Nurse in Kenya: February 2014

“The results of life are uncalculated and uncalculable. The years teach much which the days never know. The persons who compose our company, converse, and come and go, and design and execute many things, and somewhat comes of it all, but an unlooked for result. The individual is always mistaken. He designed many things, and drew in other persons as coadjutors, quarrelled with some or all, blundered much, and something is done; all are a little advanced, but the individual is always mistaken. It turns out somewhat new, and very unlike what he promised himself.” - Ralph Waldo Emerson

It has been more than a month since I arrived back here at In Step for the third time. It has been a busy and fulfilling month, full of challenges, and full of the overcoming of challenges. I’ve definitely found my way into the routine of life here, so much, in my mind, to the extent that I’m not even sure what I’ll write to you about. Daily routines have become just that, and I’m confident that the starry-eyed look has faded from my occasionally tired gaze, and has been replaced with the glance of a woman who has, at least in some way, become familiar with life here in Africa.

In many ways this leg of the mission has come much of what it was over the “summer” a few months ago: four med passes a day, boo-boo duty, a handful of exotic health mysteries to attempt to debunk, and the occasional presentation of a moderately serious disease process. I’ve made trips into town with the social workers to visit the local public and private hospitals, and learned to drive on the other side of the road after making more than a few trips to the village clinic when blood smears for malaria, or Widal tests for typhoid, are warranted. I’ve figured out how to get around to the local Ministry of Health Center, and can almost remember how to get to the Immunization Dispensary. If it sounds to you like my duties don’t sound astronomically earth-shattering to me, then you’re correct in your interpretation, but don’t allow me to lead you to believe that I’m not smiling as I write this description.

The other morning I was driving one of our older girls to her first real day of “Form One”, also known as “freshman year of high school”, before the sun came up. Sitting in the right-sided driver’s seat I carefully navigated our Subaru Forester over the craggy and pitted red clay roads before approaching the paved “highway” we call the “tarmac”. I noticed, in that early morning hour, the peculiar absence of uncomfortability and awkwardness as I drove around the many pedestrians, motorcycle drivers, and farm animals that constitute those undertaking a morning commute here in Kenya. Just before reaching the market, about ten or fifteen minutes away from home, at a congested junction with loosely-fabricated duka (shop) stands made of what seem to be two-by-fours and tin roofs, along with some free-standing concrete shacks, my headlights illuminated a pack of at least fifty or sixty cows who had taken over the road. A farmhand unenthusiastically slapped a few of them in the rear with a long stick as he shouted at them in Swahili. I laughed out loud to the young lady in the passenger seat and said, “I suppose this is rush hour traffic on Market Day, a “cow-jam”. No, we don’t have this problem where I come from.” After a few moments I crossed over onto the right side of the road where there was a small gap afforded to me by the herd, and I drove on forward into the gray dawn.

On the return trip back down the tarmac the sun was just starting to rise: a fierce pink and orange glow determined itself to cut through casually gathered collections of dark blue-gray clouds. I passed through occasional patches of fog on the down-hills. As the sun crept higher and higher in the east I admired the silhouettes of the Cherangani Hills in the distance – a majestic landscape punctuated with acacia shadows – and reminded myself to mind the piki (motorcycle) drivers around whom I was passing. It was one of the first moments I’ve had in a few weeks where I made a very deliberate emotional and mental encounter with the fact that I’m back in Africa. Most mornings I wake up from a dream still not knowing where I am – am I in Pennsylvania, or Long Island, or Binghamton? I’m still realizing where I am, that I’m back where I longed to be for those autumn months. Each day is still reminding me of what life is now – of what months and years have made it.

It’s really okay that I’m not overcome with regular bouts of sentimentality and emotionalism over the fact that I’m in Africa anymore. As you can read from many of my earlier entries I found myself enraptured and very affectionately distracted with my almost fantastic experience of living out real-time-daydreams of being in this place. I find that lately, in the past month, I’ve had the freedom to focus far more on my actual concrete purpose here now that I’m becoming increasingly more accustomed to living in Kenya. This is not to say whatsoever that my self-aggrandized infatuation with this place has dissipated completely – since having a few moments to view The Secret Life of Walter Mitty in good company I find that I still relate to his tendency to live out a fair portion of life between the ears – but in the spirit of “not taking myself too seriously” I’ll continue to enjoy the whimsical illusion that life in Kenya is largely comprised of moments without inconvenience and regularly brimming with a virtually unreasonable amount of excitement. Actually, that’s still not too far from the truth.

In the month of January we had the privilege to receive five new kids: Micah S., his sister Anita, Wilfred, Baby “Jerry” Jeremiah, and my apparent namesake Joy Julia. We have one-hundred-and-forty-eight kids now, and I’m confident that more are on the way, as they always seem to be. In time since I’ve been here I know that my experiences with Micah and Anita have had the most influence on me, in terms of my interactions with sick children. Those two kids really taught me a lot about life here, and I’m pleased to be able to share some of what I’ve learned with you.

Four days after I arrived, Jeff returned home one day with two new kids. Judging from their appearance I figured that one was about two-and-a-half, and the other wasn’t older than a year. I was instructed to assess them thoroughly and document my findings. I was surprised to see their open mouths seemingly full of teeth, and I was concerned because children as young as I had quickly judged them to be usually don’t have mouths that full of teeth. I then learned that the boy I had thought to be two-and-a-half, Micah, was actually five-years-old. His sister, Anita, was actually three.

The World Health Organization classifies physical malnourishment based on height/length and weight criteria and provides health care workers with guidelines for what kinds of supplemental nourishment are required based on the degree of malnourishment. I learned a lot about malnutrition when these two came here – I realized that they were the most chronically malnourished kids I had ever seen – I knew I had more to learn in terms of caring for them. To give you an idea of what I’m talking about, I can tell you that Anita was nearly half (only 50%) the weight of even the 5^th percentile of a child her age, and is approximately three-quarters (only 75%) of the length (height) of even the 5^th percentile of a child her age. Based on her weight-for-length ratio, she was more than -2 Standard Deviations below ideal by the standards of the World Health Organization. Micah was -2 Standard Deviations below normal for height at only 89 centimeters. At 9.1 kg he was well below -3 Standard Deviations for weight. His stated age of five years was startling considering he is, based on current clinical guidelines, and speaking very liberally, the size of a two-year-old. All this being said, here we had two adorable and precious kids who had not even received basic care and nutrition, let alone attention and affection. Now these two kids were part of our family, and it was more-or-less my job to make sure that they were even okay enough to be with the rest of the kids.

I wondered what their lives had been like before they came to us. I know how I feel when I feel unsupported or lonely, and I can’t even imagine the kind of desperate unhappiness these two must have become used to. A child’s psyche can become profoundly warped before the age of three by not being able to securely attach to a caregiver who provides them for their physical needs, of which food is arguably one of the least important. For a kid simply to not be able to run up to mom and hug her and receive the warmth of her nurturing embrace can be a devastating psychological insult when it happens for months or years. When children aren’t cared for physically through nutrition, hygiene, and affection, their growth is stunted in body, mind, and heart. In the hour or so I spent with the two of them when they first arrived I contemplated what tremendous blessing and tremendous responsibility God trusts us with – to love and care for two kids who had been previously neglected.

Speaking clinically, these two had not been completely starved. They were fed enough that they did not seem to demonstrate marasmus, which most people would commonly think of as “total emaciation”. Their ribs weren’t sticking out and their skin wasn’t hanging off of their bones, exactly, as was the case with little Chris who came to us back in June. These kids had fat chipmunk cheeks, protruding and hyperresonant abdomens, heads that seemed way too big for their bodies, and eyes sunken into their adorable faces. They didn’t have too much obvious edema, though, either, which would indicate the very serious clinical condition of kwashiorkor, also known as protein starvation. They weren’t out-of-the-woods, though, and were a bit “kwashy” as I’d say: Micah had a heart murmur and a touch of pulmonary edema. Without enough albumin (protein in the blood; he had a lower amount, we’d presume, because he wasn’t consuming enough protein) it wasn’t easy to keep extracellular fluid in the intravascular space (in the blood vessels) and it was easy for it to leak out into the other body tissues. He had a fluid imbalance, as he was also dehydrated, and the fluid that was on-board wasn’t in the right place. He also had pneumonia; we’re pleased that their chest x-rays didn’t demonstrate any signs of active pulmonary tuberculosis, though. He was on medication for a few weeks to treat these issues, and is doing much better. Anita’s problems are mostly developmental and are being remedied through high-intensity nutrition provided by the Kenyan Ministry of Health, as we consult with them in cases of starvation and debilitating malnutrition, and through a lot of TLC dished out from our devoted missionaries and paid Kenyan staff.

Today, a month later, Anita and Micah are doing well. They’re gaining weight, playing well with other children, and coming along better than I expected in terms of their development. They’re eating as well as the other children and are becoming increasingly more animated and interactive as the days pass. Anita is almost walking independently; she’s down to the one-hand hold. Micah actually started preschool a week or two ago and has even spoken a few words in the past week. (I hadn’t mentioned: they didn’t even speak Swahili when they first came. They were from a province about three hours away where a totally different language is spoken, so they couldn’t even understand us. We did have a native speaker explain to them what has happened and they vaguely implied that they understood, but still) Micah is usually seen with a smile on his face, playing with the other boys. Yesterday he spotted me from far away and ran up to me with his little arms up in the air. I picked him up and threw him in the air as he ran into my arms and then I tickled him and he laughed and laughed. That, to me, is a moment without inconvenience, brimming over with a virtually unreasonable amount of excitement. That’s my fantasy. And that’s my life.

My experiences here in the past month have been much like my experiences in the months prior, from June to September, but altogether it does feel different. It’s counterintuitive to me that I feel so comfortable here in the familiar place and in the familiar role, and yet so much has changed since then. I’m not entirely the same woman I was over the summer, and I’d like to believe that I’ve grown in faith and confidence as I’ve seen God’s calling in my life unfold into something I didn’t entirely expect. If you had asked me two months ago what I thought my life would look like today, the answer I would have given you wouldn’t have accurately described what reality is today. Today I have peace with my life – with the unexpected and unforeseen turns and twists, with the intricately interwoven tapestry of joys and sorrows that have passed through moments which at one time seemed eternal – and I am excited to continue on into the future one minute at a time.

Some people I expected to still be a part of my daily life today simply aren’t, and simultaneously there are others I’ve grown to care for, for whom I never expected I could, in the ways that I do. I am free today to have ideas about the world and dreams about my life that are entirely my own; I am able to live my life on the “broad highway” with all sorts of beautiful and mysterious sights on the horizon, like African hills and acacia trees and a countless number of other brilliant and incredible things, and I’m grateful that I don’t know which of those sights I’ll yet visit. I’m afforded the tremendous luxury to have a relationship with a Loving and Forgiving God that is accommodating and immediate, that is tangible and also eternal, and that is completely uniquely mine without requiring approval or validation from anything outside that experience. I’m blessed to experience the spectrum of life – sunrises and cow-traffic-jams, tears from injuries and laughter from playful embraces. I’m okay in my skin today, even if the blood that runs through it has had detectible levels of those pesky falciparum parasites once or twice since I’ve been back. I am who I am, who God has guided me to become, who I have had the choice in becoming. I’m an ordinary young woman who has been very extraordinarily blessed with the opportunity to learn from a seemingly endless list of mistakes and experiences, each of which has prepared me to live this life and do this work. I haven’t noticed the changes in myself day after day, but, looking back, I guess time here is different than it was before because I am different than I was before. I don’t know what that means exactly but I’m looking forward to finding out.

Perhaps I’m not without that starry-eyed look after all.