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Sunday, April 19, 2015

2 to 9, and other numbers

Resurrection.  It never gets old.

The phone rings in the morning, waking me up from a blessed 4 hours of sleep since the last middle-of-the night crisis.  The OB is taking a mother to the operating theatre for a c-section, because the baby is in breech.  For a few moments I consider, do I really need to go in?  It isn't a fetal distress emergency, just a positional problem.  But the interns are in their first weeks of training, and I can't rely on their resuscitation skills, just in case something goes wrong.  So I get up and trudge in.  The early morning halls are quiet with Sunday peace.  I review the mom's file, talk to her, prepare my laryngoscope and tubes just-in-case, more to teach my intern thoroughness than because I expect to use them.

But when the OB cuts into the uterus, thick brown fluid seeps out.  The baby has passed stool before birth, usually a sign of problems.  She is feet-first, with her umbilical cord wrapped twice around her body.  As the OB carefully extracts her, she is limp and seemingly lifeless.  Oh my.  Not a peep as the cord is cut and we rush her over to our work space.  She has a heart rate but nothing else: no breathing, no movement, no effort, just a slimy floppy body.  I grab the laryngoscope and get a tube into her trachea, attach the suction and the brown goop gurgles out.  She had breathed in the stool in utero. Not good.  We clear her lungs and then bag oxygen in, drying and stimulating her. And within a few minutes, she is wiggling and crying, protesting and turning pink.  One-minute apgar of 2/10, five-minute apgar of 9/10. 

The difference between tragedy and a perfectly normal baby.  2 to 9.

I am all for low-tech deliveries, and I guarded my own au-naturale approach as best I could when I had babies.  Birthing is a normal process that women have been doing for millenia.  Except every once-and-a-while, something goes horribly wrong.  The lifeline cord is tangled, the baby is jumbled, the birth teeters on the brink of death.  Which is why it pays to have an OB, an operating room, a paediatrician, nurses, oxygen, suction, equipment and skills all in the wings.  This could have been the worst day of this mom's life.  Instead it is a day to celebrate.

It is a privilege to witness that miracle, the nearly-dead baby transitioning to squalling normality.  The opposite of futility (see post below), the ending I would write if every story was mine to compose.  

And the individual wonder of a life revived keeps us going, but the collective balance of lives saved is equally important.  This past week, in between calls, I flew BACK to Mombasa for the annual Kenya Paediatric Society scientific meetings.  Two days of lectures, debates, presentations, data, discussion, and networking.  One of our goals as a Paeds department at Kijabe was to pursue excellence via the rigorous analysis of our work and outcomes.  We maintain two databases where we enter all our admissions, discharges, and deaths.  And we try to work on projects throughout the year. 

Collectively, we had four posters/presentations accepted for this meeting.  I worked on two of them:  the collation of three years of newborn survival comparing it to a recent study from 22 Kenyan hospitals where interns train, and another comparing intern adherence to standards for screening all patients for malnutrition and HIV before and after an educational intervention.  Both had significant results, and it was fun to put the data together.  Dr. Ima presented an unusual case, and Dr. Mary showed that her public health project significantly impacted peoples' knowledge. 

I will admit that the conference was a bit of a mixed experience for me.  It's been a draining month, well, three months, and another trip and family-separation turned out to be harder than I thought.  I'm in that post-survival-of-stress slump.  The KPA is still a cross-cultural experience, and there were many times I was reminded of being an outsider.  The complexity and competence of the academic scene in Kenya is both exhilarating and intimidating.  As a general-paeds missionary, I'm out of my element for sure.

But I believe in this process.  The individual resuscitation and the big-picture analysis of good vs. harm.  The patient and the population.  Hands-on medical care, and crunching numbers.

2 to 9, and p<0 .001.="" p="">

Friday, April 17, 2015

On Futility and the Spirit

Tuesday I ended up covering ICU for the day and night.  My colleague signed out the sickest babies in the hospital to me.  One, little F, was a 9 month old with Down Syndrome, congenital heart disease, a serious bacterial infection, and a marginal prognosis.  But when she had seemed to be imminently dying the day before, she inexplicably revived.  Her dedicated family held prayer vigils in the chapel; her mother sat by her bed and alerted us to any subtle change in her vital signs.  As so often happens, the more one pours into a patient the more attached one becomes.  As I spent most of the next day and evening struggling to keep F alive, I began to hope too.  But just before midnight, her heart stopped again, and nothing I did brought her back.  That innocent limp body gave up the soul, and I had to wake up her mother with the tragic news. 

And this might not sound very glorious, but I hated the futility of it all.  The hours and hours of careful titration of drips and oxygen, the begging for surgical help to secure a central line, the pouring through the file to understand a complicated patient and the writing of pages of notes.  The daring to hope, and then the fact that none of it mattered.  She was dead.

Then over the next two days, I had similarly tragic news from two young women who are friends, both of whom miscarried in the first trimester of longed-for pregnancies, both of whom had been trying to have a baby for a year or more, both of whom had known struggle and loss, both of whom are laying down their lives in generous ways for the Kingdom.  Both of whom I had prayed for quite a bit.  Both of whom I would long desperately to see as mothers of live, tangible babies and not as mourners holding hidden wounds.  The sheer futility of their months and months of dashed dreams was another punch in the gut.

So when I read this today from Miroslav Volf (Free of Charge), it struck a chord:

But in fact, our gifts and others’ benefits are not related as causes and effects.  They are related as the cross and the resurrection.  Christ gave his life on the cross—and it seemed as though he died in vain.  His disciples quickly deserted him, his cause was as dead as he was, and even his God seemed to have abandoned him.  But then he was resurrected from the dead by the power of the Spirit.  He was seated at the right hand of God and raised in the community of believers, his social body alive and growing on earth.  Did Christ’s “gift of death” cause his own resurrection and its benefits for the world?  It didn’t.  The spirit did. So it is with every true gift of our own, however small or large. 

Like Christ’s healings or feedings of multitudes, often our gifts offer immediate help.  We give, and the hungry are fed, the sorrowful comforted, and loved ones delighted.  We are like a tree, laden with fruit that only waits to be picked.  At other times, we give, and the gift seems less like a ripe fruit than like a seed planted in the ground.  For a while, nothing happens.  Dark earth covered with cold winter holds the seed captive.  Then spring comes, and we see new life sprouting, maybe even growing beyond our wildest imagination.

Sometimes it seems as if a fate worse than lying in the dark earth befalls our gifts.  It is almost as if some evil bird takes away the seed we planted before it can sprout and bear fruit.  We labor in vain.  We give—and it seems that no one benefits.  Yet we can still hope.  The Spirit who makes a tree heavy with fruit and who gives life to the seed that has died will ultimately claim every good gift that the evil one has snatched away.  Just as the Spirit resurrected the crucified one and made his sacrifice bear abundant fruit, so the Spirit will reaise us in the spring of everlasting life to see the harvest of our own giving.  Our giving is borne by the wings of the Spirit’s hope.

Tonight I pray that my friends will cling to this hope.  That the Spirit has seen the darkly covered seed, and will not ignore the evil one who snatches away their fruit.  That the good will be claimed back for eternity.  That their giving will not be futile.  That the hours and days and months we seem to sacrifice, the waste and ache, will not return void, but will be redeemed.  That all will one day be well, even if tonight it is so very very hard.

Wednesday, April 15, 2015

Garissa and Ziklag

 On Monday our hospital chaplain opened our prayer time asking us how we felt when we heard the news about Garissa the week before (if you somehow escaped the news of this tragedy, four terrorists from Al Shabbab walked into a Kenyan university in the pre-dawn hours of Maundy Thursday and systematically gunned down 142 students and 6 guards, purposefully selecting Christian kids, to protest Kenya's contribution to African Union peacekeeping in Somalia).  I thought:  stunned, vulnerable, responsible for concentrating over a hundred missionary souls in a potentially dangerous place, anxious, jumpy, surreal, and pretty quickly walling off my heart to panic and imagination as my mind probed the reality that MY kids are this age, one still in a Kenyan school that could be a target, the others University students just like the victims.  The hospital staff were mostly silent in response to his question, but one voiced what many must think:  I only wished I had a machine gun.  He was angry, and he wanted justice.

Evil targeting youth and vulnerability is not new; diabolical plots to demoralize have plagued us for millennia.  The chaplain proceeded to 1 Samuel 30, where David returns home and finds his town of Ziklag burned and plundered, all the women and children taken captive.  They "wept until they had no more strength to weep" and then "the people spoke of stoning him (David), because all the people were bitter in soul, each for his sons and daughters."  Grief and anger; the weary helplessness of loss lashing out to blame.  I think we can all relate to that in Kenya right now.  

The next phrase, though, is deeply beautiful.  "But David strengthened himself in the LORD his God."

In a time of tragedy, let us start with our souls.  Somehow we have a capacity for strengthening.  Worship.  Truth.  Invitation to God’s presence.  Raw clinging to faith.  David must have wondered how God allowed his enemies to triumph.  For all he knew, he and his followers had lost everything.  But he moved towards his God.  He needed that settled internal anchor to make wise decisions in his response, to keep himself from giving in to despair. 

Let us strengthen ourselves in the LORD before we bomb villages and empty refugee camps, before we allow the evil of four to quash our love for a nation.  Let us turn to our God with our sorrow, and our fear, and our questions for our children’s’ future.  The rule of law must dispassionately ensure safety and justice in this land; the law of mercy must temper our hearts as we care for patients of the same ethnic background as the terrorists.  Holding those two things together requires a serious inner strength, that only the LORD can provide.

Wednesday, April 08, 2015

Space for the Unexpected, and true Community

Those were our goals going into a ten-day period of back-to-back conferences for our field.  First a five-day Leadership training for the team leaders from our four countries, then a five-day all-field retreat for everyone.  Logistically, managing 112 people for various time periods coming from various continents (3) and countries was a mammoth task, and over the last year I would not have made it without the unflappable, steady, patient task-completing Heidi Lutjens.  In fact we started well over a year ago wrangling a date and location, inviting speakers, planning a theme and a flow.  Eventually we narrowed it down to Easter as the time period most people could come, and the Kenyan coast as the most affordable and relaxing destination.  Terrorism in Kenya, I said?  Sure, but the risk is statistically the same as being killed as a student in a school shooting in America.  Now that all is said and done, Heidi and I are both taking a few recovery days and breathing a sigh of relief.  But not just relief, true gratitude.

Because the Garissa attack sickened us with sorrow, and heightened tensions where we were as well, though hundreds of kilometers from Garissa.  Our hotel was just over the border of the coastal zone considered "safe", in the wrong direction.  We were fairly remote, and there was another group like ours also meeting.  It is not easy to invite people we love into a time of refreshment, and then sense the weight of risk and danger.  Our hotel stepped up security and our guardian angels worked overtime, and in spite of some illnesses and anxieties we emerged mostly intact.  Our hearts were with the Garissa students, mourning the cruelty and evil so palpable in that slaughter.  When you "retreat" in this part of the world, it is only a temporary gathering of strength to return to the battle which continues to rage.  And I don't mean the battle between Kenya and its neighbor.  I mean the battle for hearts to forgive, to connect, to choose love over violence.

Space to encounter God was our primary goal.  We set aside time for worship, for the preaching of the Word, for silent reflection, for small group discussion, and for prayer.  In each of these settings different people engaged with God in their own unique ways, and the Spirit was at work.  We watched as some who arrived broken with mourning, weighed down with despair, weeping with discouragement, drank from the well of God's presence and life.  Our theme was the rhythm of Holy week:  surrender, suffering, loss, resurrection, and journey.  As I doodled those words in planning months, getting over the wall of our will, descending into suffering and loss, rising into life and going out into the world, they reminded me of an EKG, so Liana Masso designed a word-logo for our time, to show that this rhythm is our heartbeat of life in a broken world:

We want our teams to fully engage in a theology of the cross.  True worship begins in the wilderness, as Michael Card writes, where we surrender our will, and lose our lives, and hold onto the God who is present and loving even when we have no evidence.  New life starts in that darkness, the subtle seed that grows.  We grasp the truth by faith, we empathize with the suffering of all around us, and we reach resurrection with scars to show that it is by wounding that God heals.  Then that resurrection power pushes us into the world, where the impossible becomes true, where power is unleashed to make all things new.  We work to bring peace to people who have been looking for it in the wrong places.  And as we move into the world, we find that the main person God is pursing is me, transforming us as we live by faith.  This rhythm of loss and life becomes our heartbeat, seeing resurrection stories over and over.

And all of this happens not as lone pioneers, but as a community of faith and work.  We loved our times of sharing stories and receiving prayer, of gathering around and laying on hands, of lifting each other's hearts and cries to the Lord.  We shared meals, we talked in groups, we danced on the beach.  Our retreat time was bookended by sacrament.  To begin, a Messianic Passover Celebration, an ocean-side sunset retelling of the exodus from Egypt in the context of Jesus' fulfillment.  We sat in the sand (at least a bit authentic to the wilderness of the Sinai), leaders washed feet, wine and unleavened bread were distributed.  And our last night closed in a time of prayer for new fields, then communion together, a circle of goodbye and benediction.

Many thanks to our supporters, who helped us subsidize some of the extra costs for travel for those who could not afford it, an purchase some supplies as we were the primary planners and hosts.  Many thanks to our Serving Center leaders who came to participate.  Many thanks to Joanna Stewart and her amazing team of childcare volunteers, including a handful of former missionaries who came to bless us on their own dime.  Many thanks to our Kenyan hosts, whose hotel became a place of respite.  Many thanks to Heidi whose planning meant that our massive bill was spot-on expectations as we settled accounts yesterday morning.  Many thanks to Scott who survived working in the ebola-zone, and quarantine, and landed just in time to walk through ten intense days of ministry with me, patiently praying and listening through meetings too numerous to count.  Many thanks to all our Sergers, whose presence and vulnerability and laughter made the entire time a delight.  Many thanks to God, who protected us and met us.

And today many thanks to two non-Serge families who invited us to four days at a nearby beach house, where we are able to lay down the responsibility that has been pretty intense over the last few months and just rest.

Planning a regional retreat is a little like having a baby--so much work and pain, you think as you go along, I am not able to do this again.  But then the reality of engaging with people we love and blessing them with opportunities to be filled, well, it makes all the struggle fade, and the relief of finishing is tinged with sadness that we will have to wait another three years to do this again (we try to have one regional gathering between our 3-year cycle of all-mission gatherings).  Thanks to all who prayed and read this far.  Signing off to rest!

Tuesday, March 24, 2015

Depth of Field

Most cameras, and I, can not focus simultaneously near and far.  I have to choose a certain depth of field, and my attention goes there.  The last couple of weeks I feel like I've been zooming the lens in and out and in again.  

Most of the day and every four or five nights the focus is tight, and specific.  Tiny little lives that struggle.  Lungs that aren't filling with air, blood that teams with harmful bacteria, intestines that aren't digesting milk, skin that is broken down or infected.  My patients weigh anywhere from 900 grams to a few kilos.  They are jaundiced or febrile or anemic or dehydrated, and they can't ask for help.  So it is my job each day to plunge into a sea of chaotic activity and sort out the serious problems from the distractions, to insist on attention to detail, to calculate and palpate and think and work.  To organize my team, to listen to their presentations, to check their plans.  To respond to emergencies, and teach.  We've been extremely crowded, wedging 28 babies into space meant for just over half that number.  We have an outbreak of a bad bacterial septic infection spreading.  It's been intense.  But I like the tight focus, the immediate crisis, the hands-on problem.  These babies are precious, and their moms are heroic.  Here is my view:

But the last two weeks have also required a zoomed-out focus, the panorama, the big picture.  Our team in South Sudan left under pressure of illness and rumor of war.  Our team in Bundibugyo has faced public pressure on the school administration, an unexpected resignation, loss which changes personal plans.  We are in discussion with multiple colleagues who are discouraged and in need of hope.  We are deeply involved in plans for our regional leadership training and then retreat, a 10-day stretch of ministry for six teams in four countries that begins Saturday.  Preparing schedules, thinking through content, meditating on talks, praying for each person coming.  This is big-picture stuff, the why and how of the Kingdom come, the survival of vision and purpose.  I invited a hundred people to a Serge party and desperately want God to meet them there.  This is one view, with parts of two teams over for dinner and prayer:

Both are the real work of the reversal of all that is wrong with the world.  Both are opportunities to pour our souls out on behalf of fragile people.  Both call for the Spirit's power.  For wisdom.  For perseverance. For patience and kindness and hope.

But it isn't easy to keep focusing in and out, to hold the full depth of our East Africa field in view all at once.  Yet Jesus does this, knowing each sparrow of a preemie whose little heart tires out, and knowing the major political forces at work between warring clans or the life-trajectories of dozens of intersecting people and families.

Tomorrow is my last day in the NICU for a couple of weeks; Thursday I fly down to the coast to meet Heidi who has been a rock of can-do organization these past months as we have planned these retreats together.  We have Friday to finish up all the details for both retreats.  Scott flies back to Kenya and meets Jack late Friday night, and they arrive at the coast with all the others on Saturday.  He has finished quarantine, and our two-month separation is down to just under 4 more days.

Pray that all these babies would be healed and strengthened and thriving as I go and leave them in the hands of a visiting Canadian paeds NICU fellow.  And pray that the last preparations for the retreat would fall into place so that many weary and hurting missionaries would meet Jesus.  And lastly pray that Scott and I would be unified in the counsel and leadership we need to bless our field, at all depths.

Monday, March 16, 2015

Death in Liberia

Many of you received an email update from me in Liberia in which I asked for prayer for Bosco, a young man who sustained burns to 70% of his body surface after the generator he was filling with gasoline exploded (he was filling it while it was still running).  

I received an email from one of the doctors still working at ELWA Hospital sharing the sad sad news that Bosco died on Sunday morning.

Even at the best medical center in the USA, his prognosis with such extensive burns would have been about 50-50.  But he survived for six weeks.  And we all thought he was through the worst of it all.  

His wife was truly amazing - Felisha.  She never left his side.  She never complained.  She would help him get into a big tub of warm water every morning and slowly peel off the sticky gauze dressings so that clean ones could be applied.  This was a pain-filled, revolting task.  There was a putrid odor that filled the room from the wounds.  She cooked every day for him on the sidewalk outside that little room.  And she always smiled when you came in the room.

I shared in the task of applying the daily gauze dressings.  I would lay the sterile gauze on so gently after applying a thin layer of Silvadene - and he would still wince from the pain - but not complain.

I discovered that he was a Chelsea football fan at one point and brought him news of one of their winning games.  It’s the only time I saw him smile.

I feel so so sad for Felisha and his family.  They were all so hopeful.  

It’s easy to shrug it off and say he lived longer than he should have.  He didn’t have a chance.  But I was with him and he was so alive so hopeful for so long.  

I offer this little piece of cyberspace as a memorial, a remembrance to a courageous and perseverant man whose life was cut short.  The Old and New Testaments are full of reminders to Remember.  I remember Bosco.  He death leaves a void, a hole, a gap which shall never be filled in the lives of his family and friends.  I pray that his family will be reminded of the Big Picture, of the Resurrection, of the Hope to Come - but I’m sure that seems very very distant at this dark hour.

Sunday, March 15, 2015

In like a Lion, out like a Lamb?

March has been one angry lion so far, ripping into our Serge field.  The month started with two funerals for close family of Sergers.  Then a medical evacuation, and soon after a political one as the peace accords in South Sudan faltered and rumors of conflict abounded.  Every few days it seems we have deep conversations with Sergers who are wondering if they can make it, life is just so hard.  Evil abounds, and last week threats and pressure caused our beloved head teacher at Christ School to resign, probably a victim of tribalism and greed.  His loss to our team there is huge.  Our teams live on the hot and dusty edges, where there are dangerous thieves, fatal diseases, needy demanding people day-in and day-out, bugs in your food, conflict with others, and the chronic background sadness of being lonely for loved ones and familiar places.  We endure separation and danger and then at some point it becomes just too much.

For me, the battle is up close and tactile, and sometimes all-night.  One call this week, amongst the 50 or so kids I was covering on our three services were a list of diagnoses so long and diverse you can't even make this stuff up:  a congential brain tumor, a teenage schizophrenic, a toddler with a perforated esophagus leaking into his lungs after swallowing a caustic chemical, a baby of uncertain gender due to an enzyme mutation that affects hormone production as well as life-threatening fluid and salt balance, several new spina bifidas, meningitis, TB, a kid with AIDS who had been doing well but came in respiratory distress, tiny premature babies, the usual malnutrition.  Yesterday on Saturday I went in at 8 am and did not stop until Sunday 2:30 am except for a quick "lunch" at 4ish.  We admitted seven new patients, including two babies with critical brain-damaging levels of jaundice that have to be treated with an exchange transfusion, in which we remove and replace the entire blood volume of the baby twice over, a little bit at a time, which takes HOURS.  Another baby who had lost almost 1/3 of his body weight in two weeks of not feeding, leading to kidney failure and labs that were off the scale.  And for good measure, a 28-week 930-gram premature delivery to a mom whose first two pregnancies ended in deaths in utero.  She's so far tiny but pink and fighting.

March has been, in a word, relentless.

This morning, as I struggled to stay awake after going back in to the hospital briefly, I thought about the Lion and Lamb image.  All through the Old Testament, God uses the Lion as a way to describe his own chosen rulers, and Himself.  A ruler, who can rend judgement in no uncertain terms.  Unpredictable.  Frightening to those who do evil, which on some level includes all of us.  CS Lewis used these passages to develop the character of Aslan, who is most decidedly NOT safe, but GOOD.  Then 1 Peter speaks of the devil as a lion on the prowl, seeking whom he may devour.  So as we go through these trying circumstances of sorrow and harshness and loss, we sense the lion tearing in.  Only we don't know, is this God allowing suffering for ultimate redemption, or Satan attacking?

Or both?  March is a picture of the span of redemption.  It comes in like a lion, with judgement and fear.  But goes out like a lamb, because the lion ultimately wins not by ripping apart the enemy, but by becoming the lamb of sacrifice.

May we see the rule of the Lion of Judah, won by the bloody helpless death of the Lamb of God.  May we fight injustice with the dangerous teeth and courageous zeal of the King of the cats, but be willing to suffer the consequences with the humility and voluntary brokenness of the smallest of lambs.

Thursday, March 05, 2015

Post-Liberia Quarantine - not quite jail

I did my homework and I planned to isolate myself in my parent’s home in California for 21 days following my service in Liberia.  I chose to come to the USA because Kenya wouldn't allow me to come back and because I know almost everybody treated for Ebola in the USA survives. However, I wasn’t expecting the level of intense scrutiny and enforcement from the Federal and State authorities which I’ve experienced.  

When I arrived at San Francisco airport on Tuesday evening, the Immigration and Customs Officer nearly gasped when he read “Liberia” on the list of “Countries Visited” on the form which I had filled out.  He immediately picked up the phone calling his supervisor.  “Is Liberia one of those countries where they have Ebola?”  He then looked at me and said, “We need to take you to Secondary.”  We walked down a long hall while he insisted a half dozen times that “this is really routine”, “they just want to ask you a few questions”, “this won’t take long”, “you are going to be just fine.”  His level of anxiety was starting to stress me out.  

I was ushered into a small room, given a mask to put on my face, and asked to wait.  A mask, really?  Ebola is not an air-borne disease - so I put the mask on the desk and waited.  After a half hour with no information, a Senior Immigration entered.  “You just came from Liberia?  And you didn’t pass through one of the five designated Ebola Screening airports (JFK, Dulles, Newark, O’Hare, or Atlanta)?  That’s not suppose to happen.”  It happened.  I had purchased my own air tickets - in separate purchases.  The first piece was the Brussels to Monrovia leg.  I had to get that in place before I could figure out the rest of the complicated travel.  My itinerary ended up looking like: Nairobi-London-Brussels-Monrovia-Brussels-London-SanFrancisco.  Kind of crazy - but it worked.  Despite not being a designated screening airport, the San Francisco Immigration Dept did manage to get the job done.  They had a prepared packet from the CDC for travelers returning from an Ebola-affected country.  It included a “symptom-checklist” and a digital thermometer.  We then went through the detailed symptom review with a CDC doctor from Atlanta by conference call, took my temperature, got every possible contact and address from me and after about an hour, I was released.  My was the lone bag left, sitting by the quiet conveyor belt from the London flight.

While in the car on the way home, I was contacted by the California State Department of Health who informed me they would be calling me in the morning to set up our Quarantine Process.  Finally reached Mom & Dad’s home late in the evening.  First time I have ever come home and not been able to hug my parents.  My dad gives the biggest hardest bear hugs to welcome me home - but not today.  During dinner I got another call from the CSDH because they wanted to give me a special number to call in case I developed a fever overnight.  “Don’t call 911.”  Those First Responders are not prepared to handle you.  Call this number and we will send a Special Team if you get symptoms of Ebola (read: Hot Zone Space Suit-clad Team).  You’ll be taken to the University of California at San Francisco which is the Regional Designated Ebola Treatment Facility.  OK.  (Gotta remember to take that malaria prevention medicine, I thought, because any fever is going to be a disaster).

The next morning I was called by a Public Health Nurse representing the California State Department of Health.  Yet another hour of questioning and explaining of the context of the situation where I worked in Liberia.  Then…4 hours later the doorbell rang and the Director of the San Mateo County Department of Public Health came to serve my “Quarantine Order”.  This was a legal document stipulating the very specific terms of my Quarantine Period.  No public contact of any sort.  I may not go anywhere where people gather.  No shopping, no restaurants, no church, no theaters.  No public transport of any kind: train, boat, plane, subway. I may leave the house only to go for solitary exercise.  And I must check in by Skype twice a day: 9am and 4pm.  During that time, the public health nurse will watch me take my temperature with the digital thermometer - and I will show her the reading on the Skype camera.  And report if I have any symptoms consistent with Ebola. Violation is punishable by stiff fines and/or  jail time.  Enforced by the Sheriff of the County.

The Director (a doctor), told me that there are currently about 1400 “travelers who have recently returned from the Ebola-affected region” who are currently being monitored and in quarantine in the United States.  Of that group about 95% fall into a “Low Risk” category meaning that they were not involved in any patient care.  I’m in the “Some Risk” Category (the other 5%)  which includes those that worked in an Ebola Treatment Unit or provided general medical care in a non-Ebola setting.  The “High Risk” Category is for those who have had a known body-fluid exposure from an Ebola-infected patient.  The “Low-Risk” group reports their temperatures but doesn’t do it in the Directly-Observed-by-Skype method which the “Some Risk” does.  Many of the “High Risk” workers seem to be admitted to a hospital for testing and observation.

So, this little vignette certainly serves to illustrate that the CDC has their game on. They are super-organized and super-serious.   I didn’t really expect this level of intensity in my post-Liberia monitoring.  Is it onerous? Not really.  Every person has treated me with kindness and respect.  The San Mateo County Public Health staff have expressed their appreciation to me personally for my sacrifice and service.  Of course, it might feel a bit more oppressive were I not staying with my parents who live two blocks from the Pacific Ocean and pamper me as if I was their only son.  Three weeks of jail = three weeks of rest.  And I got three free digital thermometers courtesy of the CDC. 

Wednesday, March 04, 2015

Leaving Liberia

After a month in the sweltering heat of Monrovia, Liberia I’m bundled in my fleece watching jumbo jets rise into the gray sky over Brussels.  Monrovia seems a distant, ethereal memory already.

Sometimes over meals at home, we go around the table sharing “highs and lows” of the day.  That seems a reasonable way to structure a few reflections on this past month:


- To the best of my knowledge, I did not ever touch a patient with Ebola.  While I did have the opportunity to tour the largest Ebola Treatment Unit (ETU) in Liberia - “ELWA-3” managed by Medicins Sans Frontiers —  I did not go to Liberia to work in an ETU.  I went to support the transitioning weak medical system with general obstetric care. I also ended up covering the whole hospital for general medicine and pediatrics on my call days.  We know from experience that the hidden collateral damage of every Ebola epidemic arises from the fact that hospitals just shut down in order to protect their staff.  The result is that children die from malaria and women die in childbirth.  I did quite a few C-sections - all good outcomes - to that end.
One of the OB wards

- I relished the opportunity to work at ELWA Hospital.  Jennifer visited ELWA way back in 1982, when she was in Liberia for the summer with InterVarsity’s Summer Mission Program.  As mission hospitals go, it’s been around a long time (1965).  It’s a shadow of its former glory though.  The Liberian Civil War of the early 1990s took a devastating toll on the facility.  It’s in pretty bad shape.  The good news, though, is that Franklin Graham, the head of Samaritan’s Purse International Relief came for a visit, was completely appalled at the condition of the place, and committed SP to building a new hospital.  They are 75% of the way into a $3.5M hospital construction project.  It’s going to dramatically transform ELWA into a new era.  But the real treasure of ELWA Hospital is the spiritual heart of the hospital.  The whole staff meets daily for a half hour of singing, Bible study, and prayer.  Their bedrock and strength is God’s Grace and Love.
With Dr. Jerry Brown, TIME Magazine Cover Star

- Working with some of the most courageous people on the planet…the Ebola Fighters.    ELWA Hospital was among the first hospitals to establish an isolation ward for Ebola patients (an ETU).  The hospital closed for a brief two weeks in August after three American missionaries were infected with Ebola, but Dr. Jerry Brown insisted on re-opening the hospital because pregnant women were going to the personal homes of ELWA’s midwives in order to deliver their babies.  Dr. Jerry Brown appeared on the cover of TIME magazine regaled in his Tyvex suit and goggles because he bravely treated Ebola patients when no one else would.  But there are many many others.  Nurses , midwives, lab techs, janitorial staff all came to work at significant personal risk, because they believed it was the right thing to do.  So far close to a billion dollars has flowed into Liberia from outside donors.  The ELWA staff have been promised “hazardous duty bonuses” by the government (approx $300/mo x 6 months for the midwives), but as of this writing, not one dollar has been received by any ELWA staff.  Are they on strike?  No they just keep working.  
With my team of midwives


- The heat.  

- The poverty.  Liberia is a hard place.  The soil is sandy and there isn’t much that grows there except palm and rubber trees.  It’s billiard-table-flat so the country has no ability to generate it’s own power from hydroelectric.  When we flew in over the capital, Monrovia, I was shocked at the darkness.  A capital city immersed in darkness?  No grid electricity.  The country runs on generators.  Liberia also has the poorest physician-to-population ratio in the world. (50 Liberian doctors for 3.6 million people before Ebola).  Doctors fled in the civil war - and of those that remained, some died in the fight against Ebola.  Life was a struggle before the war, before Ebola, and now everything is broken.

- The threat of Ebola.  While I feel confident that I didn’t actually come into contact with any Ebola patients, every patient we saw was screened for the possibility (temperature taken, symptom checklist reviewed).  Everything we did was viewed through the lens of Ebola.  Almost everyone has malaria which means that many, many patients arrive with fever.  We tested many for Ebola.  We worried about Ebola.  We wore impermeable gowns and gloves for every patient encounter.  Thankfully the NIH Ebola Lab was actually on the ELWA campus so the wait for an Ebola test was never more than 24 hours.  In the last week of my work, there was only one new confirmed Ebola patient in the whole country.  That was encouraging, but the fact that in that same week, Sierra Leone had 65 and Guinea had 33, was disconcerting.  Until all three countries are Ebola-free, none of these severely affected countries can really relax.

- The deaths.  I saw a lot of people die this month.  Most heart-breaking were the preventable deaths.  A newborn developed tetanus four days after birth because his mother was not properly vaccinated and died a horrible death of spasms and respiratory paralysis.  (Did the mother fail to understand the need for vaccination—or was she afraid to come to the hospital because of Ebola?) An 8-year old died of rabies after being bitten by a stray dog.  I poured myself into the care of a 16 year girl who had severe and protracted menstrual bleeding for over two years.  After hormonal therapy failed, we began to think she might have had an inborn blood clotting disorder.  She was in-and-out of the hospital over three weeks of February during which time she received twenty units of blood.  We finally decided that it would be life-saving to remove her uterus - but the father refused.  She died the next day.  I went to my room to weep alone.  The incomprehensible senseless deaths just weigh you down.  The death of a healthy 16 year old girl.  The death of a healthy newborn for lack of a tetanus immunization.  Doctors who die from Ebola.  Our dear friend Dr. Jonah died from Ebola back in 2007 leaving five girls and his wife pregnant with their first boy.  In our human understanding, there is no way to justify these things.  While there can be beauty from ashes and fruit from the seed which dies, the fact remains that Death steals Life that it does not own.  We have six new doctors in training in Bundibugyo who were sponsored in the aftermath of Jonah’s death—but Melen is still a widow and his only son is still fatherless.  While I have been freshly struggling with the tragedy of such pointless, inexplicably wasteful deaths, I suppose that is some small way I must admit that is only in this suffering, in wading through this wilderness, that I seek and search and cry to understand the Mystery.  And as I ponder the Infinite, squinting through the tears, God is there.  And He defies Explanation.  Here is where the Psalms of Lamentation abruptly switch from wailing to worship, from agony to faith. The alternative is bitterness and despair—and I refuse to go down that path.

It’s been a long road, this path to Ebola-Land.  Jennifer has paid a high price, keeping all the balls of our Kijabe Life in the air in my absence.  Doing all the cooking, hosting house guests, taking extra hospital call, caring for the dogs, teaching our Senior Boys Sunday School, handling a bevy of crises among our Serge East Africa Teams.  She’s been burning the candle at both ends and in-between.  I’m thankful for her and miss her desperately.

Now I’m putting even more distance between me and Jennifer as I head for California to hole up and wait 21 days to make sure I don’t develop Ebola.  I never did go “skinny dipping in Ebola juice” as one of our oh-so-compassionate blog commenters suggested that I do — so I doubt it will be a problem.  I will be taking my temperature twice a day and calling it in to the California State Health Department.  I’ve not missed a dose of my malaria medicine, so I’m hoping that I don’t get any fevers at all.

Thanks so much to all who prayed and continue to pray.  And give.  We are your hands and feet.  Thanks for your partnership.