Esther is sixteen years old. She is dying. For the last year, her father Charles has taken her to clinic after clinic looking for a diagnosis and a cure. She has lymphoma. The only hope for a cure is chemotherapy and a bone marrow transplant. Neither is available nearby or affordable elsewhere. Esther and her family live in a mud hut with no electricity. She is the eldest of six--soon to be seven--children. She lies in the bed she shares with her siblings. It is an agony for her to even turn over. She is bone thin, and developing bed sores on her hips from lying too long on her side. She doesn't eat much, but when offered rice and lentils today, was able to take a few bites. She does not complain, but the moans she cannot always suppress keep the family up at night.
Sandy is a farmer, and a resident missionary. Charles works as a laborer on the farm, and through him Sandy has come to know of Esther's plight. Sandy senses Esther's end is nigh, and comes to me for help. She is hoping to ease the pain and suffering of these final days. I agree to prescribe and administer medicine for pain.
Pablo, a surgical technician on the team, hears Esther's story and asks to accompany Sandy and I on a visit. We walk the half mile or so, Sandy greeting neighbors along the way. On arriving at Esther's home, Charles and family usher us inside. Esther is grateful for the company, and puts on a brave face. I examine her, confirm the diagnosis and prognosis, and explain that we have brought medicine to ease her pain.
She cringes when she sees the needle. I reassure her it will only hurt for a moment, then her pain will subside. She submits. Her father holds her hand as I inject the medicine into her shriveled thigh. I explain that we have brought several doses, and will return to administer them each evening so that she and her family can rest. Pablo says a prayer, and we depart, having done all we can for her.
The next two days are consumed with surgery, but Sandy keeps me updated on Esther's condition, as she has been making regular visits. Another, more effective medicine is added, but it causes itching. I give Sandy my personal stash of Benadryl to combat this side effect. On the evening of the third day, we learn that Esther has died. This is the reality of life here.
The housekeeper returned for the third time since 8 am. It was now 11:20 and I had slept in, exhausted and sunburnt and maybe a bit hungover with wine. Since his previous visit, I had risen at last, showered, and made a cup of tea.
"Are you OK?"
"Yes. I'm good."
"Are you needing anything?"
"No, thank you."
"Did you get the water?"
He'd left two bottles in the porch earlier.
"Yes, thank you."
"Do you need more?"
"I have enough, thanks."
"So everything is okay?"
"Yes. Everything is ok. Sawa sawa."
"Hakuna matata. One thing only: do not leave the door open. The monkeys are so many and they do not fear you. They will come inside looking."
He left, closing the glass door firmly. Moments later, she appeared. I watched her climb the door, rattling it in an attempt to open the latch. Her fingers searched the cracks at the edges. She scrambled up to the top where the window screens foiled her efforts.
Dropping down to the ground, she sat and gazed at me through the glass. I sat on the floor and gazed back. Her right ear was torn, her teats sagged, and the skin of her hands was wrinkled. I had no way of estimating age, but I knew at least that she had seen injury and childbirth. She was indifferent to my presence-- neither afraid nor curious, affectionate nor antagonistic. She was simply looking for food.
I remembered a small bag of almonds in my suitcase. I took out a handful and dropped them through the crack of the door frame. They scattered on the porch. She gathered and ate them one by one, looked around briefly for more, then left.
She is forty-two years old. She knows she will die soon. Even from the end of the hall, I can see how pale and frail she appears. As she draws closer, I notice the smell. It's the odor of death and decay. The chart indicates she was diagnosed with Stage IV breast cancer last year and it has metastasized to her bones. She understands there is no cure at this point. "I just want to be able to not stink so I can go out in public", she says. When I open her gown, the source of the stench is evident. Her right breast has been replaced by a tumor the size of a cantaloupe, and areas of the tumor are necrotic. She is literally rotting away.
We enter the operating room and she climbs onto the table. I hold her hand while the anesthetist puts her under. The surgical nurse cleanses her chest with Betadine. We are all near to gagging from the smell.
I remove the cancerous mass, but doing so has left a large open crater of a wound on her chest. It takes me nearly two hours to devise a way to close it by incising and rotating nearby tissue into place. At last, the bandage is applied, she awakens drowsily and is taken to the recovery room.
The stink is gone. It's all we can do, and it's enough.
The driving distance from Nairobi to Migori, Kenya is 371 kilometers or 222 miles. I'm traveling with a team of 15 other Americans, divided into three vans. We will spend the week in Migori, providing surgical services to the surrounding communities which do not have local access to such specialized care.
The road winds through city, town and countryside for nearly seven hours, providing an overview of this land and a glimpse into the lives of the people here.
A man shovels red dirt into a wheelbarrow, with no one and no structure anywhere in sight.
Small boys clad in colorful shawls of woven wool tend a herd of goats along the roadside.
A gaunt steer saunters past a row of ramshackle shops, pausing for a moment in front of Dimples Butchery, Bar & Restaurant.
Two young girls walk along, talking and laughing. Each carries a large bundle of sticks on her back.
A father walks hand in hand with three small children, past a group of donkeys nosing for food amid the roadside garbage.
Traffic creeps behind a long line of laden trucks, struggling up a steep hill. A family of baboons, including a mother with a tiny baby clinging to her back, gather at the edge of the road, hoping for scraps of food to be tossed from the trucks.
A teenage girl runs, laughing, to hide behind a shed as a boy of four or five looks around for her in an apparent game of hide-and-seek.
Acacia trees, with their distinctive silhouette, line the road and dot the distant landscape.
Birds pick at the bloated corpse of a cow lying in a ditch.
Groups of school children in scarlet uniforms smile and wave, shouting "How are you?" before bursting into giggles.
A family of five speeds past on a motorcycle.
Sheep wander between pieces of furniture for sale in front of a small cement building labeled FIVE STAR HOTEL.
Higher up in the hills, it is market day. Bunches of green bananas and bundles of sugar cane are piled high in makeshift stalls of sticks and cloth. A man selling chickens dangles them by their feet through his fingers, three to hand. Women sell vegetables from coarsely woven baskets piled high with potatoes, peas, tomatoes, and squash. Shoppers haggle over produce, testing mangos, avocados, and melons for ripeness. Small fires covered with metal grates provide a means of roasting ears of corn which are sold as a snack to passersby.
The rainy season is just beginning. We pass through showers here and there which turn the dirt portions of the road to thick red mud pocked with deep pothole puddles.
Shortly after dusk, we arrive at our destination. Migori is home to approximately 30,000 Kenyans from several different tribes. It is located 4500 ft above sea level, in the southwest corner of Kenya, just north of the Tanzania border.
Tomorrow will be spent touring the facilities, getting a crash course in how things are done here, and organizing team and supplies for the work ahead.
Musings on my travels and experiences as a Zen practitioner, trauma surgeon, and citizen of the world.
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