In Mundri

Thursday afternoon and it's 108 degrees, a dry breeze rustles through the brown grasses, and our delegation sits on the porch of the team house hearing stories and chugging water. A few hours ago we landed with MAF on the rocky Mundri airstrip. One stop for mangos and then to the team compound, which used to be a few kilometers out of town. Since we were last here two years ago the crossroads trade town of Mundri has sprawled out towards the church offices and homes until there is barely a break between the last thatch roofed tukuls and the water tank that signals the WHM homes. Michael's building projects have borne fruit as we toured five team homes (plus the former tent - now cement structure where we're staying) school room two stores and a team living area. And were greeted by the smiling Bishop Bismark with prayer, and the four industrious team members left behind who had the beds ready and salty fresh Rolexes (egg and chapatti) from the market.

Pictures to follow I hope.

And last news from Caleb, he had reached Amsterdam late from Nairobi, missed a connection, and was rescheduled. Hoping to hear he made it to the Gallagher's at BFA in Germany soon!

Along the road

Almost a week ago I pulled out of Kijabe to begin the daunting two day drive to Uganda. Fierce concentration, waving ripples of asphalt, passing hundreds of laborious trucks one daring swoosh at a time, the hot wind blowing through the open windows, bicycles ferrying milk pails, the occasional errant cow, potholes. Then the border, with our efficient Salim processing passports and insurance and fees, and finally Uganda. I am not making this up: after over 24 hours in Kenya traversing half the country, we were less than five yards into Uganda before the first shout of "how are you mujungu?". And the landscape changed as abruptly as the manners. Suddenly green, softer light, smoother roads. A whole several minutes at a time in the highest gear, unimpeded.

Then four days of meetings, prayer, meals, dips in the pool, more meetings, conversations, discussions, plans, more prayer in the simple lakeside bandas of the Kingfisher. The team leaders of all four WHM Africa teams (Kenya, Uganda, south Sudan, and Burundi ) met with our executive leadership from the states. Good preaching and a bit if cheerleading, getting us all up to date and together...

And tomorrow on to Mundri, South Sudan, to visit that team.

Internet access is slow and patchy so pictures will have to wait. But I leave you with one word picture. On Tuesday afternoon much of the group went rafting the Nile. Class 3 and 4 rapids, an unusually high water level, brilliant sun, good guides, exhilaration, deep valleys of turbulent foaming water followed by cresting peaks. It was amazing. In the midst of the roughest rapid I looked back and Caleb had fallen overboard from his raft. This river makes an 8-man raft look puny, so one head bobbing in the churning waters is pretty small. But we could see him a surface, and he was smiling. This huge spontaneous bring-it-on grin alone in the rapid.

Hoping that is a general picture of life for him as he makes his decisions about the next step.

Into the Yonder

Off we go . . . about to head out into the yonder . . in this case possibly wild and blue, certainly hot and dusty. In two more hours the kids will finish their second term of this school year, and we will pile in the car to drive to Uganda for a meeting with all our team leaders from Uganda, Kenya, Sudan, and Burundi as well as our mission executive leadership from the USA. Then on to Sudan (by air) for a five-day visit to our Mundri team, and more importantly, Acacia's home. I guess the song is playing in the back of my mind for a couple of good reasons. One, I have never driven across Kenya and Uganda without Scott, including navigating the border crossing with four kids and a vehicle. And two, Caleb got the much-awaited call last night (via Grammy!) that he was appointed to the United States Air Force Academy. This is a huge answer to prayer that creates a hundred more prayer needs. Mostly that he would hear clearly from God if this open door is the one he should step through. It is a high honor to be appointed, and particularly from Virginia via Senator Warner, one of the most competitive paths in the country. So we are proud of him, of his determination and hard work, but want him to make a free and informed decision. Which is a tall order for someone who turned 17 less than a month ago. So prayers appreciated, for Caleb as he thinks and prays and hears (we hope) from other schools in the next week or two. And for me as I drive, to be alert and safe and protected from the multitude of African road hazards. Meanwhile a part of my heart stays here at Kijabe. This week I had another four-death day, but unlike last week Mardi was there to take over for the last one. My heart is weary, and the prospect of almost two weeks without having to tell a weeping parent that their child is dead, without having to agonize over whether to stop CPR, whether to continue ICU care, well, that sounds good. But where your treasure, there your heart, and having invested a lot of hours and sleepless nights recently I will be praying for these little ones. Join me. This is Baby Faith being wheeled up to ICU Monday night after I intubated her and stuck a needle into her chest to relieve a tension pneumothorax. And this is her twin sister, Esther, who has even worse lung disease from prematurity. Their father paid for the last vial of surfactant to be found in our pharmacy, and I had the agonizing task of deciding who should get it. It would have been a half-dose for one baby . . but was a quarter-dose when I split it between them. How can you choose? But the next day we were able to obtain another vial from a hospital in Nairobi, for $800 instead of the usual $200. The parents could not pay, so we used our Needy Children's Fund donation from a recent visiting doctor and his wife (thanks, you know who you are!!). That's a lot of money on one baby, but I believe it saved her life. So far. She is also now in ICU with her sister but both are improving. It's a tenuous road, but pray that Faith and Esther live. This is a long-in-waiting dream starting to unfold in this picture. Our senior nurse Seraphin and I spent Tuesday helping the government Paediatrician and Nurse from Naivasha district hospital learn how to use CPAP in their nursery. This relatively simple technology could save many babies' lives. Thanks to missionaries before us who had the vision to set it up at Kijabe, we are now trying to help other facilities as well. Once a week my neighbor comes into nursery to perform hearing tests on the babies at high risk, who are near discharge. Here she is testing Nadia the sweet little abandoned baby. Pray for the Kenyan red tape to be cut through quickly so Nadia can move to the excellent Naomi's Village nearby where other neighbors care for orphaned children. We are saying goodbye to this year's group of interns. Here is Ndinda who works in nursery with me and makes a mean pizza, at a goodbye Scott organized for his OB team on Tusday. By the time I return from Sudan our new crew should be settling in. That's a big transition that needs prayer as well. And lastly, a happy goodbye. Baby Brian, our third survivor in a month with gastroschisis (problem in his abdominal wall with intestines spilling out) on his day of discharge Wednesday with a VERY HAPPY mom. Praying for more happy endings like this one that help us soldier on through the heartaches. Thanks to those who pray so faithfully, for our work, our kids, our family, our survival. We would appreciate special prayers in the next week that we would bless (encourage, uphold, listen well to, strengthen) our teams across East Africa.

Fearfully and Wonderfully Made

Part of the responsibility of being on call for the Obstetric Service includes handling some of the pregnancy-gone-awry complications.

Last night, I (Scott) got a call near midnight for a mother with a possible ectopic (def: "abnormal place") pregnancy. In a small proportion of pregnancies, a baby can end up getting stuck in the tubes or even out in the abdominal cavity. An uncommon and yet potentially life-threatening condition. If the baby grows to a point where the tube ruptures, there can be ruptured blood vessels and the mom can rapidly bleed to death.

Last night's mom presented in a classic manner: pelvic pain and bleeding. And indeed we found that she had an ectopic (tubal) pregnancy. Thankfully, the tube had not ruptured so she did not bleed to death. We had to excise the tube where the baby was growing (leaving the other tube for future pregnancies). What we found inside that tube is pictured below. A dead baby at about 10 weeks of age.

The perfection of this little creature shocked each one of us in the operating theatre. In a mere 10 weeks, God weaved together a tiny person with fingers, toes, eyes, ears, mouth and nose. This little one looks peacefully asleep in the nourishing tissue of its mother's womb. The sacred sorrow, however, is that the baby is dead. A severe mercy perhaps. This mother's tears continue to mourn the loss of hugs and laughter and goals and graduations. How to make sense of this death - and the reality that little creatures like this are electively destroyed in the hundreds of thousands per year. It doesn't add up in our human ledgers. I try to stay firmly rooted in Revelation 21: 4-5:

…He will wipe away every tear from their eyes, and death shall be no more, neither shall there be mourning or crying, nor pain anymore, for the former things have passed away. And he who was seated on the throne said, "Behold, I am making all things new"….

We live in a broken world which will someday be restored.

Until that day, let us love and sing and wonder...

(P.S. Double click on the picture to see a larger, more beautiful image)

Heading into another week

This is the little colorful rag throw rug in our bathroom. A months ago I posted a picture of this rug, and my kitchen cabinet knobs, small spots of order and beauty that made my house homey. Now it is unraveling in the center. The edges are OK and it's all holding together, but you can see that the wear and tear of being stepped on by six people from the shower every day has taken a toll.

For some reason this weekend I looked at my little rug and thought, that's just like me. I think it was Saturday when it took me over five hours just to sort through all the Paeds patients in nursery, the floor, the ICU, the casualty, plus consults. There were 42 or 44, I've lost track. And very few are straightforward. Most have multiple chronic problems, or have landed at Kijabe as their last resort after failure to improve elsewhere. Somewhere around the 20's I realized some important things had been picked up by others on Friday that I had missed, and felt incompetent. Somewhere around 35 one of the nurses chided me for not speaking Swahili like Dr. So and So, kind of disheartening. And before I got to the 40's more were being admitted. And just as I finished I found out that a short term colleague had sent an email to the entire hospital list which included a false accusation against me (a minor part of a long sad story but wearing none-the-less). I was SPENT. When I finally got home the weekend was passing quickly. My wonderful family was working on some spring cleaning, and I tried to participate, but before long I just couldn't do anything else. I went to bed and napped for over two hours. That is not normal for me.

I like this work and this life, but the last couple of weeks the demands of the service have been extreme. And at the same time, the looming uncertainty of yet more transition hangs ahead. We thought we'd have heard about Caleb's application to the USAFA by now, but we haven't. It seems like many we know are reeling in acceptances and scholarships, and Caleb still hasn't heard one word from anywhere. Not that I particularly want to know in some ways, it will be too final, and I dread it. Like my little rug I'm still functional, but there is significant fraying in the center. And so my first reaction is, how can I fix this, sew, mend. But frankly I don't think I will.

The slightly faded, somewhat unraveled, but still hanging-together rug is who I am. Not the clean new one that makes every diagnosis and handles every stress. There is a broken center that will be a bit unraveled, right up to the day of "all things made new". This weekend one of our kids was working on Bible homework, and there was a question: why did Jesus send out His disciples to announce the Kingdom instead of doing it himself? Yes, why? For at least two reasons the unraveled rug is good. First, as a failing messengers, we communicate the truth that the Kingdom is for people who aren't perfect and strong and always right. That the Kingdom comes in weakness, and in spite of missing threads some good is done, some love is shown, some evil is averted. An unraveled messenger becomes part of the message. And secondly, the work of being stepped on and unraveled is good for our own soul. Being a work-of-art-on-the-wall handcrafted display rug sounds more glorious, but I know I'd soon be proud of it, and afraid of any speck of dirt. Instead when I see the threads coming loose and the colors fading, I know that it's OK, that it's not me who needs to be admired, but Jesus.

Now I don't want to take the analogy too far . . . it is still good to have the edges intact. I am thankful for this community which I am coming to value more and more, the wisdom of the leadership handling some difficult conflict situations, the kindness of a friend who tuned up our car prior to driving to Uganda at the end of the week, and fellowship and prayer. I'm thankful for my colleague Mardi who is about to take over the Clinical Department Head job I've done for a year (though I am a little sad to let it go, it was a nice vote of consolation from God after losing a decade of leadership in WHM, she'll do GREAT and I need the breather). I'm thankful for my family. And fresh air and exercise and pizza and sleep and a 5-0 Man U victory and all the parts of the rug that are still woven together. I'm just saying that all those good things won't totally fix the hole in the center. And that that is OK, that's the hole that keeps us leaning on Jesus.

Paediatrics in Kenya

This week included: Nadia, below, who was found abandoned in a field with her umbilical cord attached, presumably shortly after birth. Someone brought her to Kijabe, where the police and child welfare are now involved. She was named by the nursing staff and is loved and held and fed. Seems unlikely that her mother will be traced. And a sampling of others from the last couple of days: cryptococcal meningitis, a rare fungal brain infection in a child with AIDS. Bacterial meningitis leaving a 12 year old spastic and uncommunicative. Viral meningitis in an otherwise normal kid. Pneumonia, and more pneumonia. A new case of TB, and old case of TB needing retreatment. Your basic gastroenteritis with crazy imablances of body fluids and electrolytes. A 4 year old whose parents brought him from near Somalia carrying an xray that shows his fibula (small bone of lower leg) has been almost completely eaten away by infection in the two months it took them to get care. A 2 year old covered in scabies. A 7-pound 1 1/2 year old. A teenager with sickle cell and pain. A little girl with nephrotic syndrome, a kidney disease. A baby whose mother stopped breast feeding too early in an attempt to prevent him from becoming infected with her HIV virus. A severely jaundiced 1-month old who stopped breathing while we were drawing his blood. A preemie who had lost a third of his weight after going home too early from another hospital. Toddlers with rickets, and more rickets, irritable and weak and developmentally delayed and breathing too fast. Malaria (rare here). A new diagnosis of a bleeding disorder called Von Willebrand's. Urinary tract infection. Congenital anomalies of the intestines, and the brain. And the face and the heart. We end with this little baby from the Maasai Mara, which is not just a game reserve but also people's home. He wasn't feeding or growing well due to a cleft lip and palate. But when he remained rather dusky blue on lots of oxygen Mardi wisely suspected congenital heart disease. His young parents were worried about the bill and ready to just leave, but thanks to the Needy Children's Fund we were able to pay for an ambulance ride to a cardiologist for a real diagnosis. Sadly Brian has no real connection from his heart to his lungs, and can only live until the ductus arteriosis (normally present in fetal life but closes after birth) fully shuts down. Then he will die. Our palliative care team and chaplain and I sat down and explained and prayed and made a plan for him to go home comfortably.That's a sampling of is carried into our doors in a few days. Sometimes I wish for something simpler, for consistent and treatable problems so I can feel more competent. But if I stop to think about it I know it is a gift to be challenged and stretched. To be learning. To be carrying the lives of these children in my hands, and to hand them off to my partner as well. To be honest with bad news and limitations, and to encourage those who are fearful. To form those brief but intense bonds with parents at the bedside. Agnes' mom found me today before she left the hospital, and gave me a big hug. In the non-stop pulled-in-ten-directions work these days she reminds me that it is worth it.

Kiss Goodbye

It's Tuesday night, but the week has already been long enough to be a month it seems.  Between the nurses' strike in Kenya leading to floods of patients, our fellow-consultant visitor getting sick and leaving and doubling the remaining workload, missing one of our two medical officers each day, well, it's been intense to cover about 40 inpatients including ICU, all paeds admissions, deliveries, outpatient consults, emergency room, etc.  From 8 to after 6 both days I was on the go without so much as five minutes to take a break and get a drink of water, let alone food.  Plus overnight call Monday night, much of which was spent in the ICU in between smaller issues in casualty (pneumonias, a swallowed coin) and on the floor.  Our patients are complicated, with severe malnutrition or AIDS or meningitis or TB or extreme prematurity or congenital anomalies.  It's a lot.

So by 5-6 pm this evening I was pretty spent, as my colleagues and I labored over the life of baby Agnes.  Agnes came to us last week severely dehydrated from vomiting constantly in her short few days of life.  It turned out she had a completely blocked intestine, congenitally not formed correctly, and would need surgery to survive.  Only we couldn't seem to get her stable enough to get to the theatre.  Many of us spent hours trying.  Supporting her breathing, checking xrays, suctioning, fluctuating her fluids, monitoring her labs, putting her on the ventilator and then back off and then on and off again.  Her intestinal problem was complicated by a heart defect and pneumonia.  Last night she was still fighting valiantly, and I stood by her bed through the wee hours of the morning tweaking her oxygen settings and expanding her lungs.  This morning she looked at me as I examined her, and I remembered this is a little person not just a patient, and we're her only chance.  But by late afternoon she was deteriorating rapidly, and at 10 days of age the hope of corrective surgery was dwindling.  When she remained blue and unresponsive on maximal therapy for several hours, my colleague the paeds surgeon and I made the difficult decision together that we were prolonging an inevitable death and the emotionally drained family was not served by this.  The kind and amazing chaplain Mercy came and prayed, and held Agnes' mother.  Together my colleague and I pulled out her breathing tube and wrapped her in a flannel blanket and handed her to her teary mother to at last hold, after all those days of wires and tubes and machines and lights.  

Agnes gasped a few times, grey and still, and within ten minutes she was dead in her mothers arms.  

By that time it was just me and the chaplain.  I said the things I usually try to say.  This was the fourth child who had died on my watch since Monday morning, and I think I was protecting my heart with a bit of distance.  So I was able to tell the mom about how she would see Agnes whole and well in Heaven, about what a good caring mom she is, about how Agnes knew her love and touch, about how sorry we all were, about how she could take her time.  Her tears rolled down quietly as she touched her baby.  Gently Mercy prompted her to lay the little body back on the bed.

But she just stood there, as if she couldn't quite bring herself to walk away, while we waited.  

And then she leaned over and gave Agnes a goodbye kiss.  

There was something so tender about that action, so resigned, so human, that the tears I had thought would remain at bay finally came.  

It is a holy and awesome privilege to be present as life begins, as babies take their first breaths, as children are healed.  But it is even more holy and awesome to witness life ending.  The solemn finality, the heartbreak, the courageous acceptance of our limitations, the entrusting a soul into the eternal realm, the gentle presence with those who are mourning, and those who are passing.  

Tonight I pray that Agnes' mom's heart is held up with an unnatural peace and confidence that all shall be well, in spite of the evidence to the contrary.  That in the end the time between this kiss and the next one will fade to irrelevance as she greets Agnes hello.

On Kony and viruses

Or, how should we respond to "bad guys?"

A couple of days ago Scott and I watched the KONY 2012 video made by Invisible Children.  I wasn't entirely comfortable with the message and methods, but like millions of other people I shared it forward in fb as a thought-provoking piece that draws attention to African children.  I only watched it once.  In the last 48 hours this video has exploded across social media, and because we lived in Uganda for 17 years a few people have asked me what I think.  So here goes some reflections on a sunny Friday morning in Kenya, far from those front lines (but close enough to many others that this won't be a well-researched long-pondered post, but like all of them, simply personal immediate reflections from my heart).  

First, what I LIKE about Invisible Children.

Eight million children die in the world every year.  Four million of those deaths occur in Africa, invisibly to most of the rest of the world.  The people with money and power and weapons and decisions are not often confronted with the most significant realities of our current time.  So when talented passionate young people with resources pour their lives into making the invisible visible, that is a step towards change.  We are a global community and the voices of the most vulnerable will not be heard, their faces will not be seen, unless someone with cameras and internet access and computers and the ability to write and speak in widely accessible languages, takes time and money to do so.  When Jesus was walking around Palestine, he stopped to touch and listen to and heal very marginalized people, often to the dismay of his supporters.  

The Lord's Resistance Army has left a decade-long trail of abduction, murder, rape, arson, enslavement, war, and chaos in a swathe across central Africa.   Read Aboke Girls (http://www.amazon.com/Girls-Children-Abducted-Northern-Uganda/dp/9970022563) for a chilling first-hand account of their tactics in raiding a girls' secondary school and capturing 139 13-16 year old girls for sexual slavery and use as child soldiers (109 were rescued when a lone Italian nun who was one of their teachers, and a Ugandan employee, tracked the raiders on foot and asked for the girls back).  Or watch "War Dance" (http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Dstripbooks&field-keywords=documentary+uganda+music+competition+&x=10&y=18), a well-done documentary about an LRA-affected community of children entering a music competition in Uganda.  This is palpable, unadorned evil, flourishing in a vacuum of order and resources.  Contrary to uninformed comments by an American political commentator recently, this is NOT a liberation movement fighting for Christian values.  The beliefs and methods of the LRA are demonic.  

The video interviews Luis Ocampo, the chief prosecutor of the International Criminal Court (who also has his hands full with corrupt politicians from Kenya who instigated post-election violence here a few years ago).  There is a clear message that the leader of the LRA, Joseph Kony, should be brought to justice.  This is a Biblical theme.  Some people water down the message of Jesus.  Peace and Love are strong words that can not exist in a messed-up world without Justice.  

Invisible Children has brought this story to the world.  And has used some of the resultant revenue for tangible good.  My own daughter Julia slept in a dorm built by the Invisible Children organization at a school in Gulu when her Ugandan football team played in a national tournament there.  She was the same age as most abductees.  I was thankful for the solid walls and doors that kept her safe at night.  

Now, what bothered me.

The video seems to be as much about the excitement of a popular movement as it is about the reality of war in Africa.  There is some way that bracelets and posters and marches and kits kind of bother me, can't quite put my finger on it, but by simplifying the problem and making the response a feel-good we're-cool party, something is lost.  This is most grating in the sequence with the cute blonde little American boy, son of the author, pointing to the picture of Kony as the "bad guy".  With a reference to Star Wars.  I give the creative team some benefit of doubt, perhaps this helps a wider audience relate to the problem.  But for me it was too cutesy, to trivializing.  One "bad guy" is not the root cause of the problem.  Kony only continues to survive, and perhaps thrive, because the issues he feeds on are broader and deeper.  

1.  Africans kill each other because they believe they have to for the survival of their own children.  The Acoli people felt marginalized post-Amin (who was a northerner as well) when Museveni came to power.  There were many small rebel movements who did not buy into the unifying post-Amin government.  This is the root of the Rwandan genocide as well.  And I suspect many of us would be willing to fight against a group (another tribe, etc) if we believed it was a choice between them or our kids.  

2.  Adults  join rebel movements when they are desperate.  You don't find the well-off taking those risks.  It's easier to believe the "other" tribe is a danger to your survival when your survival hangs by a thread.  Poverty and fear are the context for the LRA, and those are complex problems that require life-long investment.  Perhaps life-ending investment.  Jesus defeated evil by laying down his life.  Christians today can not defeat evil by pushing a share button or attending a fundraiser.  Those are good things, but at some level a bigger sacrifice is required.  To build schools and bring clean water, to protect the widow and orphan, to care for the environment creatively so that food and fuel are adequate to sustain life, to embody the love of Jesus in a way that the poor can hear and see and touch and be transformed.  I know this sounds hard, and I don't mean it to sound self-righteous.  We struggle with this issues, with our natural tendency to walk across the road and ignore the beat-up man on the ground.  I hope the excitement and awareness of this generation will propel hundreds and thousands to turn away from a life devoted to comfort and enter into the hard and dangerous work of teaching and healing and preaching.  It won't be easy, or quick.  Real solutions rarely are.

3.  Children join rebel movements against their will, but then they stay.  Because they've been traumatically psychologically injured and enslaved in a way that is powerful and binding.  They are targeted because this is only possible with humans who are at critical formative stages of development.  Removing Kony from his position of leadership is a good thing.  But there are tens of thousands of children who are now in their teens and 20's, who need reconciliation with their communities.  Who need land and jobs and homes and an alternate way of life.  This requires counselors, teachers, medical people, artists, parental influences, pastors.  

4.  The "big man" is part of African culture in a way that Americans perhaps do not appreciate.  We Americans are egalitarian.  Anyone can do anything.  Africans have more respect for elders, and leaders.  Putting one man's name on campaign-like posters all over the world could backfire.  People could respect him as someone able to evade international capture.  People could come to believe in his spiritual powers even more firmly.  His status and ability to inspire fear could grow.  Africans who resent western interference could actually begin to protect him.  

5.  The LRA is not the biggest problem that African children face.  Poor care for pregnant women, unsafe deliveries.  Preventable infections.  Malaria.  HIV-AIDS.  Malnutrition.  Abysmal schooling.  These are killing 3,990,000 of the 4 million.  Again the solutions here can not be condensed into a bright red one-word poster.  But as long as this video is circulating and generating discussion, let us think about the invisible majority who are taken by the chronic background of high mortality.  I watched two babies die this week directly related to the health care strike in Kenya.  Corruption on the part of politicians, and self-promoting desperation on the part of health care workers.  I just got off the phone following up the rape of several young girls in our community.  Cover-up on the part of parents, and police.  There are forces of evil at work here, bigger than Kony.  Some reports say that the LRA has dwindled to about 250 combatants.  Those are valuable lives that deserve justice and rescue, but let's pour ourselves into bigger problems too.

Perhaps oversimplification is inevitable in a culture raised on the one-minute sound bite.  Our attention spans are limited.  Few people are probably still reading this far into this post.  If you really want to get the full picture, here is a link to a blog that links further on to dozens of articles and resources:  http://rachelheldevans.com/invisible-children-kony-2012-resources

My problem with the critics, too.

It's always easy to find something to criticize when 32 million people jump on a bandwagon.  I won't say much here, but there is one issue I can't ignore.  Many of the critical comments imply that the UPDF, the Ugandan army, is just as bad the LRA.  Having been personally rescued from rebels by the UPDF, I have to say this is not a fair comparison.  They have done some bad things, as has the American military.  But as African armies go, I would rather meet the UPDF in a remote jungle than any other I can think of.  Ugandan political decisions have taken a bad turn in the last couple of years in suppressing dissent.  And whenever you have young men with guns some bad things will happen.  But the UPDF is a force of stability, working in harsh conditions, with minimal resources.  They are in no way comparable to the LRA which only exists to prey upon innocent civilians.  That said, supporting the UPDF has little impact on Kony now.  They must stay vigilant, but in reality Kony has fled far from even the border of Uganda for many years now.  It is really an African Union issue.

Here is the link to Invisible Children's response to the critics:  http://www.invisiblechildren.com.s3-website-us-east-1.amazonaws.com/critiques.html

Parting comments.

My hour to post is almost up.  So I want to end with two bigger picture comments about viruses and Kony.  First, while the video has gone "viral", one could say that Kony himself is like a virus.  A harmful, infective particle that has to commandeer the resources of healthy cells to exist and propagate.  But as Solzhenitsyn wrote, the line between good and evil runs through every human heart.  Kony's heart, and mine.  Do I believe this man is redeemable?  Am I?  Well, is there any evil too great for God to forgive?  Kony is a human being, not a virus.  As are his victims.  We can learn from our brothers and sisters in Rwanda and South Africa, and from those who are attempting peace and reconciliation in Northern Uganda, and South Sudan.  Africans lead the world in forgiveness.  The success of rebuilding Rwanda came from a military intervention to stop the genocide and establish safety (a local military, after the failure of the international peacekeepers).  Then a public, organized, system of trial for bringing the leaders to justice.  And then a community-level system for re-assimilating the perpetrators, for telling the truth, for acts of forgiveness.  Africans know how to do this in ways that are amazing and humbling, and we shouldn't get in the way.

Second, Jesus and politics do mix, just not in the way most think.  Jesus was a politically challenging figure.  It is good for Christians to think about and involve themselves in issues like war and international courts and school buildings and media.  But we shouldn't confuse our American ideals with Christian truths.  Sometimes they are parallel, but often they are not.  Even as Jesus lived on earth, much of what he said was politically shocking and confusing to his followers and detractors alike.  Here is the reading from NT Wright today, in Lent for Everyone (Friday, week 2):

But what is the real battle? For Jesus, it wasn't the battle they all expected him to fight — with the occupying Roman troops, or with Herod and his supporters, or perhaps even with the Sadducees and their would-be aristocratic clique in charge of Jerusalem and the Temple. Jesus' followers probably thought he would fight one or all of them. Having watched as he did many other remarkable things, it was quite easy for them to believe that he could fight a supernatural battle against these natural enemies. Jesus himself spoke, later on, of being able to call several legions of angels to his help. But on that occasion he refused; because that was the wrong sort of battle to be fighting. In fact, as gradually becomes clear, the real battle is against violence itself, against the normal human wickedness that shows itself in the desire for brute force to win the day. If you fight fire with fire, fire still wins. And Jesus has come to win the victory over fire itself, over the rule of the bullies and the power-brokers, in favour of the poor, the meek, the mourners, the pure in heart. It is precisely because Jesus is right in the middle of the real battle that it is vital not to confuse it with other battles. The real battle, then, is against the real enemy, who is not the flesh-and-blood enemy of foreign soldiers, or even renegade Israelites. (When the Romans crushed the Jewish rebellion in ad 66—70, more Jews were killed by other Jews, in bitter factional fighting, than were killed by the Romans themselves — and they killed quite a lot.) The real enemy is the power of darkness, the insidious, sub-personal force of death, deceit and destruction that goes in scripture by the name of 'the Satan', which means 'the accuser'. It goes by other names, too; a familiar one was 'Beelzebub', which means literally 'Lord of the flies'.

Let us follow in His steps, into harm's way, to spotlight injustice, to walk alongside the suffering, to lend whatever gifts God has blessed us with to bless others.  And let us remember that our real enemy is not Kony, but the spiritual forces of evil in the heavenly realms, the forces that will only be overcome by prayer and service, by the blood of Jesus and the living word and testimony of His followers who do not love their lives unto death (Rev. 12:11).

Celebrating

Jack, first. He turned 14 this past Saturday, in the middle of Scott and I working to save other moms and babies in the very spot of his birth in 1998. By God's mercy we were able to tag team enough to pull off a pizza and games party with a handful of other 9th grade boys. Jack at 14 is: tall (reaching Caleb imminently and soon Scott), strong, smart, driven, competitive, capable, funny, loud, sincere, contemplative, voracious. He can run miles and play soccer and rugby hard; but he also loves to lounge on the couch, watch sports on TV, read long books, and cajole his sisters into serving him. He thinks deeply about things like God and infinity and why chemical reactions happen as they do. But he also has an incredible Aylestock teasing streak that reminds me of my Uncles, especially Lloyd. As the youngest he observes and he knows just how to get a reaction. He's like a tumbling, biting, overgrown puppy around his classmates, wrestling and laughing. He LOVES good food and one of his favorite relaxations is to watch an episode of Chopped (which we somehow get on our Kenyan cable). His specialty is pesto which he makes himself from our basil in the garden, for gourmet pizzas (when we have pine nuts and parmesan that is .. .). He is faithful and loyal, ready for adventure and fun, and intuitive enough to be anxious at times about the world and the future. His adolescent lengthening lean body is catching up with his already deep voice as he turns from a boy into a man, which is happening too quickly for me. He can argue. Well. And writes beyond his years. And he's the biggest Man U fan ever; his wardrobe is mostly Man U wear and he hates to miss a game. This boy started as an embryo in a hostile war-chaos-sickness environment, so I never cease to marvel at who he has become, a miraculous redemption in a hard time. If we can get him off the couch . . . he could do about anything.

Julia's team won the semifinals in their league yesterday, in a glorious afternoon of sun and wind and cheering parents and a relaxed match (it's nice to be up 4 nil). She's built good friendships and team work and been mentored by some amazing senior girls, for which I am thankful. I can't be positive enough about sports for girls. Fellowship, exercise, health, confidence, a group to belong to, values deeper than surface appearance, serving others, disciplined time management, being outside . . very thankful for this opportunity for her. And for Acacia, whose JV team had an undefeated season in league play and went to semifinals in the varsity tournament last weekend and finals in the other tournament they entered. Acacia had an equally positive experience with lots of playing time, improved skills, respect for coach and team, etc.

(here is Julia with Rachel, her "twin" for "psych" =dress up crazy to get in the mood to win)

And lastly, this is a good week to pray for Caleb's future. By mid-March the US Air Force Academy board will have made their admission decisions. By early April he'll have heard from the other universities to which he applied. His future is a big black unwritten slate and the chalk is about to become visible. I love who he is and who he's becoming and we believe he has what it takes to be an Air Force pilot . . . or anything else God has in store for him.

Exponentially Monday

Today was about as Monday as it gets.  Which is why at 9:30 pm I am debriefing through my fingers (after assaulting my children with all the gory details at dinner, something they're quite used to).  Bear in mind that tomorrow Scott will finish our 7th call night in 11 days (5 together, 2 apart).  When you take time off to go to a conference (Feb) or organize a field-wide leadership meeting (March) it's like lifting up the edges and watching all the call days fall together in the middle.  Bear in mind this stretch oh-so-conveniently dovetailed with a health worker strike in Kenya, escalating the demand for services at faithful old Kijabe.  Bear in mind these have not been the kind of calls where one wisely imparts a little experiential wisdom over the phone.  They've been more of the blood-and-guts-at-2-a.m. type.  And bear in mind that the rest of life did not stop:  2 birthdays in the last week, 2 girls in a soccer tournament, 2 10th grade events, one sick kid, you get the idea.

I knew the morning would be difficult, because we had agreed to withdraw baby Malt from the ventilator because she showed no signs of brain activity.  Her dad, from a religion and culture that is supposed to be stoic, held onto my hand and wept.  (Crying men really get to me, two dads in one week, two decisions to stop aggressive care, is almost too much).  Malt had brainstem reflex gasps that kept her heart beating for a full hour and a half after I pulled her tube, which was cruelly agonizing, making me second-guess my decision and giving the family a false glimmer of hope that was dashed.  Two beds over we waited for the death of another child, 4 years old, a long and complicated story of malnutrition and a mysterious mass on his back that took weeks to diagnose as a mycobacterial infection.  After two months at Kijabe he was discharged back to a refugee camp on the Somali border where he got none of his ongoing care, developed an obstructed bowel that diverted out through the skin on his back, then lost his kidney function, and finally came back to Kijabe past the point of no return. Both these families are from remote areas to the northeast where they would almost certainly never encounter tangible witness to Jesus.  If I were planning it, I would have had both their children improbably and miraculously healed.  Instead their children slipped away to death.  I do think both families could see the extreme effort poured out on their child by strangers; the odd intimacy of being swept into the most crucial hours of someone's life may have more Jesus-witness in the long run than a proud victory.  I don't know, and I'm clearly not in control here.

That would have been enough for one day.  But the strike goes on, and we're packed.  In another one of those timing flukes ... in spite of my fantasies of perhaps a gentler post-weekend-call day, perhaps departing early . . . it turned out one person after another on the Paeds team had some sort of illness or family crisis or tiredness or whatever that took them out of reach for parts of the day.  So it was a non-stop day, except for running home to check on Acacia who had had a fever last night and missed school (she does feel better now, but pray for her).  At 3:30 I admitted a post-operative neurosurgical patient to the ICU (where I'm not really working but seem to spend a lot of my time).  I wonder if Kijabe is the only place in Africa a kid could have two world-leading neuro and craniofacial surgeons work on their skull and brain.  By 4 I was starting to think of the evening and rest, and deemed it wise to call the two new family medicine residents who will take call and give them a little sign-over and orientation.  We all introduced ourselves, washed hands, and I opened my mouth to tell them about the cozy humid little nursery where everyone was doing fairly well.  

Then all hell broke loose.  At that moment, a desperate call back up to ICU.  The xray I ordered ended with the little post-op patient's breathing tube being dislodged.  Only when I walked in I saw it was more than that--the little boy was pulseless and pretty much gone.  Mostly dead, but not all dead.  Another opportunity to use the PALS course skills from last month, running a full-scale code to get him back.  Which we did.  And just as that finished, a desperate call back from nursery.  Where there was another new admission of a mostly dead baby.  He had lost 1/3 of his body weight in his short 5 days of life, was blazing with fever, convulsing, and dry as a prune.  For you medical types: Na 180, K 6.4, Cr 3.1.  These are very bad numbers.  I pushed some fluids in an intra-osseous (in the bone) line until the Paeds surgery fellow who happened to walk in was recruited to get a real IV line.  It was one of those admissions where everything was harder than it should have been, no gloves, no lines, no nurses, just that time of day I guess.  Another distraught mom.  By 6 he was stabilized (though far from OK, he still may die) and I literally had my hand on the door latch to nursery when a nurse burst in with a 1 kg 29 week (very premature) baby in a cloth, just-delivered, dusky and wet and mewing slightly, heart rate falling.  Really?  This was the baby whose mom was, as per the last hour's report, no where near delivering tonight.  Yet here he was.  Thankful for Bob our clinical officer who stayed and helped me, we had to scoot one baby over to reach oxygen for this one, intubate and give the magical soapy surfactant mixture for his lungs.  It was dark, after 7, when we finally walked out the door.

Monday, to the max.  Time for some sleep.

Strike two you're out

This is Malt. She arrived at Kijabe hospital at 11 pm last night, after a seven-hour ambulance ride from Isiolo, a rather remote Kenyan town far to our northeast. In those seven hours, as her post-c-section mom held on for life, they called EIGHT hospitals and were refused admission until they finally made it all the way to Kijabe.

Why? Because yesterday the public sector nurses, clinical officers, mortuary attendants, lab and pharmacy personnel, all went on strike, for a "hardship allowance" to be added to their salaries. The entire government health system was paralyzed, leaving only private and Christian hospitals like Kijabe to suddenly fill in the gap. This was much worse than the previous doctor strike. Proving we can limp along without doctors, but we can't manage without nurses!! There are many issues of injustice tied up in who controls health funds, and how they are distributed. However I suspect that Malt's parents live on less than the INCREMENT the Kenyan nurses are demanding in their monthly salary. And there are the people who suffer and die when the strikes begin.

Malt's mom had two children, then lost two who inexplicably died just before delivery. Finally someone in her remote village sent her for antenatal care on her 5th pregnancy. She was found to have the blood type A NEG. Malt is O positive like her dad. So her mom's body began sending antibodies to destroy Malt's "foreign" blood. Sensing impending disaster Malt's mom asked for a C-section. And sure enough, by 24 hours of life Malt was turning yellow from severe jaundice and dangerously anemic.

And so we began the delicate process of putting a line in through her umbilicus and gently removing her blood and replacing it with compatible blood. Two teaspoons at a time. Over and over until we had exchanged her entire blood volume twice over. I finished at 3:30 a.m..

Malt still has a long way to go. She may live, or she may succumb. She was a bit premature, and her jaundice was severe enough to cause brain damage. The delay in her care certainly makes her survival less certain. Malt's story of a seven-hour ambulance ride to reach the 9th hospital for help is only topped by Lucy. I have to tell you that in this picture Lucy looks peaceful. She had just died. Lucy''s mom only lived about 15 minutes from Kijabe. But she labored all day at a small cottage hospital in the small town she's from. When she broke her water and started pushing and was going nowhere for some HOURS (maybe five . . . ) she was put in a taxi with some sort of nurse and they drove FOUR HOURS (12:3o to 4:30 am) to THREE HOSPITALS trying to get a C-section. At 4:30 they finally came back near home to Kijabe, where the mom proceeded to deliver a dead baby.

Well, mostly dead. There was a slight slow heart rate, with nothing else. No breathing, no crying, no moving, no eye opening, no nothing. I was called and even though I intubated the baby right away, gave resuscitation drugs and CPR and revived a heart rate for a while, Lucy's brain was gone. She didn't more a millimeter, ever. Her pupils were fixed, her reflexes gone.

Because the whole hospital was getting inundated with transfers and desperate people (did I mention the 29 weeks pregnant seizing woman? Or the two kids with meningitis?) we had no ICU space to even consider pushing Lucy along in her brain-dead state, hoping for a miracle. So I had the agonizing responsibility of calling it quits. Pulling out the tube, which was filled with excrement from this baby's stressed pre-delivery deterioration, and waiting as the heart rate fell to zero. And then sitting with the mom to explain and console. Who said through her tears, "God is faithful."

Lucy's life was not important enough for several hospitals full of people to take note and take action. We must stand against injustice for nurses, but not at the cost of the lives of the innocent. I am profoundly weary this morning. Nothing is more wearing than acknowledging defeat and waiting for death. Particularly the death of a baby who, if managed properly a few hours earlier, would have been alive, well, normal.

Not much else to say other than pray for Kenya, for justice and mercy to flow down. Because they seem pretty dammed up right now. I am falling asleep typing (we happen to hit this strike in a bad stretch where we are each on call 5 of 9 days . . two weekends in a row and two non-matching days in between, so that means 6/9 nights with interrupted or very little sleep), so I leave the last picture one of my other anchors. A morning jog with my dog, clearing the weight of that night of terrible decisions and sorrowful outcomes.

Anchors

This week has had some difficult moments.

On Monday, I met with the parents of baby J. He was born two weeks prior and came to us with jaundice and cataracts, and we later diagnosed severe hearing loss. His liver, eyes, brain, and lungs were damaged by a viral infection (CMV= cytomegalovirus) his mother contracted probably early in pregnancy. A negligible disease unless you are an unborn baby or immune compromised, and then it can be catastrophic. Baby J seemed to rebound early in his second week of life, and for a couple of days I hoped he'd just be a hearing-impaired but possibly relatively normal kid post-cataract surgery some day. But then he developed progressive respiratory distress. By Thursday night last week he was teetering on the brink of death, and was rescued by the ICU. I kept him all weekend on the ventilator, once doing CPR for a couple of minutes when his heart was faltering down to zero, once re-intubating him, and often adjusting and evaluating. We had started a new antiviral medication and hoped that 24 to 48 hours would make a difference. By Monday I could not see much improvement, and had already turned away another child who needed an ICU admission because we had no beds. So I had a long, gut-twisting, heart-wrenching conference with baby J's parents. I told them that I thought we were not helping him, and were possibly causing him more pain and more problems with this tube that was in his airway, for no real benefit, and I wanted to bring up the possibility of taking him off the breathing machine. In a country with extremely limited resources, this is a conversation we sometimes have to have.

I wanted to give them a day to adjust and think and pray. But an hour or so later they called me in to say they were ready. They stood by his incubator and put their hands on him and said goodbye. They cried. I cried.

I pulled out the breathing tube and suctioned and put him on nasal CPAP, a less invasive delivery of oxygen and air under pressure through the nose. I didn't know if he would even try to breathe. But he did. Fairly well. After an hour it was clear that he was going to fight on. He was actively moving, whimpering a bit, and pulling hard but keeping his blood oxygenated. I was cautious but slightly optimistic again. We moved him down to the nursery.

Tuesday morning I was nervous walking in, but there he was, yellow skin and bruised IV sites, fluttering eyelids, breathing away. Not great, but alive.

I still didn't think his long term prognosis was very hopeful, I'd seen him too close to the edge too many times. But these parents really got to my heart. I think English-speaking parents, without the barrier of translation, are more difficult to protect one's heart from. This mom was so completely dedicated, attentive, anxious, invested. And the dad was amazing. So caring. He came in his suit from work, and listened, and put his arms around her. I was really pulling for them.

Tuesday afternoon, I was teaching a group of a half-dozen nursing students how to resuscitate a newborn using the materials (model baby) we got at our conference. They were taking turns, putting breaths into the baby with the bag and mask. When I noticed the nurse carrying a REAL baby to the other resuscitation table, and Bob walking towards them. I left my students to check what was happening. It was baby J, with no pulse, no breathing, milk spilling out over his face. The nurse had been moving him from one bed to another, after a feeding through his nasal-gastric tube, and he vomited. He had absolutely no reserve. All those periods of marginal oxygen, all that infection in his brain, it was the final straw. So I moved from pretend CPR to the real deal, for about ten minutes we tried to revive him, with no success.

His parents came in at the very end. When they realized what had happened, they broke down. We got them into chair in a side room, where we talked and comforted and prayed again. They held his body. They said thank you. I said what I could, probably not very profound, but I hope they knew I cared.

And from there, I walked out to cook a birthday dinner.

Which brings us to the title topic, anchors. Sometimes I can't bring myself to think of another meal to prepare. Keeping the house stocked with limited time and resources, keeping kids fed, keeping laundry moving. All that lillies-of-the-field stuff we aren't supposed to worry about feels like a challenge. But this week as I took a couple of hours in the middle of a long weekend of call to make funnel cakes and play UNO with my "caring community" of 10th graders, or spent hours on Caleb's birthday cake, I realized these concrete wholesome tasks are anchors.

Stirring and kneading, measuring and washing, sorting and straightening. These daily solid tasks of life hold me. When I think about another dying infant, or the sadness of the parents, or the vast things I can't do and don't know how to help, I can despair. So I'm thankful for the necessity that anchors me to earth, that gives me a wholesome alternative to the world of the hospital. As much as I stress over coming up with another dinner, that incarnate reality steadies me

God put our souls into these bodies for many reasons. One is sanity.