Part and Parcel, Ear to Ear

I found myself yesterday afternoon in a long and tedious meeting which Scott was supposed to attend by virtue of his appointment to a community-based committee that manages the health center.  But he was being overwhelmed by 25 ultrasound referrals at the hospital (either the overzealous referring of unsure visiting doctors-in-training here for the month, or the passive-aggressive action of the usual ultrasound staff refusing to screen out the routine cases and only pass on questionable ones to Scott, in protest against action to stop them from illegal surcharges, or divine opportunities for him to serve and teach . .. he was never quite sure).  While I struggled with the restless sense that the hours were slipping through my hands leaving much left undone, I found I could not easily slip away.  For one thing, these are the people among whom I have spent most of the last decade and a half, and I care about the issues they are raising.  For another, the elected official chairing the meeting made me sit right beside him and gave a speech about how we are “part and parcel” of the community and the work.  Sigh.  So I listened and even challenged or supported various points.  Instead of “shoulder to shoulder” the idiom for cooperation I heard was “ear to ear”.  Sort of an interesting picture of us here, ear to ear with our colleagues, a meeting of the minds and a cooperative physical pushing against disease and poverty. The day only got more ear to ear as it drew to a close.  A couple of newly-weds came to greet us, and as we chatted I reflected on the privilege of moving from a relationship of parent/sponsor to one of colleague/friend.  Am I getting old?  I guess so.  Perhaps the wisdom of age or the whisper of the spirit, I decided to offer the wife prenatal vitamins, sensing she might need them soon if not immediately.  I called her aside and learned that her last period was two weeks before the wedding . . . So we did an impromptu ultrasound with our portable machine, and once again had the fun privilege of introducing new parents to the waving limbs and fluttering heart of their tiny fetus.  But this time it was not American team mates, but Babwisi friends, with whom we could share the same joy, and hug, and pull them into staying for dinner with our family.  And the due date:  Christmas Day.  Fun. By the time we cleared up from dinner and the long day and got the kids down to Friday night clubs at school (they attend games club where Jack teaches his friends great short English boggle and scrabble words, crafts club where Julia nestles in with the girls and learns to crochet and knit, and math club where Caleb reluctantly rises to the challenge of interesting problems) . . . We were exhausted, and ready to relax, settling down on the couch with Luke after about 14 straight hours on the go.  But as soon as we hit the couch there was knocking on the door, a bit ominous in the dark.  Particularly when the dark face at the door is covered with blood.  Our neighbor Buligi and his wife stood there with a knot of relatives, and we immediately sat Buligi down.  His face had been mangled from a motorcycle accident.  Scott ended up taking him down to the health center to do a little plastic surgery by flashlight with the cheerful and competent help of the theatre nurse, who was one of our original “Mother and Child Survival Project” community volunteers more than a decade ago.  Buligi’s is the second case this week of stitches in the operating theatre after a motorcycle accident:  the other was our lab technician.  Both are responsible adult men with one wife, married in the church, with jobs, families (which makes them far from average).  They are not reckless teens out for joy rides.  One was taking blood samples to the central lab, the other coming from taking soap to his boy at a boarding school.  But the crowded road, the meandering goats and pedestrians, the deep rusts and jagged loose rocks, the sharp turns and bushy roadsides . . . Make for danger.  So Scott ended the day ear to ear with our worried neighbors and our hospital staff, part and parcel of the night’s work.

Bullying

There is an interesting comment on the post about DDT, from someone who identifies himself as a coffee buyer and concludes that the concept of an entire district losing its “organic certification” is patently false. The middle-man cocoa buyers are bullying the farmers with this threat. I find that quite believable: perhaps it is this way all over the world, but the bullying culture seems well developed in Africa. On the surface the society seems relatively peaceful to the outsider, the strong clan identification and respect for elders. But underneath, there is violence and fear. Older kids bully younger ones, a huge problem at our boarding school in past years (though one we’re fighting), as new students find themselves surrounded and threatened and relieved of their stashes of sugar meant to sweeten their morning porridge, or of their pocket-change meant to buy pens or soap. Teachers bully students. A friend told Luke last night that his teacher told him that unless he stopped playing soccer in the afternoon break time, the hour and a half of exercise and recreation that breaks up the long school day, he was going to fail that teacher’s class. Men bully their wives, and parents their children, using beatings or withholding food to assert their power. Staff bully patients, berating them at times for disturbing their peace. Families bully their relatives when they accuse each other of witchcraft and extract expensive fines and rituals for peace. Harsh words, raised hands or sticks, coercive threats, turn the interaction into one of power and abuse. So the idea of cocoa buyers pressuring farmers with the threat of boycott seems quite real. And with most bullying, one must query what the bully seeks to gain. A lower price for the product, and a higher profit margin? A political point scored against a government policy? Or just a sense of control? And perhaps that points to the reason the culture of bullying thrives in a place like this. When the vagaries of international trade and exploitation of resources have depleted a continent, when the ravages of disease and drought lurk around the corner of every month, when daily survival is a struggle and the outcome by no means certain, people want a small sphere in which they feel some sense of security. They want some way to manipulate the world in their favor. So from the hungry teen all the way up to the shady businessman, the stronger pushes the weaker, and feels stronger still. Sounds like something out of Ecclesiastes, another lament. And a warning to my own heart. Lament lays the injustice before the throne of God, rather than bullying the bullies into submission.

Wrong Birds

Last night at midnight we were awakened by shouting men, a revving motorcycle, clapping, barking. We tried to ignore the noise but it escalated, and we began to wonder if thugs were bothering the Mukiddis. We went out to the porch and saw flashlights shining through our hedge, and heard a large rock rustle through the trees and thud into the grass. Star was going wild on her leash. Scott yelled at the group of men to go home to bed. They answered “Doctor, we are chasing a wrong bird. We don't like it.” Luke has lately noticed a Verreaux Eagle Owl sometimes roosting in our tree. It seems this bird is associated with evil spirits, and all our neighbors had gathered to scare it off, a collective action of noise and desperation. Evil abounds, but people have been deceived into fighting useless battles.

Tonight we will chase evil in a different way, though some clapping and gathering will be involved. We have planned an extended prayer time for our team, beginning with lament, naming and mourning the evils and then turning to God in worship, praying for the Kingdom to come. We will use Psalm 22, the words Jesus echoed on the cross. The cry that begins in despair ends in faith, and we hope to make that journey tonight, honest protest, engagement with God’s presence, and hope for the future. The psalm ends like this:

The poor shall eat and be satisfied;
Those who seek him shall praise the LORD.
May your hearts live forever!
All the ends of the earth shall remember
And turn to the LORD;
And all the families of the nations
Shall worship before him.

Posterity will serve him;
Future generations will be told about the Lord,
And proclaim his deliverance to a people yet unborn,
Saying that he has done it.

On the politics of health

Scott was called by the top elected official in the district to join with the district health leadership and all other NGO’s in evaluating progress in the fight against AIDS.  He carefully compiled the numbers, extrapolating population data and comparing statistics from the health centers to show that our HIV prevalence among pregnant women remains low (3% or slightly less), but the Kwejuna Project has had a significant impact on the care those women receive.  Since its inception four years ago, the percentage of women in Bundibugyo who receive any prenatal care has risen from 49% to 72% (we were actually up to 80% pre-ebola, so have some lost ground to recover this year).  That’s 72% of 13 thousand pregnancies . . . A lot of women.  The percentage of women coming for prenatal care who were tested for HIV went from 0% to 98% in the first two years and now hovers in the mid-80’s (slippage in interest and supply shortages).  The number of male partners tested has increased from 8 (yes, 8 men in the whole district) to over 2,000 . . . Still less than half of new fathers, but a steep incline that indicates major shifts in practice.  Pre-Kwejuna men were never even seen within a mile of a prenatal clinic!  But perhaps the statistic that most significantly indicates a strengthening of health capacity in our district:  health-unit based deliveries have tripled in number and risen in percentage of all deliveries from 19% to 33%.  Most women still deliver in their mud-walled homes alone or attended by their mother-in-law, but more are accepting the oversight of trained midwives in a half-dozen equipped birthing centers.  In a place with high maternal and neonatal mortality, this trend has the potential to save hundreds of lives every year.

At the same time, major world AIDS programs had convened meetings today in New York, a far cry from the Bundibugyo conference.  I heard on BBC tonight that while progress is being made, less than a third of people who need to be on anti-retroviral drugs world-wide have access to treatment.  New infections still outpace capacity for care.  Countries like Uganda can not meet demands, though they spend almost 10% of their budget on health (relatively more than the US) the actual outlay per person is very very low.  Nation-wide the doctor:patient ratio is two hundred times thinner than in the west; in Bundibugyo it is two thousand times more desperate.  And so we struggle on, seeing some hopeful mile markers passing,  but painfully aware of the distance still to run.

Scott’s meeting started two hours late (surprise) which was not just the lethargy of Africa-time.  Instead, a peaceful protest had disrupted the town.  Demonstrators spoke and marched against the new government policy to spray houses with DDT as a way to combat malaria.  Here the politics of health becomes very murky.  Will small amounts of residual DDT lead to environmental catastrophe, as in Silent Spring?  How does a country weigh environmental cost against the deaths of thousands and thousands of children from malaria?  Is sounds very politically incorrect to support DDT . . . But most of those voices come from places like America, where we no longer fear malaria, because we wiped out the anopheles mosquito.  Is it fair to forbid Uganda to do the same?  While I would like serious data to wrestle with these questions, the protestors had more practical concerns. Over the last decade Bundibugyo’s economy has been driven by cocoa.  It is now a major cash crop.  And the biggest cocoa buyers have made it clear that if any DDT is sprayed anywhere in this district, ALL farmers will lose their “organic” certification.  As Luke pointed out, being “organic” is one of the only things that Bundibugyo really has going for it, one of the few up sides of isolation and poverty.  The price per kilo of cocoa would be almost cut in half if the organic label is removed.  That means almost half of most family income would disappear. So will the health benefits of decreasing malaria transmission be lost in the doubling of poverty?  A very reasonable question.

Health is a political concept.  Today’s protestors were arrested as anti-government, since there is no real distinction between policy and person.  Disagreement is equated with disloyalty.  The wisdom of Solomon is needed for these impossible choices, for parents who are trying to survive by choosing between the income that allows them to pay school fees for their older children, and the marlarious soup that drives the younger ones into disease and all too often death.  A cruel irony that choosing against spraying may mean that the very child whose education the cocoa-money would have funded may instead be the next one in a coffin.  

A Tuesday Lament

Kwikilija Jakobo, age 6, died this morning, killed by inefficiency, apathy, corruption, poverty . . . I walked into the paediatric ward at 8:30 and his distraught mother pushed her way into the front, waving papers from Bundibugyo. In a reversal of referral patterns the staff at the district hospital had referred him to our smaller health center with the scrawled note “severe anemia ? Cause . . History of having got treatment in Bundibugyo Hospital, there no blood and for possible management by medical officer.” I took that to mean that the hospital was out of blood, no surprise, since our lab staff had failed to obtain the weekly supply from Fort Portal and the hospital administrator had twice this week sent for blood from the regional blood bank there but been told it was “finished”. In a classic waste of time and money, the patient’s condition probably deteriorated further because of being sent to Nyahuka, when a phone call would have confirmed that there was no blood at our health center either (or even a short conversation with any other staff would have revealed that patients with the same problem had been transferred earlier that day in the opposite direction).

First I called the regional blood bank’s officer . . Only to be told that the earliest we could get blood would be tomorrow. Upon further questioning he claimed that the entire western region’s blood supply was nil, because they had run out of bags. BAGS????? Whose fault is this? Is it the blood bank staff who fail to notice that they are using their last carton of heparinized sterile bags to store donated blood? Is it a corrupt or careless staff member who pockets the money for new supplies, or just forgets to process the order? (Evidence of both in other items this week, a disbursement of medicines listed as being worth more than twice as much as their real value, and hospital staff “borrowing” medicine from our health center to supply AIDS patients at the main hospital because their requisition forms were “lost” so that they ran out of medicines). Is it an entire country living on the margin with no reserve, so that one week the stock of an essential item can simply be gone? Is it poor communication, is it the barrier of deplorably maintained roads, the lack of fuel to transport personnel and supplies? Is it an over-zealous AIDS testing policy which, as in western countries, takes the risk of viral transmission in transfused blood from 1 in a thousand down to 1 in a hundred thousand, never mind the fact that the risk of a child dying from anemia increases from 1 in 100 to 1 in 10???? We live in the epicenter of sickle cell anemia in the world; we live in a valley where malaria is so endemic that almost 90% of children have some level of parasites in their blood; we live in a district where iron deficiency is universal, where diets are poor and intestinal worms remove tiny increments of precious heme on a daily basis.

So Kwikilija, like so many children before him, dwindled, until his heart could no longer metabolize enough oxygen to keep the watery blood circulating in his body, even as we scrambled to try and save his life, too little too late, the wailing relatives throwing themselves on the ground in grief. Raw lament from his mother; anger and frustration from me. I struggle with how to enter the fray with Jesus-style table-turning zeal, but without my own prideful self-righteousness hurting those who are already victims of injustice themselves. How to allow the waste to wring my heart, without hurting others.

Weekend Snapshots

15 Filthy missionaries, climbing through vertical gardens, loose dirt, and misting rain to reach Ngite Waterfall, a spectacular crash of loud frigid water.  The filth disappears as we plunge into the powerful force of the river.  A great way to spend a couple of hours, away from the clamor of Bundibugyo, the fold of the mountains and the hidden world of loud, cold beauty.

Thousands of polio vaccines, dispensed over two days, all along the Congo border after a wild-type polio virus infection was confirmed in the chaos that is Congo.  Dutiful Bundibugyo parents line up to protect their children.

Handfuls of friendships, which we cling to over the years, as five of our teenage-boy-sponsored-students spend an evening with us, animated conversation, a short Bible study on becoming godly men, a frank discussion of school issues.  Some of these boys have been hanging around our house since they could walk.  They are our kids’ primary friends here.  We end the evening with an episode of a TV show in which anti-terrorism special forces rescue the world . . . Later the boy who became Luke’s closest school friend, in a Fort Portal program for A level, calls just to greet.  These cross-cultural connections are difficult to nurture, and we do not take them for granted.

Two babies in trouble:  one, the only surviving twin of Michael’s right-hand water-man, who presents on a Saturday evening with an incarcerated hernia.  Because I know the parents, the recent loss, I send him to the surgeon in Bundi urgently, but warn them that the bumpy ride might temporarily solve the problem, remembering being in the same situation with Jack many years ago.  It does, but he’s admitted anyway to treat the fever and wait for surgery.  Then this evening baby Jonah, who has nothing more than a cold, but like his mother we consider the irreplaceable value of his little life, and worry over every cough and every fever.  We all decide to put him on weekly malaria prophylaxis, as if he were a foreign visitor.  Maybe we should address the injustice that puts all babies here at such a severe malaria risk, maybe singling out one baby is unjust.   But our inability to solve all the problems should not paralyze us from addressing this one precious life.  We err on the side of mercy and caution, even if it isn’t fair, and give him a four month supply of our expensive prophylaxis.

Hot rolls, long walks . . . The privilege of hosting 20-somethings, 3 university students and one grad student, includes heart to heart talks about life, and having appreciative audiences for food.  Looking over plans for nutrition research, and passing on hard-earned understanding of superstitions.  Enlarging our family tent pegs so that new faces join our worship, or speed scrabble.

Jars, a whole village’s collection, in 2 Kings 4, gathered by a widow and mysteriously filled with oil.  In the morning’s sermon the young preacher quoted William Carey’s “Expect great things from God, attempt great things for God . . “  The oil flowed to fill every pot she brought, the abundance equal to her vision and industry.  A great picture for us:  we will only see as much grace as we risk needing.  

Shall we not accept adversity?

183 women to whom the Lord gave life, and then adversity, spent the day with us on the mission. For most, you would never guess that a fatal and incurable disease defined their participation, as they greeted each other, bustled about in their brightly wrapped kitengis, balanced babies on their hips, laughed. For a few, the gaunt faces and shabby clothes reflected their struggle against the relentless HIV virus and the social ostracism that follows it. They came early in the morning to establish their place in the registration queue, clutching the tattered books that confirm their positive tests. We talk to each one individually, enquiring about their children, their spouses, their access to clinical care, their desire to take a break from child-bearing. We weigh them and their babies, offer testing to confirm whether or not the virus has passed on. They have the option to enter a side room in groups for prayer, an acknowledgement that our practical hand-on help is incomplete, that their social and spiritual pain runs deep, that we come together before the mysteries of God to plead for their survival. Our three interns and assorted other team mates joined them, a Kingdom picture of the young and educated and healthy and privileged sitting side by side with the weak and poor and sick and marginalized, all equally dependent upon the Mercy.

183 women, most with a child or two, or a sister or husband, sipping the hot porridge provided, waiting. Then Scott preached to the crowd from the book of Job. They gasped when he dramatically described Job’s mounting losses, and listened intently when Scott explained Job’s laments. We are studying this as a team right now, and what story is more appropriate for a couple of hundred people with AIDS? Job encourages the sufferer to mourn, to ask questions, to protest, to struggle. But Job also points to an endpoint of faith: holding onto God for who He is, even when life is not neatly explained by action and consequence, even when the innocent must endure great sorrow. This book goes to great lengths to refute the pat religious answer that sickness is a punishment for bad behaviour. And that is good news for 183 women who need to hear it.

Lastly, the food. The draw of the day is the provision of supplemental food: about 50 pounds of beans, a few liters of cooking oil, and a couple of packets of salt, plus a generous cash assistance to transport all of the above home. The purpose of the food is to strengthen the body’s immune system, to prolong the life of the ill, to ease the burden of the disease, to compensate for the lack of energy to wrest calories from the soil of a labor-intensive garden. But the food does more than that, it is a concrete reminder that God has not forgotten these women. Our former team mate Pamela, who organized these distributions for the two years she was here, continues to make them possible by raising the money to buy the food from a caring small group of people in her church in New York City.

Yes, these women accept adversity, with more patience than I would manage, with more of a Job-like grasp that life is not only a series of good gifts. It is a joy to be a small part of the process, though, of mixing a good gift back into their adversity.

Good News All Around . . .

My mom’s eye surgery went well, the doctor did not find the feared hole in her retina, which means her recovery will be more straightforward and she can hope for improvement in her vision within the next month.  Some of our dearest family friends came to stay with her this week, my aunt and uncle will be there soon, and my sister over the weekend.  Missionaries need rather extensive support teams, people who can fill in the gap we leave in our absence.  We are grateful.

Two new WHM Africa missionaries were approved today:  Nathan Elwood, who graduated from college a whopping three days ago, is the newest member of the Bundibugyo team.  He’ll spend about two years here before grad school, contributing to public health and education and we hope using some of his soccer and musical skills as well.  We are praying that he can raise support quickly and arrive with Jason Blair.  We need the help:  with Pamela gone, tomorrow’s major Kwejuna Project food distribution has already almost done Scott in, and it hasn’t even started yet, thousands of dollars of beans and oil and salt, medical care and family planning, weight monitoring and encouragement in the Gospel, provided to well over a hundred families.  Nathan was in the same application group as Physician Assistant Scott Will, who served here for six months this past year, including through the entire Ebola crisis.  In an “outside the box” attempt to accommodate his interests and our needs, he’ll come to Bundibugyo for a few months initially and then shift his focus to Sudan.  We see our teams as integrally related, and look forward to forging this unique partnership with the Massos and the other Sudan appointees, allowing personnel to move back and forth a bit as opportunities arise and needs shift.  Scott Will is like part of the family, so we are very glad to have him headed back in this direction.  His support-raising will depend upon WHM being approved as a partner with MedSend, an organization that attempts to free young medical grads up to serve in areas of poverty in the world by taking over debt repayment for school loans while the person works overseas.  We hope that if this works for Scott, it might encourage other newly-graduated doctors, nurses, PA’s or others, to join our fields.

Between team meeting, intern orientation, ART clinic, new nutrition admissions, setting up plans and projects for the summer, kids’ adjusting back to the new school term, patients, neighbors with needs, dinners to cook, and emails to answer . . . It has been a full half-week.  I became very aware over the day today of the teamwork that I often take for granted, and thankful for the friends with whom I labor:  Heidi organizing reports to be sure patients get their treatment, Pat counseling a newly diagnosed AIDS patient, Scotticus working to connect us with sources of nutritional help for patients, David peacemaking and preaching and supervising at school with Annelise thinking creatively about funding and discipleship, Karen accounting for money and making sure the new chicks survive while feeding her neglected neighbor kids as they go through crisis, Michael designing an improved airstrip drainage so that we don’t have planes landing in puddles again, Sarah’s music lessons with Acacia and Luke at school resulting in a haunting duet performed after team meeting tonight, Ashley juggling multiple grade levels and inspiring girls to play soccer, Kim putting aside personal interests and plans to serve the team by planning for the interns . . . And all that was just today.  We have an amazing team of people pursuing deep knowledge of God even if the path takes them through deep waters of challenge.  Sometimes I think our role is mostly to not get in their way too much!

Anyway, much to be thankful for on both sides of the ocean, at the end of a long day.

Family prayer request

Please pray for my mom, Judy, who will have delicate surgery on her eye at Hopkins on Weds 4 June.  She has lost significant vision from an “epiretinal fold” and we hope that this surgery will arrest the deterioration, and that her recovery will allow her to travel as hoped to Uganda to visit us in August.  I want to see my mom, but I mostly want my mom to see!  Thanks.

Martyr's Day

June 3rd is a national holiday in Uganda, commemorating the murder of 26 young men in 1885 who refused to recant their new Christian faith when the Baganda King, Kabaka Mwanga II, decided that their allegiance to King Jesus threatened his supremacy.  Dozens of others were similarly killed for their faith over a period of about two years, including the Anglican missionary, Bishop Hannington, who had been sent to establish the protestant church in Uganda.  The current Archbishop of the Church of Uganda, Henry Luke Orombi, says:

Tertullian’s oft-quoted statement “The blood of the martyrs is the seed of the church” is the story of the faith in Uganda. On his first visit to Uganda in 1885, the Englishman and missionary bishop James Hannington was martyred as he tried to cross the river Nile into central Uganda.  . . . Before they killed Hannington, on October 29, 1885, he is reported to have said, “Tell the Kabaka that I die for Uganda.”
Less than a year later, on June 3, 1886, the king of Buganda ordered the killing of twenty-six of his court pages because they refused his homosexual advances and would not recant their belief in King Jesus. They cut and carried the reeds that were then wrapped around them and set on fire in an execution pit. As the flames engulfed them, these young martyrs sang songs of praise. Far from eliminating Christianity, the martyrdoms had the opposite effect: If the faith of these martyrs was worth dying for, then it must also be something worth living for. Christianity began to spread like wildfire.

An inspiring and sobering story, and one that repeated itself in the 1970’s when other faithful Ugandans were murdered by Idi Amin because their loyalty to God superseded their tolerance of his crimes.  As missionaries we still upset the balance of power, we are a destabilizing force in many ways, people whose very existence challenges the traditional system of cause and effect, check and balance, calls into question the word of the dictator when it conflicts with the word of God.  We should strive to study the culture and respect and preserve most of it, to introduce God’s word in appropriate ways.   But it is the courage of the citizen, the ordinary man or woman who makes a life and death choice, that changes the country.  Bishop Hannington and others introduced truth, but it was the lives and most particularly the deaths of these young men that set Uganda on a path of change.  Ironically, we tend to think that major dramatic power-display miracles would be the way to convince a nation to embrace Christianity, would be the mark of God’s presence.  But in the case of Uganda, the victory came through death, through what looked like defeat as a powerful king cruelly disposed of those who dared to take a stand for faith.  

We work and pray, but it is the death of the martyrs, from chief page Charles Lwanga in 1885, to Archbishop Janani Luwum in 1977, to our friend Dr. Jonah Kule in 2007, that yields growth and change and life.  The way of the cross.