Funerals, Hades, And The Meaning Of Life

Funerals aren't much fun.  They are hard because you feel the empty space left by your loved-one. There are questions that you'll never get answered and goodbye's that you'll never get to really say.  You also see your friends and family suffering, remembering the good times and lamenting the missed opportunities, and their grief is also painful to watch.

Friday morning before getting out of bed I found myself wondering about the two big questions. First, what happens after we die?  As part of Uncle Mike's eulogy, my dad read an excerpt from Socrates' final speech that I have looked to in the past when asking this difficult question. Before taking the hemlock sentenced to him, Socrates attempts to allay the lamentations of his disciples by explaining his view of death and what may come next. He states that one of two things must happen. If death is simply the cessation of life and there is no afterlife or continued consciousness, then death must be similar to a perfect, dreamless night. There is no fear, nor longing nor discomfort of any kind in a dreamless sleep, and therefore such a state would be a welcomed alternative to the suffering that is our day-to-day existence. If, on the other hand, the soul is transferred from one plane of existence to another, such as the Greek's Hades or Christianity's Heaven, then all the better. What a great way to pass eternity, chatting and debating with Homer, or any other writer, philosopher, or for that matter, friend or family member from the past. Regardless of which of these possibilities is true, I can take refuge in knowing that one way or another, the dead no longer suffer.

The second big question that came up Friday morning: what is the meaning of life? While I believe that the answer to that question is different for different people, I do think a common thread runs through the various answers. Many of us would like to think that our life has been successful if we leave the world a better place, and that people's lives have changed for the better having known us. As I heard the testimonies from the many students, coworkers, friends and family members, detailing Uncle Mike's life and good deeds, I know that he did just that. And while that does not completely remove the sadness of his passing, it does help with it.

Tio Mike

Yesterday my uncle, Tio Mike, suddenly and unexpectedly passed away. He was a wonderful man, and a well-loved professor of English at Del Mar College, in Corpus Christi, Texas, for many years.  Older brother to my mom and my Tio Jack, he was the first in his Mexican-American family to go to college, quite a feat especially considering that before him, my grandmother Tita held the record for furthest advancement in school - reaching the 7th grade. My grandfather Papo worked as a filling station attendant, and growing up, my grandmother helped clean houses.  They both saw the advantages that a good education would offer and supported his decision to attend college, first at Del Mar and then East Texas State.  Now, as I'm combing through the web on this grey, rainy day in western Kenya, I came across an article detailing his receipt in 2004 of the highest teaching honor awarded at Del Mar, the Dr. Aileen Creighton Award For Teaching Excellence. The article states he was "probably the most respected and influential person on the Del Mar campus". A few years ago, he was named Professor Emeritus. Papo and Tita would have been proud.  I truly regret not sitting in on his classes to glean teaching pearls from him, though I'm happy for the handful of my friends from college that did get to take his classes.  Since I was in college, hanging out with Tio Mike was consistent and comfortable: we'd usually start with catching the latest sci-fi/fantasy movie, where he wouldn't let me pay, and this would be followed by philosophizing over a beer and pizza at B and J's Pizza in Corpus.

Working in African hospitals, death is no stranger. And while, after years of studying and practicing medicine I have a better understanding of the causes and processes of death, it is always a different experience when it is your loved one that is ferried by Charon across the river Styx. Having seen the suffering involved in long, painful deaths associated with cancer, TB, and AIDS, I'm comforted knowing that this was not in Tio Mike's cards. But what a sudden death takes away from us is the chance to ask the departed those questions we've been meaning to ask, to ask for forgiveness, and to say thank-you, I love you, and good-bye.

I'm heading home to Corpus in a few days for the funeral and to see the familia. And if I'm lucky, we'll go see a good fantasy movie, perhaps the Hobbit, and sit over a good beer and pizza at B and J's, and we'll have a chance to reminisce and be thankful for the time we had with our Tio Mike.

First Marathon

I just ran in my first marathon. Now I use that phrase liberally, as i just ran in one, but didn't actually run an entire one. I went for a jog this morning in Kisumu, and lo and behold, there was a marathon going on at the end of my block. Tall Kenyan runners without an ounce of fat glided gracefully down the street past me.  I thought why not - might as well join them for a little while.  The support crew at the water stations laughed and cheered me on, perhaps because I did not appear like an official race participant. I must have joined them for just the last 5 miles or so, and I still couldn't keep up with most of them. The race ended in the city center park, and I veered off before the finish line to keep from taking anything away from their hard work. I finished the loop back by our house near Lake Victoria. Since there wasn't anyone around to take my finish line victory shot, i decided to take it myself. 

Look Both Ways

Life in western Kenya continues to treat us pretty well.  While we lose power almost every day, and the water on occasion goes out for days, we are reminded that we are still part of a relatively small group of lucky individuals in this part of the world (for starters, simply by the fact of having electricity and indoor water and plumbing, for example). Though several of the cases are challenging and saddening, most of the patients have been doing relatively well. We see a patient with a new diagnosis of HIV, TB, or malaria most days. But thankfully, there is treatment available now for all of them.  It’s those that wait the longest before presenting to the hospital that have the hardest time recovering.  Besides the common cases of infections, we have recently cared for some patients that have suffered various types of trauma. An adolescent girl was hit by a motorcycle as she ran across the road and presented with a swollen face. The x-ray revealed a fractured jaw. Motor vehicle accidents are a major cause of death in Africa. She was one of the lucky ones that could walk away from one. She was referred to the regional hospital for evaluation by the surgeons to see if she needs her jaw wired so that it can heal well. An adult woman came in after being beaten by her son with a hammer.  Thankfully she has no broken bones and will heal, though I can’t imagine what the psychological and family healing processes will be like.

I witnessed an interesting cultural phenomenon today. An elderly man with advanced chronic illness passed away as his wife took her lunch in the next room. When I suggested that someone go tell his wife, every Kenyan health worker I asked said to allow her to finish eating before telling her the news. They said that she would be mourning for a number of days and would probably not be eating during the process.  The cafeteria crew seemed to know the family, and after she had received the news of his passing, brought her to his bedside and sang a local hymn to the tune of Amazing Grace.

The weather has been mostly fair, with cool nights and mornings, sunny blue skies in the day with temps up to the mid to high eighties and a short shower in the evenings. We can tell that the rains are letting up though, which means fewer blackouts, and hopefully, fewer malaria-carrying mosquitos. 

Ward Rounds

The little guy with the case of severe malaria was sitting up in bed this morning, awake and alert to his surroundings. It looks like he’s made it. It's pretty amazing. There were times on Monday when we thought we were watching him take his last breath. 

The ward rounds continue to bring us interesting and challenging cases. We diagnosed a teenager who had been coughing up blood for a few months with pulmonary tuberculosis. An adult patient with bad headache, body aches, and fever was diagnosed with a serious case of malaria, but was also newly diagnosed with AIDS. We’ve had two patients this week with advanced esophageal cancer, one of which has a stent that had been placed in her esophagus and is on liquid morphine for palliative care. In Africa, unlike the US where you are never more than a stone’s throw away from a narcotic pain pill, it is very difficult to come by morphine and its derivatives. I was quite happy to see that this woman with terminal cancer had appropriately been prescribed a medicine that would help ease the pain of a very debilitating disease. The medical team had a good discussion on end-of-life care at her bedside, covering some of the many issues that are involved in trying to facilitate a dignified death.  She has a difficult road ahead. 

The Bite of a Mosquito

We're back in Sagam. After an easy 40 minute flight from Nairobi to Kisumu, I met up with the local team on the ground. We had some time to catch up and unwind before hitting the road for the hour long drive to the little town of Sagam.  Arriving in the late afternoon, we visited the hospital to say hello and make sure there were no patients they needed our help on. We found a very sick toddler on the ward, his grandmother in the next bed over watching on worriedly.  The child presented in the morning, after having been sick for about three days before coming to the hospital. Earlier that day he tested positive for malaria, and now it was clear that he was on death’s door. He was barely conscious, very pale, and breathing fast and hard. As we started to examine him, he began to seize.  Piecing things together, he most likely had malaria affecting his brain, a life threatening state called cerebral malaria. As we started our treatments, we watched him deteriorate. After considering all the options, we decided that he had received too much IV fluid during his resuscitation, and he was entering heart failure. We gave some medicine to help relieve the stress on his heart, set up orders and plans for checks during the evening, and left feeling pretty sure that we wouldn’t find him alive in the morning. Amazingly, he stabilized over night. Rechecking his hemoglobin level in the morning, we found that the malaria had wrecked serious havoc on his red blood cells. He was left with only a third of the amount of blood that he should have had. He was in urgent need of a blood transfusion, and the closest blood bank that we could access was at least a two hour round trip from us. We ordered the blood and hoped for the best.

Malaria kills about 900,000 people a year around the world, and 91% of these deaths happen in Africa. Due probably mostly to a lack of immunity, 85% of all deaths from malaria are in children under 5 years of age. In the States, most toddlers die of trauma (accidents and homicide), congenital anomalies, and cancer. It’s sad to see a child in the States die of a difficult to treat congenital cardiac anomaly. Teams of medical experts give it their best, and much time, effort and hundreds of thousands of dollars are spent to try to save a valuable life. Here, things are different.  Many sick children with malaria never see a health worker, and fewer ever reach a hospital. An insecticide impregnated bed net costs about 10 dollars. A three-day course of newer “expensive” oral medications that cures the majority of cases of malaria costs less than 2 dollars. We’re back in Sagam. It is an interesting world. 

Heading Back To Kenya

Greetings from somewhere above the Mediterranean. Yesterday, with a heavy heart I said goodbye to friends and loved ones and boarded a plane in San Francisco to Amsterdam. I am enroute to Nairobi and ultimately the little town of Sagam in western Kenya, gearing up to spend another two and a half months on the ground in rural Africa as part of the MGH/CCRMC Global Health Fellowship. Our goals remain the same - to help a small, community hospital with education, systems building, and infrastructure support, while working with the local medical school to help them start their first graduate training program in Family and Emergency Medicine. I was last there from August to October, and it sounds like many things have been accomplished since then. The mostly US based crew has been working alongside the Kenyan team of clinicians, nurses, and administration on a near daily basis at Sagam Community Hospital. Ties at the medical school are being strengthened through meetings and project assessments. And on a more selfish, basic level, life for the expats appears to be getting even easier. The bats are (mostly) eradicated from the attic, the washing machine might be working, and the car so graciously lent to us gets from point A to point B most of the time.

At my feet are five external hard drives that will be part of the creation of a learning center at the hospital. Up til now, most learning materials were dusty textbooks from various decades in the past. I hope that during these next few months, we will continue to solidify our relationship with the hospital and med school through teaching and capacity building efforts. I also hope to eat lots of beans, chapati flat bread, and the local kale known as sukuma wiki.

It's not easy leaving lovely NorCal behind (the picture shows a recent day of olive picking in the Dry Creek vineyards), and it's even harder saying farewell to the people I care about. I certainly felt it more intensely this time. But hopefully someday, as I look back at why I did it and what we accomplished, we will see that it was all worth it.