliberately left
behind by United in Washington so that we wouldn't have too much weight
on the plane (they told us about that decision when we landed 13 hours
later), and about $1000 of gifts/equipment got stolen out of my bags
along the way. I'm struggling with thoughts of wishing plagues of
hemorrhoids and ingrown toenails (that would be revenge for us doctors)
on the perpetrator of that deed, since these were things that I had
planned for months to get and some of the stuff were things that people
here had given me money to buy for them. I was feeling a little bit
like Santa Claus bringing it back for people, and now I feel a bit like
the Grinch came and stole our Christmas, and there won't be any little
dog with a large bone tied on his head bringing it back. But like the
Grinch points out, stuff is stuff, and although not always replaceable,
it's not the end of the world when it goes away.

I'm trying to get more photos on the blog; they are not always related
to the stories (I'm not picturing feeding this guy to the crocs,
although come to think of it....)

October updates

2007-10-17T18:51:00.000+02:00

I see that it's been close to two months since my last group email -- time flies when you're trying to get ready for ER boards, I guess. I am currently back in the states for a brief time for my oral boards and then will be heading back to Zambia on Tuesday. I get a lot of questions about whether I'm struggling with culture shock; coming back to the US, even for a brief time, has its advantages -- I feel like I'm getting a years' worth of shopping done in a week -- but also brings you up hard against American materialism and excess. Although I don't deny that I think salad in a bag is a modern miracle, especially after the 5 step process of washing and disinfecting that I'm required to do, we spend a lot of energy on activities which are of little profit, I think.

I guess the two biggest questions I get when I'm back are 1)"What's it like over there?" and 2)"How can we help out?" I find myself wishing I was more charismatic to go out and 'sell' a project or need for the hospital, but the bottom line is that both questions are problematic at best.

What's it like in Zambia? It depends on what aspect you look at. I would say overall that it's just more extreme than life over here; I think I've said this before. In terms of work, it's more satisfying in many ways, because it allows me to be more holistic as a doctor, incorporating who I am into what I do, and the patients are more grateful and more engaged with their doctor. It's a throwback to the trusting nature that people used to have with their doctors here before the age of the internet and information overload where they depended on their doc to do the right thing and know what was best. At the same time, work is much less satisfying, as patients die or you can't help, and they are often very young. I can give many examples of patients who were just tragically cut short, and it's difficult to care for them and feel very helpless. Life outside of work is better, more simple, more fulfilling than the American pursuit of entertainment and so forth, but it's also more frustrating, more boring, and more difficult to get things done. I blogged about this recently in 'native soil', if you want to read more.
Anyway, you want to put a 'positive spin' on things so that your parents don't get too worried :), supporters don't get discouraged, and you don't give the impression that Zambia is falling apart and incredibly frustrating, because it's not. Many stories end up sounding that way, however, and it's sometimes difficult to find a balance.

How can you help out? After my friends Hilary and Tay came to visit, I was struck again by how many things go on outside of work that need help as well. People want to help with 'the kids', but that's a very nebulous term -- the kid patients in the hospital, the local kids of the hospital staff, some of the nearby village kids, AIDS orphans, local schoolkids -- all have different advantages and disadvantages when it comes to ministry. I am probably too focused on the hospital needs, because that's where I serve and spend my energy. All of those needs -- housing, electrical transformers, drugs and supplies, incoming personnel -- are ongoing and there are no guarantees that interventions to help will have the desired effect. For example, we have recently purchased some new kitchen pots and are renovating the kitchen for about $20,000, but our electrician sometimes makes mistakes and there's a real chance that there will be mistakes in installation which could cause lots of damage. But he's the only electrician around, so we may have to trust him and hope for the best. We've raised the money for a water pump so that around 20 people can have running water, but we were swindled by the guys who ordered it and so still haven't managed to get the proper pump installed, now two months later. Projects all seem to have those sort of hang-ups, but you need to get them done, so you do the best you can. I definitely feel that while I'm over there I can help facilitate things getting done properly.
So how to help? I guess from a capitalistic perspective, it's a risky investment: no guarantee of success. Don't be fooled by these NGO's who promise that 'every dollar will be spent on something' because Africa doesn't and can't work that way. But there are a lot of really positive things. I'm encouraged by the lack of graft and good accountability on the part of the people that I work with to do the best they can in a tough situation. And I'm also struck by the huge upside when things do turn out well -- getting water to people, providing good healthcare, giving comfort to patients and families, supporting people in their need -- these are things that we should be a part of as Christians and citizens of the global community. Because there are so many different ways to get involved -- education, financial projects, nutrition, infrastructure, medical care -- let me know if you have a heart for something and I'll see how I can make it work.

It's really encouraging to know that people are interested and engaged with what's going on out at Mukinge. That's easily been the best part of this brief sojourn at home. I'll be headed back in less than a week to Zambia for round 2 of my two-year commitment. What happens after next November is still up in the air, and I'm pretty content to leave it that way, with the understanding that God will show me the answer to those decisions when they press upon me.

Thanks for your prayers and support. Looking forward to talking and hearing from each of you.

Talk to you all soon.
Matt

modernization

2007-10-17T15:01:00.000+02:00

Not exactly sure that changing the font qualifies as modernization, but
it seems to at least eliminate the irritating page breaks. Hope you all
can still read it -- as my dad's eyes get worse, I get more sensitive to
these things. I've not been blogging much this week since I figured few
people want to hear about my studying habits, and some of you I've
managed to talk with in person. Suffice it to say, I should be ready
for exams on Sunday, I've managed to find most of my gift ideas (anyone
know where I can find a hammock?), and have enjoyed spending time with
family and friends. I'll catch you guys up once I reach Lusaka again!

native soil

2007-10-12T04:37:00.000+02:00

It feels pretty good to be back on American soil, even if it was the product of a 17 hour flight from Jo-burg to NYC and I still have about another 12 hours in lay-overs, transfers, and flights to come. I love the fact that the US citizens line in customs looks as diverse as the visitors to the US line in JFK. And, I'll admit it, my triple-shot latte also tastes pretty good after 4 hours of sleep and 11 months delay. These are mid-terms for me, a chance to step back and figure out what the last year has been about, where I'm headed to in the future, and where I am being led from here. We're conditioned to pursue happiness in America. I wish I could say that I was ecstatically happy all the time in Zambia, and I would have to say that I'm pretty content most of the time. But it's a complex place. Let me try to outline some of those ways.

Friendships: Mukinge has been an amazing place for friendships with some really wonderful people who I have grown close to because of all our shared experiences, but also because of who they are. There are people that are really worth spending the time to get to know -- Zambian and ex-pat alike. At the same time, Mukinge is a place where many people are there for a short time and then gone. And cross-cultural friendships are difficult because of expectations of financial/material gain that are often placed on them, differences in cultural backgrounds, family structures. So it can be lonely at times as well.

Work: Work can be really fulfilling. I put together a slide show of pictures of just a fraction of people who've we've helped -- the man who slit his throat in an attempt to kill himself and came back to his family and to Christ after we sewed him up, the woman with the massive hemopytsis holding her baby after her C-section a week later, the man fitted with his wooden peg-leg after his traumatic amputation of his leg, smiling and sticking his thumb up at the camera. I'm reminded of people's lives that I've saved over the year, people who are grateful for a gentle touch or kind word, and families who were strengthened in their faith and love for each other because of work that we did. At the same time, the slide slow reminded me of all our failures -- the immigration officer staring at the camera like he can see his own death in the lens (he died two weeks later), Josua reaching out to the camera and then laying in the high-care area of pediatrics 3 months later, dead from malnutrition, Tom sitting in his wheelchair gradually losing his smile over a few weeks as he's forced to grow up unexpectedly by the tragedy of unexplained paralysis. Some days are really good, but some days I find myself losing hope that what I'm doing makes a difference as well. I find that rationalizations that 'what would it be like if you weren't here' to ring hollow when you know about how much more effective medical care could be if you could bring the funds and personnel to bear.

Cultural adaptation: I mentioned above that we pursue happiness in America; it's in the Declaration of Independence, which in itself is so foreign to many people from other cultures, who live by the Declaration of Interdependence: on friends, on family, on the rest of the world. That transition for a bachelor who's practiced being independent for around 10 years to a culture of interdependence has been rocky at times. Part of the reason is that coming from a position of power, interdependence can very easily become just dependence, a one-way street, especially if you don't take the time to appreciate the non-quantifiable gifts that many Zambians have to offer, and Zambians don't take the time to learn about your non-material gifts as well. I was transitioning from a pluralistic society to a monolithic society, which has its own adjustments in terms of voluntarily giving up your freedoms in order to have cultural relevance. Rural Mukinge is not the cultural melting pot, something which is hard for us to understand when we go because it seems so foreign, such a great 'exchange of ideas'. When I arrived, however, I quickly realized that to make a difference I would have to change myself in order to make the differences that I can't change less obtrusive. Giving up your freedoms to be relevant -- giving up deep friendships with women because of the misconstructions that are placed on them here, changing the way you greet people, structure your day, deal with interruptions -- it's obviously the reason you go, and the lessons you learn are awesome, but it's also a painful process of subjugating yourself in ways where you're taught as an American that you should be able to pick how you're going to live your life.

I think this is going on too long for a blog -- probably half of you tuned out after the first paragraph -- so I'll stop it here, despite the adrenaline that only a triple shot latte can give you after 11 months of abstinence. Hope to talk to some of you in person, or at least by phone while I'm home.

full circle

2007-10-08T11:20:00.000+02:00

I am back in the guesthouse in Chamba Valley where I started this trip
ten and a half months ago. In a lot of ways, things haven't changed much
since I was here then; it's still hot, and full of mosquitoes, and I am
fully expecting to have another night spent sitting up and swatting bugs against
the wall. This has been made more challenging since the last time I was
here by the addition of regular power outages, so that you are
trying to swat bugs by sounds and feel alone, which is a distinctly
dicier proposition.

Despite similarities, a lot of things are really different than before, too. My computer is now full of beautiful pictures and also with emails about water pumps and visiting medical students. There is now a separate Zambia folder with funding proposals, memorandum,
minutes from various meetings, and medical protocols.

In a moment of pique last week as my insomnia kicked in and my frustration level was
high, I made a list of all the things I'd had to learn while I've been
here for 10 months. At the time I was mad because I'd been forced to learn so much in such a short period of time; now I'm feeling kind of proud of myself. Here's the abbreviated list:

How to plant and fertilize maize and a garden

WHO recommendations for malnutrition, setting up a malnutrition
protocol, components of mineral supplementation, whether commercial
mineral supplies are adequate for human consumption, price of skim milk
powder, how to purchase and deliver milk powder, where to buy peanuts,
soy, how long peanuts can be stored, where to find containers for peanuts

Basic Kaonde

How to deworm a cat

Where to hire someone to shovel off the tennis court

How to get out of trouble when you're over your head in a C-section

Dosing and monitoring of chemotherapy for cancer, HIV drugs

African vernacular songs on the piano

How to distill water, where to find distilled water for lab and OR use
(the air conditioner, rainwater)

How to sterilize surgical instruments

How to fix a tire on a motorbike

Tennis forehands

A variety of medical conditions: Madura foot, eosinophilic folliculitis,
lymphoblastic lymphoma, leprosy, nephrotic syndrome, acute rheumatic
fever, cerebral malaria, ecclampsia, uterine rupture, snake bite,
organophosphate poisoning, tropical ulcer, pin placement for skeletal
traction, typhoid fever, skin grafting, hydrocoele repair, ultrasound
diagnosis of DVT, VSD, and ectopic pregnancy

30 or so African choruses

How to dispose of medical waste

How to make nshima

Charitable organization legal proceedings

About 200 people's names

The Evangelical Church of Zambia organization and the hospitals' role
with ECZ

How to set up a computer network (well, how to fail to set up a computer network, really)

ER medicine for my ER boards

What SIM stands for, who runs SIM, how to get things done through SIM,
how to request funding from SIM, how to recruit personnel via SIM, old
SIM projects that have been conducted at Mukinge, SIM future goals for
the hospital

Pharmacy ordering systems, contacts of about 5 pharmacy delivery
suppliers in Zambia, methods of delivery, goods received vouchers

Where to find sources of lab supplies, drugs, and stores in Zambia.

The government supplier of pharmaceuticals system, ordering timetables

What is an electrical transformer, how much voltage requirement is
needed to run a hospital

How to dig a VIP toilet

Mukinge history of severe illnesses, malnutrition, malaria, history of
relationships with the local health board

Antibiotic resistance patterns for Mukinge for the last 6 years

How to put someone on the Zambian government payroll, how to find out
how many people they expect us to have on staff

Installing and troubleshooting cellphone modems, wireless cards, and
internet access on 10 different computers

It's a long list, and I edited out a fair number of things. It feels like almost everything on that list I had to figure out on my own when I got here because of the lack of long-term docs to do a
proper handoff. Like I said before, I was peeved at the time I wrote the list because I was feeling that it was unfair to have to study for my boards on top of the rest of the
things that were going on. But now, I'm kind of just proud of myself for
managing all those things. Who knows what the next 14 months will bring?

off we go

2007-10-06T14:15:00.000+02:00

Travelling is always a bit of a production when you live out in the
bush; the current crisis is a fuel shortage throughout the middle of the
country, so that one of our doctors is stuck 2 hours away by road and
can't get back. That played a little havoc with my travel plans as
well, and there's the usual last minute changes (my flight time out of
Mukinge has changed 4 times in the last 48 hours). And of course
there's just the amount of time it takes to get anywhere; I will leave
Mukinge today on the 6th, yet not arrive in the US until the 11th.
Looking forward to seeing everyone in the states at the end of the road,
though!

do we all speak English here?

2007-10-03T16:50:00.000+02:00

My head cold has made it even more difficult than usual for people to
understand my American accent here; even my Kaonde seems to be more
difficult to understand. It works both ways, though, when I had to go
over the pharmacy orders for the month and was trying to figure out why
we were ordering 'cold cramps'. Alas, the Zambian 'l' and 'r' switch
got me again (you pronounce them the same), and what we really needed
were 'cord clamps', for umbilical cords. I do sort of enjoy the idea of
ordering up a bunch of cold cramps, however, and seeing what happens....

blooming season

2007-09-20T17:33:00.000+02:00

My bluebonnets are turning out even better than I hoped they would, and
September, despite the ever increasing temperatures, is an amazing time
where most of the trees burst into bloom. It's actually quite amazing,
considering that there has been not a single drop of rain for 5 months
now, but the trees know to expect the rains in a few months and are
preparing for another season of flowering and growth. It is really
beautiful, especially the jacaranda trees which look like giant purple
afros, the flame trees with their masses of red blooms, and the
beautiful white and yellow tree out in front of my place, which
basically looks like it has grown wedding bouquets at the end of a
hundred dried sticks. I'm proud that the bluebonnets picked now to
bloom as well; it's a testament to American solidarity with the African
plant life.

Kaonde lessons

2007-09-20T17:32:00.001+02:00

I've been trying to have a little bit of improvement in my Kaonde by
studying in a nearby village once weekly for the past two months. I
really think that language learning is such a great tool to helping
patients feel comfortable and welcomed when they come to the hospital.
I think learning the language is a great way to get insight into the
culture and ways of thinking of the people that you are working with as
well. For instance, last week I learned that Kaonde doesn't have a way
to express "I have to" -- ie, I have to go now, or I have to write a
blog entry since I have not written one in almost two weeks. You can
say "I should" or "I want to", but the idea that you are at the mercy of
time constraints or external pressure just doesn't exist. Everyone is
seen to have a choice about the way they spend their time and energy,
and circumstances are relegated to a secondary role.

updates

2007-09-20T17:32:00.000+02:00

For those who I haven't let know personally, I will be managing to come
home for about 10 days this October to take my oral boards and attempt
to get some early Christmas shopping done for the folks here at
Mukinge. If any of you have a little time in Chicago or Texas during
Oct 12-22, let me know and we'll see if we can get together!

long overdue -- ER days

2007-09-05T15:41:00.000+02:00

Well, if anyone is still reading after such a long hiatus, I'm still
here. It's been a busy few weeks with various people out of the
hospital on trips, so I've been playing a few roles: OPD officer,
occasional anesthetist, surgeon, and so forth. But I actually got a
chance to be an ER doc a week ago Monday when we had a motor vehicle
accident appear with 14 passengers at around 4pm. The nature of all
transport in Zambia is that in any one accident there are lots of
victims; all cars or trucks are pretty much filled to bursting wherever
they go because there is no other way to get around. Even at the trauma
hospital where I trained, if 14 patients showed up to the ER
simultaneously it would cause a bit of a stir; here it nearly overwhelms
us every time that it happens. We default to our 'emergency plan' which
I revised a few months ago.

We were finishing up a case in the theater when we got word that they
were arriving; I scrubbed out and went to the female ward. We had to
stage a little traffic direction to bring everyone to a place where we
could triage them -- sort out who was the sickest, the next sick, and so
forth. Unfortunately, one man had bypassed the queue and gone straight
to the theater, and although he was pretty sick, there were two people
who needed to go to the OR more; one with a bilateral broken legs, and
one with a head injury.

The man with the broken legs had lost so much blood en route to the
hospital that by the time he reached the theater he died. We started
CPR and started four IV's and transfused him, and he came back for about
30 minutes, but we were unable to get enough blood into him and he died
again; this time not to recover. The second man with the brain injury
died the next day. The rest are still mostly here 10 days later,
recovering from their various orthopedic injuries as they try to figure
out ways to get transport back to where they were originally supposed to
be going.

With the arrival of the paved road to Mukinge a few years ago, things
like this will become even more common, but the protective things that
shield people from serious injuries in car accidents at home -- seat
belts, sturdy seats, air bags, antilock brakes, decent tires -- are
still a long way off. Most of these accidents come not from two people
hitting each other, but from the vehicle breaking down en route -- blown
tires, failed steering, and so forth. It's sad, because the things to
take good care of trauma patients are pretty basic: availability of
someone with surgical skill, ample blood supply, and decent transport of
accident victims to the hospital.