Conversation with Dr. Mardi Steere about Mission, Leadership, Emergency Medicine and Ebenezer Moments from her 8+ years at Kijabe Hospital.
Conversation with Dr. Mardi Steere about Mission, Leadership, Emergency Medicine and Ebenezer Moments from her 8+ years at Kijabe Hospital.
David - So today, I'm talking with Mardi Steere. This is a conversation that I don't want to have. It's about leaving about memories, and about Kijabe.And I don't want to have it because I don't want you guys ever to leave. That is the hardest part of life in Kijabe. But amazing people come and amazing people go and you're gonna do amazing things and stay in touch.
First, why don't you give the introduction you gave at the medical team the other day.
Mardi - So this is bittersweet for me as well. We came to Kijabe in 2011 and planned to stay for two years and here we are eight and a half years later, taking our leave. And in some ways, it's inevitable. You can't stay in a place forever. It's been a real opportunity for me to reflect.
David - Let me pause you real quick there. So when you first came, who is we? And then what did you come to do?
Mardi - In 2011, I was a young pediatric emergency physician with an engineering husband looking for a place where we felt like God had said "To whom much is given, much is required," and we knew our next step was to go in somewhere with the gifts and the passions and the exposure and education that we've been given. And so I came as a Pediatrician, and the hospital hadn't had a long-term pediatrician in quite a while. Jennifer Myhre had just joined the team in 2010 and my husband Andy is a civil engineer and project manager, and now, theological educator as well.We moved here with our then two-year-old and four-year-old to do whatever seemed to be next.
David - That's amazing. So give the theological introduction to the Ebenezer.
Mardi - It comes from first Samuel Chapter 7 verse 7-12, where there's a battle between the Philistines and the Israelites and Samuel lays a stone to God for being faithful and to remember what God has done. When Andy and I got married in 1998, actually, it was a scripture that was read at our wedding. And we were encouraged when these Ebenezer moments come, take stock of them, step back, and acknowledge what God has done . Those moments will be key moments in your marriage.
As I was talking to the medical division the other day, I felt like it was just another reminder that, as we have our professional lives and we work in a place like Kijabe and we serve, it's really easy to get caught up day-to-day in the daily struggles that we all have - with life and death and bureaucracy and not enough money and not enough equipment and team dynamics and conflict.
But there are these moments when we take a step back and we see what God has done.
This hospital has been around for 100 years, and I've only been here for a little over eight of them, but there are so many moments where I look back on where we've come from - and the journey that we've been on - and I see these landmark moments of God intervening.
David - How do you see the balance here between medical excellence and spiritual - I don't know if excellence is the right word - between medical excellence and spiritual excellence. I think the origins of medicine were very intertwined with the spiritual, but at least in Western medicine, it's very divorced and I feel like in some ways, what I see happening here is not taught in classrooms anywhere else.
Mardi - This is one of those things that I am going to be taking with me for the rest of my life.
I don't know who's listening to this, but Americans have a cultural Christianity where it's acceptable in medicine, I think, to ask medical questions and maybe you ask a spiritual question and saying God bless you and bless her heart, and praying for people is somewhat accepted but still it's a parallel track to medicine.
In Australia, it's completely divorced. There's almost a cultural fear of discussing the spiritual in Australia, a very agnostic country. So to be a Christian in Australia, you have to make a choice. But then when you go to medical school, it's taught to you almost don't bring that in. This is a science, and one of the things that I love about Kijabe is that they are inextricably intertwined.
There isn't a meeting that we start here without prayer. When I'm covering pediatrics, as a clinician, we start with team prayer and depending how busy things are, if you're trying to see 30 patients on rounds, you might pray for the room, as you start.
We ask the parents how they're doing, and then we pray for the mom with her permission, and for the baby or the dad or whichever caregiver is there. We ask God to intervene, we ask God to give us wisdom, we ask him to be a part of the science. We ask him to be a part of the conversations.
When it comes to the even bigger picture, when it comes to strategically planning the hospital, and our core values again - they're inextricably intertwined, and it's a gift.
One thing that I'm gonna take with me as a leader and as a clinician, is that it is not difficult to ask anyone, "What is your world view and what is your spiritual worldview? Because all of us have one in Australia. That world view might be... "I don't believe there's a spiritual realm." That's so important to know.
But what if the answer to that question is," I believe in God, but I don't see him doing anything." What an opportunity we miss.
What if we have immigrants in our population in our community, and we don't ask them "What is your spiritual and cultural world view? What do you think is happening beneath the surface?" and we don't give someone an opportunity to say without derision, "I think I've been cursed" or "There is a generational problem in my family," and we don't open up the opportunity to intervene in a way that's holistic, much we miss by not intertwining the spiritual and the physical?
The fact is every one of our communities has a spiritual world view, and shame on us if we don't explore it with them.
David - Amen. It's fascinating here because before coming here, I thought of missions as giving. The longer I'm here, the more I think of it as receiving.
When you stop and pray for a family, the encouragement received from those family members is huge. The trust and the love, and you do see people who come in the halls and you ask,
"Why are you here?"
"Because my doctor will pray for me."
Mardi - So what's interesting to me is there are some conversations going on in medicine around the world right now about this "innovative new concept of Compassionomics."
And really it's exactly what you're saying, it's not new and it's not innovative. I think that Compassionomics is our fearful way of re-exploring the spiritual.
It's taking the time on rounds to say, "How are you doing as a family, how are we doing as a team," and to take the opportunity to draw comfort from each other.
It comes from a spiritual foundation, that I think that we've lost, and I think a lot of it comes from burnout and from the way that medicine has become a business and a commodity. We're starting to re-explore through Compassionomics, and I pray through exploring the spiritual, the deeper side of medicine that around the world I think people really miss.
David - Right on.
Mardi - And if that's not reverse innovation, I don't know what is.
David - It's fascinating, this space that Kijabe fills and how we think about it and how we talk about it. I use a phrase - World class healthcare in the developing world - but when I use that, I don't mean that I want Kijabe to be the big hospital in the big city in the West, because there are certain aspects that we don't want to lose.
Yes, absolutely, it would be super-cool to be doing robotic surgery, and some of these wild technological things, but really I feel like what Kijabe excels at is not fancy and not glamorous. It fundamentals of medicine.
I remember Evelyn Mbugua telling me this one time. I asked her, "What do you think about medicine in general?"
"When I have a challenge or when I'm stuck on a patient, I go back to their history."
It's fascinating that that's fascinating!
Some of the basic fundamentals of medicine are practiced here, just looking at your patient and laying your hands on them and touching them and talking to them. A conversation is both a diagnostic tool and it's actually medicine. If the numbers are true, I know it's different from orthopedic surgery than for outpatient, but, if half of medicine is actually placebo, this stuff is really important to healing. And it's not anti-science. It actually is science to care about people.
Mardi - It's interesting when you mentioned the placebo effect. I think that the placebo effect is considered as nothing, but it's not the placebo effect, is actually a real effect. It's that time and conversation and compassion, truly do bring healing and the point of a control trial is to see in a drug-do better than that. But the thing we're doing, already makes sense.
It's interesting to me that medicine around the world is getting faster and faster and more and more advanced. Time is money. I think that around the world, we wanna save money in medicine, we wanna do more with what we have, but we're willing to sacrifice time, to make that happen. And why is that the first thing that goes? Burned-out physicians in high income countries, the thing that they love, is when they have to see more and more patients in less and less time because they know what they have to offer is beyond a drug, and beyond a diagnosis and beyond a referral and beyond a surgery.
The one of my favorite phrases in medicine that I truly don't understand but want to spend the rest of my life working on it, is a "value-based care."
I think to define value you have to define what we're offering.
If value is time, then one of the things I think that Kijabe and mission hospitals can continue to pioneer the way in is, "how do we cut costs in other areas but refuse to sacrifice the cost of time and make sure that our impact is helpful for our patients but that also helps our team members and our clinicians receive the value that comes from being a part of a meaningful conversation.
I think that's what patients want too. They don't want the robotics, they come to us because they're helpless vulnerable and afraid, and those are the things that we're treating. They trust what we tell them and if we don't have the time to build up that trust, we've lost a lot of the value that we offer.
David - What have you seen change about team? You guys have been part of this big culture change process, but I think it's something that's started long before long before either of us. What do you see is the arc of Kijabe and the archive teamwork and the arc of culture?
Mardi - So, Kenya is an incredibly multicultural and diverse country and Nairobi is high-powered and it's fast and it's a lot of white-collar and highly educated people and Kijabe is not so far from that. I think we operate more in a Nairobi mindset than a rural, small town mindset, but that's actually been a huge transition, I think, is going from presenting ourselves as a rural distant place to a part of a busy growing rapidly advancing system, and so that comes with leadership styles that become more open and more I guess, more modern in style. And so that's been the first big thing that I've just seen a huge jar over the part of the decade that I have been here is that leadership is no longer just top-down, enforced. It's participational leadership and I'm a massive fan of that. Leaders do have to make hard decisions and make things happen, but the input of the team has become a much, much higher priority in the last decade. And that's huge because our young highly-educated, highly-aspirational team members have got some great ideas and shame on us as leaders, if we don't take the time to listen to their approach to things. So that inclusive style of leadership has has been a huge arc.
And then I think the other thing is just our changing generations, millennials are not confined to high-income countries. We have a young generation of people here who aren't gonna stay in the same job for 40 years like their parents or their grandparents did, and that's the same globally. And so we've had to question, over the last decade, how do you approach team members who are only gonna be here for a little while?
Do you see that is, they're just gonna go, or do you get the maximum investment into them and benefit out of them in the time that they're gonna be here and then release them with your blessing?
And so that's been something that's been huge for me is when we've got these new graduate nurses or lab staff radiographers, to not be on the fact that three years after they come to us, they go it's to say, "You know what, we've got these guys for three years, let's sow into them, let's get the most we can out of their recent education... Let's do what we can to up skill them with the people that we've got here and then let's release them all over Kenya to be great resources for health care across the country and across the region.
David - I would say, for healthcare and for the gospel.
I've been wrestling a lot with what does it mean for Kijabe is to be a mission hospital.
I think the classic definition - I don't know if we define it as such, I don't often hear people say it out loud, but I think it's an unwritten thing - that what makes a Mission hospital a Mission Hospital, is that it cares for the poor. Hopefully on some level, or on a lot of levels, that will always be true at Kijabe.
But I'm really excited about the possibility of what you just described, that if these guys are here for three or four years and we are to training them with the attitude that they are going out as Christian leaders and as missionaries to these parts of Kenya that honestly, you and I will never touch. And a lot of the places I've never even heard of. But if we're equipping them to be the light that's the huge opportunity that Kijabe has to be missional.
Mardi - This is a much, much longer podcast, but defining mission is really really important, isn't it? I think that there's a couple of things that stick out to me as you're talking and one is that, I think mission has a history that can be associated with colonialism. And one thing I love about my time in Kenya is seeing that we are a globe of missionaries.
The church that we attended in Nairobi, Mamlaka Hill Chapel, these guys would send mission teams to New Zealand, which is fabulous. It's not that lower middle income countries are receiving missionaries anymore.
All of us need the gospel, all of us need the full word of Jesus and when you're spreading the gospel, what are you spreading?
I think that this is a much longer conversation, but I believe that we are called to go and make disciples we are called to serve the sick, we are called to serve the poor, we are called to serve those in prison.
I focus on the parable of the sheep and the goats, it is one of my life scriptures, "when you are poor and sick and needy whatever you did for the least of these, you did for me."
And what I hope for Kijabe does is that for whoever passes through our doors, whether it be patient, whether it be staff member, this is who we are, we love Jesus and we want you to know this incredible King who gave so much for us and who has an eternal life for us that starts now. And eternal life starting now means making an impact and restoring that which is broken, and it means restoring it now, wherever you are.
As our team members go out to work in other hospitals, I would hope that one of the indicators of success for us would be a lack of brain drain, because it would show that we've shown people, "You know what there are people here that need you in healthcare. And this is why I'm here."
If I had wanted to be an evangelist rather than a health care missionary, I should have stayed in Australia, for less people in Australia know Jesus that in Kenya. But I felt like my call in mission was to serve the sick in a place where I could help other people do the same. That's been my passion here, but I'm called to go back to Australia now.
Does that mean my mission life is over? Absolutely not.
It means that I'm going back to Australia to love Jesus and serve sick there and to do it in a different way.
And I think that understanding that all of us, whoever is listening to this podcast right now, wherever you you have a call to mission, it's that sphere of influence that God's put you in. It's to take care of the poor or the sick, or to love the wealthy, who are lost around you that are never gonna step foot in a church but need a love of Jesus every bit as much as one of our nursing students here in the college.
David - Amen again, that's fantastic.
So back to Ebenezers, back to the the stones. What are things come to mind as you look back over on your time at Kijabe that were hallmarks or turning points?
Mardi - There's a few of them. One evening sticks out to me because it's so indicative of the bigger picture and what we've been working towards. I'd been here for about nine months or so. . .
One of the things that Jennifer Myhre and I noticed is we started out on pediatrics was that our nursing staff were incredibly passionate about their kids, but no one had really had the time to teach them about sick kids and how to resuscitate them, just basic life support, because they were so overwhelmed. You know, there was one nurse who was taking care of 12-15 patients at a time. That ratio is now one to eight, so it's much easier.
But they just hadn't had the opportunity to learn some of the basic life-saving assessment in resuscitation skills, and so we started doing just weekly mock resuscitations with the nurses and as we got to know each other and they got to trust me and to know that I wasn't there to, to judge them, but to try and help them, we would do mock recesses every week, and people would stop being scared of coming and would come with by interested and actually came to test their knowledge.
When I started in 2011, about once a week I would get called in, in the middle of the night to find a baby blue and not breathing, who was dead, and there was nothing that I could do. But what we worked together on was setting up a resuscitation room, and setting up the right equipment.
And so after about nine months of this, I was called in for yet another resuscitation in the middle of the night, and by the time I got there, the baby was just screaming and pink, and I asked the nurse is what had happened and it was the same story as always, this baby choked on milk, they had turned on the oxygen given the baby oxygen done some CPR and they resuscitated that baby before I got there, they didn't need me at all.
And the Ebenezer for me was the was the pride on their faces. "We are experts at this and we know what we're doing."
That has just escalated leaps and bounds. Now we've got outstanding nursing leadership and they're being equipped and taught and up-skilled every day. But that was an Ebenezer moment for me that the time taken to build relationship and team and invest doesn't just bring a resuscitated baby and life is important, but it builds team and it builds ownership and pride in "this is what I've been called to do, and I'm good at it."
It's interesting because it's what you would do is individual doctors with your teams and doing the mock code.
But it's also very much a systems process for Kijabe hospital, right? A big part of solving that challenge was getting the right nursing ratios, but also setting up high dependency units to where children you're concerned about could be escalated. Did that happened during your time here?
Mardi - So when we started here in 2011, children weren't really admitted to the ICU at all unless they were surgical patients who just had an operation, and then the surgeons would take care of them and transfer them down to the ward.
So the pediatrics team wasn't really involved in any ICU care, extremely rarely. We didn't have a high dependency unit. And our definition of high dependency unit, here, is a baby that can be monitored on a machine 24-7.
This is something that shows you how reliant we are on partnerships, David. So for example, the nursing and the medical team together decided, "Look, we think we need a three-bed unit, where at least the babies who were the more sick ones can be monitored on machines."
And so, Bethany kids were the ones who equipped... We turned one of our words into a three-bed HDU in the old Bethany kids wing, and that was the first time we could put some higher risk babies on monitoring so that if they deteriorated we knew about it sooner.
And we saw deaths start to drop, just with that simple thing.
The other thing was that pediatricians who worked here in the past weren't necessarily equipped in how to do... ICU care.
And so Jennifer and I said, "Well I'm a Peds-emergency physician, and she is an expert in resource-poor medicine, between the two of us, we can probably figure this out."
We started putting some babies in ICU who we knew had a condition that would be reversible if we could just hook them up for 24 hours to ventilator. So we started ventilating babies with just pneumonia or bronchiolitis. Or sepsis, that was the other big one, something that if you can help their heart beats more strongly for a day or two, you can turn the tide.
And so we just started working with the ICU team to say, "Look, can we choose some babies to start bringing up here? And four years later we were overtaking the ICU at the time and that's why we had to build a new Pediatric ICU, which opened in 2016.
All of these things are incremental, and we stand on the shoulders of giants.
The Paeds ward existed because a surgeon said "I don't want babies with hydrocephalus and spina bifida to not get care." And then we came along and said "We think that's great, but we think that babies with hydrocephalus spina bifida, who also have kidney problems and malnutrition, should probably have a pediatrician care for them."
And over time, that degree of care, that we've been able to offer has just grown and grown. And we had Dr. Sara Muma as a pediatrician join us in 2012 then Dr. Ima Barasa - she was sponsored into pediatric residency long before I got here. That was the foresight of the medical director back then, to say "We are gonna need some better pediatric care". And then I stepped into the medical director role and people like Ima and Ariana came along and they've just pushed it further and further and further.
None of us are satisfied with what we walk into, and we keep saying we can do better because these kids deserve more.
David - That's fantastic, I think that's another way when you think about the influence and the impact of Kijabe, it's that refusing to settle.
It's to say, "Yeah this is possible. Let's figure it out." And for all the team members to say that and commit to it, and for the leadership to support that I think that's what makes Kijabe special.
I read something that the other day, it was just an interesting take, someone said [to a visiting doctor] "Why are you going to that place? It has so much."
But Kijabe only has “so much” because the immense sacrifice of so many people over so much time.
None of this showed up without the hours and the donations and years and years and years of work.
I remember you saying that about Patrick with his ophthalmology laser? How did you phrase that?
Mardi - Patrick, he's such a wonderful example of the kind of person that doesn't look for reward, but sees a need and just walks to the finish line.
He started out, I believe, on the housekeeping team in the hospital. He's been here for 20 years at least, I think, and then went through clinical office or training, which is a physician assistant level training, and then received higher training in cataract surgery. He started our ophthalmology service in 2012. Since then he had nurses trained around him. He's been doing cataract surgery, and then he said, "We've got these diabetic patients and the care we offer isn't good enough, we need a laser." He went to Tanzania, and got laser training, and now he's going to start doing laser surgery on patients with diabetic retinopathy.
He refuses to be satisfied with the status quo. And that's the heritage that we have here.
You know, talking about even a moment I feel them enormously privileged to have been here in 2015 as we as a hospital celebrated our centennial.
It took us a year to prepare for that, and I know you were a part of that process, David.
David's job was find all of the stories and all of the photos and interview all of the people and make sure to document everything that might be lost if we lose these stories now.
Being a part of that process... I was in tears so many times when we would hear one more story about somebody's commitment and sacrifice.
We've been able to write down that story from 2015, with the Theodora Hospital as we were known then. The stories of not just these missionaries but these extraordinary early nurses, like Wairegi and Salome who worked here for decades, who were initially trained informally, because we didn't even have accreditation for the nursing program.
David - We didn't even exist as a country.
Mardi - That's a really good point!
To hear those stories and to see our very first lab technician was just amazing.
And then when these 80 and 90-year-olds came over and saw the scope of the hospital as it exists now, it just gave me a glimpse into whatever we do today, we have no concept of 100 years from now, the fruit that that will bear.
And I think a missional life, is like that, isn't it?
It's being okay with not seeing fruit.
There's foundations positive and negative, that all of us lay in the interactions and the work that we do and I think all of us, our prayer is that those seeds that we plant would bear fruit. We have to be okay with not seeing the fruit with saying this has been my contribution. I've stood on the shoulders of giants and now I hand over the baton to you, who will come after me. Make of it what you will. It's not my dream and it's not my goal, I've done my part, and let's see where God takes it through you.
David - And so, very shortly, you're about to become a giant. [laughter]
I really appreciate you, I appreciate you bringing that up.
That was one of the most important things that could have ever happened. It was in the 2015. It was before we started Friends of Kijabe.
The realization for me I always come back to how long life is. It's both amazingly short and amazingly long. Watching Dr. Barnett and realizing that he worked here for 30 years, and then went back to the states, so now he's... I think he just hit 102 years old.
It really does bring in a clear view what is legacy, what does it mean and what are we building?
But also that this is very much outside of us.
We get to pour everything we have into it for a time, but then others will take up that work.
And it's both humbling, and amazing and...
Mardi - And I think it's helpful to as many of us have a sense of calling on our lives, I think that this is what God has for me now.
But we have to hold that with open hands because our view and our understanding of what God is doing is so small and what he is doing is so large.
I think sometimes in this kind of setting, you come in with a dream and a passion and a goal, but you see that path shift and change during the time that you're here and that is good and that is okay.
I think a danger is when we come in and think that we have the answers or we know exactly where God is going, and then things don't work out, and we burn out or are bitter or disappointed.
To come into a sense of mission and calling... Saying "not my will but yours be done," and to just obey in the day-to-day and to see where it goes and to be okay with the direction being different at the end than it was at the beginning - I think that's how we lead a life led by the Spirit.
We hold these things with open hands and say, "God take it where you will" and if it's a different place, let me just play my part in that.
David - Okay, I gotta dig into that cause. How do you balance that? I would frame it as vision.
I feel like a good example to look at, I don't know if it's the right one, so, you can choose a different one if you want to, but the balance between vision and practicality and reality.
Because you say that, and you are walking in the day-to-day, but I just think of the Organogram that has been on your wall, which was on Rich's, wall, which is now your's again, which is about to be Evelyn's wall. And you had this vision back in, "this is how I think the organization should work to function well."
But there's a four-year process in making that come to pass.
How do the day-to-day and the long-term balance?
Mardi - I think we're talking about spiritual and practical things combined aren't we?
I think that anyone who's in organizational leadership knows that you, your organization as a whole needs a trajectory and a long-term plan. We make these five-year strategic plans which are based on the assumptions of today and every strategic plan.
You need to go back every couple of years and say, Were those assumptions right?
And just to be a super business nerd for a minute, you base things on SWOT analyses and you base things on the current politics and economics.
David - What does SWOT stand for?
Mardi - Strengths, Weaknesses, Opportunities and Threats.
Then you do a PESTLE analysis, you look at the politics, you look at the economy, you look at the social environment of the day, etcetera etcetera.
In technology everything is changing quicker than we can keep up with. And so I think that when you're looking at a place like a happy, which is large and complex, you set yourself some goals, and you work with them, but, you know, so something's going to change.
Politics are gonna change, the economy's gonna tank, maybe there's gonna be a war on the other side of the world and we’re the only source of this, that, or the other?Maybe India falls into the sea and we start doing all of the surgeries that India was doing? I just don't even know.
One thing for me, I've been enormously privileged to have been the medical director for two different terms that were separated by two years.
And so I think I have a slightly unique perspective because from 2013 to 2016, I set the way I thought that our division would work and I came back into the role, two years later and already it had changed, but Rich had made it a better.
It's funny, I when I came into the role, my predecessor. Steve Letchford said, "Look, you're gonna need a deputy, you can't do this by yourself."
And I looked at my team and said "Um, No, I need four deputies, four sub-divisional heads because this is too much for one or two people and I can't keep my ear to the ground without it.
I came back after two years away and there were five deputies and my initial gut reaction was, "You changed my structure!"
And then I realized that Rich and Ken had made a really wise call. It did have to be five deputies for lots of really good reasons and that team of five has been my absolute rock this year.
David - Who is the team of five?
So the team of five, I've got a head of inpatient medicine and pediatrics, and specialties and this George Otieno. There's a head of Outpatient Department, and Community Health and Satellite clinics, and that's Miriam Miima. I've got ahead of Surgery and Anesthesia, and that's Jack Barasa. There's a head of Pharmacy, and that's Elizabeth Irungu. Then there's a head of what we call Allied and Diagnostic that incorporates the Lab and Pathology, Radiology, Physiotherapy, Nutrition and Audiology, and the head of that, it is Jeffrey Mashiya who is a radiographer.
What's amazing to me about that is when I instituted this framework in 2014, there were four people and they were all missionaries. And I've come back in 2018 and there are five people and they're all our Kenyan senior staff and they're extraordinarily talented and any one of them can stand in for the medical director, when the medical director is away. What a gift that has been.
David - I can't imagine how important this is for continuity. Because you think right now, you're handing off your responsibilities to Evelyn, but she has five people that...those are the executors and they actually get to groom her in leadership.
That's amazing and for the strength of Kijabe and the stability, it's indispensable.
I don't think there's another way to build a strong, stable system other than to build that.
Mardi - Yeah, that's actually one of the things that brings me so much joy as I leave is the team isn't going to notice too much the change in senior leadership because that level of day-to-day practical strategic and operational leadership is just so strong.
I think it made Ken as my CEO, I think it made his job easier to say, "Look, who should fill the position that Mardi is vacating?" He was able to say, "Who's got institutional memory and who's got leadership expertise and wisdom, and who knows how the senior leadership team works?"
Whoever that person is, they're gonna have a team around them that will mean that no voices get lost in the transition. When I took the job in 2013, hearing the voices of specifically missionaries and surgeons can be really noisy and you hear their voices, but who's listening to the head of palliative care and who's listening to the head of laboratory who's listening to the head of nutrition, which is a tiny team of four people, those voices are well represented by wise people who all listen to each other and make the system work around them.
It's a tremendous gift and there's no way to do this job without a team of people like that around you.
And you know what, that's one of my other Ebenezers, David. Thursday, we installed Evelyn as the incoming medical director. Seeing those five sub-divisional heads praying for Evelyn and as that took off, I will never forget that.
David - Absolutely. I wasn't here the first time, but I remember I should print out a series of those [pictures] because I remember you handing the hat to Rich and I remember it going back to you and then watching you give Evelyn the hat and stethoscope.
There's this legacy of people that care. It's interesting to think about... 'cause you are, I mean you’re building this remarkable team and your system and things that operate independently of you.
But at the same time, you're unbelievably special, and have given a ton over the past years and you.
As Rich phrased it, you walked in shoes that not many other people will get to walk in.
I imagine is what it's like when the former presidents get together for their picture. There's things that only only you guys will know and only you guys will have experienced.
Mardi - You know, one thing that is really special is I think a lot of leadership transitions come through pain, brutality and war.
And one thing that I noticed on Thursday, is that in the room as I handed over leadership to evil and were Steve Letchford and Peter Bird, who have both been here for decades and who've previously been the medical directors. I think there's a beauty about the transition of leadership here in the clinical division that it hasn't come through attrition, war and burnout.
I'm leaving with a lot of sadness, and I'm not cutting ties with this place to see. . . there has been a cost. Rich. I know, I would still love to be here in this position as the person who is my predecessor…but to see such strength of leadership that is here and sowing into the next generation rather than leaving when they died. They've stepped down and gone into leading other areas to ensure that the team that follows them is strong, I think that's a tremendous gift and something unique about Kijabe. People love this place and they love this team and they wanna be a part of its ongoing success in its broader mission.
David - And they love and they love that above their own glory and their own desires. I think it's what makes an organization great, it’s what makes a country great. I think it's probably gonna be easier in a place of faith, honestly, that this is God's ministry, not our own, not any one persons's.
What is FPECC? I think it's important for people to know a little bit about how hard is it to create a training program or anything new in Kenya?
Mardi - So FPECC is the fellowship program in pediatric emergency and critical care. Ariana [Shirk] and I are pediatric emergency physicians, we trained in pediatrics, and then we did specially training in how to take care of emergencies and resuscitation. And were the only two formally trained pediatric emergency doctors in Kenya.
Critical Care is taking care of kids in ICUs and currently in the country, there are four pediatric ICU doctors for 55 million people.
I don't have the stats that my finger tips, but it's extraordinarily low.
I think of the city where you live and how many ICU beds there are, and how many children's hospitals you have just in your own city if you're based in a high income country. For 55 million people, there's kids just can’t access that care.
David - Recently, I'm sure it's gone up, but two years ago, it was 100 beds for the country.
Mardi - For adults and kids. . .
In the country, there are a 12 pediatric ICU beds. Actually no, that's not true, there are 16 and eight of them came into existence, when we opened up our Peds ICU here three years ago.
David - And keep in mind, this is East Africa, of the 56 million people. . .33 million of those are under age 18. So 16 beds.
Mardi - That's right. Think of anything that can cause a critical illness. Trauma, illness, cancer, you name it, that's not enough beds.
So when I came to Kenyo, I had no dream of starting a training program that wasn't even remotely on my radar. But sometimes things just come together at the right time. It was actually University of Nairobi, where they have the only other Peds ICU, they had been working with University of Washington in Seattle to say, “Look, can you help us start some training?”
This is really important, because in East Africa there is nowhere that a pediatrician can learn how to run an ICU.
Think of the US, where every state has got multiple training programs, where pediatricians will spend three years to learn to be an ICU doctor.
There is nowhere for 360 million people in this region to learn how to do ICU care for children.
Just think about that for a second.
360 million people... No training program.
There's one in Cairo, and there's one in Cape Town, but that's for 600 million people. So I'm just taking a few of them where there's nowhere to go.
University of Nairobi was talking to Seattle. They've got two Peds ICU doctors in Nairobi and they were thinking of starting a program. Then just through several contacts, actually through the Christian mission network, one of University of Washington's ICU doctors grew up in Nigeria but she's involved with the Christian Medical and Dental Association, and so she knew about Kijabe.
The University of Washington team came out to Kenya for a visit, and they said, "Hey we heard you doing some ICU care caring Kijabe. Can we come out and see what's happening?" That was in 2013.
They came out and said "Hey what are you guys doing here?"
And we showed them around, and their minds were blown, they didn't know there was any peds ICU happening outside of Nairobi at all.
And so, we rapidly started some conversations and said "Look, why don't we start a training program in Pediatric Emergency Care and Critical Care and our trainees can train at both Kijabe hospital and Kenyatta hospital in Nairobi and they can get an exposure to two different types of ICUs. They can also take advantage of the fact that Ariana and I are here as Peds Emergency faculty, and we can split the training load.
Training programs in the US have dozens of faculty for something like this, to rely on just two doctors in Nairobi was an incredible risk even though University of Washington is supporting with visiting faculty.
So we said, "Look, we've got all these people in the country at the same time, let's just try and do it."
So we started that process in 2013.
We took our first fellows at the beginning of this year. It's taken us six years.
That's how things work here. You've got to form relationships.
University of Nairobi didn't know us real well when it came to our pediatric care. We had to get to know each other, we had to develop a curriculum. We had to let the Ministry of Health know. We had to get the Kenya pediatrics Association on side. The Kenya Medical Practitioners and Dentists Board, had to approve the program. The University Senate had to approve the program. We had to try and get some funding in place.
None of that happens quickly. It's all relationship that's all a lot of chai. That's all a lot of back and forth and making sure that you don't try and skip anything to get through the hoops, any quicker than you need to, because if you try to go to quick it falls apart. And if University of Nairobi and Kenya doesn't own this program, it's not gonna last.
And I think that's probably the first thing to take away for me is this program exists because University of Nairobi and Kenya wanted it I didn't come in here and say, "We need this.” University of Nairobi wanted it, and we said, "How can we support it?"
And so Arianna showing up here for a short-term visit - which we rapidly recruited you guys as long-term - it was God's timing because Ariana and I couldn't have done this independently from each other. It's taken both of us to build those relationships over the last six years. Arianna and I are so proud of this program.
Our first two graduates will finish this training at end of December 2020, and we hope and pray that we can recruit them to stay at Kijabe and University of Nairobi as our first home-grown faculty.
What's been lovely about that, too, is that we've connected with people all over the world who want to support this kind of thing, they just didn't know how.
David - Not did they not know how, there wasn’t a way. It literally did not exist until February 2019.
Mardi - So now, we're actually talking to colleagues in Uganda and Tanzania, and colleagues in Sudan and other places about... “Hey, is this a good model for you?”
I've got some contacts in Nigeria, they've got how many million people, 30 million people or something ridiculous? And there's no way to get this training there either.
And people all over the world want to be able to support what a country wants to start in its own strategy.
So that's something that I'm just thrilled to be leaving. Even as we leave next month, I'm hoping and planning to come back at least once a year to teach in the program for the forseeable future and to support Arianna from a distance in continuing to connect people all over the world to say, "Here's a way that your global health desires can interface with a local country's needs."
David - You two are the only Peds Emergency Medicine doctors in the country and there's a realization. . .What actually is Emergency Medicine here and what is the difference between what it looks like here versus America?
Mardi - Yeah, it's a really great question.
First of all, Ariana and I trained in a country where there are multiple children's hospitals per city. So, Pediatric Emergency Medicine is the Emergency Department attached to a children's hospital. There are less than 10 children's hospitals on this entire continent, I think. So there are no Pediatric Emergency departments.
What is really great is that Emergency Medicine combined adult and pediatric is a growing specialty here. There's been so much great work that's going on in so many countries around the region.
Rwanda last year, just graduated their first class of emergency residents.
Uganda just on the cusp, the great advocate there, Annette Allenyo is leading the charge for emergency medicine.
Ben Wachira is an Emergency Medicine trained doctor here at Agha University, and they're on the cusp of starting an emergency medicine residency training program.
You know Emergency Medicine's a funny thing. Emergency medicine in a high-income country, is a part of a functioning system. Emergency medicine in the US means that you've got ambulances that get your people to you and you've got an ICU at the other end that you send sick people to.
Emergency medicine here is. . . people showing up on our door step, we don't know how to get them here and then where do we send them?
I think that Emergency Medicine training here is so much more broad.
We're training people not only how to provide Emergency Medicine, but how to be advocates in a broader system.
And I think if you live in a high income country, you can't understand how much medical training is not about medical training. It's about advocacy and building access to care for people, no matter where they're at.
What I see emerging here is…from the start, it's collaborative.
Emergency Medicine training here isn't just training a doctor in a specialty to give you a certificate and leave you there. It's connecting you with people who are trying to get paramedic systems going and people trying to build ICU care.
That's one of the reasons we realized that our Pediatric Emergency and Critical Care program had to be both. There's not enough places to work where you've got the luxury of staying in the ICU.
Our graduates are gonna go out and work in hospitals where they will be expert trainers for the pediatricians running the ICU and the family medicine doctors running the emergency department and the surgeons who are doing pediatric surgery with just general training.
Our graduates are gonna be those advocates drawing teams together asking "How can we improve the system from arrival at our doorstep till the day we send them home."
It's a different focus in our training. Yes, the skills are necessary. You need to know how to run a ventilator and keep a heart pumping when it's not.
But it's about building a team and being a part of solving systems issues and hopefully in a way that is affordable and sustainable.
David - I love that word, systems. For me, this is the year of systems. Thinking broadly about each of these individual parts because it’s another way that healthcare here is very different from healthcare in the US. The US is just sub-specialization, that's what it's all about.
And here, there's not a fine line between. . .for an Emergency Medicine doctor, you're not sitting out in casualty waiting for a kid to come in, right?
If you want to find the emergency, you just walk around and lay eyes on every kid and there's gonna be one out of 70 children in that building, who is in trouble.
So it really is a bigger and broader way of thinking about things.
Mardi - I think another thing that's interesting to me just as we come back to the missional aspect of who we are... I think 00 years ago, a missionary was someone who would go into deepest, darkest wherever and be whoever they wanted to be.
I think as we consider what is global mission, our question needs to be, “What is that country looking for, what systems are they trying to develop and how do we help them in it?"
And that comes down to health…if you're a missionary, what does the local church want to do? What is their mission and how can we assist them?
I think we need to ask better, what system is someone trying to build and how can we be a part of it.
Because that's the key, isn't it? We're here to serve God who is restoring creation and he's doing it in lots of different ways already.
We don't need to necessarily think we've got the answer, but to say "God, where are you working and how can I be a part of it, and what does it look like?"
I think Mary Adam in her community health project, is a really lovely example of that. Community Health growth is a priority of Kenya.
So she's gotten grant funding and she is just sowing in it, she knows every county Governor in the country, I'm suspecting.
She knows how to get into the system, but how to be salt and light, and how to be the love of Jesus in making things functional and making all things new.
I think that's one thing that I think Kijabe is doing well. We are looking at health strategy and saying How can we be a part of it and love that our FPECC program is in partnership with University of Nairobi.
I love that our clinical offices have a program that we got accredited for called the Emergency Critical Care Clinical Officer program, that actually wasn't a part of hell strategy, but we did see a gap, and as soon as we trained people in that we went to the Clinical Officer of Council and said, "Hey you want to accredit this? This is a really good program. And they did, and now the Kenya Medical training training college has taken that program and they're doing their own program.
I think those are lovely examples of saying “We're here to bring restoration but we don't want to be separate from the system. Where are you going and how can we help”
David - What does that mean for friends of Kijabe? How do you see that working with Friends of Kijabe as an organization?
Mardi - What's been really lovely, about Friends of Kijabe in the last year, and I know you're excited about this, David, is in what the core the Friends of Kijabe vision and mission. I think a core part of Friends of Kijabe that we've got the CEO, the CFO and the Director of Clinical Services on the Friends of Kijabe board.
One question that I've heard you ask so many times in the last year is "Where are you going and how can we help, what are your priorities?
Friends of Kijabe exists to help the hospital further its strategy, but also exists as a bit of a connector between people in high-income countries who really want to contribute and who have passions. Where does that intersect with the hospital strategy?
So Friends of Kijabe is not going to take the whole hospital strategy and try and piecemeal help every part of it.
They're gonna say, "Hey you're a part of your strategy that are happy resonates with and that's become very clear. A lot of Friends of Kijabe funding currently goes towards whatever the hospital thinks is important. The hospital has prioritized the theater expansion project this year and that's great.
But, at its core, Friends of Kijabe also says, "We support the needy. We support education. We support sustainability. How can we get there?"
And so [FoK] has prioritized putting money towards each of those areas which happened to align with the core values of Kijabe Hospital.
So a large proportion of what Friends of Kijabe hospital is doing this year is helping us with an infrastructure project.
But every year we're going re-ask "What are your priorities, and how can we help that?" But we're also going to say, "Here is where our heart beats. Can we help with this too?"
I think one of the things about Friends of Kijabe is the trust that's developed since its inception. As Friends of Kijabe, we trust that the hospital leadership is following a strategy that is meaningful, that is sustainable, and that is in line with where Kenya is going and where the African Inland Church is going because that's who we're owned and operated by. As long as our missions intersect, I think Friends of Kijabe can trust that at the hospital is taking us in a good direction.
David - Awesome, anything else I should ask you? Anything you'd like to add?
Mardi - No. It's been an extraordinary eight years and it's been such a privilege to be here, and it's lovely to leave with joy, even as there's associated sadness. I really can't wait to see what the next few decades bring, and I'm gonna be watching both from a distance and also up close, when I come back to visit.
David - Thank you Mardi.