checkpoint

Well then.  That’s fourteen days in the books and eleven yet to go.  If you’ll oblige, I would like to take stock of things so far.

Having been

The city of Lubango itself has been a surprise.  I knew that it was a large city and all but somehow the population density, noise, and lights are not jibing with whatever paradigm I had for sub-Saharan Africa.  The amount of pollution – water, air, and ground – are more than I could have imagined.  The hilly streets are ever-busy and I imagine a Lubango-themed Frogger proving…impactful.  Having seen the countryside this past weekend, I appreciate why Angolans would flock to urban areas in search of employment and sustenance.  The end result of such congestion, however, is a Lubango that I did not envision.

A highlight of the trip was meeting and living with the Kubacki family.  There are those persons out there whom you meet and immediately say to yourself, “yes.”  The five sixths of the family that I spent time with have sincere passion for their calling and, in committing their lives to others, have a beautiful sense of self.  I believe it to be true that I am, in some way, a better person for having shared a roof those ten nights.

CEML both has and hasn’t been what I had foreseen.  It is, “the clinic on the hill,” as the locals colloquially refer.  It is a tertiary referral center with an emphasis on surgery.  It is a wonderful place to learn and develop further my fundamentals.  I was not expecting the surge of people waiting for outpatient visits daily.  Sure, there is to be follow-up once discharged but to fill the hallways for hours and hours per day?  Another thing about this hospital, which has pros and cons, is its revolving door nature.  The flux of domestic students, foreign students, residents, doctors, missionary doctors, and affiliated folks is impressive.  The pros are a wide array of exposure and opinion.  The cons are a lack of institutional memory and the gaggle of white coats roaming through the wards on rounds.

Another impression I need to touch on is the sense of community shared by the missionaries and expatriates in Lubango.  With Mitcha (the walled compound where Dr. Foster and about five other families live) as a home base, these, mostly North American, people function in an impressively cooperative group.  Pizza Night Fridays are a nice adhesive but the real good comes from a positively connoted groupthink.  Random favors, organizing group trips, co-op purchasing, and constant radio/phone communication all contribute to a collectively higher quality of life.

Is

My Portuguese ability is not where I would like it to be.  I don’t know whether this is the result of too high an ambition or too low an execution.  Let’s say some of both so that I don’t feel too bad about myself either way, OK?  Thankfully, I do have some faculty in the clinical setting but my, “conversations,” otherwise are about eight seconds long.  I am sensing the value of the so-called immersion programs whereas I go home through the week and away on the weekends speaking English every which way.  I am, though, certainly improved and understand more everyday.

I am living a much more natural, simple life.  Most of the food is not processed.  Especially at Shangalala, I was up with the sun around 6:00am and to bed after dark by 9:30pm.  One must ensure access to clean drinking water for the day.  I have not seen live television since arriving.  I wear scrubs and eat meals that are prepared.  I am immune from so much of the decision-related clutter of my regular life.

Today my rank order list is due.  A sentimental milestone along the medial training path, it is now just twenty-three days until I open my envelope.  Where is it that I will be completing residency?

This is really just whining but I am tired of bad smells.  Trash, people +/- their infections, bat poop…

I am feeling a bit run down.  The last couple days at CEML have been particularly trying.  The weight of more deaths, one very unexpected, and a string of sad surgical cases are upon me.  I debated whether or not to include the pictures below.  In sharing, I am honoring my commitment to posting honestly and am also dealing with some blue feelings.  I struggle a lot with the late stage at which so many of our patients present.  Also chief among my thoughts is the lack of medicines and machines so commonplace in the States.

An 82 year old male.  He presented with a much-progressed basal cell carcinoma.  I thought of my anesthesia-bound roommate Ben when approaching intubating and preparing such a case.  Unfortunately, his tumor had invaded both of his maxillary sinuses and his upper jaw.  We resected much of the middle of his face.  With no ventilator available outside of the OR, I am writing this wondering if he is still alive.

A 26 year old albino male.  We see many albinos in Lubango.  The expression of this recessive trait is the result of local inbreeding.  Their skin, as you might imagine, is incredibly frail under the equatorial sun.  He has an advanced squamous cell carcinoma.  We were able to save his eye for the time being.

A 23 year old female.  Hers is inflammatory breast cancer, now fungating, that has totally penetrated her chest wall.  Twenty-three years old...

Will be

The rest of my time here will be very different from that already passed.

In the morning, I leave for Kalukembe.  A one-hour flight in a nine-seat Cessna or a three-hour drive away, this is the bush hospital associated with CEML.  We make monthly trips and operate pretty much non-stop for two and a half days.  This hospital has some 200 beds and is staffed totally by nurses.  The patients seen and cases performed are those complex enough to have been, "saved for the doctor."  Pending my own experience, I will direct you to a video produced by the aviation ministry here in Angola.

I will return to Lubango Saturday afternoon.  Only to re-pack and depart on Sunday for Chiulo.  I am particularly excited by and fearful of this opportunity.  As a budding medicine and pediatrics doc, the surgeries I have seen are very interesting but not so directly beneficial for my future practice.  Chiulo is a hospital with 250 beds - children in 100 of them - that will be a less surgical experience than CEML.  I am visiting for a week with Dr. Dan Cummings.  He completed an Emergency Medicine residency some three years ago and is exploring sites for a two-year commitment in the future.  His presence also is a stopgap for the chronic staffing issues at Chiulo.  I had an opportunity to take a peek on the way back from Xangalala.

The front entrance to the hospital buildings:

The hospital is currently staffed by a single doctor: a Russian surgeon with a humorously stereotypical name:

When visiting your family members in the hospital, please be so kind as to leave your hand grenades at home:

The hospital routinely has more patients than beds.  Here is the extension of the women's ward onto the veranda:

Established in the late 1940's by the Medical Missionaries of Mary (an Irish order), Chiulo is now run by an Italian NGO.  The original Catholic mission:

Again, in advance of my own time there, I direct you to Dr. Kubacki's reflections from two weeks at Chiulo.  Be forewarned by the gravity of his post.

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All in all, I am feeling as if I were a passenger in my own car: the space is familiar and the controls the same but for whatever reason, it is difficult adjusting to the parallax.  I mean that I am still Zach: I sleep heavily, I enjoy the night sky, I feel good about myself when I remember to floss, etc.  It is just that I am passing the same twenty-four hours a day in such a different way, in such a different place.

Here’s to some more Life Experience ahead…

xangalala

It is pronounced, "sh-on-ga-la-la."  That’s right, not Shangri-La but, "sh-on-ga-la-la."  This word (which is rather fun to say) is the name of the town where I spent this past weekend.

For those of you not expert in the geography of southwestern Angola, here is Xangalala.  It is a blink-and-you-miss-it sized town way out in the boondocks.  It is just 12km from Xangongo though.  Xangongo is not a tourist destination.  It is a highway town teeming with booze, crime, and AIDS.

Why then, you should be asking yourself, did I find my way down that highway, through Xangongo, and to Xangalala?  The answer: to move the Kubacki's, my now-former host family.  Buckle up. It was a weekend worth writing home about.

Let's meet the Kubacki's.  This missionary family has an amazing history and a very bright future.  Pictured below from left to right are Meredith, Ben, Ellie, Betsy, and Tim (he's tall, the picture is deceiving).  Not pictured is current Ohio University student Luke.  Also note their worldly possessions packed and tied down!

The 6 Kubacki's have documented both their calling and lives beautifully over at http://kubacki6.wordpress.com  To briefly summarize, they spent six years deep in the Brazilian Amazon before re-locating to Angola.  Witnessing and practicing medicine all the while, they are particularly interested in more rural communities.  More about Xangalala in a bit, but when a position presented itself outside of urban Lubango, the Kubacki's signed up.

After a week or so of a bustling, normal, furnished home, my Lubango dwelling was gradually boxed up.  I came home from the hospital one evening to find the furniture in my room disappeared.

As packing and chore lists were issued from the desk of the matriarch, the reality of the move settled in for the family and their guest alike.

Always chipper, I was impressed with the way the family recognized the impending opportunity amidst the always joyous moving process.

I took off Friday at CEML to offer my able body with final loading and the trip to Xangalala.  Up at 6:00am that morning, we somehow managed to play Tetris with their belongings really, really well.  With every angle, nook, and cranny (is there any other way a person has ever used the word cranny?) considered, we departed the spacious apartment on one of Lubango's main streets for the next chapter of the Kubacki story. 

The next stop was a warehouse near the airport.  In our convoy was a super-clutch F-550.  Now loaded with more plywood than I thought would be possible, it was time to hit the road.  Prepared for rain, we congratulated each other on such a quality job with the tarp.

We (Tim, Ben, and I) descended from our topographical throne out into the countryside and settled in for our 330km drive.  Armed with peanuts, tangerines, some crackers, and water we brought up the rear along with the big truck.  The rain was nowhere to be found but in its place we found cattle.  I learned something about our bovine friends last weekend: they do not care about oncoming traffic.  Not twenty minutes into the trek, a large herd crossed the road a bit ahead of us.  We slowed accordingly and just as Tim eased back on the gas (now going easily 45mph), a straggler ran out into the road.  A huge swerve to the left in the fully loaded Land Cruiser somehow avoided Bevo.  With fatherly-expert driving skills he corrected into our lane not six seconds before an oncoming semi-truck thundered through.  Adrenaline was pumped.  We were safe.

Wind is powerful.  Mother Nature is humbling.  We men, very reluctantly, eventually accepted defeat after having stopped every couple kilometers to try and repair our now-tattered tarp.

So about that 330km drive.  That is equivalent to 205 miles.  It took us six and a half hours.  Why?  Unpaved roads.  I have mentioned the government's investment and quality of major roads before.  EN 105, however, is not yet finished.  The last 120km or so was bumpy to say the least.

A very powerful part of the trip so far was seeing the people of the countryside.  While the population density and pollution are lower, the poverty is way higher.  The slums of Lubango gave way to the literal sticks of the outlying areas.

Scores of times, as we drove by families, the children would run after our car with their hands to their mouths. Although obvious they had been coached to do so, it was very emotional to see.

Early that evening we arrived at our destination.  Xangalala was a mission established by the Finns in the 1950's.  The catch is that no doctor has worked at the hospital since 2004!  In fact, the new Kubacki house has been unlived-in for the last six years.  I told you they are into serving those who have no other services!

Pictures here are of the hospital that Dr. Kubacki will now staff:

Almost all developing clinics have patients keep their own charts.  Xangalala, however, has a medical records department: 

Need to use the clinic's restrooms?  I'm pretty sure that even the Gomer Dads Club has better facilities.

The outpatient waiting area and lodging for patients' families:

The Emergency Room:

The men's inpatient ward (room):

Welcome to the maternity ward:

Xangalala is beautiful.  The mission, and especially their home, are situated on a bluff overlooking the flood plains of the Cunene River.  This body of water goes on to form the border between Angola and Namibia and is a magnificent sight to be seen.

The crew of about fifteen friends trickled in through those dusky hours and unloaded the vehicles in anticipation of the weekend's waiting chores.

Let's talk about sleeping arrangements briefly.  This past Friday and Saturday, I slept on an uncovered cloth twin mattress in an 80℉ room with three other men using my book bag as a pillow.  I did not sleep well.  It was fortuitous though to pick up that mosquito net on the way to the airport (thanks John).

Also contributing to my poor sleep: roosters.  Some sixty feet from the window at the head of my, "bed," were some foul fowl.  Very strong with the, "cock-a-doodle," but noticeably weak on their, "-do," I was awake a little before 6:00am.

I was ready to do some work.  Tim had many tasks for the weekend and being no stranger to manual labor, I was ready to actively say thanks for having hosted.  I volunteered for demolition.  I can straight up swing a sledgehammer.  Betsy wanted a kitchen wall gone in hopes of undoing that whole 1950's lots-of-small-rooms architecture deal.  We got to work.

It turned out, however, this wall was made of 40lb. adobe bricks encased in ceramic tile, an inch of concrete, and plaster.  This 108 cu. ft. of misery took seven hours to bring down and clear.

Included in the pictures here are first Aaron, my brother in arms, and Lawrence.  Aaron and I were in for the long haul and shared an arduous day and only God knows what kinds of fungal spores in that adobe.  Lawrence (standing in the doorway) is a man.  Much like my own father, he is a laid back dude and an all-out handyman.  He lives and works on a farm (i.e. 65,000 acres) that hires the impoverished and profit shares with all involved.  He was even more legit for two reasons: a voice as enigmatically majestic as Paul Keels' and, like all dads, epic man strength.

For the collectors out there, the Carpenter Zach, Mason Zach, and Demolition Zach action figures all made appearances last weekend.  I also want to share that I peeled an orange in a single piece twice on Saturday.  The rest of the crew did a fantastic job painting every other room of the house than the kitchen and getting the family as ready to reside as possible.  The rest of the story that needs to be told, however, still involves that pesky kitchen wall.

With the floor completely cleared and swept of final debris, the plan was to preserve the top couple rows of adobe and to put a new cement header underneath.  In this manner, the ceiling in place would be usable!  A detail that I purposely omitted until now was the appearance of said ceiling.  For some reason, when we first entered the kitchen, the ceiling tiles all appeared to be bowed.  These 4' x 4' squares were sagging under the weight of years' worth of bat droppings.  That's right, guano.  The seven o'clock hour was quite the sight as those blind mammals emerged from crannies (I did it!) on the roof's edge.

It is now Sunday late morning, around 10:00am.  I was catching a ride back at noon.  I was working to repair the bat-prophylactic screens on the roof vents.  Tim was working in the kitchen cleaning up the edge for the ceiling beam-to-be.  I needed the ladder he was using and asked to use it when he was done.  As I am cutting screen on the porch, Tim emerged with the ladder saying he needed a short break.  Seconds after he left me, when out of the kitchen there arose such a clatter, we all sprang to see what was the matter.  40lb. adobe bricks, speared crags of ceramic and concrete, and a 2x6 ceiling frame had crashed down on the spot Tim had vacated not a minute before.

It was an openly raw scene as Betsy screamed for Tim as soon as it happened, knowing he had been in there.  Thankful for his safety, we all took a second - or two - to compose ourselves.  I, for one, had grossly underestimated the danger of where I had been working.

Our problems now were two-fold: delayed progress and smell.  We spent the rest of our time re-clearing the kitchen.  We were literally taking guano out by the wheelbarrow-full (that is not dust in the foreground).  I have spent some time thinking about how to most accurately characterize the smell.  I have settled on cat urine jerky.

My formerly calloused hands have gone soft with my white collar ways.  I took my left-handed blisters and my book bag and caught a ride back with Birgit and Dr. Collins.  Dr. Collins and I bonded over our mothers' shared birthday that day.  I gained further insight into his affectation for singing, spy novels, and tea.  I was able to listen to Voice of America which was a neat experience.  We stopped for more cattle.  I was treated to the story of when Dr. Foster hit and killed a goat and the owners accepted 50kg of sugar that he had in the car as reparations.  The drive only took five and half hours this time!

We got back to the Lubango city limits a touch after sunset: you know, that time of day when you're not quite sure whether to squint or to accept the low light of nightfall.  With lofty plans of blogging, reading, and getting things in order for the week ahead, I collapsed within minutes of arriving at my now empty residence.  The bed, though, was a marvelous upgrade.

Another full weekend!

tomato or tomato?

I have been on the chronic pursuit of culture since leaving for college.  I know myself and my ways but also recognize this as a 1 in 7 billion permutation of this thing we call life.

What do you value?  Whom do you love?  What’s your idea of a perfect day?  Do you, and if so to what or whom, pray?  Tomato or tomato?  These and more are the questions with which I mentally approach others.  I imagine this serves parallel purposes: to respect people as individuals and to qualify my own thoughts and behaviors.

Oftentimes, I used to poke fun at Ohio State’s ubiquitous mention of diversity as if it were a tangible item to be included on the campus tour.  Growing, aging, and experiencing experiences, however, have shown me the value of plural points of view.  This global health elective, then, presents me with an inordinate opportunity to expand my sphere of awareness.

I know neither how accurate nor how generalizable the words below are.  I am merely presenting a semblance of my own observations, conversations with knowledgeable folks, and reading.  Alright, alright, enough disclaimer.

Dear reader, please allow me to introduce the Angolan people.

This country continues to reel from a prolonged civil war following its independence from Portugal.  Just using medicine as a proxy, the government itself estimates that 47% of its citizens (some eight million people) have zero access to modern healthcare.  Extrapolate this to technology, education, and civil rights and then imagine the relative need here.

To expound on that whole civil war deal just a bit, it is important to know that it got going in 1975.  In that year there was another ongoing war, also drawn out, called the Cold War.  In super-duper-oil-rich Angola, the Americans and Soviets quickly took sides.  Based in the south, American dollars and South African soldiers aided UNITA and FNLA.  Their northern foe, bankrolled by Soviet rubles and manned by Cubans, were the MPLA.  The communists won.  Even with, “elections,” finally taking place this last decade, the MPLA have retained essentially all the political power.  Today’s implication of such is that China and Angola are best buds with cheap goods and labor coming west and that black gold going east.

This political schema, known as the most corrupt in Africa, affects your average John and Jane Angola. The administration has invested heavily in infrastructure, with major roads being quite nice and a national rail system nearing completion.  Government also controls both gasoline and the only Angolan airline.  Gasoline, primarily Diesel here, is 40 Kwanzaa/L (i.e. $1.60/gallon) literally everywhere you go nationwide.

Another repercussion worth mentioning is the lack of farming.  Into the 1970’s there remained de facto slavery in this country.  Rich, predominately European, land owners would visit the bush country, get folks drunk, have them sign unjust employment contracts, and load them on to buses the next morning.  With independence and its fresh air of freedom, farming was no one’s idea of a good time.  Today, despite much fertile land, there is a dearth of subsistence farming.  Angola must, therefore, import and pay exorbitantly for the likes of tomatoes ($5/lb.) and cheese ($12/lb.).  It is no wonder that Angola has the highest cost of living on the continent.

                                                                                                          

The disparity, as you might imagine, between income and the high cost of living is…discouraging.  Would you like to know the population of Lubango?  Yeah, so would I.  Estimates are between 400,000 and 1,000,000.  The reason for this chasm of a range is housing.  In certain areas, everything the light touches is a slum.  A majority of these brick homes have barren floors.  Their roofs are roughly measured sheets of corrugated metal held in place with perimetric rocks.  These sprawling communities have no pre-planned roads, no organized trash collection, no latrines, and no running water.  The (free) electricity poles that punctuate the skyline disappear in a web of wire near their apices.  Normally two families occupy a single one of these approximately 12’ x 15’, two-room dwellings but the actual numbers herein are indiscernible.  The sights and smells presented to my senses overburden my soul.

Despite such past and present, Angolans seem very happy.  The timely greetings of, “bom dia,” “boa tarde,” and, “boa noite,” are returned immediately and wholeheartedly.  I see many smiles and much appreciation on a daily basis.  Simple courtesies are not ignored.  Judgment is not passed near as readily as in western culture.  For example, when listening to those with an accent attempt to speak, Angolans only try to understand and keep the conversation alive.

These southwestern Africans seem to be a very relational people.  Hardships and successes are shared within extended families.  The uncle (tio) has a central role in family dynamics.  A maternal uncle oversees engagements and wedding plans.  An uncle is also the primary consenting party to medical treatment.  It is very common to see women and girls carrying their daughters and siblings (respectively I sure hope) on their backs. 

This closeness, however, does not necessarily translate to interpersonal compassion.  As mentioned before, employees do not make customers’ issues a personal initiative.  Similarly, in a medical sense, it does not seem as if Angolans conceptualize the patient as a parent/child/sibling and escalate compassion accordingly.

In hopes of summarizing, I would like to close with a poignant theme in this culture: survival.  The past and the present are the only things that matter.  Much of daily life is about making it until tomorrow.  This is true to the point that many patients are unaware of their own age.  The biggest sigh that I have breathed while learning about local culture, though, comes from the area’s tribal language, Ubundu.  In Ubundu, there is no future tense.

this is how we do it

It has been seven days since last having Internet access.  Upon reconnecting, I need to get shout-outs to mom and dad for missing each of their birthdays.  Also, what happened against Wisconsin!?

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Hey team, I imagine it's apropos to summarize an average day at the hospital.  My other aim here is to touch upon CEML’sbackground and operations.

06:30 – My alarm goes off.

07:00 – I actually get out of bed.

07:05 – Breakfast.  

Weall have our favorite foods and, from time to time, suffer from specificcravings.  While my favorite is certainlyMexican, I proclaim toast to be a close second. That’s right, toast.  Peanutbutter, with or without bananas, or hummus happento be my preferred preparations.  Toastis even more legit here thanks to homemade Angolan bread.  

07:45 – Catch a ride up the mountain to the hospital.  

I had heard that the hospital was referred to as the, "clinic on the hill."  This is an understatement.  The view along the road to the hospital is rather impressive.

The hospital is on the promontory to the right with the city of Lubango sprawled below.  Further down the road on the terminal cliff in the distance is the local version of Cristo Rei overlooking the city.

08:00 – Arrive at CEML. 

These green-roofed, one-story buildings are the hospital.  There are six of them, each serving a dedicated purpose: outpatient visits, inpatient wards, emergency room, operating room, cafeteria/offices, and storage/cleaning.

The buildings are connected by covered walkways whose shade is home to the patients' families.

Also part of CEML are, "the villas."  A one hundred yard walk or so behind the six-pack of hospital buildings is a small, permanent encampment.  For one tenth the price of being admitted, patients are able to stay at the villas and return for such things as dressing changes and medication administration.  The hospital provides a small amount of electricity and running water to those in the villas.

Once at the hospital, the day gets going.  Putting the, "E," in Centro Evangélico de Medicinia do Lubango, Mondays and Thursdays are chapelmornings.  The service is in concert withpatients on Mondays and reserved for the hospital staff on Thursdays.  For twenty minutes or so, we sing songs and heara brief message as a way of starting the day. The other three days of the week, rounds get going.

08:30 – Rounds.  

We are equipped with a men's ward, women's ward, children's ward, and ICU.  Smirking at the thought of private and semi-private rooms in Columbus, here is a typical early morning shot of the men's ward.

The doctors divide the workload and normally see two groups of patients each.  Much of the daily work on rounds is medication management.  Even in the ICU, we have no ability to place patients on a ventilator or to dialyze!  Being an esteemed surgery site, we also take care of many post-operative patients and their associated drains and dressing changes.  

As an example, the patient below had a wound that became infected and required debridement in the OR.  The relatively pathognomonic green color of his bandage suggests a notoriously nasty bacterium, Pseudomonas.  A minority of antibiotics in the U.S. can touch this guy.  Ideally, we would be able to sprinkle his wound with a gentamicin powder.  The problem, however, is that there is no gentamicin (or any anti-pseudomonal medication) in the city!  Our alternative is diluted bleach and daily bandage changes.  Your guess is as good as mine as to whether or not the limb will survive.  Daily, though, I am impressed by how healthy the unaffected area of the foot looks...

With new orders placed, notes written, and all the patients seen, rounds come to an end.

11:00 – Procedures and pertinent orders.

Most bedside procedures and other time-sinks that can be deferred to the end of the rounds are done so. As soon as we wrap up, we then double back to take care of pressing matters.

Pictures below are from one of the patients I am most closely following.  This gentleman came in with what we in the biz call, "altered mental status."  It means that his mental status was altered.  Essentially, he was a walking, talking, loving, working husband three weeks ago and now we are lucky if he is able to coherently form words.  The possible causes include such things as malaria (super common here), meningitis, stroke, sepsis, and a complication of his HIV/AIDS.  Only one day in the last nine has he known his wife's name.  His fevers continue, without pattern, even on antimalrial and antibiotic therapies.  The lumbar puncture was to rule out meningitis after having neck rigidity on physical exam. Oh, oh, I almost forgot!  Angolans are tough.  Local anesthetic is rare and valuable and so is not used for an LP like in the States.

11:30 – Either head to the operating room or see outpatients.

Mondays and Thursdays are, "non-surgical," days with only the most emergent one to three surgical cases going.  These afternoons are mostly spent seeing the scores of outpatients that fill the hall.  Every morning a throng of people patiently await their consult visit for as many as nine hours.  Constipation, cough, bloody urine or feces, and effects of high blood pressure are some of the most common complaints.

Dr. Steve Collins, my homeboy, has his ophthalmologic surgeries going throughout the week.  Since 1996, he has performed more than 15,000 cataract surgeries.  Literally curing the blind, Dr. Collins has a system.  Pay attention to the next patient already in the room (and fully conscious)!

Our other chief surgeon, and patriarch of CEML, is Dr. Steve Foster (more about he and his family later).  The son of a missionary surgeon, Canadian-trained Dr. Foster is one of the most veteran general surgeons on the planet.  With more than thirty-five years of experience in an environment that requires maximum adaptability, he is a living, breathing paragon of a man.  Pictures included here are Dr. Foster prepping a surgical site (while randomly wearing an OSU Medical Center scrub top from our recycled cache) and our post-operative pathology conference on bended knee following a cystectomy (palliative operation for bladder cancer).

13:30 – Lunch.

I am used to a world where the ideal diet is one of meal variety.  In this culture, they rather seek out meal consistency.  The name of the game is funge ("phoon-j").  There is nothing fun about funge.  It is a tasteless cornmeal mush with an unappetizing consistency that is somehow always the temperature of a last-period school lunch (much love for lunch ladies, sorry about that one).  This is a typical lunch at CEML: dried fish, greens, and a hefty helping of funge.

17:30 – Home.

I hope that suffices as a, "day in the life of," CEML.  My ten or so hour days are not dull.

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Just a bit about the hospital's history.  CEML was built in 2006 for about $4.5 million USD.  Those funds are a combination of a $1 million gift to Dr. Foster's father, some $800,000 from USAID, and other corporate and private monies.  The hospital is committed to using pledged money only for the sake of capital expenses.  All operating costs and salaries (doctors do not take a salary) are paid out of patient billings.  Care here is relatively expensive and is not accessible to the lowest wage-earners in Angola.  Patients, however, can be sure they are receiving high-quality care without the hassle of a government facility.

As Americans, thanks for paying your taxes and be proud of your country.

As world citizens, please know of the much needed good being done at the, "clinic on the hill."