2020, the perfect year to linger in the major and minor prophets. The waning years of the Kingdom of Israel, the intersecting sorrows of the modern globe. Last week I finished Jeremiah with his long acrostic poem, Lamentations. Each chapter works through the 22 letters of the Hebrew alphabet. Chapters 1, 2, 4, and 5 paint the demise of Israel and the tumult of the nations in poetic terms. But chapter 3 turns personal, a deep dive into Jeremiah's own heart in the midst of international events. And tucked into the middle of the middle chapter, a very Hebrew form of emphasis, are some of the most well-known lines in the Bible.
Sunday, August 30, 2020
Saturday, August 22, 2020
One hundred days into the Ugandan Covid epidemic, a 15-year-old "K" walked into our hospital and delivered a 1.2 kg baby girl (that's 2 1/2 pounds) ten weeks too early. Yesterday, She took her 4-pound baby home, after a 55-day marathon of tube feeds, incubators, IV lines, antibiotics, hours of skin-on-skin kangaroo care, countless replaced ng tubes. That's still two weeks shy of her actual due date. This was a Christmas school holiday baby, a young girl who had just finished her 7 years of primary school, a dad half-way through high school. The pregnancy and COVID aside, she statistically was not likely to receive further education besides the hard way. And she learned quite a lot over the last two months. She knows how to express milk and draw it up in a syringe, measure quantities, drip it into a tube. How to secure a tiny speck of life to her chest. But mostly, she learned hope. Because at first, she was quite disengaged and reluctant. Her baby did not look likely to survive, and she withdrew into a protective shell. It took the community of other moms spurring her on, and her own mother-in-law, a spunky lady who showed up to take care of her (she's only 15 remember). But it also took Ivan.
Ivan with K and baby, preparing for discharge from NICU
Ivan grew up in our orbit, his dad having been one of the young men we sent for nursing school in the late 90's. Over time he became Jack's best friend, spending much of his time at our house, and when his parents' marriage broke apart his mother asked us to take responsibility for his schooling. He was two months short of graduating from Uganda Christian University with a degree in nursing (most nurses get diploma-level education, so this is a boost to our district's skill level) when the world shut down. In the 2020 limbo, he's been volunteering several days a week and focusing on our newly opened NICU. Kacie spent time teaching him newborn resuscitation using the Helping Babies Breathe curriculum. Dr. Marc, Dr. Isaiah, Scott and I have worked with him and explained and entrusted more and more.
So a few weeks ago, when K came down with a cold and then her tiny baby got sick . . . and then stopped breathing, Ivan was on duty. He found another nurse wrapping the infant's body up in defeat. But Ivan did CPR. He sent someone to get me. Over the next week, we did everything we could to keep this baby alive, oxygen and a transfusion and medicines and monitoring. She had to be revived more than once. And improbably, she clung onto that thread of life.
Her discharge was a concrete moment of hope. It was really Ivan's belief in not giving up that saved this baby's life. And that's what the good news of God's rule seeping in looks like. It's a multi-decade process of relationship that gave this nursing student the courage to see the survival of a 1.2 kg apneic baby as a possibility. That brought in partnerships with Save The Children building a tiny NICU, brought in incubators and ng tubes. It's the refusal to write off a 15-year-old grumpy teen, and slowly coax her into being a skilled mother. It is little acts of faithful work, over and over, 55 days in a row.
Last week, we picked up urgently and rushed to Kampala for another birth. This one was right smack on time and in spite of a last-minute C-section, all went well as Jenna and Boas welcomed baby Nile. The day before, Karis and Stephen delivered baby Zaks in Nairobi. Neither of these moms had their ideal birth plan; both had hoped to be in other places, and with family support. But both faced the reality of 2020 with courage, and both are now holding nearly 2-week old healthy boys, with minimal help from anyone but a husband and very limited friends. We had the joy of being surrogate grandparents, ooohing and ahhing over the sweetness of Nile (with masks and clean hands of course) for days, and admiring Zaks on What's App.
Nile in Kampala day of birth
Zaks meeting big sis in Nairobi
Two weeks ago was the last normal Saturday I sat here at this desk, and asked for prayer for baby of "K", for our two Serge moms about to deliver, for our own weary souls. I'm still plowing through the melancholy of Jeremiah and Habakkuk . . . "in wrath, remember mercy" is his prayer in chapter 3. As their global situation devolves into chaos they see ways God moves in power to show mercy to the remnant. In the wrath of 2020's insidious viral death-march, ripping open of festering racial injustice wounds, divisive tribal fear-stoked hate on multiple continents . . . the babies represent a message of mercy. Potential. Hope. Seeds for good that will grow in ways we can't predict. God's power in several vulnerable packages.
Which, besides anxiety over survival, has been the other major current of thought in the last two weeks. Because I pulled off my shelf a 20-year old book by Marva J. Dawn called Powers, Weakness, and the Tabernacling of God. Dawn delves deeply into the Biblical passages and literature exploring the idea of "principalities and powers", something that is taken for granted to be true in African culture and Biblical culture but must be re-established for the average American audience.
We need to recover a more nuanced and holistic view of evil, which paradoxically helps us see more clearly into good. The world is broken, people sin, and there is an unseen realm of forces that are both institutional and demonic that seek to harm us. As I was writing, I was interrupted by a phone call from a friend desperately worried about his sick child, and on the way to my car to respond to the emergency my young neighbour (another kid who grew up with ours) met me to tell me about his sick daughter. COVID-19, malaria, and other pathogens are part of the frayed fabric of our world, the brokeness of the Fall, the intrinsic sorrows that are part of being human. That these children live in a town where the hospital is out of malaria drugs and never had much oxygen capacity is not part of their personal sin, it is a world system of poverty that is stacked against them. Yet there is probably sin in these scenarios too, perhaps a nurse somewhere stole or sold off the medicines meant for needy patients, or a greedy pharmaceutical company set a price high enough to finance yachts while leaving the poor to die, or a parent spent his small fees earned by his boda business on alcohol instead of a mosquito net. And behind the scenes, though Satan was defeated on the cross, the mopping up of all spiritual powers that set themselves to harm us has not been completed. In most situations we can find multiple forces of evil, and the good news is that the cross reverses the decay of a groaning creation putting us on a path towards all things new, justifies and forgives all the sins we have committed and will commit, and chains evil powers, limiting their capacity as a promise of their eventual disappearance.
The brilliance of Dawn's book lies in the way she moves from an overview of evil and the power of the Cross to . . . well, if this is most places, it would be either a name-it claim-it simplistic prosperity-promising temptation to grab the victory in full this side of time, and be financially successful, physically healthy, socially "in", and gorgeous to boot. Or a sober diatribe on personal sin and repentance that boils all evils down to individual choices and wants a uniform set of moral rules to keep things straight. But the Bible, shockingly, after affirming Jesus as victor by a literal resurrection from the dead . . . has him cooking fish and calming hearts and quietly fading away. Within a generation, his followers grasp that the rule of God is not pounding in with an army or a gilt temple, irrefutable and irresistible. The power of God comes at the end of human power, when we give up our rights, our voice, our time, our wisdom, embrace our weakness and limits, and depend fully on the grace of God. The more we get out of the way, the more people can see the glory of God.
Throughout the New Testament, then, we have seen a diversity of evidences for weakness a God's primary method, including the weakness of a suffering Messiah, the weakness of our sinfulness that necessitates a Saviour from outside ourselves, the weakness we have relative to the powers of the world, and the priority for our communities of welcoming the weak. (p 55)
I believe her final two chapters have much to say to the American Evangelical Church in 2020. If we are called to a path of the cross, of suffering, of embracing weakness . . . when did we become so obsessed with winning, with power, with control, with position, with status, with numbers? She calls us back to the basics, particularly to prayer, to fellowship, to being countercultural, in the world but not of it. She calls us to gracious generosity, to compassionate insistence on justice, to metrics of faithfulness and dependence upon God. I think that her descriptions of the early church, and of the Ephesians 6 "armour" of the Spirit, give us a challenging vision of living out the rule of God as salt and light in a world that needs to taste and see.
We need not feel overwhelmed by the cultural forces arrayed against Christianity; the battle against the powers has already been decided. And we need not feel overwhelmed when we remember that such ending of our power as we might be feeling is exactly what Christ desires for the fullness of his tabernacling. . . .The cross is the heart of history. (p 163-164)
If anyone is still reading, thank you. Because I want to end by saying, a robust theology of evil, and of good, matters. Putting the blame for a preem on the shoulders of a 15-year-old girl is demonstrably wrong. Did she sin? Yes, daily. Me too. But she also suffered the consequences of systemic evils so much larger than her. Does the victory of Jesus on the cross mean no more premature babies? Not yet! But yes, someday, no more tears at all. The dense and complex narrative of baby-of-K reflects the dense and complex narrative of the incarnation. Jesus, vulnerable, in the flesh, pitching his tent here amongst us in a decidedly marginalized people. Jesus, resisting the short-cut to power and glory, carrying the cross and meeting death head-on. Jesus, forgiving sin and healing disease and promising Heaven, because in that death and resurrection the entire order of the universe shook back towards a trajectory of hope. Jesus, choosing to work behind the scenes through the Ivans of this world, blowing a spirit of life into a dying baby, preaching the forgiveness of sin, breaking the power of evil. The full establishment of shalom is not yet here, but we catch those glimpses of glory and hold on for more.
Saturday, August 08, 2020
141 days are feeling long for all of us in Uganda, yet our troubles are only a minuscule taste of the world's. August finds the read-through-the-Bible-chronologically march in Jeremiah, in the final days of the crumbling Kingdoms of Israel and Judah. And perhaps because we have to Sergers in our Africa area awaiting childbirth, every time Jeremiah says "pain as of a woman in labor" it jumps out. Labor is inevitable yet unpredictable. You can learn about it but no two experiences are the same, no one can feel another person's pain, no one can really prepare you precisely for the experience. Anguish is going to grab those two, as it has women since Eve. I wonder if Jeremiah's mother or wife was a midwife, since he goes to that analogy repeatedly to warn the Jewish people of the trauma ahead. We are globally in the 8th month of being aware of the spread of the novel coronavirus. In January we read the early reports of a mystery respiratory highly contagious viral syndrome, briefly wondering if it might inconvenience us with impact on our May all-company conference. Now in the 8th month the entire globe is reeling with heaviness. Our US Embassy yesterday told us that if we were not paying attention before, it is time to pay attention now and assume anyone we meet is infected (link included as many American readers may find it more helpful than much of what they are hearing). We watched coverage from Georgia last night, with skyrocketing infections and the death of an otherwise-healthy 7 year old. Meanwhile we are about to celebrate the 7th birthday of a kid on our team.
That dissonance is weary-ing to us all. Perhaps being a doctor in 2020, a team leader, a writer, a human whose heart holds the heaviness of traumas and injustice past and present, is similar to being Jeremiah in the ascendency of the Assyrian and Bablyonian invasions of the known world. In chapter 6, he wonders, who should I warn? No one is listening to this, they have no delight in it. Therefore I am full of the fury of the LORD, I am weary of holding it in. We try to stick to policies of masks and hand santizer and distance and outdoor meeting, of limiting travel and interaction. All of these are counter to the Gospel-picture of community and openness and immersion. This is hard for all of us. We are weary of holding it all in.
I think our two women facing labor and delivery are way wearier than any of us, stuck in countries they did not intend to stay in for this process, unable to have family nearby, no guarantee a husband or friend can even enter the labor room with them. I know that having done this a few times including in some marginal places, there is always the nagging doubt, how bad can this get, and can I survive it? Am I strong enough? What if.. . .? And I think everyone is getting a little taste of that right now. How long can we deprive ourselves of human contact, of hugs, of parties, of connection? How long can we put our kids' educations on hold? How high is the price of a lonely 84th year, or 87th?
Last night I read a story that for the first time, malaria resistant to our main medicine (artemisinin derivatives) has been found in Africa. Two sites in Rwanda. The potential loss of lives over the next five years if this mutation takes hold and spreads is 78 million cases, over 100,000 deaths. In another year, that might have been interesting or sobering, this year it is alarming and makes me want to cry. Because those deaths occur right in front of me right now, currently due to delayed care or poor systems or co-morbidity with sickle cell and malnutrition . . but if we get to the point where we are doing all that right . . . and we are still powerless, malaria will make COVID-19 look minimal. The paediatric ward is now not even standing-room-only, because standing room is almost gone. People have to line up and wait to weave their way through mattresses on the floor because I'm squatting between two that are only inches apart. I had to put my head down on a bed fast because the umpteenth squat-and-stand left me dizzy. It is pouring rain right now. Mosquitoes are proliferating.
The childbirth analogy continues right on to the teachings of Jesus. In John 16 he is talking to his disciples prior to his arrest, and says:
"A woman, when she is in labor, has sorrow because her hour has come; but as soon as she has given birth to the child, she no longer remembers the anguish, for joy that a human being has been born into the world. Therefore you now have sorrow; but I will see you again and your heart will rejoice, and your joy no one will take from you. . . These things I have spoken to you, that in me you may have peace. In the world you will have sorrow; but be of good cheer, I have overcome the world."
Both-and. Yes, you are weary, you are facing anguish, things look rough ahead. Yes, you will have sorrow. But . .. also yes, you will have joy and you can go forward with peace, because Jesus holds the end in hand, and all shall be well. Coronavirus and malaria, racism and poverty, greed and abuse, will all be overcome.
So prayers appreciated for our two about-to-enter-anguish moms. For a glimpse of the joy of holding those newborns to see them through with courage.
And prayers appreciated for two weary doctors, in the unending sorrows of this broken world. Yesterday Scott found his two lost sheep: a woman who had laboured all night with zero progress . . . meaning he had to push against the inertia of the system, supply sutures and some of the anaesthesia medicines, often he has to wheel the patient to the theatre or put in the IV himself to get the C-section moving. The baby was not-quite-dead, and revived. Then as he was writing up the operative note, a nursing student begged him to ultrasound scan her sister. People love ultrasounds here, and want them for all kinds of inappropriate indications, and Scott is the only source of free and accurate ones so he gets weary of these requests. But he trudged back to maternity to discover an undiagnosed ruptured ectopic pregnancy, again having to set up and push and innovate to get the woman to surgery. Her hemoglobin was 2.4; she had 5.5 LITERS of blood in her abdomen, as he worked to remove the burst tube the anaesthetist transfused the little amount of blood available, and she survived. My lost sheep were a preemie that Ivan resuscitated on Weds when the staff generally were ready to call her dead . . . she got a respiratory infection from her 15-year-old mom 40 days into her incubator stay (and a glimpse of joy, that Ivan saw the potential for action, sent another mom to grab me for help, and saved this life for now). And two very very lethargic and weak malnourished children, little girls who did nothing to land themselves in families with HIV or TB or divorce and abandonment. Plus a little boy with sickle cell and malaria, on a mat on the floor squeezed between two other actual mattresses on the floor, whose labs I happened to find under some books on a desk while looking for something else . . . hemoglobin 3.8. This is why we keep pushing through the crowds to find those closest to death and focus the team's energy there. Meanwhile we are trying to teach students, and I personally am failing to remain calmly gracious at the fray. Repenting for my sense of self-righteous input; and yet also relating to Jeremiah's sense of "isn't anyone listening???"
This was Wednesday, numbers were up even higher by Friday . . .
Saturday, August 01, 2020
So when Attorney General Barr said that he did not believe there was systemic racism operative in our criminal justice system, I immediately applied that to the kind of systems-thinking we try to do in medicine in Africa.
When problems arise, the human tendency is to look for the person to blame. Bad outcome of treatment? Well, whose fault was it?
But while it is important to hold people accountable to do their jobs, most of the real progress in improving care and reaching goals comes from thinking about the system that is functioning to produce the results that we see. For instance, here are some of the problems we have been present for discussions of this week:
- A child dies of severe anaemia from Sickle Cell, because there is no blood in the blood bank to transfuse them.
- Teenage pregnancies are on the rise during lockdown, and we're all realising that many girls are safer in school than at home.
- An infant is still born because the nurse called the doctor to do a C-section, but he did not answer his phone, and so she waited for the next shift in the morning.
- Rats are eating the hospital register books and plaguing the operating theatre because they are attracted to placentas left in buckets.
- A two-year-old comes in with an abdominal stab wound inflicted by his own father who was high on a substance and mentally ill.
- Alcohol and marijuana are in our markets because the parliament gets income from this business.
- Artesunate, a key malaria drug, is out of stock because people believe it is so powerful that they sneak into maternity ward and copy the name and file number of patients so they can go to the dispensary and fraudulently take it.
- Before all schools were closed, teacher absenteeism was rampant because they take loans which they cannot repay on their salary so are constantly working other jobs.
- Government staff do not respect their supervisors because their salaries come via bank transfer not tied to performance.
- Coronavirus deaths are now three in the country (extremely low, but the beginning of the wave) because people have stopped wearing masks and distancing.
- Families complain to the police when their daughters are enticed into sexual relationships as teenagers or even younger, but as soon as the threat of action generates a financial settlement from the seducer they drop the case.
- Medicines are out of stock because the national supply chain is months behind schedule.
- A friend has to move out of his paternal home because his alcoholic brother keeps beating up the friend's wife when he is at work, and the family cannot send this alcoholic brother away.
- Another friend calls a community meeting because the neighbours have blamed a death on the statement "you should take her to the hospital; if you don't she might die" , attributing that statement rather than the delayed care as the cause of disaster.
- A neighbour limps in with snakebites because the local house construction has many gaps.
- The school gets a 2.4 million shilling water bill (almost $700, or more than 30x normal) because of a shoddy repair five years ago that has now allowed thousands of liters to silently leak into the ground.
- We are on our last tin of therapeutic milk, because our district relies on UNICEF supplies that do not reflect the reality of the need.
- Food production is inadequate for our district, because people planted so much land in cocoa over the last two decades to make some cash, at a ratio that benefits the buyers and leaves the small holders with hunger.
- A baby dies because his exhausted mother is over 40 and on her tenth delivery and she just can't summon the strength to push him out.
- A rape case is not followed up because the family can't pay the extortion required to get all the forms filed with police and medical reports.
- With primary elections approaching, people are warily testing the winds to figure out who will win, because the voting is done publicly by lining up for your candidate. So what is meant to quell rumours of ballot box stuffing becomes, in peoples' hearts, a fear that they will be punished for supporting the wrong person (whoops, your name was deleted from the payroll, spend a few months with no salary to try and sort that out).
- The further from town a school or health center is, the less likely it is to be fully staffed, because as people move up in education and responsibility they want to live more centrally with access to shops and power.