Friends of Kijabe

Conversation with Kijabe Oncologist Sarah Muma about her personal experience and the future of cancer care in Kijabe and the country.

Conversation with Dr. Stephen Dyar about building a Comprehensive Cancer Center in Greenville and the building blocks necessary to do the same in the Kijabe context.

Conversation with PAACS Anesthesiology Resident about medicine, systems, compassion, faith and building for the future.

David: I want to talk a little bit about the hospital, but I'm also curious about your life. So first, just tell me your name and what you do at Kijabe Hospital. Linette: My name is Linette. I'm a medical officer, general doctor at Kijabe. I work in the Internal Medicine department in general wards.  When COVID was here in COVID ward – now it's respiratory center, and in ICU/HDU [Intensive Care Unit/High Dependency Unit] Unit. David: Why did you end up with adults? Linette: [Laughter]Well, I love internal medicine. Anything to do with Internal Medicine, I love it. Whether it's an adult or a baby. I just love it. I feel like it's easier and maybe it's easier because of where I went to school. . . Where I went to school there's a lot of lifestyle diseases, less infectious diseases.  David: When you say lifestyle, what do you mean? Linette: Like hypertension, diabetes, things like that, which is most of internal medicine. And so, it was not like Kenya where you have infectious disease to think about. I feel like that was my foundation when I came for internship, I found this safe place, this comfortable place in internal medicine.  So, it's like, oh, I know that. It's not new to me because I've seen it, and that just made me love it more and more because I felt like I know that and now I can build on that.  I mean, it turns out you don't know anything.  You don't know what you don't know! But it's fun to build on that one. Yeah. So [Internal Medicine] is my favorite one. And why adults? I'm very emotional when it comes to kids, and my pediatric rotation was full of a lot of tears. So, I was like, “No, I need to like, get myself together and be a doctor and look like a human. . .what?  Hard-board or something. . .like nothing is touching me, I'm just okay.” But inside I'm all mushy. So, I feel like kids really remove that from me. And then adults are like, “okay, I can cry about this later, let's deal with it now.” But then kids, cry now!  [Laughter] David: That's great.  You did your you did your internship at Kijabe? Linette: Yes. Yes. David: Tell us about medical school. How in the world did you go to school where you went to school? Linette: I went to school in Russia, the Russian Federation. And it was just it was a miracle of sorts because I had no idea that I could go to school in Russia. In fact, I didn't even want to be a doctor until my last year of high school when I feel I felt the Lord telling me to be a doctor. And I was really against it for like a month. I spent a month arguing with God in my closet. Like, really? You really want me to do that? I've never wanted to do that. I want to be a lawyer. I want to be a scientist. I want to do research. I had all these other plans. David: Anything but medicine. Linette: Yeah, anything but medicine. Everyone wants to be a doctor, but who is going to take out the trash?  Who's going to be the mechanic? Who's going to be the engineer?  I don't want to be a doctor, everyone's going to be a doctor.  It turns out not everyone became a doctor - I became the doctor! God has a sense of humor because the thing that I was fighting so hard not to do turned out to be the thing that I do the easiest.   I went to med school and God make it made it so easy for me to learn and to understand the concepts. . .to understand physiology and how the body works and what drug goes with that. So, I was like, "Hey, man, it's good to follow what you feel God is saying to you." And boy, am I glad I did that.  And then Russia. A friend of mine visited from Russia. I hadn't seen her for years. She was in second year [of medical school]. She told me Russia is good. David: She's Kenyan? Linette: She is Zambian. At that time, I was living in Botswana, that's where I grew up. So, my Zambian friend comes home for holiday and I'm like, "Hey, long time, I haven't seen you. It's been years. Where have you been?" She's like, "I've been in Russia." What are you doing? "I'm doing medicine." And I'm like, okay, that's amazing. I hadn't yet agreed with this whole plan to do medicine in my heart, but I thought, "This is a good like idea to look into Russia as a school option."  I didn't want to stay in Botswana to do my university. So, I asked her questions, and she said that teachers are good, the groups are small when you study so the teachers can follow you very closely. And she said everything except that they don't speak English. [Laughter] And I feel like God literally blinded me to that because I asked every question except, "What language do they speak?" I mean, I know there is Russian, but surely, surely, they speak English, right? They're white! No, they don't. And I found that out when I landed in the country. [Laughter] So, I out of curiosity, I study Russian. I'm so excited.  I'm going to Russia! And then, I land in Russia and it turns out I have survival skills now. I decided, "Well, I'm here, so I have to keep a positive mind about it and learn it as fast as possible so that life can get easier." And that's what I did. So, I learned it and life got really much easier. David: And so that was how long? Five years? Six years? Linette: Yes, six. David: And then. So, you're from Botswana. How did you get to Kenya? Linette: I'm from Kenya. David: Okay. Linette: I was born in Kenya. My parents are Kenyan, my dad is a civil engineer.  When I was five, my dad applied for a job with the government of Botswana, and he got it. He moved to Botswana to look for greener pastures. Then the family followed him. So that's where we all grew up, me and my sisters, except for my youngest sister, who was like a bit young when they moved back to Kenya when I was in third year in Russia. When they moved back now, home became Kenya again. So, when I finished with Russia, I came home to Kenya. So now I had to learn a new language, Swahili [laughter] because, I know how to say hi, but everything else is a blur because I was five when we left. But because I had learned Russian, I was like, "This is nothing impossible. Surely it's just a language." And now I speak it fairly well. I can speak Swahili and no one knows I'm not really Kenyan, but when I speak English, they know because my accent is not Kenyan. David: Yeah, Botswana - that's like the usually the voice actors and people like on TV in America, like that's the pure like, classic African accent.  So, like in Disney movies it's always a Botswana accent. David: And so, what were challenges? Did you have time off in between in between finishing medical school and starting internship? How did you end up at Kijabe? Linette: I had a whole year of nightmare. None of my papers were Kenyan, so I went through such a terrible time. I went to try and verify my degree and they said I had to verify my high school certificate. And then when I went to try and verify that, they said I had to verify the primary school certificate. And most of that was like, we need a physical letter from the governing body in Botswana. I have no family left there. How am I going to get like a real letter from them? But thank God for friends. I asked a couple of friends to help me, and they sacrificed time from their jobs to help me chase down that. It took a whole year from the time that I came back to the time that I started internship. And even after doing the whole verification thing, turns out you don't just do internship, you do pre-internship, which is like an internship, but then it doesn't count. And then you write board exams. So, I did that. And then just as I was about to ballot for a government place in the internship, a cousin of mine asked me, “have you tried Mission Hospitals?”  She had worked for Mission Hospitals and she feels like they're great. Linette: I was like, "I've never thought of that. What's that?"  She told me, "the last interview is next week, Monday, find a way there."  So, I found a way there [laughter], showed up, did the Kijabe interview and I fell in love with Kijabe just from talking to the doctors on the panel. Dr. Arianna was on that panel that day. I was I was so in love with Kijabe. I was like, I'm done. I'm going to Kijabe!  I didn't even interview the other two places. I'm going to Kijabe - I'm not going anywhere else. So, I went home all happy. I'm like, "I'm going to Kijabe, I'm going to Kijabe!" I don't know, that was just I was just so sure. I fell in love with this place before I came here. And since I came, I've not been able to leave since, like you think about going anywhere else and you're like, okay, so what's life going to be like there? Nope, I'll stick to this one. David: What particularly do you like about it?  Linette: I love the compassion with which people approach medicine.  I mean, there is science and there's evidence and there's all that. Anyone can get that anywhere, you know? But there's a human touch and aspect that you can't buy anywhere. You can't buy that. And then a lot of these doctors are Christians. . .and missionaries, they're here not because their homes are not comfortable, or their countries are not good.  I mean, I've been a foreigner. I know it's home that's always best. It's very uncomfortable to be a foreigner sometimes, but the [missionaries] are here because they feel like their call to humanity is higher or greater than their comfort.  I feel like because God told me to be a doctor, it's great to be around people who take medicine like a calling. There's also the evidence-based approach, you know.  It's not quack medicine, it's not abracadabra. It's, "Okay, I read this paper and it says, 'This approach is better for this disease.'" And that's what we do. We do that because the best idea wins.  The best idea is tested. It's tried. It's been through trials and studies and that idea wins. So, every protocol changes according to the idea, the evidence that has come up. The system of correction for mistakes, audit, is taken very seriously. Audit helps us change protocols, change our approach. It's one thing to say, "we will do" and then it's another thing to actually do. It's a culture that goes on from the highest doctor to the lowest staffer.  Even a patient assistant adheres to the protocol. That's a cultural thing that you can't buy. If people's mentality is "I'm here to get my money and go," then they would never do that. But the fact that we say something in a meeting, and it actually happens - that's wonderful.  David: Wow. That's awesome. I love it. So, internal medicine. . .What's good about it and what's hard about it? What do you love and what's the most challenging? Linette: Let me start with what's hard. What's hard is at least once or twice a week, there is this one patient, who, I'm like, "I have no idea what's going on here." And then, once in a while, there's this patient who everyone is like, "I have no idea what's going on."  Really? That's mind boggling. But then that's also why it's great because every time you think you know, you don't know.  You don't know what you don't know. But then, every time, you find out there's more to learn. I love that opportunity to grow.   I like places where I can be put under pressure to grow.  There's no bigger force or pressure than the feeling of "I don't know." Then there's this culture of mentorship that Kijabe has. I have awesome seniors who don't make me feel dumb for not knowing. So, when I don't know, there's always someone a phone call away who might know. And if they don't know, they're so honest. I love that they're so honest when they don't know. And they're always willing to offer advice on, "have you tried this, and have you tried that and how do you check this and that?" Then they teach you how they think so that you can be a proper mentee. I love that. That's what I love about internal medicine in Kijabe. I don't know about internal medicine in any other place, but here, it's like you're free to be dumb if you're dumb and we will help you get smart. David: I don't think that's a problem for you. You're very humble. Doctor Tony Nguyen is the head of internal medicine right now, and he was telling me that. . . Linette: He's my boss and he's awesome. David: Oh, that's great. He was talking about ventilated patients, that a lot of your patients are younger. Why do patients come to you? What are their issues? Linette: Well, our vented patients are younger, and most of that is because of our resource limited setting. Because of our resource limited setting, we can't afford to intubate everyone. So, our protocol favors a younger patient with less chronic disease going on. It's very sad that we have to make that decision, but we only have a very small amount of resources - in this case ventilators. David: So how many do you have that are working right now? Linette: We have five good vents.  David: I think your definition of good is different from mine. Linette: Like, it keeps the patient alive. That's good enough. David: So, that's the distinction. There's actual good, because you have some good [ventilators] and others from 1953 and it's a small miracle. . . Linette: It's working. It's working. (laughter) David: But that makes me very nervous. Linette: It does. It does. But then we live by faith. I mean literally surviving on small miracles. So, there's two really, really good ventilators that have this nice screen. David: The GE ones? Linette: Yeah. They have all these screens that you can read. And then there's these [old] ones which are guessing some of the stuff in the background.  David: It's totally manual, right? You have dials, you can adjust, but there's no waveform, there's no tidal volume, you're just. . . Linette: Guessing. There's nothing to see. It's just put in the settings that you want and hope and pray that that's it. Then if that doesn't work, you try something else and see if that works. And that's how we live. Imagine. David: Yeah, not that that's not good, but that's what I'm hoping we can improve on someday. Linette: If I have five solid ventilators, I think I can depend on. I mean, I think they can save five lives.  David: And so, you're saying you can have protocols for younger people.  What about - I don't know if you call it a dance or juggling - interactions between different departments work because? I mean, patients are surgical or medical somewhat, but there's a lot of overlap. Linette: Yes. It's a lot of teamwork that's required because a lot of patients in the ICU are surgical. But then if they're in the ICU, they're your patient [medical team]. They are surgical, but they're still yours. And that [relationship] needs a lot of communication between us, a lot of understanding, because sometimes we see with our eyes the medical stuff and they see with their eyes, the surgical stuff.  And we don't see what they see, and they don't see what we see. So, every time we make decisions, it's important to like double back and ask them, "Okay, we want to do this. Is this going to affect what you are doing in any way? Is this going to harm the patient instead of help the patient?" Because sometimes you might do something and maybe cause bleeding or maybe it does something that we didn't intend to do, but the surgeon would have known that, and we didn't. So, it takes a lot of teamwork to survive a patient in ICU.   Linette: Sometimes when we are admitting patients, we feel like this patient might need intubation and we might not be able to give them that resource, we try our best to refer them at the door before they even get to the point of deteriorating and needing the intubation. We just tell them, "Look, it's not looking good.” Usually, it's the family we are talking to because [the patient] is so badly off, and we tell them “It's not looking good. It's likely they're going to need intensive care. We don't have room, please go to another place.” Some of them refuse. Oh gosh, some of them refuse. They're like, “we don't have anywhere else to go.”  Those are tough because they end up staying in Casualty forever. And then we end up like creating an Intensive Care Unit in Casualty because you can't just watch someone die. That's a hard thing. And then some of them die. That's the painful part because you're like, "If we had this, they wouldn't have died," but we don't. David: Do you have a sense of what it would take? I mean, we want to get we want to get some new ventilators. We want to get ten, maybe more, high dependency unit beds. What would it take to treat everybody you think we should be treating? Linette: Oh, my gosh. A lot of money! David: Well, not in the money sense, but how many HDU beds? How many ward beds? What would it take to do everything you would love to see us doing? Linette: That would be crazy, because, if I compare it to what other hospitals are actually achieving, they can have anywhere from 20 to 30 or 40 ICU beds and we have 5. So that's a huge dream for us.  And then we have ten HDU (High Dependency Unit) beds. You can imagine if they have 20 ICU, they have like double that for HDU and we have only 10. So, it's going to take that much more muscle.  Then the other issue is staffing, because we are so few in our department and a lot of our people are missionaries. It's wonderful because they are here to help, but then they can't always be here to help because they have their homes to go back to. So, we have a lot of visiting doctors who come in. Oh my gosh, when they come, we're like, oh, we can breathe a little bit, you know.  We breathe for like a month. And then they go and then we're dying again.  We have ECCCOs who are in ICU every week. David: What does that stand for? Linette: It's Emergency and Critical Care Clinical Officer. They are clinical officers who have a higher degree in critical care and emergencies. They're awesome. Awesome. They run the ICU very well. A whole ICU really depends on an ECCCO. If the ECCCO is good, they respond to the emergency quickly. They call the doctor quickly. And they a lot of times you get to [the patient], they're already intubated.  They are so good. They respond to emergencies very, very quickly.  So, there's always one just one in a whole week who does the day and then one in a whole week who does a night and then one in a whole week who does casualty. If we were to ever expand, I think more beds would be overwhelming for one ECCCO.  And sometimes we have two because there's one and then a student. But then sometimes that could slow the [senior] one down because they're trying to do teaching, you know, like they're trying to show the other one. So that would take more doctors, more critical care nurses who by the way, are so awesome.  David: And there's training, there's a lot of training going on. This is one of the things I look at. I think, "five beds." There's the patient side. There are more patients who need help.  But then the training side, Oh my goodness. We have a critical care nursing program. We have the emergency and critical care clinical officer training program. Linette: Yes. David: And when I just look at it, I think we need to take care of more patients so they can, to use an exercise term, do more push-ups.The more patients they see, the better they will be coming out of school. Linette: It's much better for them. David: And then you're also taking the nurse anesthetists. They come through. Linette: On rotations, higher degree nurses doing their rotations and the anesthesia residents and surgical residents. David: Oh, and surgical. So that's part of their that's part of their residency? Linette: Yeah, there are a lot of learners, actually. Our teams are more than the patients by far. By far. David: That's at least 50 learners in a year.  Linette: They could be more, because per week, it's crazy.  The last time I was in the ICU, I had three ECCCO students and three KRNA's (Kenya Registered Nurse Anesthetists) and one more intern and two or critical care nurses. That's ten learners.  And then if you're on the rotation, you have to teach the ICU curriculum for that week.  David: So, you're doing that teaching? Linette: Yes. Yes. I teach. Right now, I took a break because I've been so busy with my family, but I teach physiology in the school. David: Oh, for the nursing students?  Linette: For the clinical officers. Linette: I teach human physiology. David: Awesome. That is a lot. Linette: Yeah, it is. That's why I, like, put a pause on it, because I'm like, “Let me just have a baby first and then I can think about it.” David: Yeah, that's awesome. How old is your little one? Linette: He's turning one [year old] this week.  David: So, you're entering a new phase, you're starting to sleep. And you're also starting to, realize, every second there's more trouble. Linette: He can get into. Yes, I'm battling chronic fatigue. He's such a handful. He's all over the place. And then he just discovered how to walk. So now it's like, "get everything out of the way." And just when you think you got everything out of the way, he discovers another one. David: What would it take to build a proper ICU?   That will be a phase-three of the hospital master plan.  This year there will be a new oxygen and facilities plant that they're calling an Energy Center. That will go It will be just outside of Wairegi [the men's ward]. That's part one.  Part two is the new outpatient center.  And then part three will be where outpatient currently is. They want to build a huge building that will be maternity, internal medicine, ICU. I think it'll take that [building] to get to 30 or 40 beds. But I'm hopeful that we can figure out how to do something substantially more in the near term.  If we get equipment, it can roll where it needs to go.  Knocking out walls and things like that are permanent, but equipment can follow the need. If it needs to go to Centennial [ward], it can go to Centennial. If it needs to go wherever, it can go wherever. So, I hope I hope we can do a substantial expansion this year. Because it's important and it needs to happen for you guys to be able to do what you're good at. Linette: Yeah. And now we have a renal unit, so we have, super-sick patients who we used to refer because we didn't have a renal unit. Now that we have an actual dialysis center in our hospital, we get called more and more into the unit because they code on the dialysis bench and we have to go there and resuscitate.  That's an ICU patient.  They cannot be anything less.  If you resuscitate, and then you don't have a ventilator, you'll just be bagging and bagging and bagging and you're like, "okay, I'll be the vent for now." But then, "how long am I going to do this? Are we going to get an ambulance? Are we going to go to another hospital?"   Most of them don't have the money to go to a hospital with an ICU. Kijabe is so friendly, in terms of ICU cost, on your pockets. So, you tell them about any other hospital in the family is like, "no, we can't afford that happen." David: Do you have to save ventilators? You have that dialysis situation. Do you have to reserve ventilators for surgical patients? Like if somebody knows something bad just came in, they're going to surgery. Linette: All the time. Yes. Every night I'm on call, I'm like, "how many ventilators do we have?" And the ECCCO tells me we have three vents. And then they're like, “the surgery team called ICU and they said that they're taking in a complicated case, and they want us to save a vent." So, if I get any emergencies overnight and I had four vents and I'm saving that one for the surgical patient.  If I get any anything in casualty that needs an intubation, I can't accept. So, I have to refer. And that's terrible for those who come crashing because they crash, and our reflex is to intubate. We don't even think, we just intubate. And then suddenly somebody is bagging and we're like, "we don't have a vent."  Sometimes we end up having to give away the vent we have reserved for an emergency, and that causes a whole chain reaction of problems because now the surgeon is angry at you because they saved the vent for the patient, and they've already cut. And you're like, "let's pray to God that you come out of anesthesia." Yeah, it's just a jumble, it's just a mess on those bad nights. And then sometimes we have to quickly extubate someone who we didn't plan to extubate today. Maybe we plan to extubate them tomorrow, and we're like, “maybe tomorrow they'll be able to get off the vent,” and then we're like, "Okay, you need to breathe for yourself now because we're coming off now." But you see, that's a problem because you're extubating prematurely and you're like, “fingers crossed, legs crossed, please breathe.” And then they breathe, and you say, "Thank you!"  David: So how do you manage all this emotionally?  Linette: That is just it's painful. It is very painful. Sometimes there is moral injury that comes with denying the vent to some patients because you're like, “if I had intubated, I am not 100% sure that you wouldn't have made it.” I'm just basing this decision on your co-morbidities or your other diseases and the fact that you have significant disease.   There's this other [patient] with less significant disease and that you are likely to not make it. So that's a bit hard.  David: What do you do with that? Like, how do you how do you process this?  How do you not explode? Linette: Our culture in the ICU is when you have a really tough time, we debrief, we call the chaplain to come talk to us, or the palliative team. They're very good at counseling staff members about "What are you feeling about this? What are you feeling about having to extubate this one? What are you feeling about having to do this?" And everyone opens up their heart and says, "Well, I feel like crap, like this is terrible." And, well, I have a good husband at home and he's like a doctor now because I take all my stories to him. So, I just offload on him and he's a very good listener. So, I feel better because I have that at home.  I have good support at home.  David: I love that.  Linette: Yeah. It's a tough journey, but it's also fun because we see people and its life changing. It's the difference between life and death for someone. So, our extubation days are really good. Like, "Yes, you did it, we saved one! And then 10 million more to go!” Always celebrate the small wins. David: I love that. Awesome. Thank you so much, Linette Linette: Thank you for having me. David: Appreciate, you're amazing. Linette: Thanks.

Dayalan: I'm Dayalan Clark. I'm a breast surgeon from the UK. I came out to Kijabe mainly to help because Beryl [Akinyi] has been on maternity leave. Beryl is the surgeon who does most of the breast work here, and Peter Bird, who we have known for many, many years, asked if we could if I could come and help. Peter grew up in India as a missionary child with his father being a surgeon and a missionary hospital, at a mission hospital in India in a place called Mysore. And it so happened that my wife's father was also a surgeon in the same hospital, and they grew up together across a wall as neighbors growing up in India. And that was my connection with Peter Bird. I think my wife and Peter lost connection, though our respective parents kept in touch. And then when we were visiting Nairobi for a safari in 2006, we heard that Peter was here. So we were going for a safari with my wife's parents. It was their 50th wedding anniversary and they loved wildlife. So that was our treat for them for their 50th wedding anniversary. And they said, “Oh, Peter is in Kijabe, let's try and meet up with Peter.” So we came and visited Kijabe had lunch with Peter.  In 2006 I took an early retirement from my work in the NHS in the UK with the express purpose to go and help mission hospitals in need. And then in 2019 I came out to Nairobi with a group of breast surgeons from the UK to train to do a training course and a teaching course in Nairobi, and who was on the local faculty to spread the word. So we met up again and I was telling Peter how I had taken an early retirement with the express view of going in and helping mission hospitals in need. And then he turned around said, Oh, would you be able to help in Kijabe if we needed us at all? I'd love to come to catch up if he needed me. And then of course, Peter was leaving last year and Beryl was going on maternity leave. So he contacted me and said, Can you come and help us while on maternity leave? And so I'm here. That's how I'm here.  David: That's amazing. Did you and your wife meet? How did you meet? Dayalan: I went to medical school in India, which is a Christian medical school called CMC Christian Medical College Vellore. And we were classmates in Vellore and we met there and got married after we finished our house jobs and then did some mission service, which is part of our obligation in India, then did our respective postgraduate training and in Vellore again, myself in general surgery and my wife in pediatrics. And then it worked again in mission hospitals in India and then went out to the UK in 1991, never intending to settle in the UK. But God, God's wills are strange and we never thought that's going to be the plan. But that's what happened. And I was very conscious that because we've trained in Vellore, I've always grown with the feeling that I consider myself very fortunate, coming from a very average background in India. My father was a minister in the church and retired as the Bishop of Madras. So very ordinary background, but consider ourselves very fortunate to have been able to have gone to the UK and to made a career there, to become consultants there and always felt as soon as my children were on their own feet, I'm going to stop working, retire and try to give back to people who been less fortunate than myself. Wow. David: Wow. That brings up so many interesting questions. I'm not super familiar with India, but one of my dreams is - this is why I was so excited to meet you is I heard from from Dr. Nthumba when we were starting Friends of Kijabe - he said, "you need to learn about Vellore, you need to learn about this place." And so, I'd love to hear about that. But then also I'm curious just what. . .you said your father is a minister and then became a bishop. Most people in America associate India with Hinduism, Jainism, Sikhism.  Is Christianity regional? Dayalan: Christianity is much more common in South India than in North India.  Where I come from, which is South India, but the population of India is huge. As you know, 1.3 billion people and 2% are Christians. So, 80% Hindus, about 10% are Muslims. And then, like you said, the other communities like Sikhs, Jains and such like from the rest of it with Christianity being 2%. So even Clark, which is my surname, is a very Indian name, but the background to that is one of my forefathers must have been converted. And when you convert it from Hinduism to Christianity, the way you denounced your previous religion was either you took on a biblical name or you took on a very western sounding name, often a missionary who converted you. I presume one of my forefathers was probably converted by someone called Clark or decided to take on a Western sounding name. And that's how Clark has come down the generations. David: Wow. So, there's a tradition that the Apostle Thomas went to India, right? Dayalan: It's historic. Legend is that he came down to this west coast of India, which is Kerala, and then traveled down and then actually came through Tamil Nadu where I'm from, near Chennai. It's called Saint Thomas Mount. And they say that that's where he probably last either left India or died there. We don't know. But I don't think there's enough factual evidence but that's what they think happened. Yeah. David: Interesting. It's not until really spending time in this part of the world that realize Christianity developed very differently than I perceived. Southeast Asia, Africa, a lot of the early church fathers were in those places. It was not a European thing until much later on, which I think is fascinating. Dayalan: Yes.  Considering Christianity arose, Christ lived in Jerusalem in the Middle East, I think proximity-wise you can see why it happened that way. Egypt is not far from where it was and you have flight to Egypt when Christ was born. But it doesn't surprise me. Definitely there was quite a lot of Christianity around this region and moving both east to us [in India]. David: Wow. I think my understanding of our previous conversation - tell me if this is accurate - that Vellore is probably a picture of what Kijabe could be like in, I don't know, what you would say, maybe 20 or 30 years? Dayalan: Quite possibly so. I mean, the first thing that struck me when I came to Kijabe, I saw the community spirit, the closeness, and how well people got on together. And the first thing that struck me, especially with a lot of missionaries here, the first thing that struck me was this is below in the fifties or sixties because Vellore was very similar. There's a Christ-centered Mission Hospital, which was largely supported by Americans and some British missionaries, both in terms of the day-to-day running of the hospital and in personnel, which I see exactly what is happening here. And Vellore has then gone on to become one of the leading institutions in India, both in teaching and in terms of health delivery. And my only prayer is that hopefully 30, 40 years Kijabe is going to get there. One of the things that Vellore has, which probably is an advantage for them, having developed so quickly and so well, is a medical school, which I think we don't have yet in Kijabe. But I think if we have Christ at the center, everything else will follow. And I can see great things happening in Kijabe, just in the services that I've seen, in breast cancer care itself, I can see there's huge scope because we've just had a mammogram machine installed. Oh, yes, which is fantastic. And then I've helped in helping the radiographers from here, going to Aga Khan and MP Shah to get some training and of course, we're going to have a breast radiologist coming from America, starting in August. So, with this mammogram machine, we have a state-of-the-art absolutely fantastic machine, and then if we have a breast radiologist to actually drive that forward. I can see Kijabe being a fantastic breast unit going forward.  David: That's amazing. So you went from Vellore, you went from a very faith-based medical system to the NHS, which I assume was not the same. No, no. What was that like? Dayalan: The NHS as a health provider is absolutely fantastic.  You have, which I think most developed countries should aspire for, a health delivery system that is free at the point of delivery irrespective of your social status, your economic status, or who you are. Absolutely fantastic health delivery system. But one of the issues with that is that it's very secular, even though the British consider themselves a Christian country. I think that's far from what's practically happening there. So, it wasn't an issue for me. I am still involved in my church. I sing in the church choir. I'm actively involved in church activities. They've been very supportive of me coming here and by their prayers. So that balanced it out. And yes, it was different. But I think the professional satisfaction that I got from treating my patients, knowing that irrespective of whatever treatment they needed, they got it, irrespective of their economic status. And I think that is something most countries should aspire for. Any developed country that doesn't do that I think is really failing their people. And so I think Britain and the NHS is a fantastic health delivery system. It's huge and any huge system like that will have flaws, will have deficiencies. But as a principle where they can deliver good quality care which is completely free at the point of delivery, I think the NHS is fantastic. David: What does India's delivery system look like? Because you're doing a lot of fundraising for the people who are not able to pay, correct? Dayalan: Yes. So now in the UK, we have a group very much like Friends of Kijabe called the Friends of Vellore UK. And because Vellore has been training medical students for about 80 years, they have people in various countries. We have friends of Vellore in the US and the UK and Australia and in different parts. And the original role of these organizations, are charities that were set up by mission. Those who went from the UK to the Vellore worked there, came back, and raised funds from their local churches. Equipment that was not being used by discarded by the NHS was being shipped back to Vellore. So, Vellore depended a lot on these Friends of Vellore in the different countries. But the law has now got grown so big and it's completely self-sufficient for their day-to-day running for their equipment. So they don't need the Friends of the Vellore UK anymore for that. So, we've turned our focus towards paying poor patients' bills. And one of the things that often used to worry me is that, yes, the law is a fantastic institution. They give brilliant care, tertiary care for people. But what about the poor man living on the street outside or just two miles away from the law? Where does he go? I mean, he doesn't have a chance of paying those bills. Vellore has now moved on in that 15% of their income, which is a large amount, is completely for charity. Dayalan: And they're moving towards no patient will ever be turned away from the law because of lack of funds. So that's where we come in and we have said no more capital investment from us. We are going to concentrate on paying for poor patients' bills and they have a very good system which was set up in the seventies called person to person. So, a person in the UK donates money for a person in the Vellore. So that money is then raised and sent to Vellore. Vellore administers that. Every penny that that person in the UK donates goes directly to paying that poor patient's bill. And the person who in Vellore UK who donates that money gets a report of the patient that they treated and whose bill they helped to pay. That was set up in the seventies and is a very popular way of helping poor patients because the donors love it. They know exactly what's happened, the social standard, how much the bill cost, and what either the patient or their parents earn. So that was that's a very popular program and Friends of Vellore the UK that is our main contribution. David: I just had to pause. In 1970. So that meant you had to send a letter for every single patient that was helped. Dayalan: That's right. It was snail mail in those days. I remember as interns and as house officers actually filling in the form for a PCP form. Whenever the consultant knew that this patient is is not going to affect, they'll turn round to the junior, which was us. Can you please fill in a PDP form? We would then go into the patient's history, the economic background, where they live, what they earn, how many meals they have, how big their house is, and then all that details are then put together. Then the money is sent from PCP and then a sort of report is compiled by the administrator and by Vellore, and then sent by mail to the people in the UK. David: I'm just absolutely floored because I associate this with organizations like Compassion International. This is normal now. This was not normal in 1970 by any stretch of the imagination. For somebody working in the charity space, it's just mind-bogglingly cutting edge. That's so cool. Dayalan: I think Vellore has been just miles ahead of everybody else in India and even abroad. One of the other things, just to give you an example was the medical admissions when we got into medical college. So, you did an entrance exam where you qualified and then you were called for an interview and the interview took three days and the interview was hardly anything on the subject material. But it's basically to understand what is the aptitude of this individual person. Does the CMC think that this person is someone who has the aptitude to go back and serve? That was the main crux of the interview. We had personal interviews, we had group tasks, we had individual tasks, we had psychometric tasks. This is going back 50 years when it wasn't even envisaged. In the UK we now started bringing this in for our medical admission. And I was saying, “Guys, we've been doing this for 50 years at Vellore.” I think Vellore was really miles ahead of everybody else in lots of their programs and lots of their thinking and a lot of their projects. David: Yeah, that's just amazing. Wow. Is there anything you see at KJB that reminds you of what that's like? Like what are common threads? Dayalan: Well, I think the common thread is the Christ-centered attitude of what you're doing for your patients. Nobody is interested in personal gain or personal glory.  All you are interested in is that God's name be praised and that patient getting well. And I think that's probably the first thing that struck me when I came here. That's it, I think the most important thing in health delivery system within a Christian ethos. So that was the first thing that struck me. The second thing that struck me is the training system is so similar. Vellore was started by an American missionary, Ida Scudder. The training system where residents do what they were doing here, like the PAACS (Pan African Academy of Christian Surgeons) training system, the residents take personal responsibility for the patient they're looking after. They present in rounds. They know everything about that patient. And the training system was very similar. And I think what I appreciate with PAACS, even more than what we had in Vellore is ours was mainly service-oriented. Here you've introduced some teaching into it. Also, you have, at least in surgery, regular teaching sessions which we didn't have in the Vellore. The onus was on the individual to go read up. And whereas here [in Kijabe] you have a structured training program with structured teaching from starting from the basic sciences, going right up to the operating skills, which is fantastic. David: How do how does the skill level of our [Kijabe] trainees match up to other places you've been? Dayalan: I think the training here, the skill level is fantastic, and I think it's what I like about the system is it's actually geared towards the African setting in that they have a general training which we don't have in the UK. We've moved away completely, but the UK can afford to do it because it's a developed country and they have the NHS which will look after everyone, whatever they need is, whereas here it's not the case. And so, I think the training is very broad here, very good here. And having seen the final-year residents, I know they're going to be doing the exams shortly and they will go out and I'm confident they would be able to manage most surgical conditions. And when I say surgical, not in the narrow sense of the UK, but in the broad sense of what Africa needs. So I think the skill levels are absolutely fantastic for this residency.  David: For some of the non-medical people listening. What are the biggest surgical needs for Africa? Dayalan: I think the surgical need for Africa is to be a generalist where you can actually have a basic understanding of surgical diseases, know what the pathology is, and be able to quite rightly identify the problem and treat it adequately. One of the things I've noticed here is I've seen lots of patients being referred from elsewhere who actually have no knowledge of how that disease should have been treated but are willing to have a go because of either bravado or there's a financial incentive because if they did something surgical, they're going to get paid for it. And I think that's where PAACS really stands out in that they've grown them quite well and by the end of their training they know exactly what to do. David: Do we know why breast cancer is so common? I know we're a referral center, so I have a skewed sense because that's so much of what we see in Kijabe. Why is it so prevalent? Why is it affecting young people? Do we have answers to those questions? Dayalan: Interestingly, the statistics we have shown that breast cancer is a disease of the developing country. When I was in India, working in rural India and Assam in the last few years, I didn't see very much breast cancer, rural India, villages, not so much. You go to the urban cities in India, it's more common. And similarly, Kijabe seems to get a track because of the reputation we have of having treated breast cancer for a long time. With Peters reputation, we are a referral center for lots of people around the area and so I think Kijabe and Kenya are also going in the direction of the other developing countries where breast cancer is getting more common. And I have a simplistic view to this and I've discussed this with you before in that the things that increase your risk for breast cancer, even though each of them is small, are much more common in the developed countries. Things like the oral contraceptive pill, and hormone replacement treatment, all of these are extraneous estrogens which your body is not used to and taking them increases your risk. Things related to childbirth. Not having children increases your risk.  Having children and the number of children you have is protective. If you have more children, you are more protected against breast cancer. The same way breastfeeding. In the West, there was a huge fad against breastfeeding and using artificial milk.  Breastfeeding is protective in developing countries like India and Kenya. It's a necessity. If you don't breastfeed, it's economically not possible to actually buy powdered milk. And so, it's because of necessity, you have to do it. Everyone breastfed. Each of these is a small risk, but if you add them cumulatively, they become a higher risk. And I think as more countries, the developing countries are getting more developed and getting more Westernized, all of them are following the same trend that we have in the West, and this is increasing the risk. And so, breast cancer is getting more common in developing countries, unlike it was 20 or 30 years ago. David: Wow. This just sounds both sad and scary. Dayalan: It is. Because statistics in the cities in India show that they're almost catching up with the West in terms of prevalence of breast cancer. And it's probably this whole modernization shaping the West and doing all the things that they think the West is doing, which is good. David: I was having a conversation with Rich Davis today about research. The thing that comes to mind is autism. How rare it is for for it to be seen here? Yet in Nairobi, it's much more common each year that goes by. I don't know if your wife has had this experience in anywhere else you travel. Each year that goes by, Arianna sees a few more children [with autism]. And it's I wonder if there are similar factors. I wonder what the correlations are and where it comes from? Dayalan: I think definitely you can. My wife's in the same field, she's a pediatrician also. And there's no doubt that that incidence is increasing. But also, I think we're more aware of conditions that we didn't know 20 years ago. So 20 years ago, autism was just about coming, making it very similar to screening for breast cancer, pre-invasive breast cancer like DCIS, we didn't know these conditions before, but slowly we're getting more. Research helps with that. We've got good screening programs both in the US and in the UK, fantastic breast screening programs, and so we're learning much more as we go along with each intervention that comes about like screening. So I think we're going to see more of it. And the more you see of it, the more you get to know of it and the more you get to know of it, the better it gets for patients and health benefits. David: What would have happened in Kijabe, if you did have breast cancer 20 years ago? There were probably very few chemotherapy options? I guess you could have done a mastectomy, but there was no reconstruction. I mean, was it a death sentence? Dayalan: Almost.  One of the problems we have in Kijabe and in Kenya and the whole I think is patients present much later, as a result of which the prognosis is not going to be as good as countries like yours and mine, where we have good screening programs, we pick it up early. If you take breast cancer in the UK now, two-thirds of the patients are going to be alive and well in 20 years' time. In Kijabe it's going to be a complete opposite statistic, roughly just off the top of my head, where two-thirds would be dead after 20 years. But that's because they present so late. So, yes. We've got much better in the treatment everywhere. And the problem we have is a lot of the new treatments in breast cancer, i.e., chemotherapy.  Monoclonal antibodies unfortunately are very expensive. So while in the UK where you have the NHS, where [cost] doesn't matter, in Kijabe and in Kenya, it's much more difficult to access all of these. But saying that, in the three months that I've been here, patients are being given the same chemotherapy regime that we use in the UK. Thanks to NHIF, thanks to patients' awareness, they're able to access monoclonal antibodies, not to the extent we would in the UK, but definitely, it's available and now we give our patients that treatment, and of course reconstructive surgery has moved on miles. Dayalan: In terms of the treatment options we have, it's increased phenomenally. When I started in the UK 30 years ago, we had one chemotherapy regime for breast cancer. Now we have 20, maybe 30 regimes that we can use - different chemotherapeutic agents and if one fails, you go on to the next and so on and so forth, which we didn't have 20 years ago. I think treatment for breast cancer is really looking up. And with the new mammogram machine, I think one of the big things that we should be looking at is setting up a screening program for the local people because the mammogram machine is not going to be busy with the amount of breast cancer work that we do. So really what we need to be doing is developing a screening program, going out into the community and telling them, come, let's have a look, get some mammograms. Let's pick this up early. If you have a cancer, we'll sort it out for you. 

Conversation on faith, work-life balance, parenting, stewardship, leading through the pandemic,

Elizabeth Drum Interview:  David: You started a new position a little while ago, is that correct?   Elizabeth: I have a couple different responsibilities.  I became chair of a committee within the American Society of Anesthesiologists.  They have a committee, the Global Humanitarian Outreach, within the American Society of Anesthesiologists  that was originally envisioned as a way to send US anesthesiologists to other countries to help in educational efforts around anesthesiology.  Over time some of those programs grew/changed/morphed.  Eventually that committee developed into the GHO.  I have been on that committee for years and just became the chair.   There are a number of things that committee does within the ASA.  We support two programs, one is in Rwanda, one is in Guyana.  The goal is to help with anesthesiology efforts in those countries.   The program in Rwanda was originally a partnership with the Canadian Anesthesiologists’ Society.  So, the two societies went and taught residents in Rwanda.  Over time the Rwandan Anesthesia Society has grown stronger, more robust, there’s now graduates who are leading the teaching efforts.  The ASA and CAS efforts have changed more into supporting the faculty, helping them learn to become educators and leaders, and not so much providing hands on teaching, but supporting the leaders in that country.  It’s an amazing testament to the value of education and training local anesthesiologists who then can become leaders in their country.  The efforts in Guyana are similar, they’re not quite as far along, but there is now a Guyanese anesthesiologist who is in a position over all the graduate medical education in the country and another anesthesiologist who is now head of the Guyana anesthesia society and training program.  Again, similar thing, they started with not too much and are slowly growing.  Those are really exciting things that our committee has done.  Another thing, 5 of 6 years ago, I started a program within the GHO committee where we send senior-year U.S. anesthesiology residents to a low-income country for a month to get to experience what it’s like to live and deliver anesthesia care in another country.  Not so much as a mission model, you go for a month and do work, you start to understand what the educational needs and systems are.  Each year we send 6 or 8 residents, we have now sent 50.  Started in Ethiopia, and now Uganda and Malawi.  We also sponsor visiting scholars to come to the ASA meeting every year, to spend a little bit of time as an observer, to hopefully build some long-term relationships to help them in their development as leaders of anesthesiology programs in their home countries.  One of my goals is to gain visibility within the ASA about the importance of this work.  Believe it or not, is not universally understood with U.S. anesthesiologists that there is need or value for working with others around the world.  There are definitely people who want to make some humanitarian contributions but don’t really know how to go about it.  I have a couple of other things I’m working on.  There is an organization called the World Federation of Societies of Anaesthesiologists.  Basically, a society of societies.  Any country that has a society of anesthesiology can be a member of this.  They have separate committees.  Some provide educational opportunities.  There is one in Nairobi, in pediatric anesthesiology, those travel and spend time at Kijabe.  There are other programs around the world in pain medicine, and other stuff.   WFSA does a lot of advocacy work.  They do work preparing statements in line with WHO guidelines, helping member societies advocate for and navigate local politics.  I just became part of the larger board of directors.  David: That’s lovely.  I have met several of the visiting pediatric anesthesiologists.  That work is what makes a program like this PAACS thing possible.  It’s not only a matter of education; it’s creating an environment where people can succeed after they have that education.  Good on you, thank you!Elizabeth: It’s true in our US hospitals and training programs, so why would we not think it’s important in the rest of the world?  It’s one thing to train people, it’s another to sustain them, maintain them, help support them in their career growth.  In many parts of the world, anesthesiologists might be the only one in a community or in a large geographic area.  We need to find ways to support them – simple things like continuing education, how to learn new techniques, how to have collaboration/cooperation when you have a difficult case, how to work together to improve not only educational systems, but care systems, how to lobby ministers of health and education.  These are difficult things, even for those with a lot of resources.   David:  I don’t know how big you want to go, but you are definitely familiar with Africa. . .what is the picture of the need for anesthesia in Africa?  Elizabeth:  I think it’s safe to say, the need is probably overwhelming and staggering.  If you could actually think what the need is, you could get depressed, thinking how would we ever meet the need?  The standards that organizations like the WFSA advocate for are in terms of how many providers you need per population.  In terms of a place like the US, we’re way above recommended minimum which might be 10-20 surgeons, anesthesiologists, obstetricians per 100,000 population.  In many countries in Africa, those are in single digits.  For example, Ethiopia, which has more than 100 million population has a couple dozen anesthesiologists.  On any given day, there are more than that at my one hospital in the United States.  Kenyan and Uganda are a little better, but not a lot.  Most of Sub-Saharan Africa, which is what I’m most familiar with, has such a lack of anesthesiologists.  Even if you look at other anesthesia providers, whether they are nurse anesthetists or KRNAs or different names that are given to non-physician anesthesia providers. . .even when you count those, they are not enough to care of the population. First and foremost, we have got to find ways to increase the numbers of providers.  But that in itself is not sufficient.  You need numbers, but you need quality care.  In addition to that, you need the support systems.  You need a hospital that has water and electricity and understands the basic concepts of sterile technique and infection prevention and control, and quality & safety systems that support surgical care.  Then you have to have pre-op and post-op care.  You need nurses and you need ways for patients to get to a hospital.  You need to figure out which hospitals should be doing which types of surgical procedures.  Each country has its own political and governmental ways that’s organized.  There are certainly limitations in what is available.  There is a never-ending need.  You can easily get overwhelmed with thinking about the need.  When that gets too overwhelming to me, I like to back off and think, what can we do and how can we make an impact? Taking care of one patient is one thing.  Teaching someone else to take care of that patient is a secondary thing.  Then teaching people how to teach other people to take care of that patient has a magnifying effect.  And then helping anesthesiologists, among others, understand what it takes to make that whole system is important.  A surgeon can’t do it alone.  Anesthesiologists are an important part of the whole team that needs to provide excellent peri-operative care.  In too many situations, anesthesiologists and others are an afterthought.  David:  This is something I was ignorant about.  What is the role of an anesthesiologist in a developing country?  It’s a lot broader sometimes than what it is in America, right? Elizabeth: The American medical education system is a little different from many other countries in the world, even Western countries.  The length of education, the responsibilities, how it’s organized and paid for.  It’s a different system of how care is delivered.  In the United States, in academic medical centers with trainees, there is always an anesthesiologist available, so a resident who is a trainee is never caring for a patient without supervision of a fully trained anesthesiologist.  Our medical education hierarchies are pretty well described.  And the delivery of care is pretty well structured and organized.  That is not necessarily true in most LMICs.  There are different levels of anesthesia providers who are doing the best they can with the education they have and the tools, equipment, medications that are available to them.  But in a place like rural Ethiopia, for a population of 1 million in one area, there might be one physician, and that’s not an anesthesiologist, that’s a general practitioner.  In the way that a physician cannot be responsible for all the medical care, there is certainly no way an anesthesiologist cannot be responsible for all anesthesia care.  The same is true for surgeons.  So, you have rural hospitals, whether they’re called district hospitals, or whatever, you can get basic medical care.  If you show up with a broken leg or an infection, you may get some level of care.  You might get some antibiotics, or your infection cleared out, or a cast for your broken leg.  If you need something more sophisticated, you have to go somewhere else.  Anesthesia care is the same way, the most highly trained anesthesia professionals are usually in the big cities and in big hospitals, which means the rural areas are less well-served, not only by anesthesia providers, but by surgeons and nurses and equipment.  One of the challenges is One of the challenges is finding a way to provide the needed care in the rural areas and matching all the needs together.  It doesn’t do you any good to have a surgeon but no anesthesia provider, or the other way around, an anesthesia provider with nothing to do because there is no surgeon. One of the things that has become evident over the last decade or so is - what is the bare essential minimum?  The Lancet commission describes Bellwether procedures.  They have a list of procedures that are the minimal procedures you want to be able to do in a district hospital, not a tertiary care hospital.  Things like treatment of abscess, putting a tube in if someone has a collapsed lung.  If your hospital can do these three things, you can probably meet the basic needs of your community.  These are emergency c-section, fixing a leg fracture that requires operative intervention, and doing emergency surgery for an abdominal issue.  If you can do those three things, and have the anesthesia team, you can meet the surgical needs of the community at a basic level.  None of that is necessary glamorous.  It’s not plastic surgery.  It’s not elective.  It’s basic surgical needs, and if you can meet those, you can meet the needs of the community.  Those are the goals that governments and institutions are working towards – how can we provide those basic needs?  David: In Kijabe, for the developing world, we are a pretty advanced setting.  What does somewhere like Kijabe make it worth investing in for these training programs?  We are in the in-between space.  We are rural, but not super-rural, you can get to Kijabe in an hour-and-a-half from Nairobi.  Is Kijabe an ideal set-up, in some ways, as you look at the training sites you have been involved with.  What makes you happy about what we are starting out with?  Elizabeth: A couple of things.  Clearly, the basic infrastructure exists at Kijabe to provide comprehensive care to a whole population.  That’s from birth to adulthood.  That’s from basic outpatient needs to complex surgical intervention that requires intensive care afterwards to survive and get back to health.  In that sense, it’s not a rural, remote place that does a few things, but it has comprehensive care.  It doesn’t offer everything to everybody that a bigger city might, but you don’t need everything, everywhere.  From that sense, it’s really a good way to look at what does a population need in order to not only meet the basic minimum, but to try to use the advances in medical and surgical care to improve someone’s health, not just react to when you fall and break your leg or infection, but how can we try to promote health among a population.  Kijabe allows people who are learning and training, and people who are more advanced in their career, to see the value of working together in teams and partnerships.  For too much of medical history and training in America and many Western countries, there are hierarchies and traditions of who is in charge, and who has the power, and who gets to make the decisions which may or may not be in the patient’s best interest – a culture of education and training which is not necessarily supportive and positive.  Those things are slowly coming to light and being addressed in American medical education, although we have a long way to go, IMO.  I think, in a place like Kijabe, the camaraderie people develop by living and working together in a small community and over a long period of time shows the value and benefit of partnerships and collaborations and working together to try to improve the health of your community. . . In a place like Kijabe, having anesthesiologist training will help show that physician anesthesiologists and non-physician anesthesia providers can work together collaboratively.  There are too many examples around the world where relationships of different providers are antagonistic.  It happens among anesthesiologists. It happens among another health care professionals.  In a place like America, where there are other factors at play, politics and finances, it detracts from the care that patients need.  There is value in people seeing the benefit of collaborative relationships.  For much of medical history, surgeons and anesthesiologist haven’t always been collaborative and working together.  Some hospitals have better cultures than others, and it’s clearly beneficial for patients if they work together, but that’s not always the case, so that has to be modeled.  Same between specialists.  If an EM physician asks for help from a urologist or general surgeon and the attitude is “why are you bothering me?” nobody benefits from that.  In a place where everyone is in it together, people learn this attitude.  Another thing that Kijabe is working towards is finding ways to train people to go into communities where there is not the level of care that Kijabe offers.  That’s a tricky thing to teach someone to do.  You want them to have every benefit, but you want to train them, “what happens when you to go into an area where you don’t have all this stuff?”  That’s true in America, that’s true in Africa.  It’s difficult, it’s not a simple formula.  It does help remind you to learn the basics, and how to do no harm, how to prepare and advocate for what you need.  If we train these people and they all end up in Nairobi, it doesn’t do any good for the rest of the country necessarily.  Finding that balance is difficult, and it’s going to take thoughtful dialogue among leaders about how to meet those needs.  One of the things that some of the training programs have in Kijabe have worked on is to train people to go to other places in Kenya and other places in Africa where there are not so many.  If you can provide a team, a surgeon and anesthesiologist and other support staff, for an operating room at a hospital, that’s what you need.  David:  Your answers made me really happy.  It’s easy for someone like me to overlook the culture of collaboration.  When I had surgery a few years ago, Mark [Newton] did the anesthesia.  Mark called Mike [Mara], the orthopaedic surgeon, and Mike called Rich [Davis], and they’re all together working with me, and they’re all friends, together working on me.  I haven’t thought, until you said this, what it means to be living together in this community as neighbors.  It’s fun.  It will be interesting to see who are the first residents in the class.  We go to their kid’s birthday parties.  It’s a special place to get to know each other on many and deep levels. Anything we should talk about to wrap up? Elizabeth: We just had a series of interviews for applications in the first class of trainees.  Hopefully in the next weeks and months, we’ll be able to move ahead with selecting our first two trainees.  Our initial goal was to start this month, but because of COVID, government regulations, we’re not there, but hopefully this year we’ll be able to start with the first two.  We have to balance the needs, to train those two well, and make sure we support them.  It’s a beginning of the journey, not the end, many more trainees who can train other people, who can go out and provide care that needs to happen around the world.  David:  I speak on behalf of Kijabe when I say this, we are grateful to you for your support and advocacy in getting this program to where it can take off.  Thank you. 

Olakunle Idowu – Anesthesiologist, MD Anderson David: I know you said it’s a long story, but I’d love to hear the short version of the long story.  I’m Nigerian, I was actually born in Nigeria.  I’m the last of four children.  My siblings were born in Boston, but my father, who is a math professor took a position at the university of Dos.  We were living there when I was born.  I came to the United States when I was 3 years old.   I grew up in Maryland, went to University of Maryland, I’m a Terrapin.  I went to the Virginia Commonwealth University for medical school, SUNY Downstate in Brooklyn, NY for Anesthesia Residency, and Critical Care here in Houston, which is what brought me to Houston.   Since then I’ve spent time in private practice and in academics.   Initially I left private practice and came MD Anderson for 3 years, then my wife was recruited to Yale in New Haven CT, we went there for a year, decided to come back, and here I am!  (Laughter) There’s been some moving and shifting, but I think along the way that God has revealed things to us.  We feel Houston is home even though our families are in the northeast.   My wife is a pediatric anesthesiologist, she works at MD Anderson as well.   David: When you say critical care, is that anesthesia or normal medicine.   Kunle: The track is critical care through anesthesia, it’s a one-year internship after training, I spent a year at UT Houston, and during part of that time I was at MD Anderson, which is how I connected to the institution.   David: What do you love about your work?  Why anesthesia?  Aside from talking to me, what gets you out of bed in the morning? Kunle: (audio drops briefly) Learning includes lessons about life, about vulnerability, about faith, about spirituality, about strength, perseverance, about conflict.  I think working both in the operating room and also having experiences in critical care. . .they’re very different environments.   In the operating room, most people walk into the hospital, most procedures tend to be elective, the intent is that things end well.  That is always the expected outcome, or what people perceive as a good outcome – to get through surgery or whatever procedure they are having.   In the ICU the dynamic is very different.  Expectations and goals change daily, hourly, by the minute depending on the patient situation.  Sometimes you find yourself healing not through intervention but through support and prayer and walking side-by-side with patients.  That is where my energy comes from, that’s what wakes me up.   You know, I drink coffee like most people, to get me going.  But somehow when I get in front of a patient I’m up, I’m there, I’m present.  David: Have you done any overseas work lately?  What you describe sounds like the role of somewhere like Kijabe.  When an anesthesiologist comes, they are everywhere, they’re in the operating room, they’re in the ICU, they’re in the emergency department if something goes strange. . .they’re everywhere.   Kunle: Compared to some of the other people involved in this project, I’m fairly new.  I’ll tell you that story.   In coming back to MD Anderson, I pivoted in terms of focus.  There’s something in me, and there’s something that’s always been in me.  I have relatives or people who are Nigerian, who came here as immigrants who for training with the intent of going back.  My father came to the States for post-graduate training, but never returned to Nigeria permanently.  So, I’ve understood that there has always been this void, not only in Nigeria, but across the continent, in terms of people who receive opportunities who receive opportunities overseas whether in the States or across the world, and never return.  It’s almost like there’s a resource that’s been taken away. . .people don’t go back to even plant seeds to grow.  I think people are realizing this, and that itch. . .I’ve always had that itch to be involved in this work.   I was initially looking to do things in Nigeria and I was looking to start projects I was looking to start a symposium and looking for schools/teaching hospitals in Nigeria to connect with.  I connected with HBO.  They have a site at Kat Karmasi, Ghana.  My wife and I were set up to go this April for a two-week trip.  She was going to help with Pediatric Anesthesia education and I was going to teach a fundamentals critical-care support course, because critical care mortality is extremely high across the continent.  That is one thing that is very clear.  The contact I have there is very concerned about obstetric mortality, the availability of resources and ventilators is limited.  I work with Louis Pisters, a urologist at MD Anderson, and he’s connected with PAACS.  He said, “you know, I work with a great organization.”  He’s a person of strong faith and conviction.  I attended a meeting with PAACS and learned that there was an Anesthesia task force.  Everything about the project aligns with my personal goals and how I see myself.  It brings my faith, it aligns my faith, my practice, and this internal feeling – this urge – to start doing more global outreach.  The timing couldn’t be better, and I have support from my institution to do this.   That’s how I got involved.  Long story, but I’m extremely excited because at the center of it is God, and my love for Christ.   Through medicine, I’ve affirmed the idea that only God can perform miracles.  We are tools that he has put here to carry out his will and to be blessings upon others.  You know, blessed to be a blessing in a sense.  That’s how I practice and that’s how I see this project.  Everything that I’ve come to understand about Kijabe, that’s my understanding of the center, of the people there, of you and your work.  I’m just excited and so very thankful and grateful.   David: That’s awesome Have you ever heard of Howard Thurman?  He was an African American pastor.  He was Martin Luther King’s spiritual mentor.  I went down the rabbit trail this weekend and I ended up with a book of his sermons that I got on Amazon for a dollar – that’s the best dollar I’ll ever spend – he’s got this amazing passage about medicine as ministry.  It’s so, so good and reminds me of what you just said. He goes through the entire passage and ends up with the statement that “every hospital, every clinic, every consultation room should be an altar for the burning heart of God.”   Kunle: Absolutely.  You can almost draw a parallel to the pandemic.  You see how limited our understanding of the human body and where is this virus coming from?  All these resources focused on one thing. Right? Its human will that we are going to control this, yet every day we are reminded that we are not in control. There is only one person in control of all of this.    These are the same interactions that happen on a daily basis in the hospital.  When it comes to cancer care you realize it.  People often want to treat the numbers, or they see a CT scan. “I have to fix this.”  That’s the human instinct.   You learn how limited you are, in the sense that you could do everything and not change the outcome.  You could do nothing, and the outcome can be favorable for the patient.  It’s because God is in the center of it.  He has a masterplan.  You have to step back, realize your place, that you are just a tool.  You cannot fix the situation. You just have to trust God.   That’s why I bring spirituality and I bring faith.  MD Anderson is obviously not known per se as a Christian institution.  I always ask people, are you a person of faith?  Regardless of their background, most other religions or people who consider themselves as being spiritual, they are open to prayer.  Prayer is universal, for everyone.  I pray for them.  I know my father, but I pray for them.  I love that aspect of medicine.   David: If we get you over here, you’ll meet Jack Barasa, our head of surgery.  Whenever you talk to him, he says a similar thing about Kijabe “this is God’s hospital.”  He says, “We do these things, and somehow a patient gets better.  We do the exact right thing and they don’t get better.  Or we make a mistake and somehow, they walk out the door three days later.  It’s very clear that we are not the ones in control of the situation.”  My wife had this awesome mentor in Alabama.  When she was in residency, she had a really low moment.  Her program director called her into her office, and she said, “Arianna, you need to trust God. You do not hold the keys to life and death.  A patient could walk in the door, and they could walk out even if you do everything wrong.  This is ultimately not about you.” That’s the big challenge of what you do in medicine, how to work with all your skill and all your power yet know your limitations and to be at peace with that at the end of the day.  Kunle: I think about these things every day.  I reflect on the day and the lessons learned.   Even for me, as I’m caring for patients in stressful situations, that He is my quiet in the middle of the storm.  I can only trust Him to give me the thoughts, wisdom, understanding, compassion.  It has made me a better person, ultimately.  David: What do you say to a family member, say you’re in ICU and you have a patient who is not doing well. How does it go?  What is running through your head and what are you trying to convey to them?  Kunle: It’s tricky, a lot of it depends on their background.  It depends on their knowledge of medicine.  It depends on the conversations they have had prior to the moment.  In critical care, you tend to have limited access to the patient’s perspective.  Either because people are too ill to communicate, or because they are on mechanical ventilation and have a breathing tube and they just can’t talk.  So, you have to rely on surrogates.   I take a few days, when a patient isn’t doing how I would expect.  I take a few days and really try to understand the situation, before I jump in and try to give a perspective.  I want the family or the caregivers to know I am taking my time to reflect, to comb through things, and make sure we have explored all options.  I ensure through communication and bedside manner that I am there to support them in any way that I can, whether that is moving around hospital resources and so forth.  I remain objective about the data points.   “This is what this shows, this is where we are, this is where we were yesterday.  Your loved one (the patient) doesn’t have control of the situation, I don’t have control of that situation, and you don’t have control of the situation.  So, we must take it one day at a time, using God-given tools every single day to apply.  He will show and reveal to us how your loved-one responds.  In the meantime, the tool that we have, the most powerful one, is prayer.”   I remind them, I pray with them, and I offer the hospital chaplains for support.  Sometimes in situations when there is no family around, we still bring chaplains in to pray, or I will pray.  That’s typically how it goes.   I’ve seen a difference from when I first started practicing, because people trust you more, they understand you can’t fix the situation, and they know that you’re on their side.  It also reminds them that in the middle of all storms, you must stand firm and rest in your faith. . .in God, in Christ, and he will see you through.   I don’t have to go too far to know how blessed I am in a cancer hospital. I’m reminded every day.  It’s a topic that really hits home, and I spend a lot of time in this area because of how important it is to me.   David: That was an amazing answer actually.  Always when I’m doing these things, I’m thinking what is a universal concept?  Beyond we are trying to put this (anesthesiology) program together.  When someone is going to connect with on a personal level, whether they do medical work, but I think it applies to any area of our lives.   Anything you would like to add in closing?   Kunle:  I would like to say I think it’s exciting to be involved in something like this.  My hope for this project is that it expands – on God’s time – to different parts of Africa, because the need is there.  Not just in anesthesia, but in emergency medicine, in surgery.  There are so many specialties and there is so much expertise needed.  You have people there who want the knowledge, who want the help, who need the resources.  And you also have people who are unfortunately dying from very preventable illnesses, diseases.  We want to use God’s given tools to help.  Those tools are knowledge.  Those tools are prayer, that’s the best one in the box.  Community support.  The resources that we can pull together from our institutions in the United States.  The great resource in having the Christian community at the soul of all this, that unites us, and I’m very excited about the future.   David: Kunle, this is fantastic.  I would talk to you all day if you were not going to work.   Kunle:  Thank you so much.  

Greg Sund David: [00:00:00] Good afternoon and good evening. We have no idea what time zone you guys will be in when you're watching this, but I am David Shirk. I'm director of Friends of Kijabe, and I'm sitting here with Greg Sund, our newest addition to the Kijabe team. Greg: [00:00:17] We moved here from a small village, rural hospital in Burundi, where we have been for about five years. David: [00:00:26] What was your training and background and specialty in the States before you started doing this Africa stuff? Greg: [00:00:34] So I'm a board-certified anesthesiologist. I did a fellowship in cardiothoracic anesthesia and I was in private practice for several years before we moved to Burundi about five years ago. And during my time in private practice, I was doing annual trips to various places in Africa and kind of prayerfully trying to discern with my wife where God might be calling us to. And we ended up at this hospital in Burundi, which was a teaching hospital, and it was a place where I could not just do anesthesia, but also teach anaesthesia to medical students and nonphysicians.  David: [00:01:22] What was the terminology for them?  Here we call them KRNA, Kenya Registered Nurse Anesthetist. Did you guys have a designation? Greg: [00:01:29] So that's one of the problems, is that the training for nonphysician anaesthetists is variable from country to country. In Africa, there's no continent wide standard. And so in Burundi, they were anesthesia technicians and so they had a bit less training than the Kenyan nurse anesthetists have here. And unfortunately, it's different in every country. And unfortunately, there's still a lot of hospitals in sub-Saharan Africa where the anesthesia is being provided by underqualified and sometimes not even trained providers who are just there to fill in the gaps. David: [00:02:13] And this was the case in Kijabe for a very long time. I want to get into Burundi, I want to hear more about that, because I actually don't know - I know you, and I know some of your colleagues, but I don't know much about the hospital and particularly the medical kind of situation that you guys were facing there before that. Why does somebody who's a private practice anesthesiologist in America walk away from that and move to Africa? Greg: [00:02:42] Yeah, well, ultimately, it was definitely a calling from the Lord that he laid on our hearts after doing frequent trips to Africa. I saw just the massive discrepancy in anesthesia care between what's going on in most of sub-Saharan Africa and what's going on and in the United States. And I was just really convicted that here I have the ability and the capacity to go to a place like Burundi or Kenya and teach anesthesia. And it was something that the Lord laid on my heart and thankfully on my wife's heart as well. David: [00:03:23] That's awesome.  And you guys came out...so you've been doing short travel trips and then you moved for a year in 2013? Greg: [00:03:31] Yeah, it was twenty fourteen. We moved to Burundi for a year and we joined a multi-specialist team that had just settled there a few months earlier that I had met on one of these short-term trips to Tenwek hospital in Kenya in 2010. We heard they were moving there [Burundi]. They had three surgical specialists and the anesthesia care at the time was provided by one non-physician anesthetist with coverage by some, actually, non-trained, providers. Their community health worker, who normally gives vaccines, was taught how to give Ketamine to get people through surgeries and caesarean sections on at nights and on the weekends. They asked me if we would come out for initially for a year to help work with this one non-physician anaesthetist to try to help increase her capacity for what she could do, and during our year there, we realized that there's actually, an anesthetist training program that sends students to this [Kibuye] hospital.  They're actually medical students who had a required anesthesia in critical care rotation and there was no anesthesiologist to teach them. And so we felt like this is where we were called to be for longer than just one year. So we went back to the States to support raise for a year, and then to France for a year for language training, because it's a Francophone country, and then in twenty-seventeen we moved there and we've been there up until just a few months ago. David: [00:05:12] We've had this KRNA program in Kijabe for about a decade [2007]. Officially. I think before that, unofficially. What what is the difference between anesthesiology training for a physician level anesthesiologist versus for nurse-level in Africa? Greg: [00:05:34] In general, nonphysician anaesthetists are there to put the patients to sleep, to monitor them during surgery, to wake them up. Physician anesthesiologists are there to be consultants for more complicated cases, when complications arise at any time during the perioperative period. They are also, typically in Africa, the ones that will be a lot more involved in intensive care medicine, in post-operative pain management, and also in leading and teaching medical students, anaesthetists, students and other other health care specialists that that need some training in anesthesia, critical care and or resuscitation. David: [00:06:31] What's what did ICU care look like in Burundi versus what it looks like somewhere like Kenya?  I know Kenya, we're behind America, but you still walk in to [Kijabe] ICU and we've got real ventilators and usually good oxygen supply, right? Greg: [00:06:49] Yeah, I think in the entire country of Burundi, there are about 12 ICU ventilators, unfortunately, none of them are at the hospital that I worked at. Those are all at the main university teaching hospital in the capital city. And when we arrived, there was no Intensive Care Unit. During my time there, we made a small step forward by designating four surgical beds that we were where we were able to do a little bit more intensive monitoring, nursing surveillance. But it was still a far cry from what you have at Kijabe, and what we're used to in the U.S. David: [00:07:35] What would what you want to see if you were to think five, 10, 15, 20 years out? What would you like to see happen in our region, in East Africa?  You could speak to Burundi or you can...I don't know how familiar you are with other countries?  So answer however you want. Greg: [00:07:57] I would say anesthesia care and critical care in general are very variable right now. And there are a lot of places where anesthesia is simply not safe. Mortality under surgery in sub-Saharan Africa, in general, is twice what it is in the US. And so there needs to be a great deal more invested in training nonphysician anaesthetists, which ultimately needs to be done by physician anesthetists. And that's kind of leading into why we decided to move to Kenya. David: [00:08:34] Awesome. David: [00:08:35] Mark Newton does some sessions here just on training. Training trainers, essentially. That's the that's the vision, right? Greg: [00:08:43] If you're teaching people who are qualified to teach others, that's the Biblical model from the 2 Timothy Chapter 2 - "teach others who will be able to teach others who will be able to teach others." Greg: [00:08:57] And so that's a big part of why we moved here. We saw that what we were doing, training nonphysician anesthesia providers in Burundi and medical students was good work and it was important, but it wasn't sustainable in the long term. And so in Burundi, for example, there are only seven physician anesthesiologists..  [00:09:20] I was the only one working outside the capital city. And so that leaves the vast majority of hospitals without any anesthesia consultants, without somebody who can manage critically-ill patients in an intensive care setting. And so ultimately, during our time in Burundi, I came to realize that Burundi was not alone. There are a lot of other East-African countries where this is the case. [00:09:47] If you look at the numbers, there is a recommendation by the World Federation of Anesthesiologists to have a minimum five physician anesthesiologists per one-hundred-thousand population. David: [00:10:06] How many people are in Burundi? Greg: [00:10:08] So the number in Burundi came out to. . .it was about zero point zero one eight [0.018/100,000], I believe.  It's better in Kenya [1.7/100,000], but it's still far from five per one-hundred-thousand. And so I came to realize over our time in Burundi that sub-Saharan Africa, while it does need more nonphysician anaesthetists, in order to to form and train more nonphysician anesthetists, we have to, at the same time, train physician anesthesiologists. David: [00:10:41] So what has the groundwork looked like for building up to this training program starting? Greg: [00:10:47] There started to be some discussions going on between a small group of us who are anaesthesiologists, who are missionaries in Africa in twenty-seventeen. Three years ago, and most of us had been exposed to or involved in helping to do some anesthesia training with surgeons under the PAACS, which is the Pan African Academy of Christian Surgeons. And so we already had some relational foundation with PAACS programs and the leadership of PAACS. We started talking together as a group about the need to start creating Anesthesiology Physician Anesthetist training program.  It seemed to us logical to try to partner with PAACS. And so, last year at the PAACS board meeting in Chicago, a group of us went and presented the idea of starting an initial, anesthesiology residency program under the umbrella of PAACS to their board. It was received favorably and they agreed to allow us to start this initial program in January twenty-twenty-one here in Kijabe. David: [00:12:06] Awesome. David: [00:12:07] And what has to what has to fall in place for things to kick off in January? I assume there's a few things. Greg: [00:12:16] Thankfully we have now three board certified physician anesthesiologists that will be serving here myself, Dr. Roger Barnette and Dr. Mark Newton. Both of them have been here already previously for several years. So that's the first piece. And we can check that one off. The second piece is we do need funding to support this program. To train each resident costs about twenty-five-thousand dollars a year per resident. Greg: [00:12:53] Our plan is to start with two residents and build up from there. And so we are currently in the support raising phase of this. David: [00:13:03] How long is the program? Is it three years? Greg: [00:13:05] Yes. So, all of our, anesthesiology residents will have done one a one year internship that might be done in Kijabe. It might be done elsewhere. But once they're once they've completed that, it will be three years of anesthesia and critical care training also. David: [00:13:26] That means total sort of three years. So seventy-five-thousand dollars per resident to get through the entire program. Greg: [00:13:36] The other thing you know, once that piece falls into place, the next thing we need to do is recruit our first two residents. The announcement that we would be starting this program was just sent out three weeks ago. Within a week we had over one hundred inquiries and within a week later, we had over 30 applications already submitted. We're currently, the the anesthesiology council under PAACS, is currently in the process of going through those applications,to find who will be our first two residents. David: [00:14:15] It's exciting. Yeah, it is really, really cool. It's been a dream long, long coming. David: [00:14:22] And then the other side of this, I assume that these guys will do have a bond service bond similar to how the surgeons do so, where the surgeons, if they come under PAACS, they're obligated to work the same number of years at a Christian Mission Hospital. Is that the same? Greg: [00:14:41] So that's our plan. And that's the model. Greg: [00:14:45] A big reason for that is because typically it is the rural areas that are that are underserved, both in terms of surgeons and anesthesiologists. And so, we're really looking to to recruit and train people who are going to go to those hard places and live in those rural areas where, you know, unfortunately, their salaries might not be as high as they would be in the city. And, their lifestyle is going to be very different. So, it's definitely a calling from the Lord, because they're going to have to give up a lot of the lifestyle that they might have in the bigger cities. Greg: [00:15:23] So that is our plan, to recruit residents who are who want to do that,  are willing to serve in rural mission hospitals after their training is done. David: [00:15:37] It might be worth explaining, because I'm sure some people will not be familiar with terms like missionary.  If somebody is not familiar with how the structure works, missionary might sound like an odd or archaic word. But but it's important to set up like what the need is because it gives a framework for what somebody like you or Roger Barnette or Mark Newton, how your life looks logistically, and why we need people to help with this training program. So what does it mean to be a missionary and how does that process work for you being here? Greg: [00:16:24] Wow, that's a that's a big question. David: [00:16:27] I mean, more practically than theologically, it's somebody who is sent by God. I felt a you talked a little about that in the beginning, as a spiritual call from God. This is your purpose. This is what you feel like you're being led toward in your life. But then what does that what does it look like practically after that? Greg: [00:16:49] I think those of us who are doing this feel called to to go to places where we can minister to the needs of people, both physically and spiritually. And so, you know, we're not just here to teach anesthesia. I'm not just here to teach anaesthesia, but also to to to disciple and to try and deepen my students, my residents, and hopefully my patients, to the understanding of who Jesus is, what he's done for me and and and the world, and point them to the hope that we have in him. Greg: [00:17:28] Logistically speaking, those of us who are missionaries working in medicine outside of the U.S., typically that means that we give up our salaries and we have to live off the support of others. So for all of us, we have a team of supporters in the U.S. Who give some give once a year, some give monthly, to meet all of our the expenses that that we have our living expenses and that allow us to be here and do this work. So for a lot of us that's going to be churches in the US or individual families. But that's really the only way that we can be here and continue to do this work. Greg: [00:18:17] Then that financial support goes through our mission agency. We are here under mission agencies who also care for us, who keep an eye on us, who help us logistically with all the particularities that come with living in rural Africa, which we can't be here doing what we're doing without them either. David: [00:18:42] I think this is helpful for people to understand the framework and complexity because we've talked about several organizations, and I don't want anybody's heads to get muddled over by this. But it's just important to know that it takes multiple organizations to make these things happen. So, they have their different roles. Your mission agency is Serge. But we've got PAACS, who's the overseeing body for the for these [training] programs. And we've got COSECSA, the College of Surgeons of East, Central, and Southern Africa, who's the accrediting body for the thing. And then we've got the little organization out of all of them, Friends of Kijabe, which is our nonprofit just dedicated to Kijabe Hospital.  David: [00:19:31] You have a great question of "Why, David, why are you doing this? What's your role in this process?  Why would funds come to Friends of Kijabe instead of PAACS?" David: [00:19:42] The short answer is ultimately funds are going to both. But Friends of Kijabe, we have connections with people who pass through here over time. And Kijabe Hospital has been around for 100 years. I think we're...2020...we just turned one-hundred and five [105] in May. So there's just a deep, deep network of people who care. And ultimately, this is why I think Kijabe is a cool place, is because we get to be part of these training programs that affect not just this one place, but affect the entire region. So for me personally, my role is just to help you guys amplify your message with the people we already have connected. And so that's our hope with Friends of Kijabe - essentially as money comes into Friends of Kijabe, a portion goes to PAACS for the education resources and a portion ends up at Kijabe Hospital. And we will just, really, follow the Anesthesia Council's instructions on where to write the check.  The biggest involvement of Friends of Kijabe, though, is the storytelling and connecting donors and just helping, hopefully, in that process. Greg: [00:21:03] Yeah, we're really grateful for friends of Kijabe. As I mentioned, the need to raise twenty-five thousand dollars a year per resident to us is a big part of this. And we are, as an Anesthesia Council, not really equipped to to do that. And so we were really grateful David and Friends of Kijabe agreed to help us with that with that arm of this program, as these guys are amazing. David: [00:21:34] You know, I spent a lot of time with Roger Barnette over the years, a lot of time with Mark Newton, and what they do for our countries, Kenya and Burundi, and for these parts of the region, and for our world, these guys are amazing.  For you [listening] as potential volunteers, once the world returns to normal, you will be really, really valuable. I know there's some people probably watching this. Joleen has been here. Usually, every summer she will come over for a month. I believe Liz Drum has been here before. Matt Kynes, we're hoping to get him here for a longer term basis, but he's been here, pretty regularly, teaching. And I know Roger Barnette has had some folks over from Temple and Mark Newton has brought folks from Vanderbilt.  Those connections are also really, really, really important.So if you're watching [or listening to] this, I know for some of you it may be possible on a regular schedule, and for some of you and may be less frequent, but it is a huge, huge, huge help for the people doing this [anesthesiology] on a daily basis, to either give them an extra hand, or give them a week or two off, where they can recover and get back into the fray. So definitely, as if you're watching this, keep that [a volunteer visit] in the back of your mind. David: [00:22:54] Also, how you can participate?  There's really three ways of really participating. You know, there's the financial component, there's the volunteer component, and then there's making connections with with colleagues that you may have around the States or around the world.Anything you would add to that? Greg: [00:23:19] No, I would second everything you just said. And yeah, I would encourage any anesthesiologist out there who's watching this, to come see for yourself. Kijabe is a really special place. A big part of the reason why we're able to start this program is because Kijabe is a place where we do get short-term volunteers who come and help and teach and give the long term folks a break. And it also is great because it gives the students a different perspective, because everybody who comes has something different to teach different areas of expertise, different experiences to share. And and all that, I think, is what's going to make this program so rich. David: [00:24:04] For me, this is really exciting because I've come in with my wife, Arianna, a pediatric emergency medicine doctor. We've been in Kijabe almost seven years now. When we came, we would hear legends, honestly, about these people who started these programs and how they came to be. So for me, just looking at this, this is just amazing. This is something that one hundred years from now, people are going to look back on and think, "Wow, this started there in this specific place with these people." Greg: [00:24:41] Thank you, David. Appreciate all that time and all your help. So it's exciting. David: [00:24:46] And so for all you guys out there who might be watching [or listening to] this, thank you in advance for however you are able to join us in making this making this dream of better quality, more accessible, more affordable health care a reality for people everywhere in the world. So thank you. Thank you.

David: So today I'm talking with a pastor Benjamin.  What's your full name and what your role at Kijabe Hospital? Benjamin: My full name is Pastor Benjamin Kioko Mutuku.  My role in Kijabe Hospital is being the staff chaplain in the department of chaplaincy, dealing with the staff in the hospital - spiritual, psychosocial needs.   David: I don't think this role exists, very much, in America. I don't think it's normal.  Usually when people think of hospital chaplains, they think of what your teammates do - visiting with patients and visiting with families in crisis.  But, a lot of your work is with staff members.   Benjamin: Yes, yes.  David: I assume probably a lot of that work is in crisis, maybe some of it is during peacetime.  Benjamin: Yeah, one of the main things that I think the hospital had in mind when they advertised for the position, was the realization that the staff get so much fatigued. While we have chaplains who talk to patients and chaplains who are assuring in relatives and praying with them, no one does that with the staff. And so that's how the role came up.   Coming in, it was interesting, it was one of those difficult things, that you don't know that exactly where to start. It was a new office. I came in with my senior, Reverend Ndivo, who was coming in as a manager. For both of us, it was new.   What year was that?  Benjamin: It was 2014 and we were...  David: So, we came (to Kijabe) together. . . Benjamin: Yes, we are growing old. Yes, so the has been several years of a lot of the experience. I think I have learned a lot being in in this office  David: Maybe it's such an obvious question is that it’s silly to ask, because I know most people listening this are medical, but what are the challenge or challenges for being a staff, a medical person, in this environment? Benjamin: One of the greatest challenges is trying to understand people in their context.  A lot of times the things that people struggle with at work, they carry them from home.  So, its. . .that people have baggage they're carrying, and that affects their productivity. Secondly, us being a Christian institution there's always the question of how we integrate my faith and break the sacred/secular divide.   My faith and a profession. How integrate them? So that I'm a Christian throughout and not just one in a while David: Yes, you're not here for eight hours being one thing and then home being another. I feel like this got me. Something I had to do for friends of Kijabe, they wanted a donation to be used only for secular purposes, but there's not a delineation between secular and faith-based in Kijabe, A CT scan is not a Christian CT scan or a non-Christian CT scan.  It's a CT scan, and its part of the whole process of giving somebody healing.  There's not such a clear delineation between somebody's body and their mind and their spirit.  Benjamin: Exactly.  David: And that's what you guys are trying to address.  Benjamin: Sure.  A Christocentric approach life is ideally the mentality that we are looking at.  That every staff who comes to Kijabe hospital realizes that everything we do, we want to do it to the glory of God. Yet, they come with marital issues.  They have the baggages of relationships, they have baggages of families breaking up and economic issues.  A lot of times you meeting people here, and you're asking yourself, "So we exactly where do I start?” I think one of the refreshing facts around my experience, I realize that I am not and end.  I have the responsibility of pointing them to Christ.  That makes the difference, and I think that has helped my work be a bit easier.  Someone comes with an issue that is affecting their productivity, affecting their delivery. I want to point them to Christ as a solution to their issues.  Another person who comes - the doctors, nurses have had a bad outcome and they need debriefing.  I’ll need to come in and help with debriefing them and also supporting them, psycho-socially, psycho-spiritually.  All that has been happening around on this office and it's quite an interesting. . . adventure, I’ll call it.  David: So, pretend I'm a doctor and I just made a mistake, or I have done something that led to a bad outcome.  What would you say to me? I would want you first to appreciate your limitation as a person, as, actually, a gift that points you to God.  You realize that you are not one who owns all knowledge, it is owned by God.  I think one of the most important things is when you give your best, at times it's not even the best there is, that can ever be given.  Even sometimes, your best will not always be the best.   I want to help you come to that realization and I want to walk you through your mind.  What exactly is going through your mind?  What did you expect from yourself? And do you think that you had greater expectations of yourself than you can actually do, or did you rely on the knowledge of God.  Are you getting to a place of self-blame?  I just want to walk you out of that thought process to a place you can actually say that, it's okay, at times, to not know and be okay with it. I think what I want to bring out of your mind is the fact that you are not the solution to people's lives.  You are a vessel that God uses.  Together as you are doing the work you are doing to help people, you are pointing to His sufficiency, not your own.   David:  Wow.  That’s really, really important. That was actually a huge part of Arianna’s journey before we even came here, was getting some advice that the control that somebody has, as a doctor, is limited.  They can do their best they can do the extent of their knowledge, but this person does not actually hold the keys to life and death. Benjamin: That's right, exactly.  David: Sometimes a person does their best and it doesn't work out, and sometimes they make mistakes and the patient is fine.  Benjamin.  That’s the truth.  Exactly.  Yes.  You make mistakes that you are really sure are actually mistakes you're wondering how this patient is surviving.  And they’re doing very well.  The sovereignty of God out of the whole situation stands out.   David: Alright, so imagine I’m. . . who should I be?   This time, I want to be a new College of Health Sciences clinical officer. Let’s say I just finished my clinical officer training and I’m hired on at Kijabe Hospital.   Who do you want me to be in five years? And then what steps? Or how do you guys get involved in moving somebody toward what you want them to be? Benjamin: One of the great designs that I’ve realized works is that every person who comes in, we make the assumption that they are growing Christian, because they have professed their faith as Christians before they come here. And, so we want to build them, to see the theology of medicine and understand it.   Now, I call this ideally, practical theology, where you're trying to apply theory into daily issues. And so, even for journalism, for anything that you get to do, I believe there is a theology, there's God’s perspective of that. And so, there must be a theology for security. There must be a theory for all the disciplines, including clinical medicine. Ideally, we want to help people learn, “What are the basics of theology around suffering, and what is God’s perspective on suffering?” Right there we see it in Genesis all the way through Revelation.  We want these people to see the world in the context of scripture rather than doing it the other way ‘round.    We want people to have that mindset, so we take people through discipleship that helps them learn their place before God and learn who they are and how to grow in their faith, but have very important conversations is all this goes on, conversations that include:  Why do people suffer?  Why do good people go through hard times?   Why is it theologically correct for people to actually expect bad times and hard times?   You want this person to be able to see the world in the eyes of God.  You bring enough disciplines into it.  You have ethics, you have Christian ethics, you have theology, you have medicine and you're trying to see all that in the face of “what does the Bible say about all these things?”  So that, at the end of the day, when the clinician sits back and they're watching and they're looking at a patient five years after, they have all this information amalgamated in their minds and they are able to process.  This person, beyond the cure and everything, they need to hear about the love of Christ. That’s the big goal, the big goal we have.   David: It's interesting, the theology of medicine. I've been thinking about this week, this week, because I don't... I think, again, in the secular versus sacred, I think some of this is lost. A lot of the framework for medicine is based off of Christian theology of suffering, of compassion. The story of the Good Samaritan is pivotal in medicine.  We definitely practice this in Kijabe, right? Anybody who walks through the door, we care for and treat, no matter their background, no matter where they came from. It’s the idea of loving our neighbor, whoever our neighbor is. That's a fundamental, fundamental aspect of medicine, that you treat without judgement.  You don't withhold mercy from anybody.  I do think that's a concept that emerged out of Christian tradition.  Benjamin: Yeah, one of the main things that Christ talks about throughout. . . and it's interesting, when he's talking about what is going to be happening when he's separating the goats and the sheep.  he's talking about, at the end of the day, he’s going to be saying, “I was sick, and you never cared for me.  I was in jail, you never came. . .”  The ministry of mercy and compassion.  Out of that, he’s going to tell people, “depart from me ye workers of iniquities.” It’s very interesting that he gives that story to talk about how he's going to separate, which means that these things are very important.  Not just to the world that we are in, but in the Christian faith, they are a manifestation of who we really are. If Christ is in us, then we will desire mercy.  If Christ is in us, if he’s the one working in us, we will give grace, even when it doesn’t seem logical.  We will do more, and Christ will work in us to achieve this in us. That’s very, very, very important. David: That's fascinating, and I think there's something so compelling about that.  There’s such a divide between what people say they believe and then any kind of good action.  There are so many examples of people talking and talking and talking, then doing bad things. But then I see these people come here and I think it's very refreshing for them to realize, "Oh wow, there are people who are actually just doing things motivated by faith.” Rather than. . .faith is used as a weapon, oftentimes.  But here, it's used as, for lack of a better term, a bandage.  It’s used to bring healing and its used to bring wholeness.  Benjamin:  Two things, I’m thinking at the moment about the source of morality and absolute morality.  One of the writers of African theology talks about Africans being notoriously religious.  You know, even before the missionaries came these guys would just walk through the forest and find this very big tree and someone decides that, “if someone can make such a big tree, then there must be God, and this must be his home.”  And so, they will start making shrines around such places. And so, they believe that there is a God who is the source of morality, right and good and all that. On the other side, I think we have a lot of relativism that has come out. What do you believe is a source of morality, why you do the good that you do? Are you're doing good because you believe in the right thing to do? Or you doing good so that good is done to you?   And so, a lot of the people who come here, including Mslims. . .there is actually a narrative among the S_mali, and most of the M_slims who come around, say that “God lives in Kijabe.”  They believe that the Christians in Kijabe are actually Christians who manifest the living God.   We usually have, in the waiting areas, some preachings that are given, and the M_slim family members that have been keeping a relative here realize at the pastor is supposed to come to preach there around 12:30 has not come, so they go to look for him. They will find him and say, “I did have not see you today. What happened?  We are waiting for you. We're waiting for you to come and share.”  That just shows you there is a great expectation of the people who come here.  There is something very fascinating about Kijabe. So how better would you do that then support the staff who are supposed to be the vessels that God is supposed to use. David: It's interesting, I've had patients say that to me before. I’ll say, "Why are you here?” And they say, “Because you will pray for me. Doctors here will pray for me.”  That’s a big deal. Benjamin: I have been involved in interviews and a lot of people keep talking about that. “I've had heard about Kijabe, even before you start a surgery, they pray for you, they encourage you.”  I want to be part of such a team. Keeping and encouraging such culture is one of our greatest responsibilities. David: You answered one of my questions - How do you endure?  How do you personally walk through challenging situations? It sounds like your (approach) is just realizing this is not, “This is not my responsibility to fix it.” “It’s my responsibility to, to listen and share and to...but to point. . . Benjamin: to Christ. I like music though.  Oftentimes in the evening, I go find my guitar and write. I write things that looked like abstract, but I know what they mean. Just trying take it out. I think you'll come through difficult times and you get to a place, where you're totally alone in the world, and just to cry at just take it out when you feel like it's just too much. One of the things that we need, a lot in the hospital is a clinical psychologist. We have faced a lot of our people or students who are in need of that.  We’ve tried to collaborate with guys who are able to manage such people. And I've gotten to the point where I think, I think I should just do it.  I also need that to understand exactly, “How do I manage in all these things, and how do I also help the staff?”  We are getting to places where people can get disorders.  Mental health is something that nothing much has been done around. And so, one of my greatest goals this year is to heighten awareness around the mental health. David: When you say nothing is done around (mental health), that’s in Kenya, not just in Kijabe,  Benjamin: I don't know the statistics right now, but we hardly have a Clinical Psychologist here. So, you'd actually give advice you'd share with people, and you cannot manage you cannot prescribe, you can’t do anything. So, we end up sending them to Kenyatta... Some of them are students, some are our staff.  I wish I knew more.   I keep reading much about that. I've been reading much about theodicy, ethics and trying to use all that knowledge. I think I've got into that place where I just need to just go ahead and do it... Because I think it would add great value, not just for the staff, but we also get even patients we get patients who come having tried suicide and you can already tell that they are actually in disorders - borderline disorders and all kinds of disorders, potential and you feel you don't have the capacity to deal with this.   David: That’s an important framework that should not be a given here (in Kenya) because I think in a lot of churches, answers have always been spiritual to mental health problems.  Maybe they are sometimes, but a lot of them are an actual medical condition that that I need a medical answer. That's not to the detriment of something spiritual but it's just a realization of "This is something happening in somebody's brain. . .” Benjamin: And it's a process that needs to be worked on.   Yeah, so this actually the... What has happened to me, there is a feeling that is the belief that is attached to it, but there is actual pain that needs to be processed.  At times that whole process is ignored.  At the end of the day, the rates of suicide are going really high. At the end of the day, we see a lot of depression getting to people, and they don’t know that it is even depression.  So, hopefully, if God gives us the grace, we would be able to heighten the dissemination around such issues.  People should not keep to themselves, there is actually a way that we can deal with our issues.  David:  It is something that will happen, just not soon enough, I'm sure. I've heard with the new interns the government is requiring them to do some psychiatry rotations.  The problem is I think there's only three psychiatrists in the country.  What do we have, 47 million people? It’s the chicken and the egg problem.   Benjamin: It’s a big problem.  I know every theologian cannot be a medic, but we can do what we can with what is at our disposal.  And I think the most important thing is for me every day to go home feeling that I gave my best.   David: Kabisa.  You said a word, a minute ago I wanted to come back to a seminary word, theodicy. What is theodicy? Benjamin:  The concept behind theodicy is the theology of suffering.In it carries a lot. It carries God’s justice, it carries God’s righteousness, it’s about how God has spoken around something through scripture.  What light are we supposed to cast on it?  Our worldview as Christians.  I think that it's one of the most important things, I think should be every Christian institution.David: I'm trying to think about my own perspective on suffering. I’ll be curious what you think of this.  Where I’ve personally come to is: I will never fully understand why, but the suffering is very real, but our call to action seems fairly clear.  Our call to action as people of faith, is to step into it, is to go towards suffering with whatever gifts or talents or abilities, or resources to. . .Benjamin: to make it bearable. David: Yeah, that's a good way to phrase it - and try to carry somebody's burdens. Yes, because there are many things we can't eradicate, but presence is a big deal in suffering.Benjamin: It is.   I have a friend of mine who is an atheist.  We went to high school together, and those are actually some of the things that made him walk away from the faith.  He believes that religion is the cause of all pain that is in the world.   Scripturally, we see a different cause of pain.  We see sin entering into a magnificent world.  At this point a lot is happening against humanity that was never supposed to be. But whose choice was it?  Who is responsible for the pain and suffering?  It's actually more of a wage that we’re getting, of course, because the wages of sin is death.  And sin entered all the way since Adam.  When we are looking at pain, our human minds teach us to look for someone to blame.   You meet a lot of patients who have found the person is they want to blame.   "You can’t say that God cares about me when I lost my ninth pregnancy."  "There’s no way you can say God cares about me when I have never owned a child that alive."   "I’ve undergone 30 surgeries, how do you say that God loves me?  What is it that I did against him?"  So, there’s a lot of pain that we are going through.  The greatest premise that we need to be around is the fact that we are in a fallen world.   Evil and pain happens because we are part of a fallen world.  At times we think we are not responsible for it, but think about Adam and Eve.  It’s very easy for us to throw the blame, but given the chance, I don’t think we would have done better.   David: There was a really good line in a new song that just came out recently. It's re-written as if Adam had said... “Eve, put the apple back on the tree, we have everything we need.”   I feel like the answer there is no answer. Yeah, the lady who lost a ninth pregnancy, that's a perfect example. What she needs in that moment is not a sermon, she needs somebody to love her and to say, this is to say You, you didn't cause this. It’s not a fault with you.  It happened.   Benjamin:  It happens and it could have happen to anyone. We are in a fallen world, we're in the presence of pain. David: Yeah, and the opportunity to love somebody through that, is probably the only way for them to experience some kind presence of God, I feel like, in that in that bottom, lowest situation.  Benjamin: Exactly, just that presence, the ministry of presence, as they call it.  And also trying to listen to them knowing that you are not called the answer to every question they have. God knows how to answer his questions.   David: Ooh, that’s a good one Benjamin: It may be today, maybe two years after, 20 years after. . .Eventually, he knows when and how to say it best.   David: I think that's the thing I'm struck by with this conversation, you're overwhelming trust.  You have a huge level of trust.  That’s a big deal. Benjamin: I think the one who's been forgiven more, loves more.  I have been this guy who's grown up through my teenage life - and I was a real teenager.  I have seen God walk with me.  In times God has taught me lessons that are really, really painful...the hard way.  Talking about my life, the last 34 years, it tells you I am growing old.  It's been a work that I have seen God involved in, throughout.  For instance, this past year, we have had a lot of issues around spirituality and mental health, just trying to walk with these people made me feel I need first to halt have been doing my Master’s degree in leadership and management, and see if I can do a clinical medicine so that it answers the questions are asking and helps people deal with their real issue. And so, at some point, I get to that part where if it's not adding value to the people I am serving, that I don't need it. David: That’s actually a big deal to put a professional thing on hold for the people you're doing. Actually, I had a similar experience this year, I was coming for an education program that I think would be really good.  But I had to stop and think, “Is this actually helping me help the people I care about, is it helping me serve the people I here to serve?”   At the end of the day, it would be fun, it would be interesting, but as a distraction for my actual work. And I need to stop, and I need to focus. For me, actually, a lot of times, focus in just having time and energy to be available and be present.  Too walk around the hospital and at the run into somebody, to have a conversation, and connect.   Benjamin: And that brightens people’s lives greatly.  There’s nothing great as someone who doesn’t even know me or where I come from, but they actually care about me.  I don't think there's a greater way to point people to Christ.   I remember a guy who went to seminary, ahead of me.  After class, if he didn't have a class, and he was not in the library, he would be away evangelizing around the community.  Throughout, that was his life. And so, we called him evangelist.  Three months after his graduation, he passed on. It was a great testimony to everyone, because everyone felt that he has done his part. I mean, he put his priorities right. Getting academic accolades is great and getting a lot of them, it gives a lot of titles and makes you feel important.  But you have not realized your importance until you have lived a significant life. I think significance is about what value you add to people.  That’s the most important bit, and I think God quickens our hearts towards this.   David: That would be a great billboard, significance is what value you add to people.  Significance is not what you get, it's what you give.  Benjamin: It’s what you give. I heard John Maxwell once talk about significance.  Significance is the place you leave legacy around.  Success is when you add to yourself.  But, significance is when you add value to others.  You actually leave a legacy at significance, not at success.  Success has all been about you.  Significance has been about what you have been to others.   Christ, I think, looking throughout his life, if we choose to be Christocentric, it’s about what we give, not what we save for ourselves.   So, at the end of the day, the question is “How do I become more effective and efficient in what I give, so that it has a lasting influence in people's lives?” David: Wow.  That's really wise the way you just said that, “How do I become effective at that?” Because it's not just to give until there's nothing left of you.  That can be selfish, “I'm just giving, giving, giving, until I have nothing left and look at me.” But giving in a way that actually helps the people you're trying to serve might be different from abjectly pouring yourself out in a not effective way. There's still logic and still a lot of purpose to it. Actually, I think giving a healthy ways. . .sometimes you're pouring yourself out completely, but I think if it's in line with your gifts and in line with what God has given you, it can be very fulfilling personally also. Benjamin: That’s how you find that is a should at the end of the day, that's how you find the satisfaction in a calling.  That’s how you find peace. You may actually not carry a lot home. At times, you may not even have enough for yourself and family.  But the fact that you actually are living your purpose is great.  Christ was purposeful in everything that he did, including the last breath he gave out. He was purposeful.  I think that's the calling.   David: How do you mean, the last breath he gave it out? Benjamin: It was all to the glory of the Father.  He first talked to the Father and said, into your hands I hand over my breath.  He didn’t breathe last purposelessly.  He breathed it out into the hands of God the Father, so that God would use it to bring redemption around here.   David: Okay, this goes back to seminary also.  I didn’t go to seminary, I narrowly escaped.  But, the Hebrew word for breath and spirit or the same word, right? Sometimes it's translated as spirit, but it's the same thing. “I give you my life, I give you my spirit, I give you my breath,”  Benjamin: Yes, interesting.  It all goes back to the fact that God created man and put in him. . .what breath?  The life-giving breath.  It came from God.  Whatever comes from God has to go back to him in value.  God is a good investor.  He does his thing wisely.  So, when Christ is giving back his life to the Father, he gives it back with a world saved. . .a whole redeemed world.  Ideally, it is finished.  Christ gives it back to God full of value.   I think everything that we give, even smiles, should be purposeful, should be right from the heart, should have the concept of bringing good fruit back to God.   David: Wow, that’s amazing.   One other question I have for you.   A lot of people who would listen to this are people who come out of short-term visitors, some people who come into the hospital.  Is there anything that they should know just about what it's like to interact with hospital staff as somebody coming in from outside for a short time? Benjamin:  I think that that's a very important question. Because a lot of people come to Christian institutions thinking that it's next to heaven.  They forget that these are normal people who have their own struggles.  Each one of us are different places when it comes to sanctification. All of us are growing. And so, one of the most important bits is - they should always come with the question of “What value can I add to the lives of these dear ones.  And what value can they add into my life?” I think that's one of the greatest questions that they can keep asking throughout. David: That's a great perspective. Actually, it’s making two assumptions. It’s both, I have something to offer, and I have something to learn. Having both of those attitudes simultaneously, I think that's a really good attitude toward life in general.   Benjamin: It builds trust amongst people, because people cannot work together unless there is trust.  But with that openness to learn open heartedness.  As for someone who's coming here, you want to carry a very objective (view) that this people all made in the image of God as I am in the image of God.  That means there is a lot for me to take from them, there is a lot for me to take from them in terms of learning.  So, it’s mutual, and that calls for trust.   Trust has to be from a very objective kind of understanding.   Also, the people who are on the receiving end, need to realize that these people are not coming here because they have everything they need, they are also looking for opportunities to serve.  These are a great foundation for them to carry the right perspective.   A great question to ask is, “Why has God opened this opportunity for me?”  Because probably it's a smile I need to share with someone, and that may be all.  It may be “insignificant,” but it may mean everything to someone.   David: I feel like there's really, really great value in noticing people. There are these universal principles, right? Somebody being noticed and feeling valued.  It's just huge for somebody to think, “Wow, this person from, whether it's from Kimende or whether it's from Atlanta, this person is genuinely interested in who I am.” Exactly, I think that is such, that's a powerful. . . Benjamin: Yes, it’s quite an intentional approach to people, and I think that's how God wanted to be for us.  When I'm talking about death, a lot of times, I ask people what is death, according to them.  I think death is a separation of the physical and non-physical.  I’m dark right, and you are white, right?  But, that person speaking in me, have you ever met him, leave alone this body?  You have never seen him.  Are you able to tell his complexion?  Do you know his height?  Let’s assume you’re a surgeon, where does he hang inside this body?  I don’t think you will find his home, I don’t think you are able to see him.  This is what we call a “tent,” and there’s a real person.   We have tribes, different ethnic groups, we have different citizenship and all that. But that person speaking in me is the human person that I am.  The truth is, that person probably has no complexion, no gender, that is the real me.  If we can learn to look for that person in every person we meet, then we would realize that people are dignified, and people are the same.  At the end of the day that is the person who God breathed in this body and he lived.  At the end of the day, that is the image of God in us.   We will learn to see beyond complexions, we’ll learn to see beyond tribes.  We would learn to see as God sees, and that’s wisdom.   David: Wow, thanks Benja!  That’s a good way to close.

David - What is your name and what do you do at KijabeLilian - I’m Lilian and I’m an Ob-Gyn in Kijabe, for the last four years, but been here a lot longer.David - When did you start?Lilian - 2007, internship for two months, elective term, 2009 internship for one year. I left for 8 months and came back in October 2010. Then residency, and I came back fully in 2015.David - Who is your husband and when did you meet?Lilian - He’s George (Otieno) – we met in undergraduate in our third year of medicine and surgery. When we came to Kijabe from the first time we were already dating.David - Lilian is head of Ob-Gyn at Kijabe, here you say obs/gyn, is that right? George was head of internal medicine, but now he’s promoted right? He’s inpatient subdivision head. Both do so much for the hospital, they’re amazing.What we’ve been talking about lately, and working on, are some of your needs for the OB department. Some we’ve gotten sorted and some are in process. Two years ago, we were having a big problem with the delivery room. And now that’s done.Lilian – Thank God. Now we can walk in and smile and not be embarrassed. That used to be my nightmare. For example, patients come, they don’t know where the delivery room is, and they walk into this ugly room. That used to be a very big problem for me, it was nothing for a woman delivering her first child. I’m happy.David – And now it’s really nice.Lilian – Thank you for spearheading that process for renovation.David – It’s night and day different. I think there is a process we are going through, not just in Kijabe, but in Kenya, where the bare minimum is not acceptable anymore.Lilian – No it’s not. We have to give the best to our women. . .and to any patient who walks into any hospital. I think we have gotten used to the poverty mentality to the point that we are not willing to go the extra mile to make things better, as opposed to just living today.David – We were just talking with a doctor who wanted to come visit a clinic doing more open surgeries than laparoscopy. Which is reality for a lot of places. But here in Kijabe, I feel like we have the option to do things with excellence. That’s why you’re here!Lilian – That’s why we are here. To make a difference, and to live our purpose too, which is to do everything with excellence.David – What we’ve been talking about is how as Friends of Kijabe, we can help with the Obs/gyn department – what is feasible to do, and in some ways, what is the Christian thing to do.Why don’t you tell me about the patients or populations/demographics that have been the most stressful, and that we agree these might be able to most easily address their needs?Lilian – Among the patient populations we’ve been concerned or have special interest about have been cancer patients who come and need urgent care, yet they’re not able to pay for the services offered. These are patients who are coming and don’t have National Insurance Cover. National cover requires three months to mature, even if someone was to apply as soon as the diagnosis is made, but that is too long to wait.David – Because with cancer, usually they’ve waited too long anyway right?Lilian – Yeah, so by the time they are coming, we need to make radical decisions at that point. As much as it may be a small population, we feel like the care they deserve should be accorded to them, regardless of their financial status. That’s why we feel they need support.David – So for gynecology-oncology patients, do they require surgery and chemotherapy or sometimes just surgery?Lilian – It depends on the type of cancer and the stage or the spread. Early cervical cancer patients might require only surgery and that is it, unless they have evidence of spread, like in the lymph nodes in which case they need chemo-radiation. In case of radiation-therapy they have to be referred out of Kijabe.David – Chemo, you can usually do here now?Lilian – Ovarian cancer, most of those cases will go through surgery, then eventually will require chemotherapy after, which can be given to them in Kijabe.Some cases are strict referrals, for example, advanced cases, which are not operable. We will refer for the combined chemotherapy/radiation therapy. The few we are able to handle here require chemotherapy and surgery.David – This is becoming a big issue in Kenya, it’s all over the news.Lilian – It’s all over the news. I think, partly because of improved diagnostics. There is more advocacy for screening and early detection. There are over 3,000 deaths from cervical cancer every year.Our joy has been able to sort patients at an affordable cost compared to what they would have to pay in Nairobi.In 2016, we had 11 cancer surgeries for gyne. In 2017, we rose to 31, in 2018, we had 41. We hope this year we can have an even higher number that are detected early to get surgical management. There is more awareness and people are coming through referrals and we are doing aggressive screening for cervical cancer.David – I don’t know if it would directly relate to your patient population in Kijabe, but life expectancy in Kenya has grown 1 year every year for the last 15 years. Fifteen years ago, life expectancy was 48 and now its 63.Lilian – Yes, it’s 63 now.  It’s an improvement. As much as we know many are still dying, I really think there is something positive happening as far as improving primary health care and advocacy for many things, with health being a big agenda for the president. We are seeing a lot happening even in the country places. We appreciate that they are doing something.David – That’s gynecology/oncology, what’s your other patient demographic that you personally stress over? This isn’t something out there, it’s something very close to your heart.Lilian – For gyne-onc, I’ve also lost family through cancer and I think there is so much we can do in terms of primary prevention and early detection, which is not really emphasized so much. I think for Kijabe that’s one area we could do well in.A second type of population we see are young pregnant women who need emergency care and they can’t access to the point of saying “don’t admit me.” We know that whatever happens on the other side, the care they will get is substandard.For example, a patient who comes with preeclampsia in the 7th month of pregnancy, the baby requires newborn ICU admission and the mom require HDU or ICU care, clearly you can’t refer those patients because of finances.There are teenage girls with unplanned pregnancies coming with no insurance cover, who require emergency, comprehensive obstetric care. That population is at very high risk for mortality and morbidity for both mothers and babies. They may be few, but those few deserve to live.David – you’re concerned specifically about abortion or if the baby does come, what happens to the baby afterwards.Lilian – We’ve had different encounters with primary school, high school girls coming and wanting a termination, and we’ve said no. But even if we say no, we are supposed to be giving them solutions, alternatives. Who is going to help with the clinics? They are already high-risk by virtue of age, by virtue of them wanting to terminate. Who takes care of the clinic bills, who takes care of the delivery, who takes care of the child afterward in postpartum clinic reviews? If baby requires specialized care, what happens? These are young girls who are prone to depression, psychosis, suicide, and I feel like they deserve better because that’s a point of ministering to them. I think those few hours we spend with them are enough to actually change their lives, not just because of their condition, but even in terms of eternity.These high-risk patients that come to us and they don’t have better options, I think they deserve more. Especially those who come with unplanned or what you call crisis pregnancy.David – There is precious-few resources for things like that.Lilian – One, young people are condemned by society for making wrong choices. Two, there are no options given to them. If they are given, they are poor options, like terminations, which means going to the backstreets to terminate. It is cheaper of course and it won’t be known. That has resulted in high mortality for girls.Among the top 5 [maternal] killers in our country, we still have abortion. Beyond hemorrhage and hypertension, have abortion topping because of girls going to the back streets for termination of pregnancies.As we take care of them and do abstinence and user protection, when all those steps have been bypassed, we need solutions for these girls.David – I’ve seen Kijabe babies be placed in homes.Lilian – There are many options, it’s just I think we don’t take that time that has to be spent walking with such, there is the financial aspect that must be considered from way before, during pregnancy, delivery and thereafter. We have a few rescue homes that do a job for these girls, but not all go to the rescue homes. So, can we be a sort of rescue home in terms of the medical care that we’re giving.David – And we can make sure that they are not making bad decision for lack of finance. A delivery in Kijabe is $250 or $300.Lilian – That could be all it takes for them to actually see there is hope.David – Who is the one you were telling me about that came with the grandmother.Lilian – At least a happy one. This was a sixteen year-old, who got pregnant while in form 2.  For you guys, that would be 10th grade. Every time she would come for a clinic, she would be accompanied by the grandmom who would pay the bills for the clinic. And the grandmother would make sure she was okay.This was a grandmother who lost her daughter, and her daughter left her with a grandchild who became pregnant. She was taking care of the great grand-child after the delivery.I think what really made my heart feel warm was the love, and the fact that she was there to support her and tell her, I’m here, I will pay your bills, and I’ll take care of my great grandchild, and you’ll go back to school after the first few months.That love shown to this young girl who may have opted for termination if there was no other option.The grandmother was able to afford some coins to walk through the journey. No fancy clothes for the babies, but maybe, some coins to buy a packet of chips, to say, “I’m here for you.”David – One other one that was very special for several of us and for me personally, the first time I walked through this process, was a teenager who came in with a pregnancy, I think it was twins and they lost the first twin. I think it was 30 or 32 weeks. I heard about it from Dr. Mary Adam, “Hey, there’s this little baby and the mom has gone, she has abandoned.” All the nurses and the doctors at the hospital, said, “this is our baby.” That was the first person we ever crowdfunded for individually. The way it happened was amazing. I walked through the NICU one day with a camera. She raised her hands up to me. "You want this picture don’t you? You want people to take care of you!" In that picture she was wearing a diaper that came up to her neck, and now when you see her, she is two years old, she is round and chubby.For what it takes to do the right thing, in my mind, it’s such a tiny amount of money, to take care of the mother and the baby.We do have some general funding coming in toward this. We hope that can increase over time, as some of our obgyn’s become involved. Also, any of you guys who might be listening to this, anyone who gives to the Friends Fund, a portion of that goes to vulnerable patients. Basically we want to say yes when someone needs something. That’s the goal.Anything you would like to add?Lilian – Just requesting humbly for support wherever it comes from. Of course we are very grateful for those who have had Kijabe in their minds, and for whichever way they support, whether by been human resource, whether it’s financial, whether it’s prayers, whether it’s encouragement.David - AbsolutelyThe Estimated Incidence of Induced Abortion in Kenya: A cross-sectional study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546129/

FULL EPISODE EPISODE SUMMARY Conversation with Dr. Mardi Steere about Mission, Leadership, Emergency Medicine and Ebenezer Moments from her 8+ years at Kijabe Hospital. EPISODE NOTES David - So today, I'm talking with Mardi Steere. This is a conversation that I don't want to have. It's about leaving about memories, and about Kijabe.And I don't want to have it because I don't want you guys ever to leave. That is the hardest part of life in Kijabe. But amazing people come and amazing people go and you're gonna do amazing things and stay in touch. First, why don't you give the introduction you gave at the medical team the other day. Mardi - So this is bittersweet for me as well. We came to Kijabe in 2011 and planned to stay for two years and here we are eight and a half years later, taking our leave. And in some ways, it's inevitable. You can't stay in a place forever. It's been a real opportunity for me to reflect. David - Let me pause you real quick there. So when you first came, who is we? And then what did you come to do? Mardi - In 2011, I was a young pediatric emergency physician with an engineering husband looking for a place where we felt like God had said "To whom much is given, much is required," and we knew our next step was to go in somewhere with the gifts and the passions and the exposure and education that we've been given. And so I came as a Pediatrician, and the hospital hadn't had a long-term pediatrician in quite a while. Jennifer Myhre had just joined the team in 2010 and my husband Andy is a civil engineer and project manager, and now, theological educator as well.We moved here with our then two-year-old and four-year-old to do whatever seemed to be next. David - That's amazing. So give the theological introduction to the Ebenezer. Mardi - It comes from first Samuel Chapter 7 verse 7-12, where there's a battle between the Philistines and the Israelites and Samuel lays a stone to God for being faithful and to remember what God has done. When Andy and I got married in 1998, actually, it was a scripture that was read at our wedding. And we were encouraged when these Ebenezer moments come, take stock of them, step back, and acknowledge what God has done . Those moments will be key moments in your marriage. As I was talking to the medical division the other day, I felt like it was just another reminder that, as we have our professional lives and we work in a place like Kijabe and we serve, it's really easy to get caught up day-to-day in the daily struggles that we all have - with life and death and bureaucracy and not enough money and not enough equipment and team dynamics and conflict. But there are these moments when we take a step back and we see what God has done. This hospital has been around for 100 years, and I've only been here for a little over eight of them, but there are so many moments where I look back on where we've come from - and the journey that we've been on - and I see these landmark moments of God intervening. David - How do you see the balance here between medical excellence and spiritual - I don't know if excellence is the right word - between medical excellence and spiritual excellence. I think the origins of medicine were very intertwined with the spiritual, but at least in Western medicine, it's very divorced and I feel like in some ways, what I see happening here is not taught in classrooms anywhere else. Mardi - This is one of those things that I am going to be taking with me for the rest of my life. I don't know who's listening to this, but Americans have a cultural Christianity where it's acceptable in medicine, I think, to ask medical questions and maybe you ask a spiritual question and saying God bless you and bless her heart, and praying for people is somewhat accepted but still it's a parallel track to medicine. In Australia, it's completely divorced. There's almost a cultural fear of discussing the spiritual in Australia, a very agnostic country. So to be a Christian in Australia, you have to make a choice. But then when you go to medical school, it's taught to you almost don't bring that in. This is a science, and one of the things that I love about Kijabe is that they are inextricably intertwined. There isn't a meeting that we start here without prayer. When I'm covering pediatrics, as a clinician, we start with team prayer and depending how busy things are, if you're trying to see 30 patients on rounds, you might pray for the room, as you start. We ask the parents how they're doing, and then we pray for the mom with her permission, and for the baby or the dad or whichever caregiver is there. We ask God to intervene, we ask God to give us wisdom, we ask him to be a part of the science. We ask him to be a part of the conversations. When it comes to the even bigger picture, when it comes to strategically planning the hospital, and our core values again - they're inextricably intertwined, and it's a gift. One thing that I'm gonna take with me as a leader and as a clinician, is that it is not difficult to ask anyone, "What is your world view and what is your spiritual worldview? Because all of us have one in Australia. That world view might be... "I don't believe there's a spiritual realm." That's so important to know. But what if the answer to that question is," I believe in God, but I don't see him doing anything." What an opportunity we miss. What if we have immigrants in our population in our community, and we don't ask them "What is your spiritual and cultural world view? What do you think is happening beneath the surface?" and we don't give someone an opportunity to say without derision, "I think I've been cursed" or "There is a generational problem in my family," and we don't open up the opportunity to intervene in a way that's holistic, much we miss by not intertwining the spiritual and the physical? The fact is every one of our communities has a spiritual world view, and shame on us if we don't explore it with them. David - Amen. It's fascinating here because before coming here, I thought of missions as giving. The longer I'm here, the more I think of it as receiving. When you stop and pray for a family, the encouragement received from those family members is huge. The trust and the love, and you do see people who come in the halls and you ask, "Why are you here?" "Because my doctor will pray for me." Mardi - So what's interesting to me is there are some conversations going on in medicine around the world right now about this "innovative new concept of Compassionomics." And really it's exactly what you're saying, it's not new and it's not innovative. I think that Compassionomics is our fearful way of re-exploring the spiritual. It's taking the time on rounds to say, "How are you doing as a family, how are we doing as a team," and to take the opportunity to draw comfort from each other. It comes from a spiritual foundation, that I think that we've lost, and I think a lot of it comes from burnout and from the way that medicine has become a business and a commodity. We're starting to re-explore through Compassionomics, and I pray through exploring the spiritual, the deeper side of medicine that around the world I think people really miss. David - Right on. Mardi - And if that's not reverse innovation, I don't know what is. David - It's fascinating, this space that Kijabe fills and how we think about it and how we talk about it. I use a phrase - World class healthcare in the developing world - but when I use that, I don't mean that I want Kijabe to be the big hospital in the big city in the West, because there are certain aspects that we don't want to lose. Yes, absolutely, it would be super-cool to be doing robotic surgery, and some of these wild technological things, but really I feel like what Kijabe excels at is not fancy and not glamorous. It fundamentals of medicine. I remember Evelyn Mbugua telling me this one time. I asked her, "What do you think about medicine in general?" "When I have a challenge or when I'm stuck on a patient, I go back to their history." It's fascinating that that's fascinating! Some of the basic fundamentals of medicine are practiced here, just looking at your patient and laying your hands on them and touching them and talking to them. A conversation is both a diagnostic tool and it's actually medicine. If the numbers are true, I know it's different from orthopedic surgery than for outpatient, but, if half of medicine is actually placebo, this stuff is really important to healing. And it's not anti-science. It actually is science to care about people. Mardi - It's interesting when you mentioned the placebo effect. I think that the placebo effect is considered as nothing, but it's not the placebo effect, is actually a real effect. It's that time and conversation and compassion, truly do bring healing and the point of a control trial is to see in a drug-do better than that. But the thing we're doing, already makes sense. It's interesting to me that medicine around the world is getting faster and faster and more and more advanced. Time is money. I think that around the world, we wanna save money in medicine, we wanna do more with what we have, but we're willing to sacrifice time, to make that happen. And why is that the first thing that goes? Burned-out physicians in high income countries, the thing that they love, is when they have to see more and more patients in less and less time because they know what they have to offer is beyond a drug, and beyond a diagnosis and beyond a referral and beyond a surgery. The one of my favorite phrases in medicine that I truly don't understand but want to spend the rest of my life working on it, is a "value-based care." I think to define value you have to define what we're offering. If value is time, then one of the things I think that Kijabe and mission hospitals can continue to pioneer the way in is, "how do we cut costs in other areas but refuse to sacrifice the cost of time and make sure that our impact is helpful for our patients but that also helps our team members and our clinicians receive the value that comes from being a part of a meaningful conversation. I think that's what patients want too. They don't want the robotics, they come to us because they're helpless vulnerable and afraid, and those are the things that we're treating. They trust what we tell them and if we don't have the time to build up that trust, we've lost a lot of the value that we offer. David - What have you seen change about team? You guys have been part of this big culture change process, but I think it's something that's started long before long before either of us. What do you see is the arc of Kijabe and the archive teamwork and the arc of culture? Mardi - So, Kenya is an incredibly multicultural and diverse country and Nairobi is high-powered and it's fast and it's a lot of white-collar and highly educated people and Kijabe is not so far from that. I think we operate more in a Nairobi mindset than a rural, small town mindset, but that's actually been a huge transition, I think, is going from presenting ourselves as a rural distant place to a part of a busy growing rapidly advancing system, and so that comes with leadership styles that become more open and more I guess, more modern in style. And so that's been the first big thing that I've just seen a huge jar over the part of the decade that I have been here is that leadership is no longer just top-down, enforced. It's participational leadership and I'm a massive fan of that. Leaders do have to make hard decisions and make things happen, but the input of the team has become a much, much higher priority in the last decade. And that's huge because our young highly-educated, highly-aspirational team members have got some great ideas and shame on us as leaders, if we don't take the time to listen to their approach to things. So that inclusive style of leadership has has been a huge arc. And then I think the other thing is just our changing generations, millennials are not confined to high-income countries. We have a young generation of people here who aren't gonna stay in the same job for 40 years like their parents or their grandparents did, and that's the same globally. And so we've had to question, over the last decade, how do you approach team members who are only gonna be here for a little while? Do you see that is, they're just gonna go, or do you get the maximum investment into them and benefit out of them in the time that they're gonna be here and then release them with your blessing? And so that's been something that's been huge for me is when we've got these new graduate nurses or lab staff radiographers, to not be on the fact that three years after they come to us, they go it's to say, "You know what, we've got these guys for three years, let's sow into them, let's get the most we can out of their recent education... Let's do what we can to up skill them with the people that we've got here and then let's release them all over Kenya to be great resources for health care across the country and across the region. David - I would say, for healthcare and for the gospel. I've been wrestling a lot with what does it mean for Kijabe is to be a mission hospital. I think the classic definition - I don't know if we define it as such, I don't often hear people say it out loud, but I think it's an unwritten thing - that what makes a Mission hospital a Mission Hospital, is that it cares for the poor. Hopefully on some level, or on a lot of levels, that will always be true at Kijabe. But I'm really excited about the possibility of what you just described, that if these guys are here for three or four years and we are to training them with the attitude that they are going out as Christian leaders and as missionaries to these parts of Kenya that honestly, you and I will never touch. And a lot of the places I've never even heard of. But if we're equipping them to be the light that's the huge opportunity that Kijabe has to be missional. Mardi - This is a much, much longer podcast, but defining mission is really really important, isn't it? I think that there's a couple of things that stick out to me as you're talking and one is that, I think mission has a history that can be associated with colonialism. And one thing I love about my time in Kenya is seeing that we are a globe of missionaries. The church that we attended in Nairobi, Mamlaka Hill Chapel, these guys would send mission teams to New Zealand, which is fabulous. It's not that lower middle income countries are receiving missionaries anymore. All of us need the gospel, all of us need the full word of Jesus and when you're spreading the gospel, what are you spreading? I think that this is a much longer conversation, but I believe that we are called to go and make disciples we are called to serve the sick, we are called to serve the poor, we are called to serve those in prison. I focus on the parable of the sheep and the goats, it is one of my life scriptures, "when you are poor and sick and needy whatever you did for the least of these, you did for me." And what I hope for Kijabe does is that for whoever passes through our doors, whether it be patient, whether it be staff member, this is who we are, we love Jesus and we want you to know this incredible King who gave so much for us and who has an eternal life for us that starts now. And eternal life starting now means making an impact and restoring that which is broken, and it means restoring it now, wherever you are. As our team members go out to work in other hospitals, I would hope that one of the indicators of success for us would be a lack of brain drain, because it would show that we've shown people, "You know what there are people here that need you in healthcare. And this is why I'm here." If I had wanted to be an evangelist rather than a health care missionary, I should have stayed in Australia, for less people in Australia know Jesus that in Kenya. But I felt like my call in mission was to serve the sick in a place where I could help other people do the same. That's been my passion here, but I'm called to go back to Australia now. Does that mean my mission life is over? Absolutely not. It means that I'm going back to Australia to love Jesus and serve sick there and to do it in a different way. And I think that understanding that all of us, whoever is listening to this podcast right now, wherever you you have a call to mission, it's that sphere of influence that God's put you in. It's to take care of the poor or the sick, or to love the wealthy, who are lost around you that are never gonna step foot in a church but need a love of Jesus every bit as much as one of our nursing students here in the college. David - Amen again, that's fantastic. So back to Ebenezers, back to the the stones. What are things come to mind as you look back over on your time at Kijabe that were hallmarks or turning points? Mardi - There's a few of them. One evening sticks out to me because it's so indicative of the bigger picture and what we've been working towards. I'd been here for about nine months or so. . . One of the things that Jennifer Myhre and I noticed is we started out on pediatrics was that our nursing staff were incredibly passionate about their kids, but no one had really had the time to teach them about sick kids and how to resuscitate them, just basic life support, because they were so overwhelmed. You know, there was one nurse who was taking care of 12-15 patients at a time. That ratio is now one to eight, so it's much easier. But they just hadn't had the opportunity to learn some of the basic life-saving assessment in resuscitation skills, and so we started doing just weekly mock resuscitations with the nurses and as we got to know each other and they got to trust me and to know that I wasn't there to, to judge them, but to try and help them, we would do mock recesses every week, and people would stop being scared of coming and would come with by interested and actually came to test their knowledge. When I started in 2011, about once a week I would get called in, in the middle of the night to find a baby blue and not breathing, who was dead, and there was nothing that I could do. But what we worked together on was setting up a resuscitation room, and setting up the right equipment. And so after about nine months of this, I was called in for yet another resuscitation in the middle of the night, and by the time I got there, the baby was just screaming and pink, and I asked the nurse is what had happened and it was the same story as always, this baby choked on milk, they had turned on the oxygen given the baby oxygen done some CPR and they resuscitated that baby before I got there, they didn't need me at all. And the Ebenezer for me was the was the pride on their faces. "We are experts at this and we know what we're doing." That has just escalated leaps and bounds. Now we've got outstanding nursing leadership and they're being equipped and taught and up-skilled every day. But that was an Ebenezer moment for me that the time taken to build relationship and team and invest doesn't just bring a resuscitated baby and life is important, but it builds team and it builds ownership and pride in "this is what I've been called to do, and I'm good at it." It's interesting because it's what you would do is individual doctors with your teams and doing the mock code. But it's also very much a systems process for Kijabe hospital, right? A big part of solving that challenge was getting the right nursing ratios, but also setting up high dependency units to where children you're concerned about could be escalated. Did that happened during your time here? Mardi - So when we started here in 2011, children weren't really admitted to the ICU at all unless they were surgical patients who just had an operation, and then the surgeons would take care of them and transfer them down to the ward. So the pediatrics team wasn't really involved in any ICU care, extremely rarely. We didn't have a high dependency unit. And our definition of high dependency unit, here, is a baby that can be monitored on a machine 24-7. This is something that shows you how reliant we are on partnerships, David. So for example, the nursing and the medical team together decided, "Look, we think we need a three-bed unit, where at least the babies who were the more sick ones can be monitored on machines." And so, Bethany kids were the ones who equipped... We turned one of our words into a three-bed HDU in the old Bethany kids wing, and that was the first time we could put some higher risk babies on monitoring so that if they deteriorated we knew about it sooner. And we saw deaths start to drop, just with that simple thing. The other thing was that pediatricians who worked here in the past weren't necessarily equipped in how to do... ICU care. And so Jennifer and I said, "Well I'm a Peds-emergency physician, and she is an expert in resource-poor medicine, between the two of us, we can probably figure this out." We started putting some babies in ICU who we knew had a condition that would be reversible if we could just hook them up for 24 hours to ventilator. So we started ventilating babies with just pneumonia or bronchiolitis. Or sepsis, that was the other big one, something that if you can help their heart beats more strongly for a day or two, you can turn the tide. And so we just started working with the ICU team to say, "Look, can we choose some babies to start bringing up here? And four years later we were overtaking the ICU at the time and that's why we had to build a new Pediatric ICU, which opened in 2016. All of these things are incremental, and we stand on the shoulders of giants. The Paeds ward existed because a surgeon said "I don't want babies with hydrocephalus and spina bifida to not get care." And then we came along and said "We think that's great, but we think that babies with hydrocephalus spina bifida, who also have kidney problems and malnutrition, should probably have a pediatrician care for them." And over time, that degree of care, that we've been able to offer has just grown and grown. And we had Dr. Sara Muma as a pediatrician join us in 2012 then Dr. Ima Barasa - she was sponsored into pediatric residency long before I got here. That was the foresight of the medical director back then, to say "We are gonna need some better pediatric care". And then I stepped into the medical director role and people like Ima and Ariana came along and they've just pushed it further and further and further. None of us are satisfied with what we walk into, and we keep saying we can do better because these kids deserve more. David - That's fantastic, I think that's another way when you think about the influence and the impact of Kijabe, it's that refusing to settle. It's to say, "Yeah this is possible. Let's figure it out." And for all the team members to say that and commit to it, and for the leadership to support that I think that's what makes Kijabe special. I read something that the other day, it was just an interesting take, someone said [to a visiting doctor] "Why are you going to that place? It has so much." But Kijabe only has “so much” because the immense sacrifice of so many people over so much time. None of this showed up without the hours and the donations and years and years and years of work. I remember you saying that about Patrick with his ophthalmology laser? How did you phrase that? Mardi - Patrick, he's such a wonderful example of the kind of person that doesn't look for reward, but sees a need and just walks to the finish line. He started out, I believe, on the housekeeping team in the hospital. He's been here for 20 years at least, I think, and then went through clinical office or training, which is a physician assistant level training, and then received higher training in cataract surgery. He started our ophthalmology service in 2012. Since then he had nurses trained around him. He's been doing cataract surgery, and then he said, "We've got these diabetic patients and the care we offer isn't good enough, we need a laser." He went to Tanzania, and got laser training, and now he's going to start doing laser surgery on patients with diabetic retinopathy. He refuses to be satisfied with the status quo. And that's the heritage that we have here. You know, talking about even a moment I feel them enormously privileged to have been here in 2015 as we as a hospital celebrated our centennial. It took us a year to prepare for that, and I know you were a part of that process, David. David's job was find all of the stories and all of the photos and interview all of the people and make sure to document everything that might be lost if we lose these stories now. Being a part of that process... I was in tears so many times when we would hear one more story about somebody's commitment and sacrifice. We've been able to write down that story from 2015, with the Theodora Hospital as we were known then. The stories of not just these missionaries but these extraordinary early nurses, like Wairegi and Salome who worked here for decades, who were initially trained informally, because we didn't even have accreditation for the nursing program. David - We didn't even exist as a country. Mardi - That's a really good point! To hear those stories and to see our very first lab technician was just amazing. And then when these 80 and 90-year-olds came over and saw the scope of the hospital as it exists now, it just gave me a glimpse into whatever we do today, we have no concept of 100 years from now, the fruit that that will bear. And I think a missional life, is like that, isn't it? It's being okay with not seeing fruit. There's foundations positive and negative, that all of us lay in the interactions and the work that we do and I think all of us, our prayer is that those seeds that we plant would bear fruit. We have to be okay with not seeing the fruit with saying this has been my contribution. I've stood on the shoulders of giants and now I hand over the baton to you, who will come after me. Make of it what you will. It's not my dream and it's not my goal, I've done my part, and let's see where God takes it through you. David - And so, very shortly, you're about to become a giant. [laughter] I really appreciate you, I appreciate you bringing that up. That was one of the most important things that could have ever happened. It was in the 2015. It was before we started Friends of Kijabe. The realization for me I always come back to how long life is. It's both amazingly short and amazingly long. Watching Dr. Barnett and realizing that he worked here for 30 years, and then went back to the states, so now he's... I think he just hit 102 years old. It really does bring in a clear view what is legacy, what does it mean and what are we building? But also that this is very much outside of us. We get to pour everything we have into it for a time, but then others will take up that work. And it's both humbling, and amazing and... Mardi - And I think it's helpful to as many of us have a sense of calling on our lives, I think that this is what God has for me now. But we have to hold that with open hands because our view and our understanding of what God is doing is so small and what he is doing is so large. I think sometimes in this kind of setting, you come in with a dream and a passion and a goal, but you see that path shift and change during the time that you're here and that is good and that is okay. I think a danger is when we come in and think that we have the answers or we know exactly where God is going, and then things don't work out, and we burn out or are bitter or disappointed. To come into a sense of mission and calling... Saying "not my will but yours be done," and to just obey in the day-to-day and to see where it goes and to be okay with the direction being different at the end than it was at the beginning - I think that's how we lead a life led by the Spirit. We hold these things with open hands and say, "God take it where you will" and if it's a different place, let me just play my part in that. David - Okay, I gotta dig into that cause. How do you balance that? I would frame it as vision. I feel like a good example to look at, I don't know if it's the right one, so, you can choose a different one if you want to, but the balance between vision and practicality and reality. Because you say that, and you are walking in the day-to-day, but I just think of the Organogram that has been on your wall, which was on Rich's, wall, which is now your's again, which is about to be Evelyn's wall. And you had this vision back in, "this is how I think the organization should work to function well." But there's a four-year process in making that come to pass. How do the day-to-day and the long-term balance? Mardi - I think we're talking about spiritual and practical things combined aren't we? I think that anyone who's in organizational leadership knows that you, your organization as a whole needs a trajectory and a long-term plan. We make these five-year strategic plans which are based on the assumptions of today and every strategic plan. You need to go back every couple of years and say, Were those assumptions right? And just to be a super business nerd for a minute, you base things on SWOT analyses and you base things on the current politics and economics. David - What does SWOT stand for? Mardi - Strengths, Weaknesses, Opportunities and Threats. Then you do a PESTLE analysis, you look at the politics, you look at the economy, you look at the social environment of the day, etcetera etcetera. In technology everything is changing quicker than we can keep up with. And so I think that when you're looking at a place like a happy, which is large and complex, you set yourself some goals, and you work with them, but, you know, so something's going to change. Politics are gonna change, the economy's gonna tank, maybe there's gonna be a war on the other side of the world and we’re the only source of this, that, or the other?Maybe India falls into the sea and we start doing all of the surgeries that India was doing? I just don't even know. One thing for me, I've been enormously privileged to have been the medical director for two different terms that were separated by two years. And so I think I have a slightly unique perspective because from 2013 to 2016, I set the way I thought that our division would work and I came back into the role, two years later and already it had changed, but Rich had made it a better. It's funny, I when I came into the role, my predecessor. Steve Letchford said, "Look, you're gonna need a deputy, you can't do this by yourself." And I looked at my team and said "Um, No, I need four deputies, four sub-divisional heads because this is too much for one or two people and I can't keep my ear to the ground without it. I came back after two years away and there were five deputies and my initial gut reaction was, "You changed my structure!" And then I realized that Rich and Ken had made a really wise call. It did have to be five deputies for lots of really good reasons and that team of five has been my absolute rock this year. David - Who is the team of five? So the team of five, I've got a head of inpatient medicine and pediatrics, and specialties and this George Otieno. There's a head of Outpatient Department, and Community Health and Satellite clinics, and that's Miriam Miima. I've got ahead of Surgery and Anesthesia, and that's Jack Barasa. There's a head of Pharmacy, and that's Elizabeth Irungu. Then there's a head of what we call Allied and Diagnostic that incorporates the Lab and Pathology, Radiology, Physiotherapy, Nutrition and Audiology, and the head of that, it is Jeffrey Mashiya who is a radiographer. What's amazing to me about that is when I instituted this framework in 2014, there were four people and they were all missionaries. And I've come back in 2018 and there are five people and they're all our Kenyan senior staff and they're extraordinarily talented and any one of them can stand in for the medical director, when the medical director is away. What a gift that has been. David - I can't imagine how important this is for continuity. Because you think right now, you're handing off your responsibilities to Evelyn, but she has five people that...those are the executors and they actually get to groom her in leadership. That's amazing and for the strength of Kijabe and the stability, it's indispensable. I don't think there's another way to build a strong, stable system other than to build that. Mardi - Yeah, that's actually one of the things that brings me so much joy as I leave is the team isn't going to notice too much the change in senior leadership because that level of day-to-day practical strategic and operational leadership is just so strong. I think it made Ken as my CEO, I think it made his job easier to say, "Look, who should fill the position that Mardi is vacating?" He was able to say, "Who's got institutional memory and who's got leadership expertise and wisdom, and who knows how the senior leadership team works?" Whoever that person is, they're gonna have a team around them that will mean that no voices get lost in the transition. When I took the job in 2013, hearing the voices of specifically missionaries and surgeons can be really noisy and you hear their voices, but who's listening to the head of palliative care and who's listening to the head of laboratory who's listening to the head of nutrition, which is a tiny team of four people, those voices are well represented by wise people who all listen to each other and make the system work around them. It's a tremendous gift and there's no way to do this job without a team of people like that around you. And you know what, that's one of my other Ebenezers, David. Thursday, we installed Evelyn as the incoming medical director. Seeing those five sub-divisional heads praying for Evelyn and as that took off, I will never forget that. David - Absolutely. I wasn't here the first time, but I remember I should print out a series of those [pictures] because I remember you handing the hat to Rich and I remember it going back to you and then watching you give Evelyn the hat and stethoscope. There's this legacy of people that care. It's interesting to think about... 'cause you are, I mean you’re building this remarkable team and your system and things that operate independently of you. But at the same time, you're unbelievably special, and have given a ton over the past years and you. As Rich phrased it, you walked in shoes that not many other people will get to walk in. It's special. I imagine is what it's like when the former presidents get together for their picture. There's things that only only you guys will know and only you guys will have experienced. Mardi - You know, one thing that is really special is I think a lot of leadership transitions come through pain, brutality and war. And one thing that I noticed on Thursday, is that in the room as I handed over leadership to evil and were Steve Letchford and Peter Bird, who have both been here for decades and who've previously been the medical directors. I think there's a beauty about the transition of leadership here in the clinical division that it hasn't come through attrition, war and burnout. I'm leaving with a lot of sadness, and I'm not cutting ties with this place to see. . . there has been a cost. Rich. I know, I would still love to be here in this position as the person who is my predecessor…but to see such strength of leadership that is here and sowing into the next generation rather than leaving when they died. They've stepped down and gone into leading other areas to ensure that the team that follows them is strong, I think that's a tremendous gift and something unique about Kijabe. People love this place and they love this team and they wanna be a part of its ongoing success in its broader mission. David - And they love and they love that above their own glory and their own desires. I think it's what makes an organization great, it’s what makes a country great. I think it's probably gonna be easier in a place of faith, honestly, that this is God's ministry, not our own, not any one persons's. FPECC What is FPECC? I think it's important for people to know a little bit about how hard is it to create a training program or anything new in Kenya? Mardi - So FPECC is the fellowship program in pediatric emergency and critical care. Ariana [Shirk] and I are pediatric emergency physicians, we trained in pediatrics, and then we did specially training in how to take care of emergencies and resuscitation. And were the only two formally trained pediatric emergency doctors in Kenya. Critical Care is taking care of kids in ICUs and currently in the country, there are four pediatric ICU doctors for 55 million people. I don't have the stats that my finger tips, but it's extraordinarily low. I think of the city where you live and how many ICU beds there are, and how many children's hospitals you have just in your own city if you're based in a high income country. For 55 million people, there's kids just can’t access that care. David - Recently, I'm sure it's gone up, but two years ago, it was 100 beds for the country. Mardi - For adults and kids. . . In the country, there are a 12 pediatric ICU beds. Actually no, that's not true, there are 16 and eight of them came into existence, when we opened up our Peds ICU here three years ago. David - And keep in mind, this is East Africa, of the 56 million people. . .33 million of those are under age 18. So 16 beds. Mardi - That's right. Think of anything that can cause a critical illness. Trauma, illness, cancer, you name it, that's not enough beds. So when I came to Kenyo, I had no dream of starting a training program that wasn't even remotely on my radar. But sometimes things just come together at the right time. It was actually University of Nairobi, where they have the only other Peds ICU, they had been working with University of Washington in Seattle to say, “Look, can you help us start some training?” This is really important, because in East Africa there is nowhere that a pediatrician can learn how to run an ICU. Think of the US, where every state has got multiple training programs, where pediatricians will spend three years to learn to be an ICU doctor. There is nowhere for 360 million people in this region to learn how to do ICU care for children. Just think about that for a second. 360 million people... No training program. There's one in Cairo, and there's one in Cape Town, but that's for 600 million people. So I'm just taking a few of them where there's nowhere to go. University of Nairobi was talking to Seattle. They've got two Peds ICU doctors in Nairobi and they were thinking of starting a program. Then just through several contacts, actually through the Christian mission network, one of University of Washington's ICU doctors grew up in Nigeria but she's involved with the Christian Medical and Dental Association, and so she knew about Kijabe. The University of Washington team came out to Kenya for a visit, and they said, "Hey we heard you doing some ICU care caring Kijabe. Can we come out and see what's happening?" That was in 2013. They came out and said "Hey what are you guys doing here?" And we showed them around, and their minds were blown, they didn't know there was any peds ICU happening outside of Nairobi at all. And so, we rapidly started some conversations and said "Look, why don't we start a training program in Pediatric Emergency Care and Critical Care and our trainees can train at both Kijabe hospital and Kenyatta hospital in Nairobi and they can get an exposure to two different types of ICUs. They can also take advantage of the fact that Ariana and I are here as Peds Emergency faculty, and we can split the training load. Training programs in the US have dozens of faculty for something like this, to rely on just two doctors in Nairobi was an incredible risk even though University of Washington is supporting with visiting faculty. So we said, "Look, we've got all these people in the country at the same time, let's just try and do it." So we started that process in 2013. We took our first fellows at the beginning of this year. It's taken us six years. That's how things work here. You've got to form relationships. University of Nairobi didn't know us real well when it came to our pediatric care. We had to get to know each other, we had to develop a curriculum. We had to let the Ministry of Health know. We had to get the Kenya pediatrics Association on side. The Kenya Medical Practitioners and Dentists Board, had to approve the program. The University Senate had to approve the program. We had to try and get some funding in place. None of that happens quickly. It's all relationship that's all a lot of chai. That's all a lot of back and forth and making sure that you don't try and skip anything to get through the hoops, any quicker than you need to, because if you try to go to quick it falls apart. And if University of Nairobi and Kenya doesn't own this program, it's not gonna last. And I think that's probably the first thing to take away for me is this program exists because University of Nairobi and Kenya wanted it I didn't come in here and say, "We need this.” University of Nairobi wanted it, and we said, "How can we support it?" And so Arianna showing up here for a short-term visit - which we rapidly recruited you guys as long-term - it was God's timing because Ariana and I couldn't have done this independently from each other. It's taken both of us to build those relationships over the last six years. Arianna and I are so proud of this program. Our first two graduates will finish this training at end of December 2020, and we hope and pray that we can recruit them to stay at Kijabe and University of Nairobi as our first home-grown faculty. What's been lovely about that, too, is that we've connected with people all over the world who want to support this kind of thing, they just didn't know how. David - Not did they not know how, there wasn’t a way. It literally did not exist until February 2019. Mardi - So now, we're actually talking to colleagues in Uganda and Tanzania, and colleagues in Sudan and other places about... “Hey, is this a good model for you?” I've got some contacts in Nigeria, they've got how many million people, 30 million people or something ridiculous? And there's no way to get this training there either. And people all over the world want to be able to support what a country wants to start in its own strategy. So that's something that I'm just thrilled to be leaving. Even as we leave next month, I'm hoping and planning to come back at least once a year to teach in the program for the forseeable future and to support Arianna from a distance in continuing to connect people all over the world to say, "Here's a way that your global health desires can interface with a local country's needs." David - You two are the only Peds Emergency Medicine doctors in the country and there's a realization. . .What actually is Emergency Medicine here and what is the difference between what it looks like here versus America? Mardi - Yeah, it's a really great question. First of all, Ariana and I trained in a country where there are multiple children's hospitals per city. So, Pediatric Emergency Medicine is the Emergency Department attached to a children's hospital. There are less than 10 children's hospitals on this entire continent, I think. So there are no Pediatric Emergency departments. What is really great is that Emergency Medicine combined adult and pediatric is a growing specialty here. There's been so much great work that's going on in so many countries around the region. Rwanda last year, just graduated their first class of emergency residents. Uganda just on the cusp, the great advocate there, Annette Allenyo is leading the charge for emergency medicine. Ben Wachira is an Emergency Medicine trained doctor here at Agha University, and they're on the cusp of starting an emergency medicine residency training program. You know Emergency Medicine's a funny thing. Emergency medicine in a high-income country, is a part of a functioning system. Emergency medicine in the US means that you've got ambulances that get your people to you and you've got an ICU at the other end that you send sick people to. Emergency medicine here is. . . people showing up on our door step, we don't know how to get them here and then where do we send them? I think that Emergency Medicine training here is so much more broad. We're training people not only how to provide Emergency Medicine, but how to be advocates in a broader system. And I think if you live in a high income country, you can't understand how much medical training is not about medical training. It's about advocacy and building access to care for people, no matter where they're at. What I see emerging here is…from the start, it's collaborative. Emergency Medicine training here isn't just training a doctor in a specialty to give you a certificate and leave you there. It's connecting you with people who are trying to get paramedic systems going and people trying to build ICU care. That's one of the reasons we realized that our Pediatric Emergency and Critical Care program had to be both. There's not enough places to work where you've got the luxury of staying in the ICU. Our graduates are gonna go out and work in hospitals where they will be expert trainers for the pediatricians running the ICU and the family medicine doctors running the emergency department and the surgeons who are doing pediatric surgery with just general training. Our graduates are gonna be those advocates drawing teams together asking "How can we improve the system from arrival at our doorstep till the day we send them home." It's a different focus in our training. Yes, the skills are necessary. You need to know how to run a ventilator and keep a heart pumping when it's not. But it's about building a team and being a part of solving systems issues and hopefully in a way that is affordable and sustainable. David - I love that word, systems. For me, this is the year of systems. Thinking broadly about each of these individual parts because it’s another way that healthcare here is very different from healthcare in the US. The US is just sub-specialization, that's what it's all about. And here, there's not a fine line between. . .for an Emergency Medicine doctor, you're not sitting out in casualty waiting for a kid to come in, right? If you want to find the emergency, you just walk around and lay eyes on every kid and there's gonna be one out of 70 children in that building, who is in trouble. So it really is a bigger and broader way of thinking about things. Mardi - I think another thing that's interesting to me just as we come back to the missional aspect of who we are... I think 00 years ago, a missionary was someone who would go into deepest, darkest wherever and be whoever they wanted to be. I think as we consider what is global mission, our question needs to be, “What is that country looking for, what systems are they trying to develop and how do we help them in it?" And that comes down to health…if you're a missionary, what does the local church want to do? What is their mission and how can we assist them? I think we need to ask better, what system is someone trying to build and how can we be a part of it. Because that's the key, isn't it? We're here to serve God who is restoring creation and he's doing it in lots of different ways already. We don't need to necessarily think we've got the answer, but to say "God, where are you working and how can I be a part of it, and what does it look like?" I think Mary Adam in her community health project, is a really lovely example of that. Community Health growth is a priority of Kenya. So she's gotten grant funding and she is just sowing in it, she knows every county Governor in the country, I'm suspecting. She knows how to get into the system, but how to be salt and light, and how to be the love of Jesus in making things functional and making all things new. I think that's one thing that I think Kijabe is doing well. We are looking at health strategy and saying How can we be a part of it and love that our FPECC program is in partnership with University of Nairobi. I love that our clinical offices have a program that we got accredited for called the Emergency Critical Care Clinical Officer program, that actually wasn't a part of hell strategy, but we did see a gap, and as soon as we trained people in that we went to the Clinical Officer of Council and said, "Hey you want to accredit this? This is a really good program. And they did, and now the Kenya Medical training training college has taken that program and they're doing their own program. I think those are lovely examples of saying “We're here to bring restoration but we don't want to be separate from the system. Where are you going and how can we help” David - What does that mean for friends of Kijabe? How do you see that working with Friends of Kijabe as an organization? Mardi - What's been really lovely, about Friends of Kijabe in the last year, and I know you're excited about this, David, is in what the core the Friends of Kijabe vision and mission. I think a core part of Friends of Kijabe that we've got the CEO, the CFO and the Director of Clinical Services on the Friends of Kijabe board. One question that I've heard you ask so many times in the last year is "Where are you going and how can we help, what are your priorities? Friends of Kijabe exists to help the hospital further its strategy, but also exists as a bit of a connector between people in high-income countries who really want to contribute and who have passions. Where does that intersect with the hospital strategy? So Friends of Kijabe is not going to take the whole hospital strategy and try and piecemeal help every part of it. They're gonna say, "Hey you're a part of your strategy that are happy resonates with and that's become very clear. A lot of Friends of Kijabe funding currently goes towards whatever the hospital thinks is important. The hospital has prioritized the theater expansion project this year and that's great. But, at its core, Friends of Kijabe also says, "We support the needy. We support education. We support sustainability. How can we get there?" And so [FoK] has prioritized putting money towards each of those areas which happened to align with the core values of Kijabe Hospital. So a large proportion of what Friends of Kijabe hospital is doing this year is helping us with an infrastructure project. But every year we're going re-ask "What are your priorities, and how can we help that?" But we're also going to say, "Here is where our heart beats. Can we help with this too?" I think one of the things about Friends of Kijabe is the trust that's developed since its inception. As Friends of Kijabe, we trust that the hospital leadership is following a strategy that is meaningful, that is sustainable, and that is in line with where Kenya is going and where the African Inland Church is going because that's who we're owned and operated by. As long as our missions intersect, I think Friends of Kijabe can trust that at the hospital is taking us in a good direction. David - Awesome, anything else I should ask you? Anything you'd like to add? Mardi - No. It's been an extraordinary eight years and it's been such a privilege to be here, and it's lovely to leave with joy, even as there's associated sadness. I really can't wait to see what the next few decades bring, and I'm gonna be watching both from a distance and also up close, when I come back to visit. David - Thank you Mardi.

FoK - How long have you been in Kijabe? You delivered on what date? Dorine - I delivered on the 2nd of May 2019. I came in a week before, the 27th of April. FoK - And today is July 9th? Dorine - No, it’s the 8th, it’s our monthiversary, we got married on the 8th of February. Happy monthiversary! I think the baby’s charts say 65 days of life or something like that. 72 days, I’ve been here. FoK – So this is your home? (laughter) Dorine - But I look forward to going to my real home. FoK – Why did you come to Kijabe? Were you in labor, were you concerned? Dorine - I went into labor two days before the 27th when I was at home, it was a Friday evening. Prior to that I was on two months bedrest. I was already working from home, my office was kind enough to let me do that work from home. On that Friday evening I went into labor. I called my doctor, I was seeing a gyna. She gave me some prescriptions to take to stop the labor, but in about two hours if it didn’t stop I would meet her at the hospital. called her and she gave me some prescriptions to take to stop the labor to delay the labor, if it doesn’t ease off in two hours we could proceed to the hospital. In two hours, I would meet her at the hospital. We had planned to deliver at Coptic hospital, so that’s where we headed. We got there, but the labor kept progressing so we started off on steroids and all the other things. That was around midnight, along with the meds to stop contractions. By 3:30 am, we were sure we were going to deliver. The issue was at the hospital, there was no neonatal doctor or nurse. Advanced as we were in labor. The doctor told me, "here, we can see the head, do your thing." But as God would have it, she told me on the next contraction, "You push," but the next contraction never came, it just subsided. It subsided enough for me to get off the table and walk back to the waiting area. I proceeded with the meds, I even slept. By that time, we needed a transfer because the hospital didn’t have a neonatal ICU, which we really needed. We check the hospitals in Nairobi or it was crazy the amounts they wanted, 300,000 deposit. Kenyatta told us they had, but as soon we were discharged, they called back and said it’s gone. In the height of that pressure my husband remembers, "I don’t know why we didn’t think about Kijabe Hospital." We’ve interacted with Kijabe Hospital before, there as a time my mother needed a surgery. We called through some people we know, confirmed they did have a NICU bed available, and that’s how we made our trip here. FoK – That’s really important, even though they didn’t have the full resources, that they gave you steroids, they did the right things so that when Gabriel came, he was healthy. How big was he, how much did he weigh at that time? Dorine - Gabriel was born at 1040 grams, but he dropped weight to 840 in the following days. So we began our climb from 840. He was tiny then, I didn’t know where to touch or hold. His current weight is 2350 grams as of this morning. FoK - When he was like that, when he was little and you were scared to touch and scared to hold, what did the doctors and nurses advise you at that time? Did they coach you on how to interact with him? Dorine - Okay, my husband saw him first, then I saw him shortly after. He was delivered about 2 pm. I saw him about 7 pm, I think they were working on him somehow on the resuscitation table. I stretched out my hand and thought, where? Where would that be. But they were encouraging, encouraging you to come to terms, this is your baby, he is absolutely tiny, but he’s in the best of hands. Actually that reassurance came before I got to Kijabe. They said, we have an ICU bed for you, and once we know you are coming, we will keep it for you. Because when I was coming it wasn’t obvious that I was going to deliver on the same day. But they were very reassuring all along. In terms of the many questions I had, statistics for what’s the survival rate and all those things. The stats were really good. As much as they were careful to alert me to risks the baby will face, we also have a lot of success. Compared to Mr. Google which told me a lot of scary information. They answered many of my questions. It has been a reassuring journey that the doctors are available to walk with you. FoK - What would you say to a mom who is in the situation you were in several months ago, what would you say to her as far as encouragement or hope, how to face what’s ahead. Doreen - The journey is very scary, it is tough. There is a room where we go to express milk for the baby. That’s where you meet everyone who is going to pursue the nursery. The first few days they walk in, and I think I was the same, they are very scared. I remember a woman, who walked in, not even a 26 weeker, maybe a 30 weeker, but still tiny. One of the things I told her, is you need to change your mindset, your expectation. You will not be here for two days, you will be here for a longer time, much longer but it will be doable. Every day will be better than yesterday. It’s been an interesting position. I didn’t know that’s what I was coming to do here. In fact, they call me the welcome-er. Everyone who comes new, they come to fetch me. D, come, there’s someone new, she has a tiny baby, come talk to her. FoK – That’s amazing, though. We see that so often around here. You’re here having care for your baby, but it’s a ministry you’re engaged in. Dorine - It absolutely is. FoK - It’s not just the Kijabe staff doing ministry, it’s also you guys as moms caring for each other. Dorine – It’s one of those things I didn’t think was going to be part of my ministry. I’m a singer, worship ministry I’m familiar with. This one is a new ministry. But God has been gracious. And it’s been tough, some days it’s tough, when the baby is not doing well, the first couple of weeks, those are really low. Those were very tough. The baby had all sorts of things, one after the other. If it’s not respiratory, an infection. It was tough. In that toughness, God somehow managed to make me tougher, in the toughest way possible. Lack of sleep, every two hours, it’s not even two hours, it’s more like 30 minutes the most sleep I ever got was 30 minutes. But the next week there is someone in your shoes, they need you to say that one thing that will encourage them to come back the next day, to toughen up beyond what you yourself can do. It’s been a serious growth opportunity. FoK - Are there any bible verses or quotes or sayings, or songs even that come to mind as you are trying to toughen or persevere? Dorine - I will not remember where it come from, but there is a verse it says, “the Lord will perfect everything that concerns me.” (Psalm 138:8) That’s what I keep repeating to Gabriel, I will stand by his incubator and pray over him and remind him that, “Dude, the Lord is perfecting everything that concerns you.” So, if it’s respiratory issues that week, The Lord is sorting this respiratory issue, not just sorting, perfecting. That’s what I’ve been believing, even now as I wait for him to get off of oxygen. He is going to perfect that. We’ve come a long way I’ve seen perfection in all those ways. Then the wall of the nursery, has that beautiful verse, “I knew you were formed in your mother’s womb.” Me, I was surprised by Gabriel’s arrival at 26 weeks, but God wasn’t. One of us needed not to be surprised. What you cannot control. What I, as D. cannot control, God can control. I sort what I can. I can express milk for the baby, fine. I can stand by his incubator and pray for him, I will do that. I will stand with a fellow mum, or just sit there and let them cry, if that’s what they need. But what I cannot control, just let it be. The doctors are sorting it. God has put them there, he’s using them to sort out whatever it is. It will be fine. It’s easier said now that I have walked the path. (laughter) FoK – It’s not so easy in the moment. Dorine - In the moment, you will yourself to remember those things. I’m glad I have been spending time in the bible before now, cause you need to remind yourself those things. Ultimately, God is the one who knows how this is going to play out, and it’s played out well. FoK – How has this been for you and your husband to do together? I still want to meet him, I haven’t met him yet, but I’ve heard stories that he’s really tall. Dorine - He’s 6’3, not only tall, really huge, big boned. I think Gabriel is following suit. He’s been absolutely supportive, absolutely awesome. We don’t live near Kijabe, maybe an hour or so from Nairobi, but he’s made every effort to come by. In the beginning he would come, maybe 3 or 4 times a week. On the weekends he’ll always be here. Even with the traffic, he would come after 7 and leave again to get home by after 9. Every weekend when he comes by, he will bring a cooked meal, a hot one. He will take his time and cook. He’ll ask what do will you want to eat this weekend. He’s been awesome, but it’s been a strain for him as well. The commute. The uncertainty. You know I’m here, when I’m called to nursery I’m there to see. He has to wait for relayed information, especially in the beginning, he’d worry. I never took my phone to the nursery, and already we knew there had been a slight issue. I was waiting for the doctors to do their rounds, and it was a couple hours before I came back. He had looked for me frantically, he had called everyone, he even called Kijabe Hospital. It's been strenuous on him, but he’s also really prayerful. I thank God it’s him I’m doing this with. He’s more patient. He tends to take his time in a situation. He won’t react spontaneously as much as I would. This has taught me a lot of patience as well. We talk often, we spend the little time we have well. It’s been tough, but good. FoK – Anything else I should ask or you would like to say? Dorine - This experience for me has been multifacted. In the beginning there was lots of uncertainty, lots of worry, anxiety. All those things you are told, “don’t be anxious.’ We were anxious. We prayed yes, with thanksgiving, but in the moment, it’s absolutely all these emotions. You are worried. I didn’t get any sleep after he was born. I couldn’t sleep, and even when I slept I feared to wake up. “Dorine, you’re being called for the nursery.” That was the worst, you know. Maybe, it was not even for the baby, maybe it was just to go and express milk. But that in itself was enough to send panic. Initially it was a lot of high-stress condition. I think God that He gave me the strength to still hold on. As much as we want to know is everything okay, the strength (is) to be optimistic, I’m going to walk in there and the baby is going to be fine. And even if he’s not right now, he will be shortly. And it always came to pass. It’s made me more prayerful as well. Pray at all times, more prayerful. This idea of “have faith”. . .I think sometimes when you say it, when you’re not in the situation, it’s more of “I have faith,” and you know full well there’s food somewhere to eat. No, no, no, this brings the meaning of faith. You have no idea how it’s going to play out, but you have faith. It’s also been tough. Kijabe Hospital is really great in terms of the facilities, the doctors, the nursing staff. But on the other hand, things like the food. (laughter) FoK – I’m sure, for three months. Dorine - There are many other things that you cannot compare with home or that could really be improved upon. But for us the facilities were the main thing that we needed. I absolutely miss home every day. . .you know these small things. But the main reason we were here, I’m glad were here. Especially in light of the debate that has been going on in Kenya about abortion rights. . .you know we want to legalize it in Kenya. I wish some of those people could be here to see life does not begin at birth when the baby is born at full term. They should see life at 26 weeks. Life begun when these two human beings mate, that’s when we should start protecting a life. I felt strongly about it now, I don’t know what word is stronger than strongly. Dorine - Yes, Kijabe has been home. I’ve made friends, lots of friends. Patients. . .they come and go, you say goodbye, escort them to the gate. I’ve escorted so many, carrying their luggage, say goodbye. Goodbye, see you. You welcome many others. The staff here become familiar, most on name basis. The doctors, the nurses, the support staff, the canteen, the askaris, pretty much everyone. I think I’m really an outgoing person, so I like to know people. FoK – Last fall we had a celebration and invited back some of our NICU moms. The oldest baby who came is 19 years old, she’s tall! It’s amazing to watch what happens afterwards, how these children are growing and doing. I’ll say to you, you’ve been wonderful to my wife and to Dr. Ima. I don’t know the nurses as well, but I know you’ve been wonderful to them. That’s a really big deal because it is stressful and it is hard, but you have handled it gracefully. We appreciate you for that.

Pastor Helmers: Grace be to you from God our Father and our Lord Jesus Christ. Acts 10:34 34 Then Peter began to speak: “I now realize how true it is that God does not show favoritism 35 but accepts from every nation the one who fears him and does what is right. 36 You know the message God sent to the people of Israel, announcing the good news of peace through Jesus Christ, who is Lord of all. 37 You know what has happened throughout the province of Judea, beginning in Galilee after the baptism that John preached— 38 how God anointed Jesus of Nazareth with the Holy Spirit and power, and how he went around doing good and healing all who were under the power of the devil, because God was with him. 39 “We are witnesses of everything he did in the country of the Jews and in Jerusalem. They killed him by hanging him on a cross, 40 but God raised him from the dead on the third day In the name of Jesus, my dear friends, it is truly an honor to be here with you this morning. This is my second visit to Kijabe Hospital. I was here in 2017, and was honored to witness the ministry of Kijabe hospital. I was able to walk to you and see what you do for Jesus and his people in Kenya. When I left Kenya and went back to the United States, and I can honestly tell you. I couldn’t stop talking about this place. I was impressed with your motto, everywhere I turned staring at me, healthcare to God’s glory. I was impressed with the commitment of all of you, the commitment providing quality healthcare for the people of Kenya. The commitment to providing training for future healthcare workers in Kenya. The commitment to minister to the spiritual needs of patients in this hospital. I’ve never witnessed a hospital in the US that had healthcare to God’s glory. I see it everywhere here, and it struck me so deeply. And your commitment to the three pillars of your ministry. I was also deeply impressed by your commitment to Jesus. He’s our savior isn’t he? But he’s also our Lord. Lord of the church and Lord of our lives. See what you are doing here in Kijabe Hospital, I would say in simple, plain English is a downright good thing. That’s what Peter is trying to say as he describes Jesus’ ministry in his sermon. Peter talks about Jesus’ death – a death on on the cross that atoned for the sins of the world, so that everyone regardless of their race, their nationality, their language – all might live with God forever. He talks about Jesus’ resurrection, a sign that the power of sin and death over us has been destroyed by Jesus of Nazareth, the son of God. And that because he lives, we too shall live and join that great throng mentioned in the book of revelation, that throng from every tribe and nation and language offering praise to God forever. I made special emphasis in reading of one line, that always grabs my attention, “he went about doing good, and healing all who were oppressed by the devil.” One simple line, isn’t it, “he went about doing good.” What better thing could be said about a person at the end of their earthly journey, “he went about doing good.” What better thing to be engraved on a headstone in a cemetery, “this person went about doing good?” You’re doing good at Kijabe Hospital, you are doing what Jesus did – going about doing good. Why did Jesus do this? Go about doing good even to the extent of dying on the cross. Very simply put, Jesus was filled with compassion. Several times in the gospel it says Jesus met this person, Jesus met that person, and he is filled with compassion. In the Greek language it says, his gut was moved by what he saw. Compassion is a Jesus word, isn’t it? It’s what Jesus is all about. Compassion is his nature. It’s his words and his works as he shows his love for people. I think there are three things that encompass compassion. (every good sermon has to have three parts!) Compassion means having eyes that see It’s easy to look away sometimes. Some situation are so tragic that it’s downright hard to look at them. I’ve been going to Uganda once or twice a year since 2005. the first time that I went I saw thousands of children, protruding stomachs, children who were hungry, who were sick, who were dying. I remember being overwhelmed by it. I had seen it on television in the united states, but to see it up close with my own eyes, that was something else. Jesus had two good eyes. He saw people who were hungry, lame, deaf, blind. He saw people who were grieving over the loss of loved ones. Jesus was not afraid to see hurting people with his two good eyes, and that’s where compassion begins. Compassion means having hearts that can be moved. Sometimes we get hardhearted don’t we? We may see a tragic situation and say, well, that’s not my problem. Or we may see someone in need and say, well, they brought it upon themselves. But Jesus, this son of God, son of Mary, he’s an emotional guy. He has a heart that can be moved. We are told in the gospels that Jesus looked out over the city of Jerusalem and he cried, because they rejected them as messiah. When his friend Lazarus died, Jesus wasn’t afraid to show his emotions. He wept. Jesus is not afraid to let his feelings be known. He’s not afraid to be vulnerable. He sees and hears and his heart is moved. Compassion is having eyes that see, hearts that can be moved, and willingness to do something about it. We see and feel sorry for someone, sometimes it’s difficult to take the next step. Maybe it’s too costly, maybe it’s too dangerous. We’re not willing to give God what God has first given to us. But Jesus, he’s not only able, Jesus is willing. A man with leprosy came up to Jesus one day and said, “Lord, if you want to, you can make me clean.” Jesus says, well, I want to! And he touched him. Jesus is able and willing. Jesus fulfills those words in Isaiah that talk about the messiah coming and about restoring creation and restoring human beings. Jesus speaks these words of Isaiah about himself. The spirit of the Lord is upon me because he has anointed me to preach the good news to the poor. He has sent me to proclaim release to the captives and recovery of sight to the blind, to let the oppressed go free, to proclaim the year of the Lord’s favor. That’s Jesus, with eyes that see, a heart that is overflowing love, deeply moved as Jesus willing to do something about it. Jesus willing to give what he has a son of God – to give his power, to give his grace, to make people whole again. To go about ministry to the whole person, soul and body. Because he has eyes that see, a heart can be moved, and he wants to do something about it. Jesus gives and he gives and he gives, almost until he has nothing left to give, when he dies on the cross to pay the price of our sinfulness, hat we might be set free from a guilty conscience, that we might be set free from the power of the devil, that we might be set free to go into the world and be Jesus to others, to be his hearts and to be his hands. In the US we have an expression, he’s preaching to the choir. What that means is that the preacher is talking to people who already know what he is talking about, and that they are doing what he says they ought to do. I feel this morning like I am preaching to the choir: People who are already the heart and hands of Jesus. People who have eyes to see, hearts that can be moved, overflowing with love. People who are willing to give what they have first been given – knowledge, wisdom, skill to make bodies whole, to uplift souls and spirits. To give people the peace of Jesus, peace the world cannot give. I feel like I’m preaching at the choir, but I’m going to pray for you, but I’m going to go a little bit farther. I’m going to pray that you may continue to do this good work. I’m going to pray that God will pour out an extra measure of his holy spirit so that you may increase in what you are already doing, the existing hospital, future operating theatres, whatever happens in this place, that you may do it all for Jesus for the glory of all. Prayer: I thank you that you have given me the opportunity twice now to see a spectacular place, to see a downright good thing that is happening at this hospital. I pray for each one gathered here today, I thank you for the faith you have planted in their hearts. I thank you for the commitment you have given them. I thank you for their willingness to use their gifts for the welfare of your people, for your glory alone. Be with everyone here, deliver them from evil, be with them from the hour of temptation to be less than what God has created them to be. Pour our your spirit on them so that they may have courage, faith, and can continue your good work in this place. In the name of Jesus, amen.” Ken Muma I would like to thank Friends of Kijabe Two years ago we had a retreat to brainstorm about how efficiently and how best to partner together. We came up with a raft of things that looked so impossible them, but they are coming to fruition. I’d like to thank David Shirk, we’ve been walking this journey together. I’d like to thank your church members from Lutheran, we are forever grateful. I’d like to thank this boy, Joe Lehman, who started a crowdfunding campaign and the person who raised the most money would have a mention of their university and their university football team for who they love the most. That is why today I am wearing an Ohio State Jersey, because the ones who gave the most amount is from Ohio State. I want to thank this boy very much, and the family and the parents. Asante sana, wherever he may be, I hope this message reaches him. I was just comparing him to my boy – while he is doing crowd funding, my boy is chasing after baboons. (laughter) Africans, where did we go wrong? Thank you to all. And thank you to a core team that has been instrumental in delivering this project. I saw Dr. Bird somewhere. He has been instrumental in providing the wisdom and experience of how the project was done in the past and bringing that experience to this final concept. I’d like to thank Dr. Barasa who has been the lead of the project as the head of surgery. I’d like to thank and acknowledge Dr. Hansen in abstentia. He has been instrumental, he did the original mathematics about the needs and future needs based on the number of surgeons and the trajectory of the growth of training. I’d like to thank Grace Kamau and the infection control team and the peri-operative nurses and everyone who participated in giving information for the Archeterion team. . .and the people who developed (the design). Thank you very much, even the education team with Dr. Evelyn Mbugua. This is an example of when everything comes together in perfect harmony. But above all, I’d like to thank God for making this a possibility. Asenteni sana.

PAACS Part 1 Good morning and welcome to the first PAACS episode. PAACS stands for the Pan-African Academy of Christian Surgeons and on the next two episodes I’ll be sharing conversations with graduates and faculty in the PAACS training programs at mission hospitals in Kijabe and around Africa. Nothing done at Kijabe Hospital is in isolation. Surgeons have been training under the PAACS program at Kijabe for more than a decade, and I think the PAACS program develops some of the best Christian leaders on the planet – not just surgeons, but Christian leaders. Friends of Kijabe is a support organization – we support the work of Kijabe Hospital in general and we support the work of PAACS at Kijabe through infrastructure projects like the Operating Theatre Expansion or through needy patient funding. I’m excited to share these conversations because they paint a vision of what is possible. Dr. Jacques in Malawi describes the blessing PAACS is in African Healthcare The second interviewee is anonymous because of a sensitive location, but he articulates the intersection of mission, medicine and the gospel perhaps better than anyone I’ve ever interviewed. Dr. Beryl Akinyi, associate director of PAACS at Kijabe, talks about paying it forward – giving young surgeons the time and effort that was given her, to help them succeed. Please enjoy! David – You’ve been these multiple different places, you’ve seen PAACS working all over the continent, what is your impression on the work? Jacques – The work of PAACS? This is incredible, incredible work. As an African I can say clearly, without doubt, PAACS has been, and it is, and it will be a blessing for Africa. A real blessing for Africa. My real joy is, I come from nowhere, God allowed me to be a general surgeon, then on top of that, God allowed to become an educator with PAACS. I’m so happy to train others, just as Paul trained Timothy. This is my real joy, to train others. PAACS is a real blessing for us. David – Where is nowhere? Jacques – DRC is a huge country, blessed by several resources. But when you go to DRC, you will say what I am saying. People live in poverty, people die of simple health issues, people are not really educated. With all the conflicts that are happening in DRC, I really pray for my country. David – Where do you see yourself 5 or 10 years from now? The ways of God are sometimes difficult to understand. I don’t know why God didn’t allow me to find a suitable hospital in DRC to work and serve my people. He sent me instead to Cameroon to Mbingo hospital. I don’t know know why God has allowed the instability in Cameroon and sent me way down to Malawi. I don’t really understand, but I know as long as I’m on the path of our Lord Jesus Christ, I’m content with His plan for my life. But one day, if He allowed me to return to DRC, I would only say, “Thank You!” Y Interview David: One of the unique benefits of PAACS, you’re training not only surgeons, you are training Christian leaders. When you look at these wide-ranging systemic problems, that’s what you are teaching them to address. What does that look like in how you work with your students and how you are teaching them? Y: It’s really interesting to see how our residents are growing academically, but also spiritually. We recruit residents that are believers, they love the Lord, they want to share what the Lord has given to them. Some of them, they want to be missionaries, to go to remote places to help the needy people. But when they come to the training environment, they get more. We are trying to fit into the curriculum Bible studies, discussions that are related to what they are doing. How can you show the love of Christ to a sick patient? You might heal somebody with medication, but the way you touch the patient, the way you speak to the patient, the way you care for his well-being and the well-being of his family. This in our context, is very important. These are some of the things we try to emphasize, not just to look at the patient as a sick person, but as a person who has spiritual needs. Those spiritual needs need to come up so you will have the opportunity to talk to them. There are various ways we help our residents by demonstrating. As a teacher, I do all I can to help my resident understand why I am so compassionate to my patients. Why should I come and greet my patient? Why should I come and sit at his side and talk to him in a gentle way? Most of our patients are Muslims. It’s so amazing that when you offer prayers to them, they will always say “Yes, pray for me, pray for me so that I will get well.” And if we pray, we pray in the name of Jesus. We will tell them we are praying in the name of Jesus. And if they are healed, Jesus healed, not us. So, we integrate that into the system. We also help our residents to be residents that are telling the truth. That sheds light not only on the patients but on other workers. Did this thing happen? Did you do this test? No teacher, I did not. It helps to know we are not there only for the surgery, for the pathology, but we are saying to our resident, “Be honest in your deeds.” “Did you examine this patient?” No teacher, I did not. When we grow and understand honesty is part of the thing that reflects Christ’s life, it changes things. David: What’s interesting about that, is it shows the trust they have in you as a teacher. Y: One of the things I see in residents or workers, if they see the teacher saying, “I’m sorry, I think I should have done this thing differently.” That changes a lot in the life of the resident, the nurses, the team. For the teacher to say, “I think I made the wrong choice here. It was my fault.” It makes a lot of difference. This type of training I like so much because it carries me, because of who I am, and I should show respect and be honest to myself. If I am wrong, and I know that I am wrong, and I refuse to confess that, my resident will not do that. We know as a teacher, we do things, not intentionally, but if we make mistakes we must come back and confess them. And if we do that, the resident will train in the perspective that, if you are wrong, you have to say that you are wrong. It doesn’t have to be a hidden thing. It is a be a normal thing to say that you are wrong. “I’m sorry for doing that. I will not do this next time.” David: That’s so profound. Sometimes the hardest things to do are the ones that even a little child should know. This is an issue for every medical provider everywhere in the world. Am I willing to own the truth and speak the truth? Y: Really, we have a lot of opportunities. (Our country) is 99% Muslim. Most people who come to our hospital come for their health problems and this gives us opportunities to share Christ with them. It’s sometimes very easy to engage into a discussion with somebody. A few weeks ago, we got a gunshot injury. Somebody went to another country, bought a car, thieves pursued him to his house, and in his sleep, they shot him. The bullet went through the left side of his abdomen toward the right side. It passed in between two vertebrae, did not go into the spinal cord, just passing near. We took him into surgery, repaired about 4 bowel perforations, his ureter was cut, some of the vertebral vessels were so destroyed. But his function was not affected. Looking at the x-ray, “Is he really moving his legs, this man?” Looking at the entry, he narrowly escaped being paralyzed for his life, but it didn’t happen. That really gave us the opportunity to open the discussion, how God was merciful on him. We took the x-ray, showed him what could have happened to him. We opened that discussion, shared the love of Christ with. We are engaging in communication to lead him to Christ. So, trauma, getting into training, if I didn’t know how to repair these things, I wouldn’t have the opportunity to do that, to share Christ with someone. We see such scenarios in our hospitals most of the time. I’m really happy with the vision that PAACS has. We are going to change the way we do medical mission, because the Lord is in the process of changing the way we do medical mission. Why am I saying this? I used to be the only doctor in my hospital. When I came back I spent about 9 months being the only surgeon. I would be on call almost every night. That was the situation of each mission hospital about 20 years ago. Missionaries would come from overseas, they would go to the place where the need is overwhelming, and they would be the only doctor or surgeon in that place until they burned out. Do they have time with the patients, to share? If you look at the workload, you say “No, they probably do not have.” I’m proud to say, today we have 8 residents and we are planning to go up to 10. So, we will train and we will send. We are multiplying ourselves, instead of the past idea of just doing it. And we are multiplying with the local people, who understand the language, the politics, the places they need to go to. Medical mission is changing, it’s spreading, and I think now we are getting it right. Jesus started with 12 disciples, he concentrated on those 12, and taught them, and after that, they went all over. That’s how Christianity came to us, Christianity came to Africa. If they did not teach and also send, it would never happen. I think that PAACS is taking that hope. We are teaching, we are training, we are making disciples, and we are sending them to go spread the word. That is the positive thing to me in this situation. David – What motivates you as a surgeon, what gets you out of bed at three in the morning? Beryl – I’d say in Kenya there is a big surgical need, the fact that I can meet that and later they come back and they’re smiling, that motivates me. The other thing that gets me out of bed, is I’m heavily involved in training of residents. When I see someone comes in so green, and they graduate as a surgeon, to me that’s a very big motivation - we’ve added someone to the workforce, meeting the need within the country and Africa in general. How do you think about, and how do you talk about the surgical need in Kenya? Is there an easy way to describe it? Beryl – That’s one burden of having poor patients coming in late. The other problem comes in terms of workforce, when people are not properly trained to offer the service that is needed. Those who are trained or skilled, especially in subspecialties are very, very few. That means we have increased waiting time for anyone to get their treatment, and that just makes the burden heavier and heavier. That’s what I’d say currently. David – You were talking about how there is very limited sub-specialization, but a lot of you as general surgeons choose an area of expertise a little bit, even if it’s not on a diploma. What is that for you, what do you love doing? Beryl – Two things, I like doing breast surgery and surgical education. Breast surgery is a little bit individualized, direct to one patient. Surgical education, you are multiplying yourself, I’m not just one person doing this, I’m teaching many people at different levels. David – I have watched you in theatre, and you are a very good surgical teacher. You are very patient, very gentle, you are willing to take longer on a procedure so the person you are working with can learn to do it right. How, practically, do you think about surgical education? What are the things you do on a daily basis in your teaching role? Beryl – Currently, because Kijabe is a training site, we have general surgery, orthopaedic surgery, and pediatric surgery fellowship. I am the assistant program director for the general surgery program, but I coordinate the learning for all basic sciences for all these specialties. That has made me read more, but has also made me focus more on the bigger picture, what’s the need for all these individual students? I’m trying to organize, so that in the five-year-time that all these trainees are here, they get what they need to get to make them a better surgeon. As an individual, I’ve had people who invested time in me, so I could be a better surgeon. That drives me, because if they didn’t invest this time and energy in me, I don’t think I’d be what I am today. So, as an individual, I try to use those good qualities, to make me a better teacher for my residents. David – How does faith play into what you do with your teaching and even with patients? Beryl – God has called us to be good stewards with whatever talent he has given us. To me, being a surgeon is what God has given me, and that is what drives me. God has called me to be a good steward with this talent or this gift. Each time I go to the hospital to work, to teach, I do it for God, not necessarily for the patient or for somebody else to see me. If I do it for my own glory, or for the patients or everyone else to see me, at some point in time I will be tired if I don’t get any good feedback. Knowing I’m doing this for God, drives me to be better and better each day, because that’s what He requires of me. I’d say I’m very grateful to Kijabe and over all to the PAACS program for offering an opportunity for me to learn as a surgeon, to do what I love most, and for all the people who invested their time and energy to help me grow. I’m grateful to Kijabe as a hospital and to PAACS as an organization.

Read the full transcript with graphics at: https://friendsofkijabe.org/blog/a-response-to-cured-into-destitution/

Watson: For you specifically, I want to get a sense of how that transition was. You said you were very successful as a wedding photographer. I know for me, I only do photography as a hobby, but I get that feeling of joy when I get the perfect picture, and edit it, and I’ve given a few people some of my productions, and I’m so happy. And to go from that, where that doesn’t directly translate. For Arianna, her medicine translates directly. But you, there was a time of trying to fit into this huge jigsaw puzzle that is Kijabe, there was a lot of faith and trusting in God, how was that like? How did you end up where you are and in what you are doing. David: Wow, you are so good at this, that is a great question. For me, photography was not an end, it was a means to an end. I love creating things, I love exploring, and doing things that I’ve never done before. That’s the part of photography I loved, creating something out of nothing. This was not here before, and now it is, you’re bringing something new into the world. That was the part I enjoyed most about photography. That definitely translates into the work I do with Friends of Kijabe now. There is not a definite map, a definite script. There are concepts. Watson: Like a framework. David: There is a framework, that’s a good way to phrase it. There is a framework for my job, it’s very people-focused, it’s relationship-focused, a big part that I enjoy is it is creativity-focused. How do I call people into the work that is happening here, how to I let them feel engaged with that, how do I give them something that resonates with their hearts? It’s really interesting and challenging. Most days, I wake up and what I do during the day, I did not know existed when I woke up. An email comes through and there is a new challenge or problem to solve, that aspect is really fun. But finding that place was a challenge. What realistically happened is, I never found it on my own. When Ann Mara - she had been working to start Friends of Kijabe for several years - when she and Mike were transitioning to Ireland, she said “Hey, here’s this thing, can you make something of it?” And my answer was, “I have no idea.” (Laughter) But I called Arianna’s uncle, John Richter, and he was the exact right person. He said, “Let me go down the hall and talk to my friend.” And six weeks later Friends of Kijabe existed, and the next question became, now what do we do with it? Watson: Now we have a non-profit. David: A little bit like photography, it is a season, in the back of my mind, I’m always aware of that. How do I build something where I’m both completely in the center of it, outside of me. Watson: Self sustaining. David: It (Friends of Kijabe) won’t ever be self-sustaining in the sense where it can run on its own, but how do I give other people the tools where they can carry it. It’s a really fun, interesting challenge. Watson: I see. I like how you started by saying you were somehow able to boil down to the core reason of why you like photography so much. Once you said that statement, it clicked in my head that as a creator, a content creator or as a creative, you definitely had a place to plug in. Even if it didn’t exist before, or it wasn’t clear in the beginning. It’s something that God worked behind the scenes, to get Ann Mara to approach you, and then you had the exact right person to call, and the exact right processes that went through, and Friends of Kijabe is now existing and is functioning in such a way. Sometimes I look at the beginnings of something like this, and then I imagine ten years down the line how those people will be looking back and wondering, “How did this begin. How did they go through the initial teething problems? And how did they get the first tens and hundreds, and millions?” because I believe it will be millions. David: It really is interesting and that journey. . . I feel like, at least in our family, there are two kinds of people, the Arianna’s and the David’s And Arianna is the one who knew, from the time she was 5 years old that she wanted to be a doctor in Africa. Intellectually she had no idea what that meant, but she literally wrote down on paper, “I’m going to Africa.” For me it was the total opposite, where I’ll wake up and not know exactly where I want to go during a day. So, we balance each other out very well in that sense. That leading, and continual doors opening, and the orchestration. . . You hear people sometimes talk about God’s tapestry, like weaving of a tapestry. That is so unbelievably evident in my life. I can look back and say, Wow! This led to that, this led to that, this led to that. It’s nothing I would have imagined 15, 20 years ago, that I would be in these places. But it’s amazing, it’s really good. Watson: For a creative like you, whose 9-5 is creating content, and you find out in the morning what you need to do that day, how do you keep on top of your to-do list? How do you stay productive? David: The biggest challenge is being productive in the right direction. And even with work there are lot of things like that, there are things that take a lot of time that don’t yield results and there are some that are simple that are the most important. Trying to remember to make the most important thing the most important, that’s the biggest deal. Watson: Prioritizing your tasks, and like you said, it’s an 80-20 principle. 20% of your work is what ends up achieving 80% of your outcomes. Now, at the beginning of your week, Monday through Friday or for you, Monday through Monday. How does your day look like, how does your week look like? How do you project and know I’ll spend these days doing this project and these days doing another project? David: I do like the way you phrased that, because that’s the way I view my work, project by project. Even making a podcast or doing my emails, I still see those as an individual thing. Sometimes I can spend 8, 10, 12 hours on one email, putting it together. That’s not phrased exactly right, that’s not phrased right. I need better picture, I need another story. It can take significant time to put those together. The best weeks for me are the weeks where I start out and I have nothing planed. Or maybe only one or two things, so when interesting things come up I can pursue them. I’m not a naturally organized person. I don’t know if you’ve met Ree’L, but she and her husband Jason moved to Kijabe a few months ago. She’s super-super organized, loves spreadsheets, and she’s been helping me with the hardest part of my work, which is accounting. I can do it, but it’s just not my skill set. I’m glad I worked on it for the last year-and-a-half because I understand what’s happening. But to have somebody else who loves that to say hey, “here’s my numbers, let’s look at and discuss it.” Being able to hand off things that are life-draining, offloading some of those things, that’s been really helpful. I’ve done that to Salome also. One of the temptations for me is to be in the hospital, doing things that don’t move Friends of Kijabe forward. Not that they’re not important, but do they have strategic purpose. Are they moving us toward big goals? Watson: Are they high-yield? David: Exactly. One of the things that has changed for me is because of John Richter, our board chair, our board guys and Ken Muma – sitting together and saying, “What is the purpose of Friends of Kijabe?” And we decided I should be doing the one biggest thing that there is. This year we decided that is fundraising for operating theatres. So instead of me having 27 jobs and trying to juggle all of them, I have one job and then multiple ways to accomplish that. That has been unbelievably freeing, because when someone comes up to me in the hallway and says, “Can you come up with money for this little thing,” I can say, “no that’s not my job this year.” Not that it’s not important, if I can, I’ll try to help them think about how to succeed. But I’ll try not to take it on to myself as my responsibility. My responsibility is, “What does the Director General say, what does my Board Chair say?” Watson: I think it’s really important for creatives to have clarity about the big picture and the big goal so that you don’t end up getting lost in your own mind. You can have so many ideas and so many projects that you begin and reach half-way and another great idea comes in and you want to start. But the really big goal reigns you in, but gives you more freedom do really dive deep, to your heart’s content. David: That is a fantastic way to phrase it. It’s been really fun, and a big mental shift for me. Arianna’s family - I keep mentioning them, but they are all amazing - I was talking to her aunt a little while ago, and she said, “When you’re really going to see success is when you get crystal-clear about your message and the change you are making.” I feel like I’m on the verge of that, it’s in my head but I don’t fully know how to articulate it. But keeping the main thing the main thing is a part of that. We’re 103 years into Kijabe, and what does it take to make another hundred years possible? What steps do we have to do today to get to forever? Kijabe Forever, how do we get there? The answer to that a lot of times is not another blood pressure cuff. Really, it’s getting people to work as a team on the most important things, then moving to the next most important thing. Ken Muma said, “David, why are you fundraising for that over there?” “Well, because it’s a need.” “Yeah, of course it’s a need, there are so many needs. But if you do this one big thing, it can do many. It can fund, maybe not all the things, but thirty of them instead of one need.” That’s the difference between meeting needs and actually being strategic. Watson: I see, it’s like synergism. When you pool all your energies together, they multiply, don’t just add up, they multiply on top of each other, and you have a bigger impact together than alone. Wow, that must have been a really interesting meeting. David: That’s the big change that I hope will continue in the coming years. That’s why we’re doing work as a hospital on culture change. To get people to view each other as part of a team, working together, for the good of everybody. It takes a lot of time and a lot of repetition, a lot of meetings, but it’s really, really valuable. It’s fun to watch happen, and fun in my little way, to be a part of it. Watson: You mentioned doing stories, and the accounting part of your job. As far as what you were given from the DG, are there several ways of meeting that goal as a department or Friends of Kijabe, under which you can have little projects? Like stories, part of that is podcasts, photos, and something else. Do they all fall under something big, like a main three or four? David: The core of it is how to build a team, a wide, diverse team who is very engaged. I’ve thought a lot about different stakeholders this year, there’s expat missionary doctors, Kenyan missionary doctors, partner organizations like Samaritan’s Purse and Bethany Kids, our Friends of Kijabe board, and donors who have either served as doctors here or are connected to doctors here. That’s more how I think of it. How do I serve them, how do I give them what they need? The way I think of it, this is God’s ministry, this is God’s mission in Kijabe. We get to partake in that, we are stewards of it in some sense. How do I enable people to participate in what God is doing here? That is the core of my job. What do I need to give them to be involved, to come along on that journey? This was a big turning point last year, I read some book, it was terrible, but the title was amazing: Who Do You Want Your Customers to Become? Instantly, I thought, “Who do I want the people around me to become?” There are donors, my kids – who do I want my kids to grow up to be? Who do I want my wife to be, how do I want her to succeed? Thinking of people not as static, but as we’re all on this journey, and how do we build the journey together, how do we go together? That was a really powerful image to me. It’s different for the different groups, but there are a lot of overlaps, but at the core of that is what you said, it’s stories. The reason we do what we do is because of stories, right? It’s our motivation. What story do we tell ourselves about the world we live in and our place in it? From you talking, a big part of your story is the opportunity to help people, to make communities better, to give people wholeness and life. That’s a really big value to you. It’s way more valuable to you than money or having a really nice car. Reinforcing that for people, giving them vocabulary, ways to think about that, ways to speak about that is a gift, it’s a really big gift. Here’s the most important thing that’s happening in the world, this is a significant part of God’s work. Both, “here’s how you can be a part of it,” and “wow, you are a part of it, look at what that means, look at the significance of it.” For another doctor listening to you talk, they realize, “oh, this is why I went into medicine.” It’s a reminder that this is what the essence of following Jesus is all about. And we have to constantly be reminded of those things. Watson: That’s true, that’s true. I like that approach. Stories. The stories we tell ourselves affirm and confirm our reasons for doing the things we do. And hearing it come from someone else reminds you of why you started and why you are going on. I do envy you, it’s an amazing job you do. David: But you’re a part of it, that’s the big thing. It’s not me alone. That’s the fun part of it now, being able to connect people like you to some who you will meet and others you may never meet this side of heaven. But that you can still somehow have an impact on their lives, I think that’s phenomenal. Watson: Have you talked to the neurosurgeon, Dr. Kim? I got to hear behind the scenes how Kijabe hospital is able to over a 1.2 million shilling surgery at 100,000, surgeries in Nairobi that cost ten times what they do in Kijabe. How much he has given of his time, resources, mobilizing friends and mission agencies. Those stories remind me of why I fell in love with Kijabe, and why I want to stay. They give me drive to do more, achieve more and be more. People are doing it and it’s possible. You know every one person who is helped, that’s a family who is represented, that’s a community, a village, an estate. It spreads out. All the negativity in the world, in the country. I like to think of myself as a focal point of good. Like in the perspective of God knows if Watson is there, something good is going to happen there. I don’t need to send legions of angels, I just put that guy there, and I know he’s going to change the area. And I put this other person there and this other person there. And the country will change because it’s beginning in those points. David: One of the next people I want to talk with is Ima Barasa. She said when she talks to Interns, it is in terms of light and dark. We did this today, this is light. We beat the darkness with this specific action, it was a victory for the light. Watson: I was listening to an audiobook recently called Atomic Habits. He says every action we do is like we are casting a vote. You want to have as many votes as possible for your good habits and few as possible for your bad habits. Imagine every time you do something you are in a polling booth casting a vote. If every time I’m doing something for a patient, I do my best. If I’m called at three in the morning, I wake up, I take the call, I give my advice, I do what I am supposed to. I am casting a vote to the good. Eventually we’ll have enough votes to turn the tide. If we lose, we lose by the one vote I didn’t cast. If we win, we win by the vote I did cast. David: I like that, turning the tide. It’s an interesting aspect of being in Kijabe and Kenya right now. In your lifetime, it’s gone from a mostly impoverished nation to now a developing nation and it’s on this upward trajectory. These decisions you’re making and these things that you’re doing have not necessarily been done here before. There is a template and a road map for them, they have been done in other hospitals in other countries. But it’s the first time it’s been done in Kijabe. These little steps you take will influence far, far downstream. When you talk about, “how do we set up the 24-hour trauma service?” It’s never been done here before. You know it can be done, but you get to be the first to do it. Watson: I don’t want to hold out, to be negative for the many months It has not yet happen. But instead I want to contribute to the push to make it happen. Another example he gives, if there is a block of ice on the table and it’s 15 degrees, then the temperature starts to rise, but the moment it goes from 28-29 and you begin to see it melt, it’s not the one degree change that melted the ice, but the increment of all the small changes. Every day I go to work, we talk about it, we engage people about an improvement in theatre, the time when it happens the atmosphere will be right, everyone will be ripened. And it will be all the more successful because of the small gains we’ve that been getting all this time. Improving efficiency, training the scrub techs so that the ones at night are just as good as during the day, the equipment at night is just as good as during the day. David: I like that. I had this moment over the summer, we were in the woods camping by the river. There had been a rainstorm, and there was this one drop on at tree. And I’m picturing that falling to the ground and then making its way to the river and where it joins all these other drops. It’s this huge river, but it’s really one drop plus one drop plus one drop, and all moving in this direction together. Watson: And all together they are so powerful David: That’s the beautiful thing about Kijabe, there are so many people actively doing that. We do fight, there are differences, usually not of whether something is good or not good, but differences of priority. Watson: It’s more trying to, as you said, but it’s never “you shouldn’t even be doing that.” It is different angles heading forward. David: Thank you Watson!

During internship I came to Kijabe, I scrubbed in theatre, I had excellent teachers, and I fell in love with surgery. I totally fell in love with surgery. The ability to take someone who is broken, and someone who has been taken out of society because of one issue or another, and then you go into theatre and fix the problem, and they can plug back in. Especially in orthopaedics, they’re not walking, you fix the fracture, and the next day they’re walking and able to go back to work. I fell in love with that, I fell in love with the impact on every patient that comes our way. You see, I believe it’s the bad outcomes and the negative things in your workplace that really flesh out your character. You don’t escape complications, you don’t hide it from the family members, you don’t cover up anything. But you do your best, and you make sure the patient is getting the best possible care, and that’s what I saw from him. It shook me because, wow, these patient’s lives are in our hands, but sometimes they come very sick. I also saw that it’s possible for you do the best you can, and trust God for the outcome. Families will appreciate the human element of a doctor. You are scientist, but they need a human being to explain to them what is going on, to make them feel comfortable and confident in what you have done, that there is nothing that you’ve done wrong and what is going on is even something you are burdened by, you don’t just brush it off and go on to the next patient. Friends of Kijabe – That’s a good answer. Are there certain surgeries that are your favorite? Watson – I like to do trauma. Trauma has the highest (patient) satisfaction rating, and also the highest need. It is quickly becoming one of the top-five causes of mortality and morbidity in Sub-Saharan Africa. Surgical disease is overtaking Malaria, HIV, all these communicable diseases combined. And there are so few trauma surgeons. Of course, I love doing arthroplasty, it is the second most satisfactory surgery in the whole world after cataract surgery. Friends of Kijabe – You mean satisfactory in the way it changes a patient’s life. Watson – The kind of impact it has on people’s life is significant. It changes life on the patient side. Cataract surgery is number one, you can blind and now you can see. Hip surgery is number two, you could not walk and now you can walk. Friends of Kijabe: What do you feel like are your biggest motivations as a physician? Watson: What I feel really drives me is that I believe I was put in Kijabe for a reason. I believe very heavily in God’s direction and in God’s calling. I believe I’m called to be a doctor, and not just that, I believe I’m called to be a doctor specifically in Kijabe. Every time I interact with a patient, and every time I discharge somewhere home, in my mind and in my heart, I get the confirmation that this is where I’m supposed to be, this is what I’m supposed to be doing. Second after that is the satisfaction of helping people, I love helping people in an area that I’m skilled and knowledgeable in. That gets me out of bed in the morning; I know there is someone in need and I know how I can help, so I go and do it. Having an impact in the community and in the nation is also part of my motivation.

Nolen - It’s a lot of fun trying to learn new things and culture. One of the things I love is how (Kenyan) families take care of each other. That’s something I think the U.S. system should adopt. It’s so endearing to see how much patient families show up and are just there, take care of things, rally around each other. It’s something I love to see. There’s times when I see a patient in clinic and I’ll tell them you have a very complex problem. I can always fall back on, “Hey, why don’t come next time with your family?” And we’ll have a group discussion. Shirk - One of your big challenges is how to take care of Needy Patients, it sounds like many of your patients do have good family and support networks. But some don’t, and that can be hard, how to get them the care they need. Nolen - That touches on issues within this sphere of global health. We are on the fringe of healthcare with ENT otolaryngology. When people think of healthcare, most people think about maternal health, communicable diseases, cardiovascular disease. Here in east Africa, there are big minds thinking about how to take care of populations. And ENT isn’t a central focus of that nor should it be the central focus. But if you are dying of head and neck cancer, it’s important to you. If you are child with right-heart from adenotonsil hypertrophy, it’s important to you. And that’s true in any field of medicine. It a bit challenging because ministries of health, the surgeon general back home isn’t thinking “how can we alleviate nasal obstructions around the world?” But for patients having problems in our area, we want to help and treat them. I tell everyone back home when they ask what it’s like over there (In Kenya), it’s great, it’s really wonderful. The challenges are missing friends, family and Mexican food. . .and maybe college football. The not being close to family when kids are so little is the hardest part. The desire for them to know their grandparents, their aunts, uncles, cousins. When we are home they look at relatives like a stranger. We hope to help them know their roots, where they come from, and how loved they are. If God came down and said, " David, I’ll grant you one wish," knee jerk response is to be able to tele-transport. To teletransport friends and family here. On Sunday afternoons to have the kids be around their grandparents, their aunts and uncles. That would relieve 99% of the internal conflict in living away from the US. Shirk - Why is it worth the stress of being away from family, the financial sacrifice, to be here? Nolen - I think it’s seeing God. I see and experience God in real, tangible ways here. I don’t think I had to leave the US to experience that, but it is making an intentional choice to follow where you think God is leading. It’s hard sometimes and easy to think of physical and tangible things you "sacrificed." Seeing what He is doing in Kijabe. Hearing the stories of where this hospital started over a hundred years ago, the improbabilities of it being what it is today, seeing so many of my colleagues, what they are doing. . .witnessing these miraculous outcomes. Even yesterday I was giving exposure to an orthopaedic surgeon and neurosurgeon to the top of the spine through the mouth. The patient comes in barely able to move and he’s going to leave being able to walk. To me that’s just miraculous. Being part of that is really, really fun. It’s really compelling. It’s what draws me in and keeps me here. You see God move, you taste what God is about with his redemptive work.

Ginny and I had both an outward and inward call to Africa. Outward is Mark Newton saying to me, Rodger you’d be perfect for this environment because you love Africa, you love the people, you’re an academician and you know how to teach. And he paid me a left-handed compliment, you’re older and not scared of old drugs, older technology, or lack of technology. We had been interested in missions, not for years but decades, so we had felt an inward calling. We felt when those two things coalesced it was time to think about it and consider Kijabe. When we think about low resources or limited resources, we usually think about medications and technology, but actually human capital is huge. At Temple, I could get an I.D. consult, a cardiology consult, all kinds of studies in a fairly short period of time. Here a lot of those specialists are not present so you can’t consult somebody and get another opinion, you have to create the opinion on your own. There is a saying within medicine, you don’t choose your specialty, your specialty chooses you. When you go through rotations a third or fourth year, some things just resonate with you. Getting up at 4 am and going in to do pediatrics, anesthesiology, surgery, internal medicine - somehow at the end of the day, you don’t know where the time went because you were totally engaged, enjoying it, captivated by it. Some people that happens over multiple locations, some people it’s just one thing that stands out. I would say you need to evaluate what resonates with you and move in that area. Missions has changed quite a lot in the last few decades. 30, 40, 50 years ago, they were looking for a surgeon who would do everything. Do the spinal, lay the patient down, do the surgery, handle the complications. But now, especially at places like Kijabe or Tenewek, there is a need for internists, pediatricians, emergency room physicians, anesthesiologists. A big need here is for an infectious disease consultant. At this stage in overseas missions, almost any specialty could find a place to use their skill set. With every KRNA class we go through a discipleship study called Gospel-centered living. We debrief with them, the second class talked about how they had become a community, a family, there was no longer a spirit of undercutting and competition that had existed before. They recognized that came about as they realized the depth and breath of Jesus Christ. I think many Christians think that if you believe in Jesus, you’re saved, your sins are forgiven. . .but after that, it’s just a lot of hard work. It’s a gate you enter in, but then as you walk the path you’re working every day to follow the rules and obey the laws. We try to explain to them, your sins are forgiven, but the righteousness of Christ is credited to your account. When God looks at you, he sees the righteousness of Christ. As if that’s not enough, we are adopted as sons and daughters. and we have the inheritance rights of sons and daughters. I think it’s in John 6, the disciples ask Christ, what do we have to do to please God. The only thing you have to do is believe on the one he has sent. As you mature in Christ, it’s a walk of repentance and faith, it’s not a legalistic structure of following the rules. It’s really a relationship. You know repentance in the Bible can also be translated as returning, and that speaks to the relationship. Repent from your sins, return from your sins into relationship. Lots of things are different here in a faith-based hospital. We pray with every patient before we anesthetize and they go under for surgery. I’ve been walking through the ICU where I’ve had patients stop me and ask me to pray with them. And I’m happy to do that. I think medicine is a very tangible way of showing the love of Christ. The thing I’ve grown in over the last years is resting in the sovereignty of God. God is good, God loves us, it doesn’t mean difficult things don’t come into our life One thing we ask our discipleship students is, “if God were looking down at you right now, looking at you, Rodger Barnett, what would be the expression on his face?” Most people would say, “The expression on his face is condemning or angry or just disappointed that I’m not doing a better job.” But in actuality, God rejoices over us with singing. If we come in faith through Christ, He rejoices over us. There is a lot of security and peace in understanding that God is sovereign, he has all this in control and the chaos that I experience on a repetitive basis doesn’t mean his plan for redemption and renewal of this creation isn’t moving forward. David – Medicine and healing as a picture of a renewal is very tangible to people. I was blind and now I see, I was lame and now I walk. I get it, this has just happened in my body, and now I understand what that means for my spirit now. It’s the tangible benefit of love and faith through medicine that is unbelievably powerful. African Inland mission, when they move into a new community, set up a health, education, and church. It’s those three things together that help a community to adopt and receive faith. One of the things that is going to happen is Mark Newton and I will be so old we won’t be able to be here. The goal isn’t just care for patients, and it isn’t even just to train people, it’s to train clinicians to train other clinicians so it becomes self-sustaining. The lack of safe anesthesia and safe surgery account for more deaths than HIV, TB, and Malaria all added together. Though it’s not easy to corral these diseases, they can all be cured with medication, HIV can be stopped, TB and Malaria can be cured. Safe surgery, safe anesthesia, you need skilled practitioners operating in a complex structure. That’s why it’s so much harder to get a handle on it, the structure involved and the timeline to train people is so long. In many ways, I feel like what we are doing at Kijabe is a drop in the bucket. There’s maybe 1,000 well-trained clinicians in Kenya able to safely administer anesthesia, for a country of 50 million. But it’s like the mother Theresa quote, “if you cannot feed 1,000 people, feed one.” I think of that often when we are doing surgery that can be life changing for a Kenyan child. There’s probably a huge number we are not affecting, but at least that one is being touched today.

Great quotes: You can’t just have this sudden burst of energy and make it to Canada. You have to embrace the journey, embrace the patience, embrace the suffering. Your feet are like, “bro, what are you doing to me!” That’s when it comes to the point, if it hasn’t been a dream for a while, you’ll drop out. It just has to boil down to, “how bad do you want it?” If you’re going out there expecting to be fulfilled everyday, expecting to be on this high, expecting to be stoked. you’re going to drop out so fast. If you’re not ready to suffer most of the time, then it’s not going to happen. If this isn’t a dream, don’t do it, it’s really hard! The trail makes you work through pain in your life, and distills that. You have to learn to take your thoughts captive. There is a direct correlation and mental positivity and stamina and physical ability. When I would have negative thoughts, it would totally destroy my ability to produce and go over these passes. You wake up in the morning and start thinking in circles. I thought about this yesterday, maybe I should think about this today. You never want to think about how many miles you have to do, that will destroy you. And you never want to think about negative things or people you are bitter about. I’m not going to dwell on these things, I’m going to dwell on the beauty of creation, dwell on the blessings the Lord has given me. Once you do something like this, it gives you the ability to dream bigger! A big thing I learned is how to find beauty in the small things, not always these beautiful vistas. There was a 300 mile section in northern California, where we’re hiking through smoke. How do I find beauty in this clump of mushrooms or in the moss on this tree? If I walk out the door thinking I am going to take an Ansel Adams picture, I will be inevitably frustrated. Right? But if I walk out the door looking for what is the smallest, simplest beautiful thing I can take a picture of – it’s virtually everywhere. It’s impossible not to take a great picture. When I was in the wild, the best picture would be a rain drop or a flower, and that one little thing could illustrate the scene better than the whole. (David - all other quotes are Chris) Sometimes you’re on a ledge and you’re so hungry that every peak looks like an ice cream cone and every rock looks like a loaf of bread. It’s frustrating because you’re thinking “I’m in the most beautiful part of the world and all I can think about is pizza.” It makes you feel weak, it really does. But that’s important part of the trail, where you get the point you realize how small and how weak you are. There is a lot of addiction on the trail that frustrated me, you hear, “I’m going to conquer this trail, I’m going to conquer this mountain.” There is this thing, “I’m out here to take down this piece of nature.” But I saw in my friends a shift from “I’m going to conquer this,” to “I’m going to conquer myself.” And you realize that nature is so powerful and can squash you at any instant. I remember being in a snowstorm in the cascades and thinking, if the Lord’s hand is not on me, I could so easily walk off a cliff fall into this white oblivion. At that point you realize, I’m not here to conquer this, I’m just here to conquer my own doubts and my own physical limits. A lot of my friends and myself got to the end of this trip and you don’t get the feeling of “I did it. Heck yeah!” It’s more like a feeling of awe and humility and total wonderment of what the Lord has created. . .and the power of his create and the elements of himself. And the realization of there is some much here than I thought. It’s humbling. You don’t see a lot of pop-star through hikers. It’s more like, “I’m very small.” I think one thing this trail has taught me is that we have these plans, these dreams for the future, God’s plan is so different often, and he takes care of us through these unknowns. I got to the point where I said, God, I don’t know how you are going to help me, I don’t know how you’re going to provide, but you’ve provided every single time in the past and I just have to assume you’re going to do that this time. .

On challenges of giving patients the best treatment, in a timely manner, for affordable cost. Caring for trauma needs versus scheduled elective surgeries Importance creating and utilizing the necessary teams. Origins of Isaac's attitude and heart for medicine.

Conversation Notes: What is unique about Kijabe Hospital? What did your dad do that you are proud of? Why are your parents amazing? What was your domestic violence/sexual assault project for the hospital? Struggles with trust - what does it mean to trust in God when your life is turned upside down? Book Discussion - Option B by Sheryl Sandberg (not plan B*) What is it like having to come up with a plan B? Imagine you were talking to a new missionary family before they moved to Kijabe - what would you tell them? What do you feel the vision of Kijabe Hospital is? What was it like to grow up around S.li ministry? What do you want to do with your life?

Why are you in Kijabe? Purely because of a conviction. . .I get to be part of an ecosystem of healthcare that yes, at times may not be perfect, but everyone in it seems to be geared toward giving these patients the best. I'm really convicted that this is where God wants me, he's made a way this far, and I'm totally enjoying what I do. Watching lives be changed, and being part of what God is doing in these patient's lives." Looking at the history of what Kijabe has been and where it is today. The places it’s been through, and what has been happening at the hospital in the few years I have been here, one thing is apparent, Kijabe must have been set up with God’s mission at the purpose at the center of it. All the rest of us are, we can choose to be used for this mission and purpose, or get out of the way. Somehow, every day, there are patients whose lives are permanently changed because of what we do, and somehow it seems this happens in spite of us! (laughter). We look at the big picture and see that God is still at work, his work will still go on. People are coming, needy patients are coming, people in distress from physical or spiritual conditions. Our job as physicians is to look at this and choose to be a part of this. What does it look like to choose to be part of God’s work? There is a subtle reminder, it’s not about us. I’m a surgeon, and us surgeons you know, we have ego problems. But every so often something happens to remind me, this is not about me. I can offer this patient surgery, but I must pray for them. And when I pray, what am I asking for, what am I hoping for them, what I can do with my own hands or what God can do? It’s not easy. . . how to remove yourself from self-motivations, or ego-centric motivations in patient care. You have to keep reminding yourself, yet always doing the best for a patient, each patient at a time. That is profound. You are saying, you’re both trusting God as completely as possible with these patients, but also working with all your heart. The work we have and the skills we have, they are not our own. God uses wants to use them for something. There is always going to be something bigger to it that is God.