The bell tolls

It's early Sunday morning and the drums are pounding. Deep, holding bass thumps with rhythic higher pitched hypnotizing beats wafting through the background. In a few minutes, a mournful call pierces the African pre-dawn calling the faithful to the first prayer of the day with a long, drawn out "Allahu akbar!" Finally, to complete the symphony, church bells start tolling across town as the dawn breaks. But the music is rudely interrupted by a harsh clanging on our sheet metal door that can only be pounded out by the bare knuckles of a nurse seeking a doctor.

"Yeah?!" I mumble.

"C'est moi, it's me, Augustin."

"I'm coming!"

I fumble for my shorts hanging over the foot of the bed and stumble out the door to the porch where I open the screen door and come face to face with our charge nurse bearing a flashlight and a small carnet which serves as our patients' portable medical records.

"I just received a young boy who has respiratory distress. His whole chest caves in and you can hear the noise of his breathing clear across campus."

As I hurriedly put on my scrubs and follow Augustin through the bushes, around Lazare's fire pit, under the mango trees, on top of the straw and horse poop, to the side of the container, and through the gate into the hospital compound I understand what he means as I can hear a high pitched rasping coming from the dimly lit emergency room door.

A young boy is slouched across his mother's lap as she balances on a stool holding him up under the arm pits as his lower chest literally caves in all the way to his spine while desperately trying to suck in oxygen as he lets out a stridorous breath. His eyes are bugging out and almost rolling back. I listen to his chest with my stethescope and hear practically nothing. I place it on his neck and hear loud stridor. I get him to open his mouth and where the back of his throat should be is a smooth, bulging mass.

I'm afraid I won't get him to the OR in time. I call Caroline to help me and pick up the child in my arms as I jog over to the OR, flip the padlock to the secret code, insert the key in the door and burst into the OR. Fortunately, this morning the batteries have held their charge through the night and we have light. However, I'm afraid the power will go out any minute so I send Augustin to wake up Steve to turn on the generator.

Meanwhile, I lay the child on the operating table and give him a shot of IM Ketamine while Caroline searches for an IV. Just then, power goes out but I hear the slowly increasing thump thump thump of the Lister engine starting up and in a few seconds I can turn on the overhead OR lights and we are back in business.

I dump the cardboard box of endotracheal tubes on the floor as I rifle through them searching for one small enough for my patient. I finally find a 6.0 uncuffed tube and grab the laryngoscope out of the bottom drawer of the anesthesia machine as I slip on gloves. Caroline now has the IV running and the boy is now under Ketamine anesthesia. I find a guide wire, put it in the ET tube, check the light on the laryngoscope, raise the bed and open the kid's mouth. There is no way I'm going to see the vocal cords, the entire back of the throat is swollen shut.

I toss the equipment aside, grab a 15 blade scalpel and a suture removal kit, slice vertically down the middle of the neck, find the space between the tracheal and cricoid cartilages and poke through into his wind pipe with a hemostat. I spread it open, suction out blood and shove in the ET tube. I then hook up a bag and give him some breaths. The chest rises and I see vapor in the tube. I check with a stethescope hear breath sounds only on the right. The tube's in too far. I pull it out slightly, confirm there's now bilateral breath sounds, suture the wound closed, suture the tube in place and continue bagging.

His oxygen saturation is now up to 92% from the initial 35% so I stop bagging and just let him breath through the tube. His sats hover around 84-88% which isn't great, but without a ventilator and labs to follow it's more dangerous to bag him then to let him breath on his own.

I then try to place a nasogastric tube so he can be fed past the obstruction in his throat. It won't pass the mass. I stick my finger in his mouth and try to shove the tube in through his nose while feeding it past the mass with my finger. Suddenly, pus gushes out his mouth. I've ruptured the peritonsillar abcess. I quickly suck out the foul smelling pus and am relieved that it was so easily taken care of.

We wheel him out to his room and give his family instructions.

Later that evening, I go to check on him and find his tube choked up with secretions. We have a suction with a trap that allows me to put one end down the ET tube and then by sucking on the other end pull out the gunk into a chamber between the two ends. Very high tech. He starts to breath easier. I tell Jason to check on him every hour and suction as needed.

The next morning, he is awake, but tired and breathing fairly easily through the tube. I have the family members sit him up, suction him one more time even though it's pretty clear and move on to the other hospitalized patients.



In less than 15 minutes, Annie comes running up to me.

"Stuff's coming out his trach, he's not breathing!"

I run back to his room, chase out the family members and see instantly his tube is clogged up with pus that's dripping out. As I grab the suction to clear his airway I see he's not breathing and his eyes are rolled back. He has no pulse. As I suction, Jacques starts chest compressions. When the airway is clear I attach the bag and start breathing for him.

We take him to the OR quickly. We attach our cardiac monitor. He finally gets a heartbeat back with a pulse but after a few minutes it slows down again until we do more chest compressions to bring it back. We try multiple doses of Atropine and Adrenaline. His oxygen saturation stays in the mid to upper 80's when we bag him. But he just doesn't want to come back. Finally, after 90 minutes we are forced to stop. We wrap him in a cloth and call in the family. The dad nods, he's been expecting it. He wraps the boy up in his arms, carries him out and the family mournfully walks out the gate.

The drum beats on. The call to prayer continues. The bell keeps on tolling.

Ostomy

"Doctor, you need to see this baby." Samedi calls me to the ER. "She's only 7 days old, but she's never had a bowel movement."

I pull back the curtain and see the frightened mother holding her newborn baby in her arms. The infant's belly is markedly distended, but still somewhat soft. I listen and hear good bowel sounds. The mother says she breastfeeds well and goes on to prove it by feeding the baby right in front of me. I examine the perineum and the anus is present.

"Samedi, get me a glove and some lubricant."

He comes back in a few minutes, I slip the glove on my right hand, apply some goo and gently press my pinky into the tiny anus slowly dilating it until my finger can go all the way in. It's a blind rectal pouch as I suspected.

I inform the parents that their little girl will need surgery immediately and they agree.

Without x-ray, I'm forced to guess exactly the extent of the malformation of the colon. I'm hoping it's just the sigmoid (the last part of the large intestine). Sarah and Simeon tag team the anesthesia calculating the tiny doses of Atropine and Ketamine for it's small, 2.4 kg frame. We strap her into the "papoose" so she can't move, prep her distended abdomen with betadine, scrub and drape and before cutting, pray.

I decide to gamble that I can make a colostomy from the descending colon so I cut a small circle out of her skin to the left of her bellybutton, cut through the fascia and muscles and enter the peritoneal cavity. Small intestines burst out under pressure and I can't get them back in. I move to the center and make a midline incision releasing the pile of intestines to the outside air. I then bring back those that have gone out the side hole and explore inside. The colon hasn't formed (atresia) all the way from beginning to end. The whole thing looks like a long appendix running from cecum to rectum.

Everything is so tiny. I take a part of the ileum about 10 cm from where it joins the cecum and clamp the bowel with non-crushing clamps. I divide the intestine and slowly identify the miniscule vessels in the mesentary and clamp/cut/tie them. I then open up the distal end and suction out all the meconium resting there and suture it closed in two layers. I then pull out the proximal part through the side window, sew the wall to the strong fascia, evert the gooey mucosa and suture that to the skin. I then suck out all the stool from 9 months in mommy and 7 days in the real world and close up the midline incision after irrigating profusely.

I write post-op antibiotic and immediate breastfeeding orders and go home.

Except for a fever the next day found to be malaria and treated with blind rectal pouch quinine suppositories, she has a routine post-op course and is just waiting to have her sutures removed in a few days.

Lubambashi

The plane has stopped. I thought we were going directly to Lubambashi but we suddenly find ourselves on the ground at another airport. Apparently it was planned since I see people getting up and climbing down the stairs that open up from the tail of the old 727 airplane. I was actually extremely cold during the flight so I decide to take a breath of Congolese air outside. A sharply dressed young Congolese man is standing at the foot of the stairs just under the middle engine. We strike up an easy conversation until he notices something dripping on his suit.

I think it is fuel at first, but on closer inspection, it turns out to be simply water. The man is very friendly and I explain that we are with Adventist Medical Aviation and are doing some research on maybe doing some medical work in Democratic Republic of Congo and in Congo Brazzaville.

At this point our attention is caught by a large mobile staircase being pushed past us to the right engine of the plane a few feet away. Some men scramble up to the engine and start taking off the bottom enclosure. As jet fuel starts to cascade out, the ground crew rushes around collecting plastic buckets to catch it in as a small lake starts to form and flow off the runway.

A man in a suit rambles up lugging an ancient, twisted metal tool chest that folds out from the middle into several trays carrying some large, simple tools. He selects a large screwdriver and climbs up the ladder to the now-exposed engine as a couple of blue-overall wearing maintenance guys scrape out the fuel left in the bottom of the casing.

The mechanic tinkers around and eventually manages to pull of what appears to be the fuel filter. He takes off the filter and examines the cover which appears to be missing a gasket. He shows it around to a few other people amidst the shaking of heads and then puts it right back on. He tightens it up well as the blue guys mop up the remaining jet fuel with rags. Meanwhile, more ground crew have sloshed the tarmac underneath the engine with buckets of sudsy water.

The engine cover goes back on and we are escorted back up the stairway into the plane. Miraculously, we take off and land again at Lobambashi without further incident.

A thin, lighter skinned man with a huge smile, blue ringed brown eyes and a warm handshake greets us at immigration along with a short, stocky dark man who speaks some decent English. We breeze through passport control and are taken to the Adventist Surgery and Gynecology Clinic in a Toyota Hilux Surf SUV. The Hilux Surfs are everywhere but unfortunately no boards or waves are to be seen anywhere.

Most of the vehicles in town have the steering wheel on the right side of the car even though they drive on the right since most of them are imported from British East Africa.



We arrive at the clinic and are told there is an emergency. They are just waiting for the surgeon, Dr. Delgado to arrive.

When I inform them I'd like to assist, they drag me up some steep winding stairs to the attic which serves as pharmacy and stock room. I'm given a pair of elastic waist band scrubs and slippers too small for my feet and I quickly change and enter the OR.

It is small and long with tile running from floor to ceiling. Xrays showing obvious bowel obstruction are illuminated on a viewer straight ahead over the operating table. On the table, covered in a hospital gown is a young, 14 year old girl with a nasogastric tube coming out of her nose attached to a bottle of 5% dextrose for gastric lavage.

At the foot of the table is a metal table covered with a dark green cloth covered with shiny instruments and presided over by the surgical assistant robed from head to foot in the same dark green. His white surgical gloves rapidly arrange the instruments guided by his barely visible eyes behind a blue mask and protective goggles.

At the head of the bed is a jolly, pudgy man in ill-fitting scrubs whose large smile can't be contained by that silly piece of paper trying to pose as a surgical mask. In answer to my inquiries he shows me his anesthesia setup.

The archaic monitor is black and green with erratic QRS complexes running together on the EKG lead making their form, rate and rhythm almost impossible to interpret. But that is child's play next to trying to read the systolic and diastolic blood pressure and heart rate which for some reason are projected as mirror images of themselves.

The anesthesia machine consists of a metal table with bars on the back. An oxygen extractor behind the machine runs a jerry-rigged tubing apparatus up to a canister attached to the bar. The inhaled anesthetic is put in the canister and regulated with a twisting knob that the anesthetist proudly says he made himself. He shows me the scoring marks on the knob that let him roughly know the concentration given.

Laid out in an orderly fashion on the table are 4 endo-tracheal tubes, a laryngoscope and three unmarked syringes containing, according to him, Valium/Atropine, Thiopental and Succinalcholine.

Just then, Dr. Delgado bursts into the room. An Argentinean of Peruvian descent, Delgado has been in DRC for over 20 years. He started at the Songa Adventist Hospital before moving to Lobambashi and opening this surgery and gynecology center. He is known all over the region as the best surgeon around, is personal friends with the governor, has performed over 12,000 major operations there and has trained countless young, Congolese physicians and medical students in the art of surgery.




But I was to learn all that later. For the moment, Delgado was focused on the task at hand.

"What's her story?" He asks the resident who called him in.

"She was sick since Friday, went into another clinic on Saturday, was given malaria treatment and sent off for a bunch of lab tests and x-rays. After three days, she was getting worse and the family brought her here. When we examined her, she had an acute abdomen with signs of obstruction. As soon as we told the family she needed an operation, they wanted to evacuate her to South Africa until we assured them you would come yourself and do the operation."

"Ok, well she obviously needs surgery, it's too bad they waited. I'll go scrub."

Soon the operation is under way. On entering the abdominal cavity, we find pus everywhere with the small intestines stuck together. It takes awhile to clean things up and separate out the intestines to find just what we suspected, a perforated appendicitis.



After the appendectomy, massive irrigation and placement of a drain, Delgado leaves the closure to the residents and he starts telling me about his latest project: a new surgery hospital on the outskirts of town.

The girl is extubated and wheeled off to post-op recovery in stable condition.

The next morning, Delgado is flying to South Africa himself so we meet him at 7:30 in the suburbs of Lobambashi. He has been given 100 hectares by the government where he's built himself a beautiful house and is almost finished with his new surgery hospital. A local Muslim business man from Lebanon has financed the project to the tune of over $1,000,000. The equipment and initial medications are a combination of donations from the AMALF (Adventist Medical Association of the French Language) and purchases from a Swiss company that refurbishes medical equipment.

There will be two full functional Ors, a minor procedure room, a post-op recovery room, an ICU, private rooms, and an outpatient center. Everything is beautifully tiled and the solid, hard wooden doors have been imported from South Africa. It will probably be the best surgery center in between Nairobi and Johannesburg.

Also, on the 100 hectares, Delgado is helping build a Conference Office for the local SDA mission and an Adventist Church.

That evening, I check up on our young patient and she is lying comfortably with no fever and only slight tachycardia. Her abdomen is still slightly swollen, but soft and I already hear a few bowel sounds. I talk with the father who is eternally grateful and tells me that his son has just returned from a visit to Orlando, Florida where my parents live and his daughter wants to go there for nursing school.

As he gives me a ride back to the Union offices where I'm staying, I offer to put him in contact with the SDA nursing school at Florida Hospital and he likes the idea and takes my email address. He insists we come eat at his restaurant the next day but unfortunately, we already have plans.

The last day before heading back to Kinchasa, I make my final rounds and find the girl in even better condition having already passed gas letting us know that bowel function is returning. I pray with the family one more time leaving her in God's hands.

Kinchasa-ball

Kinchasa has a sort of sport found maybe no where else in the world. I don't know if anyone has actually named it, but it seems the rules are well known. I'll call it Kinchasa-ball and it's played out every day on the wharfs of the city where the ferry crosses to Brazzaville.

There is a walkway from the street to the pier that is enclosed by steel bars that serves as the playing field. The game starts as the ferry prepares for crossing. Somewhere out on the street, the visiting team starts it's preparations as the trucks arrive bearing all kinds of cheap, processed goods for the markets of Brazzaville. Hordes of "runners" gather. Yellow and blue vests are handed out. The players have the option of wearing them over their shoulders and backs, tying them around their necks, or wrapping them around their heads as turbans. Most wear pants cut off just below the knees, ragged t-shirts and flip-flops. The players come in all sizes and shapes, but all are wiry tough and most are quite buff.

Meanwhile, the home team gathers at the elbow where the walkway curves around through a gate, runs parallel to the river for 50 feet before making its final turn down the gangway to the rusted out ferry boat teeming with spectators. The home team consists of a couple of player-coaches and five or six large, uniformed port authorities. The one who appears to be the head coach is of average height, has a scowling face and wears Arabic robes. His piercing eyes glare out from behind small spectacles perched on his flat nose. The "assistant" coach is a huge man with a beer-belly and a large, pocked marked face with a smug grin permanently hovering ready to pounce.

Gary, Jeremy and I have stumbled upon first row seats just behind the home team where the passengers wait to cross over the Congo River into Brazzaville on speed boats.



The first member of the visiting team pads around the corner, his slippers flip-flopping across the cement in cadence to his labored breathing as he struggles under an enormous load of yellow soap bars balanced on his sweaty scalp. The home team is just warming up so they let the first one pass.

The second is not so lucky.

A smaller man, with a 8 foot wide plastic wrapped burden of cracker rolls perched on his head, jogs down the gauntlet towards the corner where the uniformed home team waits. Each of the port authorities carries a doubled up rope in his hand which he occasionally fondles with the other hand in eager anticipation of feeling it zing down on another human beings flesh.

As the man approaches, the head coach steps out and grasps the side of the opposing teams load. There is a brief struggle as the unfortunate man desperately tries to keep his precarious balance. Finally, he is forced to drop down his load next to the leering home team members. He argues briefly and half-heartedly as if it's the thing to do even though he knows it's hopeless. Meanwhile, the same scene is repeated over and over. Most get through the gauntlet, but randomly, someone will be pulled down using their top heavy loads as leverage against them.

The game continues as those who have been pulled aside run back to the street and come back shortly with something in their hands to pass on to the home team in the form of a "secret" handshake. However, they don't seem to take too many pains to make it secret and don't seem to be ashamed at all of the blatant bribery and corruption.

In fact, after a giant, hulk of a uniformed man on the home team pulls down a tiny man half his size carrying double his wait he lifts his massive head into a victorious grin as he air boxes like Rocky his fists pumping the air in jubilant victory.

The worst is still to come. The visiting team has recruited some new players. A line of 5 blind people walk slowly up each left hand placed on the shoulder of the man in front with a guide showing the way. In their right hands, they carry some small bundles of merchandise for which they will be paid a few cents allowing them to honestly earn a living playing Kinchasa-ball.

There is no mercy. The coach himself steps out with an evil grin and pushes them back. They stumble trying to keep their balance, sightless eyes rolling around in their lolling heads. Kinchasa-ball is not for the faint of heart.

Next is a man in a wheelchair. It is a tricycle that allows him to pedal the front wheel with his hands. The chair has been loaded with goods and he is perched on top pedaling furiously. Surely, he'll make it through the gauntlet! But no! Our brutish giant lumbers a few steps forward and places his beefy hand on the cripples chest as he sneers out his order to stop! He too must pay to get through.

After about half an hour of intense competition, the game winds down, the gates are shut and the ferry pulls out slowly from the dock. The home team gives each other satisfied smiles as they finger their fat pockets as the visiting team, slowly climbs back up the gangway, sweat dripping from their soaked shirts and glistening on their ripped, but tired bodies.

Congo

The never-ending, impregnable jungle finally gives way to a twisting silver snake of the river. My first view of the Congo is not as earth-shattering as I expected, but it is thrilling none the less to be looking on that legendary waterway immortalized in so many writings feeding central Africa with its numerous tributaries and irresistible tug towards the ocean.

I am crammed tight in the left rear seat of a Cessna 172. Gary and Jeremy have flown me straight from Bere down to Moundou and across Central African Republic and over the Democratic Republic of Congo where I get my first glimpse of its mighty river. There is a water jug between my feet and provisions stacked to the ceiling next to me forcing me to curl up almost in the fetal position. My only relief is to turn from my right to my left side occasionally and immerse myself deep into an absorbing book…in this case, “Seabiscuit”.

We descend across the Congo River and into the tiny airport of Kisangani. The immigration officials look fierce and determined to shake down these foreigners for some “tea money” until Gary starts speaking to them in Swahili and explaining that he grew up in Eastern Zaire (as DRC was called then). We are then whisked through the formalities and taken into the Congo Frontline Mission compound by the Mosiers.

Over meals rich in pineapple, bananas and avocados—a feast for this fruit starved Chadian—we hear about their efforts to start a medical mission program to meet the scandalous medical needs of the outlying villages. For now, a simple canoe with an outboard motor and a local doc takes them a few miles outside of town to provide basic malaria, malnutrition and parasite treatments. As they come face to face with burn victims, people maimed for life through various accidents and the incredible infant mortality rates they realize that much more needs to be done.

As the stories unfold around me, I am taken back to the three and a half months I spent on the Amazon River working with the Luzeiro mission launch program back in 1994. I remember reading the stories of Leo Halliwell and his wife as they opened up the Amazon basin with their little medical launch and handfuls of quinine for malaria. As I mention this outloud, Keith walks over to the bookshelf and pulls off their story, “Light in the Jungle”, which I hadn’t read in 15 years.

I start reading that very night as deep longings I had buried inside over the years start to be awakened. The river is calling me.

The next day Gary and I go to help Keith and his dad try and negotiate with the Ministry of Public Works for the use of a bulldozer to clear the jungle from the land they want to build their school on. Things are rough for a while and negotiations tense until I mention that I am a doctor and we are interested in opening a medical river boat program.

Suddenly, the scowling Minister stands up and stretches out his hand with a big smile on his face.

“I’m a surgeon too. I’ve operated on everything. Welcome, colleague. If you ever need any papers or authorizations to get this project through to the right people, just bring it to me and I’ll accelerate it right through.”

We finish and head out the next morning for Brazzaville, Congo. There we happen to meet up with the president of the West Africa Division of the Adventist Church and the Secretary General of the General Conference as well as one of the under secretaries of the GC. As we are given the tour of the mission compound we come across a map of Congo.

There, again, the River jumps out at me.

Running all the way up the border between Congo and the Democratic Republic of Congo it then branches off into the interior of DRC. However, another major tributary continues up the border until it reaches Bangui, the capital of Central African Republic and then curves eastward across the border of CAR and DRC. Hundreds of smaller tributaries pour into the River from the Congo side making it possible to reach most of the abandoned little villages with a medical launch.

Sunday, I finally get to touch the Congo River. We have somehow managed to get all the stamps and pay all the fees to get in a boat crossing from Brazzaville to Kinchasa. Nowhere else in the world are two country capitols this close. As the motor starts up and we start weaving our way through the slalom course of grass and reed floaties scattered across the breadth of our course, I dip my hand into the cool water and lean back to smell the river air and absorb the majesty of its greatness.

We are given the tour of Kinchasa by the honorable Bahati, a member of the House of Representatives, and find ourselves at the Adventist mission station. Years ago, the church had built a hospital boat that never got off the ground thanks to the civil war and was finally sold for a pittance in 2003. We wanted to find out what happened to it. The president of themission escorts us up to his office and spreads out on his desk a wad of
pictures of the boat under construction and the all-but-finished product. It is almost exactly what I’d been imagining and looked remarkably similar to the boats I’d worked on in Brazil.

The next morning our Hewa Bora flight takes off from Kinchasa bound for Lubambashi as the early morning sun casts a warm glow across the River as it spreads out in a flood plane filled with islands above the falls downriver. It is beckoning…

Stuck

I'm calmly chatting with Doug in the air-conditioned OR in Bere. We are just finishing up a routine hernia operation. The external oblique is closed and we are preparing to close the skin. Before starting the surgery, I'd passed by the charge nurses, Augustin, deep in conversation with the midwife, Hortence. I briefly caught the words "breech presentation". I almost stopped to ask what was going on, but ignoring that still small voice I continued on to surgery rationalizing to myself that it must just be a prenatal visit or something or they'd come and tell me for sure.

So Doug and I take our time on the iguinal hernia repair which I do with mosquito net mesh as usual. Suddenly, Hortence's head pops into the OR through the swinging doors.

"There's a woman...the legs and body're out...the head's stuck...been that way for awhile...we can't..."

"I'm coming! Doug, close up the skin." I cry as I strip off my surgical gown and bloody gloves and race out through two sets of swinging doors, a screen door, around the corner, under the veranda, through another screen door and right into the tiny delivery room where I see a floppy set of legs and arms with no head plopped on the delivery table between a woman's bloody spread legs. The room is packed with Augustin, Hortence, a mid-wife student, another nurse, Dr. Jacques, a family member and now myself.

I start to shout out orders.

"Augustin, get me the symphysiotomy kit!"

"Hortence, bring me some gloves."

"Prudence, I need a syringe and some lidocaine."

"Jacques, a 20 blade scalpel."

As everyone goes off running I slip my hand in and with a few futile tugs confirm that the baby's head, extended on it's neck, is stuck.

Everyone back in a matter of seconds. I slip on the gloves, draw up the lidocaine, open the instruments, inject quickly over the pubis, put the scalpel on the scalpel handle and speak directly to the woman.

"Don't move whatever you do if you want this to work! Augustin, Jacques, grab her legs and pull them up and out!"

I slice through the skin and cartilage and feel the pelvis pop open. The baby slithers out. I clamp and cut the cord. I whisk him off to the exam table. He has no heartbeat, tone, movement, cry, respiration, color, nothing. I try and clear out the gunk in his mouth and nose and do chest compressions for a couple minutes before silently covering him with a rag.

I turn my attentions to the mother. I start to examine the position of the placenta and notice two things at once.

First of all, her belly's still really big. Secondly, there's a bulging bag of water in her vagina. Twins!

I break the back of water and out pop's a full head of hair. Within seconds the second twin is delivered, pulling up his arms and legs, grimacing and screaming his little lungs out. He's alive!

Niger

I am back in Africa but this welcome is far different than the one I'm used to. Sarah, Gary and I have just flown 8 hours across the desert from N'Djamena to Niamey, the capital of Niger. We cross dry grasslands, rocky outcroppings and fingers of the Sahara itching ever southward. Arriving over Niamey, we circle the Niger river and the new bridge being built by the Chinese before making a smooth landing at the airport. As we taxi up we see large men in black suits and dark glasses walking over to meet us. Dick, Kari, Scott and Mindi are huddled together with Bill and Barbara Kirker in front of the VIP welcome center. Are bags are taken over on carts and the men in black whisk us through immigration and customs and out the front where black mercedes and land cruisers wait with chauffeurs leaning casually against the front fenders.



Hazard lights flashing we make our way through the city ignoring lights and stop signs as other cars pull over to the side to let us pass. We arrive at the President's guest house overlooking the Niger and the irrigated fields crowning its banks. A sumptuous, yet simple supper awaits us. Air conditioned rooms, white table cloths, sodas and cold water on the side and comfortable couches welcome us in style. Conversation flows easily as we are from time to time interrupted to meet more important people in dark suits.



The next morning starts with a tour by Jason Brooks of the ADRA office and school where bright kids in sharp uniforms smile and shout out English phrases they have learned. The school is an impressive combination of underprivileged kids sponsored to go where they'd never have the opportunity to go otherwise, and rich kids who pay big to get a good education. All have become equals in their matching uniforms.



Then we're off to see the big wigs starting with President Mamadou Tandja himself. Circling around the winding, well-guarded roads up the the governmental palace is a little surreal. We climp up the massive steps and enter through a metal detector into an inner courtyard with high ceilings, traditional carved horses on stands, pictures and maps on the walls and a 10 foot giraffe carved out of the twisted root system of a tree.



We are finally ushered into the President's office where we are presented by Bill Kirker as the group possibly willing to take on the management of the Maine-Soroa Hospital, which just happens to be in the President's home town. I translate for Dick as he presents the President with a gift from Loma Linda University. The President is very gracious, poses for photos with us all at the end and decides on the spur of the moment to give Dick on of the carved horses in his lobby.





Whirlwind tours with more Mercedes and Land Cruisers and flashing hazards take us through the turbaned Tuareg Minister of Health, the distinguished, glasses-on-the-nose Minister of Education, and the plump, take-no-prisoners US Ambassador.



The next day we fly 800 km across the desert, east towards Chad with a quick stop at the only Christian hospital in Niger. A quick, chicken dinner probably providing the source of our later diarrheal illnesses and a too short crash on floor mattresses inspected by a mouse and many mosquitos and we take off again the next morning for the last 600 km to Maine-Soroa. Two flat tires and mostly good roads later and we are stopped at the side of the road in the middle of a desert with widely spaced scrub trees, and goats, sheep, donkeys, horses and camels wandering through.



As we get out of the cars, a crowd gathers around as we are welcomed by the governor, the mayor, the prefect and a host of other dignitaries from the region who then escort us into town in front of the king's quarters, in front of the central mosque and next to the market. A crowd has gathered. Brightly decorated horses mounted by robed, spear-and-sword-toting cavaliers prance on the sidelines. School kids in uniforms wave and chant. Turbaned, shirtless boys twist and contort in front of drum-pounding musicians beating out a fast rhythm accompanied by a bulging cheeked flute player. We push through the crowds to where chairs and couches have been arranged. The toothless, ninety-year old king nods and shakes hands as his eyes bulge out from behind coke-bottom glasses.






Speeches are made, kids dance and sing and recite and shout poems and slogans, horse-men dress out and shake their weapons, traditional dancers move and shake, and Dick is crowned "Wokil". He is brought crosslegged onto a mat in front of the king while his side-kicks circle around dressing Dick in a traditional, blue robe with elaborate embroidery, a red, felt skull cap and crowned with a turban. The "Wokil" is the king's new ambassador to the world, and in the absence of the king, his word is law. The ceremonies ended we end up at Bill and Barbara's for a feast of goat with couscous cooked in it's belly.










The next morning is another whirlwind tour of Barbara's Second Chance School for kids who have never been to school and are passed the country's maximum age (9 years old) for entering elementary school, the king's court, the Prefect's office, on to Diffa to see the governor and back to Mainé to check out the ancient air strip. Friday morning we finally get to see the hospital newly named the Kirker Hospital in honor of Bill and Barbara's efforts as first Peace Corps volunteers and then as the only doctor for years in this extreme eastern city of Niger founding a hospital where before there was none. Now, the hospital is being revived after years of neglect with some new hospital wards and the hope of a new management team, nursing school and maybe even specialty services to serve the underserved populations of Eastern Niger, Western Chad and Northern Nigeria.



We all crash Friday evening and Saturday with staggered episodes of vomiting and diarrhea. Another feast of splayed roasted sheep and couscous goat on Saturday night with the hospital staff finishes off our stay in Niger. Sunday morning, Sarah, Dick, Kari and I head off in Bill's Land Cruiser across the desert, up north and around the top of Lake Chad. 13 hours of desert, many camels, much sand, a few Lake Chad thick-horned cows, one gazelle, one desert fox, a large bird whose name I forget, clusters of white brick mud huts with flat, horned corner roofs, one half-hour stuck in the sand barely getting out episode, one border crossing where we are the only car to have passed in two days and we arrive in Chad at Bol.





I am welcomed back to my host country by a couple of moto taxi-men trying to scam us into believing that the airport is a long ways away and only they can show us. We ignore them and continue through the one road town to the hospital where the charge nurse who happens to be on duty informs us that Gary and the Bere Hospital chaplain, Noel, have just arrived and are over at the regional medical officers home.



The regional medical officer is a friend of Noel's and he welcomes us with a big smile and a feast of macaroni and tomato goat sauce which we partake together on a mat on the floor with the tray of noodles in the middle. Everyone digs in with his own spoon and washes it down with bananas and cold water. The next day, we fly off with Gary over the vast expanse interconnected lakes which is what remains of the great Lake Chad. Massive herds of cattle wander in long lines like ants across the green fields watered by what is still one of Africa's largest lakes only to end abrubtly in the sands of the Sahel. After landing in Moundou and showing Dick and Kari the progress on our Surgery Center project there, we finally arrive back in Bere.