HAPPY 15 TO CALEB

We celebrated Caleb's 15th early, together, the last day we were in Kenya with him. But today is his real birthday, and it is sad to be apart. His dorm parents and guardians will recognize the Bday later in the week I think, but today he's kind of on his own. This, right now, is the cost, paid by our kids and our parents and us. It is mostly worth it, by faith it is ALL worth it, but that does not mean that we don't feel the sorrows along the way.

Meanwhile we are steaming in soggy Bundibugyo, the tropical rain forest where clouds smother in unseasonable dampness. And Luke is shivering in Boston, as the East Coast gets yet another snow storm, concluding a weekend interview and hoping to get on a plane tonight back to Kenya. Life goes on, the Saturday surge of people and issues and contracts and money owed, domestic disputes next door, disappointing grades as exam results come back for some, future plans for our boys, issues at school, neighbors who are sick, projects, demands. And today, the return to normal rhythms, breakfast with the Johnsons and Nathan, greetings at church. In the midst of separation and uncertainty the song we sang this morning comes to mind . . "kangumire hali Yesu" . . I cling to Jesus.

must-read

This is Kevin Bartkovich's testimony as presented at Exeter where he now works. Powerful. I didn't think I'd cry over the story again, but I did. Read it: http://kwegesiya.blogspot.com/2010/02/meditation.html.

Marching to End Chronic Hunger

After a very brief check on the Johnsons this morning and hurried rounds, we went up to Bundibugyo town with Nathan and Emily to attend the launch of World Food Program's new campaign against chronic child hunger. Another interesting out-of-the-missionary-box day: first, the entire event had its conception really in the scientific surveys performed by our team, which showed that levels of chronic malnutrition reflected in stunting were more severe in Bundibugyo (and parenthetically Karamoja where our OPC-friends work) than any other area of Uganda. About 45% of kids slow down their linear growth in response to constant infection and inadequate food. Their striking shortness is just a marker for how hard their little brains are struggling to grow and develop, against the odds. So it is no wonder when later they fail to achieve adequate standards in school. Chronic undernutrition is a COMPLICATED sort of multi-factorial issue, a final common pathway of social injustice, poor choices, family disintegration, inescapable infectious diseases, poor roads, watery starchy protein-poor foods, unstable marriages, poverty, generational cycles, gaps in educational opportunities for the girls who will become mothers, individual greed and sin. So there is no one easy answer, and attacking the problem means asking an entire culture to consider child-nurturing practices and ponder where we have gone wrong, and how important a change would be, and what it might look like. Which is just the sort of place that missionaries should be, advocating for the voiceless children, contributing scientifically to the debate, and reminding us all that the issues stretch from microbes to heart-attitudes, and praying for God to send organizations with expertise and resources to do so much more than we could ever do on our own.

So back to today. Scotticus and Stephanie's research led to some papers, and that led to some contacts and short-term work in Kampala, and attention for Bundibugyo. Right at the time when WFP was changing its policy to address underlying causes of malnutrition and not just distribute food. Visits ensued, articulate and eager WFP staffers came and talked to us, and we expounded on all we've seen over the years. WFP hired a very creative and professional media-campaign guru named Richard who then mobilized many others. The government Ministries took note. There were trainings, meetings, ideas, proposals. And songs were written. Richard contracted two local talents to collaborate on a catchy-beat tune in Lubwisi that extolls parents to care about their children's nutrition. The major messages they chose to focus on were about balanced, varied diets, the impact of malnutrition on brain growth and school performance, the responsibility of men to care for their families (another original song: What is a Man? Who is a real man? Someone who drinks when his family is hungry? NO!) All of this came to a head today, when the launching celebration took place.

We arrived just in time to march with a brass band through Bundibugyo Town. ALL around Bundibugyo town, actually. Picture a sure drum and mostly-in-tune brass tubas and trumpets, banners, dignitaries, local people in campaign T shirts, us, and a thousand kids, winding through the market and up and down streets, waving banners and drawing attention. I looked down a lot to keep my footing on the uneven stones and mud. But it was great fun. The ladies I was marching beside laughed a lot. About half-way through I turned around to Scott and said "If only they would play 'When the Saints Go Marching In'" . . . and sure enough, a few minutes later, the tune changed and that was the next song! Sadly and foolishly I had changed at the last minute into my cheap Christmas heeled shoes, which I thought were more appropriate with my dress-up outfit, but as it turns out are not ideal marching shoes so now my feet are throbbing with blisters. I'm sure there's a lesson on vanity there, or a good parable about taking on some pain for the children of Bundibugyo!

Other highlights of the day: meeting two very interesting young men, PhD's from America and Italy now working with WFP, and having a long talk over lunch about the causes of hunger, and life in Bundibugyo. Seeing a creative mime/dance troupe from Kampala perform. Watching our own local musicians dance and perform their new song. Trying to concentrate on the political speeches when they switched into Lubwisi and weigh just what was being said. Having Scott called on twice to pray. Hoping that the several-thousand-onlooker crowd would take some of the message home.

Praying that Bundibugyo will be redeemed, that an awakened awareness of the impact of hunger on children will lead to real change.

Pediatric Advanced Life Support, and Reporters: Just another day . . .

I am mentally exhausted this evening, but as I think back on the day, I realize it contains just the mix of raw life-and-death and bizarre circumstance that I appreciate about being a missionary.  The day dawned grey after all-night rain, so my new friend Dr. Emily and I grabbed umbrellas and made our way through the muddy streets towards Nyahuka.  I rarely walk:  my bike is my usual mode of motion, but that was not so fair to Emily.  And I enjoyed the slower pace, the greetings along the way, stopping in at CSB, hugs to Justine who has completely transformed the library (Annelise's vision realized at last), hearty palm-shifting hand-shakes with staff, enquiries about my family.  At last we reached the hospital.  In spite of earlier quiet, Asusi warned me the ward was filling up.  But with her and Balyejukia, and Nathan and Emily, we began to work our way through.  Nice to have another pediatrician to discuss cases with, a fresh young American academic perspective.  Asusi and Balyejukia also know what they are doing, a strong team, and I tried to keep affirming the excellent decisions they had made in my absence.  Dr. Emily has begun to research the diagnosis of TB in children, a subject dear to my heart, and we had a couple of perfect examples of the challenge of sorting out a malnourished child's root problem.  We were just deciding to put a 4.9 kg (10 pound) 3 year old twin with Sickle Cell anemia back on TB therapy (she had defaulted a year ago), when a family carried in their limp and unconscious infant.  Balyejukia quietly called me over, with the words "this is a hopeless case".

Well, as it turned out, he was right.  Let me begin by saying that 6-week old Tumwine did die at about noon today, probably because he had begun convulsing during the night and the flooded river made it impossible for his family to reach the hospital until mid morning.  But rather than feeling helpless and discouraged, I was left with a sense of marvel that our little primitive ward and team functioned so professionally.  Because I had just re-certified in PALS (Pediatric Advanced Life Support), it all seemed so familiar.  Bounding peripheral pulses with mottled skin and a 7 to 8 second capillary refill:  distributive shock, most likely septic.  Gasping respirations, cool, unconscious, critical.  We jumped into ICU mode, and my team was amazing.  I didn't even get to try one of my new spiff intraosseous needles because Balyejukia was so quick with the IV access.  Thanks to several lectures on septic shock I didn't hesitate to push hard on fluids.  We had ambu-bags from Heidi's nurse friends, and Emily assisted the child's breathing throughout the almost two hours of hard work.  Fluids, dextrose, antibiotics, oxygen, epinephrine, an ng tube, labs, and prayer.  Airway, breathing, circulation.  Whenever his heart rate dropped, and sometimes stopped, Emily and I would do CPR for a minute or less and he'd come back.  Asusi was ready with every medicine, and corrected one of my dosing orders, which I thanked her for (which is a nurse-doctor scene straight from the PALS text).  OK I did have to dig up money for fuel and oil to get the hospital generator started to hum the oxygen concentrator to life, but it DID hum to life.  Sadly, though the baby's circulation improved, he never woke up, and over the course of the second hour his pupils stopped responding to light, until they were fixed and dilated, a sign of irreversible brain damage.  At that point we had done cpr numerous times, and it was taking longer to get his heart back each time.  I decided to do a lumbar puncture, more to have a head start on anyone else who became ill in the family than to hope to save this baby.  The cerebrospinal fluid was grossly bloody.  A hemorrhagic infection, or trauma?  Either way not a problem we could cure.  I am thankful God provided Emily that day, as we had to make the hard decision eventually to let him go.  The next time his heart stopped, we continued oxygen and waited a minute.  Nothing.  His grandmother, resigned, accepted our condolences.  We removed the tubes and wrapped his little body.

And then walked out into a ward that was filled with reporters and cameras.  Yes, Nyahuka Health Center, in the news.  Tomorrow World Food Program is sponsoring the launch of a new educational push to draw attention and action towards the problem of chronic undernutrition in Bundibugyo.  I believe that this is a direct result of Stephanie Jilcott and Scott Ickes' advocacy and research.  Several teams of people from Kampala, UNICEF and WFP, have come out to investigate, to talk to us, to ponder the fact that 45% of kids in Bundibugyo are stunted in their growth because they suffer hunger.  Almost half.  The impact is devastating, but quiet, felt in poor school performance, in lethargy, in sorrow.  Ahead of tomorrow's major launching party to-do, WFP brought reporters.  And so we suddenly found ourselves answering questions for the New Vision, the Monitor, the Independent, while Uganda TV cameras rolled.  A bit flustering.  I tried to remember the important stuff, emphasize social issues, team work, multi-factorial causation necessitating creative holistic approaches, education for girls, etc . . . but who knows what I actually said and how it will come out.  Bewildered parents who agreed to talk had their photos snapped a dozen times or more, with their skinny scabby kids.  

Last patient of the day, patiently waiting until the ward quieted down mid-afternoon, an HIV-infected mom on anti-retroviral therapy,  with a not-yet-infected baby, deciding to wean.  Thanks to the conference I had good data for her on this issue, and a more scientific and reasonable assessment of her risks, which are GREATER for weaning (death of the child from infection and diarrhea and malnutrition) than for continuing to breast feed (death from AIDS).  She still wanted to wean, so we affirmed her choice.  And prayed for her, and talked about her life, too.

So, a crazy day, but not so unusual.  Families in crisis, looking for help.  Opportunities to pray, to offer advice, to teach, to advocate, to emphasize, to protect.  Individual tiny important lives, in the balance.  An entire society, also in the balance, pondering big cultural questions of family unity and responsibility and the impact of adult decisions on child survival.  Jesus reached people through their concern for their kids, children who convulsed, who had fevers, who died, whose parents came to him in their time of sorrow.  I'm glad to be a small part of a good team of Ugandans and missionaries doing the same.

God's Welcome

7 pm, a light misting rain and a setting sun, the team gathered at the up-til-now Masso home waiting to welcome the Johnsons.  Jack and Julia and Ashley and Anna have posted welcome signs and decorated the porch, Loren has a full-team dinner cooked and keeping warm in the oven, Nathan has pushed the electricians and the house-crew to be finished and ready for this moment.  We look up, and there is a brilliant full-sky arching rainbow, fully visible from start to finish, spanning their entrance.  Then we hear Scott's horn, and he drives leading the way up the hill, followed by the Johnsons in their car, through the rainbow and into their new home.  Scott jumps out with the new black lab puppy he and Travis picked out yesterday evening.  As Amy notes, could their life not have been full and complicated enough with 23 bags, 3 kids including a not-quite-4-month old, a new job, a new home, a new country?  But the puppy makes a house a home, and Lilli is clinging to this little guy for dear life.  The whole group spills out, slowly, gathering shoes and emerging from seat belts, watching the last color of the rainbow fade in the evening light, welcomed by neighbors, and entering their new home.  Patton is immediately mesmerized by a toy rocket left by Gaby, and delighted with the "Cars" sheets on his bed.  There is much chatter and laughter, going from room to room, the sense of a year-long journey of faith finally ending there.  

Not ending, of course, only beginning.  Just as Noah's landing from the ark was not so much the end of their survival of the flood disaster, as it was the beginning of a new life in a new land, a holy freedom to walk out into the world and live for God, under His promise to restrain the consequences of sin, to give us all space and grace to plunge in.

half-home

Three of us are back at home: I drove Heidi's car (she actually flew to the USA for the funeral of her grandmother) with Jack, Julia, Ashley, and visiting Dr. Emily Pearce (med-peds resident from Indiana University, we met by blog and email thanks to Bart connections at Blacknall when she was an undergrad at Duke), ten trunks, and some groceries, back to Bundi yesterday.  Today Scott will lead the Johnson family in our truck and the former-Pierce now-Johnson-mobile with the rest of the loot, medicine, food, 3 kids, and . . . a puppy. As Scott said last night on the phone after failing to get my passport extra-pages (US rules), and failing to get an extension on one of the aspects of our work permits at immigration (Uganda rules), and sitting in Kampala city traffic for HOURS, does it really have to be this complicated?  Prayers for peaceful hearts in massive transition much appreciated all around.  Good to be back in our own home, in spite of the fact that dust, roaches, and lizard droppings abound.  Life is just a lot of work.  

Goodbye again

Woke up this morning realizing that for the first time in two weeks, we're back in a different country than Luke and Caleb. And missing them even more, because of that. During the conference we stayed at the Moffat guest house: one of the truly great deals left in Africa I suppose, we ended up spending about $4 per person per day on lodging and another $4 per person per day on food. Pretty basic, but that allowed us to bring the whole family for less than a single doctor would pay at the conference center.

And more importantly, to taste from the fringes a bit of Kijabe/RVA mission life.

We toured Kijabe hospital on Friday: busier than when we worked here during an evacuation so many years ago, but not completely different. 260 beds, 112,000 outpatients/yr, 2000 babies delivered/yr, 9000 surgical operations/yr. Forging ahead to build African leadership: where there were once only missionaries and 3 Kenyan interns, now there are about 8 Kenyan fully-qualified "consultant" physicians and probably 2 dozen doctors-in-training. The missionaries still serve a vital role, but one that is slowly shifting into the background, as it should, year by year, bit by bit. There are ventilators in an ICU and preemies in incubators, and pounding construction as new theatres are built, and hundreds upon hundreds of personnel bustling about. It's pretty impressive. Peaked into the two-bed delivery room where I had Caleb in 1995 on the left-side bed, and Jack in 1998 in the right.

Jack and Julia attended a day of classes at RVA. I think the thing that struck them most was that they blended in, that it was not immediately obvious to everyone because of their skin color that they were different. And that the classroom atmosphere was less intimidating than a Ugandan secondary school, the work more easily understood and accomplished. Kind adults invited Jack to a class party one evening for 7th grade, and he bravely walked right into the fun, no hesitation. Reassuring to parents who wonder about our kids' adjustments.

We really stayed an extra day, though, to see the social event of the year, known as "Banquet". Because of the conservative mission roots of the place no dancing is allowed, so the equivalent of the Junior/Senior prom is an elaborate dinner theatre. Juniors and their parents and sponsors work for months to prepare a creative set, this year with the theme of ancient Greece (last year Luke's class created Willy Wonka's Chocolate Factory). Between acts, a gourmet meal is served. Caleb was a tunic-clad waiter, joining many other 10th graders to serve their older classmates for the evening so they could sit at beautifully decorated tables in their formal-wear enjoying the show. The whole thing is very hush-hush in the weeks leading up to the BIG NIGHT, the theme is a CAREFULLY GUARDED SECRET, so that the Seniors are surprised when they walk into the hall. The evening begins with the guys at their dorm getting dressed, taking photos, arranging flowers, corsages. Parents were allowed to hang around with cameras and pin on boutonnieres. Luke and one of his best friends decided to carry on a tradition of wearing two garishly tacky 70's loud suits that had passed on from generation to generation, surfacing every couple of years or so to much laughter. I admit that we were a bit shocked when we saw our son . . . worried that the elegantly dressed young lady he was escorting would burst into tears or at least second-guess her choice of a date. But he was having such a blast with his buddies and all assured us the girl has a great sense of humor . . . After many dorm photos the boys then go in small groups to the girls' dorms where they are allowed in one by one to pick up their dinner partner for the night, whom they escort arm-in-arm up a lantern-lit path to the hall. Watching, I'd say it's a healthy introduction to genteel manners for a bunch of kids who have grown up in some pretty primitive circumstances, and a memorable milestone for their final year together.

The evening lasts well past midnight (2 am??) so the boys were both pretty tired by Saturday. We made a family Bday (early) lunch for Caleb, and it was probably the most extended and relaxed time we had with them the whole two weeks, just hearing about the night and hanging out and eating without any other guests. On this Wednesday Luke leaves for his quick weekend-interview trip. Which leaves Caleb on his real Bday (next Sunday, 28th) the only Myhre in Kenya, the first time one of our kids will spend a Bday with NEITHER parent present. The rain soaks Kampala, dreary, the very atmosphere dripping with goodbye. I suppose though that goodbyes will be part of the essential fabric of our life from now on, with kids at boarding school and soon college, with ministries and travel.

overload and emptying

It is not just our truck that is sagging with good things:  our lives are full, too.  I've learned that I"m high-extrovert AND high-introvert.  Which means that the flood of interesting people, relationship, fact, and input from the conference and travel is great.  But that the lack of any sort of down time is wearing.  Good stuff, but so much of it at once!  

Here is a paragraph from Bethany's meditation on Lent (connect to the entire poetic and wise post from the side bar):

All I am trying to say is that you hear quiet things more clearly when some of the loudness is removed. This lenten season allows us to step away from some of life's noisiness to create space for the quiet thunder of our Creator. In that way, the giving up actually creates space to receive something you didn't even know you were missing.

Amen.  I know I'm thirsty, but riding the crazy rapids of the last couple of weeks, I haven't stopped to realize how. Or for what.  So praying for a little Lenten quiet, a season of hunger and thirst, a pre-feasting focus on that which we truly desire.

exodus

We exited Kenya yesterday, and I was catching up on my Bible reading in the car. I'm in Exodus.  As usual, life and story move in parallel.  We approached the border with trepidation, piled high with about 16 trunks/bike boxes/bags/coolers . . topped off with a double baby jogger.  Most all spiff, new containers, labeled from the US with airline stickers. Nothing illegal, it is perfectly OK to bring your stuff to Africa.  Only this wasn't mostly OUR stuff, and we didn't have a list, and to a Kenyan or Ugandan customs agent it could have looked like loot we had accumulated in Kenya to sell in Uganda.  Our axels nearly sagged with the weight.  In spite of the fact that God miraculously made a way through for out expired-visa-coworker on the way into Kenya (remember the angel-directed bus that swept into immigration flustering and hurrying the process??), here we were again, worried.  It didn't help when our border agent began suggesting tedious day-long bureaucratic processes that would have put all the paper-work in order.  

So we prayed and pressed on, but not with amazing faith.  Still, God helped us.  No one asked so much as one question.  We were waved on.

When I read about the Isrealites on their desert-crossing journey, it is easy to wonder why they doubt.  God provides rescue, they rejoice, but a few days later they are ready to give up and doubt again.  At each challenge along the way they are quick to assume abandonment.  

Yesterday, I realized, we're the same.  One deliverance is great, but no guarantee of the next, and we so quickly worry about the next steps.  The way ahead looks so unsure.  God tells Moses that the people are not ready for battle, so He graciously leads them on a detour where He can strengthen their faith with smaller trials of water from the rock and manna from the dust.  What looks to them like an unnecessary and directionless waste of time actually serves to build community, build faith, prepare them for the conquering of the land.  I need that perspective for the weeks and months ahead, deliverance in desperation to steel my heart.

sneaky grief . . .

 . . . stalked unexpectedly in a lecture on pediatric pain control during procedures yesterday, which reminded me of a horrific night in Bundibugyo hospital about ten years ago with Caleb having surgery under somewhat minimal anesthesia, trading off his cries for the risk of him not breathing.  Which in the context of this weekend's bout with pneumonia and the previous evening's return to school and separation, suddenly just overwhelmed my heart, so that I was hardly tuning in for the rest of the morning and as soon as Scott presented a sympathetic face at lunch the dam burst in embarrassing snotty tears.  Grief is that way, hiding in the shadows, ready to pounce when least expected.  

Later a sweet moment, a gift of memory that balanced that context.  We braved the rough dirt-road trek up the ridge in the evening to visit the home of the Kenyan lady who helped us back in 1997-8 when we had evacuated from war and were working here until Jack was born.  Over the years we've kept up with visits or short-term work together.  How many people can walk into a Kikuyu log home in Kenya and find several pictures of their kids displayed on the wall?  I love that.  We prayed for her elderly prayer-warrior mom and her brother with cancer, and thanked God that she now has a full-time job.  She was one of the first people in this world that Jack saw . . and here he was playing with her mangy puppy and drinking ginger-spiced tea.

Job said, the Lord gives and the Lord takes away, but in either case, blessed be His name.  Even in the small details of our lives, grieving over our struggles and losses but rejoicing in the gift of a kind friend.

Pulled

Pulled in many directions, mostly good ones.

The conference, a constant flow of interesting and important talks, sincere people, fantastic ideas.  In almost every hour there is a challenge for a new direction we could pursue to improve health, something we should change in our practice, reminders of things we have dropped.  In every break, there is another person we can meet, inspiring heros who have forged further down this road than we have, or young faces whom we would love to encourage to stick with this crazy life.

The guest house, a creaking old dorm of rattling window panes, a mix of teens and toddlers, a dozen of us around the table most meals.  Building community with our new and old team mates, trying to pay a bit of attention to our kids, touching base with long-term friends around RVA/Kijabe.  This weekend our boys were on "mid-term" break.  We had thought of getting away as a family, but Luke was pretty content to stay on-grounds since about a quarter of the senior class was doing the same, and he has never been on-station and out-of-dorm, to zip around on his friends' motorcycles and hang out at their homes.  Plus we had another team birthday (celebrating 7 in a month, 3 Myhre, 2 Johnson, plus Bryan C and Anna L!).  

As it turned out, it was good that we stayed.  Caleb came down with a pretty serious pneumonia on Friday, either a complication of the influenza or a secondary bacterial infection . . by Saturday morning he looked concerning enough to consider hospital admission, but turned the corner shortly thereafter (it's pretty handy to live in a doctor community where a friend has a portable pulse oximeter handy).  We skipped our classes that day, Scott took the other kids into Nairobi for some fun, and Caleb and I had some down time for recovery.  I am SO THANKFUL his illness hit exactly on our visit weekend for fast recognition, diagnosis, and treatment.  

Messages from students back home in Bundi, concerns about team mates whom we have asked to do a lot, thinking ahead of what faces us on return and through 2010.  Travel arrangements for Luke, invited to interview at a small engineering school where he applied for college, sending our just-17 year-old alone from Kenya to Boston for a weekend at the end of the month.

Pulled:  medicine, a world of data and learning, kids, relationships we value, the impending launch of one son to American life in university, the whisper of ever-present risk as God heals another serious family illness, glimpses of the future with new team and even potential-team, responsibility for those we love back in Bundi, bigger perspective as we encounter people from dozens of countries doing hundreds of good things.  Releasing a grip on the future, and walking by faith for the day.

The Johnsons

The Johnson family has arrived, like a gust of fresh air.  Sincere, eager, kind, affirming, interested, humble, competent, friendly, they jumped out of a van impossibly stacked with more trunks and bags than you could imagine. Creative Lilly, fun Patton, and sweet baby Aidan, three precious fragments of delicate humanity deposited here.  After all the goodbyes, at last a hello, a looking forward.  After many struggles, more partners to put their shoulders into the Kingdom together.  Hooooooraaaaaay.

CMDA

When we were in college, people described the experience of URBANA, the triennial student missions conference in the US, as "trying to get a sip from a fire hydrant."  So much amazing and relevant experience and information flowing past, a torrential outpouring of resource, that left one encouraged, overwhelmed, stunned, challenged, changed.  Twenty-five years later, this week at CMDA feels similar.  Though it is a tiny event compared to URBANA, we see the same element of passion for the nations, the same atmosphere of worship and zeal, the same congregating of admirable saints, and the same wealth of relevant experience and information all around us.  Our days begin before dawn so we can by in the car on the way by 7.  The morning worship includes teaching from veteran missionary and pastor and professor Robertson McQuilken.  Then there are four different simultaneous options for lectures and workshops, a total of 28 to 30 per day.  We go from hour to hour engaging with statistics about HIV and breast-feeding from studies just being published, brought by one of the most global-thinking competent lecturers I've ever heard.  Then on to a panel of experienced missionaries presenting their thoughts and experience about spirituality and healing.  Next a cardiologist presenting cases, or a radiologist teaching us how to differentiate benign and malignant tumors of the liver.  Or an update on changes in immunization policy.  At breaks and meals we meet new and old friends.  Among all the 6 billion people in the world, these few hundred are probably the most like us, and the sense of connection and understanding comes as a relief.  We stand in awe of the programs others have managed to wrest out of chaos, we listen with great thankfulness to professors who have given up two weeks of their year to come and teach us.  Then another 45 minute drive back to Kijabe where Ashley and the kids have prepared a dinner, we sit around a long table for 11 as the sun sets and the Kijabe winds whip down the mountain, rattling the window panes.

Reality inserts itself in real-time, occasionally, messages from Bundi, emails, calls, which have to be quickly discussed and juggled during the fraction of time left in the day.  Or yesterday, as I walked out of a lecture and saw an sms from Caleb, temp 101, feeling sick, admitted to the school infirmary.  A bit ironic to be talking about sick kids while my own lies alone, so I find an earlier ride back and sit with him for an hour or so.  Sad to see him there, but at least thankful that this time I CAN SEE him.  Praying his bug is much quicker to leave than Luke's week-long bout.

Luke, 17 years of life

Luke celebrated another Kijabe-based-birthday yesterday: we've ended up here in Kenya as he turned 2 (to have Caleb), 5 (evacuated and waiting for Jack), probably another couple for previous CMDA conferences, and now 16 and 17 here at RVA. The 8th of February was also our first day of conference: an intense morning of Pediatric Advanced Life Support doing CPR on mannequins and interpreting EKG tracings, then back to the mission house where we're staying to cook dinner and cake for the Bday, with huge help from all, especially Ashley. Luke and Caleb came down the hill with two friends to join our WHM family group including the newly-arrived Johnsons, Heidi, Ashley, and Scott Will. We played bowl-full-of-nouns with a Luke theme (such as "Mile-High-Over-the Nile Bungee Jump" or "Number 18 Parkville Community Soccer League" or "the Mujangile"), prayed, ate, sang, and sent him back to study. Luke at 17 is a young man who inspires confidence and respect, towers at 6 ft 2 in at least, laughs with his friends, can be impatient and restless, devours books, solves problems, plays soccer with passion and skill, and is poised to launch into life. He will do so his own way, and it will be good.

Four Pillars

As we pulled through the first week of CSB and getting ready to go to Kenya for our CMDA conference, I noticed with thankfulness four pillars who support our team: the "singles", as they are collectively titled, when their group is distinguished from the families.  Single people face a unique set of challenges on the mission field, not the least of which is that they have no spouse or family to cushion their loneliness when leaving home in America, and no buffer of continuity as others come and go.  And as a group who are younger and generally on a 18 month to 2 year time-line, they can sometimes feel peripheral or temporary.  But on our team, they are a core of strength.  Our teachers, for instance, are so much more than that.  Anna and Ashley do teach, but they also function as most of  the other positive adult influence kids from our culture have in their lives:  aunts, Sunday school teachers, neighbors, family friends, coaches, camp counselors, baby-sitters, role models, you name it.  This week Anna was on loan to the Sudan team to make their retreat time possible by teaching and encouraging the Masso kids, while Ashley took it upon herself to not only pack up curriculum for teaching our kids while in Kenya but also to think of art supplies, balls, recipes, and general life.  They make up what is lacking in the lives of MKs who have busy, distracted, stressed, or otherwise struggling mothers!  I guess that's been obvious for years.  The long line of teachers who have made our life possible in Bundibugyo have done so by taking a VERY broad view of the word "teacher".  They are joined by nurse Heidi, who has lots going on in her own life and growth, but from my view of the Universe was placed in Bundi because God knew I would otherwise not have survived.  It is invaluable to have a colleague who gets me, and is a friend, as well as one who does a lot of the behind-the-scenes administration that keeps the medical care flowing.  And Nathan, who spans both of those roles as a teacher as well as the primary point person for the BBB outpatient nutrition program.  We offered rather late for him to come to the CMDA conference with us, since he's entering med school next year.  He decided to stay in Bundi.  As we packed up yesterday morning, and Scott was handing over this thing to do and that thing to check on, we were getting in the car feeling a bit guilty about leaving him there, and a scene from Sahara (great movie) came to my mind.  In the scene the young hero-character calls his boss with a grim report on the situation at hand.  The boss says "I can't ask you to go in there" and the young man, who is of course just about to do the dangerous and impossible, replies "that's just the thing sir, you know you don't have to."  Nathan's that kind of guy.

Today I'm thankful for all four of these brave souls, who put up with us, with a difficult culture and living situation, with lonely separation from family and friends.  We are grateful for families too, of course, the Clarks who are nearing the one-year mark and the Johnsons who landed in Africa last night.  But a team takes a good mix of people, and we really need our "singles", pillars in the temple.

Mobile Study

When we arrive at the conference, day 1 will be an intensive course called Pediatric Advanced Life Support (for me) and Advanced Cardiac Life Support (for Scott).  This is not our first time to take it, of course, but it has been many years (should I confess I've never even SEEN an AED, the automatic defibrillators that I hear are in malls and airports and schools and everywhere these days??).  In order to offer the certification efficiently we're supposed to have studied the manual and completed a pre-test and reviewed 12 case studies.  So we're studying in the car, our only "down" time to prepare.  As we drove out of Bundi I opened the text.  And realized, I love this stuff.  Equations where cardiac output is related to stroke volume and heart rate, where the world makes sense in numbers and diagrams.  Pages of drugs where one has to choose, where there are options.  Glossy tables, color coded ideas, science, data.  Sometimes I forget how much I love medicine that is technical and effective. As I'm reading, I get a call from the health center, the blood bank is empty, I make more phone calls and beg for type B for my little friend with the UVA T-shirt who has a hemoglobin of 3.  Which is not even an emergency here, just a moderate deviation from the average marginal life.  The contrast makes me shake my head, and try to remember as in a distant dream a world where I might have just written an order in a chart:  transfuse 150 ml PRBC . . .and within a few hours it would be done.  Where Mr. UVA would have been on a heart monitor, pulse-ox chirping, oxygen available,  in a clean room surrounded by functional up-to-date equipment and attended by an army of professionally trained staff.  Instead, I'm calling from one district to another and doling out shillings for transport and hoping a set of tubing will be obtainable when the blood finally arrives, and that he'll have stayed alive two days eating beans from a common bowl and hanging out on his mattress.  All to say that a foray into the world of PALS, with its protocols and order, feels a little like going home.

At the Border

The Uganda-Kenya border, a brown-water creeping creek traversed by a single-file creeping line of masive transport trucks, women with baskets of bananas, scruffy kids peddling water, belching buses.  We sit now in the border zone, pounding sunshine at 10 am.  A woman passes with a large red duffel on her head, enterprising young men try to talk us into samozas or chapatis.  Our border agent Salim haggles for Kenyan road permits and car insurance while Scott leads the flock of fellow-missionary-first-time-over-the-border friends through the immigration process, and Jack, Julia, and I watch the cars.  We have left Uganda behind for a while, but only after a merciful miracle.  SW's visa had expired, and in spite of attempts to update it our time in transit was too short to accomplish that.  So it was with trepidation we approached the Uganda exit-immigration counter.  We could have been asked for anything from the full fee to a huge penalty to refusal to let him go to who knows what, . . .arrest?  Scott prayed.  Just as they put their passports on the counter, a big red safari-bus of Africans in transit pulled up, and disgorged a hundred passengers who pushed into the line.  The weary clerk did not even look at SW's dates.  Stamp, stamp, next please.  Hallelujah.  Now for more lines and paperwork and permits and money and questions and stress on the Kenya side, the usual ambiguity about price and procedure that always keeps you a little off-balance, a little unsure.  The zone is crowded, active, the rip tide of two countries' loose citizens milling, crossing, looking for opportunity, passing the day.

countdown to take-off

In about 8 hours we should be driving out of Bundibugyo, on the way to Kenya.  Every two years the Christian Medical and Dental Association puts on a 2-week conference for missionary doctors, so we can stay current with our continuing education hours and keep our medical licenses up to date. Of course it is also a wonderful opportunity to be encouraged, to not be ALONE.  Due to the timing of my Dad's death we missed 2006, and the post-election violence in Kenya led to cancellation in 2008, so it has been six years since we last attended.  This time we will be taking along nurse Heidi and PA Scott Will, and meeting our new doctor-colleague-team mate and family Travis and Amy Johnson, who will land in Nairobi tomorrow and wait for us.  And Ashley, to teach Jack and Julia while we're in class.  We're quite an entourage of 7 adults and 5 kids . . made even more complicated by the news today of ongoing insurmountable car difficulties for the Zoolander (the former Bart-mobile shared by the singles) which means that our truck will be the sole ground transport for all.  All of us but Scott Will are sharing a very simple guest house at the Moffat Bible College adjacent to Kijabe and RVA.  Though it is about 40 minutes' drive from the conference site, no kids/families are allowed at the conference facility to maximize space for missionary and national doctors.  So we'll be in a sort of commune, cozy, probably not overly-comfortable, but likely to be memorable.

Meanwhile, that means with travel to and from, we'll be away from Bundi for almost three weeks. Which feels like a LONG time, and less-than-ideal timing.  Scott has been severely pulled and pushed by the inevitably bumpy transition into the new school year.  And so leaving for a few weeks puts a huge strain on the last day here, friends still desperate for school fees for their orphaned siblings, our beloved dog with maggots from sand-flies, biting ants swarming outside our bedroom window, deciphering complicated spread sheets and making adequate money available for programs, persisting at the bank long enough to will one's way through the passive-aggressive managers, sitting down with visitors, the typical afternoon crisis of a fever in a neighbor's kid, the usual.

However, there were some reminders during the count-down-to-departure today that God smiles.  My first patient was sporting a very clean, spiff, University of Virginia (our school) T shirt.  And nothing else, of course. He was a 4 year old sickle cell patient whose smile and energy belied his hemoglobin of 2.2.  Of course we see all kinds of American-slogan shirts all over the place in the thriving used clothes trade, but I'd never seen a UVA shirt that wasn't ours before.  Fun.  The next bed held a child from Congo with severe malaria, no history of immunizations, looking bewildered by the whole hospital experience.  I shamelessly give every patient a little wrapped candy as I begin my exam, which distracts them, and as a gesture of good will counteracts the rumors used to scare children that white people are spirits who have come to eat them.  This kid looked at the candy so hesitantly, and held it so carefully, I was pretty sure he'd never seen such a thing before. Throughout the day I was struck by the competence of Olupa and Asussi, the nurses I love to work with.  I would put my confidence in them over most anyone I know (doctors included) to care for critically ill Ugandan children.  Then Nathan walked in to join us, and the next patient was one whom he had identified at an outpatient nutrition program months ago.  The child had been severely ill, basically starving, and would have died unless his path crossed with Nathan's and BBB.  He completely recovered and was back for a minor gastrointestinal illness.  Then my favorite little guy at the moment, Obeni, with TB, reached his weight goal today, another small gift for me as I hate to walk away from these kids.  Later Nathan told us about Day #1 at our newest outpatient site in Butogho where he spent the afternoon, an area that our extension workers identified as having prevalent nutritional problems.  Baguma Charles trained the clinic staff and volunteers in January, and today they screened kids for enrollment.  Everyone was so excited to see the program begin that they flocked to the health center, calling their neighbors to join, drawing pasers-by off the street.  Nathan estimated that at least 200 kids showed up, mostly NOT malnourished.  But among them they picked out 17 who were severely malnourished enough to qualify.  

Only 19 more minutes in today.  And the countdown of hours until we load the truck and pull out ticks on.  Time to finalize packing, to rest these kids in the Healer's hands, to accept what has been left undone, and go.  So we can come back, more ready to care.

welcoming home

Nathan arrived safe and sound, a welcome sight around 4:30 last evening, amazingly awake, strong hugs.  As our friends return from Christmas there is a sigh of relief, the realization of their absence and the hole they left, the-world-is-more-right feeling of being back together.  Now Clarks, Ashley, and Nathan are all home.  A dry-season perk is that the insect population is marginally less overwhelming, and since the inside of the house remains solidly in the 90's until well after sunset, we've been eating by candlelight on the little brick-and-bougainvillea patio outside.  So in the midst of a hectic week (the two babies I thought would die survived but a third I hoped would turn around didn't . . . Jack in tears after his first beginning-of-term exams when he realized he had made mistakes on almost every math problem. . . Scott mediating a dispute over which staff member needs the newest computer left to the school . . . letter written to explain why we are supporting the church leaders' decision and not over-riding their authority in a recent church dispute . . . accounting and prayer and stretching out the last of our food . . ) it was a taste of heaven to eat together, the candles flickering in a rare breeze, insects chirring, hearing stories of med school interviews and family times.

Monday, heat, bustle, beginnings

Monday, the start of a new work week, of a new month today, and of a new school year in Uganda. And of a team retreat for our Sudan team, and so the beginnings of dreams and plans and listening to God. The first day for CSB to be up and running without a missionary head teacher. And so a few impressions from today, mid-way through . . .

Heat: the dry season has at last arrived, after a month and a half delay. The oppressive cloud cover broke in a massive storm, and since then mid-day temps soar, dust rises, rain is infrequent. It is drier, but not exactly dry, maybe a drop in humidity from 99% to 85% (I'm making this up) and a rise in temperature from 85 to 99 (well, not quite that high perhaps, but in the mid-day on the road it must be close). Kind of a Bundibugyo balance to keep the misery index constant. And child after child on the ward had temps well over that, 102 seemed to be the average today. HEAT, from the sun and from the body fighting infection, purifying. Purifying me, too, sweating it out, and pursuing contentment in all circumstances. Thanking God for two top nurses, Olupah and Asusi, pleasures to work with even in the heat, and a welcome sight on the Monday when all the rest of the medical WHM team happens to be out of town.

Bustle: The community alarm clock is a person whapping a metal wheel rim well before 6 in the pre-dawn darkness, because the primary school two doors down has decided to institute a boarding section. Meanwhile the hundreds and hundreds of non-boarding school students all began to flock on the roads today, assorting themselves into color-matched pods of one school's uniforms or another. Bodas carrying parents, trunks, people missing work to pay school fees, prayers, anxieties, scramble, the massive effort one can only appreciate in a country where 50% of the population is under age 15 and where education is seen as the ticket to success in life, and for the clan.

Beginnings: I watch my students' trunks being checked as they enter the CSB gates, greet teachers who are sweating through that onerous task, pop my head into the school nurse who is tasked with performing pregnancy tests on all comers, sit in the line of fee-paying parents. The bursars listen patiently to everyone's stories, dutifully marking down what payments are made, issuing receipts, gently chiding those who did not pay all their fees from last year, checking off lists, explaining the categories of payments. The staff and returning students mingle with hopeful parents, all greeting, recognizing old friends, a pleasant sort of chaos on the school porch. Staff with new duties look serious and determined to fulfill them. New signs are on the office doors. Deus smiling, quietly going about his supervision. I wonder how much grief underlies the day as people re-start life here without the Pierces; I know they are missed, and I suspect they are grieving somewhere on their travels, knowing school has begun. The sad reality of ways that part, of following a call they've heard to move onward, of being left here behind. We alternate between hopeful reassurance that life goes on and students and staff will manage, and weary wondering if all the loose ends they held together will unravel too far.

It is almost 8 hours since I left home this morning. I've seen two babies that will not likely live through the night, jaundiced and feverish and fragile newborns. Another whose mother bled to death less than six hours ago, leaving the family to cope with an orphaned newborn, which thanks to surrogate breast-feeding support should be possible. A 10-year-old in a coma, with signs of increased intracranial pressure, spinal tap looks very clear but waiting for results, prognosis also poor. Blood dripping into a child with sickle cell anemia, a hope-it's-not-too-late transfusion. A preemie who made it up to 925 grams today. Two new diagnoses of TB and one who is on his second week of therapy and finally starting to improve. There are knocks at the door, notices about meetings, complaints about water flow, flat tires and honking horns, and my own family who will expect a dinner sometime soon, good news from Luke that he's back in classes and out of quarantine as of Friday . . . And so another Monday passes.