On the difficulty of aid

Bundibugyo has received thousands of insecticide-treated mosquito nets from UNICEF, bundled in bales with labels from as far away as Japan, hefted on ships and trucks, stacked in warehouses and then heaved into pickup beds, unloaded at health centers.  What could be better than handing out protective nets to pregnant women and young children, preventing the most vulnerable from being infected with malaria parasites?  Malaria remains the number one killer in Bundibugyo, as in most of sub-Saharan Africa.

But getting the nets hung over the sleeping forms of the unborn and recently-born and about-to-give birth is more difficult than one might think.  A few months ago the hospital administrator was jailed, accused of stealing hundreds of the nets, to sell. Since then the nets do seem to be making their way to the health centers as intended.  But yesterday the staff launched into their litany of complaints about this program.  If even they can not hand out a free boost to their fellow citizens, no wonder we struggle.  Here are some of their observations:

• Women who are pregnant take the nets back to their parental home, not to their husband's home where they are living.  This points out the tenuous nature of marriage:  the net belongs to the woman but since she is a temporary member of her husband's household, she risks losing it.  Also she considers it his job to buy the net that protects his unborn baby, so why should he be let off that hook by UNICEF?  So the nets given to pregnant women are not slept under by pregnant women.
• Women return for maternity multiple times using new names or saying they lost their card, so they can acquire more free nets.  Perhaps not a tragedy if they were hanging those nets up over more of their children . . .but the story is they can easily sell them to merchants.  
• Many people never take the net out of its bag.  It becomes more of a talisman, a symbol of protection or wealth, that would be spoiled by actual use.
• As the program gathers momentum, the sense of entitlement grows, and when the "man with the key" was gone last Monday the nursing assistant feared being practically lynched by the angry crowd of pregnant women!
• The lure of a free gift brings many people to the clinic (generally good) but also many who don't belong there (not even really pregnant), which in a marginally equipped system means that the resources are diluted and those women with real medical concerns can be lost in the crowd.

I asked for one bale of the nets to be kept in the Paediatric Ward store, and I am now dispensing them at discharge to kids who are admitted with severe malaria.  My reasoning is that the parents have just narrowly escaped losing their child and will be motivated now to believe the risk is real and therefore use the net, the net will be going to a house which we know harbors malarious mosquitoes, and the child is particularly vulnerable to fatal consequences from re-infection.  Still, it would be ideal to follow these kids a week later and see how many are actually sleeping under the nets.  In a house made of mud bricks or wattle walls, how easy is it to hang a net?  In a house plagued by rats, how many get chewed through?  In a home where mattresses are shoved side by side on the floor to accommodate many kids, how easy is it to hang and use only one net?  

Yes, there are difficulties, even in giving away something as straightforward as a mosquito net.  But these issues are not insurmountable.  Attitudes can change.  The same parents who beg, borrow, and steal to manage school fees for their kids can learn the value of a mosquito net.  We all want the same thing:  a thriving, live child who grows up to his/her full potential, whose mother survives her subsequent pregnancies too and stays involved in his/her life.  A few ounces of filmy white netting can be the wall that shuts out death.  It's aid worth giving, even if it is difficult.

Countdown

Jack and Julia made a count-down calendar to Grammy's arrival on
Wednesday. Every day they tear off one more number from the back of
the door, and spend the rest of the day saying : "Guess what? ONLY
FOUR MORE DAYS . . . ." The excitement builds. And I'm thankful that
in spite of spending 14 of our 15 years as parents on the continent of
Africa, our children securely sense their connection to all of their
grandparents, aunts, uncles, and cousins. Our sense of family spans
the thousands of miles, but the countdown to a real hug is still sweet.

Dragon lumps and deeper unveiling

We will finish Voyage of the Dawn Treader tonight, in our second or third time through the CS Lewis Narnia series.  These books are always fresh with Lewis' grasp of reality, seen more clearly in the imaginary worlds.  In this book a boy named Eustace is inadvertently pulled into the adventure with his cousins, and Eustace is not a nice boy.  He's self-centered, complaining, wimpy, and often just plain mean.  He sneaks off from the others and ends up in a dragon's lair, where his greed turns him into an actual dragon.  When he emerges, he is big, lumpy, scaly, and frightening.  In fact at that point his physical form reflected the truth of what his heart was like all along.  This chapter coincided with our Sacred Sorrow chapters on Jeremiah, where Card points out that God's judgement on Jerusalem is to simply make visible what was already spiritually true, the city had lost her true glory.  And it coincided with my turn to share prayer meeting with Annelise, who suggested that we organize our prayer requests under the headings of "unveiling" and "inviting" (I found out later that her intent was more along the lines of beauty and Song of Solomon, but that's OK).

The Spirit used this coalescence of readings and thoughts to unveil the dragon lumps in my own heart.  Many missionaries point out that the challenges of living cross-culturally, or in poverty, or under constant stress, do much to make our sin more visible.  Eustace was always beastly, but he didn't really know it until he saw himself as a dragon.  And I've always been judgmental and impatient and self-concerned, but Bundibugyo makes it much easier to confront those issues on a daily basis.  Being pushed to the limit can be a good step towards pulling back the surface of nice-ness.  When Mackline died in my care, another kid named Christopher dwindled from what I think was basically a slow poisoning by his grandmother's herbal enemas, and I watched yet another child gasp his last agonal breaths this week, I was left with a sense of failure and sorrow and discouraging, scaly, desire to run away from it all.

But in Eustace's case, the unveiling down to the dragon layer is not the final unveiling.  Later he meets Aslan, the lion who pictures Jesus in the stories.  At Aslan's instruction he peels off the dragon scales, but every time he does so he finds another layer of hard, ugly dragon-flesh underneath.  Finally he allows Aslan to use his sharp claws and go deep, removing all the layers of dragon.  And underneath is the new Eustace.  The real Eustace.  A frightened, lonely boy who no longer wants to be isolated by his mean-ness, a bright child with a kernel of courage who wants to be loved.  

The unveiling of judgment (making visible what was spiritually true) allows the unveiling of healing (ripping off the hard crust of sin to reveal the true soul God made).  The untame lion may seem to wound, but he really frees.  There is a hymn which says:

When through fiery trials thy pathway may lie

My grace all-sufficient shall be thy supply

The flames shall not hurt thee I only design

Thy dross to consume and thy gold to refine.

And there the "inviting" comes in.  What we really need, is the Presence of God.  Card's book points out that it is rarely what we ask for, but always what we truly need.  All the burning and washing, peeling and pain, are simply means of removing the barriers between us and God.  

Whom shall I fear?

I read Psalm 27 this morning for staff Bible study at the Health Center.  About 20 people come weekly, and we alternate between spiritual and medical topics.  Scott had challenged us as a team to take the teaching from Sacred Sorrow and try and apply it in our lives as cross-cultural missionaries.  My first study for Ugandans was on Job, and today we looked at David.  Background Bible literacy is low (not surprising for a place where the Bible does not yet fully exist in the language), so I had to tell a few stories to show that even though David was a King he suffered:  he was haunted by enemies, often on the run in hostile wilderness places, plagued by his own lusts and sins, grieved the loss of a baby to illness and a grown son to armed insurrection, betrayed, and at the end of his life ill and infirm.  But in all of this he held onto God, tenaciously, honestly, in lament as well as in praise, often alternating between the two in a single breath.

Psalm 27 is one of the places where David's bold faith and naked pleas come together.  He talks a lot in this Psalm about fear.  So I asked the staff to go around the circle listing fears, and here is a sample of what I heard:  evil spirits, sickness, death, famine/hunger, war, inability to provide for children, poverty never getting better, being cursed by jealous people, AIDS, malaria.  All of these fears seem quite reasonable here, because all are things that most of our staff have experienced.  It struck me that I was sitting between a man whose child I had watched die this year, and a woman who is ostracized because she is from another tribe.  But then I asked them to look at the Psalm, and consider what David's worst fear was.  Surprisingly it was something that none of us mentioned:  the fear that God would abandon him.

Is it my presumption that allows me to overlook this fear?  Does God ever hide His face?  If our personal sins cause God to withdraw, then how do we explain the most poignant expression of God-abandonment in history, Jesus' cry from the cross "My God, my God, why hast thou forsaken me?"  God turns away from our sins.  But does He also obscure HIs presence, veil His face, to build our faith?  To show us our true appetite is actually FOR His presence, not for His gifts?  He seemed to lead David often into places of wilderness, where the gaping chasm between what we hope for and what we experience looms painfully.  In the wilderness David learned true worship.

The psalm ends with this:  wait on the LORD.  Not on answers, solutions, relief.  Wait on the unveiling of the presence of God Himself.  

Ebola Hero admitted to Medical School

On December 16, 2007 we lauded several heroes of the Ebola response in
our blog, one of which was the Clinical Officer who spearheaded the
response at the very epicenter of the epidemic, Julius Monday. He
fearlessly put himself in harm's way for the good of his patients all
the while managing not to contract the dreaded disease himself. In
the midst of The Plague he chose not to run but to care for the sick
and the dying, both before and after he knew the lethal identity of
the viral agent. His clinical acumen, compassion, and endurance
caught our attention and after the epidemic was over we publically
promised (at the District Ebola-Free Celebration) that if he could
garner an admission letter to one of either of the top two medical
schools in the country (Makerere or Mbarrara) that we would privately
sponsor him through the newly established Jonah Kule Memorial
Leadership Fund.

Well, by God's grace that day arrived today. Julius called me from
Mbarrara with his Medical School Admission letter in hand- jubilant
and thankful. "Thanks, thanks, thanks Doctor Scott for your prayers!"

It is a long road he faces. Five years to complete the degree and
then another year of internship. Six years is a long time. It's
still a struggle to face the travel on this road without Jonah, but
Julius is one of the sprouts that we see coming to life from the death
of Jonah's grain of wheat. I look forward to seeing the heavenly
accounting: the lives saved, the suffering snuffed, the compassion
extended by Julius Monday in the memory of our colleague and friend.

Please pray for Julius Monday.

Paradox Tuesday

The two smiling, thriving girls whose malnutrition had been cured went home today.  Both had been transformed from stick-figures to plumpness, from lethargy to life.

But two others died.  Including Mackline, the pitiful orphan who came too far too late.  Her first sips of milk and ORS threw off her precarious balance, and the life drained out of her.  The other death was of an infant with AIDS--though he had tested negative a few months ago, and his mother weaned him, he must have become infected in the last month, and he dwindled to death in the short course of a week, in spite of IV antibiotics, fluids, and milk.

While the two celebrants packed their belongings to return home from their weeks of hospitalization, Mackline's aunt wept lonely tears as the staff helped her bundle her things for her trek.  And that is the way the battlefront looks.  Victories and defeats mingling together, from bed to bed.  Birungi Suizen came to greet us all today: a whopping 10.8 kg (he used to weigh 5!), he is actually getting close to being a within-normal weight for his age.  But as we passed him around, digging up candy from pockets and teasing him, smiling, remembering the miracle of his life, another patient returned, the withered premature infant of a 15-year-old mother, 1.45 kg.  Will he look like Birungi Suizen one day?  Seems doubtful.

The two deaths made me review our records:  58 admissions for nutrition in the last two months.  6 deaths.  About 10%.  Of those six, four died within the first day, all children who came from distant reaches of the district, too late.  The other two were born to mothers with AIDS.  So do we need more case-finding outreach?  Better initial stabilization?  Is 10% the devil's toll, the inevitable margin of loss?  Much of me rebels against that defeatism, but I admit to feeling that way at the moment.  There is great value in professionalism (doing the best we can with our resources, first do no harm, and all that), but we as doctors, and as westerners, can also live with the delusion of being able to save everyone.

So, as always, walking the paradox.  Rejoicing with those who rejoice, weeping with those who weep, examining my own heart to know if I have been negligent, fearful of what I might find, weary of the war.

In celebration of provision

Scott unloaded the UNICEF boxes over the weekend, so these stacks
greeted me when I opened my medicine store today. I quickly unloaded
the new scale and length board and set to work measuring everyone on
the ward. After rounds I got all the boxes onto shelves, since they
can't be stored in contact with the floor. The disbursement we were
sent almost perfectly fills the store room--I remember when Scott
built it that I was thinking it was way too big to be of use, but God knew that
we would need the space. Just like He knew we'd need the food for the
continuing arrivals of the desperate. Today's newest patient:
Mackline, not yet a year old, whose mother died in a village on the
other side of the mountains (2 hours' DRIVE from here) and who then
ended up in the care of a great aunt in Ntandi (more than ONE HOUR
drive away). She is more than three standard deviations below normal
weight, and a good portion of that is the edema fluid that has
accumulated in her protein-deficient tissues.

Some of the packets spent only a matter of minutes in the store before
going right back out to feed the hungry. Week before last (Faces of
Hunger and Healing, July 16) I posted pictures of children who were
cured, and at the bottom of the list an anxious girl clinging to her
mom, and a hungry little girl holding her red cup. Those two should
be discharged within a week, the first now smiles and laughs and
greets me, the second is up from just over six kilos to NINE today!

From the hospital I biked straight up to Karen's for our semi-monthly
nutrition team meeting. As Karen prepares for Sudan, she is getting
all the accounting in ship shape to hand over to Sarah while we wait
for more team help. Sarah majored in economics, and with Luke going
to boarding school and Acacia to Sudan, half of her teaching time is
being freed up. We were all relieved when she volunteered to step
into Karen's role tracking and distributing the $65 thousand a year
that flows through BundiNutrition into four major areas: direct
purchase of food for the malnourished, dairy goats for milk for babies
whose mothers have died or who are HIV-infected, the chicken coop for
eggs and demonstration garden for fodder, and the salaries of the
three extension workers who manage the nitty gritty of all this.
These funds come from you, our friends, people who organize their
friends to buy goats or who decide to invest in the Kingdom by
providing food for the least of these. Every month about 150 kids get
some kind of help: nutritious eggs and beans or gnut/soy paste, goat's
milk, in addition to the UNICEF food. Some are HIV-infected, others
are orphans, some have mothers who are unable to manage, all are in
need of a boost to cling to life. That's 150 families who directly
experience the provision of God, and many more who are related to
those and see what is happening.

And amazingly, if all pledged funds come in, we should have exactly
what we need. Just like the store being exactly the right size. This
week one of our donors wrote that God moved her to give a bit above
her pledge, and a few months early . . . Over and over we see evidence
that it is God who cares for these children, and God who provides, who
anticipates the next Mackline and makes sure that there is milk. We
merely watch on the sidelines and give you commentary so that you can
also rejoice.

Re-Creating

The root of the word recreation is to become re-created, to have that
breath of life re-breathed into the soul. For me, that is facilitated
by the isolation and beauty of nature. It did not take much
convincing to get the four single WHM women to join a 24-hour camp-out
in the rainforest this weekend. We piled our gear in Pat's car Friday
afternoon and headed for the Ituri Rainforest, set up in a clearing in
the woods, grilled vegetables and marinated chicken, told stories
around a blazing campfire (and learned Larissa is a bit of a
pyromaniac), and scurried for the shelter of an old Myhre family tent
(which we had to resurrect with pirated poles) when lightening and
wind threatened a storm. In spite of the rest of the district's
drenching we slept peacefully dry! Saturday morning we hiked through
the boggy forest. As usual most of the animal life was jumping
through the canopy: five different species of monkeys on our hike,
plus a few squirrels and rare birds. Closer to the ground we saw only
prints in the mud: sitatunga, bush pig, forest elephant, buffalo,
baboon. The hike took us by two hot springs, sulfurous steaming
moonscapes where boiling water bubbles through the crust of the
earth. Our guide told us that the local people used to sacrifice
children there to thank the gods of the springs for the salt they
collected. A stark reminder of the grip that fear and evil have held
on this place that we love, Bundibugyo.

By mid-day Saturday we were back to real life, including a brisk trek
through the Nyahuka river to reach the family home of a nurse friend
whose father had died. The burial was over but we found the family
still sitting exhausted on dried banana leaves scattered on the mud
floor of their house. . . . I went because I remembered how much I
appreciated the many, many friends who supported my family when my
father died. The situation was a bit similar, with Rose being the
oldest, the medical daughter, who helped take care, but in her case a
stroke had debilitated her father for many years. Like us there was a
mixture of relief that her father's suffering had ended, with the
sadness of missing him.

Last but not least, the highlight of the weekend for the Myhre
kids . . . every Sunday afternoon we play a little game of family
soccer for about an hour or so in the yard. This year we've had the
tremendous advantage of Miss Ashley's skill and Miss Sarah's efforts,
so that when we play adults vs. kids it is a pretty even match. Scott
treated us all to team jerseys his last trip to Kampala, so the final
photo shows us post-game, a bit muddy and sweaty but definitely re-
created!

Accounting Heroes

Do you know who blew the story that King Leopold of Belgium had turned Congo into a personal kingdom run by slavery?  An accountant.  A clerk at the shipping docks added up what went out to Congo, and what came in to Belgium, and concluded that the balance was not in Congo’s favor.  This led to the awareness by the rest of the world that rubber was being obtained by drastic measures (including cutting off the hands of those who did not tap enough trees).  

So accountants can be heroes, particularly in the world of aid, of missions, of development.  This post is a small tribute to some of those heroes.  Jerry and Dwight in our Sending Center.  Scott, David, and Karen, who manage tens of thousands of dollars each, carefully planning, tracking, submitting receipts, being responsible for Kwejuna project, CSB, and BundiNutrition.  Michael, at least we hope soon, handling money for development in Mundri, Sudan.  And Scott again, because all the miscellaneous and sundry needs of team and widows and projects and orphans pass through his hands.  All of these people do lots of other things too, but their non-glamorous desk time may be the most important.

Where are the brave accountants, the careful people who are patient enough to sit at a computer or use a calculator, to save the world?

On weeping, waiting, and hope

Read the following list of woes and guess where in earth it is referring to:  loss of land to foreigners, scarcity of drinking water and firewood, forced labor, bad government, famine, widespread rape, slavery, proliferation of orphans and widows, breakdown of community life. Sounds a bit like Africa, particularly the immediate areas around us in Eastern Congo, Sudan, Rwanda . . . But it is actually straight out of Lamentations chapter 5, a description of the fall of Jerusalem.  In the face of that destruction Jeremiah weeps and waits, for hope.

It’s been a weeping and waiting kind of week here, actually a weeping and waiting kind of life. And usually I think I’m waiting for solutions, for answers, for change.  But Lamentations says we are waiting for hope.  Waiting for a glimmer of God’s presence.  Because that is what we really need, even though I think we need much “more” which is actually much less.  Like food for the hungry and justice for the poor and rest for the missionaries . . .

Pray that in the spurts of relief and answers we would not be satisfied with less than God Himself.  Pray that hope would come.  Here are some glimpses of it this week:

• Right now Scott has a truck full of UNICEF supplies, heading back from Bundibugyo.  It was touch and go.  He went to their office in Kampala which seemed to trigger the release of the goods, but they were sent via a UNICEF driver to Bundibugyo and mistakenly off-loaded at a district store.  By the time we traced them we worried that we would never see them again . . .but all is well.  A major answer to prayer.  The most severely malnourished inpatients will be drinking this milk powder for months to come.
• Thanks to vision from Michael, persistence from David, and footwork from Kasereka, CSB was able to obtain three UNICEF water tanks that were donated to the district for school use.  These are worth many thousands of dollars, freeing other CSB funds for the many other needs of the school.  Amazing.
• A friend from UVA days is funding the salaries of the three nutrition extension workers for three years.  Wow.  This allows our ongoing donations to go for food, and allows the sustainable parts of the program (chickens producing eggs, goats producing milk and more goats, gardens producing food) to be built and secured.  We are so grateful.
  

Many days, like Jeremiah, I feel that this calling is too much, that we are “caught between a difficult God and the service of His impossible people” (loosely quoting from the Card book).  Then we get generous friends and amazing supplies from unexpected places, and it is a brief parting of the clouds to keep us moving forward.  Weeping we wait, and hope does arrive.