Top Up

Bundibugyo has what may be the highest prevalence of Sickle Cell Anemia in the world. And the kids who don't carry a sickle cell gene are universally exposed to malaria (which destroys red blood cells and suppresses their production), universally eat iron deficient diets (low in meat and animal products), and universally are infested with intestinal parasites (which suck microscopic amounts of blood constantly). The result is that almost all kids walk around with a level of anemia that would cause a panic in any American emergency room, and the ones who are sick enough to be admitted to our ward would probably be in a high-level intensive care unit in a place with the resources. So in a typical day on a 25-bed ward, we probably are doing anywhere from 3 to 6 blood transfusions. Topping them up, so to speak, getting that hemoglobin up over a whopping 5 gm/dl, enough to keep the heart pumping and brain awake.

I've noticed recently, though, that there is an alternative top-up going on. By my patients' beds I've started seeing bottles of Top Up ketchup. This is NOT HEINZ, shall we say. I'm not sure any real tomatoes are involved. It is a gelatinous goo, a cancer-causing red color, and sweet. But to the very concrete-reasoning patient population, what looks like blood should be good for making blood, so I see moms spooning it into their kids. As if they needed another reason to vomit . .

One of our favorite patients, Aligonilla, has been topped up three times in the last three days, and yet today is still at only a hemoglobin of 4.4. He was barely alive at 3, but once he's over 4 he sits and colors, smiles, talks, plays. This is the child I alluded to in the gap in blood supply this weekend, when he looked like he could have died, and if he had done so he would have been the 6th or 7th child of his father to die, and the 2nd one in three weeks. We've been struggling for his life since he was born, he's been admitted numerous times, he can't possibly live a normal lifespan, but for now he's topped up and back from the brink of death, so we're all relieved.

And all in a day's work: diagnosed a new 4 year old child with AIDS today, her mother is an articulate lady who actually has a job and connections but out of fear had refused testing in pregnancy, but when we saw the girl, moderately malnourished with a chronic draining ear and huge patches of fungal infection on her skin, we sent her for her test, which was positive. That was balanced by another 4 year old whose mother had died . . the Grandmother was sure the child had AIDS too, and an initial test had been positive, but the confirmatory tests were all negative, so we just told her to go home and live a normal life and thank God. Then there was a lady 7 months pregnant with twins who walked 8 hours from across the border in Congo for an ultrasound with Scott: he was packing up to leave mid-day when she arrived, but once he heard the whole story he regretted feeling frustrated with her lateness! So many stories, these are only a few, that we feel over-the-top.

Need a bottle of Top-Up, perhaps, for energy and faith!

On sheep and shepherding

We studied John 10 this week (I am the Good Shepherd), then Psalm 23  (The Lord is my Shepherd) came up in my daily devotional, and this morning at CSB chapel Peter Were commented on one of the songs sung by the choir which the Spirit used to convict his heart about his responsibility as a shepherd.  When the theme comes up three times in three days from three directions, it is always a clue that this is important.  What is God trying to tell us?  For one, that we are NOT the good shepherd, we are simple sheep.  We need a protector and a leader, someone well-armed and far-seeing who can be responsible for us.  There are many animals one can imagine performing noble rescues or learning tricks.  Sheep are not among them.  We are helpless to even find our own sustenance.  We are clumsy and easily swayed, fearful and unoriginal.  The more we see our sheepishness, the more we know our need for the Shepherd.  WHM and Paul Miller use this famous cross chart:  the more we grasp the depths of our sin and the heights of God's holiness, the bigger the cross becomes, the greater our knowledge of God's power and love.  And we're in that sort of a season here:  Friday Scott was summoned to a meeting of disgruntled teachers worried about their contracts after the unfiltered consultant report (which suggested cutting the staff size in half to save money) was inadvertently passed on without a careful explanation that we are not planning to take every recommendation as an immediate plan.  It all ended well, but again with our team, our patients, our ministries, the sheer complexity of the need makes us practically bleat and run for the fold.  And the more we acknowledge that, the more we will see the Shepherd's grace as the true source of success.

So we're sheep.  But we're also called to do a bit of surrogate shepherding here.  Ez 34 says that God will judge between the sheep .. . and those found abusing the flock in their roles as leaders will be punished.  Like the hirelings it is tempting to run when the going gets rough.  When there is no blood for transfusion and a child I've known from birth is about to give up his 8 year struggle with sickle cell right in front of my eyes, I'd rather get away.  When people aren't happy with the way we've planned or managed something, and feel let down or hurt, it is tempting to avoid them.  And like the thieves, I know that my heart often wants to use my colleagues for their gifts or work rather than valuing them for the essence of who they are.  We are NOT the Good Shepherd, the One who sacrificially goes ahead to clear the way of all danger, whose voice leads through the palpable darkness of death's shadow.  

So what can we do?  This morning in church the preacher referred to Jesus as the Lamb of God.  It struck me that the Good Shepherd became a sheep, the one sheep who would be sacrificed, bled, cut, eaten.  In order for us to grow from sheep towards shepherd.  To follow, yes, but to lead others as well, not based on our quality wool or spiffy hooves, but on the power of the life of the Shepherd in us, drawing others into His paths, being led together by Him.  So let us be shrinking sheep, aware of our feebleness, but whose lives embody the wisdom and power of the real Shepherd in such a way that HIS grace automatically exudes from us for the good of those we're called to lead.

The Struggle Continues: Snapshots of Kwejuna Project

276 HIV-positive women, plus several hundred more children, aunts, neighbors, husbands. 122 children evaluated, weighed, reviewed: 16 newly confirmed to be NOT infected, two newly diagnosed HIV-positive. 5 tons of beans. 300 kg of salt. 4 prayer warriors interceding on the side. A couple of dozen volunteers, missionaries and Ugandans, registering, weighing, carrying, testing. 600 cups of porridge, to bide the crowd through the long day. Untold angels enjoying the spectacle of the happy terminally ill meeting together. Pat shared with us the testimony of two of the women: they thanked God for their HIV-infection, because it was the reason they came to know Him. Scott with his check-lists and organization moving the whole process along. Two supporters in New York who never see the blessing they bestow by funding this effort.

This is Dieu-Merci. Her mother quipped that she did not become infected through an HIV-positive husband: she became infected through SOMEONE ELSE"S HIV-positive husband. Hmmmm. When this baby was born, she looked like she needed God's mercy in more than just her name. She was tiny, and hospitalized with a serious infection of her miniscule leg and knee joint. Though her mother had never settled down much before, she took seriously the responsibility of this baby that she never expected to have. She was persistent and aggressive in seeking care. Because of her life-threatening early infection, I had little hope that the baby would turn out to be HIV-negative. But today she had her third and final negative test. She escaped. God's mercy.

Biira Latifa's mother sat at my station looking confused. She did not know the child's birthdate, or even age, and seemed confused on the name. She could not come up with any paperwork to show any previous care or testing. Her vagueness came across as deceit to me, and my quick-to-judge heart suspected fraud (we do get people lying about who they are or their kids are, to try to get food .. . ). I spied an immunization card in her bag and made her pull it out, expecting to prove mistaken identity. But it was the right kid, and the mom seemed embarrassed that she was so flustered. She did not look so well herself, and other women began to tell her what to do. Perhaps she was anxious, or perhaps the HIV has affected her mentally. We sent Biira for testing. An hour later they were back, waiting for the result. I told her that Biira was negative, not infected. She clapped her hands above her head, loudly, praising God and attracting attention. But then she bent down, covered her face with her hands, crying. It made me get tears, too. Here was this mom that I thought was deceitful and incompetent, but she was trembling with relief about her daughter, thankful.

These are two small snapshots of a day full of noise, bustle, facts, figures. Real people with real stories, too numerous to tell: Byaruhanga with his mom Luci, back from months of disappearance. Mumbere with his faithful grandmother, feisty as ever, infected but thriving on ARV's. Another careful mom who begged for yet one more test on her child, too scared to believe the good news until she had it in triplicate over the course of two years. Broken-hearted women asking for prayer for their children left with grandmothers and fathers, because they've been chased away from the family, stigmatized with their infection. Women smiling at each other's children, greeting old friends. Women who have been with us for five years, pressing on. Small struggles in a continent-wide battle against AIDS.

Playing to Heal

When we admit malnourished children, their wilted spirit often mirrors the condition of their body. Most do not bother to protest my exam much, they are listless, apathetic, resigned to a lethargy that began as hunger and is now the atmosphere in which they live. Over days and sometimes weeks, as their sapped energy is replenished by nutritious milk, eggs, and beans, the resurrection which starts from the cellular level eventually expresses itself in eyes calm and widely open, or at long last a smile. We tell the caregivers that this process of recovery requires more than just calories: the children need warmth, human contact, care, love, interest, and play. Their mind and spirit need to be reached even as their body is reviving. Occasionally a nurse will have the time or energy to hold one of the kids, or we might get hand-me-down toys or books from boxes from home, or from team mates. Because most kids don't become malnourished while living with particularly energetic or upstanding adults . . . the caretaker's indifference can be part of the problem. So this month we are happy to welcome a visitor who is a marriage-and-family therapist in the States. Today Karen sat on the floor of the ward, with the bag of toys she brought. Around her were gathered some of our most pitiful little friends: Azibu with AIDS who has increased her size by 50% in the last month after dwindling to near-death levels, or Aligonila with sickle cell disease who has spent his entire life a step away from death, weeks and weeks in the hospital for blood transfusions. Others who I've only seen lying in bed now sat and held a doll. The adults were curious, attentive. We hope that Karen can model healthy playful interaction, in a way that encourages continued work with these children after she leaves. We've asked her to teach at our staff meeting on Friday, too. And meanwhile her husband Dan is absorbing all he can on rounds and in the outpatient department, his training as a PA about half done. They are a couple we would love to see God calling back into Kingdom work in Africa.

And there is a side-story of redemption in these pictures, a staff member who seemed hostile, who seemed reluctant to work, passive-aggressive. In my self-righteousness and judgment I condemned her work-avoidance. Then I talked to another friend for insight about what was going on below the surface, and was reminded that this lady had an infant who died this year, and neither we nor many other staff went to her home to console her or attend the burial. Ouch. Here I am ticking off missed days, and there she is in mourning, feeling bitter. Instead of nagging her, I began to invite her to join in our nutrition work, and one day brought her some books to use in her health education efforts. As she softened, and even smiled at me, I asked her if she'd like to work with Karen this week, and she agreed. Hard to remember sometimes in the midst of chaos and too-much-work, that our colleagues are also human beings, and need the same TLC that the malnourished patients do to draw out their true selves. Not easy for harsh and demanding doctors like me! Lord have mercy.

Monday

Monday, the launch of a new week, feeling portentous after the rumbling introduction of Sunday's earthquake. On the cell phone with SIL (Wycliffe translation team) by 6:30 to confirm the lack of rain so that their early AIM-Air flight could land by 8 am. Several Americans and Ugandans stretched their legs and smiled tentatively as they climbed out of the the Caravan airplane, glad to be on the solid ground after the cloudy sky. We loaded up 3000 new copies of Acts in Lubwisi and with Pat transported the team to their first venue. There is a translation consultant here for two weeks to check the book of Romans: like our CSB consultants this summer, a mature Ugandan man, not a foreign missionary, who will go chapter by chapter, verse by verse, through the book with our two translators. Also along for just the day, a literacy group following up on the use of an AIDS-prevention story booklet, and another group of Ugandans who will help develop a Lwamba orthography. Yes, the Lubwisi Bible still leaves out a significant minority of Lwamba speakers, so SIL is launching plans for a second translation project! We left all this in Pat's hands and saw patients for a couple of hours . . then back to the airstrip for the arrival of another flight, this one bringing the smiling faces of Dan and Karen Thrush. Dan is a Physician Assistant Student, and his wife is a marriage-and-family-counselor, and we hope they are both potential long-term Africa missionaries in the future . . at least if a few weeks with us does not discourage them too much. We left them in Nathan's capable care, the hospital in Scott Will and Heidi's hands, and then spent much of the rest of the day at the special welcome ceremony for the new Bishop of the Rwenzori Diocese for the Church of Uganda. This occurred in a a semi-outdoor all-day church service with singing and preaching and prayers. I know some of the theology becomes distorted as we hear it from the periphery . . but from the Bishop himself we heard a humble and Biblical message. In fact the theme of weakness came through again, as he said it was not his wisdom or power that enabled him to serve, but the power of Christ in him. And he challenged the assembled hundreds of people to respond to God's grace by presenting themselves, separating from sin, leading transformed lives, that demonstrate the Gospel (Rom 12:1,2). Probably 80% of the congregation stood and came forward for the altar call, which is frequent here as people respond en masse and feel compelled to do so multiple times. From there it was back to the airstrip to pick up the pilot who had spent the rest of the day in Sudan, some interactions with team mates, and dinner. Ran into CSB teachers who had been monitoring exams . . .Monday was also the first day of O-level exams, the all-important month-long 20-some papers of testing that students must complete to graduate from hight school. And our day ended when we heard our dog making strange choking noises about 10 pm, ran outside to find her straining at her chain because she was being attacked by biting ants. THOUSANDS AND THOUSANDS of them! All over our yard. Scott got out with industrial amounts of ant-killer and did battle. The Kingdom goes forward in outreach, translation, conversions, dedication, health care, schooling . . . but the ants remind us that we're still in enemy territory.

More on Confidence

This morning's sermon was from Acts 18, and new for me, to see that Apollos from the end of the chapter hailed from AFRICA.  This was very encouraging to the preacher and others . . the idea that God took this man, who had partial knowledge of the Gospel but was bold and willing to preach, and used him to build the church.  The point was that we should expect God to use us even with the little we have to offer--reminded me of the theme of late of strength in weakness, and opened the horizon, that this is not just a phrase for struggling missionaries but perhaps a parable of Africa, an encouragement towards confidence in God's power to use this continent to bless the whole world.

Parenthetically, the service started with a call to repentance, based on the collective experience of a middle-of-the-night earthquake.  We were all awakened at 3:39 am by a 5.0 quake--that's strong enough to shake the bed for sure, and rumbly and long enough to send most people running outside.  And sobering enough to remind the congregation of eternity!

Africa Wins!!

Last night we watched the Under-20 World Cup Football (soccer) Final match, held in Cairo, between Brazil and Ghana. It was the first time an African team had made it to the finals I think, and a pretty big deal since the World Cup is held next year in South Africa. This was the teen-version of the event, and since many of the best players in the world are 19 or 20 years old, an exciting match, the culmination of around-the world qualifiers and play-offs. We've been able to hook into satellite TV for sports for most of the year now. We don't use it much (time and power are issues!) but it has become a real way to relate to our friends in our home (a missionary justification? oh well, thankful for a little cheering to balance out all the smelly blood-and-guts real missionary work). Our CSB students are on a weekend mid-term break--two had to go back to school after dinner because their major O-level exam period starts Monday, and they are in high-gear. But three stayed for a football sleep-over.

Brazil came out strong, dominating the first half hour. And Ghana looked hesitant, cowed. And I watched our three young footballers, who play for CSB and most every day of their lives, wilting on the couch, bracing for yet another demonstration of Africa's inability to compete and win. I've read some commentary that Africa's crisis is not economic, political, environmental . . . Africa's crisis is a crisis of confidence, a legacy of colonialism, of encountering the rest of the world centuries behind. My heart was wilting with theirs, with the millions of teenage boys just like them all over the continent, watching. When one player was red-carded midway through the first half, in a call the announcers described as "harsh", we all assumed that would be the end and the heavily favored Brazil team would conquer the Ghanaians, who now had to play the rest of the match one man down.

But the game went on, and on. 0 to 0 at the end of the half. 0 to 0 at the end of regulation time. 0 to 0 at the end of the first period of overtime. 0 to 0 at the end of the second period of overtime. The boys from Ghana held on, determined. The hopes of the crowd rose. After 120 minutes of play, the championship went to penalty shoot-outs. And even then, the whole match hung by a thread. Each team scored their first two tries, then Ghana was blocked. It looked like it would be over, then Brazil was blocked. And so it went through the normal 5-shot penalty shoot-out, still tied. The sixth shot for Brazil was taken by the player who had dominated regular play. The keeper from Ghana, who had already had a fantastic game, was seen on his knees praying. Brazil missed, Ghana drove in the final shot, and won 4 to 3 on penalties.

This is the first time an African team has won. I'm sure it was terribly disappointing for Brazil, but frankly they win a lot of football. It was very exciting to watch these boys who look just like our friends, hang on, maintain their poise when they were down, fight hard, and win. Praying it will be a small ripple that spreads across the continent, building confidence.

Parents' Day

Once a year, CSB celebrates Parents' Day, an all-day all-school affair which is the only time that parents come en masse to enjoy and celebrate their childrens' performances, to tour the school, be amazed at the computers, critically inspect the dorms, meet the faculty. As with most things relating to an edge of the Kingdom, there is potential for greatness, and for disaster. Last year was one of the worst Parents' Days ever . . . and this year was one of the best. We prayed that God would be glorified, and that the parents would be pulled into the vision, caught up in what God is doing, confident and loyal. I think both happened. Torrents of rain got the whole day off to a late and slow start, and made me wonder if we were in for another disappointing day. But from start to finish God showed up, in unexpected and clear ways. The student drama, rather than a meandering soap opera, was a well-played story of a man who turned to hospitals and a witch doctor for healing (pretty dramatic scene of incantations) to no avail, and then met a group of Christians who took him for prayer, and important demonstration of God's power being greater than science or spirits. The entire cast came out at the end to recap the story in an original song, pointing to Jesus. Beautiful. Even the "fashion show" which could have been an opportunity for bad taste was scripted by the counselor, a lovely Christian lady, and as the students proudly crossed the stage in outfits from various parts of Uganda the narrative kept pointing to God's creativity. There were choirs and poetry. And traditional dance, which for me and I think most parents was an important statement that we at CSB are not trying to erase culture, and that we value the ancient artistic expression that our students continue to learn and practice. Then of course, no day is complete without speeches, many. And at times these speeches can turn whiny, accusatory, demanding, or inappropriately disrespectful. Not this year. The District Education Office representative is an Inspector of Schools, so when he got up to talk I braced myself for a list of our shortcomings. Instead he launched into a beautiful speech about how Christ School was a demonstration of international commerce: that Americans exported love to start this place. The parents' and students' representatives, who usually present a list of demands, instead spoke very positively (another miracle, the parents' rep was an old man dressed in clothes that clearly identified him with another religion, but he had only good things to say and challenged parents to send ALL their children to Christ School). David reviewed the years' accomplishments, the way that the administration had chosen to consolidate what we are doing and do it better, the improvements in student government, discipline, food, the impact of Scripture Union and a couple of visiting speakers on the spiritual climate, and gave all the statistics on performance on national exams. Scott closed as Chairman of the Board, and did a beautiful job of promoting the sense of ownership of the school by all. He said that we took a long look this year at this 11-year-old . . and like our own 11-year-old, the school is growing but not grown, there are still long ways to go. For this we need two things: prayer, and the wisdom of our elders. Just like an African family calls clan elders to advise, we called two consultants and our mission leadership this year to evaluate the school. He reaffirmed out commitment as a mission to the school, and ended with Psalm 118 again, challenging the parents to have faith, not in US, but in God as the school moves into the next decade of growth, and asked them to join us in prayer specifically for the new Head Teacher.

The students milled about on the edges, the parents listened attentively, laughed and cheered, and patiently sat through the hours of program until the "lunch" was served at about 6 pm. Then we picked our way through the mud, tired and grateful.

Goats for the Hungry

The third batch of Christmas-goats went out today, the real beasts that were purchased as tidy decorative ornaments last Christmas.  Eighteen more families were blessed. I slipped into the back row first thing this morning, as Pastor Kisembo preached from James about real religion combining faith and love, and God's love being tangibly shown not just in these goats but in the gift of His only child.  Lammech and John thanked the women for coming and challenged them to see this blessing as one which they could then return upon others as they brought back the kid-goat offspring.  But the highlight for me was Maculate.  Early this year she landed on our pediatric ward, the embodiment of the prophecy of the pitiful newborn left in the desert (Ezekiel 16).  She had little intact skin from a terrible infection, and we sent HIV tests which came back positive.  Her mom was about 16 and almost as pitiful as she was, quite ill and thin and struggling.  I thought we should offer compassionate care, but truly believed this baby had little chance of survival, and the mom not much more.   Now Maculate  is a solid, healthy toddler, miraculously UNinfected.  She and her young mom were seated front and center, waiting for their goat.  A completely transformed story, a young mom grasping onto life, and a baby who can grow and live.  I love seeing the revival of hope.

into the deep

The first day we reached the ocean, we were too sick to do more than hear the waves.  But by the second we could at least drag our selves down to the sand, lie in the shade of the mangroves, read, pray, rest, and watch the surf churning in and out.  As beautiful as that was, it was not a real experience of the ocean.  For that I had to get into the water, wade past the tangles of sea weed in the shallows and dive into the waves.  Bob with the surge of the tide, taste the salt, and swim.  Later we sailed and kayaked out further, dipping into the clear warm Indian ocean, exploring with a mask and fins, the mysteries of corals in the shade of passing clouds, the elusive flashes of fish, the waving invitation of algae.  I love the ocean.  There is a power there, an ever-changing rise and fall, an unpredictability, an infinity.  Which is beautiful viewed from the shore, but that view from the safety of the sand lacks fullness and reality.  It is safer to stay on the shore and admire, but much more memorable to dive in.  And more risky.  

I wondered how much of our collective religious approach to God is an attempt to enjoy Him from the shore, to discuss the waves, make tide tables, run for safety in the storm, and dip our toes in the surf when the sun comes out.  A good start, but the waves beckon us to plunge.