A Great Rift:

Reflections from a Kenyan Mission Hospital

At Kijabe you may hear a cool wind in the early morning. The canopy is interrupted where the other missionary physicians live, Dr. Albright’s side of the hospital. And so there are fewer monkeys overhead, but at least as many selfrighteous roosters and overexcited dogs.

At 6:15, it is still dark in this part of Kenya when walking past a purple hibiscus down the dirt track to the main gate. A few patients are arriving early to queue, and the night guards are still perky enough to be joking with one another. Above their guardhouse, a colony of weaverbirds chatter from their upside-down nests. I did my best to relay these sights and sounds to my fiancée during our early morning devotional reading. Wistfully, she must remain in Virginia while I am spending a fortnight in Kenya — magical Kenya — without her. It is the country that captured her heart on the first college trip and in the book Out of Africa, and the place where she returned to live for a year with a Kenyan host family.

Ten minutes before 6:30, I update and print a homemade pediatric neurosurgery inpatient list using excel. Nursing mothers and their babies, about thirty sets of them on the neurosurgery service, are starting to stir, especially those bedded in the corridor. If the nurses have interpreted the previous night’s orders correctly, the day’s cases will now be nil per os and have intravenous fluids running.

A nurse sitting beside me looks up from her bible to say, “Good morning Doctor!” and I feel a surge of self-importance. I am here as a medical student, and I am not perturbed in the slightest when people mistake me for a licensed M.D., which I will be in a couple of months. I too am a Christian, keen to lend my talents to a well-deserving and faithful audience.

Soon thereafter the team assembles in the hallway — Dr. Albright, Taylor, Barnabas, Veronicah, and myself. These are good people from whom I can learn — a senior American neurosurgeon (who had written the textbook), a visiting American resident, a Nairobi resident, and a Kenyan mid-level. If all goes according to plan, I too will be a neurosurgery resident by the beginning of the summer.

Kijabe Hospital by night. Photo courtesy of T. Abel

The day before I left Kijabe my local cellphone rang. A man introduced himself as the Headmaster of Kijabe Boy’s School. A girl from his home village had agreed to marry me, he had heard, and the village’s matron had requested, by phone, that he meet me in person. The next day we met ceremonially in the cantina over Chai tea. He had come, he began, to discuss the bride-price of twenty head of cattle.

Staring at the straight face of this older but formidable Kenyan educator, I suddenly realized how my friends feel when trying to discern if I am being deadly serious or making a dry joke; I thought of Betsy, a spunky Delilah, energetically telling people “look at his eyes! You can see that he’s joking by the eyes!” when I try to be clever with a new acquaintance. The headmaster’s eyes blinked, and I sighed in relief that he was only kidding. I pretended to bargain, taking the line that her shorter height entitled me to a discount; but he insightfully retorted “the smaller ones have more energy so they are more expensive!” My fiancée was moved that her Kenyan host family remembered her as one of them. These were moments where I could not help but agree with the Albrights’ blog reflections: “We continue to be awed by the beauty of the sky and the valley seen every day from our living room window—and also by the beauty of the Kenyan people.”

During rounds we see work from the previous day: the lumbar incision from a myelomeningocele repair and the scalp wound from a ventriculoperitoneal shunt. We measure head circumferences and palpate between skull bones. Gains or losses in head size are the immediate feedback for our surgical efforts. Wounds are re-dressed and brief progress notes jotted in the paper charts. Five or six cases a day is a heavy, but typical, load for Dr. Albright.

One side of the pediatric neurosurgery ward.

We also see patients scheduled for the coming day — a thalamic brain tumor, a rhizotomy, a kyphectomy. This is unadulterated medicine without the hassle of insurance pre-authorizations or tort lawyers or fat-skimming administrators, and it is exciting to me. Taylor confirms that consent forms have been signed by the mothers, or, when the mother is illiterate, stamped with an inky thumb. They seemed always to smile or laugh when signing consent forms — as if it were ludicrous that we would invoke their medical opinion. And of course we round on a number of patients with complications: infection; wound dehiscence; shunt malfunction. These are sick patients — there is nothing dubious about the severity of these conditions and it is a refreshing departure from some clinics in the US.

As the morning draws on, increasingly hungry babies cry louder. By the time we reach the final patients, Taylor breaks off to prep the first case. Looking around, it is a room full of hospital cots, above which biblical murals overlook the sitting mothers and their lumps of baby-stuffed blankets. The protagonists have different complexions than those in stained glass at my home church in Virginia; I pause to consider whether Moses was more likely to be white or black or neither, and realize that I cannot say. To me these children blend into a confusing list of biblical names. To Dr. A they are more: for example, the shy young girl sitting on the cot had received chest compressions for 29 minutes and 30 seconds after she arrested intra-operatively. While offering prayers, Dr. A had determined to persist for half an hour before surrendering her death.

Opening the brain to remove a tumor.

Usually the operating theater is a refuge from the chaotic wards; there is relative order there. It is quiet enough to hear Dr. A’s prayer before each surgery and his precise instructions to the Kenyan scrub nurse Zipporah as she passes him the donated instruments. When the background lights flicker off a generator starts. Some sounds like the buzz of the electric scalpel are familiar while other OR sounds are anachronistic like the patter of rain on the tin roof.

“Do we have fun living here? Heck no” the professor reiterates, “but there is a complete sense of purpose, and we would not be anywhere else.” This is the fourth year for Dr. A and his nurse wife, Susan, as fulltime practitioners in this vintage African Inland Church hospital. On one level, they are establishing the first African pediatric neurosurgery fellowship; on another level — the level that keeps them separated from a well-funded retirement in the US — they are following God’s call to Kijabe.

Disease and medicine cross most barriers. They bring a Somalian woman who cannot speak Swahili or English with her baby to the same hospital as a Nigerian couple with their child, and all have come to Kijabe for its rarity of having pediatric neurosurgery. A visual survey of our census would reveal, in more cases than not, disproportionately large heads supported weakly by smaller bodies. Many of the patients have some form and degree of hydrocephalus. For some this resulted from meningitis that compromised the part of the brain that reabsorbs fluid, and the impressionable skull gradually expanded. It must be reassuring for these mothers to find their children are not “one-of-a-kind” freaks.

Thumbprinted consent and British dating system.

Others’ mothers lacked folic acid; these were born with neural tube defects. Not only can the spinal cord pouch out from from an unsealed spine, but hydrocephalus often rears its head later in life. A lack of leafy vegetables (sources of folate) or the pernicious effects of “fumonism” from moldy corn may explain the increased prevalence of the deformity in East Africa. Having performed 249 myelomeningocele repairs last year alone, Dr. A likely runs the largest operative center in Africa, and possibly the world, for these debilitating congenital defects. As he systematically rounds on each mother-child each morning, his poker face hardly betrays the shock or sadness he may internally harbor. I mused internally, “how would Betsy handle giving birth to a deformed child?” and as quickly concluded she would love it as unconditionally as she does everyone else.

Baby with encephalocele before surgery. Photo courtesy of T. Abel

As obstetric, plastic, general, pediatric and orthopedic cases crank up in Kijabe’s eight operating theaters, the neuro team distributes its work within the team. Veronicah takes charge of managing the “floor” patients in Susan’s absence, completing the tasks assigned during rounds while also examining walk-in patients who overfill waiting rooms. Taylor and Barnabas arrange to share the role of first-assist for Dr. A’s cases, while I try to be helpful or at least stay out of the way.

Consults often arise in the middle of cases, usually in the form of a desk clerk who comes into the OR saying, “Someone is looking for neuro team.” One such of these consults led me to have to single-handedly deliver my first “bad news” to a patient. I had examined her in a consult room, received the MRI scans from her husband, and presented the situation to the surgeons. “Looks bad, probably a GBM”, they had said of the massive and advanced infiltrating brain tumor. “There is not any way to fit her into the schedule until April, and that may well be too late for her. She needs a biopsy, preferably somewhere with radiation.” I broke Kenyan protocol by being direct with bad news, but that seemed like the right thing to do.

One of the entrances to Kijabe Hospital.

Several days earlier an emergency add-on interrupted the flow of pre-planned pediatric surgeries. The case was an exploratory craniotomy on a Masaii criminal investigator whose skull had met the wrong end of a machete. Sewed closed two days prior by a well-intentioned surgeon, he was now febrile with an indicting CT scan. Purulence poured out when Taylor snipped the superficial sutures, and at that moment, Dr. A walked in with Dr. Couture, a visiting professor of pediatric neurosurgery who had just arrived with his family. Perhaps as a test, Dr. A asked him to scrub right in and help Taylor perform the case. Later, when the surgery was finished and the older man was still febrile in the ICU, we would have to weigh the benefits of ordering powerful antibiotics against his family’s ability to sell cows to pay the pharmacist. Other costs included his bumpy ambulance rides to Nairobi for imaging: CT scans that cost $65 or MRI scans that were $190. We would look at these in the lightboxes near his ICU bed while hearing chatter from swallows nested in the window eaves.

Radiographs in the operating theatre.

One evening I wandered into the ICU as he was being re-intubated by my roommate, a Texan internist, for increased work-of-breathing. The Texan, William, and I had bonded as housemates and also as like-minded types who learned about medicine through our dads. While I had grown up on a farm in Maryland, he had learned to shoot and ride on a Texas ranch. We dusted off the extra ventilator, plugged it in, calibrated the settings, and yet could not seem to get the oxygen levels to rise properly. Naturally, we wandered to the other side of the ICU to borrow a different one, and in doing so noticed that the saturations of every ventilated patient had started to drop — we ran from bed to bed, leaving someone at each site manually “bagging” the sedated patients. We dispatched someone to call the engineering office but no one was there. This would not — and could not — happen in the US. A high-acuity ICU and the “Africa time” mentality seemed as oil-and-waterish as a white Anglo-Saxon Protestant like me and his first encounter with a Kenyan handshake.

Like Karen Blixen, who had taken it all as Romantic adventure until realizing that her cheating husband had passed her syphilis, I began to wonder if doing neurosurgery in Kenya was the right thing. The luster was fading. Things that I had ignored at first began to add up in a different light. For example, in Kenya it is important to greet one another before conducting business. And Kenyans are eminently interruptible, even when they are in the middle of a task. This is quaint until you realize that someone has stopped to talk to you on their way to draw emergency medicine for a seizing child. Or until a nurse stops for tea while delivering a “stat” electrolyte blood assay. It is one thing for missionaries to vaccinate against polio; it is an entirely different undertaking to open a child’s brain for a deep tumor and subject them to weeks of challenging rehabilitation.

I thought of the emergency room scene several nights before. Sheepishly, a nurse had approached Taylor as we were leaving for the night from several consults from Mombasa. Would he mind helping with a patient who had stopped breathing? In slow motion, we went from joking about a long day to standing front and center around an arrested teenage girl. As Taylor and I took turns compressing the chest at our best guess of 100 beats per second, I suppressed my desire to run away and have no part of the ineptitude. No one knew her medical history, no one knew where the epinephrine was, there was no defibrillator, and her single IV line slipped out as someone tried to cut off her dress with a scalpel blade, as there was not even a pair of scissors in the entire emergency department. The only reward for our efforts was a profuse vomiting reflex. After the chaplain was called, Taylor and I had not lingered to hear the pediatrician break the news to her unsuspecting mother.

How had my fiancée handled this dissonance? Was she somehow immune to the disappointments? Perhaps that was the illusive answer as to why she was attracted to me — she was naïve about reality. A twinge of insecurity crept over me; was I just like the new Kenyan constitution’s provisions for women’s civic rights that she had helped promote — that is, something that was a lovely idea but quickly marginalized and perhaps, in the first place, a bridge too far?

I thought about nurses’ bewildered laughter during the handful of emergencies I witnessed, of the stealing that happens peripherally, of the child’s body that was kept as ransom until his hospital bill was paid (Dr. Albright discovered this after noticing the father lurking around the hospital days after the child’s death). I wondered, in a country with large needs in areas far more mundane than neurosurgery, whether to label our efforts rational or vain. I flirted with trusting a recent magazine article on why privileged white people should just send money and not actually disrupt other cultures with their physical presence. Is it conceivable that someone as brilliant as Dr. Albright could have made such a huge mistake? Being the son of a neurosurgeon, I knew the Achilles heel even before Dr. Albright shared the old joke during a case: “What’s the difference between God and neurosurgeons? God knows he’s not a neurosurgeon!”

Taylor and Dr. Albright under the microscope.

As morning’s cases progress in the theater, Veronicah screens the waiting room for surgical candidates. Admissions bring names like Moses, Immanuel, and Meshack — but there are other memorable ones like Brad Pit and Ric Waren. Poor Brad had the smallest head I have seen in a baby, a heart defect, and a missing thumb.

An hour after noon the Kenyan theater staff circulate out to take lunch in the upstairs mess hall. Kitchen ladies dish out beans, cabbage and potatoes in ample portions. Milky chai is self-serve. Operating theaters are prepped quickly for the next cases and some days it is possible to clip along at paces surpassing those of most academic hospitals in the US. There are also times, though, where the anesthesia nurses are distracted playing cellphone games while the patient’s cardiovascular status is quietly turning south.

By late afternoon it is sometimes necessary to cancel the last case though, particularly if there has been an unexpected holdup, like the malfunction of a drill or the scarcity of an anesthesiologist. Short of an emergency, the final case is being closed around 5:30. As Dr. A retreats to work on administrative tasks or carry forward his research, the rest of us circle back to see where Veronicah needs help. One evening alone we admitted eleven new babies to our service. Because my name had been on the admission orders, I was awakened by the nightshift nurse: “Dr. Henderson? We have a question about the sodium in one of your patients.” It is the kind of call a resident receives every five minutes, and indeed I redirected the call to the covering resident, but it was an early taste of the weight of medical responsibility.

My two weeks’ time was enough to hear several recitations of Dr. A’s survival pearls: “establish low expectations; be flexible; maintain a sense of humor; be patient.” Even still, I demanded of a particularly optimistic mid-level one day “With so many patients here at Kijabe — how do you do it?” In the same heartbeat she looked up from the patient chart to state the obvious: “By God’s grace.”

In quiet tones different Westerners at different times confided to me, “Christianity here is a centimeter deep and a mile wide.” A century ago Kijabe became one center of a non-denominational Pennsylvania-born organization with a vision for “Christ-centered churches established among all African peoples”. African Inland Mission broke apart into daughter institutions near the time of African independence movements, and the Africa Inland Church of Kenya now reigns over the semi-autonomous, and alcohol-free, hamlet. And for that reason, patients flock to Kijabe because they feel the incentives are more aligned with their own best interest, as the lead physicians are Western-trained missionary doctors.

A week after returning home I sat in my Charlottesville church. The sermon began with a Sochi Olympics tie-in to the gospel’s call to “be perfect as your heavenly father is perfect”. Her message, at least the part that I remember, was a rhetorical demand: “We long for face-to-face engagement, not performance-based evaluation…Can we stop basing our worth on our work? That’s what God wants for us…to lay down our desire for the gold medal.” It seemed that she was advocating for a more Kenya-like society. Internally I mused whether she would want her brain-doctor to have the same “results are not critical” attitude.

Sometimes my friends and I ask: “What does the Kingdom of Heaven look like?” and “How do Kingdom subjects live?”, questions presumably invoked by Kijabe’s founders who chose the motto Healthcare to God’s Glory. Is it more Kenya-like, or is it individually results-based? Do healthcare workers rush around performing urgent tasks or do they pause to engage one another? How do we guarantee good results when “love does not keep score”?

If God opens doors for me into a neurosurgery residency on March 21, I will soon don the apparel of an altar boy in the high Church of Western medical efficiency — I will hurry and ruthlessly accomplish my task lists. I will refer patients for state-of-the-art radiation and meet best-practice guideline requirements.

But is this sufficient for delivering healthcare to God’s glory? If the sermonist is right, I will need a component of Kenya — a reminder to stop and greet, to laugh and joke, to invoke God and see his hand — a reminder to dwell in community with those around me — just maybe not always during an emergency. Clearly the Kingdom needs neurosurgery; particularly pediatric neurosurgery. God must hurt when a young child suffers from a treatable condition. I also expect that God calls the Kenyan ICU nurses to be more vigilant, and for the emergency physicians to exercise excellence in their preparation for cardiac arrests. And of we Western-trained physicians, I suspect we are called to better remember our reasons for hurrying: to preserve the relationships, and not the accomplishments, that define us.

Betsy and I are different, some days as different as Grace and Law with a great rift between. She can be naïve and I can be cynical. And how boring the world would be if we did not have one another.

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