Looking back, I had no idea at the time how unique the situation in Kenya had been. Kijabe Hospital had piped oxygen. Tubes leading from central tanks or large oxygen concentrators snaked down corridors and behind walls to arrive, almost magically, at the patient's bedside. What this system allowed was the delivery of high pressures, such that very ill clients with dangerously low levels of oxygen could receive ample amounts of the life-giving gas.

The set-up was not perfect. It was expensive. A colleague, on the receiving end of a powerful jolt of electricity, was thrown five feet and nearly killed switching the source between tanks. A hyper-sensitive valve shunted oxygen between the surgical suites and the intensive care unit. I was in charge of the latter and sometimes had to "steal" oxygen at night from the theater. To do so required a practiced art: one used the heel of the hand to imperceptibly nudge the valve, bleeding excess pressure from the theaters to the unit. However, if you weren't careful and moved the valve too far, the pressure released to the ICU was enormous. Patients wearing prongs would suddenly and unexpectedly receive a tremendous blast of air into their nostrils.

We have no such complications in Malawi. There is no piped oxygen. All we possess are semi-portable concentrators like those used by emphysema patients at home in the US. These machines can produce only 5 liters per minute of oxygen, as opposed to the 15 liters one can extract from a high-pressure system. The clinical difference is significant.

We now have eight concentrators, in various states of repair. Formerly we had only three. On one occasion we had five patients in need of oxygen and had to "split" the supply, such that four patients received 2.5 liters per minute only. At that time, the uncle of one of our nurses arrived in respiratory distress due to tuberculosis. We had no more oxygen to share. I called all over the city until finally locating an available unit. He had to travel to a Catholic hospital more than an hour away, where he died the next day.

I remember visiting a mission hospital in Tanzania in 2003. A lone oxygen concentrator was being shared by two patients ON DIFFERENT WARDS. The oxygen tubing lay stretched out on the floor and across the corridor. One had to be careful not to trip on it.

Still, our machines have saved many lives. By attaching a special mask which prevents the re-circulation of carbon dioxide, the effective oxygen concentration can be enriched. These masks cost a few dollars in the US, so I routinely have visitors bring them over. In the last few months the lives of three very ill patients with TB were saved because of these masks and our basic concentrators. One of these was a 19 year-old woman, infected at birth with HIV.

Earlier this year a newly diagnosed HIV-infected man presented with severe pneumonia. It took me two days to realize that he was withdrawing from alcohol. We treated the withdrawal and placed him on the special "non-rebreather" mask. Although his oxygen levels remained dangerously low, he was young and strong and appeared to be improving. One morning on rounds, I told our physician assistant, "Good job. This is quality medicine. I am impressed he is recovering."

That morning was a Tuesday following a three day public holiday. One oddity in Malawi is that, although electrical load shedding is common, blackouts in certain areas do not occur during holidays. No one bothers to go into the utility company and turn off the grid to that area of the city.

So we were not prepared that night when the electricity was cut. A stand-by petrol generator had been installed and configured to run a single socket. This socket did not accept the power plug for the concentrator. There was only a small amount of petrol in the generator anyway since the whole country lacked fuel. The power went out for three hours.

It did not take that long for this young man to die. Once the supplemental oxygen ceased, he only survived about 20 minutes. When the nurse called to tell me the news, I was stunned, numb.

One comes to Africa hoping to elevate the level of care. Sometimes it seems as if the challenges diminish you instead, forcing you to adopt a kind of learned helplessness.

**

Alice, our nursing assistant, calmly informed me that she had brought her brother David, who was in the midst of an asthma attack. It took a single glance to appreciate how sick he was. Living in a village over an hour away, he began having symptoms the night before and went to a local clinic, which did not give him steroids. By the time he got to a Catholic hospital the next morning, it had been over 12 hours. It's a good hospital, and they did given him steroids. His sister then brought him to us.

Before rushing off to see other clients, I instructed the nurse to begin continuous nebulizer treatments in an attempt to open the airways. We injected him with a large dose of steroids and administered oxygen. (When an asthmatic develops low oxygen levels, the attack is very severe, which was certainly the case here.)

What transpired over the next 72 hours can only be described as a triumph of the human spirit and an exhibition of a truly remarkable will to live.

What David managed to do was breathe. Breath by excruciating breath. Based on his respiratory rate, he did so nearly 175,000 times--as if through a straw. Or, more correctly, he succeeded in breathing OUT through a straw, like one of those you use to stir your coffee. In asthma, the primary problem is not so much getting oxygen in as getting carbon dioxide out.

We flooded his body with steroids to reduce the swelling and inflammation in the lungs. Sometimes he was too exhausted to suck on the nebulizer, so we administered injections of adrenaline. (When the now deceased president of Malawi suffered a cardiac arrest in April, it took over an hour to locate a single vial of adrenaline at the central hospital. David probably received the equivalent of 10 vials over those three days.)

Sometimes I would come to check on him. He looked like a marathoner running in place, totally focused on the road and the task ahead of him. I don't think he even saw me. He just breathed, lips pursed and taught, lungs a cacophony of whistling. In, out, in, out...175,000 times.

Asthma will clear, eventually, or the patient will succumb. David was a wayfarer in the desert, who knows the oasis is out there, in a general direction, but doesn't know how far or if he can make it. Parched, baking, he just had to keep walking...

In the US, or in Kenya, we would have intubated such a patient. Doing so is challenging, since the pressures within the airway attain extremely high levels and there is a risk of lung injury and collapse. Usually, the patient has to be heavily sedated or even paralyzed, allowing the steroids and aerosolized medication to slowly relax and open the lungs. Then the patient is allowed to wake up, to move, and ultimately to come off the breathing machine.

There was no such option for David in all of Malawi. If he was to survive, he would have to continue his excruciating, lonely sojourn in the desert. Any attempt to sedate him, for reasons of comfort, would have reduced his drive to breathe.

At one point his condition appeared so dire that I elected to place him on a "non-invasive" ventilator, or CPAP. What this means is a special pressure mask which assists the respiratory effort but requires neither a tube down the throat nor sedation.

The problem was, we had had absolutely no success with this machine in Malawi--precisely because we cannot deliver the kinds of high oxygen levels available in Kenya. In fact, at Kijabe we had saved many lives with the device, including that of the young man who tended our garden. He also experienced a severe asthma attack, and the mechanical assistance helped tide him over until the lungs improved. Amanda and I sponsor the schooling of a Kenyan girl who survived an episode of HIV-related Pneumocystis pneumonia because of CPAP. So the machine can be life-saving.

I told David we would try, and that he should feel better in 30 minutes, or not at all. If the latter, we would simply remove the CPAP and go back to the oxygen through the nose. I worried that, if that happened, he would just tire out and stop breathing. Determined or not, David would sooner or later face a physical, mathematical limit.

David nodded his understanding, and I attached the complicated headgear. Fortunately, he soon signaled that the added "positive pressure" was helping, assisting his own worn out respiratory muscles, and he relaxed. That night he wore the CPAP intermittently and had begun to turn the corner by morning.

David did recover. In my career, he was by far the sickest asthmatic to survive without intubation. It was an incredible act of bravery and almost super-human endurance. It may have been a courage of necessity, but it was courage nonetheless. As Dylan Thomas would have him do, he refused to go gently. Many, including myself, would just have relented, would have let that good night wash over and release us.

Yet he did not do it alone. It is important to review the reasons why this happened. Some years ago a missionary, with help from his church and UCLA medical school, opened this clinic. A few years later a generous person contributed money to renovate a section of the building to become a hospital ward. Money for quality medicines had been given. A nebulizer and CPAP and oxygen concentrator had been donated. Missionary doctors were sent by churches and friends, meaning the hospital did not have to pay them and instead could use the money to open a hospital ward.

Without these pieces, David would be...well, he would not be.

**

Last month I was rounding on the ward on a Saturday morning. When I had finished the nurse told me that the door to the private clinic had been left unlocked. I was irritated, to say the least. An open door in that location could allow unauthorized access, especially because the intermittent power supply meant that the alarm system frequently shut off, leaving the building vulnerable.

This oversight meant I had to enter the main facility, get into another office, and dig through a tangled, jangling collection of keys worthy of the jailer at the Chateau d'If in The Count of Monte Christo.

While digging around for the right set I saw a woman approach the main door. The outpatient services are closed on the weekends, and we only accept admissions through the clinic due to financial and personnel constraints. I approached the glass doors and told the woman, "Chipatala chatsika." The hospital is closed.

I knew she had a baby on her back. I also know that I studiously, intentionally avoided looking at this child, as if doing so would somehow obligate me to do something.

Again, the woman pleaded, "Chonde." Please. Again, I retorted, "Chipatala chatsika."

Drawn by a rhythmic motion, my eyes momentarily ranged toward the baby, around one year old. Her head was bobbing. It was bobbing because she was seizing.

Malaria. 

I motioned the mother toward the external hospital ward entrance and returned via the internal corridor. She told me the child had been fine just two hours before. She was on her way to the central hospital when the fits began. The temperature was high. A rapid test for malaria was positive, and we immediately initiated therapy.

Once mother and child were settled, I re-entered the main building to deal with the unlocked door. (I never did find the right key.) In the corridor, alone, I let out an anguished, guttural cry. What is wrong with me? I had almost turned away that child. Why am I here? Did I not come for just this purpose, for just such people?

Apart from adequate structures of accountability and support, it is possible to fall very far.

Everyone hits a limit-or exceeds it. Such a time has come for us. So tomorrow we head back to the US for a much needed three and half month furlough, to recharge and then to return to Malawi at the end of September. We hope to touch base with as many of you as possible.

Yours in Struggle,