Parenting in Bundibugyo

At Friday hospital staff meetings, we alternate weeks between continuing medical education topics, and Bible studies.  One of the things I love about Africa . . it makes perfect sense to all concerned that the forum for scientific and technical information sharing, and for spiritual formation and growth, could be the same, because it is all about investing in staff as whole human beings.  I had just read the chapter in Proverbs about "train up a child" and so this week I summarized a pamphlet by an old-time teacher and writer, JC Ryle. called the Duties of Parents.  And it struck a chord.  We missionaries have noted the slide into semi-abusive rudeness amongst groups of kids on the road, or decried the increasing levels of thievery.  But I realized yesterday that the adults with whom we work are equally distressed.  Perhaps adults of EVERY generation look critically upon the young.  But the hospital staff at least believe that a seismic cultural shift has occurred.  They are mostly concerned about disrespect, which makes sense, since the veneration of elders (extending to appeasement of ancestors) is a central aspect of African tradition.  Many spoke of how they were raised, and contrasted the current state of affairs, the lack of proper greeting, kneeling, body position, tone of voice, obedience.  Ryle's book is very non-pc but eminently practical.  Habits formed in youth stick, so parents have the greatest opportunity to mold character.  He covers the basics:  love not anger, example not lecture, consistency not apathy-punctuated-by-outbursts of correction.  He builds on the foundation of regular Bible reading, prayer, and public means of grace.  It's good stuff.

Afterwards I've been thinking more about what I heard in the discussion, and what I've seen in 16-and-a-half years.  And here are some factors, from the staff and from me, that led to this behavioural shift.

1.  Population pressure.  More people.  More children surviving. Overwhelmed parents.  Less supervision energy per child.  Less space, less boundary for a family.  Bundibugyo continues to lead the country in fertility rates, and Uganda continues to lead most of the world.  There are just a lot of kids here, and more every day.  Peers become a relatively greater influence than elders, due to sheer numbers and time.

2.  War.  The massive displacement of the late 90's continues to influence culture now.  People were crowded (see #1).  They mixed up clans and tribes in camps, diluting distinctives.  Soldiers moved in, with money.  People were willing to do most anything for food, and less likely to freely share than before.  They did not have great hope for the future, making it less important to discipline children.  Who minded about niceties of politeness in a survival situation?

3.  UPE.  Universal Primary Education came in right after the war.  Suddenly every child was supposed to be in school.  Classrooms were impossibly crowded.  Infrastructure and staff expansion lagged far behind the explosion in school enrollment.  Throw a hundred kids who have emerged from an IDP camp into a classroom with one or no teacher . . and the bullies rule, the strong survive.  Education is great.  Taking children away from their parents and culture, and keeping them in chaotic unsupervised classes for most of their waking hours most months of the year may not be.

4.  Development.  We are becoming less isolated, more connected to the rest of the world.  Good.  But outside influences are very, very powerful.  A culture that has seen itself as backwards and inferior (an idea perpetrated by conquering tribes and colonial administration) quickly latches onto new styles and new ways, without always deliberating the cost.  Translation and literacy, support for dance troupes and traditional leaders by missionaries, all help, but have not kept pace with the rapid introduction of media.  Parents do not strive to teach and enforce a culture which they have been made to doubt.

5.  Cocoa.  Last but not least, the cultural changes have occurred at the same time as a major agricultural shift.  Cocoa requires less daily labor than food crops, and is much more profitable.  Parents are less dependent upon their children's physical labor. And more empowered to be away from home, spending their cocoa money.  Perhaps even some of the social security that was invested in having well-raised kids to care for you . . now rests on a good cocoa garden, which does not talk back.

6.  Freedom.  Good liberating truths can also have unintended harmful side effects.  As a culture becomes less fearful of spirits, ancestors, evil that lurks in the shadows, then there is less enforcement of social norms.  Good if those norms have been internalized, or if a different motivation (holiness, gratefulness, honor) pushes out the heart of fear.  But if fears diminish without a compensatory increase in faith and love . . then we are left with unafraid, self-centered, and potentially destructive individuals.

The youth are the single greatest resource of Bundibugyo.  They are abundant, and wonderful, and needy of guidance.  CSB provides the kind of structure and instruction they need, but that's only 340 out of over 100,000.  Older parents mourn, and need encouragement.  Midlife parents need to draw upon God's limitless grace, and be inspired by hope that their children are not lost. Those who were teens in the war years are now young parents, and if their generation does not reverse the slide into cultural dissolution, who will?  

Christ School 6, Kakuka 1

The football season began, finally, this afternoon. It seems the district, for now, is standing squarely behind CSB and against the trouble makers who protested last weekend (though rumors swirl that the dissidents are not backing down quietly, and others swirl that the ring-leader school will receive a 3 year ban from district play. Whew). How football explains the world . . . so true even on this level, all the intrigue of vying for position, for money, avoiding shame, seeing what you can get away with, politics, jealousy, it's all right here. Which is why it's worth standing firm, and fighting for what is fair.

Politics aside, this afternoon CSB was scheduled to play the only other team in our group of five which is still participating, Kakuka. Sure, they showed up late, and then the officials were even later, so the 2 pm game started after 4. Sure, two of the Kakuka players were disqualified because of being too old (you have to be within 6 years of finishing primary school to play) but since they had no subs, our team decided to let them play anyway. We all just wanted a real game, at last!

And it was great. Our boys played hard, and well. The very first goal of the season was scored by our own "son" Mutegheki, who in a very Rooney-ish move dribbled, passed ahead to the outside corner beautifully, ran straight to the middle, received the pass back, and drove it in. I think each score was completed by a different player, which shows the depth of the team. I recognize a lot of Nathan moves in their play. It was all a bit rougher and less controlled than when they scrimmaged each other, and they still have lots of room for improvement, but it was a great, morale-boosting game. Deus was cheering on the sidelines and delighted the students by laying down on the field after a successful penalty kick. The coaches were striding and shouting, the crowd was reasonably orderly but entertained, the girls sang praise songs and drummed and danced until they were hoarse, Julia danced on the sidelines with her friends while Jack hung out with his, we cheered with some teachers, and dozens of raggedly dressed little urchins swarmed the field whenever they could, seemingly trying to get close to their hero/role models, the CSB team.

It's only football, not graduating from University. Yes. But it is the most visible success of the school to the community. It is a display of discipline and team-work. It is a chance to shine, to be cheered, that these kids will possibly never have again. It is a demonstration of the possibility of standing bravely against foul play (hiring mercenary players was routine when Kevin first started). It is a time for students and staff and community to all be on the same side, wanting the same thing.

Christ School will never be easy, precisely because the powers that be do not want it to be here. It will always be a clashing ground of good and evil, of Kingdom values and harmful practices. However, days like to day give us a glimpse of hope. Healthy students playing their hardest, excited onlookers, a wholesome afternoon for hundreds of community spectators, the joy of the game, and general conduct that stands out as unique in this area. We heard this week that the church which gave the single largest donation to CSB last year decided not to repeat their gift this year, and that another major donor might also choose to drop out. But at the same time, we had unlooked-for gifts from two completely unexpected places thanks to two team mates, for which we are grateful. This is Christ's school. It challenges our faith to move it ahead when a third of the costs can not be met by the poverty-level tuition and have to be raised by us and our WHM colleagues. But today we remember that it is Christ who cares about these kids, and moves people to give, if we can only hang on we will see wonders even greater than the 6 to 1 score line. Amen.

Mercy Seen

Thanks for prayers for my mom, whose surgery went well.  She can't notice any improvement yet in her vision . . but she also did not LOSE vision in the procedure, and her doctor is hopeful that over the next few weeks of healing she will see more clearly.  This is a mercy for which we are all thankful.

I pried open one of my patients' eyelids today to look in the inner eyelid for signs of anemia (a handy place to check on a dark-skinned child) and was shocked to see his cornea completely scarred, occluded, cloudy, from an infection at the tender age of 4 months.  It was a reminder to me of fragility of the vision we often take for granted, and the common humanity we all share in the face of health problems. My mom has supported two friends of ours here, one a 4 year old girl born ON HER BIRTHDAY (!) to a nurse friend of ours who sustained an eye injury, and the other a teenage student friend of ours who developed glaucoma, because her own eye illnesses have made her empathetic to those of children with fewer resources and options.  In the end, though some care is more skilled (Hopkins) than others  (mine), we all depend upon God's healing mercy.  Grateful.

Lobbying

The issue of pneumococcal vaccine for Uganda has continued to occupy my thoughts and heart.  It is a matter of justice (equal protection from easily preventable deaths for all infants whether they are born in Boston or Bundibugyo), good scientific sense (putting the vaccine resources into places where the impact will be highest), mercy (responding to the shockingly high rates of death here).  Over the last few days a UNICEF contact gave me the phone number for the doctor in charge of Uganda's national vaccine program. We had a great conversation in which I learned that he had just submitted a formal request for the addition of the pneumococcal vaccine to GAVI.  GAVI is the Global Alliance for Vaccines and Immunizaitons, an international organization dedicated to facilitating the increased availability of vaccines in poor countries.  Perfect.  I simultaneously got a negative reply from the manufacturer about donating the vaccine directly, so that door is closed.  So the one organization that can possibly manage to scale up pneumococcal vaccines for all children in Uganda actually HAS A PROPOSAL sitting on a desk somewhere requesting just that.

I've written to GAVI, pointing out the extreme nature of the pneumococcal disease burden in Bundibugyo related to the highest prevalence of sickle cell disease in the world.  But my email is unlikely to make much of a difference.

Prayer, on the other hand, could.  Do we really believe that?  Is prayer just for individual spiritual issues . . . or is it for lobbying?  The heart of a king is movable through prayer .. . so the heart of an international scientific committee should also be fair game.  I don't want to take resources away from anyone else, but I do believe I can make a case for the fact that if there is one place in the world to offer the pneumococcal vaccine, it should be Bundibugyo.  After all, matters of justice, good sense, and mercy are all over the Bible.  Matters of child survival form themes of Bible stories from Moses floating the NIle to Herod slaughtering the innocents. Death from pneumococcal bacteria is part of the impact of the Fall on our world.  Fighting against that is legitimate Christian endeavor.  

So please pray that GAVI would fund and implement a program to bring this not-so-new vaccine to Uganda.  For those readers in more comfortable parts of the world, I'll just add that I saw a 6 month old today with a droopy, weak, sluggishly reflexive right leg, a sudden onset of paresis that could be polio (tests pending).  Vaccines here are not a school requirement or an inconvenience, they are the line between walking and being paralyzed, between living and dying.  Let us lobby on our knees.

Heavenly Advocacy

Last week, we studied a psalm and the topic of prayer in out hospital staff meeting.  And challenged the staff to pray for change, to take their problems to God, first. Well, the problem on their mind was electricity.  We had approached an organization to fund connecting the health center to the power lines, but been denied that money, so we had in our hearts that we'd somehow manage to do it ourselves.  Scott (with LOTS of help from Nathan!) has been managing a contract to connect the school and most of the mission houses.  He did our personal house connection himself, which was relatively straightforward. Working with a contractor for the rest of it has NOT been straightforward.  It has been a tedious, slow, frustrating, messy, and expensive process.  So taking on yet another project, the hospital, looms like a shadow.  But we need the electric power for oxygen, and for our blood and vaccine storage fridges.  So we believe in it and know it is something we want to do, but have not been able to manage it yet.  Last week, however, the staff prayed.

And two things happened.  A church related to one of our team mates decided to link an upcoming fundraiser to us, APPROACHED US, and agreed to fund electricity.  Then a few days later, the chairman of the electric board in Bundibugyo town APPROACHED Scott and told him he wanted to handle the initial phase of the connection himself, because he'd been convicted in his heart that this was an important public health issue.  Suddenly the two main obstacles, money and skilled personnel, were gone.

I have a fairly long list of things that I think are important projects, services, issues.  Much longer than we can actually accomplish on our own energy.  Much more expensive than our current resources allow.  But this week's uncanny convergence of events reminds me of the obvious.  The best way we can advocate for the redemption of Bundibugyo is to stimulate prayer.  Even though we've seen this over and over (like the time the mothers of malnourished kids prayed for a change in the UNICEF decision about providing milk) . . I need reminders like this hopeful electricity story.

So, on the long list, next up:  PNEUMOCOCCAL VACCINE.  The "prevnar" immunization against pneumonia is standard in the USA.  It is NOT standard in Africa, where much greater proportions of children are dying from this particular bacterial infection.  And it is a distant dream in Bundibugyo.  However, this is probably the most important place in the world for this particular vaccine to be given. Because this district has the HIGHEST prevalence of the sickle cell gene in the world (45%!  THAT's A LOT).  And the number one infectious killer of young kids with sickle cell is the pneumococcal bacteria.  In our pediatric ward, 11% of admissions are for sickle cell disease.  We're a small health center yet we average 12 new diagnoses a month (I doubt many big-city specialty hematologists see that many).  The vaccine has the potential to save many thousands of lives.  

I don't know how to make the manufacturer (Pfizer) donate it.  Or make UNEPI (the vaccine program) decide to include it as essential.  Or make the Ugandan Ministry of Health, or the United Nations, or any other powers that be choose to initiate a new vaccine program in a place as remote and tenuous as Bundibugyo.

But God does.  So as we advocate here on the ground, let us also advocate on our knees.  And draw others into doing the same.

VISION

Please pray for my mom, who is having a delicate and complicated eye-surgery tomorrow at Hopkins. She has the best care in the world. But she also has three major different problems in the same eye, a history of multiple other surgeries there, making it a very complex and risky situation. Her vision has deteriorated significantly in recent years (impacting things like driving and reading, pretty significant for a person living alone), and we hope this surgery will prevent a further progression towards blindness. Pray her post-op vision would actually be IMPROVED.

Jesus did a lot of vision-healing . . because vision is so central to life and survival and enjoyment of this world, so much a part of who we are in God's image. I know He would delight in answering our prayers for yet another! And though we are so far away (and thankful that my sister will drop everything in her life to accompany my mom) we know that our collective prayers please our Father who likes to give us what we ask for.

Football Season Begins . . .

Off to a Bundibugyo start . .

The tournament consists of four groups, each group has 2 to 5 teams that play each other, the top teams advance to quarter and then semi finals. Our group is the largest, so we were to have three different days on which we would play each of the other four teams (one day we play twice). The whole thing is to be done between today and Easter, only 3 weeks. There should have been four games today, starting early this morning. By ten nothing was happening. By noon it became clear that only one other school was coming, and they were not a school we were slated to play against today. It seems that though the plan was agreed upon at a meeting of head teachers, one of the schools had second thoughts about the fairness of some of the policies, and convinced others to boycott. Passive-aggressive, the preferred conflict style. Meanwhile our team and Kakuka's milled about in their uniforms, the sun beat down with more and more heat, the community pressed up to the fence to see what was happening, the hired police had nothing to do, the referees and district games personnel sat at their tables waiting, and nothing happened. Finally mid-afternoon they decided that the no-show teams should forfeit, the two teams on site (Kakuka and CSB) got automatic wins. We proposed a "friendly" match (outcome would not count in the tournament) just to give our team and Kakuka's experience, but Kakuka preferred to go home rested and injury-free.

And so, what ensued was probably the best football match ever played on the CSB pitch. Christ School starters vs. the second-string team helped by Nathan and Alex, two coaches (Bwampu and Ajeku also coach, but sat this one out). The progress these boys make year to year is so noticeable. Kevin got them started down a path of discipline and skill, but it seems the improvement now is exponential. The game was a 1 to 1 draw, because there really is little difference between our starters and our subs. Nathan scored the goal for the second team on a cross from Alex . . which in my opinion was like Ashley's goal in the staff/student girls' game Monday, a reminder to the kids that these coaches know what they are doing. There was good passing, ball control, strong shots, team work. Really fun to see.

Hopefully the girls will have a few games eventually. And hopefully the boys will play someone besides each other, multiple times, in the next few weeks.

Today was a reminder of the power of sports to bring the Kingdom forward. Hard work, accountability to team mates, following rules, taking risks, a taste of success, the approval of adults, the importance of physical and mental and spiritual strength all combined. Then the grace to be blessed by good uniforms, helpful teachers, a level pitch, things that are rarely found here. Coaches have the opportunity to instruct, to challenge, to encourage, to lead. This is an area of missions to Africa that should grow. So few African kids have the opportunity to play sports this way, supervised and taught. And yet so much of who we become in God's image can happen on a football pitch!

Lastly, since we are pondering missionary football coaches . . . a tribute goes out to Josh Trott, one of our first. Who is now engaged to be married to a young woman named Lydia. No doubt they will be bringing just such opportunities to needy kids in inner-city Philadelphia. Congratulations.

the way it is supposed to work

Since things rarely happen the way they are supposed to, it is important to take note when they do. To shout. To laugh.

M.U. went home today, cured. He was one of those rare kids who came in simply HUNGRY. He had a mother, and a father, and no chronic incurable diseases. Back in December he got sick with something, a typical diarrhea virus or malaria. He stopped breast feeding, because he just didn't feel well. He was over 1 and a half, so his mom did not push it when he didn't want to nurse. But he never bounced back the way a healthy kid should. He dwindled, until he was picked up by one of our outpatient programs. His weight for length was so low that Nathan referred him for admission rather than treat him as an outpatient. Like many, he got worse before he got better, dropping down in that first week. But then he turned the corner, got his appetite, began to drink the UNICEF milk. And he came back to life. Woke up. Smiled. Began to stand, and then walk. And then play. He is the kind of happy child you hate to send home because he's such a joy to see every day!

He and Kabasa both packed up and went home today, amazing examples of moving from death to life. And three other kids who all had TB: two in joints which I may have missed if I had not gone to our recent CMDA conference and learned more about the subtleties of TB diagnosis, and been emboldened to start sticking more needles into places I had feared to go. All five of those kids would have been dead within a few more months, and all five should live normal lives now. Another discharged 8 year old boy had presented with severe anemia, bloody diarrhea and vomiting, perhaps dengue fever, but went home much improved. His dad said he had no way to come back for follow-up because they lived hours away . . he had spent all his money to get here because he knew his kid was really sick and he'd heard this was a hospital where kids got help.

Many times, things don't work. Many things blow up in our faces (as our colleague experienced with a generator yesterday, which led to no injuries but a BIG MESS). Many times we are misunderstood, or we blow it relationally.

But some days we get to see kids cured, and then we forget the messy frustration and feel that the struggle was worth it. Scott led us in John 16 yesterday in Bible study, where Jesus uses the analogy of childbirth to demonstrate that pain is forgotten when joy emerges. He asked us: is there real joy without passing first through pain? A good question for life, in Bundibugyo and elsewhere. Maybe not. For this evening we are just happy for our little patients' cure.

celebrating richness

Invited three good friends over for dinner last night, to introduce them to the Johnsons. Two have kids in the age-range of Lilly, Patton, and Aidan. And as much as a bunch of little ones can connect in spite of a spread of age and language and experience, they did, rolling balls to each other across the floor and stacking blocks, giggling and chasing with Jack and Julia in the middle of it all. It was an evening of richness. We are rich to have three women of strength and beauty and character as our friends here, Melen, Olupa, and Assusi, all people who work very hard to serve others in spite of difficult circumstances in their lives. And rich to have new friends courageously coming into this place with an intention to stay, to love, to live.

It wasn't until they walked in that I realized it must be near Jonah's Birthday. His mom had to think about it a minute, and then we confirmed he had turned 2 on the 8th. Only two days late . . and thankfully Amy had baked a cake (!). Jonah was delighted by the attention, amused by the candles, and mostly interested only in the soccer balls. So another richness, the survival of this smiling child, with his father's name and face.

And a last amazing surprise gift of the day yesterday: A NEW TEAM MATE. Yes, a young woman who is a senior in college and had applied with WHM to work in Africa . . . at the last moment, as plans fell in place, the Sending Center people in charge realized her overlap with her potential team potentially left her alone much of the year, which did not seem wise. So over the weekend we got the message that she might be a possibility for Bundi, she came to interview in Philly on Monday and Tuesday, and yesterday we heard she's officially our newest team member: Chrissy Chipriano. We are praying that the richness she brings to us will be matched by the rich blessing of fast fund-raising which allows her to graduate in May and arrive in September. Welcome Chrissy.

quotes of the day

"Heal-or-Heaven".   Prayed this morning that God would either heal Ivan Tumwiine, or take him to Heaven.  Not something I normally pray, but this child has suffered for about four weeks, his little skeleton draped with sagging wounded flesh, his swollen feet the most substantial part left of him.  He's got sickle cell anemia and probably TB too, and he came in starving.  Whenever he gets some milk into his gut, he loses more ground from diarrhea.  When he refused to even sip from a spoon for a while he had an ng tube, but eventually the energy loss of fighting it seemed to outweigh its value.  His mom had another baby while he was admitted, so now she has to divide her time, and he's frequently left moaning on his bed.  Some kids can be pulled back from that, but metabolically Ivan's body has so altered in his months of slow death that I'm not sure he can turn around, and if he does the impact on his brain might be severe. I'd love to be proven wrong, and Kabasa who got two candies today (instead of the traditional one candy) for reaching his target weight is a living reminder of those children who take a long time but do eventually heal, and smile, and chase balls.  After praying the Heaven-or-Healing prayer early morning, I cautiously looked at Ivan's bed when I walked in the door, but there he was, alive, barely.  

"They left us without an answer".  Sat in briefly as John led a group of community leaders today in a discussion of improved agriculture techniques, after the dozen or so had toured our demonstration garden.  John's point and purpose was openness, cooperation, sharing of ideas and information.  The group was all for that.  Information, in this culture, is power.  Give away your food, but don't give out knowledge!  So our agriculture group's effort today was counter-cultural in the best way.  Interestingly, one of the men mentioned that last week in the build-up to the WFP anti-hunger campaign, someone came and met with their village (he thought it was a woman but seemed unsure).  She asked the parents why they think their kids are stunted.  People gave many ideas . . . but she never told them the answer.  I'm sure this woman left with a good sense of community discussion and mobilization and inclusion, and the reality is that stunting is a complicated endpoint reflective of many problems.  However her audience was left with the assumption that SHE knew why their kids were stunted, but she wasn't telling them!

"Christian brotherhood is not an ideal which we must realize; it is rather a reality created by God in Christ in which we may participate".  Last night we initiated our CSB staff Bible Study for 2010.  We had surveyed the teachers to see if there was interest, and what time would be most convenient for them.  Even when people express verbally or on a survey that they want a Bible Study, one never knows who will show up at 8 pm after a long day of work.  However, almost ALL of them did!  I think there were 25 of us, which is an unwieldy size, but they wanted to meet together rather than in smaller groups.  We are attempting Bonhoffer's book called Life Together, which is a study of Christian community.  All of the basics of a Christian life are there, but in the context of living in community (which we do) and in the context of Bonhoffer's opposition to political evil and personal suffering (which is a pretty African context, too).  Chapter 1 emphasizes grace:  our community may not match our mental ideal, which frustrates us and tempts us to demand that others change . . better to realize that we live in a real place of God's placement and choosing and look for ways to be thankful.  I was convicted of my own complaining heart, and long for the real love Bonhoffer describes which brings freedom to others as we long for Christ's best in them rather than OUR ideas for them.  Praying this study bonds us, missionaries and school staff, in a common goal.

"You number my wanderings . . "  Psalm 56 was our theme for early prayer meeting this morning.  It perfectly mirrors our vacillation between that desperate sense of being swallowed up by too much work, un-solvable problems, evil and corrupt people . . and then the flip side that God is our refuge, that He is FOR us.  I particularly appreciate the fact that God knows all 17 beds the Johnsons have slept in in 2010 as they wandered this way, and knows where the rest of our paths will pass this year.  He does not promise to avoid tears, but He does save them up in His bottle.  Sorrow and sojourn come, but He notices, and only allows what has purpose.  Clinging to that.

"At least you can stay for life".  This is my favorite.  Yesterday afternoon Scott was working with our new calf (he and Jack and Julia put up a fence!).  An acquaintance came zipping in on his motorcycle, having just heard the rumor which circulates every few months that we're pulling out of Bundibugyo.  He was relieved to find that we were still home.  Then he said to Scott .  . "Doctor, I know this is a hard place to live, but at  LEAST you can stay for . . . . (we're expecting something like one more year . . .) .. .LIFE."  Hmmm.  I guess compared to "at most you can stay for eternity", life is a short "at least".