Loss

Chris McConnachie, the co-founder of African Medical Mission and an Episcopal missionary for nearly 20 years, died yesterday morning at home with his wife and children around him. I work closely with his wife, Jenny, but I had come to know Chris these last few months and admire the tremendous impact he had had on orthopedic medical care in this region. Not many people leave successful careers in the United States and move to one of the poorest parts of South Africa and then stay there for the rest of their lives. He set an amazing model for many people, including me.

The mood has been somber and dreary lately but Itipini remains open and we are still tending to patients, while we support Jenny and prepare for Chris’s funeral next week. Right now I am figuring out how to get the Itipini choir, which will sing at the funeral, and a dozen Itipini employees, who want to attend, to a funeral that is sure to be huge, all in my little VW.

True Acceptance

I went to find one of our TB/HIV patients the other day to take him to an appointment. I wasn’t quite aware of this but he and his wife run a store and a shebeen, with their bedrooms in the back. A shebeen is an unlicensed bar; in a shantytown they are purveyors of beer that comes in milk carton-like containers and homebrew.

The man I was looking for wasn’t ready when I arrived but a woman sitting in front told me to have a seat (on a milk crate) and wait. (I think that’s what she said – it was all in Xhosa but she certainly was making welcoming hand motions. Or maybe they were the hand motions of someone who is three sheets to the wind at 10:30 in the morning, I don’t know.) I noticed she had a tin can in her hand and she noticed I noticed it so she kindly offered me some of the quite revolting brown liquid inside. It was a bit of a dilemma as I didn’t want to be insulting anyone’s hospitality but I also wasn’t about to drink homebrew. I turned her down but in as gracious a way as possible, given the language barrier and her inebriation.

Acceptance is often indicated by small gestures and remarks. I think being offered homebrew is one of them.

To Stand With and Advocate

Last Friday, some men rushed into the clinic and – in a rapid stream of Xhosa – told us Fumanekile, an HIV/TB patient who has been rapidly deteriorating lately, was very sick. When we went to check on him – in his tiny, cramped, run-down, but clean and well-maintained, shack – he was unconscious, with depressed vital signs and shallow, irregular respirations. We loaded him on to our stretcher and put him in the back of our truck, where I climbed in the back, ready for another Mthatha ambulance run.

There wasn’t much I could do on the ride to the hospital. We don’t have any portable oxygen canisters in the clinic; the ride is so bumpy and stop-n-go I can barely take a pulse; and I couldn’t keep up an encouraging conversation as he was unconscious. About all I could do was hold his head to ensure it didn’t hit the seats in the back of the truck.

The hospital was what you might conjure up if asked to describe a stereotypical African hospital scene – patients on beds in hallways, patients in wheelchairs outside, loads of patients waiting on benches, nurses everywhere but no one apparently in charge. It was chaotic and it was distressing. I asked Fumanekile’s sister, who had come with us, to find an empty bed (fortunately her English is not bad) while I went and made sure we parked the truck as close to the door as possible.

But when I returned, his sister had not found a bed – when there’s no one clearly in charge, it’s hard to know whom to ask. I had long since decided the best response to the chaos was to act confident, in control, and knowledgeable (though I felt none of the three) so I barged into the actual ward where they were seeing patients (as opposed to letting them languish in the hallways). As I was barging in, I saw two somber-looking men wheeling a coffin out. I thought first, “Will that be Fumanekile in a couple hours?” Then I thought, “There must be a free bed here somewhere!” There was but I had to wrangle the nurse for it, explaining Fumanekile’s condition – basically making up vital signs and using the words I remembered from my ambulance department days that sounded most sophisticated and indicative of the worst possible condition.

In any event, we got him on to a bed and into the ward – jumping two other people who were waiting on beds outside the door to get in – where the nurses began to examine him. I had to hold back, because from my Nome ambulance department days I was used to seeing patients get oxygen, have blood drawn, and so on and so forth. One nurse took a blood pressure (surprisingly high, given the circumstances) and then another began to take an oral history from his sister.

His sister is a very capable and competent woman whom I respect a great deal. But I figured this wasn’t an easy situation for her and she might have to be in the hospital for a while so I figured she deserved a chair. The only one I could find, though, was behind an official-looking desk, scattered with official-looking papers. But since there were no official-looking people there, I thought the chair could be put to better use and carried it over to his sister, pantomiming the secrecy of the operation. We both laughed.

And that was about all I could do. I gave his sister my phone number (on the package of an alcohol wipe), not expecting her to use it – her English is alright but I doubt we could communicate very well on the phone because there would be hand motions – and some money, to get back to Itipini if need be and to call her family.

During mission training in June, one of our presenters asked us to introduce ourselves by picking a verb that would describe the work we were hoping to do abroad. I picked something basic like to “serve and learn” but two of my colleagues were a bit more creative and their verbs have stayed with me. Harry, who is in Jerusalem, said he was going to “stand with” and Kate, who is in the Dominican Republic, said she was going to “advocate.”

It occurred to me as we were driving away that I had been standing with Fumanekile during the trip. It wasn’t much but it was something. And when we got to the hospital, I became his advocate and ensured he was seen immediately. (I don’t even want to think about the racial implications of my advocacy. Did the nurses see him first because he was the most acute patient or because there was a tall white guy insisting they do so? Why could I find a bed so easily when his sister could not? Why should I be his advocate and not everyone else’s?) I like how expanding my vocabulary makes me think I’ve actually done something useful.

I learned on Monday Fumanekile is still alive; he can’t speak but has regained consciousness. His mother came to town from a village and his siblings have been to visit him.

Also on Monday, I visited a patient in his shack. He cannot walk, is distressingly thin and emaciated, and has a worryingly low CD4 count. It never ends.

An obvious lesson on culture that still takes 900+ words to explain

Sometimes I like to pause for a moment and try to remember what I was like before a certain experience. For instance, when I graduated from university, I tried to remember the Jesse Zink of four years earlier to see how much university had changed me. I’ve engaged in similar exercises with graduate school and my time in Nome and various other experiences and it is fascinating how much I can learn from a brief period of reflection.

I’ve started to think about how much I identify with the Jesse Zink of just three months ago who set out to South Africa not knowing what to expect, with only a vague idea of what he would be doing, but full of conviction that he would be doing something good. The answer is, not very much.

It truly is remarkable how much my ideas on development, mission, cross-cultural communication, and so forth can change (some would say mature) in just a few short months. For one thing, I quickly realized that what I am doing is less important than who I am. I also awakened to the centrality and fundamental shaping power of the cultural barriers that are inherent in this sort of work, which I had tended to minimize and/or believe I would be able to overcome fairly easily. And even though I came here with the belief that I would learn more than I would give, actually putting that into practice can be harder than saying it.

When it comes to cultural differences, I think my initial inclination was to take a laissez-faire approach to the issue, i.e. let’s all just practice our cultures together; I won’t judge yours if you don’t judge mine. This belief was no doubt shaped by the idea that culture mainly consists of a group’s songs, clothing, dances, worship habits and so on and so forth. That might be a starting point but it’s not sufficient for any substantial work. In order for me to truly be able to help people in Itipini, I have to get to know and understand how and why people act the way they do. This is particularly important on cultural issues like attitudes towards women or beliefs about the length of the work day, to name just two of the truly important factors that make a people a people. It is hard to put all this in words but life in Mthatha is so different to the Protestant-work-ethic-driven, efficiency-prizing, results-maximizing culture I am familiar with in North America that I can’t just let this culture carry on past me; I need to struggle with it and learn about it and understand it to be even moderately effective. You can’t just transplant someone from one culture and expect him or her to be immediately effective in another, which sounds obvious to me now but is not perhaps something I understood three months ago as clearly as I do now.

On many issues, I am happy to learn what the people of Itipini have to teach me, particularly when it comes to music and food, again the surface issues of a culture. But when it comes to topics I think I already know something about, like medical care or education, I think, “Well, I know how to do this – here’s what we’ll do.” Sometimes, the obtuseness of the new way of doing something seems so flagrant I want to scream and shout and grab somebody by the neck and shake them before I realize this is perhaps not the best way of realizing God’s reconciling mission. This might be more the result of a personality trait than anything else but it is hard in these situations to truly put into practice the idea that I can learn more than I give. At the very least, it is not my first reaction.

Many American doctors come to Bedford Hospital, where I live, to volunteer for a month. They are universally lovely people and I have felt privileged to know them… and watch them struggle with this exact issue. They show up, thinking they know a thing or two about orthopedic surgery (which they do) and want to operate as they do back home. But then they get stymied by long lunch breaks, anesthesiologists who show up late, different attitudes about health care, and a whole host of other issues. In my own way, I have the same struggles at Itipini, which I’m not always aware of as such but as I think of them more I’ll try to share those specific stories.

All of this has implications for my thoughts on how best we can help the developing world. But none of those thoughts are fully-formed (or even partly-formed) as yet so I’ll hold off on them here.

I once saw a representation of culture as an iceberg, with the parts we can easily observe (music, clothing, etc.) as the 10-percent above water. Of course, there’s the other 90-percent of the iceberg/culture we can’t see but that still affects what we do. In fact, I’m becoming convinced we can never truly surmount cultural barriers. What we can do, however, is attempt to surmount them and break down bits and pieces of them in ways that show forth our best, faith-based qualities.

So the moral of the story is cultural differences matter and I’m learning that and changing as a person as a result. Sometimes it helps to re-learn the obvious.

Thousands of Words

Transkei Traffic Lights

Here’s what I saw out my window the other day, at one point not three or four feet from my front door.

Now, before you say, “How nice, Jesse has cows in his front yard,” consider the side effects.
(Yes, that is a picture of cow poop on my blog.)

In general, cows, goats, sheep, roosters, dogs, and who knows what else freely wander around Mthatha. As they are often found in the middle of streets, some people refer to them as “Transkei traffic lights.” Between the animals and the horrible pot-holes in the roads, the joke is that only in the Transkei do the drunk drivers drive straight and the sober drivers swerve to avoid all the obstacles.

All in a day’s work

An occupational hazard of working in a dump, I learned the other day, is occasional flat tires on your car. I surprised everyone, including myself, by successfully changing it all on my own.

Actually, I had help.

“Our Father, We Art in Heaven…”

Every morning, before the clinic opens and pre-school begins, we have a short morning prayer service. I don’t understand many of the prayers but I really enjoy listening to the singing.

The pre-school teachers use the prayers as an opportunity to teach the children a bit of English. Before the prayer, the children are told, “Fold your arms” and they reply, “I am folding my arms.” Then they are told, “Close your eyes” and they reply, “I am closing my eyes.” Some seem to get the message but not all of them.
The children also know a few prayers in English. One pre-school teacher always has them repeat this prayer after her: “Dear Lord, for these three things I pray: to love thee more dearly and follow thee more nearly, day by day, Amen.” They always forget the third part of the prayer – know thee more clearly! I am figuring out how best to delicately inform the teachers of the whole prayer.

My favourite English prayer, though, is the Lord’s prayer, which the children have evidently learned only phonetically as it always begins, “Our Father, we art in heaven…,” which strikes me as a theological alteration to the poem that is not quite called for. In any event, the prayer is too long for them to remember all at once so when they sing it, by the middle of the prayer it has descended into an anarchic cacophony of various bits and pieces that concludes with, “forever and ever, Amen!” always said with great gusto.

10 or 18 per cent?

A big part of what we provide in the clinic is over-the-counter drugs that the people of Itipini can’t afford on their own. Many people have pretty straightforward complaints – cough, fever, stomachache, diarrhea, etc. – that can be treated fairly easily. So we give them some painkillers or cough syrups or whatever and send them on their way.

There’s one catch, though. If you get prescribed a liquid drug, like cough medicine, you need to provide your own container to take it home in. The vast majority of people bring an old gin bottle, like the one in this picture. When I first arrived, I was convinced all our patients were heavy drinkers.What makes the situation even odder is that one of our cough medicines is 10 per cent alcohol and the other is 18 per cent. Some patients, I am convinced, know exactly what symptoms they need to complain of to get the 18 per cent syrup. Since we don’t formally measure any of our syrups – we just sort of fill up the bottle until it looks about right – patients will sometimes glare at you when you hand them their bottle back and say, “Kancinci!” (“It’s too little!”) It’s amazing the amount of colds people seem to complain of on Friday afternoons!

Wanna Help?

Since so many of you have asked how you can help people in Itipini, here’s a list of things we can always use more of. If you send them to me (address in right-hand column), I’ll make sure they get put to good use and send you pictures of them in grateful hands.

Blankets – It gets cold at night in Mthatha and when you live in a shack that doesn’t keep the rain out, it can get quite cold.

Clothes – For many of the pre-school children, I know all the clothes they have because in a span of two or three days they’ve exhausted their wardrobe. It’s the same for everyone in Itipini so donations of clothing for all ages, from infant to elderly, are always welcome.

Books – I’ve begun a library for the children in Itipini and am always looking for more books. As the children don’t read English, books with good pictures are great. Books, though, are very heavy to mail so I understand if you can’t donate these.

Life-Enriching Items – The children in Itipini don’t have a lot to do for most of the day. They run around, play jacks with stones, scrawl hopscotch lines in the dirt, and get in fights. So games and toys you enjoyed playing with as children – coloring books, crayons, hula hoops, balls, bubbles, yo-yos, etc., etc., etc. – are more than welcome.

For all these items, please only send new or gently-used material. The people of Itipini may live in a dump but they take very good care of what they have and make it last a very long time.

If you don’t want to send items but still want to support the work in Itipini, check out the web site of the African Medical Mission, the organization started by Episcopal Church missionaries Chris and Jenny McConnachie that funds the Itipini Communtiy Project, for ways to contribute financially.

And if you can’t contribute anything at all and just want to read the blog, that’s great too!

The Obvious Reality

I realize that I have not written much about HIV/AIDS yet. The virus is a/the fundamental force shaping life in many contemporary sub-Saharan countries, including South Africa, and I imagine it is the first thing many people think about when they hear the word “Africa.” Perhaps because it is so central to my work, it has been hard to tell any individual stories so here are some loosely-related thoughts on the issue.

People with HIV are certainly a part of my daily routine. There are many people in Itipini with the virus and their medical records are marked in such a way that it is obvious to me as soon as I look at the record that they are “positive,” as the preferred nomenclature has it. (A common question is, “What’s her status?” and regardless of the context people seem to know that the question refers to HIV.) What was initially notable for me was that many of the people whose records said they had HIV looked perfectly healthy to me and nothing at all like the pictures of emaciated and dying mothers and children you occasionally see when the western media does a feature on Africa. I am now in the habit of checking to see when a patient was first diagnosed and many have been living with HIV for four or five years or longer and still look quite vibrant to me. In medical terms, they are non-symptomatic and they aren’t even taking anti-retroviral (ARV) drugs like many non-symptomatic patients in the western world are. So for my first few weeks in Itipini, I started cultivating the foolish notion that this whole HIV thing was overblown.

My eyes are opening a bit wider each day, though, as we have been having a bad run of HIV-related illnesses lately. Patients are helped in by friends, carried in on stretchers, and in one case brought in by wheelbarrow, because they are so weak they can barely move. Some of these are the same people who I had initially thought were quite healthy-looking. It is stunning how fast one’s health can change. Sometimes I take these people to the hospital and it can be a bit unsettling to drive with a passenger who is so obviously suffering and to be able to do so little.

In South Africa, if you can’t afford ARVs the government will pay for them when your CD4 count (a measure of your white blood cells, I think) goes below 200, which is clinical AIDS. (A healthy person’s CD4 count is between 1000 and 2000, I think.) But there are a lot of obstacles to getting on ARVs, not all of which I pretend to understand. We can’t distribute ARVs at our clinic so they have to go to another government clinic that is about 20 minute walk away, a tough slog for someone whose CD4 count is below 200. The clinic keeps close count of your pills to make sure you are taking them all; if you lose a couple, you can be taken off ARVs. One of our patients had a CD4 count in the 160s in March. He tried to get on ARVs then but for one reason or another has not yet. He returned a CD4 count of 17 the other day, which is in the I-can’t-believe-you’re-still-alive territory. When he went to the clinic to see about getting on ARVs, they told him to come back next week. I hope he’s still alive then.

(To answer a common question, I don’t know what the ARV cocktail in use here is. I know it’s not the most up-to-date one in use in the U.S. but it’s also not AZT.)

When I was in Cape Town the other weekend, I happened to see an excellent production of the musical “Rent.” When I first saw the movie version a few years ago, my favourite song was the one sung by the members of an HIV support group, “Will I?” The lyrics are simple, “Will I lose my dignity? Will someone care? Will I wake tomorrow from this nightmare?” When I saw the show this time, I was overwhelmed by how the song spoke to my current work. I might not be able to snap my fingers and make these people better but I can do my part to ensure someone does care about how they are doing and that they will suffer with as much dignity as possible. How do you have dignity when you are reduced to being transported in a wheelbarrow?

In which I reveal myself to be a cold, heartless missionary

This is a picture of Petros, a 22-year old unemployed resident of Itipini who helps us out around the clinic on most days. Petros can be invaluable to have around – he is fluently bilingual, knows how our record-keeping system works, and can dispense TB drugs and cough syrups with ease. When I am stumped trying to find someone’s medical records, I ask for his help. When we are overwhelmed by patients, he capably deals with the minor concerns and recognizes bigger issues for what they are. When I am trying to communicate with a patient and can’t, Petros interprets. Here’s a guy who hasn’t had much of a chance for anything in his life, freely and voluntarily offering his time to help out his community.

Despite this, and I’ll look uncharitable saying this, I have to admit I don’t care for him all that much. And I can’t really put my finger on the reasons for my dislike. I have trouble making small talk with him (and that’s saying something for me – I can almost make small talk in Xhosa now). Whenever we drive anywhere together, he always wants to listen to the South African hip-hop station at full volume, which I can only tolerate for so long. He sometimes asks me for money and I don’t know how to respond. He’s kind of sullen and detached at times. He hasn’t been able to find a job in the time I’ve been here, nor, does it seem to me, is he looking very hard. Basically, I’d like Petros a lot more if he were a lot more like-able. (Thank you, Mr. Obvious-Man.)

Sometimes I think it would be a lot easier if Petros just didn’t show up. I delude myself into thinking I can do anything he can do (definitively not true) and I can do it better (also not true). If he didn’t come to work, we wouldn’t have this awkward situation of the two of us sitting side-by-side with nothing to say to each other. So – and I hate to admit this – I have even on some days given him the cold shoulder and tried to show him that I’d prefer he not show up. And, occasionally, it works.

There’s at least two lessons here. My workplace in Itipini, even though it is in a shantytown in South Africa, is not all that different from workplaces anywhere else. People are people and sometimes you like people and sometimes you don’t like them. And that’s true regardless of whether it is mission work in a clinic in South Africa or any other kind of work. Learning to get along with your co-workers is a challenge that does not go away.

The second lies in Petros’ name. It is a constant and inescapable reminder of a favourite Bible verse of mine, Matthew 16:13-20 in which the Apostle Peter says Jesus is the Messiah. Jesus replies, “And I tell you, you are Peter, and on this rock I will build my church.” Jesus is making a bit of a pun as Peter’s Greek name is Petros, which is the Greek word for rock. I’ve always interpreted this passage as indicating Jesus’ preference for the outcast and lowly of society, like the fishermen and tax collectors that Peter and his fellow Apostles were. And if Jesus had a preference for those kind of people surely I should as well, right?

Every time I want to give Petros the cold shoulder, I have to think of his name and when I do I think of how he is a rock and perhaps exactly the kind of rock Jesus prefers. That sort of stops me in my tracks.