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Tuesday, May 19, 2020

Complex Proximity: #COVID-19UGANDA day 60, going on 600

"Proximity helps us to appreciate complexity. It begets empathy. . . prohibits simplistic solutions.. . causes us to be emotionally invested in the issues. Proximity, then, should be a priority. Mission that is not up-close-and-personal is inadequate." (McCullough, Global Humility)

The call to prayer echoes in the darkness, moonlight on the mosquito net. Fighting this rhythm is a losing battle so we embrace it and stretch to meet the day while it is still the cool hour of stars fading, the outline of palms against the greying sky. A bit of routine anchors the day: exercise, Bible reading, coffee, prayer, breakfast, quick check of news and communication, then out the door. Masks on. We have a permit to drive the 8 miles to Bundibugyo Hospital, with maximum of 3 people in the car. Ivan, a final-year nursing student who grew up with our kids, usually waits just at the road to ride with us, as we open and close the gate to keep our rambunctious dogs in the yard. The mountains are clear, sharp, jagged. We used to see snow routinely on the peaks. This year, none so far. But the way the road hugs the ridges that flow into the valley turns us towards the mountains as we climb, and I always think of Psalm 121, my Dad's favourite.

The 8 am staff meeting trickles to a start as we park in the dirt lot in front of the administration building. We stand a meter or two apart in a semi-circle. A different staff member is tasked to chair the meeting each week, choosing someone to offer the opening and closing prayer, asking for the night nurse's report. 15 admissions to Paediatrics, one death, total on the 25-bed ward is 55 or 63 or whatever the day holds. 5 C-sections over the last 24 hours. 8 babies in NICU. 25 on male ward, and can one of the doctors please review bed 17? And so on. Then there is open reaction, and inevitably, the tenor is this: we couldn't give medicines because the key was missing, there is no more artesunate, we couldn't call the on-call doctor because we had no airtime, we are out of guaze, there is no sterile gown for the next surgery, there is no suture, can we please buy a bulb syringe because we almost lost a baby for lack of suction, we are out of A+ blood. This entire system hangs by a million fragile threads. Matters of a few dollars are life and death. There is so little margin. Yet I admire the process, the attempt to build teamwork, the value on every person being heard, the courage to plug on in spite of a thousand barriers.

From there we disperse to the wards. Scott begins seeing all the women on maternity. I start in NICU then move to Paeds ward. At times we are alone, doing vital signs, getting history, examining, writing notes. Squat and lean over the patients on the floors, stand and discuss. Scott lugs the ultrasound and a bp cuff, I have my hand santizer and a bag of gloves, a pulse oximeter. The masks make communication even more frustrating. At times a student or volunteer tags along, helpfully filling out lab forms, repeating my instructions to help moms understand. Most days our colleagues Dr. Isaiah and Dr. Ammon come in and out, as we choose the busiest wards and they know we need help, but they are also pulled to this politician's sister and this staff member's grandfather. I try my best to note the sickest first, but inevitably I find a child severely ill on my last section of beds. Or a nurse brings in an actively convulsing new admission. My methodical march through the ward always takes turns and detours. Scott ends up with a C-section, or does extra ultrasounds. Jessie and her team point out a child from their nutrition office who needs labs, or who is not improving. I call Dr. Isaiah or Ammon for advice, or the lab in-charge to find out if the machine for bilirubin happens to be working today. I try to focus on each kid, say a prayer as I listen to a chest, not let my mind wander to the next problem, be alert to a clue of a rash or a paleness or a story that doesn't quite fit together. As I see patients I direct them into a small room where nurses sit and inject our limited options, either an antimalarial or one of two antibiotics. Others go into the opposite side room and get tablets for going home, others are given therapeutic food from the nutrition team. Others are placed on one of the three tables in the front where they get a blood transfusion, or some IV fluids, or oxygen.
In the late afternoon, I am toast. It is hot. The masks make it feel suffocatingly so. There are always more problems than we can manage. By 1, or 2, or 3 we wind down, perhaps we run to the pharmacy to spend $20 or $30 on stop-gap medicine measures, to buy ng tubes or ORS. Then it is back into the car, switching the N-95 mask for the cloth non-medical mask. I let my N-95 bake in the sun of the dashboard as I will reuse it for at least 6 days. More alcohol swabbing of everything. Uganda cases are almost all truck drivers at this point, but the march of the virus through Africa is inevitable. The WHO expects 250 million cases. It is hard to imagine.

Back at home, we often have a scheduled meeting, in person with a team mate (socially distanced outside!) or by facetime or other internet medium with a team leader around our area. Today Scott and Patrick spent hours pouring over budgets, because the schools have permission to open in two weeks ONLY FOR THE SENIORS . . . we struggle with the justice of paying our staff, verses the financial reality that every month we lose $5,600 because parents are not paying tuition. When we bring back just 1/6 of the students, continue to pay staff, and resume providing meals for everyone, the losses will continue at about the same pace. The reality of coronavirus never quite recedes to the background. Not just the finances. The masks, the curfews, the limited movement. The uncertainty. Will we ever be able to bring the rest of the students back? What will this mean for the longterm education of this generation? As frustrated as we are with all of that, coronavirus also hits home personally. We listen to a nurse friend tell us about her diagnosis of COVID after her brave few weeks of work in NYC. She has a full body inflammatory rash, a racing heart and low blood pressure. Coronavirus is not just about inconvenience and politics. It is about the random but real young healthy person who develops severe symptoms and lands in a hospital bed. Pray for Allyson.

In the evening we were about to zip down to the market town for milk, but as we come out of the gate, we spot a Great Blue Turaco and have to stop and watch. In the past week we've also seen a crested eagle, and a hornbill. Scott waters the garden and I scavange for dropped mangos and avacados under the trees. All our shopping is on foot, unless a team mate has organized a small cargo delivery from Fort Portal. There are phone calls with moms and kids and sisters, news, or catching up on the latest rules from the President, or preparing for the next day as we make dinner and wind up the day.

The needs of Bundibugyo and the joys of Bundibugyo are complex. They are intertwined. And impossible to understand from a distance. Only by walking through a day, and another, and another, by touching the sick, fumbling with Lubwisi under a mask, praying with a team mate, strolling in the heat to buy tomatoes, answering another knock from a person with a problem, figuring out how to improvise when the incubator doesn't work . . . only by being right in the mire of the world do we get to be on the front row for redemption. 

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