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Sunday, December 21, 2014

Christmas Letter and Greetings

These twin girls graced my last call night, and are an appropriate Christmas image.  I was in the NICU around midnight and heard there was a mom in labor with twins.  The first time I peeked my head in it was chaotic, too many people and no babies in sight, so I went back to finish doing a lumbar puncture, then returned.  The mom was described as "mentally retarded", and I am pretty sure she was Down's.  22 years old, but mentally like an 8 or 9 year old, and terrified of the pain. She had a saint of a mother who was trying to coach her through it, but clearly everyone in the room was getting very frustrated with her.  She would promise to push, but when the contractions came she went berserk, or crossed her legs writhing, or gave little three-second push attempts.  I jumped into the fray, taking her left hand and leg while her mom coached on the right, talking, cajoling, explaining, trying to help her.  At one point even her mom walked away and she started to wail, more worried that her mom was mad at her than that she was in labor.  She was so sweet, so scared, so eager to please, but so unable to do what she needed to do.  So unfair.  The OB on call decided to take her for a C-section.  I'm the only one who was thinking, if this is Down Syndrome, she has a 50/50 chance of each twin being affected. Well, the least I could do was advocate to get her mom in the room with her, which we did.  And to give the babies the best start we could.  

And out came two little girls, looking perfectly formed, crying.  Hooray for this brave mother, who will have the joy of holding and feeding and watching these children.  Hooray for the long-suffering grandmother, who will be the primary caretaker.  Hooray that I was wrong about Down's or the odds were ever in her favor or God gave this family a major break.

Down's gets to me because of my nephew, who is equal parts handful and wonder, love and willfulness.  Imagining him trying to understand and go through this kind of pain breaks my heart.  I was texting with my kids in the US after the delivery (perks of time zones, even at 2 or 3 am I have family awake) and tried to articulate the reason this story gets to me.  I think it is the combination of innocence and pain.  Which is the Christmas story.  Mary, inexperienced sexually, young, away from home, in labor.  To have Jesus, the ultimate innocence of the Son of God combined with the ultimate pain of the cross.

May you this Christmas find the present reality of a God who took on all of that, for us, for love.

Our Christmas letter to supporters is here for download . . . 

And don't expect to hear from us for the next week or so.  Assuming Luke is truly at the airport, we are out the door in the next hour to head to climb Kilimanjaro as a family.  Off the grid, on our feet, and up to the top of Africa for the next week.  Merry Christmas.

Grace at the Fray (A Christmas Travel Story)

Living on the fraying edge, we sometimes hang on by a thread.

And no more so than when trying to gather our widely scattered children home.

First there are tickets to figure out, months ahead of time, guessing exam schedules, holding out for the best prices.  Then there are the hopeful hints to friends to pick them up from dorms and take them to the airport, something we can't do for them as distant parents.  For Caleb there is a mound of paperwork to leave the country, and to enter Kenya. Then they have to make it through a trying semester, finish classes, study, stay up into the late hours of the night, tie up projects, write papers.  And we plan ways to drive two hours to the airport on this end, to arrange for work and life to allow the gap for the 5-hour round-trip ordeal. Times three.  A few days before there are flurries of texts and phone calls about what to bring perhaps, or about what we'll do together, or packages to be received from team mates ordering American this-and-that. There are reminders (or we forget to remind) about getting cash for travel, about early checking in, about how to transfer planes in Europe.

When it finally comes time for the kids to travel, everyone has already invested quite a bit.  So when the in-the-airport texts come saying : Mom, can you please call, it's kind of a crisis here . . . My heart frays, for sure. For Julia the issue was that she was returning to Kenya on the end of a round trip ticket which began at graduation.  We know that any American traveler can pay for a tourist visa, but they were unhappy with her expired Kenyan dependents' pass and her lack of a documented return trip.  I guess they worry that Kenya will reject her and they will have to fly her back at their own expense.  I was able to quickly go home and email her one-way return-to-US in January ticket on another airline, and talk to the person on the phone.  Whew.

For Caleb, I slept through the first struggle.  It is never good to wake up and find 17 missed texts from 3 to 4 am, saying things like "Luke, can you get Mom to wake up?".  By 6 when I saw them it was all over, but the initial United Airlines person who was checking Caleb in flatly refused because the back of his well-worn passport is, literally, frayed.  It went through the wash a year or so ago.  He's been to a half dozen countries with it since, no problems.  But this guy decided it was an illegal travel document, and suggested Caleb delay three days.  As you might imagine, his semester is extremely demanding.  He hasn't been home here in a year.  Three days would make him miss our Kili climb.  He was pretty distraught.  In the end he walked away to make phone calls, looked up rules, decided the worst that could happen would be that he'd be detained along the way, and decided he would take the chance.  He went back and got a different agent who didn't blink an eye.

But his near-misses were far from over.  He flew Denver to Washington, had an 8-hour tedious wait in the airport, then Washington-Addis Ababa (13 hours) and Addis-Nairobi.  The middle, longest flight left 1 1/2 hours late.  For no clear reason.  Caleb had only an hour to make the connection in Addis, so he was pretty sure to miss that.  We were trying to call and email and get through to see if he'd be put on another flight today, no guarantee since they seats may have been full.  And the airport in Ethiopia is CHAOTIC.  Swarms of people, unruly lines, no clear monitors or gate numbers, buses taking people to planes (never sure if it's the right one).  Thankful for two things that saved us:  ALL THE FLIGHTS are so late that the connection was still possible, and Caleb didn't wait around but charged straight through, asking questions to find his way.  Otherwise he wouldn't have made it. Late, but here.

Quote of the day: "I think I just crossed the entire human spectrum of efficiency from USAFA to an African Airline."

Well, two down, and one to go.  The last is Luke, who passed the last exam of his first semester of med school and is now on the flight to Addis.  Besides a broken phone and a burned hand, we don't know of any crises yet with his travel.  But he's not here yet either.

Friday, December 19, 2014

Keeping watch over . . .

Shepherds are not an unusual sight around here, one of the perks of Christmas in Kenya.  We still get arbitrary politics, pregnant teenagers, donkeys used for transportation, people and animals sheltering together, stars so vivid you can nearly touch them.  And the joy of births, many, which we coach and struggle through and celebrate.

 Today's Advent thought, though, is about watching and community.  This week has been a fairly nonstop and intense one clinically as I jumped into covering colleagues, feeling grateful that I get two weeks of leave coming up.  After working four Christmases here, our medical director (cheers for Mardi) insisted that this year we take off. So in the run-up to that I've been trying to fill in and help my colleagues who will so graciously allow me to be gone.  On Thursday, however, my friend Dr. Sarah insisted that I leave early.  Which was excellent, because I had a quadruple recipe of Christmas cookies to roll and cut for an Advent party that night.

Only I got home, and found that our dog Star was AWOL.  She is 14, and lumpy and slow and sometimes gets confused.  I've run with her for years and years, but now she drags behind and sometimes takes wrong turns.  So I was worried she might walk off and be unable to get back home.  We called for her.  Then Scott went out on a short walk looking for her as I got started on the massive cookie project (I'm estimating I made several hundred).  No sign of Star.

On my way home I had passed three guys trimming the thorny hedge on a path near our house.  I thanked them for their pre-Christmas spiffing work.  They were not familiar faces to me, and looked on the thin and scruffy side.  Every time I went out the door they seemed to pause in their work and watch.  It made us feel a little stalked, as I took in laundry.  But I decided to tell them about the missing dog, and ask if they'd seen her.  They had, in the yard, some hours back.  Oh well.  Jack came home and we sent him out to look further afield on his piki (motorcycle).  No Star.

By this time I had accumulated cookie help so I decided to go out searching for her myself.  As I walked out the door, the young men I had talked to called to me.  They said they had seen Star.  I was having a hard time understanding where, so I just followed them.  Two houses over there is a trash pit, about 6 feet deep.  There she was, in the bottom of the pit, looking shaky and forlorn.  I ran home to get Jack (they guys were clearly a little hesitant about the dog) who climbed into the pit and lifted her out.  Rescue success.  Jack the hero.

But not the only hero.  If those guys had not been hauling off the cut branches in a wheel barrow, they would not have seen her. She was not barking.  I'm afraid in her state she might have just died down there.  Two days before Caleb and Luke get home.  That would have been so hard.  I was so thankful for the watchful help from these strangers.  I gathered up a plateful of Christmas cookies for them.

It was easy to feel a little suspicious of these laborers lingering over a job, watching our house.  Privacy is a luxury.  Need leads to community, I find.  I would not have found Star without the kindness and willingness of strangers to watch out for us, to get involved.  The Shepherds in Luke were probably the age and economic station of these three.  Perhaps a bit marginal, perhaps the kind of people who one would not want lingering around the manger.  But they were watching.  And they had the privilege of finding a real star, and the saviour. In western culture, these might not be the people we would choose to come visit our newborn.  But God chose them to watch, and to see.

Real community is like that, watching for signs, alert to the angels, ready to celebrate and to help.  I'm thankful for that today.

(A few pictures from more community, the evening Advent open houses we've been having rotating around Lower Station.  About 40 people came last night . . . a real party!)


Thursday, December 11, 2014

Behold, the virgin shall conceive . . .

This prophecy occurs in Isaiah 7, the passage in today's lectionary.  And both Matthew and Luke make a clear connection between Mary and this passage.  But I think we've lost sight of the reason this is important, when we see Mary with the halo, as if she was uniquely worthy of motherhood, and we immediately dismiss her with an emotional distance and irrelevance.
Look again.  A virgin, pregnant.  Paradox, juxtaposition, the impossible possible.  Something from nothing.  Creation.  Grace.

The point is to show God's power, God's action, God's presence in the story.  To show that the rescue is coming from outside human endeavor and will, to show there is another dimension of reality that we do not control.  To show that the humble and unlikely are chosen to bear the gift of world-transforming love.

Mary should give us all hope, that any of us can be the means of grace in a world gone awry.  Her state of virginity is to make the entire story one of grace.

So it is worse than ironic that the retelling of the story somehow turns her status into a subtle, or not-so-subtle message, that God is looking for the (quote-unquote) holy and pure to deserve blessing.  It is bordering on blasphemous if her virginity becomes a message of "be like this to enter the Kingdom." One need only read the rest of the beginning of the Gospels.  There is a list of the genealogy of Jesus, and besides Mary, four other women are noted.  Not one of them was a virgin before the relationship that resulted in the all-important human lineage that led to the Messiah.  Two were widows who took initiative to pretty much seduce their male redeemer-relative in order to get pregnant.  One was a prostitute by profession, who jumped sides when the Israelites started their invasion.  And one was an adulteress.  So it would be hard to extrapolate from that data that God chooses women-who-have-kept-the-rules to be key participants in the redemption plan.

One would conclude, rather, that God likes to shake up expectations, and do the unexpected.  Hence, the virgin shall conceive.

Christmas has been coopted by rules, which is the opposite of the point.  Mary should make us catch our breath in wonder, not that she was such a perfect young woman, but that God can do anything.  Behold, I make all things new. To see the way our human bent to turn grace into law is so insidious and powerful, consider even St. Nicholas, aka Santa Claus, who started off giving gifts to poor children.  He should be a beautiful symbol of God's merciful generosity.  Instead, as our youngest pointed out listening to music playing at dinner last night, we miss the entire point with the "making a list and checking it twice, going to find out who's naughty and nice."  NO!

Christmas is grace, pure and simple.  Which is truly good news, for all of us.

Serge-Chogoria partnership: Recruiting a new team!

Scott and I have the pleasure as Area Directors of assessing new team possibilities for Serge.  We were invited to visit Chogoria Hospital, on the eastern slopes of Mt. Kenya, where a consortium of missionaries and Kabarak University are attempting to resurrect a Family Medicine Residency (master's) program.  We found a solid facility, with dedicated staff, excellent nursing, strong community support, vision, and hope.
 Almost 100 years ago, in 1922, supplies to build a house in the forest were loaded onto 70 ox-carts in Nairobi in April, and arrived at the new site in October.  Dr. Clive Irvine spent his life building not only a hospital but a nursing school and a public health system, plus primary and secondary schools, and a church.  In recent years, the supporting mission from Scotland decided that Kenya was no longer a strategic focus for their funds.  The PCEA church continued many of the programs on their own, but now they would like some help.

The dream is that Chogoria, Kijabe, and Tenwek would all be sites for training Kenyan doctors who want to be able to handle most of what comes to a District hospital.  Acute care, emergency medicine, operative OB, neonatal resuscitation, internal medicine, and some of the standard, common surgical procedures.  Young physicians who have completed a year of internship and then worked to get some experience would come to one of these three sites for a residency program, which in Kenya is called a Master's.  This fits our passion to provide excellent care to the poor, showing the
compassion of Jesus in a hands-on manner, while training a new generation of Kenyan doctors to do the same.  

The main thing lacking:  consultant physicians to be the teachers, to disciple and supervise and encourage these residents.

There are houses ready and waiting.  There is a pretty functional hospital that is sure to fill up when patients see the services return.  There are dedicated Kenyan nurses and administrators and groundskeepers and chaplains and lab technicians and interns who want some experienced doctors to come alongside and teach and help them.

The location is a gateway to Eastern Kenya, and beyond, where many unreached people groups still exist.

Perhaps even best, there is leadership in place from one of the only Family Medicine trained doctors in Kenya, and from a mature family (read, "our age") who sensed God calling them into a second career after 25 years in the Navy directing an Emergency Medicine Residency.

Interested?  Fill out a Online Go form :

Monday, December 08, 2014

A billion sparks

When Mary starts to understand what is happening in her body, in Luke 1, she gets a glimpse of the impossible. Life growing supernaturally.  God-with-us as a fetus.  A world-changing infant.  In her song she anticipates the scattering of the proud, and conversely the exaltation of the humble and the filling of the hungry.

The Advent message always includes this inversion, this against-the-odds outcome that blows away the categories the world assigns.

In this context, I can't help but to keep thinking of the Kenyans murdered in Mandera.  They were the poorest.  People don't live under tarps in a rock quarry on the border of an enemy land breaking rocks by hand into gravel unless they have no other options.  Advent gives hope that these people, whose earthly lives were short and bleak in many ways and ended in unspeakable horror, will be honored in Heaven.

And the Queen of Heaven just may be a mom who I also can't get off my mind.  A couple weeks ago we admitted a tiny jaundiced hungry baby.  Some responsible citizens had organized and brought the baby and his mother to the hospital.  Baby W ended up admitted to the ICU as he battled serious overwhelming bacterial infections in his blood and urine.  We actually seemed to be clearing the infections, but his liver was failing.  What made his situation so desperate was that his mother was mentally retarded, and lived with her own mentally retarded mother.  Which is why neighbors had to band together to bring them for care.  She was able to feed and hold him when told to do so, but in a better world would have been in a group home with careful supervision.  Instead she was probably raped, and became pregnant, with zero social support or capacity.  When Baby W was dying one Saturday morning as I came in for rounds, she was sitting by his bedside, seemingly unaware.  I asked the chaplain to come up and meet with us, and tried to explain the situation to her.  I suppose I expected that this was a bitter best, the kind of death that saves untold future suffering, the early end of a life that was doomed from the start.  And I did not think Mama W would comprehend the finality of his death.

Was I ever wrong.  I think her wracking sobs as she held his little lifeless body and said goodbye were perhaps the saddest thing I've ever seen.

She had next to nothing in this world, and she lost the only thing she had to love, the only love she was getting back, her baby.  Her IQ may have been quite low but her emotional intelligence was perfectly able to grasp her loss.  I didn't know what to say, or how to say it, so I just put my arms around her and shed some tears too.  Then came home and completely lost it.

Bludgeoned rock-breakers, and a broken woman in grief.  These are the people for whom Advent is more than cookies and carols.  Advent is survival, is hope, is an eternity where wrongs turn to right.  Advent brings the billions sparks of life that are the people of Africa and floods the cosmos with their light.

Thursday, December 04, 2014


The lower-station families at Kijabe have started a tradition of a half-hour evening Advent activity, for as many nights in the month as there are willing hosts.  The first was at our house tonight, and our theme was the Glory of the LORD Shall be Revealed, from Isaiah 40 and the Messiah.

We read scriptures from Exodus 24 and 40, 2 Chronicles 7, Luke 2, and Revelation 21, as the kids drew a timeline with symbolic pictures for each place where God's glory was seen.  The mountaintop of Sinai, in clouds and thunder.  The tabernacle and then the temple, in bright shining dense light, overwhelming, driving out the celebrants, a presence by day and night.  The angel host startling the shepherds, announcing God's glory encased in a baby in a manger.  And then the final repository of glory, revealed to all flesh:  the City of God, the New Jerusalem, where precious gems glisten from walls and all is light.  All of these manifestations of glory were irrefutable to the observers.  Anyone present could see them, and they left no ambiguity, no doubt.

But I had the kids leave a space between the Luke 2 angel chorus and the Revelation city.

The space we live in now.

Where glory is obscure.  Hidden.  Not overwhelmingly obvious to all flesh.

Then we read one of my FAVORITE Christmas books, Papa Panov's Special Day.  In this story Leo Tolstoy tells of a humble shoemaker, and in his age and loneliness one Christmas Eve he hears a voice telling him that Jesus will visit the next day.  He looks eagerly for Jesus in all the people on the street, and in his impatience to find Him the cobbler is reluctant to invite the cold and poor street-sweeper in for soup, or the ostracized single mother begging for rent.  But as Christmas day ends, his disappointment in not seeing Jesus is transformed to peace when he realizes that Jesus exists in the "least of these".

So the glory is veiled, and to find it we have to search the highways and byways, we have to talk to the poor, invite them in, serve and love.

The kids went back and drew people in that 5th space, then we glued a small piece of fabric, a veil they had to lift to see that picture.

This advent, lift the veil.  Look for Jesus in those least noticed by the world.  Find glory broken up and diffused into a billion sparks.  

Tuesday, December 02, 2014

Longing presupposes Lack. Or Advent thoughts after the Mandera quarry massacre.

Advent season is upon us.  I revel in the decorations we have been putting up in the middle of Africa for two decades, the Messiah playing on an ipod, the cheery fire crackling as Kenya’s delayed rainy season seems to have arrived with intent to pour down two months’ worth of rain in two days.  The Advent calendars are hung, and candles lit.

But Advent is not, first and foremost, a season of ribbons and light.  It is the season of longing, waiting, expecting, preparing.  And longing implies a lack of that for which we long:

Peace on Earth, because the world is now at war.
Light, because the darkness presses. 
Reunion, because we are fractured and lonely.
All things made new, because they are so, so, broken.

In Advent we do not gloss over the chaos and darkness and evil.  They are the context of coming. 

Here in a land where terrorists attacked a bus last week and brutally shot 28 people, then attacked quarry workers in their tents shooting 32 and beheading 4 of them this morning, where we admit children spindly with malnutrition, where in the last week we lost a 4-year-old to TB and had a teenager in the ICU with previously unrecognized AIDS . .

In such a land, watching for the coming of the King is a matter of life and death.

So we begin Advent fully acknowledging the swirling sea of darkness, blood, tears.

We light a candle, a small circle of light, the beginning of victory.

Note:  Here’s what we’re reading this advent
Comfort Ye My People (Bruner) (link here)
Preparing for Christmas (Rohr) (link here
Following the Star, online daily devotion from d365

Sunday, November 30, 2014

A desert of hope

For the last week I had the rare opportunity to travel to an area of Africa that is recovering from civil war and both witness and participate in the rebuilding of a nation.  Great stuff.  I could write volumes but if I do I won't be invited back, so I'll just give some vague and general observations.

Jesus said, "You have heard that it was said, 'You shall love your neighbor and hate your enemy.'  But I say to you, love your enemies and pray for those who persecute you, so that you may be sons of your Father who is in heaven.  For he makes his sun rise on the evil and on the good, and sends rain on the just and on the unjust. . . ."

Scene One:  Eating dinner late one evening, six chairs pulled up around a small round table, goat and rice and chips and chicken, I look around.  Four nations, all of whom have reason to distrust one another due to past injustice and acts of terrorism.  But in that moment we are humans only. We share stories, childhoods, dreams, hard work, ambitions, hunger and joy.  It is all to easy to think of any category of people as dangerous, or different.  The remedy is to meet one on one. This is what the Kingdom will be like.

Scene Two:  Straining to understand a language that seems to be English only all the consonants are pronounced differently, I listen to a Family Medicine Resident present a patient.  I am doing rounds with the only post-graduate trainees in the country, teaching about fluids and apnea and feeding and infections and all the familiar (to me) nuances of pushing down the appalling 10% infant and 10% maternal mortality in this place.

Scene Three:  Fifty 5th year medical students crowd into the classroom, and I lead them through and evidence-based approach to child survival interventions, question them on a differential diagnosis of chronic cough, draw a 4x4 table to explain the concepts of a test's positive predictive value.  The brightest is a girl seated to the side with the few female students, veiled, but whenever I meet her eyes I see she gets it.  This is the hope of the future.  These are the people who will decide policies, promote public health, perform surgeries, comfort the dying.  They are the only resource of this desert, human potential, the sheer will upon which development will build.

Scene Four:  This one was the most surreal.  After a week of solid work, we take a late afternoon off to climb (with an armed escort of course) a hill that overlooks the town.  Half-way up a little girl who is outwardly indistinguishable from the cohort of her scampering cousins sits by the side of the steep rocky path.  "You speak English?!" she pipes up in a shockingly American accent.  J is 12, back from California on a visit to her maternal relatives, a bit unnerved by the heat and dust and unfamiliarity.  She takes my hand like a lifeline and we climb together.  Welcoming, educating, loving the nations as they pour into America yields trust and makes the world a smaller place.

Scene Five:  A little girl whose requisite conservative dress includes a long flowing flammable polyester dress gets too close to the open cooking fire, and goes up in flames.  We don't see her until five days later when she is severely dehydrated, in respiratory distress, minimally conscious.  The polyester melts into her skin and the burns are deep.  In spite of careful dressing and a line and fluids and antibiotics and oxygen, she does not survive.  The last half hour I lean over her bed with a bag-valve-mask I found on a shelf, and keep her breaths coming and heart beating, but I know we have lost the battle.  I am frustrated that unlike Kijabe, I can't talk to the family and comfort them as I am used to.  I don't have an ICU with a ventilator and pressors.  This is a preventable, tragic death.  Someone looking for the next public health campaign:  flame-resistant fabrics in all countries where girls both have to cook and cover themselves at age 6.

This country is a paradox of rubble and hope, of harsh sun and cold night, of burgeoning new universities and extreme poverty.  I am thankful to have been the recipient of their hospitality, and to have been a tiny part of the sun rising and rain falling.

Thursday, November 27, 2014

Thanksgiving thoughts

This may have been the first time in my life I was completely away from any family and any semblance of Thanksgiving.  More on that when I get back, but for now let me reflect on thankfulness.  Everyone is thankful for their families, but never so much as when your only contact is a hasty minute or two on the phone because you're in a country where you're not sure who is listening or where/how you can get more airtime.  I am thankful that persistent friends woke one of our kids up for an early flight to the West Coast when her phone malfunctioned.  I am thankful that all three USA kids are with Scott's parents in CA, being stuffed like proverbial turkeys by Nana's amazing cooking, and riding bikes along the ocean to refresh their weary souls.  I am thankful that our Serge team in Kijabe took in Scott and Jack for a true celebration with friends from multiple countries.  I am thankful for a creative-cook of a husband who made this brick-oven turkey even though I didn't get to eat it (and who has effectively become the primary responsible adult in our household over the last couple months with my travel and work making me less and less functional).  I am thankful for my family-of-origin being together in West Virginia in spite of snowy roads.

But for this post let me be thankful for something else, with thoughts spurred on by the great philosophical movie, Two Guns.  We watched it on our TV service, which means about 20% was blipped out, but there is a scene in the middle where the two main characters are sitting in a bar.  Mark Wahlberg gives a speech on "why we fight", and it is for the guy next to you, your colleague and comrade who is with you in the struggle.

So today I am thankful for my Paeds team at Kijabe.  As of this week, we are fully staffed for the first time ever, as Dr. Arianna began work officially on Monday. Four full-time paediatricians, augmented by one short-term and two once-a-week part-timers.  Last week was a doozy, with one person out for a death, another on leave, and several other issues pulling us in multiple directions, as is generally the case. Yet as I walked back and forth on the familiar path to the hospital, juggling critically ill intubated patients with uncertain diagnoses, talking to families who were resistant to care, making hard calls on a baby whom we had resuscitated over and over, the usual, things that could easily drag one down, I was surprisingly unfazed.  I realized with gratefulness that in all these situations and more, I am working with a great team.  We approach patients with the same level of concern and dedication, we have a compatible framework for decision-making.  We pitch in for each other.  We are friends.

This was one of our primary goals coming out of our longterm planning retreat--strengthening team relationship is the essence of staying power.

So a tribute today to the Paeds team, whom I am missing, and the beauty of community in life and work.