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Two Stories (Finances: part 11)

Sat, 07 Nov 2009 05:34:00 GMT

As Jesus started on his way, a man ran up to him and fell on his knees before him. "Good teacher," he asked, "what must I do to inherit eternal life?"

"Why do you call me good?" Jesus answered. "No one is good—except God alone. You know the commandments: 'Do not murder, do not commit adultery, do not steal, do not give false testimony, do not defraud, honor your father and mother.'"

"Teacher," he declared, "all these I have kept since I was a boy."

Jesus looked at him and loved him. "One thing you lack," he said. "Go, sell everything you have and give to the poor, and you will have treasure in heaven. Then come, follow me."

At this the man's face fell. He went away sad, because he had great wealth.

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One day Peter and John were going up to the temple at the time of prayer—at three in the afternoon. Now a man crippled from birth was being carried to the temple gate called Beautiful, where he was put every day to beg from those going into the temple courts. When he saw Peter and John about to enter, he asked them for money. Peter looked straight at him, as did John. Then Peter said, "Look at us!" So the man gave them his attention, expecting to get something from them.

Then Peter said, "Silver or gold I do not have, but what I have I give you. In the name of Jesus Christ of Nazareth, walk." Taking him by the right hand, he helped him up, and instantly the man's feet and ankles became strong. He jumped to his feet and began to walk. Then he went with them into the temple courts, walking and jumping, and praising God.

Constantly (Finances: part 10)

Fri, 06 Nov 2009 05:00:00 GMT

The constant requests for money have become somewhat grating on my ears. Almost daily someone has come up to me asking me for a handout. Sometimes the money is for them personally. Sometimes it's for a family member, or a distant relative, or a friend of a friend. My close Kenyan friends ask me for money. Hospital workers I don't know very well ask me for money. Patients I've known for three months ask for money. Patients I've just met five minutes ago ask me for money.

I have found it extraordinarily difficult to look into these people's eyes and not see them as just another poor African, but rather as a whole person, with hopes and dreams, worries and fears, families and clans. I'm sure they have an equally difficult time seeing me as nothing more than another mzungu with a lot of money.

It turns that I was nowhere near as ready as I thought to deal with the poverty that surrounds me. On the one hand, I just want to shout at the top of my lungs, "I can't help everyone! It's too much! I can't do it all! I can't!"

On the other hand -- I sort of can. After all, $250 really isn't that much. I have many times that amount in my bank account. I could easily and single-handedly pay for Ednah's kids to go to school. With my savings account, I could even give her enough money to assure a good educational future for all three of her children.

I could pay for Julius' son, who's going to medical school at Kampala University in Uganda and needs 400,000 shillings ($5300) a year for six years until he graduates. Five thousand dollars is a lot of money -- but what is that compared to my own medical school costs, which were nearly $40,000 a year?

I could pay for Kibor, the old man I just met with an intertrochanteric hip fracture. He needs 400 shillings ($5.30) to travel to Eldoret for a dynamic hip screw (a far better treatment than the ten weeks of Perkins traction that I could give him at Kapsowar). His son says that relatives in Eldoret will help pay for the operation, but he doesn't have a single cent to pay for the matatu ride to get his father to Eldoret.

I could pay for these people. That is to say, it's not for lack of resources that I don't pay...that I won't pay...that I haven't yet paid...that I might pay...that I might not pay...

I can't say, "I can't pay." Because I can. Sort of.

I mean...I can. I can pay. No qualifications.

Except that...I don't know...

I don't know how to deal with this. I don't know how to deal with being "rich." I don't know how to react to all these people, perpetually asking me for cash. I don't know what exactly prevents me from giving money to everyone that asks. It seems to me that doling out money to all who request it isn't the wisest thing to do, but I can't easily articulate why it isn't. They are, after all, desperately poor. I am, relatively speaking, endlessly wealthy.

Should I be giving out less money? More money? All money? No money? Am I perpetuating a condition of learned helplessness? Or am I helping raise up a new generation of healthier, better educated, more responsible Africans?

Am I meeting a need, or am I just creating one?

Am I the rich young man, or am I the apostle at the temple gate?

Rich and Poor (Finances: Part 9)

Thu, 05 Nov 2009 05:30:00 GMT

My mind was consumed with a mixture of pity, sorrow, and confusion. It seemed awful that a loyal and longstanding hospital employee couldn't make enough money to send her own children to school. Furthermore, Ednah, unlike so many other Kenyans, had never brought up her need to me. The subject came up almost by accident.

Here was a loving and honest woman in need -- and somehow, I was struck by the unfairness of it all. The unfairness of wealth and poverty, of stature and servitude. Ednah lived in a typical Kenyan home, a rectangular building 8 x 24 feet, made of sticks and mud cement. There was no electricity, no running water, no sit-down toilets. She built a fire over a ground stove every day to cook meals for her husband.

Ednah came twice a week into my home. She saw how I lived -- modest compared to Western standards, but kingly by her own. I had a nice mattress, a dresser, and a closet. I had a laptop computer and a small library of books. I had a propane-fueled stove, an electric kettle, and a toaster. I had a flush toilet and hot-water sink. I had all these things that she could only dream about for her own home.

She never said anything. She never complained, never grumbled over my relative wealth, never held a grudge for my prosperity. I would set out a 500 or 1000 shilling bill every time she came so that she could do my shopping for me while I was at work. I must have laid out enough money over the past couple months to easily pay her children's school fees. But she never even brought up the topic. She would just go shopping in the market, buy the things I needed, and then faithfully give me the change with a receipt for all her purchases.

(I later learned the vast majority of the hospital employees don't make enough money themselves to send their children to either high school and/or private school. Ednah eventually talked to the headmaster at the public high school, who allowed Wesley to go back to school with the understanding that all the fees must be paid before he graduates the 12th grade. Thus, Ednah has three years to settle the entire bill with the school. Likewise, she has to settle the bill for her younger two children at the private primary school before they graduate 8th grade.)

Ednah's Children (Finances: part 8)

Wed, 04 Nov 2009 05:29:00 GMT

I was also confounded when I heard about Ednah's situation. Ednah, my house-helper (i.e., my savior), comes to my house on Tuesdays and Fridays. She pretty much makes my bungalow respectable. She does my laundry by hand, mops the floor, and washes any dirty dishes. She'll take the money I leave out for her on the kitchen counter and go into centre to shop for food and necessities: toilet paper, detergent, bananas, chicken, etc. Then, to top it all off, she'll look me a lovely dinner (she has a knack for cooking Western dishes) and leave it warm on the stove as I come back home from the hospital in the evening.

I came across her situation incidentally. I had been given some Hershey's chocolate candies when I went to visit other missionary doctors in Nairobi. I asked Ednah if she wanted to take some chocolate home for her children.

"Ah, actually, my children are at boarding school now. Oh, except for one! He's home now, so maybe he can have some."

One kid is home? Why's that?

"I can't pay the school fees, so he's just staying at home right now."

The situation became clearer as I queried Ednah more. She has three children: Wesley, Lorna, and, Lawrence. Wesley, the one without school fees, is in 9th grade. Lorna and Lawrence are at a private boarding school, both in 7th grade.

Both in 7th grade? Are they twins?

They are not. Lorna is a year older than Lawrence, but when she transferred from a public Kenyan primary school to a local private boarding school, she was found to be academically weak compared to the other private school students. So she was held back a year and joined her younger brother.

Kenya is notable for having free public education up till grade 8. The quality of the public education, however, is extremely variable, as evidenced by Lorna's experience. High schools grades 9-12, whether public or private, require school fees. Wesley needed 3,500 shillings ($47) to go back to 9th grade.

3,500 shillings -- that's not very much, I thought to myself.

The situation, as it always is, was more complicated that. In fact, Ednah really didn't have enough money to send any of her kids to school. The younger two children were staying at their private boarding school only because Ednah had begged the headmaster to refrain from kicking them out while she looked for more fees.

How much are their fees?

"I need 16,000 shillings more [$215] to pay for their school fees. I've only paid 2,000 already."

I was dumbstruck. Ednah needed nearly 20,000 shillings total to keep her kids in school -- and this only just for one school year. Between the three children, there were thirteen school-years left to pay for before all the kids would graduate 12th grade.

The scourge of Africa (Finances, intermission)

Tue, 03 Nov 2009 04:50:00 GMT

Several days after I originally wrote the previous post about Anna and her sick brother, he was transferred to the national referral hospital in Eldoret. He died a couple days later. Anna said the official cause of death was meningitis.

"Meningitis?" I asked James later that day. "That seems odd for a healthy young police officer."

James replied, "Ah, you know, the family says he was wasted. Completely wasting away. Aiyayaya, and then he died."

"So what does that mean?" I asked.

"What? Unajua? C'mon! There's only one disease in Africa that causes wasting in young people. There's only one wasting disease. Mbaya sana, so bad, so bad."

James shook his head and sighed.

Later I confronted Eunice, who I knew to be good friend with Anna and her family.

"Eunice, the wife -- she needs to get tested."

"Yes, I know. I even told her, she needs to get tested, and take medicine if positive. Lazima, she must."

"Is she going to come?"

"Sijui, lakini, I think she will come. I hope she will come."

"Nataka kujua." I want to know what happens.

"Yes, I will let you know."

I sighed. Despite nationwide access to antiretrovirals, the stigma is so high that many people often refuse to get tested, or, even if positive, to admit that anything is wrong.

Besides his wife, Anna's brother leaves behind four young children, ages 10 to 3.

Savings (Finances: part 7)

Mon, 02 Nov 2009 05:00:00 GMT

I later asked James about the concept of savings.

"You see, there's really no concept of savings. None, kabisa. People just don't save money."

I challenged him, for I knew that both Eunice and Thomas had saved money and bought land in local villages to build houses and farms for eventual retirement.

"Ah yes, you see, it's OK to save for a house, or school something. But otherwise, nothing. People never save money for any other reason. They don't have a rainy day fund. It's not culturally accepted. It would be bad luck, to save money for something bad that might happen in the future."

I asked James if he knew how much Anna made per month.

"About 9000 bop. That's all."

Nine thousand shillings. Anna made $120 a month, working 50 hours a week, being on call every third or fourth night. She earned 60 cents an hour for her hard and dedicated work.

The next day, I talked to Thomas about the situation.

"You know, daktari, Anna's situation is very difficult. She has six brothers. And you see, she supports them and their families. When someone like that has a job in a hospital or something, they are expected to be giving their family money. So she pays her brothers and for her brothers' children's school fees and such. She only takes home herself maybe three or four thousand shillings [about $50] a month."

I was staggered. Anna -- a single woman making in one month what I, even as a surgery resident, made in a day-and-a-half -- was using most of the money to single-handedly support her six siblings plus her nieces and nephews. No wonder she didn't have any cash reserve.

Emergency Cash (Finances: Part 6)

Sun, 01 Nov 2009 05:00:00 GMT

Another hospital worker, one much closer to me, recently asked me for money. Anna is one of the operating room nurses -- one of the best, at that. I walked in the sterilization room during morning chai time. The staff was sitting on the counters, drinking their chair. Anna talking to Wilson and Christine, two other theatre nurses, in Marakwet, so I couldn't understand anything. Then Wilson turned to me and spoke in English.

"Anna's brother is sick."

I looked at Anna, and she nodded her head solemnly.

"I received a phone call. He's very sick. They say malaria, and he's on IV quinine. But he's vomiting, vomiting, vomiting, can't keep anything down, is very weak, can barely talk. What to do, what to do."

Anna, usually very self-composed, looked preoccupied and morose.

"He's in Central Meru District. He's a policeman there. I don't know, what to do, what to do. What do you think, daktari?"

I wasn't sure what I was supposed to say. The diagnosis sounded fishy. Normally, healthy young men do not get life-threatening malarial infections causing persistent vomiting and requiring prolonged IV infusions.

They say malaria, huh? Well, I mean, quinine should work well.

Wilson piped up. "It costs 4000 shillings to go to Meru for Anna to see her brother, go and return. Can you help, daktari?"

Uh, yeah, sure, no problem. I don't have the money with me right now, but I'll go back to the house at lunch and get it.

I later brought a 500 shilling bill and handed it to Wilson, as Anna had gone out for her lunch break. Later that night I was called in for an emergency, and Anna was at theatre. She pulled me aside.

"Daktari, you gave 500 shillings?"

Uh, yeah. Why? Do you need more?

"Wilson said it was 4000 to get to Central Meru and back."

Yeah, I remember.

"Four thousand."

Oh. Um, did no one else give you anything?

"No, nobody has anything."

And you don't have any?

"Nothing."

You have nothing? No savings, not a shilling?

"I have nothing, nothing. What to do, what to do?"

I was confused. The situation didn't seem to fit with James' statement that "giving money is never an emergency." Anna, besides being a good scrub nurse, was also a long-time hospital employee. She had worked at Kapsowar for over 15 years, making a steady salary. It dumbfounded me that someone like her, after so many years, would have no savings, not a single shilling of disposable income. I also didn't understand why nobody else in theatre could have helped her out. Was there truly no one who had even a few hundred shillings to give her?

Salaries (Finances: part 5)

Sat, 31 Oct 2009 04:00:00 GMT

A few weeks later, I heard Jackline was leaving the hospital, along with a number of other nurses.

Why? I asked.

"Pay. They just don't pay us well enough here."

You mean the hospital? Kapsowar Hospital doesn't pay you very well?

Ah, no! Are you kidding? Not at all!

I asked Jackline how much she made as a nurse at Kapsowar. The answer: 10,000 shilling a month ($135). I learned that government hospitals would pay upwards of 24,000 shillings a month for an experienced nurse.

So are you going to a government hospital? I asked Jackline.

"Me? No. I'm moving to Maasai, working with an NGO on HIV vaccine trials."

Wow. That sounds very exotic. How much are they going to pay you?

"Twenty thousand."

Twenty thousand shillings. Double her current salary. How could I blame her for leaving? And yet, I couldn't help but feel slighted. Who was going to take her place? Where would we find another good, caring pediatric nurse like that?

Personal Debt (Finances part 4)

Fri, 30 Oct 2009 04:00:00 GMT

The first hospital worker to ask me for money was Jackline, one of the pediatric nurses (and a good nurse at that). She told me that she had put up her national ID (an identification card that all Kenyans are issued) as collateral so that her nephew could be released from another hospital. However, the bill had 20,000 shillings outstanding, and until it was paid in full, she couldn't get her ID card back. Would I be willing to pay?

I was confused by the question. Did she want me to pay the entire thing?

"It's a sign of respect," said one of the medical missionaries I met in Nairobi. "In America, it's rude to talk about how wealthy you are; but in Africa, people think they're giving you respect by asking for money. They're acknowledging that you are wealthier than they are, and they think it's a good thing to bring that up. They think: you're successful, you're rich -- why should you be ashamed of that? And why can't you give some money?"

Wealth, of course, is all relative. As a volunteer doctor at Kapsowar, I make no salary, and I have to find supporters at home to pledge financial funding -- that is to say, somewhat ironically, I have to ask people for money so I can live and work in Kenya. I live in a house with electricity, propane gas, and running hot water. For this privilege, I pay $10 a day -- an astronomical sum for most Kenyans. However, my total financial support for this year abroad is less than 30% of what I would have made as a surgery resident in California.

Another missionary offered some more insight. "They have this thing, where they ask you for money, then mention the total amount they need, then just wait expectantly. They never suggest an amount they want from you specifically, only the total amount needed. Just remember, they don't expect you pay it all, or even a huge chunk of it. They just want a donation, and then they'll move onto the next person on their long list."

I asked James for advice. James, though Kenyan, was raised his entire life in the cosmopolitan city of Nairobi. His standard of living and lifestyle is not terribly different from mine: he owns a laptop computer, watches DVDs of "24" and "Prison Break," and listens to music on his stereo system. Indeed, for him to work as a doctor in rural Kapsowar is almost as much of a cultural shock as it is for me.

"Ah, you know, when people ask me for money like that, I always tell them that I'll think about it. I'll think about it and pray about it -- and then I do. And I always remind me them that I want to help them out, I really do. But I don't give money right away. Ah, never. There's never an emergency like that. I always think it over, for about two weeks, before I give the money. Two weeks is a good time, to make sure it's nothing rash and that it's a serious need."

I took James' advice. A couple weeks later, I gave Jackline 500 shillings.

Patient Bills (Finances part 3)

Thu, 29 Oct 2009 04:01:00 GMT

As is true in much of the developing world, patients aren't allowed to leave Kapsowar Hospital, even if they're discharged, until they've paid their bill in full. Though there's a burgeoning social insurance program, medicine in Kenya is more or less a cash-only system. Patients often come in with emergencies and receive life-saving operations or medications. However, after they recover, they are essentially held hostage on the hospital campus until family members bring in the money to pay the bill. (As bleak as this may sound, Kapsowar Hospital stands in contrast to some other hospitals, where treatment -- even life-saving treatment -- isn't given until the bill is paid up front in full. Thus, people can die at the doorstep of a hospital for lack of immediate cash.)

For the patients without family, without clansmen, without any connection to their home village, the situation can be depressing. Despite the suggestions from staff members and physicians, the hospital administration does not have a reliable mechanism to deal with these destitute patients. Thus, they stay in the hospital for weeks or months, with no discernible means to pay off their bill. One patient, abandoned by her family, couldn't pay the relatively small bill for the delivery of her baby. By the time someone stepped in to help (Christina's home church in Indiana has been raising support to help some of the impoverished patients here at Kapsowar), her baby was close to crawling.

I've helped pay off several patients' bills now. In fact, several hundred dollars that I had previously raised in support for my own living expenses has instead been diverted to help with these patients' bills. One of these patients, Elias, came to the hospital after a fight. Another man had bitten off a big chunk of his lower lip. About 30% of his lower lip was missing. Fixing it would involve a V-wedge excision and reapproximation -- an operation that I had seen pictures of before, but had never witnessed or done myself.

Being the excited, blossoming plastic surgeon, I was excited do some traumatic facial reconstruction. The results I had seen in textbooks looked really good. I hoped to do as much. Of course, Elias had no money to pay for the operation. (Non-emergent operations require a deposit up-front.) So I told the financial office, "Just let me do the operation, and I'll take care of the money afterward."

Elias went to surgery, and I performed the operation. It went decently, though I could not have been sure of the final result until the swelling diminished after several weeks. I discharged him from the hospital a couple days later. The nurses told me that he was so thrilled to hear that I had paid for his hospitalization in full (about $150) that he had promised to bring me a sack of potatoes on his follow-up visit in appreciation.

He never came back.

(Somewhere, out there, is man with a couple dozen tiny stitches on his mouth and chin that still need to be taken out.)