Dirt Bikes - by Avery

In West Africa, the cheapest form of transportation for the average Joe is the small motorcycle (aka “moto” ). These are used both for personal transportation and as taxis. These bikes are very often from Chinese companies who make extremely cheap scooters and motorcycles with an engine of 125cc or less, which is pretty small. 

I myself have a Yamaha YZ85 dirt bike, a higher quality bike imported from Japan. My dad was awesome to buy it for me, and we hope to sell it to another missionary kid here when we leave. This bike is a LOT of fun as it’s a 2-stroke competition bike with an amazing amount of torque. Even though it’s pretty small, I’ll say it’s way better and way faster than many bikes here. 

Although it’s a great bike, Yamaha is a Japanese company. Since it seems like 99% of all bikes here are Chinese, fixing a Yamaha/finding parts here is nearly impossible. There is a TON of dust in the air because of the desert and winds, so wear and tear on engines happens pretty quickly. Getting something like this here and keeping it running is quite an adventure. 

Garage David in Dapaong

Here are the steps we took:

1. Arrive in Mango and quickly figure out that our “car” is at the end of its life. It is clear that we need a few motorcycles to get to the market, for dad to go to and from the hospital quickly, and just for having fun (not much else to do for fun here).
2. Talk to “Uncle Adam”, the go-to missionary for logistics here,  about what motorcycle he would suggest we get. He says that Chinese bikes would get beat up pretty quickly and that we should instead consider a bike that he’s “had his eye on” in the capital city. He was, of course, talking about the 2014 2-stroke race bike at a place called “Garage Petite Japon” in Lome. He told us “that’s the bike I would get if I was you” and that it was “a great learning bike”. 
3. Take delivery of the bike from a taxi sent up from Lome (9-hour drive). It cost 800,000 CFA francs, or about 1,600 USD.  Who knows how many owners it’s been through; the cost of a new one at home is more like 5,000 USD.
4. Dad takes it for a test ride. When he comes back, we tell him that he did a small wheelie while starting out, and he didn’t know it.
5. Finley and I learn to ride our first motorcycle, which is in fact a competition motocross bike:0
6. Run out of gas and discover that 2-stroke oil isn't sold in our town. We borrow 1 liter of it from the construction shop on compound and promise to pay it back with an order of oil from Lome.
7. The bike manual says that some pretty serious maintenance has to done on the bike “every fifth race”. We don’t take it too seriously, but we do order some parts for the bike to be sent here when our Grandpa visits.
8. Grandpa’s flights get thrown out of whack because of weather issues, so instead of easy travel here, he has to fly from Indianapolis to Atlanta to Amsterdam to Casabalanca, Morocco to Conocou, Benin, and THEN to here. Almost before he even took off, we knew the luggage with our parts probably wouldn’t make it here because of all the switches.
9. Grandpa gets here with none of his bags. A few days later, we receive two of the three bags, and OF COURSE the most important parts were in the third bag. We highly suspect the bag was stolen because of the fact that Delta claims the bag was said to be delivered to the airport here..
10. Right after Grandpa leaves Togo, the ol’ YZ starts to have problems. Unburned oil starts to leak out of the muffler, and the bike has a rapid loss of power. Troubleshooting online says that it’s likely because of a worn piston, rings, or cylinder. Just so happens that those were the parts to be brought with Grandpa.
11. We do actually have the piston rings, which are usually the first thing to go bad in a motorcycle engine. Another missionary guy kindly offers to take us and the bike to Dapoang, a city north of here with a certified Yamaha workshop. We stuff the bike in the back of his Landcruiser. The people there do a nice job of putting the new rings in.
12. The bike runs great again….for about a day. It then starts having the same problems as before.
13. An older missionary kid here helps me clean out the carburetor, as that can also be a problem with these things. No improvement.
14. We order an engine rebuild kit on Ebay and ship it to Iowa City  to be sent to a visiting medical student who will bring it out here. There isn’t good enough internet on the hospital compound, so I have to go into town to another house to order it.
15. The medical student arrives with all his bags! We send the to Daopong along with the parts laid in the back of a station wagon taxi and receive it back 4 days later.
16. After 3 months of sitting in the garage on a stand, it finally works!

Brothers

Plenty of fun places to ride here!

Ride to the Ghana border

Some noise and air pollution :)

Because

As I think through the potential “why” answers in my previous post,  I have been trying to journal my personal answer. Here are my top 5 reasons based on my 6 months away so far.

1) Calling / obedience - 14 years  ago I came to Togo as a medical student. A series of events that followed convinced me that one of my God-given purposes in life is to continue to help out here. While we couldn’t have known what that would look like from year to year - we have tried to make progress toward joining in what God is doing here.  Elements along the way - career change, supportive co-workers / family / friends and all the ways God encourages us through his mercy on us and the people here - keep us linked to this work.

2) I love and admire West African people. I think they must be some of the toughest people on Earth. They are very stoic in the face of suffering yet warm and gregarious in daily life. 

3) We have friends here. You get to work with amazing teammates in places like this. Many have a unique view of the world, understanding what seems like an alternate universe in terms of cultural dos and don’ts, developing world financial realities and life in the absence of basic infrastructure. Some have an unstoppable faith and commitment. Some are in the second half of life and bring a wealth of knowledge and experience to the problems at hand here. It is a close knit community in many ways - something I haven’t always experienced in life elsewhere.

4) I want to hold the big disparities in our world in my mind. Something along the lines of “to whom much is given, much is required.” A few examples of what I mean…  When we asked our guard for help killing a rat in the chicken coop - he did it fearlessly (I wasn’t about to get near the giant thing) and then cleaned it and cooked it over a makeshift campfire that same night. We spend more in a week in groceries alone than some laborers here make in months. I drive past half-clothed kids at the local dump and ladies carrying water on their heads to their homes and then shop for fully finished homes online for our return to Stateside life. Yesterday, a patient came in with this non-union femur X-ray from a nearby sizable city - the impression at the bottom means “good healing”. 

5) I want to love without fear and raise kids who do too.

Recently I had a terrifying nightmare of a terrorist attack here. I woke up with so much adrenaline release that it took awhile for my pounding heart to slow down. 

The following morning I read a BBC News story about an attack in the country to the north of us, this time on the French embassy there.

http://www.bbc.com/news/world-africa-43257453 

Later that day I was taking time on rounds to explain post-op care to a patient. I had repaired his bilateral groin hernias the day prior, the fourth such attempt for him. He had first undergone surgery at an “Arab Hospital” (later he clarified a Qatari one) in Cote d’Ivoire followed by two hernia repairs in Burkina. 

He was very happy that he had essentially no post-op pain in comparison to the pain that he described of prior operations. This was probably because I had severed a few nerves in cutting through all the scar tissue from his prior operations.  He seemed to really understand my explanation of how the hernia mesh I had placed works (my typical “reinforcing wire in concrete” analogy). I suggested he follow up in a month, at which time he pointed out that he lived north of Ouagadougou and it would be difficult to return. 

I had this fleeting thought - “What if he is one of the ‘bad guys’?”…. I asked, “If he is from so far away, why did he come here?” He said he had heard that “the work here is good,” as my translator put it. Now we were tracking together through smiles, both happy that our paths had crossed. I made him a deal - if he had no post-op problems - he didn’t need to return for follow up. I explained the 10 kg lifting restrictions. He asked about his relationships with his wives. I felt that we had a mutual understanding of his recovery plan. If I didn’t hear from him again, I’d assume he was doing well. 

Then, I asked if I could pray for him before he left. “No problem” was the reply throughout the translator…. I felt the nudge to go further. I explained that I had read just that morning about the problems in Ouagadougou and I told him I would pray for him and the Burkina people. My translator, who also happened to have trained some as a nurse in Burkina, and the patient seemed to appreciated where I was coming from. I asked God some of my typical requests for patients who I am about to discharge… thanking him for them, asking for their healing, asking that they would know Jesus better though their time here. But for this guy - I added prayer for his people, for peace and safety. 

It was a special time filled with the joy of love edging out fear.

Why

“It is worth asking why a health care professional who is capable, respected and experienced would leave his or her home, job and loved ones to go to a challenging, exhausting and possibly dangerous destination.”

This sentence leads off a very insightful section in the Global Humanitarian Medicine and Disaster Relief chapter in Wilderness Medicine, a fascinating textbook in the medical library here. 

According to the authors, providing medical relief is the primary motivation for most involved in this work. This relief first involves action such as a surgical procedure or consult, then being with patients physically and emotionally in their suffering and then bearing witness so that those suffering do not do so alone.

It has been helpful to read a concise list of potential answers to this “why” question, to reflect on my own motives and to understand where others involved in this type work might be coming from. Each reason listed in the chapter has merits and drawbacks and it is noted that many ideals are “mulled over” in the course of these deployments. Here are my take-home notes from the textbook on this subject.

1. Help people in need / relieve suffering - This is a laudable goal that the world could aspire toward more. One drawback is when the “helper’s high” or “doing something good” can be self-serving and used as a means to a personal end. This desire might not suffice if the culture served in has no grid for “volunteering” and assumes an ulterior motive for the service. While volunteerism is commendable it can lead to financial and domestic difficulties if not done with balance.
2. Testing oneself - In the absence of diagnostic technology or readily available specialists, an austere environment might hone physical exam skills, resurrect knowledge from medical school days or push some into learning new procedures. In contrast - skills needed in your home role might be neglected and require re-learning.
3. Medical tourism / adventurism - Our credentials can be a ticket to world travel. Having a “cross-cultural experience” has many benefits but this attitude might segue to “voyeurism and reductionism that can trivialize patients and their situation.”
4. “Check-mark syndrome” - Working in an emergency situation is just “one more box to tick off the list of having done it all.”
5. Fleeing a negative situation / finding oneself - Some may be looking to get away from personal relationship failure, professional frustration, or disillusionment with values of their home society. They might find a cause to channel their energy toward. 
6. Personal conviction, philosophy or religious belief - These ideals can serve as a sufficient motivation to serve and advocate. People of this mindset might feel that the suffering they see needs be shared with a wider audience and speak up on behalf of their patients. Local governments might not share the worker’s sense of social justice or beliefs which can limit their advocacy in the interest of patient or team safety.  Challenges arise when “there is discordance between foreign ideals and local culture, politics and traditional power structures.”

The section in the textbook concludes with an observation that we are all complicated humans who sometimes experience boredom and ambivalence in the midst of joy and fulfillment. However, we better understand the human condition when we enter into and see the “beauty and brutality” of the lives of others. This challenges our ideas about how the world works. Also, we see what we have in common can transcend great distance and our differences in language and culture.

Lassa

This is a very well-written recent article about a disease that surfaces in this part of the world at this time of year.

Lassa Fever Erupts in Nigeria - the New York Times

Because people with Lassa Fever who need to be hospitalized are often quite ill, they tend to be the more severe cases and have high viral loads that increase the risk of transmission to healthcare workers.

My friend Todd died of this illness and was the index case in this region two years ago. The date of his death (Feb 26) is actually the anniversary of the opening of the hospital that he was so instrumental in building.

Some of our teammates here have spent amazing amounts of time to get us prepared for this season. Any time a patient presents with a fever, we have to run through a checklist to profile their risk of having Lassa Fever and it adds another dimension to the stress and ethical complexity in caring for these patients. It is a gut check to consider our love for our patients and if that love is enough to conquer fear.

I remember thinking soon after Todd died that this horrible disease needs a protective vaccine against it.  So, I am very excited to learn of the funds and collaboration being directed by the Bill and Melinda Gates Foundation, vaccine companies and others toward this goal! There are two sometimes competing thoughts in my mind about these sorts of healthcare disparities in the world. On the one hand - you “change the world by changing systems” and on the other you change it “one life at a time.”

...Got the T-shirt

It was such an encouragement to host friends from back home for a brief stay earlier this month. My dad and an orthopedic surgeon friend travelled a long and weather altered route from Indianapolis - (scratch Detroit) - Atlanta - Amsterdam - Casablanca, Morrocoo - Conocou,Benin - to here….. for an 8 day stay. Predictably their luggage was lost in the shuffle but the bulk of it made it eventually. 

We worked hard to see and facilitate operations for many patients with long-standing orthopedic problems. There were times of high yield learning and fun adventures too. 

It was a rare privilege to have my dad in the operating room with us.

It is a blessing to have a wise, energetic and adventuresome dad for me and grandpa for my children. He liked off-road motor biking more than I would have guessed. I found something he is actually afraid of. Hippos!

However, I think the memory of going to see them was worth it.

Baby

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Trauma Stewardship

I recently read Trauma Stewardship - An Everyday Guide to Caring for Self While Caring for Others by Lipsky and Burk. It wasn't an easy read and is not a particularly well written book, but it did shine a light on challenges of staying healthy in the midst the heartbreak that is so prevalent here.

It’s not that any one scenario has been overly traumatic, but there is a steady dose of suffering, death and frustrating experiences in this type of work. The most beneficial section of the book was the list of “trauma exposure” responses, as I recognized some of my own tendencies in the list. Here are the ten that resonated the most with me including my personal examples and each with a supporting comic illustration from the book.

1) Feeling helpless and hopeless - thinking that what you are doing doesn't really matter in the end (systematically).

2) A sense that one can never do enough - but that you must still try to do enough.

3) Hyper-vigilance - double checking and micromanaging.

4) Inability to embrace complexity - preferring the simplistic explanations in my mind like "they just don't care" over "there is probably   a cultural explanation for their lack of urgency."

5) Minimizing - My wife and kids can out me on this one whenever I ignore their complaints and explain they "don't know how bad some people have it."

6) Chronic Exhaustion - I am trying to give myself space on this, learning from a senior surgeon that you just don't have the same stamina in this climate (I take 12 minute power naps after lunch almost every day).

7) Inability to Listen / Deliberate Avoidance - I am prone to this when facing patients who I can't offer a quick solution to and prefer to have someone else deal with them or make the interaction as short as possible.

8) Sense of persecution - thinking that my credentials back home carry little weight here, I just have to "fit into the system" and I don't get respected if I can't communicate well.

9) Anger and Cynicism - I really try to avoid this but I suspect this tendency is proportional to time spent here. New people come in and see the beauty and the hope. The long-term teammates buried their founding colleague out by the soccer field....life is hard... there is opposition around every corner.

10) Grandiosity: An Inflated Sense of Importance Related to One’s Work - I want to take credit for good outcomes but not bad ones.