Who is Worth It?

Last night I had only been asleep a little more than an hour when my pager went off.  1 a.m.  We have a 28-weeker in the nursery, please come.  

I arrived to find a pink little infant boy being assisted with his breathing, as his tiny rib cage pulled hard to move air into his not-ready-for-this-world lungs.  He was tiny but kicking. We've seen smaller, but few survive who are this young (28 weeks) here. His HIV-infected mom had been seen a few days ago with serious bleeding, but refused admission.  Instead of the therapy that might have prolonged his 6+ month (28 week) gestation to a survivable 30 . . or stimulated the development of his lungs  . . she went home and perhaps expected death.  Last night she returned in late stages of labor and popped out a reasonably sized (1270 grams) 28 week boy.  

A boy who proceeded to not cooperate with the program of living.  An all night struggle.  The parents said they could not afford the treatment (surfactant), about $200, which replaces the lung lining that is not yet developed in this stage.  So we tried him on our bubble CPAP, oxygen and pressure to open lungs and help breathing.  But he did not do well, and his xray showed significant respiratory distress syndrome, so after 2 hours I decided we should just give the surfactant anyway and dip into our Needy Children's Fund to cover it. This is not an easy decision as the funds are very limited, and using them on one baby means we won't have them for another.  So I had to struggle:  was this baby a good choice?  Might he survive?  It is very very hard at 2 or 3 in the morning, alone, to weigh this.  I think it was his little kicking feet.  He seemed to be a fighter.  

Nothing is simple, I intubated him but thought I'd tape the tube in and get an xray, which led to the tube coming out, which led to more attempts and having to stop and resuscitate him several times, and help from a friendly anesthesia nurse who happened to be in for another C section in the middle of the night (bless Lucy).  We gave the surfactant and he seemed to respond, his oxygen sat level was over 90 (good).  Somewhere in there after attempting IV's in all extremities and finding the veins too fragile, I put in an umbilical venous catheter for the first time since residency (quick review of procedure in Harriet Lane and then forge ahead).  

Ah, I thought, this has been a long night, the intern was busy elsewhere so I ended up writing up all the notes too, and by 4:30 I was walking out the door, tired but at least I felt we'd done something (evaluated four other sick babies over those hours too, several who were critical inpatients and one new admit).  

Home, the prospect of almost 2 hours of sleep, climb into bed, pager goes off immediately, stat page to nursery.  Seems the preemie didn't respond well for very long.  Same trek, full moon, mysterious clouds, sleepy guards, back to the nursery.  We checked everything we could, bagged some more, tried to get an ICU bed, but there was none available.  In my heart I didn't think he was a good choice for the limited ICU resources either.  28 weeks, four days at home with mom bleeding, no steroids, poor response to surfactant . . . so with a heavy heart I brought the mom in to see him for the first time, in case it would be her last.  We stroked him, and watched him struggle with oxygen sat levels down in the 70's.  Not good.  I pulled each nurse aside, explained what had been done, asked if they had any other ideas, and made the hard decision for the team that we had reached maximum effort.  Now it is in God's hands, I told them and the mom.  Meaning in God's hands to die, I thought, though I prayed that he would live.  We started calling the chaplain.  I left at almost six, the full moon not quite setting, the birds beginning to stir.  There was nothing else for me to do there, and I wanted to be home when the kids woke up (only one parent now, Scott is en route to WHM meetings in America).  As I got them breakfast almost an hour later I called the nursery, a little surprised not to have been called back to his death, but realizing he might hang on for some hours.

How is our preemie?  Oh, he's fine.  What do you mean, fine?  Well, his sats are over 90%, and he looks comfortable.

This baby may or may not survive in the long run.  He has far to go.  Is his life worth $200?  An all-night effort?  Is it worth that even if he doesn't live more than a day or two?  Did I make the right decisions?  One can always choose life whole-heartedly, but in a limited-resources setting one life might cost another.  He is occupying our last incubator.  The next baby might not be able to get the surfactant because he did.  I might have caused his parents longer agony and larger bills, which in this HIV-positive family might impact the health of the three children they already have.

When I put him in God's hands, I didn't really hope for a lot.  God doesn't always plan things the way I do, and my prayers have become less certain of their outcome.  God's hands did not imply that I was, or am, sure of his survival.  But God knew our limits, and with at least our one available incubator and medicine and oxygen and tests and warmth, I think we were meant to offer all we had.  Perhaps it was a widow's mite that will be multiplied to life.  Perhaps not.  This baby's worth is equal to mine, or the President's, or the richest man alive, so we trust that if God does not heal him now, it is not a matter of being unworthy, but a matter of mercy and a better plan.  

High and Low

High of today had to be assisting in the delivery of a baby in the front seat of a matatu parked in front of the hospital . . alerted to the evolving scene as I saw another patient in casualty but heard the screaming mom outside, who just couldn't make it those last few yards inside. I took the blue baby girl and RAN all the way to the nursery, but by the time I got there she was crying, and all was well.

The rest of the day blurs together: rounds, teaching, notes, labs, run home to start some bread dough, consults. The usual, as Kijabe is a mecca for the floppy, the weak, the neurologically devastated, the wasting away. More seizures and poor growth, calculations and xrays. Low is that Scott is on call for ICU, but all 4 patients there are pediatric, so when he got called in the middle of dinner I ended up leaving our 7 guests and 4 kids to fend for themselves and joined him for a few hours, as he intubated two critically ill babies and we sorted out their therapy. Then the real LOW came in precisely the same spot as the high, 12 hours before . . standing by the same bed . . admitting an 8 month old with intractable seizures, maybe a viral encephalitis. As I talked to the intern the nurse said "Doctor!" and we looked at the baby, who had been in respiratory distress, and now completely stopped breathing. Flat. Still. Nothing. The intern reached for the ambu bag (ventilating equipment) and I reached for the baby and at that very moment the power went out. Completely. Pitch black nothing. I fumbled in my pocket for a tiny flashlight I carry, tried to get the mom to hold it so I'd have hands for the baby, she was in hysterics and unable, I grabbed the dad's hands and showed him what to do, and at that moment the power came back.

High number two: came home just now to find the girls had washed all the dishes and put everything away. I love boys, but tonight I have to say, hooray for girls.

Specialization is for Insects

Monday on the Paediatrics Service (since Mardi just posted an appeal for visiting volunteer docs, here is the 11 pm off-the-top-of-my-head recap of what came across my service today, just to whet the appetite):  rickets, malnutrition, tuberculosis, pneumonia, more pneumonia, gastroenteritis, more gastroenteritis, chicken pox in a burn patient, hypernatremic dehydration and septic shock, renal failure, recurrent pyelonephritis, question of sexual abuse, precocious puberty, increased intracranial pressure with impending herniation, probable cerebellar tumor, colic, seizures, more seizures, heart arrhythmia, meningitis, bacteremia, diaper rash, viral hepatitis.  And an email introduction of an admission tomorrow with TB osteomyelitis.  

So when, at 5:30 pm in the casualty department, I was giving the intern on call instructions about an admission I had just evaluated and how to call me with issues, he looked at me and said "But Dr. Jennifer, you aren't on call" and I could have hugged him.  I was so in the groove of all day and night Sat, Sun, and Monday, it hadn't occurred to me that I was no longer responsible.  I walked home in the deluge of rain (courtesy of my chivalrous 16 year old who showed up with an umbrella, either hoping to extract me for getting dinner or just being a gentleman).  Who knows what tomorrow will hold.

a typical Kijabe weekend

S  t  r  e  t  c  h  i  n  g   days and nights at the hospital.  This is our monthly weekend on-call.  The paeds service suddenly ballooned to 40-plus patients, half NICU and half older babies and children on the Paeds ward.  Just when we lost our visiting professor and when our Kenyan paediatrician colleague took a week off to teach elsewhere, of course . . . And hardly any of these kids are straightforward cases with solvable problems.  My head is still spinning in spite of hours reviewing and examining them yesterday and today.  Thankfully we're on call with two bright and competent interns.  So when one called Scott at 2 am for help with a breech delivery, and the other called me twenty minutes later just saying "please come", we knew we were in trouble.  A mother trying to deliver twins, first one became lodged bottom-first, compressing the cord in a situation that could easily have ended in death.  Scott managed to wrest the baby out, though he broke the baby's arm in the process, a small healable price to pay for survival. Unfortunately the delay before he was called meant the baby had suffered a prolonged hypoxic period, and he was floppy with no effort to breath for a long while, later developing convulsions.  His prognosis is guarded.  But after that Scott and Dr. Anne whisked the mother into the theatre for a C-section to deliver the second baby, just as the womb almost ruptured.  This baby was also blue and limp but responded to our efforts and was crying by the time he was a few minutes old.  Our work-life has diverged from each other so much since Bundibugyo, it was kind of nice to be working together, even though it was from about 2:30 to 5 am.  

Guests.  A pleasure to welcome our friends who are now living on the coast, and have two boys our boys' ages.  They started off relatively close to us in Uganda all those years ago, and we've crossed paths repeatedly over the years.  In a place where we generally feel like the "new" people, it's nice to have history with someone.  Nice also to have their boys drifting in and out, making pizza together or waffles, giving us that team feel that we miss.

Games.  Jack's last JV football game, a 1-1 tie, good effort but not quite enough to make semi-finals.  Acacia off to a game in Nairobi, victorious, and Caleb to a draw.  And cheering for Julia in her last Bball game of the term, a decisive win over a team with a 6'5" Sudanese 13 year old . . . I'm so thankful for sports for our kids, especially for the girls, promoting a healthy self-image, exercise, friendship, teamwork, fun, belonging.  Kudos to Mr. Gonzalez, Mr. Davis, Mrs. Chedester, Mr. Hazard and Mr. Dahlman, who have coached most evenings and weekends for the last few months.  Coaches are our unsung heroes.  

Events.  Caleb taking SAT subject tests, all attending the high school drama "Death on the Nile" based on an Agatha Christie book, baking brownies for Julia's class to sell at intermission, working on maintaining our database for patients, planning for visiting doctors, coordinating upcoming meetings, thinking through protocols and improvements with other doctors, editing essays, washing dishes, coming up with meals, washing clothes, getting them out on the line in brief respites of sun and pulling them in ahead of squalls of rain, all has to be fit in around the hours in the hospital and calls on the phone.

Family.  Ruth's 79th birthday.  Luke suffering recurrent debilitating back muscle spasm and pain from the injuries he incurred on his motorcycle accident this past summer.  Feeling regret that we miss important life milestones, and impotence to help those we love.

Burdens.  Bearing the sorrow of kids who aren't coping.  Mostly other peoples' whom we see in the clinic, and listen to, and pray for, and ache over.  There is a high cost to this life, and much of it is borne by our children.  

Rejoicing.  The best for last:  a very very generous and faithful friend, who has supported BundiNutrition heavily over the years, decided to step in the gap for Christ School this year.  Please thank God, and pray for this family to be blessed with the same measure they are pouring out for us.  This gift and other responses to the recent appeal reassure us that in spite of opposition and set-back and disappointment, God still has plans to use CSB for the Kingdom.  A key family whom the Johnsons had hoped to work with mutually decided their gifts would fit better elsewhere, which was a huge loss all around, so this unexpected bounty of provision was well timed.

That's a taste of a Kijabe weekend.  Driving rain and moments of golden sun, premier league football on the television, Caleb and a handful of RVA students singing the Hallelujah Chorus with the local church choir in worship this morning, greeting hospital friends on the road, pondering management of a syphilitic rash or an obstructed bowel, gathering a gaggle of 10th grade girls for cookie baking, trying to think clearly in weariness, this is life.

HELP! End of year crunch time at Christ School - Bundibugyo

Travis and Isingoma have been crunching the financial numbers at Christ School this week.

As most of you know, World Harvest Mission subsidizes the operating expenses of Christ School each year in order to keep tuition fees affordable for the average subsistence farmer of Bundibugyo District. On average, WHM helps to raise about $50,000 per year to help cover the basic costs of running a boarding secondary school - namely, paying teacher salaries and buying food for the students. We operate on a shoestring…our average teacher salary is something around $175/month and we feed each of our students for less than $1/day.

Unfortunately, in 2011 we had a major donor default on major pledge. We don't blame the donor (he has promised to contribute in the future), but we are left with a significant gap in 2011.

Travis and Isingoma are estimating

that we need

about $12,300

to finish 2011 at Christ School -Bundibugyo in the black.

(that means paying the final month of salaries to our teachers!!)

WOULD YOU CONSIDER GIVING TOWARDS THIS CRITICAL NEED?

CLICK HERE TO BE TAKEN TO THE WHM DONATION SITE FOR CHRIST SCHOOL…. Any amount, little or large, is appreciated. Thanks so much.

the weight of a Wednesday

Esther, floppy as a fish, dressed in blue, with sparkling brown eyes that follow our movements, a babbling tongue.  She's a normal 1 year old mentally, trapped in a body that barely moves.  Her mother died giving birth, so her stout and steady, coarse-featured competent grandmother stepped in to rescue her.  For a year she's been feeding, bathing, carrying this child, who grew in size and responsiveness but never managed to hold up her head, to sit, to play, to crawl.  As a last ditch effort, her grandmother accepted money from a friend to travel across the country to Kijabe, determined to hope.  Instead she ended up with me, hand on her shoulder, as she wiped the tears subtly with a blanket edge, then broke down in sobs.  Esther seems to have a form of muscular dystrophy, and is unlikely to survive very long here.  She will never do very much.  I hated watching this dignified older Kenyan lady sob, hated being the one to bring her dream of cure to an end.  But I stood there and talked and then prayed, because it is important for the family to understand the truth.  

An hour later, a hyper little two-year-old flitted around the outpatient exam area.  Who would have guessed that she was brought here to rule out rape?  I couldn't find any definitive signs, and as time went on it became clear that the mother and father were separated , and the rape accusation was actually directed from her to him.  We could not untangle the truth.  In the end we called in the police-based child welfare officer to ascertain the safety of sending this little girl home.  I'm afraid this country will not protect her, or the many children like her.  That she'll be abused by those whom she should be able to count on for sustenance.  

Same room, another hour or so later, I was called by our clinical officer for help.  As soon as I opened the door the stench almost knocked me over.  Incontinence of stool and urine, chronic and powerful.  I tried to breathe shallowly and appear unaffected.  The 3-year-old little boy smiled at me, disarming, charming.  He has been having seizures for the last couple of months, getting more and more frequent, and now has a staggering gate, loss of speech, and inability to control his excretions.  We fear a brain tumor, and arranged for a head CT.  When I examined him his pants were chock full of pasty overwhelming stool, and soaked with urine.  His mom was dressed poorly and I suspect just too overwhelmed to keep him cleaned up.  I'm sure Jesus would have put this sweet little boy on his lap.  

Back to the ward, where baby Mercy waited for the results of her bone marrow biopsy.  She is a diminutive 4 1/2 pounds at age 2 months, tiny, curly dark hair and huge eyes.  She has many anomalies, at least two of which could use immediate surgery . . only she has very few platelets, so no one wants to take her to the operating theatre for fear of bleeding her to death.  I was pretty nervous about poking a needle into her bone as well, but she survived that.  For someone with a long list of problems (cleft palate, heart defect, ano-rectal malformation, microcephaly, not to mention anemia and low platelets) she looks pretty cute and cuddly wrapped in her blankets.

All of these children have potentially disastrous, lethal prognoses.  All are oblivious, mentally intact, eyes seeking out contact, face ready to brighten and smile.  And when they do, all give my heart a tinge of grief, a sigh under the weight of this world's sorrow.

We have plenty of other kids too, malnourished and dehydrated, oozing pus from a huge scalp incision, incessantly convulsing, breathing too fast, languishing with fever.  This week however I feel the burden of those who trust, who look me in the eyes, who try to connect.  Who hope for help in this world.  And who probably won't linger long.

Sunday Contrasts

Yesterday we spent in the misting rain, shivering at times, cheering most others, back and forth between 3 football (soccer) games for Jack's JV and 5 for Caleb's Varsity in the annual RVA football (boys) and basketball (girls) tournament. It is a community event, with seniors selling grilled burgers and chicken and pizza and salads, parents meeting up with kids and old friends, faculty mingling. The best moment for me was Caleb scoring the tying goal in the first round against the team that won the whole tournament in the end. The final game came down to overtime and then a penalty shoot-out, which we lost 3 to 2. But it was valiant and muddy and crazy and tense. And followed immediately by Acacia's pizza party for a handful of her classmates, celebrating her 14th birthday. A great thing to be able to host this with Karen. Due to rain we had to be mostly inside, but the girls' chatter and the candles on Karen's home made apple pie were cheery. At Acacia's request, Karen and I made a breakfast this morning of crepes with strawberries and whipped cream, before they went off to Nairobi for the day with family. I love our blended family here, the extra mom and dear friend staying under our roof, the shared Bday fun.

About the moment the party was all over Scott starting shivering, and within the hour he was knocked over by some infection. The last few days (weeks? months?) really wiped him out anyway, a complicated patient with unusual neoplastic tissue only a few weeks post partum, a difficult surgery, and then a long hard phone call which was the culmination of a week's worth of sorting out a conflict. I think his body was just over-the-limit, so when an infection hit, it hit HARD. He's not spent a day in bed like this in ? I can't remember. So he missed the early morning visit to plant a tree with our friends who lost their baby. I sort of invited myself when I heard they were commemorating her birth and death, and they were gracious to let me come. After days and days of rain there was a moment of sun, fresh earth, a simple scripture, tears, memories. As we talked it struck me that I was glad to be there on so many levels. As a fellow mom who lost three babies of about the same size, the lonely mourning of miscarriage now shared. As a doctor, closure to walking through this week with the frightening bleeding and shock and transfusions and ICU. But mostly as a person who misses the intimacy of our small team, someone peripheral to the massive intricate complexity of Kijabe/RVA, in this small moment we were able to delve deeply into a life, and I'm thankful for that.

Birthday and burial, all within the hour. Life is so like that. Sickness and crepes. The clouds part for a few hours of sunshine, and then return. A toddler giggles as mourning parents weep. All true no matter how incongruous.

Prayers for Scott's healing appreciated. I am just emerging from almost two weeks of intestinal issues, still not sure if the disease or the cure caused the most problems, but it wasn't pretty. Hope he doesn't take that long to improve . . . we need him.

Things that make me happy

It is raining, incessantly, the kind of build-your-ark drenching that leaves us with a muddy floor, damp clothes draped over chairs, and a harrowing ride back from the airport last night as many cars stalled in the gushing rivers that flooded Nairobi's streets. ( You have to be in a foot or two of water on a major highway, being sprayed by trucks, slipping in the dark, to realize how important it is to think through where all the water which falls should go, and how important engineers are!). Rain does NOT make me happy. But it makes everyone else happy. Thankfulness for the rain is the first phrase out of everyone's prayer mouth this week, Kenyans, missionary kids. They get it, that we need this moisture to eat, to survive. I am cold, and would like to see the sun, and dreading standing in the rain to watch soccer all day and to cook pizza for Acacia's party tonight. But I dutifully put rain first because it makes Kenya happy. This is the spread of loot from Dr. Raymond, visiting paediatrician from Alabama who has been a voice of wisdom and stability working in our department this month; Dr. Lesley, Mardi's friend visiting from Australia for two weeks; and Dr. H who could not come this time but sent a suitcase with others from Europe! We now have some really important life-saving items like ambu-bags for infants and preemies, oxygen tubing, specialized IV lines. Some donated, some bought at these doctors' own expense. Mardi and I spread it all out and divided it up and delivered it, Christmas in October. One thing that REALLY makes me happy is that my dear friend Karen came to visit. A perk of holding her daughter hostage I guess. Yesterday she and I took a long walk, then later slipped into 7th period choir class to listen to Acacia (top left), Julia (a few girls down the back row) and Caleb (with the bass section in the middle of the back) rehearse Christmas music for their concert in late November. Glorious. This rug makes me happy. We had a disintegrating cheap mat in the bathroom, until I was craft shopping with my Mom on her way to the airport yesterday, and found this cheerful rag rug. It is heartening to see the colors with the blue bathroom walls, and step out of the shower onto it. And while I was buying gifts to send back to my sister, niece and nephews, my mom insisted on buying me this necklace. Note also the warm red hoodie, and three layers of clothes. Skyping with Luke was the most cheering part of our evening. We miss him so much. It makes me happy to just see his face in his dorm room, hear about his Gospel choir concert and organic chemistry and plan to meet his RVA friends in NYC this weekend. His news: winter arrived. New Haven is COLD. The seniors working together is another fun sight. I spent last evening with Julia's class, but snapped this as I looked for Caleb to hand him a sandwich because he missed dinner. The girls have given him a note of encouragement with his number (8) for the tournament today. He worked for about four hours after his game last night, then got up at 615 to work two more before the tournament today, all on the food that the seniors sell to raise money for their end-of-the-year class trip. Not sure when college apps fit into all this, he's exhausted. This bright knobs always make me happy, when the roaches are running off the kitchen counter I try to focus on this little spot of beauty. My mom sent these months ago, but these remind me to be thankful that she made it back safely to the USA after a month in Kenya.

Two views

Some evenings I can wrest a half hour or more in between work, scrambling to see games, a quick check of email, preparing to cook dinner, folding laundry, clean up. So when I can, I love to go for a short run or walk with Star. One of our favorite routes is directly across the field in front of our house, catching a path that leaves the station houses behind and meets a relatively flat old road or railroad cut, to the airstrip. It is a gravelish path, used lightly by foot traffic from the valley up to Kijabe. Yesterday as we jogged along, I was struck by the different views to my left and my right.

To the left of the road, the trash dump for the station. Heaps of garbage, columns of smoke rising from the attempt to burn the trash. An old man was picking through the pile, looking for anything useful. And between the road and the dump, a ditch filled with grey, bubbly, putrid water, the effects of sunless days and drenching rains. The stench is nauseating, the view distressing. A stray dog lopes through.

To the right of the road, however, eucalyptus bushes lend a balancing fragrance, with their silvery-green leaves and exotic scent. The valley falls away over boulders and acacias. In the distance, the sun filters through clouds, a golden light on the tops of mounts Suswa, Margaret, and Longonot. The horizon is endlessly far away, hazy and beautiful.

One path, but two views, both real.

And as I jogged along, it struck me that this is a picture of life. As we move along our path, we can look left or look right. We can see the putrid or the sublime, because both are there. Neither should be ignored, but there is some choice involved in which way we spend most of the time looking. And I've been looking left too much.

Looking left, my heart sinks when a kid misses a deadline for a school event, sits on the bench for a game, does not get invited to participate. But if I looked right I'd be thankful for school even if we are at times peripheral. Be thankful for a season without injuries, even if playing time has been disappointing.

Looking left, I feel inadequate and incompetent in my work and in most of life. Looking right, I'd be grateful for the blessing of being around people who are smarter and more experienced than I am. To the left, another baby with incurable complicated heart disease, who will die sooner rather than later. To the right, a child whose bone marrow aspirate showed his cancer was cured.

Looking left, my heart protests the way God allows suffering in the lives of people I love. Looking right, I see the privilege of walking through a hard and dark valley with friends this week.

Looking left, I am tired of the intestinal parasite that has wiped me out, as well as the toxicity of the cure. Looking right, I realize how great it is that no one else in the family got it.

Looking left, the tension of living in a country on the edge, tense, unstable, wondering when the next grenade will be launched. Looking right, the reality that life goes on almost normally.

This month started with an absolutely life-draining, mistakes-made, non-stop call weekend. I think I started looking left then, and now three weeks later I've hardly appreciated the view to the right. God sent my mom to organize my kitchen and play games with my kids and cheer us on. He sent two visiting doctors to allow a little breathing space in life, mentors, gift-bringers who have taught and supported in amazing ways. He sent friends to fix our car. He sent us a weekend break. Bethany reminded me that praise and thanks are instruments of war. That when we're under attack, the way to survive and emerge is by remembering thankfulness. By looking to the right. How many Psalms are written just this way? A lament of left-ward looking, true, painful, and then a transition to look rightward and remember that which is also true and beautiful, even if distant.

Pray that as we plod along this road, we'll balance the left-view of the trash dump by taking long right-views of the sun on the valley.

Kenya at War

Kenya invaded Somalia this week, and President Kibaki officially declared a state of war.  It is a peculiar war, waged by Kenyan military across their border in cooperation with the weak government in Mogadishu against the kidnapers and insurgents who control much of the territory in between.  The reality of this is pretty far removed from idyllic Kijabe.  Pretty far, but not completely.  Today as I walked to the market with Acacia, I saw police stopping and checking vehicles as they approached the hospital.  Our neighbor pointed out that  one was wearing blue flip-flops with his blue police uniform which cut into the intimidation factor a bit.  Emails are circulating about security awareness, because Al-Sha_bab has threatened to bring their campaign of terror and bombs to Nairobi in retaliation.  This station has a history of angelic protection from attack during the Mau Mau uprising decades ago (Mau Mau who were later captured reported turning back from attacking missionaries and children at the school, because of the strong perimeter of military they saw, when in fact there were none).  So one could look at it either way: a dangerous spot as the largest concentration of American missionaries in East Africa and the perfect target for anti-USA or anti-Christian terrorism . . . or a very safe spot protected by God Himself.

In other news today, Burundi was named as the most corrupt country in East Africa.  Our new team has their work cut out for them,  Every step of their work, from building houses to getting vehicles to approving curriculum to rehabbing the hospital to sourcing clean water . . will be met with the obstructing frustration of inefficiency and bribe-seeking.  Uganda has cracked down on anti-government protestors again, even as a hundred US military "advisors" landed to assist in the capture of Joseph Kony, murderous and deluded leader of the LRA.  Our Uganda team is back in business, with new team mates Josh Dickenson and Pamela Stephens.  Josh was an intern with us who went on to finish a PhD in Engineering in Florida.  And as soon as he landed he was swept up in trouble-shooting diminished water flow in the pipleline that provides tens of thousands of people with life-saving clean water.  As soon as the Johnsons landed they were sick, a key CSB donor landed unexpectedly early for a visit, and another team mate had an injury requiring stitches, so it's back to the usual push.  Pushing for the Kingdom, and being pushed back.

Please pray for peace in Kenya, for protection from terrorism.  Pray for courage in Uganda, and wisdom, and provision as our team puts their shoulder to the plow, as our CSB students and friends take their life-determining national exams.  Pray for vision and growth in Sudan as our team hosts 5 businessman interested in micro-development.  

Pray for our family too. One more week with Grammy, Caleb feeling the crunch of application deadlines, some disappointing grades and games, some very heart-rending patient stories, all felt more acutely by me because I'm muddling through an unpleasant case of dysentery for the first time in over a decade (just after I told a new missionary that I eat freely when we're out in Nairobi and never get sick . . . ).  

One can be lulled into the protected beauty of this place, of a structured hospital, of competent colleagues, of seemingly normal teen life and school, and forget that we are living in a war.  Right now, both spiritual and literal.