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Saturday, February 17, 2018

Going home

Tomorrow we're heading back to Uganda for the week, the place we called home for 17 years. It's actually the longest we lived anywhere in our lives, where all our children took their first steps and said their first words and grew to be who they are.  Yet we've been away now for 7, and life has moved on.  Bundibugyo has a paved road and electricity, a published Lubwisi-language New Testament, and exponential increases in college graduates, health care workers, cash crops, water projects, cars.  In these 24 years child deaths in the world have been cut in half and if the improvement is not quite that neat and stark in Bundibugyo, it's at least going in the right direction.  There are more churches and schools than one could count.  Still, change comes slowly across generations, and the people we love face stiff challenges.  Malaria is still rampant.  Girls are still lured into early sexual relationships for survival.  Corruption and injustice still take a toll.  Fear and gossip still undermine the freedom of living in the love of God.  Politics still play out in a way to enrich the winners at the expense of the losers.
our yard, about 1999?

Christ School Bundibugyo has been right at the heart of our team's strategy to incorporate Kingdom values on the real-life soil of a place steeped in violence.  Now in it's 20th year, it is a boarding secondary school where (to the best of our ability) girls are safe from exploitation, sit in the same classes with the same opportunities as boys, even travel to national sporting tournaments.  This alone has the greatest impact possible on child survival; so much evidence that the best public health intervention is to educate girls.  Boys as well learn to respect others and themselves, to work in a system based on merit and kindness rather than corruption and grabbing.  There is a focus on science, a computer lab, a strong math program.  Students compete in music and dance that preserves cultural traditions.  There is a library, with actual books.  Through small groups and chapel, young people encounter the good news on a daily basis.  A long strong line of Sergers have invested significant parts of their hearts in this work. We now have a Ugandan Head Teacher, Kenneth, whose work over the last couple of years has resulted in the best performance of any school in the district.  We'll be celebrating that news with the staff, and congratulating them.  We'll see some of the graduates who are thriving.
One of the reasons we believe in this school--all our kids attended.  Luke with his class about 2005.

And yet . . . every year, from the first to the twentieth, feels like a year-long struggle against ever-present evil.  This year of drought the cocoa harvest dwindled at the same time that world market prices fell, so parents who almost universally rely upon the crop for money for school fees defaulted on payment.  For the first time we were late with teacher salaries.  Rumors swirled, violence was threatened.  At another point, there was a massive cultural consternation about our response to a teacher whose physical punishment of students was both illegal and unconscionable.  And on and on.  We still need to subsidize the school to keep it affordable.  We still need Serge workers who can walk a delicate balance of encouraging the staff and managing a project that is largely in local hands.  Both the funds and the personnel have worn thin.

So the next week we'll be listening to issues, looking at budgets, strategizing with the leaders, to move into this 20th year of operation and dream of the future. We'll also be visiting with our team who do many other things in Bundi:  water projects, church leader development, nutrition and agriculture, children's literacy and evangelism, physical therapy, sports ministry, medical care, community health.  We'll see the kids with whom we've had long relationships as something like foster parents, many now launching their own families and careers.  We'll see old friends who walked with us through some of the hardest days of our lives, and new ones who carry on in fresh ways with their energy and vision.

It feels intimidating.  It's hard to go home.  It's hard to absorb change.  It's hard to confront suffering.  It's hard to help untangle problems that seem intractable.  It's hard to have faith that we have anything to offer.  We're walking into this trip after a pretty trying week.  We've lost some patients, and beat our heads against the passive-aggressive wall of inaction, or the impossibility of sparse staffing.  I really like my team and have enjoyed several teaching opportunities this week, but giving multiple lectures while also managing patient care takes time. We've had visitors.  I had a bug that knocked sent me to bed early with aches and exhaustion.  That's life, but we're depleted. 

So it's good to remember this isn't about us.  God can reach into our weakness and pour through us something good for our Ugandan friends and our teams.  Prayers appreciated that we would bring a sense of God's presence and blessing.

Monday, February 12, 2018

Portrait of a Winner

This is not the portrait of a winner.  Or is it?

Tomorrow begins the season of Lent.  Per the highly recommended Biola Lent Project (a daily offering of art, music, poetry, Scripture, and a thoughtful essay, you can get the daily email or add it to your smart phone home-screen to look at daily for free) the tradition of Lent includes six practices: self-examination, repentance, prayer, fasting, self-denial, reading, and meditating on God's word.  We are culturally aware of the denial part (no dessert for six weeks??) but the full picture is much richer.  The purpose is not to build stamina, gain points with God, look more fit, prove toughness.  The purpose is to prepare for the manner in which Jesus changes the world.  

Because it's not a winner-takes-all-by-force manner.  It's a shockingly unconventional, supra-political world renewal.  That's why we need inner preparation.  As we move through Mark's gospel, we are now in chapter 8.  Jesus' followers are fixated on free food and flashy miracles, envisioning a coup that will eliminate the oppressive Roman domination of their homeland and bring them back into their rightful place as BEST.  RULING.  IN CONTROL of the land. The pharisaic approach reminds me of today's Taliban or Moral Majority--let's make sure everyone follows the jot and tittle of our careful religious structure, let's get some military and legislative control over the offensive personal lives of the citizenry, because that's what it means to be God's country.

But Jesus is heading towards the cross.  His path to the throne passes through not just the shadow of death, but ACTUAL death, defeat, loss, grief, pain.  He's not going to lead an army, write new laws, win an election, dazzle the crowds, debate the high priest, strike down the corrupt king.  Instead he's heading straight towards an apparent disaster.  He's going to change the world by a sacrifice that defeats evil in a dimension we can't yet see, and reverses the arc of the universe from decay to glory.

This is a work of subtlety.  It's not going to feel great much of the time.  It's going to require gritty perseverance in hard places, exposure to danger, personal loss.  It's going to keep us out of step with the world's winners.  It's going to require eyes that look beyond the surface, pondering the essentials that make life beautiful:  faith, hope, and love.  It's going to take us on paths where people don't offer awards; where they question our sanity.  We can't do that on a steady diet of platitudes and superficial half-truths.  We can only endure by Lent-like seasons of inner conditioning.

The end of Lent is Resurrection.  There is a table, a party, a celebration.  This is not a faith of perpetual misery . . . instead it is a rhythm of fasting that leads to feasting.  But we can't short-circuit the process, and pound our way through to comfort.  That's what the 1rst century Palestinian Hebrews wanted; that's what the 21rst century prosperity preachers promise.  But that's not Jesus' way.

Let's pray for a season to examine, ponder, re-set our sights, paint a new picture of winning, and embrace the way of the cross.

(painting photo from our museum day in London with Julia's RVA classmates, sadly didn't capture the artist credit)

Saturday, February 10, 2018

Not a boring life: astonishing things

Healing then, and perhaps healing now (though we don't always realize it), can never be simply a matter of correcting a few faults in the machine called the human body.  It always was and is, and perhaps supremely so in Jesus' actions, a sign of God's love breaking in to the painful and death-laden present world.  It was and is a pointer to the great Healing that will occur when the secret is out, when Jesus is finally revealed to the whole world, and our present stammering praise is turned into full-hearted song.  When Mark urges his readers to follow Jesus, he envisages, not a boring life of conventional religion, but things happening that would make people astonished.  . . .

The closer we are to Jesus, the more likely it is that he will call us to share in his work of compassion, healing and feeding, bringing his kingdom-work to an ever wider circle.  Unlike magicians in the ancient world, performing tricks to gain money or personal kudos, Jesus is concerned to bring his disciples into the work in which he is engaged.  The Christian life, as a disciplined rhythm of following Jesus, involves not only being fed but becoming in turn one through whom Jesus' love can be extended to the world.
(Mark for Everyone, NT Wright, commentary on healing the deaf and dumb man, and on feeding the 4000, Mark 7 and 8)

Not a boring life, for sure.  This yawn (pictured) aside, some days you just need a full-fledged theological pep talk to put the craziness into perspective.  A surgery or an antibiotic are more than just little tweaks to slightly malfunctioning physical systems.  They are signs that flare out the truth, that life has broken into this disintegration and decay, that the end involves a great reversal, that the Creator has not forgotten the dusty specks we are.  And that believing all that leads to the privilege of holding life in your hands and participating in the healing love that pours out on the world.  So enjoy the photos below from the last day or two, and remember the big picture.

This is the baby from the post Scott wrote about the mom that spent hours on buses and vans to get here for her 5th C-section. Blissfully unaware of the danger averted.
A rare theatre selfie--turns out Friday not only were we down to 1 consultant, 1 medical officer, and 1 intern to do the paeds work usually done by a team of 10-12, maternity said they had no spare nurse to go receive a baby from an emergency C-section, so Scott called me to come.

Turns out it was good he did--this little one weighed 950 grams and was born at 29 weeks with only a barely perceptible, slow heart thump.  No movement, no breathing, floppy, purple, scary.  But some ventilation and oxygen and warming and drying and resuscitation brought him to life, for now.  There's always hope, particularly after God brought this experience the SAME DAY . . . . 

. . . we went down to the local protected area by the Lake, walking distance from our house, Friday evening.  As Scott paid our $3 fees, I started chatting with this cute preschooler.  Which gave his mom courage to say:  " I always see you and tell people, that's A's doctor, she took care of him at Kijabe in 2014.  You're Dr. Jennifer right?  A was 900 grams, born at 6 months, and we were in the NICU for 2 months with you.  Now he's in school and doing well."  Well, as you can imagine that was a bit encouraging.

This mom told me her 1-month premature boy was her first live child . . she had previously miscarried twins.  I told her, the same thing happened to me!  And her son was born the day before (and 25 years after) my son's birthday. Kind of sweet.

So many malnourished little ones, needing oxygen, needing fluids, needing attention.  It's tiring but there are also times when we remember, this is a privilege, to participate in renewing their hope.

This is a red-throated white-fronted bee-eater, one of the most beautiful and graceful birds ever, and we have dozens around our house.  We often see them mornings and evenings.  A reminder of God's eye for beauty and care for the small details.

Here are a few more photos (from Scott so better!) of Friday evening's walk to the lake.  Another joy we have in engaging with God's bigger work is hosting team mates from distant places, in this case Rhett visiting his daughter Elizabeth from Uganda for RVA's mid-term break.  

We are always part of a huge world-changing process, but it takes eyes to see and ears to hear.  May we open our hearts to observe.

Wednesday, February 07, 2018

Luke Myhre: A quarter century of wonder

Dear Orthopedic Surgery Residency Program Director:

In case you google Luke Myhre, now you know two things.  He likes bones, and he's turning 25 tomorrow.  This photo was taken over Christmas here near his home in Kenya, holding an elephant femur we came upon in a game park.  If he hadn't opted for medicine, he would have been a ranger protecting wildlife from poachers.

Twenty-five years ago tomorrow, he was born a month premature, and from the first week of his life he demonstrated characteristics that will make him an excellent orthopedic surgery resident:  a tenacious determination and an inhuman ability to remain alert.  Sleep was never his strong suit.

He was 8 months old when we moved to Uganda, where he lived for the next 17 years.  His childhood prepared him well for survival in tough circumstances including evacuating under rebel gunfire and surviving an ebola epidemic.  More than the dramatic crises, he learned to feel rich in circumstances that would qualify as poverty-level in the USA (no indoor plumbing, no grid electricity, no phone or TV service or even a post office for many years).  He had to be confident and resilient to spend his days cross-culturally with his friends, to bravely enter Ugandan school as the only foreigner, and later to go to a boarding school that was a 23-hour grueling 2 1/2 day drive from home.  This childhood was actually rich: rich in community, in beauty, in adventure, in reading, in love.  

At age 17 he graduated from high school and went to Yale University on a scholarship, fulfilling premed requirements while pursuing a broader education in the history, culture, and language of the continent where he grew up.  He graduated with honors and by amazing grace got another scholarship to go to medical school at the University of Virginia (our state of residency).  In these almost 8 years of pursuing degrees, he's maintained friendships here in Africa, coming back many summers to work on diverse research projects from exploring a link between malaria and congenital neural tube defects, to using cell phone messaging to improve post-trauma care and follow-up.

Now he's turning 25, and embarking upon a career in orthopedic surgery.  Whoever matches this young man will get a creative, outside-the-box cross-cultural thinker, an intellectually curious person who will make a mark on the world, who will combine physics and public health and mechanics and intensive care all into his surgical skills.  You'll get a resident characterized by supreme loyalty, self-sacrifice for his fellow residents and patients.  Your community will be enriched by his talent for gathering people around food and fun.  He's an athlete and strong and smart but so are most of your applicants.  Take it from us:  he's brought us joy for 25 years and we know he'll do the same for you for the next 5, or more.

Jennifer A. Myhre, MD, MPH
Scott D. Myhre, MD, MPH
Unbiased sources of medical student evaluation

Tuesday, February 06, 2018

The least of these...

As I (Scott) arrived at the hospital this morning, I did my usual preliminary pass through the Labor & Delivery area scouting for potential problems or emergencies.  The day shift midwife was bustling amidst at least ten pregnant women in various stages of labor and informed me that there was a mother who just arrived and needed a C-Section.  I nodded and asked her give me a short summary.  

“She’s a  32 year old mom in active labor at term with four previous scars.”  That means she has had four previous cesarean sections.  Some mothers are able to have normal vaginal deliveries after one (or even two) c-sections (called a VBAC: vaginal birth after cesarean).  But a mother whose uterus has been cut four times would be at very high risk of a uterine rupture if she were permitted to labor.  I took one look at the mom and could see she was really contracting.  She was flexed at the waist, leaning on her elbows on the bed, eyes squeezed shut as she endured a long hard contraction.  The midwife was preparing to examine her cervix so I waited to find out how urgent this case was going to be.  The midwife gasped.  “She’s eight centimeters.”  That’s 80% of the way toward the baby’s delivery.  So we needed to act quickly.

It took about a half hour to get her prepared and into the operating theatre (shockingly efficient for our hospital).  As part of the routine pre-operative care, I inserted a catheter into the mom’s bladder and found the urine to be bloody.  The baby’s head was like a battering ram, propelled by the strong uterine muscular contractions, smashing against the mom’s pubic bone - and the poor bladder caught in the cross-fire.  But at least there was no evidence that the uterus had ruptured…

Doing a c-section on a mother who has had four previous c-sections is no small challenge.  It often seems like someone has poured glue into the abdomen and let it set.  Everything is adherent to everything else.  In this case, the bladder was stuck high up on the uterus making access to the baby difficult.  But we manage to deliver a healthy baby - 3.2 kg.  As I put the mom back together, I conversed with the senior nurse who assisted me in the surgery and we discussed this mother’s story.

“Did you know this mother is from The Bush,” she said.  Typically that means “far away.”  However, it this particular case, this patient came from a village so far away, that the actual name of the village is “Bush.”  Prior to the surgery I was looking at her little blank notebook which some women use for antenatal care.  The entirety of her antenatal care consisted of two third-trimester dispensary visits where they measured her blood pressure only.  The routine antenatal blood tests (such as blood typing, HIV & syphilis testing, and hemoglobin level) were never done.  No advice was given about the need for or timing of an elective cesarean.  She didn’t know the date of her last menstrual period so there were just question marks about the dating of her gestation.  No ultrasound.

Last night, the patient went into labor, but she lives in Bush and her husband has no means of transport.  So they waited until morning.  They had to ride three different matatus (12-person mini-van) for over three hours to reach our hospital.   As we explained the need for a C-section, she quietly nodded.  We handed the consent form to her sign, but there was an awkward pause and look of confusion.  She could not read or write and didn’t know what to do with the pen.  I felt so sad for her.  She managed to make some semblance of a signature.  And then we went through the same awkward process as we offered and explained the option of a tubal ligation.  Thankfully, she was eager for a permanent family planning solution.  This could potentially save her life.  Today was her fifth C-section.  Going for a sixth could be deadly.

This afternoon, I have been thinking about this patient.  I’ve often said this year that I find it so difficult to understand what my Kenyan medical colleagues are thinking.  But wow - trying to get inside the experience of a patient who does not read or write is nigh impossible for me. What I can imagine though is that her life is defined by her family and tribe.  That she loves her new baby more than life itself.  That she came to our hospital hoping against hope that she and her baby might somehow survive.  And I count it a privilege to be part of a team that laid our hands on her and assisted in that miraculous process of a new life exploding from the inside of a woman.  

Sunday, February 04, 2018

Perspective gained by space and time

"If you can see a thing whole," he said, "it seems that it is always beautiful.  Planets, lives . . . But close up, a world is all dirt and rocks.  And day to day, life's a hard job, you get tired, you lose the pattern.  You need distance, interval.  The way to see how beautiful the earth is, is to see it as the moon.  The way to see how beautiful life is, is from the vantage point of death." (Shevek, character in Ursula K. LeGuin's The Dispossessed)

As we slog through time sequentially, we don't always see the whole picture.  Hard things happen, and they are truly painful, and they become part of our stories.  But, as one of my characters says, they aren't the end of the story.  It's only from the vantage point of death, or eternity, that a life's full beauty can shine.  And to bring that sublime thought down to earth, it sometimes helps to look back a few months or so to feel less discouraged.

Friday was the last day of rounds with the current set of interns; they switch services every three months through their year, rotating in OB/GYN, Paeds, Surgery, and Internal Medicine.  They come in quite vague about babies and children, and often leave with some sense of accomplishment.  I noticed on rounds on Friday, the row of 9 of the smallest preems (2 per incubator and one yet-to-be-squeezed in, and that was before 2 more were born that afternoon . . ) every single one had appropriate increments of milk feeds in their nasogastric tubes and IV fluids in their veins, every single one was gaining about 1.5% per day of body weight.  THIS IS NO SMALL THING.  It takes time to learn how to gently and meticulously manage beings who weigh 2-3 pounds (this row is 800 to nearly 1600 grams).  On the other side of the room there is a row of the 1600-1800 size, tubes out, learning to breast and cup feed.  My other intern had appropriately corrected the management of a critically ill and dehydrated baby admitted overnight, and had thought through some of the more complicated cases on his service.  In short they had both come a long way.  We're trying to measure what we do with pre and post tests and a core curriculum, and both of these interns raised their score by 20 points over the 3 months.

It's also great to finally have the nurses settled.  December was chaos as the strike ended and assignments were reshuffled, then at Christmas and into January many took their accumulated leave (strike time doesn't count as leave . . ).  So finally we have the queen of Kangaroo Care (skin to skin warmth and nursing of babies by their moms) back in action. The twins pictured here were SO SICK at birth, yet to see them now you'd hardly remember it as they move into their third week.

At home on the weekend this is what my table looks like as I review labs and cases with the intern.  The point being, a year ago no one was following very closely, especially on the weekends.  So there's that.

These are the senior preems, Kangarooing.  When deaths feel overwhelming it's good to look and see the lineup of babies who make it through a harrowing month or more to grow enough to go home.

This is what 3 babies-per-incubator looks like.  Crowded or cozy?  It's an infection-control nightmare but the alternatives aren't great.  We don't turn anyone away.  Some are born at home, or at small clinics with no capacity to manage an infant, so are sent here.  My Medical Officer colleague who did her internship a few years ago, and is now working on Paeds, commented this past week that when she was an intern these babies were not surviving, and things are so much better now.  Good reminder that my perspective is so limited, and people looking over a longer interval see more change.

And it's not only the babies:  here are 2 moms-per-bed awaiting C-sections this week as Scott was working to get them into theatre.  I think the patient resilience of Kenyans, the willingness to share a bed and to endure discomfort and to sacrifice for their children, will win out over all obstacles, eventually.

This is a Monday pep talk to ourselves.  The point is, it's all disease and crying close up, but when you get the distance of a day or a rotation or a year or a lifetime, there is great beauty.

Passivity and Push and Peter

Neither being passive or pushy carry positive connotations, yet both feel inevitable in a world warped by evil.  Once upon a time we learned that the two extremes of conflict are the most dangerous:  the obvious end of the spectrum is violence, but the mirror image is equally damaging, that of passive-aggressiveness.  Violence is the purview of the powerful, and passive-aggressive responses the fallback of the powerless.

Disclaimer: we're more likely to be accused of being pushy than passive.  As people whose solid education and  skin color communicates privilege, not to mention our roles in leadership and teaching, I am hesitant to complain about passive-aggressive behaviour realizing that it's roots run deep into colonialism and injustice.  However, as people who have put in 2 1/2 decades of struggle and love, there are days that the energy to push back against waves of passive indifference just drain us.  This is going to be a long post, for the few who wonder what work-days are really like.  Feel free to skip to the last few paragraphs.

Thursday was one of those days.  The push started Wednesday afternoon with a dangerous, brain-damaging level of bilirubin (jaundice) in a lab result in a baby brought in several days old.  The mom's O+ blood was reacting to the baby's B+.  I was pretty sure we needed to do an exchange transfusion, but there were two babies with the same name and some confusion about the lab samples and blood was not available and all the usual barriers.  In a hospital with no in-house call by anyone above the intern level, and with very sparse staffing, the administration had determined that we can do exchange transfusions (removing the baby's blood and replacing with donor blood) only in the daytime.  So we prepared Weds for the procedure on Thursday, and agreed we'd check one more level Thursday morning just to be sure.  We can generally only get labs five times a week--they are drawn Monday through Friday and batched throughout the day, with results released about 5-6 pm each weekday evening.  So it was a PUSH process to get the lab to agree to run an early (meaning 10 am) sample and release the results to allow us to proceed. 

Thursday I am the only consultant, our medical officer (resident-level doc) came in bravely trying to help but was clearly sick and I sent her home, so it was me and the interns, and then one of them said at 11:30 am he had to go home as well because he'd had a bad night of call.  THANKFULLY the jaundice had improved overnight and the level dropped significantly, so I was feeling like we might be OK, just me and one intern for our 40+ Newborn unit babies and our 20-30 on the paeds floor . .  .

Until we got to the LAST TWO BABIES out of all those that we rounded on.  Due to rampant infections my new colleague and I appealed that babies from other health centers who are referred to us be grouped in the third of our three Newborn Unit rooms, as a gesture of isolating new bugs.  In a busy and poorly staffed place (remember we are supposed to have over 200 nurses, the government has supplied about 80 and the hospital has hired another 50 from the small fees collected for beds and meals . . . and we only have just over half the doctors we are due, meaning about a quarter of what we need . . .) it's key to group patients by illness and by severity for attention and efficiency.  So my infection control attempt failed to carry the caveat of "and please tell me if the babies in isolation are amongst the sickest".  One of the two was 5 days old and slightly premature, jaundiced, vomiting, distended, had never passed stool, looked like a surgical emergency for bowel obstruction.  The other was also about 5 days old, jaundiced, gasping, with the cold hands and feet of shock.  Both had been admitted overnight by the exhausted intern who had left without telling us about them, and neither had any IV line, had received any medications, or had had any diagnostic tests.

I thought the shocky baby would die soonest, so focused on that one.  Two intra-osseous line attempts both failed because we don't have needles with stylets, so they plugged with bone.  Then it occurred to me that I might be able to still use the umbilicus, and with no instruments other than a handle-less blade I cut down and removed clot and jerry-rigged an ng-feeding tube as an emergency IV line, pushing fluids and antibiotics, while the nurse was setting up an oxygen system called CPAP.  Once that baby stabilized slightly I did a lumbar puncture thinking he may have meningitis, drew blood and moved on to the other.  Again had to put in an IV, do a lumbar puncture, etc all on a bench the moms use for seating because in the isolation room there was no other space, and all with moms helping me hold because the nurse and intern were swamped with other babies.  This one I thought needed to get to Kijabe or Kenyatta for surgery, but an x-ray is needed to make that request convincing.  The general MO of the x-ray department is to finish all the outpatients, then take the portable to the newborn unit last thing in the day.  By that time there may not be power, or it just gets pushed back until tomorrow.  So when I went personally to the department to try and get the tech to come mid-day, and he said "I'll be there in five minutes" I said "I'll just wait here and go with you" knowing he wouldn't.  He looked so flummoxed that I felt sorry for him.  So I speed-walked back to the Newborn unit (the furthest building from xray) and picked up the crib and carried the baby in the crib to x-ray myself.  Got a lot of stares, but it worked.

The day before Scott had to personally wheel patients to the operating theatre, do all the prep work, make phone calls to get the anesthesia in place, pushing hard to save a baby or a mom's life, only to later discover his team sitting in a lounge having tea.  Not that you shouldn't drink tea.  It is just the exhausting sense of inertia.  It's why six hours in this hospital wipes you out as much as 12 hours in another one.

There are times when we both feel the quandry of what is dangerous passivity (ignoring labs, delaying action, failing to show up, failing to call for help, pushing work off to someone else, missing days and more days of duty, staying silent in the face of rumors of harmful decisions or practices) versus what is a gentle and slow approach to cultural change.  There are other times when we feel the quandry of what is unpleasant pushiness (imposing our ideas, insisting on certain standards, doing work ourselves that our trainees should be doing, giving too many negative reactions) versus what is a needed stand for justice. And I know I don't get it right most of the time.  I end up tired and frustrated.  The baby in shock improved for 24 hours and then died.  The baby with the bowel obstruction thankfully went to Kijabe for expert surgical care. 

Which brings us to today's sermon from chapter 2 of 1 Peter.  Our preacher had a challenging passage about submission to the government and to authority in a week in which Kenyans saw their TV stations taken off the air and opposition leaders violently arrested.  The latter part of the chapter, he showed us, exactly parallels Isaiah 53.  Jesus is the one who pushed against the hypocrisy and injustice of the worldly leaders right through to death.  Yet one could also see the cross as passive, in that he did not bring change by force.  Jesus can meld the paradoxes of push and passivity into a non-violent protest that redeems by sacrifice. 

Would you pray for us to model that?  It sounds impossible. Would you pray for Kenyans to model that?  Because the spectrum of conflict actually comes around full circle.  The powerful (the government, the army, the wealthy) can push their way.  The average person passively shrugs, tries to stay out of the way, and hopes it will all blow over, unsure.  But then the poorest of the poor can be manipulated into the push of violence that serves the elite again:  they have little to lose, and a restless energy that can turn protests into riots.  Kenya has teetered on the brink of this all year.  What would redemption look like in the massive public health sector, and in this country?  How can average people and doctors like us live by Isaiah 53, by 1 Peter 2, by the cross, in a way that opens a path of life?  

Friday, February 02, 2018

Candlemas: a holiday for soul-stretched parents, for winter-weary waiting, for neglected witnesses

I use an app that follows the Church Calendar for daily Bible reading, so occasionally come upon a holiday that surprises me.  Today we celebrate Candlemas, which falls 40 days after Christmas and so marks the day that Joseph and Mary brought their baby Jesus to the temple (story in Luke 2).  Their visit fulfilled two traditions:  one, that the firstborn son belonged to God in a special way and had to be redeemed by a sacrifice in memory of God's rescue of the entire nation of Israel when they were slaves in Egypt (Exodus 13), and two, that a woman who had given birth was now declared ritually pure again (Leviticus 12, and remarkably congruent with the typical 6-week post-partum check up we practice now).

In this story we see the humanity, and the poverty, of Jesus and his family.  They could not afford the lamb sacrifice, so brought two turtle doves.  There would be many people performing the same rituals every day.  But the Spirit prompted a prophet named Simeon to go to the temple that day and meet this family as they entered, holding the baby up and calling him salvation, a light, glory, hope.  Privately then, he turns to Jesus' mother and soberly prepares her.  Being a light to the world is a heavy burden to bear.  Many will speak against this child, even in our own soul you will feel the piercing of the sword.

What a picture of parent-hood.  The delightful promise a baby represents.  That pure potential, that perfect joy, that world-changing life at its start.  But the lurking shadow of heart-aches to come, of mystery, separation, danger we are unable to prevent, watching helplessly from afar.

The day coincides with the exact mid-point between the Winter solstice and the Spring equinox, an ancient marker, halfway out of the darkest night for the northern half of the globe.  That's why countries have traditions about badgers or groundhogs peeking out to see their shadow and predict just how nasty the next six weeks will be, and that's why the name of the holiday reflects a tradition of bringing candles to the church for blessing.  Christmas has come, resurrection lies ahead, but we're still a flickering candle in the dark.

I also love the subversive equality of this day, a widow, a very old woman, gets to hold the King in the Temple and bear witness.  Truth depended upon two eye witnesses, and as will happen at the resurrection, women get a key voice in the new Kingdom.  At the presentation in the Temple and at the tomb in the garden, so few actually saw the import of this baby and man.  So few probably listened or remembered.  For most, as in the painting, there was chaos and noise and confusion.  But two people recognized the import and they still bear witness to the truth.

Malcom Guite writes of the day in a sonnet from "Sounding the Seasons".

They came, as called, according to the Law.
Though they were poor and had to keep things simple,
They moved in grace, in quietness, in awe,
For God was coming with them to his temple.
Amidst the outer court's commercial bustle
They'd waited hours, enduring shouts and shoves,
Buyers and sellers, sensing one more hustle,
Had made a killing on two young doves.
They come at last with us to Candlemas
And keep the day the prophecies came true;
We share with them, amidst our busyness,
The peace that Simeon and Anna knew.
For Candlemas still keeps his kindled light;
Against the dark our Saviour's face is bright.

A day to capture the paradox of parental glory and pain.  A day to recognize the cultural connection of the real baby Jesus to the ancient traditions of exodus and rescue.  A day to foreshadow that this family who could not afford a lamb, had birthed the Lamb whose sacrifice would ultimately rescue from the slavery of evil.  A day to light a candle that testified that darkness cannot overcome light.  A day to ponder just how often we miss the important story:  what baby amongst the dozens I touched today goes unrecognized for a life that will bless many, what purposes might God be working for good in the massive crowds protesting here in Kenya?

Wednesday, January 31, 2018

Oh Kenya, what next?

Yesterday Raila Odinga, the long-time politician (he's over 70 years old which is no small feat in this country) who was ultimately declared the loser in the presidential election held his own swearing-in ceremony as "the people's president".  He swore an oath to uphold Kenya's constitution, on a Bible, and gave a short speech.  President Uhuru Kenyatta who had been declared the actual winner after two full elections in August (the courts declared invalid) and October and was sworn in officially months ago warned that this alternative ceremony would be a treasonable offense.  Police were prepared with tear gas, security details the government routinely provides politicians were withdrawn, and three TV stations were shut down.  It looked like another day of disaster and violence was about to ensue as thousands and thousands of people gathered in the center of the city.

(photos from news sites still posting on line)

Instead, the day unfolded peacefully.  Raila's supporters cheered. The country had to admit that vast numbers of people are not satisfied with the politics.  Without police reaction, the violence was kept to a minimum.  Unlike the normal post-Raila event, there were no riots, no looting, no rocks and battles.  Kenyans turned out for a peaceful protest, and impressively did just that.

Still one has to wonder, what next?  It seems the government wisely decided not to provoke a confrontation that would escalate to bloodshed, and let the event occur then fizzle.  It seems that Odinga's deputy declined to show up.  Life went on.  Swearing oaths is an important cultural institution, with layers of meaning I'm sure I don't understand.  What does a deeply divided country do now?

Limp forward I suppose.  We still don't have enough staff.  Our hospital is running on less than half the number of nurses we should have.  Only one new doctor has been posted in spite of losing others.  Oxygen petered out on the weekend.  It's not clear whether our internship program will stay accredited.  Today we found that a little 8 month old girl who dodged AIDS from her infected mother inexplicably has a brain tumor.  There is always another sorrow which we are ill equipped to handle.

Kenyans excel in humor and resilience, and courage.  They will keep marching to protests, and keep plodding to work.  Here's to hoping they find ways to focus this activism on holding their elected representatives accountable, quashing corruption, and innovating solutions.  Oh Kenya, may justice be our shield and defender so we can dwell in unity, peace and liberty.

Sunday, January 28, 2018

The power of beauty

Like Job, we need regular infusions of wonder to counteract the despair of suffering.  God pointed Job to the beauty and mystery and majesty of creation as the only real answer to the deepest questions that Job's losses posed.  So if we could add one more lesson learned to the post below about walking with those in pain, it would be this:  look at the hippo.  Get outside, surrounded by trees and clouds, by flamingoes and zebra.  Or go to an art museum, or a concert.  Or enjoy Scott's photos (click on each picture to see a higher resolution version).

Walking with the suffering: some thoughts along the way

We face death and heartache every day.  Just for this week:  people we loved had surgery, went to funerals, found out about unexpected pregnancies and losses, faced false accusations.  My mom lost her best friend suddenly. A 35-year-old Serge worker (not in our Area) collapsed with a cardiac arrest and is still semi-conscious in an ICU in a foreign country where his wife and young children cling to hope.  A 39-year-old worker with another organization with whom our teams in Nairobi partner closely died in a paragliding accident in the Rift Valley; our colleague George led her memorial service yesterday even as his own family grieved.  Emergency trips to the USA for a stage-four cancer diagnosis in a dad, a funeral for a grandmother, a sickness in a child.  Another missionary doctor family (not Serge) left the field abruptly when their young daughter's abdominal pain turned out to be a widespread malignant tumor.  My intern yesterday felt ready to give up, he's exhausted and had had two babies die one after the other in the afternoon.  Our former Bundi team leader Travis heads for yet more invasive tests to enter an experimental trial for the metastatic colon cancer he's been fighting for years.   We sat with a hurting missionary whose deep personal pain just did not make sense to her.  And none of those stories are more than a few days old.

So the op-ed piece I read yesterday, written by Duke Divinity School professor Kate Bowler, caught my eye.  She writes from the place of suffering to talk about how people respond.  Her words are well worth reading as she grapples with the false prosperity-Gospel so popular in America and Kenya.  Here is a summary with our own thoughts included.

Don't minimize; Do acknowledge.  Cancer and grief and betrayal and loss feel so overwhelming, sometimes I know our first reaction is to cut the problem down to a manageable size.  Maybe we compare--sorry you miscarried in the first month but at least you didn't bury a baby after going through 9 months of gestation and a full labor and delivery.  That kind of thing.  We even do it in our own minds, trying to convince ourselves that we should't feel sorry because others have it much worse.  How can I complain that I miss my kids when I saw 3 out of 4 at Christmas and my colleague hasn't spent Christmas with his kids in 8 years?  So the first way to be helpful to others and ourselves comes right out of the Psalms--state the problem, cry out, admit the hurt, see the pain.  List the losses.

Don't build a box; Do embrace mystery.  The second response we often have to overwhelming sorrow is to try and get control. Develop an explanation.  This happened because that person didn't wear a helmet or get a vaccine or spend enough time with their kid.  That happened to them but I'm not going to let it come near me.  We build a box of logic, of cause-and-effect, of theological justification.  The entire book of Job pretty much consists of his so-called friends probing to find out what he did wrong to deserve such tragedy.  Or the people who bring the blind man to Jesus and ask, who sinned, him or his parents?  Over and over, God busts our boxes.  Job was more righteous than all around him, and God never actually explains Job's suffering.  We read some of chapter 40 in worship this morning.  God's only answer was:  would you condemn me that you may be justified?  Look what I made.  In other words, we have to embrace the mystery that suffering and blessing both come into our lives unexpectedly, that these are ways God disrupts our comfortable limiting explanations and reminds us that God is God and we are not.  Jesus answered the blind man's friends by saying, this happened to reveal the glory of God.  We pray honestly but we embrace the mystery that God's ways of working may not make sense to us.  Ever, or at least in this world.

Don't hide; Do practice presence.  It's hard to be with suffering people.  I lose multiple patients a week.  When it happens in front of my face, when the child is in my hands, when I hear the mother's wails, it hits me a lot harder than when the intern calls after it's all over.  Sometimes suffering feels contagious.  Sometimes we just don't know what to say. But the one thing some of Job's friends got right, like the women at the cross, was to just sit and mourn with him.  To be present carries great power.

Don't give up; Do point to truth and hope.  Related to hiding, as cancer or broken relationships or disabilities drag on, it becomes harder to hang in there with the sufferer.  And it's hard to speak the truth in love without sounding like we are minimizing or explaining away.  That's why this one has to come last, after naming losses, embracing mystery, practicing presence.  Only then are we ready to point towards redemption.  We do have some truth that we can share.  The arc of God's story stretches out of view, but we've been given some glimpses of the ending, and it is good.  Love is stronger than death.  God is working in all circumstances.  Nothing can separate us from God's love.  None of those statement imply that one must muster up positive prayers to generate the outcome they wish for.   But all of those statements provide a bedrock and a beacon to walk through the next day, and the next.  When we are suffering, we need to lean on truth and mercy, and sometimes we need others to remind us of those things.

Thanks Kate, and Travis and Amy, and parents of Kim, and many other saints, for bearing witness along your stony paths.  We need your voices.  Help us to listen, show us how to bear the cross, and lead us to resurrection.

Sunday, January 21, 2018

How we failed A.: a story of chronic illness in a resource-constrained place

We walked into the hospital last week for our first day back:  staffing changes, absent interns, the usual crowds and needs.  Scott was orienting new visiting residents and evaluating women for surgery and I was catching up on complicated patients and deciding on treatment plans, both of us distracted by also trying to pay attention to our visiting mom and to various team issues.  About half way through the morning I walked into one of our isolation rooms and nearly stopped breathing.  The 11 year old boy I saw sitting there truly looked like a skeleton.  His skin stretched taunt enough to see the shape of each bone. He greeted me in English and even smiled a little, and his mom said he'd had some mouth sores the last two weeks and lost a bit of weight because he wasn't eating, but now he was doing better.  No one could look like that in two weeks.  So over the next few days I learned his story. 

His story on this earth is now over, but I offer a few details in the hope that we can change the next story. 

A. was born with HIV infection, but he and his mom did not know that until 2010 when he was 4 years old.  About half of children who are born HIV-infected in Africa will progress to AIDS and die by the time they are 1 year old.  He was in the other half who struggled along.  So our first failure to A. and his family was that his mom was not diagnosed before or during pregnancy, so she took no drugs to prevent transmission of the virus to A.  Our second was that he was never screened after birth.  So by the time he was 4, this HIV infection had advanced enough that he weighed less than 20 pounds (9kg).  At that point he and his mom got the sad hard news of their trouble, and entered clinical care.

From 2010 to 2017 he went to clinic at least every three months.  I looked through pages of his notes.   He was prescribed anti-retroviral drugs, and Septrin to prevent infections.  He first had a blood test to quanitfy his viral load, the amount of HIV virus circulating, in 2013.  Why not earlier? Another failure of our world, that places like Naivasha with high burdens of HIV still lag behind places like America in availability of testing.  The tests are sent away, there is a lag time of weeks to months to get results, they are done infrequently. The test came back with terribly high levels of virus, meaning that his drugs were not working.  Kenya protocol requires that a child with a poor response to drugs be counseled for compliance and retested in 3 months and then changed to a stronger combination.  Instead he was tested once a year from 2013 to 2017, every time with sky-high unacceptable results.  But no changes made.  He was growing from 20 to 40 pounds (10 to 22 kg), getting taller, going to school.  So our system failed to realize this child had unchecked untreated HIV in spite of taking his medicine faithfully, and did not respond.

In 2017, his records show his weight dropping every visit.  From 22, 21, 19, 17, 16, 15, to 14 kg (40 down to 30 pounds).  Finally in November someone realized that his dropping weight and his high-viral-load results meant he should change medicines, and switched him to a regimen that should have been the first choice years and years ago.  But he kept dwindling.  By the time he was seen in January he weighed 12 kg, and then when he was sent to be hospitalized, 11.  That's 24 pounds as an 11 year old, the same as his weight when he was five, having lost HALF HIS WEIGHT in a year.  In spite of this someone checked a box on his record each visit over the last year saying "weight loss?" "NO".  Another failure.

After a lifetime of untreated HIV infection, after dwindling to a skeleton, after probably having HIV-associated malignancies and opportunistic infections running rampant, I saw him the last few days of his life.  We had treated his sores and we gingerly tried to re-feed him, offering limited calories through a nutritional milk that he loved.  His temperature remained cold, his labs were off the charts abnormal.  He needed an ICU and a miracle and we had neither.  Friday night my intern texted me to say that A. had died.

I believe A. is now healed.  That he has a seat of honor at the wedding feast of the Lamb.  That he's no longer hungry or weak or cold or in pain.  That the "all things new" promise of Revelations extends to him, right now.  I only wish it could have started 11 years ago.  Or before that.  That's why we are here, why we do what we do.  Bringing that all things new into this place.  Please listen to this Hillsong video of the song we played for church this morning, in honor of A.


Writing is in my blood, the desire to process, to share, to explore ideas, to shape memory.  But for the last month I have been unable, because the fullness of life itself has been too varied, to rapid, to overwhelming to leave time for thinking about it.  Christmas and New Years were, for us, a discipline of living in the present moment. 

The week before Christmas all our kids except Caleb arrived in Kenya, Luke brought Abby to brighten up our family, and we all went to a house on the coast of the Indian ocean that we've rented several times before.  Warm waves, fresh tropical fruits and fish, games of bananagrams, walks in the sand, snorkeling, it was a glorious four days.  Then we spent three days camping in Tsavo National park, celebrating Christmas in the wilderness, our stockings strung between palm trees and our tents overlooking a muddy river populated by crocodiles and hippos.  Dust and driving, elephants and gazelles, sunsets and sunrises, Christmas traditions over the campfire. 

That week of true holiday, in the holy-days sense of turning away from normal time and giving focus to the presence of God in tradition and in each other . . was truly refreshing.  We don't want to hide the fact that we take vacation, good restorative adventurous memorable days, boosted by the generosity of our moms.

Back in Naivasha we returned to work between Christmas and New Years.

Then we flew to London and bused on to Battle (site of the 1066 conquest of England by the Norman King William) for two weeks of Serge work--first a conference for all the team leaders around the world, then our usual semi-annual meeting of the Area Directors and Executive Leadership Team.  Seeing our East and Central Africa group brought us much joy as we ate meals together and held endless sidebar meetings.  We prayed specifically and earnestly for so many people and issues.  

As the meetings ended, we met Scott's mom Ruth at the airport in London for a two week visit, and flew back to Kenya together.  We've been back to work but also entertaining Ruth: seeing patients, having meetings, teaching lectures, making phone calls, interspersed with introducing Ruth to friends, going on a weekend overnight to a lovely lodge and driving in a game park seeing animals and birds.
At the airport
For once, Ruth can enjoy OUR cooking 
Watching the sunset in Naivasha 
Game driving at Lake Elementaita

So, in short, since mid-December we've been immersed in the lives of our kids, our teams, and one of our moms.  Meaning very little space in our conscious days has been left for writing.  Thanks for coming back to our site, and reading this far.  Thanks for the Christmas cards!  And we're back.