rotating header

Sunday, May 21, 2017

This week's reading from around the Web

First for some good news, for the first time ever, an Ebola epidemic response includes not just isolation and case contact tracing, but VACCINES (read here).  Having lived through the discovery of AIDS, the devastating spread, the development of treatment . . now we get to live through watching Ebola progress from an incurable scourge to a preventable disease?  Amazing.

When we spoke in the USA on our home assignment a year ago, we often mentioned the fact that childhood deaths world wide had decreased by HALF in the nearly 25 years we've been working on the fraying edge of survival.  Much of that is due to vaccines and improved antenatal and delivery care.  The Gates Foundation's annual letter is a good read, even if you don't agree with everything they do with their money, you can see the potential impact upon JUSTICE by targeted giving.  Hooray.

Not everything in our part of the world is looking up, however.  This blog is a no-holds-barred questioning of world response to the drought and famine in Somalia, from someone who lives in a nearby country and works closely with that part of the world.  Thought-provoking, and most of it applies to all our efforts to help rather than hurt.  One of the most innovative responses involves software developed in Kenya to map hot-spots of post-election violence, this time adapted to famine and response in the horn of Africa.

This post is for the 4% of the population who struggles with their gender identity and sexual orientation, and those who love them. Meaning all of us.  It is written for the missionary community, and more balanced and kind than most things one reads.

And this one is for the many families who have chosen to enfold traumatized children, by foster care or adoption, or being counselors, teachers, neighbors, friends.  Sobering.  Our prayers are with you.

Ebola, vaccines, child survival, drought, war, mental health, love--these are big topics, important topics.  However one can not credibly get through the week without having also spent some time on the crisis-per-hour flow of news out of Washington, DC.  I always find it best to read the actual transcripts of speeches and decide what you think based on the words.  Here is Trump's speech at Liberty's graduation, more articulate than much of what is reported, and starts with some inspirational words about defending truth, swimming against the current, using your blessings to make the world better.  But the speech once again conflates the USA with the Kingdom of God in a way that leads down a well-trodden historical path of destruction, power as the way to enforce faith.  It never ends well.  At its best, justice can mitigate against our human greed and tribalistic self-preservation, but we still fall far short of love.  So we find a messy week of crisis once again, careening from press conference to press conference.  Christianity Today tries to untangle some of what Comey's movitves might have been as his faith and political service hit the wall of Trump's demands for loyalty.  And this editorial reminds us that as entertaining as the late-night-show sketches may be (where reality and satire are so close it is becoming impossible to tell the difference), the real response to a discomfort with the way America has turned is to get involved in the political process.  That's democracy.

If the week leaves you despairing about democracy, may we recommend this movie we stumbled upon on on our TV programming.  This drama follows the true story of Seretse Khama whose integrity, courage, and determination brought Botswana from the 3rd poorest country in the world to one of the most free and prosperous in Africa. Positive story out of Africa, not to be missed.

Finished another great book this week:  News of the World, by Paulette Jiles.  Because third-culture-kids are on my heart and I find poetic writing to be one of life's great pleasures, I loved this book.  Historical fiction about an old frontier soldier who ends up responsible for returning a re-captured 10 year old girl of German descent to her Texas relatives, after four years of living as a Kiowa original American tribe member.  They have no common language or experience.  The way their relationship grows as they pass through dangers, and the author's grasp of the way the dichotomy of cultures in those formative years leaves this girl stranded outside all worlds . . . well, enough said.  Read it.

Less poetic, but a gripping story based on real life (as was the one above).  Jodi Picoult bravely grapples with race and injustice in our society.  I almost quit after chapter one which I found unconvincing in medical details.  But I am so glad I stuck with the book.  The story is told from three voices, and the male white-supremacist one is strangely compelling.  His character is also modeled on a real-life person who came out of that world to work for justice.  If you start it, stay with it to the end.

Of waves, wind, and eye directions

In Naivasha we attend an international fellowship, a church meeting in a school, half Kenyan half expat types from a number of other countries, with the simplicity and transparency of people who know the world is not right but the Kingdom comes.  Many weeks I get to play the keyboard for worship, accompanying some very talented vocalists and guitarists.  We are a small handful in an unadorned cement upper room, plastic chairs, down to the basics of prayer and fellowship and worship and proclaiming truth.  We had come to Naivasha looking around for a very cross-cultural Swahili-only church (as if we were somehow special missionary types), only to realize we NEEDED this welcoming fellowship after our stressful weeks.  These people are the real deal.  Some operate businesses in the area, others teach, run a safe house for abused and abandoned kids, heal trauma with kindness, facilitate students learning about care of creation, creatively organize job training and discipleship.  Prayer requests grapple with tribalism in school dorms, war in South Sudan, distant kids and parents, rain and drought, the hope for peace as elections approach.  A real body of Jesus simply trying to love others and depend on God.

One of the songs our worship leader chose today is a remake of the hymn "It is well with my soul".  You should listen to it right now.  The stillness of soul is not predicated upon a well-ordered calmness of circumstances, it comes in the midst of the waves and winds of distress.  This, is faith.  One of the choruses says, through it all, through it all, my eyes are on you, which reminds me of 2 Chronicles 20:12.  When the people faced impossible odds and potential annihilation, they had no recourse but to look to God for deliverance.  This story became very meaningful to us in some hard days in Uganda.

Playing it today, our hearts went out in prayer to many windy, wavy, heartbreaking situations for people we love.  Dear friends, who were colleagues in Uganda and are now finishing graduate training in the states, found their infant son blue and lifeless yesterday morning.  After CPR and an admission to the pediatric ICU he is alive and yet the cause of his life-threatening event and his eventual outcome are still not certain.  Other supporters and childhood friends also had a baby this weekend, a difficult delivery during which mother and baby both nearly died, and this infant is also tenuously holding onto life in a neonatal ICU.  Here in Africa, one of our teams has had an inordinate burden of struggling kids and crumbling infrastructure, in what feels like a wave of spiritual oppression.  Two other teams are in areas with cholera outbreaks, a potentially deadly infection.  The rainfall in Kenya still lags behind normal (about a quarter of the expected this season).  We encounter loss, hardship, conflict, mental and physical illness, loneliness, every day.  Our oldest needs to make a pretty life-determining decision this week about his residency choice, and needs prayer for clarity that will carry him through the next decade of intense work.  The second will be jumping out of an airplane five times in the next week; we pray the weather holds for him.  Near-death days for beloved friends, chronic struggles for weary teams, life directions for our own flesh and blood.  We feel the buffeting of those storms.

Yet in that very place of shaking, of breaking, we pray for the grace to cling to the truth that all shall be well.  One who is good, fiercely so, painfully so, writes the end to this story.  

When Job struggled with the big questions of suffering, God told him to look at the hippos.  Literally, to ponder the wild beauty and independence and balance of creation.  Besides playing for worship, the highlight of the week was a visit from our great friend Bethany which prompted us to do a little walking safari Friday evening.  We can walk from our house across the highway to a small Kenya Wildlife Service preserve by the lake.  On this particular evening, we saw wildebeest, zebra, giraffe, impala, waterbuck, hippos, more zebra, fish eagles, cormorants, pelicans, storks, herons, egrets, plovers . . . and just at dusk, two black-backed jackals sauntering across the path and into the bush.  It was a holy moment of wonder, of remembering a goodness that undergirds all of us, of glimpsing a glory that has been obscured by brokenness but not erased.

Enjoy Scott's photos of the evening, and pray for those we love to know that all shall be well.

Wednesday, May 17, 2017

Post-strike, pre-strike, the status mid-week

Today we were remarking with a fellow physician:  the sheer uncertainty of this year wears one down.

The Nakuru county government signed an agreement last Friday to pay all the doctors in our county according to their strike demands:  the 50% increase in base salary, various allowances, the arrears for the months they were on strike.  On Monday the docs started trickling back in to work.  Some have been supplementing their income in private venues, but others feel the crunch of months of missing salaries.  No interns returned, because that group decided their much-interrupted training year was OVER and the new year's group are not scheduled to begin until June 1. Today we had our (except interns) full team of 2 consultants and 2 Medical Officers (finished internship and working for a few years before applying for master's or residency degrees), and 6 clinical officer interns who have learned a great deal by being forced to work without much of any help but me.  Scott's team is a bit less intact, with his consultant partner out of town for the week and some personal issues/sickness with his Medical Officers.  Still, we both felt the relief of working in partnership today. It's just more fun to have people to discuss cases with, to lend a hand, to know you're not alone, to even converse with in a more friendly way, to plan for teaching conferences and improvements.  Sometimes Scott comes out of surgery and says, this is what I was made to do.  Today, he called me in as a woman whose baby had severe distress was being prepared for a C-section, but as I walked into the theatre the mom was pushing her baby out naturally, on the operating table, into Scott's hands as he scrambled to be ready.  The baby was blue and covered in muck, but those lungs filled with air as he cried lustily.  He was big and strong and mad.  We all rejoiced.  A great outcome.  Enough doctors, enough nurses, good care.

Sounds good, except for one detail.  The signed agreement between the county government and the doctors still hasn't translated into actual cash.  So we heard today that if the doctors don't see a change on their computer-generated pay-slips (which isn't quite money, but enough to make them believe the money is coming) by 5 pm Friday, the strike resumes.

Maternity (and therefore newborn unit too) has been consistently fairly busy, but the Paeds ward is still less than half full.  It seems the public and the outpatient screeners still don't really believe that the week's resumption of duties will last more than a few days.  In fact everyone is pretty skeptical.  Will this government, focused solely on re-election, spend money on health?  Money that could be spent on influencing votes?  Votes that would keep them in power, accessing more money?

We shall see.

Which brings us back to the exhaustion of uncertainty.  Without interns the evening and night coverage is still sketchy.  With no docs at all it becomes much worse.  The lower patient volume makes it a bit more manageable.  But many of those who come are the most poor and the most desperate.  Some severe malnutrition, some kids who are breathless or in pain or convulsing.  And we know that empty beds most likely do not represent healing; instead they represent confusion and barriers to accessing care.

Today's Bible reading came from the pruning the vine passage from John 15.  Perhaps that is the strike effect.  Cutting away expectations, cutting away comforts, cutting away extraneous uses of time, cutting away entanglements.  Making space for light, for growth, for fruit.  Praying.

Saturday, May 13, 2017

The View from the Hall

The view from the hospital hall, not always clear.  The prophet in me wants to shout for immediate justice even if it means turmoil; the pastoral side wants to see people grow in grace and love and knows that any calling down of fire and brimstone would singe my impure heart as well.

So we keep on keeping on, lending a push towards life where we can, speaking up when we can, recognizing the mercy that keeps us all alive.

 Like a baby born face first, which doesn't work very well, but by the time Scott got there and considered the C-section he was coming out mouth first.  Here he is two days later, looking like a prize fighter, but remarkably feeding well.  Life is rough, even for an infant, but mercy so often prevails.

Or this chest xray, which took so many days to get due to malfunction of the portable machine, the baby was actually better.  These are not great lungs.  These lungs should have had surfactant, an expensive medicine that helps premature babies.  Instead this baby limped along very sick on CPAP for a week and a half, and is now on just a whiff of oxygen.  I think he'll make it. Mercy.

Or this moment in the Newborn unit, teaching my clinical officer interns how to manage a baby just after delivery, watching them get the steps of resuscitation.  This one skill could make a significant impact on survival anywhere they go.  The night before, Scott had been called in for an emergency C-section after a trainee overdosed a mom who was being induced to deliver and went into a continuous tetanic contraction.  The baby wasn't really breathing much, but instead of giving breaths, the student was running around looking for D50 (high concentration sugar-water IV) to give in the rectum.  Hmmm.  Maybe time to review this skill.  Once Scott noticed what was happening he asked the anesthetist to intervene.  Apgars 4, 4, 10.  Knowing how to give some breaths makes a difference.

But there are many many other moments when the view from the hospital corridor has my ready to yell, or cry.

 This is about 30 pages of bills, totaling over 4 million shillings (over 40,000 dollars, or 40x the annual income of the average Kenyan).  Baby J is a 2 month old twin.  In late February, in the last strike, his mom landed at a local private hospital where she eventually got a C-section, but by that time he was in dire shape.  His brother was revived and fine, but he was limp and not crying.  He was sent to a private ICU in Nakuru where he was on life support for over a week and in the ICU for a month.  After a brief discharge home he was sent to another private hospital in Nairobi, again on a ventilator for a prolonged time, again in the ICU for weeks, with surgery to put in a feeding tube in his stomach.  This week his family's insurance and funding ran out, and they were sent in an ambulance to us. From the highest level of pediatric luxury and excellence, to a place with no monitor, an oxygen concentrator, some dedicated people but not much else.  I reviewed his records, and examined him, and had a frank talk with his dad.  Baby J will never be OK.  His brain was severely damaged around birth, his head has never grown, he can't swallow, can't cry, is severely malnourished.  It is wonderful to love such a baby; it may be criminal to extract a family's entire savings, and those of their relatives, before telling them the truth.  The dad thanked me for telling him.  The kind of person who could even dream of accessing this kind of care does not usually come to Naivasha, until they are completely bankrupt.

This baby's course makes me very sad, because I have to wonder if he represents the forces that keep the strike going.  Private hospitals, owned by politicians and senior doctors, making money off the people who have nowhere else to go?  I know that this does not represent the majority, but one has to wonder.  We are taught in public health that when something that hurts people (usually a disease) keeps spreading, look for the forces that favor continuation.  Could a profit motive be one of them?

I don't know, but it's been a long week.  An extremely premature baby (25/40 weeks) who lasted only a few hours after being rushed here from a peripheral facility.  A 2-week old who had lost 1/3 of his body weight because his mom had no milk.  Babies who can't breathe well, babies with severe levels of jaundice.

And towards the end of the week, the little girl who was supposed to go to the safe house, almost slipping through our fingers as her mom wanted to refuse, and she stopped talking again.  But a victory when the social worker and the police agreed to put her there yesterday.  Mercy again, mercy that feels like a small drop in the ocean of horrible things that have probably happened to her.

The view from the hall is so partial.  I can't see the long trajectories of peoples' stories before and after their moments of crisis. Working nearly alone, I get to put my arm around patients, feel the tears, and pray in a way that happens less when I'm part of an insulating gaggle of students and colleagues.  Trying to trust, the saved life of a mom with a ruptured ectopic pregnancy or another with a ruptured uterus because Scott takes them into the operating theatre, the the slow recovery of babies we care for day by day, are worth the hours and the sorrows.  Unable to see the years that precede and follow in each person's story, we have to trust that our moments of intersection work as points of mercy that change the world.

Wednesday, May 10, 2017

A Failing System, Another Strike, and 30 Years of LOVE

We're back. 

On Friday, as we were driving to the airport to leave America, the doctors in Nakuru County went on strike, again.  Only a few counties have resumed their strike, but the general public health situation in Kenya is, in a word, sad.  After 100 days of striking from December to March, the government promised a 50% salary increase among other things.  However, the April salaries, paid out a week late, did not reflect this increase, and no salaries for the strike period were released.  It's messy.  The president claims funds were sent to the county governments, the county governments say they don't have the money, and in the general obscurity of corruption the doctors have once again thrown up their hands and walked out.  And as always, the patients pay the price.  

We arrived late Sunday night, and showed up Monday morning to see what was happening.  Maternity services had been suspended over the weekend, but once Scott showed up the Medical Director cobbled together a plan to reopen.  All the paediatric ward patients had been sent home or transferred, except the burn patients who are cared for excellently by nurses.  But the newborn unit (NICU) babies had nowhere to go, so I found 25 still admitted.  Over the last three days, we've both plunged once again into that ambiguous zone of trying to walk a fine line.  We don't want to prop up a corrupt system; but we don't believe leaving the poorest people to die is a good way to effect change.  So here we are, again.

This baby, for instance, is alive by the mercy of God.  And here is why we work.  On Friday, her mom came to Naivasha which is the busiest maternity unit in the region, and offers reasonably safe deliveries to 500-600 women a month.  She was in labor.  She was told to go find a private hospital because the doctors had just walked out.  So she went a few blocks up the road to a small private hospital with questionable standards, who told her that she needed a place with capacity to do a C-section because her baby was in distress.  This hospital does C-sections at ten times the cost of Naivasha, so I suspect the real issue was that she couldn't come up with that money.  Next she went to Mai Mahu, which is about an hour away.  On arrival there, she was close to delivering, and her baby came out covered in meconium with Apgars of 4, 4, and 5.  Not good (good = 9 or 10).  So they told her, this baby needs higher level care, go back to Naivasha.  So she did.  20 hours of run around and poor care and danger, to get back to her starting point.  By God's mercy this baby actually is perking up and doing fairly well.  But she could easily be dead, or permanently disabled, due to the run-around, due to the finance departments, the governors, the health departments, the unions, the doctors, the broken systems in Kenya and the sadness of this world.  Similar story for another baby, same private hospital, this time the family came up with a deposit so they did the C-section.  But the mom was Rh-negative, so the baby had a high risk of severe jaundice with brain damage.  As the baby became jaundiced, the little private hospital (with no capacity to treat) told them they would need referral, but held on to them for an extra 24 hours until they could clear their bill.  Finally they returned to Naivasha.  Not sure how that one will turn out yet.  

Here is another reason we work.  This line-up demonstrates Kangaroo care.  Each of these moms is holding a baby weighing between 1 and 1.4 kg next to her skin (2-3 pounds).  I have 9 of them right now, and they are either going to get some antibiotics and tube feedings and daily weights and occasional labs and oxygen at Naivasha, or they are going to die.  
Or another reason:  Nurses who care.  We have some pretty dedicated women (mostly) who are going the extra mile, once again, during the strike, and we like supporting them.  Or another:  Clinical Officer Interns whose education has been chaotic in the months of uncertainty.  I have six now, and they are learning a lot about babies, labs, feedings, xrays.  Or another:  Scott just got back from doing an emergency surgery on a woman whose uterus ruptured when she went into labor with her 6th baby, after a previous C-section.  The baby died, but the mom was saved.  

Or one more reason.  A 14 year old girl goes missing for 4 months, then is dumped off back in her neighborhood severely anemic, traumatized, not speaking, so her mom brings her into the hospital.  This town has some dark pockets of unspeakable evil.  A colleague asked me to see her, and she held onto my hand and whispered in Swahili, "I want you to help me.  Let me stay here.  I don't want to go home."  Thanks to my neighbor who volunteers at a safe house down the street from us, we hope to move her there tomorrow.  She can get counseling and the staff will help with a police investigation. My heart breaks for her.  And I can't conscience her being left with no resource for care.

And this is only the tip of the iceberg of only three days back.

Meanwhile USAID announced they would cut off funding for the Kenyan Ministry of Health.  40% of the Ministry's budget comes from USAID.  In subsequent clarifying announcements, America is saying they are "only" cutting funds for administration until the massive scandalous corruption is addressed, and Kenya claims that all TB and HIV programs will continue.  Really?  

These are hard days for Kenya.  We feel the compassion you might feel for a friend who is going through hard times--even if they bring much of the problems on themselves (doctor friend shakes his head and says Kenya has the resources, we should be able to provide health for our people) you still grieve the sorrows.

Yesterday we celebrated 30 years of marriage.  May 9, 1987.  We were med students, looking forward to this life.  30 years later, we're old(er) doctors who worked all day to plug the holes in a failing system, then went out to our favorite Indian restaurant which is technically a truck stop on the East African Highway.  Wouldn't ask for anything else than the ongoing adventure of living day by day with this man, on the edge where evil eats away at the poor, and a simple faithfulness pours out a bit of the world-changing love we have received.

Wednesday, May 03, 2017

JOY JOY JOY, We came to Georgia for Ranger Graduation!!

Sometimes I wonder if we have that mark of Cain that is mysteriously mentioned in Genesis, that people see and then bless us in spite of our failings.  One of our friends and supporters generously bought us tickets to come to Caleb's Ranger Graduation.  Our colleagues gave us their blessing to miss a week.  A person we have not yet even met offered us an AirBnB to stay in, with my mom, sister, Jack, Julia, and one of their friends from Duke, only a few miles away from the Army base.  Our family drove umpteen miles and hours to be here.  And everyone kept it a surprise.  So that Thursday, at 2 in the morning, we pulled into Fort Benning.  A few hours later we were waiting with the other families by the gate where the soon-to-graduate soldiers would be released.  Caleb was expecting a room mate to meet him; when he saw us we all cried, hugged, laughed, and rejoiced.  That is a moment, and a week, we will long remember.

Friday morning dawned cloudy, as we gathered in outdoor stands to watch a thrilling demonstration of Ranger training (including helicopters dropping people on land and water, zip lines, rappels, explosions, hand-to-hand combat, squad formations, and even a bit of slapstick humor thrown in).  There were flags and music and speeches and then each new Ranger dissolved into the crowd of families to have their tab pinned on by someone significant to them.  A final re-formation, and they were done! After three months of minimal sleep, minimal food, constant stress, physical strain, psychological mind games, simulated combat, noise, darkness, cold, wet . . . they were free.  We had a celebratory lunch, champagne toasts and grilled meat and the beginning of four days of rehabilitation.

From Friday evening to Tuesday night, we drove about 2000 miles.  Yikes.  Up to West Virginia to our farm, where Luke, who had missed the graduation, was able to meet us for 36 hours off of his surgery rotation.  Hikes, swimming in the river, wild flowers, spring breeze, warm hugs at church, more grilling, firing the pizza oven, cakes, food, food, food, and rest.  Then we drove back to Durham to hang out with Julia and Jack one more time, in the middle of their exam week, again blessed by friends who gave us dinner and a place to stay.  Then a brief stop in Charlotte to connect with my family again, and back to Fort Benning, to the same kindness of the Air BnB cottage and sunshine and a pause to breathe.  Caleb starts his 3-week Airborne course on Friday and we leave that day to fly back to Kenya.
Please thank God with us, for allowing Caleb to pass through the deep waters and emerge resilient.  For letting us hug him in person.  For unfolding the perfect long weekend of many great meals to cook, naps and slow nights, the surround of Spring, sun, music, people who love him.  Hours to listen and talk.  Except for rather many car miles and never getting all four kids at the same time, I can't imagine a better post-Ranger recovery time.

Meanwhile we're still doing phone calls and emails with our teams, working on documents, corresponding and counseling and rooting from afar.  It's never easy to have our hearts in multiple places, but for this week we are thankful to focus in America on our favorite people in the whole universe.  Grateful for this week, and ready to turn back to the work ahead.