Winter 2017 letter

Friends and visits

A couple weeks ago, our cousins, Abby and Elizabeth Cummings, came from Philadelphia to visit us in Kalukembe. . . for the second time! Impressive not just for their bravery in coming but for the fun they brought through their talents and gifts. Thanks, guys!

Sunday school at our local church. The kids were excited to have visitors from another continent. Strangers are often referred to as "Chinese," the largest population of foreigners in Angola. Amusing to be called such.

Abby reading to Eliel and Naomi. One of the many, many times Abby read to the kids. Their English skills  advanced quite rapidly during the visit!

Witnessing joy in our work. Abby and Elizabeth accompanied us most days on rounds. This was a follow-up visit from M., 2nd from right and with her husband, mother and baby. She was in a taxi accident with her baby in June and suffered severe traumatic brain injury, comatose in our hospital ICU for weeks. It took 3 months before she could talk, and she now can walk with the help of a walker. Nelson Andre, at far right, supervised her care during her long recovery on the physical therapy ward. In M's case, i cannot think of a better-named place where she recovered: the "Elavoko" ward means "Hope" in Umbundo

Sharing in education. Elizabeth, who is a nurse practitioner at Childrens Hospital of Philadelphia, brought 2 baby mannequins to help in several hands-on resuscitation sessions on Maternity.

Never in short supply. A mother on the ward kindly allowed her newborn to be borrowed for further demonstration and practice with the nursing students.

Onsen, Angolan style. We drove with Abby, Elizabeth, nurse Avelina and her girls to Kalepi area, about an hour and a half away, where hot water bubbles up in a marsh. Zeke and Eliel dipped themselves in water that locals also use for irrigation. 

Encouragement balloons. With balloons Abby and Elizabeth furnished, Zeke, Eliel and friends passed through the wards to hand out encouragement to patients. It was also an encouraging visit for us to have Abby and Elizabeth around, sharing in the beauty of Kalukembe and seeing the challenges people face in their lives here.

Visiting a remote place

Early last month, i (Daniel) visited Lumbala Nguimbo in the far eastern side of Angola, near Zambia. The church re-opened a medical clinic there, posting this lovely couple, pictured below, for two year service. It took 3 days by truck for others who helped open the clinic to arrive; i flew by plane with the couple and others in 3 hours. Neither of them are from the area originally; so we desire they will be encouraged in this new, isolated and challenging place of work. For instance, the nearest hospital with surgical services is in Huambo, about 2 days car ride away. 

Kochi and Flora, with their youngest son, Ululi. They were relocated in October to Lumbala Nguimbo. Kochi is a lab technician and Flora is a nurse. They will be responsible for diagnosis and treatment at the clinic, forming the core of the staff there. 

Highlighting the challenges facing people in the Lumbala Nguimbo area, this little boy had sudden onset stridor (difficulty breathing) about a month before we saw him in the clinic. He had been admitted to the local government hospital for treatment for "asthma," but by physical exam we suspect his problem is an upper airway obstruction (perhaps a coin or other object). However, no x-ray in the immediate area (and an ultrasound probe was too big to easily identify anything in his neck/upper chest), no likely laryngoscope or bronchoscope that could help for intervention for two days journey explains well the frustration of both the medical staff and the reluctance of the family to leave even when offered transport by truck.

Ladies and their family members from Lumbala Nguimbo who were taking the return flight to Kalukembe for fistula care. In a country of more than 25 million and high rates of birth complications, caring for women with vesicovaginal fistulas is a service with profound impact. Kalukembe is one of only two hospitals in Angola with care for fistulas offered yearlong.

Lumbala Nguimbo IESA medical clinic, foreground, with lab to picture left

Our beautiful Kalukembe.

Our beautiful Kalukembe. The Mission Hospital aerial view by Marijn Goud. We have about 500,000 people in the catchment area, only emergency surgical and blood transfusion services between three major provincial capitals (radius of over 200kms). Please pray for the work here. our colleagues who we work side by side with, and for His love to be made known. Maranatha.

Thanks together

Ok, i think we left our last post with something about struggles. But struggles are not all we experience. We all have struggles, no doubt. But man, there are many things to look around and and be so very thankful for. Like looking at rays of light and tracing them to their sources, we are thankful for our Maker who made an incredibly beautiful world. Wanna share a few rays of light with you; and without your partnership in this endeavor of love, we could NOT be here, witnessing God's blessing and glory. Thanks, Sister! Thanks, Brother! We treasure your presence in spirit with us. (And if you didn't receive a letter of thanks from us recently, good chance it was in a bag of our colleague which got ransacked by airport authorities--to their shame, because we only included beautiful drawings done by our young friends here. i think they made off with a whopping $10, which was to be for postage).

Visit to Chitutu clinic this month. Patients waiting for consults benefited from health discussion facilitated by our friend and colleague, Petra Jobse. A great encouragement to see many people participate and receive care. We keep hoping and praying for improving access to health services for people in rural communities around Kalukembe. This clinic is a small, affirmative step realizing that.

This mother came for prenatal care in April to Chitutu, having suffered to see 3 babies die shortly after birth. She acted on advice to stay near Kalukembe hospital from the month prior to her due date. After having a cesarean delivery in July, she is here with a healthy boy at one month! A real joy to witness a healthy baby and we hope he continues to grow into a healthy child. We are hoping in the future to fix up a home in the patient villa next to the hospital for expectant mothers like this woman to stay in. 

The Chitutu visit from Zeke's perspective. He came out with us for the day to Chituto clinic and was given the camera to document his experience. . . interesting to "see" from his perspective--looking at peoples' feet and table legs, grass, tree stumps, etc. He later participated in history taking from the ladies who came for prenatal visits. He got pretty good at asking about pain, fetal movement, any bleeding or pain. . . lots of fun to have with us!

Student nurses posing with patients-turned-artists. These kids have been rays of light; and not just because they recovered from their illnesses (2 with osteomyelitis, one with a parotid tumor). They joyful demeanor, cheerful smiles always gave me delight to visit them and see their progress.

Perhaps you saw this on FB already. . . but was lots of fun for me to get an animated refresher on peripartum emergencies by my favorite partner! Dr. Nicholas Comninellis (of INMED) and Priscila gave CME talks to nurses on a range of topics the end of July. Through partnership with the Fistula Foundation and others like you, we have been able bring nurses to Kalukembe for a couple days of continuing education. We usually receive good opportunities to discuss management and diagnostic challenges the nurses face in their clinics.

Eliel with his buddies. Energetic to sometimes exhaustion for me, but these kids are a part of our lives and share in its joys with us.

Opportunity to train: Priscila with Rosy, who is learning to perform obstetrical ultrasounds. Through partnership with Hope for Our Sisters, free prenatal ultrasounds were extended to 31 ladies in an area over 120km from the nearest hospital with surgical services: Kalukembe hospital where we serve.

Somebody's crazy kids in dad's consultation room. Definitely rays of light. But don't tell them that--might get to their heads.

Namibe and other happenings

Since our last writing we've been reading about Dr. Helen Roseveare... and her being whittled to be used as an arrow in the Lord's quiver. She was an amazing woman living in 1960's war-ravaged Congo who, despite the violence of war, personal threats and attacks, she plodded along caring for patients, building hospitals, setting up nursing schools, and just serving. While in Angola the war ended with the 2002 cease-fire, in someways Caluquembe is a little like the Congo and things can get pretty ugly. The ugly, Helen said, is often our self-righteous blindness to the needs of others... often this ugliness creeps in and interferes with what ought to be a self-lessening work of caring for a patient... in my case this manifests as frustration with being interrupted enumerable times on rounds for questions ranging from when will students get electricity (not thought to be my realm of responsibility) to the urgent need of operating right at the end of the day (as in a ruptured ectopic pregnancy or cesarian delivery). The interruptions force me to pause my self-determined triaged clinical work to talk to someone seeing their own problems as most urgent. In fact, abdominal pain for 10 years is probably not most urgent, but i still struggle to hold back my first reaction of frustration rather than patience and willingness to listen, redirecting and counseling (and of course recommend seeing me during clinic hours). It's an unpleasant struggle that's working on my character, but the greater lesson is God is worth the struggle. As John the Baptist said as his disciples abandoned him for Jesus, "He must become greater. I must become less."

Since May:
Our organization's CEO, Greg Seager, visited us at Kalukembe; we've renewed Zeke's passport in Luanda and now await the renewal of our visas (submitted the beginning of June); we've shared theology of health and specific topics related to men's health in Namibe province in June; we've butchered a couple chickens; we've claimed a cat as a pet; we've collected firewood for the cold season; we've had many warm fires together in the evenings; we've planted seeds for herbs; we've shared in women's health talk at a local church; we've done a few fun science experiments with boats and rafts; the vice-ambassador for the US and colleagues visited Kalukembe in the beginning of the month; we've spent 5 days on a farm in the desert with other missionaries for spiritual refreshment; we've had a two-day nursing continuing education seminar with Priscila and Dr. Nicholas Comninellis speaking (more later).

Keep us in mind and prayer:
Our electrical project won't be able to have the presence of an experienced electrician this year or early next year. In the meantime, there are lots of lightbulbs and basic wiring that need to be replaced and we are using funds given by you and organizations for that. We anticipate having some solar power installed at the hospital to at least stabilize the telephones and perhaps even the blood bank refrigerators. Keep praying our electrical challenges would find sharp minds, able hands, and wise money to resolve.
Our patients: These past couple weeks have had a share of tears for young women and small children who have died from eclampsia, malaria, severe dental infections and burns, respectively.

Zeke and his "ferocious" kitten, Buster. 

Greg Seager at the wheel, driving by fields of Chituto in May. Even though there were some missed communications around his arrival, Greg proved resilient and encouraged us in his time here. Big thanks for your patience with us, Greg!

Daniel sharing why health matters with men from the Namibe area's evangelical churches

Labor of love. Naomi here with Beltazar, one of the hospital maintenance workers, putting cement on what will be refurbished rooms for fistula women to stay in while they receive care at Kalukembe. 

Our kids playing with our friends, the Hoyme children, at a beach in Namibe in June.  Beautiful ocean.

Naomi's roosters.

Naomi, (our carnivore who prefers fried goat giblets over chocolate cake) loves all animals. So we've been loving on these roosters for a while. We keep them on a leash, they sleep in our living room, and usually eat dinner WITH us.They are just annoying at 2am and 4am when the crowing in room begins. :) 

 

 

Sometimes we eat them for dinner. 

Extending care

One of our hopes in working in the Kalukembe area is that we would be able to help people who are helping people help people better! Visiting a couple clinics that the hospital oversees (the IESA denomination oversees around 25 clinics) monthly this year helps us help this way that much more. Hope this following small description helps give a picture (Have you ever noticed how much "help" shows up in our blog? i apologize; often, my self-editing skills fail).

Caconda is a town about 45km north of Kalukembe, has an established IESA clinic that has fallen on difficult times since the national financial crisis. In addition to fewer medicines in their pharmacy, the number of patients seen per day fell from 60-80 to 10-15. Our hope has been to see patients with them and help generate income to pay for more medicines and salaries. The needs from Caconda certainly never waned, as most of our cases at the hospital of uterine rupture come from the are from there, as well as liver failure by traditional medicines. Sitting and eating with staff after seeing patients together has brought great opportunities to learn about other workers' queries and knowledge levels. Augusto, the nurse clinician, has had a good list of questions each visit and a real heart to help the people of the area. Going into these visits i thought what the clinicians could learn would spread greater healthcare value than what i could do in seeing numbers of patients. But even in a place not too far from our hospital, there are people who cannot go farther to see a doctor, either financially or through other constrictions. So even if it was to diagnose terminal cancer and have heart-to-heart talks and prayers, I've been touched by the direct connections with patients there.

Chituto is another place with a new IESA clinic about 170km from Kalukembe to the southeast. This is the youngest clinic in the denomination, opened in 2016. The nearest government hospital has one nurse, barely any supplies and performs no procedures. Even though it qualifies to have doctors, none have ever been there. Most patients are among the poorest of the region and the nursing and lab staff rotate from Kalukembe hospital. Just getting there is exhausting enough, driving in rainy season through the lakes of mud; but fun to share time with the clinic's administrator who also is an outpatient nurse clinician at Kalukembe. In March, Dr. Steve Senichka accompanied us and made lighter work for ultrasound visits. About 80% of the ladies who've been seen for prenatal ultrasounds had no prior prenatal care until seeing me and over 90% were in their 3rd trimester. Though it's not what i usually do, i hope prenatal counseling even from this emergency medicine-trained doctor will translate into wiser decisions women and families will make about labor.

We hope we can continue to share positive developments through interactions with staff at these clinics and in the communities they serve. Concretely, several patients have been referred and operated on in our surgical weeks at the hospital. Likewise, several patients have been started on tuberculosis treatment; and chronic ailments probably continue to nag both patients and myself :) And we keep leaving advice for increased community outreach through the clinics. . . perhaps one day, there will be more public health offered through these places. But also relationally, we hope to share a growing bond with our staff who serve in limited and challenging circumstances--no easy online resources or CME conferences to attend. But they keep working with what they know and what they have. We're grateful to these hard-working servants.

Ok, time for a diary of pictures!

Patients lining up at Chituto clinic. Only 45 of the 110 registered were attended to that day. ...

"What? Another S3 heart sound?" Dr. Steve Senichka examining another patient with heart failure at Chituto clinic. It is common to see patients in advanced stages of heart failure. The most frequently seen causes of heart failure range from infections to pregnancy to untreated hypertension

With the team of lab technicians and clinicians at Caconda clinic. Augusto is at picture far  right

Zeke and his friend, Bruno, making charcoal to sell. It's a steep lesson in  supply-and-demand economics.  . .  Zeke's 400% mark-up price for a bag of charcoal hasn't captured many enthusiastic customers with so many other competitors underselling the same product. Keep at it, bud. You'll figure out a way to buy a bike some day.

The kids outside of our tent in the yard. For Zeke's 6th birthday, we had a boys-of-the-family sleepover in the tent. They outlasted me: i fell asleep reading Robin Hood in mid-sentence. 

And happy birthday to the most beautiful woman! i am so glad we can share life, work, and chickens together!

Spring 2017 Update

Fear. Friendships. Faith.

We have a group of half-dozen neighboorhood children who we love. The brothers Nuchu, Innho, Inginho live in an adobe house with their father who lost both his legs to a land mine. They are too poor to go to school and mostly gather branches to sell as fire wood to patients. Their smiles light up any room. There are the siblings Luis and Filomina, intelligent, articulate kids whose mother is an old fistula patient who has been abandoned by her family. She sells charcoal for 30 cents a pile to other patients to earn money for food. They've recently started to go to school! And then there is Bruno whose tiny body and funny shaped head is probably a consequence of neglect and abuse (which he casually mentions), but whose gentle heart has broken mine. 

They are all sweet, generous, trust-worthy and kind. They are the best gatherers of wild edible fruit - and our boys now often go hunting with them. They are fun playmates who join us on many walks. On our walks they also introduced us to the "River Kukala" - a small stream nearby where cattle come to drink (and poop), ladies wash clothes (and diapers), and snails with schistosomiasis live (we suspect - they certainly live is MANY places around the country). Schistosomiasis is an insidious, dangerous disease. The version we have can cause bladder cancer, chronic infections, infertility, etc. . . I'm afraid of it. Well, to be honest I'm afraid of lots of things (malaria, typhoid, earthquakes in large cement houses, rabid dogs, etc). . . but when I think of my sweet babies I worry even more. So what do I do when they want to join their friends swimming, running, playing, jumping, washing in the river? I  wring my hands. I say no. But then I often capitulate. We go down to the river. They have a great time. I don't know if this is the right answer. But I do know that this world our God created is so beautiful. Our friends and children are intensly enjoying, celebrating and glorifying Him in it. Should I stop this? I know that Jesus walked in dangerous paths, traveled in storms, and even took his disciples into these places. I'm not trying to say that going down to the river is the cross I've been asked to carry... but it causes me to pause and pray... then thank Him and (as my Nana Mary Spencer reminded me) to hold everything I dearly love in the palm of my hand... an open palm. 

PS. We will be occasionally, empirically taking praziquantel :)

Resuscitating Shinseiji (Neonates)

A hearty thanks to our friend and colleague from Huambo, Jordan Yarborough. She endured rough roads south to reach Kalukembe last week. And then put on a great course for nurses and students, our 3rd annual resuscitation of the newborn. Over 60 students participated, including nurses from the district's government health posts. It was especially sweet to have nurses from these government positions participate so that we might have opportunities for closer collegial relationships with them. With so much lack of cooperation in Angola's health care sector, it was a big bonus for me to hear that one of the government nurses came back another day to repeat the course because, as she said, she didn't remember all of it the first time.

In case you didn't know, Angola is ranked worst in the world for neonatal mortality and children under-5 mortality. A course like this that Jordan did is immensely helpful. i remember when we first arrived, the first thing nurses seemed to do when a baby came out limp from a c-section or vaginal delivery was to draw up (too much) epinephrine and stick it in the baby, flick the chest and watch. Now, there is an improved culture of drying and stimulating the baby, moving to positive pressure breaths and chest compressions before drawing up (still too much) epinephrine.

To give a picture of the challenges to better outcomes for women and babies, i'll lay out a typical story of a woman who might get transferred to our hospital. Most women might get one or no prenatal visits during pregnancy. And even if they go for prenatal visits, they often do not get good counsel about laboring at or near a health facility. So a woman might labor at home or go to a 'clinic' by a 'nurse' in the village who likely would not do any monitoring during labor and give several injections of oxytocin. If these measures did not produce, then the family might take the woman to another health post often by motorcycle; this post in turn might refer to a health center where the woman may or may not be checked for progress of her labor. If discovered that the woman has uterine rupture, she would be transferred to our site. But if not, she might have another step in the delay of care and sent to the government hospital across town (another motorcycle ride) where no materials are available for a cesarean delivery. Then, after further delay, a transfer would be arranged to our hospital. After perhaps 2-3 days of labor this way, it's no surprise then to see sad outcomes: neonatal death or sepsis; birth injury to the mother leading to vesicovaginal fistulae later on; uterine rupture; uterine necrosis; postpartum hemorrhage; you name it and it's probably happened.

Enter this course. It's one act of good beating back the forces of darkness! There's no question that one of the babies born to our hemotherapy survived during the course week because of direct application. One life saved for sure, and many more we hope will be impacted!

Naomi and her Angolan building blocks. Pretty sure this ranks well with developmental milestones

Eliel: our Lord-of-the-Flies boy. That's Mulberry juice, in case you wonder

Zeke in his superhero costume. Smashing!

Jordan and some of the nurses from the neonatal resuscitation course. Proud resuscitationists!

At the staff appreciation snack/closing ceremony. Great work, guys!