Advertise on podcast: Friends of Kijabe

Dr. Annviola on her journey to pediatrics, why she loves Kijabe, growing up in Kibera, amazing patient stories. Why Pediatrics? "If I don't do it, who will?"

Conversation about training in Kijabe, safe deliveries, the healthcare landscape in Kenya, and the benefits of the Kijabe resident housing project.

About Kabarak University-Kijabe Hospital family medicine training, healthy communities, the advantage of learning in Kijabe (access to advanced equipment/clinical opportunities), and a little about Friends of Kijabe.

Conversation with Dr. Hellen Kihoro about training, faith in medicine, specialization, dreams for Kenya.

Conversation with Dr. Etienne Mastaki about his journey from DRC to Kijabe, Anesthesiology training, Faith in Medicine, and the benefits of building resident/fellow housing in Kijabe.

"I want to be a doctor for African people. I want to work in Africa. There's so much healthcare need in this continent that if we, as the medics who've been trained, just stay around and work for our people, there will be a huge difference. Then we'll start becoming the policy makers. We'll be like, 'now we've worked in this place. We need to change this policy to this.' And then slowly by slowly, we'll see the change."

Conversation with Kijabe Oncologist Sarah Muma about her personal experience and the future of cancer care in Kijabe and the country.

Conversation with Dr. Stephen Dyar about building a Comprehensive Cancer Center in Greenville and the building blocks necessary to do the same in the Kijabe context.

Conversation with PAACS Anesthesiology Resident about medicine, systems, compassion, faith and building for the future.

David: I want to talk a little bit about the hospital, but I'm also curious about your life.  So first, just tell me your name and what you do at Kijabe Hospital.   Linette: My name is Linette. I'm a medical officer, general doctor at Kijabe. I work in the Internal Medicine department in general wards.  When COVID was here in COVID ward – now it’s respiratory center, and in ICU/HDU [Intensive Care Unit/High Dependency Unit] Unit.   David: Why did you end up with adults?   Linette: [Laughter]Well, I love internal medicine. Anything to do with Internal Medicine, I love it. Whether it's an adult or a baby. I just love it. I feel like it's easier and maybe it's easier because of where I went to school. . . Where I went to school there's a lot of lifestyle diseases, less infectious diseases.    David: When you say lifestyle, what do you mean?   Linette: Like hypertension, diabetes, things like that, which is most of internal medicine. And so, it was not like Kenya where you have infectious disease to think about. I feel like that was my foundation when I came for internship, I found this safe place, this comfortable place in internal medicine.    So, it's like, oh, I know that. It's not new to me because I've seen it, and that just made me love it more and more because I felt like I know that and now I can build on that.    I mean, it turns out you don't know anything.  You don't know what you don't know!  But it’s fun to build on that one. Yeah. So [Internal Medicine] is my favorite one.  And why adults? I'm very emotional when it comes to kids, and my pediatric rotation was full of a lot of tears. So, I was like, “No, I need to like, get myself together and be a doctor and look like a human. . .what?  Hard-board or something. . .like nothing is touching me, I'm just okay.” But inside I'm all mushy. So, I feel like kids really remove that from me. And then adults are like, “okay, I can cry about this later, let's deal with it now.” But then kids, cry now!  [Laughter]   David: That's great.  You did your you did your internship at Kijabe?   Linette: Yes. Yes.   David: Tell us about medical school. How in the world did you go to school where you went to school?   Linette: I went to school in Russia, the Russian Federation. And it was just it was a miracle of sorts because I had no idea that I could go to school in Russia. In fact, I didn't even want to be a doctor until my last year of high school when I feel I felt the Lord telling me to be a doctor. And I was really against it for like a month. I spent a month arguing with God in my closet. Like, really? You really want me to do that? I've never wanted to do that. I want to be a lawyer. I want to be a scientist. I want to do research. I had all these other plans.   David: Anything but medicine.   Linette: Yeah, anything but medicine. Everyone wants to be a doctor, but who is going to take out the trash?  Who's going to be the mechanic? Who's going to be the engineer?  I don’t want to be a doctor, everyone's going to be a doctor.    It turns out not everyone became a doctor - I became the doctor! God has a sense of humor because the thing that I was fighting so hard not to do turned out to be the thing that I do the easiest.     I went to med school and God make it made it so easy for me to learn and to understand the concepts. . .to understand physiology and how the body works and what drug goes with that. So, I was like, "Hey, man, it's good to follow what you feel God is saying to you." And boy, am I glad I did that.   And then Russia. A friend of mine visited from Russia. I hadn't seen her for years. She was in second year [of medical school]. She told me Russia is good.   David: She's Kenyan?   Linette: She is Zambian. At that time, I was living in Botswana, that's where I grew up. So, my Zambian friend comes home for holiday and I'm like, "Hey, long time, I haven't seen you. It's been years. Where have you been?" She's like, "I've been in Russia." What are you doing? "I'm doing medicine." And I'm like, okay, that's amazing. I hadn't yet agreed with this whole plan to do medicine in my heart, but I thought, "This is a good like idea to look into Russia as a school option."  I didn't want to stay in Botswana to do my university. So, I asked her questions, and she said that teachers are good, the groups are small when you study so the teachers can follow you very closely. And she said everything except that they don't speak English. [Laughter] And I feel like God literally blinded me to that because I asked every question except, "What language do they speak?" I mean, I know there is Russian, but surely, surely, they speak English, right? They're white!   No, they don't. And I found that out when I landed in the country. [Laughter]   So, I out of curiosity, I study Russian. I'm so excited.  I’m going to Russia! And then, I land in Russia and it turns out I have survival skills now. I decided, "Well, I'm here, so I have to keep a positive mind about it and learn it as fast as possible so that life can get easier." And that's what I did. So, I learned it and life got really much easier.   David: And so that was how long? Five years? Six years?   Linette: Yes, six.   David: And then. So, you're from Botswana. How did you get to Kenya?   Linette: I'm from Kenya.   David: Okay.   Linette: I was born in Kenya. My parents are Kenyan, my dad is a civil engineer.  When I was five, my dad applied for a job with the government of Botswana, and he got it. He moved to Botswana to look for greener pastures. Then the family followed him. So that's where we all grew up, me and my sisters, except for my youngest sister, who was like a bit young when they moved back to Kenya when I was in third year in Russia. When they moved back now, home became Kenya again. So, when I finished with Russia, I came home to Kenya.   So now I had to learn a new language, Swahili [laughter] because, I know how to say hi, but everything else is a blur because I was five when we left. But because I had learned Russian, I was like, "This is nothing impossible. Surely it's just a language." And now I speak it fairly well. I can speak Swahili and no one knows I'm not really Kenyan, but when I speak English, they know because my accent is not Kenyan.   David: Yeah, Botswana - that's like the usually the voice actors and people like on TV in America, like that's the pure like, classic African accent.  So, like in Disney movies it's always a Botswana accent.   David: And so, what were challenges? Did you have time off in between in between finishing medical school and starting internship? How did you end up at Kijabe?   Linette: I had a whole year of nightmare. None of my papers were Kenyan, so I went through such a terrible time. I went to try and verify my degree and they said I had to verify my high school certificate. And then when I went to try and verify that, they said I had to verify the primary school certificate. And most of that was like, we need a physical letter from the governing body in Botswana. I have no family left there. How am I going to get like a real letter from them? But thank God for friends. I asked a couple of friends to help me, and they sacrificed time from their jobs to help me chase down that.   It took a whole year from the time that I came back to the time that I started internship. And even after doing the whole verification thing, turns out you don't just do internship, you do pre-internship, which is like an internship, but then it doesn't count. And then you write board exams. So, I did that. And then just as I was about to ballot for a government place in the internship, a cousin of mine asked me,  “have you tried Mission Hospitals?”  She had worked for Mission Hospitals and she feels like they're great.   Linette: I was like, "I've never thought of that. What's that?"  She told me, "the last interview is next week, Monday, find a way there."    So, I found a way there [laughter], showed up, did the Kijabe interview and I fell in love with Kijabe just from talking to the doctors on the panel. Dr. Arianna was on that panel that day. I was I was so in love with Kijabe. I was like, I'm done. I'm going to Kijabe!  I didn't even interview the other two places. I'm going to Kijabe - I'm not going anywhere else.   So, I went home all happy. I'm like, "I'm going to Kijabe, I'm going to Kijabe!" I don't know, that was just I was just so sure. I fell in love with this place before I came here. And since I came, I've not been able to leave since, like you think about going anywhere else and you're like, okay, so what's life going to be like there? Nope, I'll stick to this one.   David: What particularly do you like about it?    Linette: I love the compassion with which people approach medicine.  I mean, there is science and there's evidence and there's all that. Anyone can get that anywhere, you know? But there's a human touch and aspect that you can't buy anywhere. You can't buy that. And then a lot of these doctors are Christians. . .and missionaries, they're here not because their homes are not comfortable, or their countries are not good.    I mean, I've been a foreigner. I know it's home that's always best. It's very uncomfortable to be a foreigner sometimes, but the [missionaries] are here because they feel like their call to humanity is higher or greater than their comfort.  I feel like because God told me to be a doctor, it's great to be around people who take medicine like a calling.   There's also the evidence-based approach, you know.  It's not quack medicine, it's not abracadabra. It's, "Okay, I read this paper and it says, 'This approach is better for this disease.'"   And that's what we do. We do that because the best idea wins.  The best idea is tested. It's tried. It's been through trials and studies and that idea wins. So, every protocol c

Dayalan: I'm Dayalan Clarke. I'm a breast surgeon from the UK. I came out to Kijabe mainly to help because Beryl [Akinyi] has been on maternity leave. Beryl is the surgeon who does most of the breast work here, and Peter Bird, who we have known for many, many years, asked if we could if I could come and help. Peter grew up in India as a missionary child with his father being a surgeon and a missionary hospital, at a mission hospital in India in a place called Mysore. And it so happened that my wife's father was also a surgeon in the same hospital, and they grew up together across a wall as neighbors growing up in India. And that was my connection with Peter Bird. I think my wife and Peter lost connection, though our respective parents kept in touch. And then when we were visiting Nairobi for a safari in 2006, we heard that Peter was here. So we were going for a safari with my wife's parents. It was their 50th wedding anniversary and they loved wildlife. So that was our treat for them for their 50th wedding anniversary. And they said, “Oh, Peter is in Kijabe, let's try and meet up with Peter.”   So we came and visited Kijabe had lunch with Peter.  In 2006 I took an early retirement from my work in the NHS in the UK with the express purpose to go and help mission hospitals in need. And then in 2019 I came out to Nairobi with a group of breast surgeons from the UK to train to do a training course and a teaching course in Nairobi, and who was on the local faculty to spread the word. So we met up again and I was telling Peter how I had taken an early retirement with the express view of going in and helping mission hospitals in need. And then he turned around said, Oh, would you be able to help in Kijabe if we needed us at all? I'd love to come to catch up if he needed me. And then of course, Peter was leaving last year and Beryl was going on maternity leave. So he contacted me and said, Can you come and help us while on maternity leave? And so I'm here. That's how I'm here.    David: That's amazing. Did you and your wife meet? How did you meet?   Dayalan: I went to medical school in India, which is a Christian medical school called CMC Christian Medical College Vellore. And we were classmates in Vellore and we met there and got married after we finished our house jobs and then did some mission service, which is part of our obligation in India, then did our respective postgraduate training and in Vellore again, myself in general surgery and my wife in pediatrics. And then it worked again in mission hospitals in India and then went out to the UK in 1991, never intending to settle in the UK. But God, God's wills are strange and we never thought that's going to be the plan. But that's what happened. And I was very conscious that because we've trained in Vellore, I've always grown with the feeling that I consider myself very fortunate, coming from a very average background in India. My father was a minister in the church and retired as the Bishop of Madras. So very ordinary background, but consider ourselves very fortunate to have been able to have gone to the UK and to made a career there, to become consultants there and always felt as soon as my children were on their own feet, I'm going to stop working, retire and try to give back to people who been less fortunate than myself.    David: Wow. That brings up so many interesting questions. I'm not super familiar with India, but one of my dreams is - this is why I was so excited to meet you is I heard from from Dr. Nthumba when we were starting Friends of Kijabe - he said, "you need to learn about Vellore, you need to learn about this place." And so, I'd love to hear about that. But then also I'm curious just what. . .you said your father is a minister and then became a bishop?  Most people in America associate India with Hinduism, Jainism, Sikhism.  Is Christianity regional?   Dayalan: Christianity is much more common in South India than in North India.  Where I come from, which is South India, but the population of India is huge. As you know, 1.3 billion people and 2% are Christians. So, 80% Hindus, about 10% are Muslims. And then, like you said, the other communities like Sikhs, Jains and such like from the rest of it with Christianity being 2%. So even Clark, which is my surname, is a very Indian name, but the background to that is one of my forefathers must have been converted. And when you convert it from Hinduism to Christianity, the way you denounced your previous religion was either you took on a biblical name or you took on a very western sounding name, often a missionary who converted you. I presume one of my forefathers was probably converted by someone called Clarke or decided to take on a Western sounding name. And that's how Clarke has come down the generations.   David: Wow. So, there's a tradition that the Apostle Thomas went to India, right?   Dayalan: It's historic. Legend is that he came down to this west coast of India, which is Kerala, and then traveled down and then actually came through Tamil Nadu where I'm from, near Chennai. It's called Saint Thomas Mount. And they say that that's where he probably last either left India or died there. We don't know. But I don't think there's enough factual evidence but that's what they think happened. Yeah.   David: Interesting. It's not until really spending time in this part of the world that realize Christianity developed very differently than I perceived. Southeast Asia, Africa, a lot of the early church fathers were in those places. It was not a European thing until much later on, which I think is fascinating.   Dayalan: Yes.  Considering Christianity arose, Christ lived in Jerusalem in the Middle East, I think proximity-wise you can see why it happened that way. Egypt is not far from where it was and you have flight to Egypt when Christ was born. But it doesn't surprise me. Definitely there was quite a lot of Christianity around this region and moving both east to us [in India].   David: Wow. I think my understanding of our previous conversation - tell me if this is accurate - that Vellore is probably a picture of what Kijabe could be like in, I don't know, what you would say, maybe 20 or 30 years?   Dayalan: Quite possibly so. I mean, the first thing that struck me when I came to Kijabe, I saw the community spirit, the closeness, and how well people got on together. And the first thing that struck me, especially with a lot of missionaries here, the first thing that struck me was this is below in the fifties or sixties because Vellore was very similar. There's a Christ-centered Mission Hospital, which was largely supported by Americans and some British missionaries, both in terms of the day-to-day running of the hospital and in personnel, which I see exactly what is happening here. And Vellore has then gone on to become one of the leading institutions in India, both in teaching and in terms of health delivery. And my only prayer is that hopefully 30, 40 years Kijabe is going to get there. One of the things that Vellore has, which probably is an advantage for them, having developed so quickly and so well, is a medical school, which I think we don't have yet in Kijabe. But I think if we have Christ at the center, everything else will follow. And I can see great things happening in Kijabe, just in the services that I've seen, in breast cancer care itself, I can see there's huge scope because we've just had a mammogram machine installed. Oh, yes, which is fantastic. And then I've helped in helping the radiographers from here, going to Aga Khan and MP Shah to get some training and of course, we're going to have a breast radiologist coming from America, starting in August. So, with this mammogram machine, we have a state-of-the-art absolutely fantastic machine, and then if we have a breast radiologist to actually drive that forward. I can see Kijabe being a fantastic breast unit going forward.    David: That's amazing. So you went from Vellore, you went from a very faith-based medical system to the NHS, which I assume was not the same.  What was that like?   Dayalan: The NHS as a health provider is absolutely fantastic.  You have, which I think most developed countries should aspire for, a health delivery system that is free at the point of delivery irrespective of your social status, your economic status, or who you are. Absolutely fantastic health delivery system. But one of the issues with that is that it's very secular, even though the British consider themselves a Christian country. I think that's far from what's practically happening there. So, it wasn't an issue for me. I am still involved in my church. I sing in the church choir. I'm actively involved in church activities. They've been very supportive of me coming here and by their prayers. So that balanced it out. And yes, it was different. But I think the professional satisfaction that I got from treating my patients, knowing that irrespective of whatever treatment they needed, they got it, irrespective of their economic status. And I think that is something most countries should aspire for. Any developed country that doesn't do that I think is really failing their people. And so I think Britain and the NHS is a fantastic health delivery system. It's huge and any huge system like that will have flaws, will have deficiencies. But as a principle where they can deliver good quality care which is completely free at the point of delivery, I think the NHS is fantastic.   David: What does India's delivery system look like? Because you're doing a lot of fundraising for the people who are not able to pay, correct?   Dayalan: Yes. So now in the UK, we have a group very much like Friends of Kijabe called the Friends of Vellore UK. And because Vellore has been training medical students for about 80 years, they have people in various countries. We have friends of Vellore in the US and the UK and Australia and in diff

Conversation on faith, work-life balance, parenting, stewardship, leading through the pandemic,

Elizabeth Drum Interview:    David: You started a new position a little while ago, is that correct?     Elizabeth: I have a couple different responsibilities.  I became chair of a committee within the American Society of Anesthesiologists.  They have a committee, the Global Humanitarian Outreach, within the American Society of Anesthesiologists  that was originally envisioned as a way to send US anesthesiologists to other countries to help in educational efforts around anesthesiology.  Over time some of those programs grew/changed/morphed.  Eventually that committee developed into the GHO.  I have been on that committee for years and just became the chair.     There are a number of things that committee does within the ASA.  We support two programs, one is in Rwanda, one is in Guyana.  The goal is to help with anesthesiology efforts in those countries.     The program in Rwanda was originally a partnership with the Canadian Anesthesiologists’ Society.  So, the two societies went and taught residents in Rwanda.  Over time the Rwandan Anesthesia Society has grown stronger, more robust, there’s now graduates who are leading the teaching efforts.  The ASA and CAS efforts have changed more into supporting the faculty, helping them learn to become educators and leaders, and not so much providing hands on teaching, but supporting the leaders in that country.   It’s an amazing testament to the value of education and training local anesthesiologists who then can become leaders in their country.   The efforts in Guyana are similar, they’re not quite as far along, but there is now a Guyanese anesthesiologist who is in a position over all the graduate medical education in the country and another anesthesiologist who is now head of the Guyana anesthesia society and training program.  Again, similar thing, they started with not too much and are slowly growing.  Those are really exciting things that our committee has done.   Another thing, 5 of 6 years ago, I started a program within the GHO committee where we send senior-year U.S. anesthesiology residents to a low-income country for a month to get to experience what it’s like to live and deliver anesthesia care in another country.  Not so much as a mission model, you go for a month and do work, you start to understand what the educational needs and systems are.  Each year we send 6 or 8 residents, we have now sent 50.  Started in Ethiopia, and now Uganda and Malawi.   We also sponsor visiting scholars to come to the ASA meeting every year, to spend a little bit of time as an observer, to hopefully build some long-term relationships to help them in their development as leaders of anesthesiology programs in their home countries.   One of my goals is to gain visibility within the ASA about the importance of this work.  Believe it or not, is not universally understood with U.S. anesthesiologists that there is need or value for working with others around the world.  There are definitely people who want to make some humanitarian contributions but don’t really know how to go about it.   I have a couple of other things I’m working on.  There is an organization called the World Federation of Societies of Anaesthesiologists.  Basically, a society of societies.  Any country that has a society of anesthesiology can be a member of this.  They have separate committees.  Some provide educational opportunities.  There is one in Nairobi, in pediatric anesthesiology, those travel and spend time at Kijabe.  There are other programs around the world in pain medicine, and other stuff.   WFSA does a lot of advocacy work.  They do work preparing statements in line with WHO guidelines, helping member societies advocate for and navigate local politics.  I just became part of the larger board of directors.   David: That’s lovely.  I have met several of the visiting pediatric anesthesiologists.  That work is what makes a program like this PAACS thing possible.  It’s not only a matter of education; it’s creating an environment where people can succeed after they have that education.  Good on you, thank you! Elizabeth: It’s true in our US hospitals and training programs, so why would we not think it’s important in the rest of the world?  It’s one thing to train people, it’s another to sustain them, maintain them, help support them in their career growth.  In many parts of the world, anesthesiologists might be the only one in a community or in a large geographic area.  We need to find ways to support them – simple things like continuing education, how to learn new techniques, how to have collaboration/cooperation when you have a difficult case, how to work together to improve not only educational systems, but care systems, how to lobby ministers of health and education.  These are difficult things, even for those with a lot of resources.     David:  I don’t know how big you want to go, but you are definitely familiar with Africa. . .what is the picture of the need for anesthesia in Africa?   Elizabeth:  I think it’s safe to say, the need is probably overwhelming and staggering.  If you could actually think what the need is, you could get depressed, thinking how would we ever meet the need?   The standards that organizations like the WFSA advocate for are in terms of how many providers you need per population.   In terms of a place like the US, we’re way above recommended minimum which might be 10-20 surgeons, anesthesiologists, obstetricians per 100,000 population.   In many countries in Africa, those are in single digits.  For example, Ethiopia, which has more than 100 million population has a couple dozen anesthesiologists.  On any given day, there are more than that at my one hospital in the United States.  Kenyan and Uganda are a little better, but not a lot.  Most of Sub-Saharan Africa, which is what I’m most familiar with, has such a lack of anesthesiologists.  Even if you look at other anesthesia providers, whether they are nurse anesthetists or KRNAs or different names that are given to non-physician anesthesia providers. . .even when you count those, they are not enough to care of the population.  First and foremost, we have got to find ways to increase the numbers of providers.  But that in itself is not sufficient.  You need numbers, but you need quality care.  In addition to that, you need the support systems.  You need a hospital that has water and electricity and understands the basic concepts of sterile technique and infection prevention and control, and quality & safety systems that support surgical care.  Then you have to have pre-op and post-op care.  You need nurses and you need ways for patients to get to a hospital.  You need to figure out which hospitals should be doing which types of surgical procedures.  Each country has its own political and governmental ways that’s organized.  There are certainly limitations in what is available.   There is a never-ending need.  You can easily get overwhelmed with thinking about the need.  When that gets too overwhelming to me, I like to back off and think, what can we do and how can we make an impact?  Taking care of one patient is one thing.  Teaching someone else to take care of that patient is a secondary thing.  Then teaching people how to teach other people to take care of that patient has a magnifying effect.  And then helping anesthesiologists, among others, understand what it takes to make that whole system is important.  A surgeon can’t do it alone.  Anesthesiologists are an important part of the whole team that needs to provide excellent peri-operative care.  In too many situations, anesthesiologists and others are an afterthought.   David:  This is something I was ignorant about.  What is the role of an anesthesiologist in a developing country?  It’s a lot broader sometimes than what it is in America, right?  Elizabeth: The American medical education system is a little different from many other countries in the world, even Western countries.  The length of education, the responsibilities, how it’s organized and paid for.  It’s a different system of how care is delivered.  In the United States, in academic medical centers with trainees, there is always an anesthesiologist available, so a resident who is a trainee is never caring for a patient without supervision of a fully trained anesthesiologist.  Our medical education hierarchies are pretty well described.  And the delivery of care is pretty well structured and organized.  That is not necessarily true in most LMICs.   There are different levels of anesthesia providers who are doing the best they can with the education they have and the tools, equipment, medications that are available to them.  But in a place like rural Ethiopia, for a population of 1 million in one area, there might be one physician, and that’s not an anesthesiologist, that’s a general practitioner.  In the way that a physician cannot be responsible for all the medical care, there is certainly no way an anesthesiologist cannot be responsible for all anesthesia care.  The same is true for surgeons.   So, you have rural hospitals, whether they’re called district hospitals, or whatever, you can get basic medical care.  If you show up with a broken leg or an infection, you may get some level of care.  You might get some antibiotics, or your infection cleared out, or a cast for your broken leg.  If you need something more sophisticated, you have to go somewhere else.  Anesthesia care is the same way, the most highly trained anesthesia professionals are usually in the big cities and in big hospitals, which means the rural areas are less well-served, not only by anesthesia providers, but by surgeons and nurses and equipment.  One of the challenges is One of the challenges is finding a way to provide the needed care in the rural areas and ma

Olakunle Idowu – Anesthesiologist, MD Anderson   David: I know you said it’s a long story, but I’d love to hear the short version of the long story.    I’m Nigerian, I was actually born in Nigeria.  I’m the last of four children.  My siblings were born in Boston, but my father, who is a math professor took a position at the university of Dos.  We were living there when I was born.  I came to the United States when I was 3 years old.     I grew up in Maryland, went to University of Maryland, I’m a Terrapin.  I went to the Virginia Commonwealth University for medical school, SUNY Downstate in Brooklyn, NY for Anesthesia Residency, and Critical Care here in Houston, which is what brought me to Houston.     Since then I’ve spent time in private practice and in academics.     Initially I left private practice and came MD Anderson for 3 years, then my wife was recruited to Yale in New Haven CT, we went there for a year, decided to come back, and here I am!    (Laughter)   There’s been some moving and shifting, but I think along the way that God has revealed things to us.  We feel Houston is home even though our families are in the northeast.     My wife is a pediatric anesthesiologist, she works at MD Anderson as well.     David: When you say critical care, is that anesthesia or normal medicine.     Kunle: The track is critical care through anesthesia, it’s a one-year internship after training, I spent a year at UT Houston, and during part of that time I was at MD Anderson, which is how I connected to the institution.     David: What do you love about your work?  Why anesthesia?  Aside from talking to me, what gets you out of bed in the morning?   Kunle: (audio drops briefly) Learning includes lessons about life, about vulnerability, about faith, about spirituality, about strength, perseverance, about conflict.  I think working both in the operating room and also having experiences in critical care. . .they’re very different environments.     In the operating room, most people walk into the hospital, most procedures tend to be elective, the intent is that things end well.  That is always the expected outcome, or what people perceive as a good outcome – to get through surgery or whatever procedure they are having.     In the ICU the dynamic is very different.  Expectations and goals change daily, hourly, by the minute depending on the patient situation.  Sometimes you find yourself healing not through intervention but through support and prayer and walking side-by-side with patients.  That is where my energy comes from, that’s what wakes me up.     You know, I drink coffee like most people, to get me going.  But somehow when I get in front of a patient I’m up, I’m there, I’m present.    David: Have you done any overseas work lately?  What you describe sounds like the role of somewhere like Kijabe.  When an anesthesiologist comes, they are everywhere, they’re in the operating room, they’re in the ICU, they’re in the emergency department if something goes strange. . .they’re everywhere.     Kunle: Compared to some of the other people involved in this project, I’m fairly new.  I’ll tell you that story.     In coming back to MD Anderson, I pivoted in terms of focus.  There’s something in me, and there’s something that’s always been in me.  I have relatives or people who are Nigerian, who came here as immigrants who for training with the intent of going back.  My father came to the States for post-graduate training, but never returned to Nigeria permanently.  So, I’ve understood that there has always been this void, not only in Nigeria, but across the continent, in terms of people who receive opportunities who receive opportunities overseas whether in the States or across the world, and never return.  It’s almost like there’s a resource that’s been taken away. . .people don’t go back to even plant seeds to grow.  I think people are realizing this, and that itch. . .I’ve always had that itch to be involved in this work.     I was initially looking to do things in Nigeria and I was looking to start projects I was looking to start a symposium and looking for schools/teaching hospitals in Nigeria to connect with.  I connected with HBO.  They have a site at Kat Karmasi, Ghana.  My wife and I were set up to go this April for a two-week trip.  She was going to help with Pediatric Anesthesia education and I was going to teach a fundamentals critical-care support course, because critical care mortality is extremely high across the continent.  That is one thing that is very clear.  The contact I have there is very concerned about obstetric mortality, the availability of resources and ventilators is limited.  I work with Louis Pisters, a urologist at MD Anderson, and he’s connected with PAACS.    He said, “you know, I work with a great organization.”  He’s a person of strong faith and conviction.  I attended a meeting with PAACS and learned that there was an Anesthesia task force.  Everything about the project aligns with my personal goals and how I see myself.  It brings my faith, it aligns my faith, my practice, and this internal feeling – this urge – to start doing more global outreach.  The timing couldn’t be better, and I have support from my institution to do this.     That’s how I got involved.  Long story, but I’m extremely excited because at the center of it is God, and my love for Christ.     Through medicine, I’ve affirmed the idea that only God can perform miracles.  We are tools that he has put here to carry out his will and to be blessings upon others.  You know, blessed to be a blessing in a sense.  That’s how I practice and that’s how I see this project.  Everything that I’ve come to understand about Kijabe, that’s my understanding of the center, of the people there, of you and your work.  I’m just excited and so very thankful and grateful.     David: That’s awesome   Have you ever heard of Howard Thurman?  He was an African American pastor.  He was Martin Luther King’s spiritual mentor.  I went down the rabbit trail this weekend and I ended up with a book of his sermons that I got on Amazon for a dollar – that’s the best dollar I’ll ever spend – he’s got this amazing passage about medicine as ministry.  It’s so, so good and reminds me of what you just said.   He goes through the entire passage and ends up with the statement that “every hospital, every clinic, every consultation room should be an altar for the burning heart of God.”     Kunle: Absolutely.  You can almost draw a parallel to the pandemic.  You see how limited our understanding of the human body and where is this virus coming from?  All these resources focused on one thing. Right? Its human will that we are going to control this, yet every day we are reminded that we are not in control. There is only one person in control of all of this.      These are the same interactions that happen on a daily basis in the hospital.  When it comes to cancer care you realize it.  People often want to treat the numbers, or they see a CT scan. “I have to fix this.”  That’s the human instinct.     You learn how limited you are, in the sense that you could do everything and not change the outcome.  You could do nothing, and the outcome can be favorable for the patient.  It’s because God is in the center of it.  He has a masterplan.  You have to step back, realize your place, that you are just a tool.  You cannot fix the situation. You just have to trust God.     That’s why I bring spirituality and I bring faith.  MD Anderson is obviously not known per se as a Christian institution.  I always ask people, are you a person of faith?  Regardless of their background, most other religions or people who consider themselves as being spiritual, they are open to prayer.  Prayer is universal, for everyone.  I pray for them.  I know my father, but I pray for them.  I love that aspect of medicine.     David: If we get you over here, you’ll meet Jack Barasa, our head of surgery.  Whenever you talk to him, he says a similar thing about Kijabe “this is God’s hospital.”    He says, “We do these things, and somehow a patient gets better.  We do the exact right thing and they don’t get better.  Or we make a mistake and somehow, they walk out the door three days later.  It’s very clear that we are not the ones in control of the situation.”    My wife had this awesome mentor in Alabama.  When she was in residency, she had a really low moment.  Her program director called her into her office, and she said, “Arianna, you need to trust God. You do not hold the keys to life and death.  A patient could walk in the door, and they could walk out even if you do everything wrong.  This is ultimately not about you.”   That’s the big challenge of what you do in medicine, how to work with all your skill and all your power yet know your limitations and to be at peace with that at the end of the day.    Kunle:   I think about these things every day.  I reflect on the day and the lessons learned.     Even for me, as I’m caring for patients in stressful situations, that He is my quiet in the middle of the storm.  I can only trust Him to give me the thoughts, wisdom, understanding, compassion.  It has made me a better person, ultimately.    David: What do you say to a family member, say you’re in ICU and you have a patient who is not doing well. How does it go?  What is running through your head and what are you trying to convey to them?    Kunle: It’s tricky, a lot of it depends on their background.  It depends on their knowledge of medicine.  It depends on the conversations they have had prior to the moment.  In critical care, you tend to have limited access to the patient’s perspective.

Greg Sund David: [00:00:00] Good afternoon and good evening. We have no idea what time zone you guys will be in when you're watching this, but I am David Shirk. I'm director of Friends of Kijabe, and I'm sitting here with Greg Sund, our newest addition to the Kijabe team.   Greg: [00:00:17] We moved here from a small village, rural hospital in Burundi, where we have been for about five years.   David: [00:00:26] What was your training and background and specialty in the States before you started doing this Africa stuff?   Greg: [00:00:34] So I'm a board-certified anesthesiologist. I did a fellowship in cardiothoracic anesthesia and I was in private practice for several years before we moved to Burundi about five years ago. And during my time in private practice, I was doing annual trips to various places in Africa and kind of prayerfully trying to discern with my wife where God might be calling us to. And we ended up at this hospital in Burundi, which was a teaching hospital, and it was a place where I could not just do anesthesia, but also teach anaesthesia to medical students and nonphysicians.    David: [00:01:22] What was the terminology for them?  Here we call them KRNA, Kenya Registered Nurse Anesthetist. Did you guys have a designation?   Greg: [00:01:29] So that's one of the problems, is that the training for nonphysician anaesthetists is variable from country to country. In Africa, there's no continent wide standard. And so in Burundi, they were anesthesia technicians and so they had a bit less training than the Kenyan nurse anesthetists have here. And unfortunately, it's different in every country. And unfortunately, there's still a lot of hospitals in sub-Saharan Africa where the anesthesia is being provided by underqualified and sometimes not even trained providers who are just there to fill in the gaps.   David: [00:02:13] And this was the case in Kijabe for a very long time. I want to get into Burundi, I want to hear more about that, because I actually don't know - I know you, and I know some of your colleagues, but I don't know much about the hospital and particularly the medical kind of situation that you guys were facing there before that.  Why does somebody who's a private practice anesthesiologist in America walk away from that and move to Africa?   Greg: [00:02:42] Yeah, well, ultimately, it was definitely a calling from the Lord that he laid on our hearts after doing frequent trips to Africa. I saw just the massive discrepancy in anesthesia care between what's going on in most of sub-Saharan Africa and what's going on and in the United States. And I was just really convicted that here I have the ability and the capacity to go to a place like Burundi or Kenya and teach anesthesia. And it was something that the Lord laid on my heart and thankfully on my wife's heart as well.   David: [00:03:23] That's awesome.  And you guys came out...so you've been doing short travel trips and then you moved for a year in 2013?   Greg: [00:03:31] Yeah, it was twenty fourteen. We moved to Burundi for a year and we joined a multi-specialist team that had just settled there a few months earlier that I had met on one of these short-term trips to Tenwek hospital in Kenya in 2010. We heard they were moving there [Burundi]. They had three surgical specialists and the anesthesia care at the time was provided by one non-physician anesthetist with coverage by some, actually, non-trained, providers. Their community health worker, who normally gives vaccines, was taught how to give Ketamine to get people through surgeries and caesarean sections on at nights and on the weekends.  They asked me if we would come out for initially for a year to help work with this one non-physician anaesthetist to try to help increase her capacity for what she could do, and during our year there, we realized that there's actually, an anesthetist training program that sends students to this [Kibuye] hospital.  They're actually medical students who had a required anesthesia in critical care rotation and there was no anesthesiologist to teach them. And so we felt like this is where we were called to be for longer than just one year. So we went back to the States to support raise for a year, and then to France for a year for language training, because it's a Francophone country, and then in twenty-seventeen we moved there and we've been there up until just a few months ago.   David: [00:05:12] We've had this KRNA program in Kijabe for about a decade [2007]. Officially. I think before that, unofficially. What what is the difference between anesthesiology training for a physician level anesthesiologist versus for nurse-level in Africa?   Greg: [00:05:34] In general, nonphysician anaesthetists are there to put the patients to sleep, to monitor them during surgery, to wake them up. Physician anesthesiologists are there to be consultants for more complicated cases, when complications arise at any time during the perioperative period.  They are also, typically in Africa, the ones that will be a lot more involved in intensive care medicine, in post-operative pain management, and also in leading and teaching medical students, anaesthetists, students and other other health care specialists that that need some training in anesthesia, critical care and or resuscitation.   David: [00:06:31] What's what did ICU care look like in Burundi versus what it looks like somewhere like Kenya?  I know Kenya, we're behind America, but you still walk in to [Kijabe] ICU and we've got real ventilators and usually good oxygen supply, right?   Greg: [00:06:49] Yeah, I think in the entire country of Burundi, there are about 12 ICU ventilators, unfortunately, none of them are at the hospital that I worked at. Those are all at the main university teaching hospital in the capital city. And when we arrived, there was no Intensive Care Unit. During my time there, we made a small step forward by designating four surgical beds that we were where we were able to do a little bit more intensive monitoring, nursing surveillance. But it was still a far cry from what you have at Kijabe, and what we're used to in the U.S.   David: [00:07:35] What would what you want to see if you were to think five, 10, 15, 20 years out? What would you like to see happen in our region, in East Africa?  You could speak to Burundi or you can...I don't know how familiar you are with other countries?  So answer however you want.   Greg: [00:07:57] I would say anesthesia care and critical care in general are very variable right now. And there are a lot of places where anesthesia is simply not safe. Mortality under surgery in sub-Saharan Africa, in general, is twice what it is in the US. And so there needs to be a great deal more invested in training nonphysician anaesthetists, which ultimately needs to be done by physician anesthetists. And that's kind of leading into why we decided to move to Kenya.   David: [00:08:34] Awesome.   David: [00:08:35] Mark Newton does some sessions here just on training. Training trainers, essentially. That's the that's the vision, right?   Greg: [00:08:43] If you're teaching people who are qualified to teach others, that's the Biblical model from the 2 Timothy Chapter 2 - "teach others who will be able to teach others who will be able to teach others."   Greg: [00:08:57] And so that's a big part of why we moved here. We saw that what we were doing, training nonphysician anesthesia providers in Burundi and medical students was good work and it was important, but it wasn't sustainable in the long term. And so in Burundi, for example, there are only seven physician anesthesiologists..    [00:09:20] I was the only one working outside the capital city. And so that leaves the vast majority of hospitals without any anesthesia consultants, without somebody who can manage critically-ill patients in an intensive care setting. And so ultimately, during our time in Burundi, I came to realize that Burundi was not alone. There are a lot of other East-African countries where this is the case.   [00:09:47] If you look at the numbers, there is a recommendation by the World Federation of Anesthesiologists to have a minimum five physician anesthesiologists per one-hundred-thousand population.   David: [00:10:06] How many people are in Burundi?   Greg: [00:10:08] So the number in Burundi came out to. . .it was about zero point zero one eight [0.018/100,000], I believe.  It's better in Kenya [1.7/100,000], but it's still far from five per one-hundred-thousand. And so I came to realize over our time in Burundi that sub-Saharan Africa, while it does need more nonphysician anaesthetists, in order to to form and train more nonphysician anesthetists, we have to, at the same time, train physician anesthesiologists.   David: [00:10:41] So what has the groundwork looked like for building up to this training program starting?   Greg: [00:10:47] There started to be some discussions going on between a small group of us who are anaesthesiologists, who are missionaries in Africa in twenty-seventeen. Three years ago, and most of us had been exposed to or involved in helping to do some anesthesia training with surgeons under the PAACS, which is the Pan African Academy of Christian Surgeons. And so we already had some relational foundation with PAACS programs and the leadership of PAACS. We started talking together as a group about the need to start creating Anesthesiology Physician Anesthetist training program.  It seemed to us logical to try to partner with PAACS. And so, last year at the PAACS board meeting in Chicago, a group of us went and presented the idea of starting an initial, anesthesiology residency program under the umbrella of PAACS to their board. It was received favorably and they agreed to allow us to start this initial program in January twenty-twenty-one here in Kijabe.   David: [00:12:06] Awesome.