THE STRIKE IS OVER

Poetry or prayer, who can say, but we are all happy to have our interns back.  I wish I saw more good coming out of this for Kenya, for the doctors themselves and more so for the poor whom they serve.  But we're glad it is done, and hope not to experience that kind of stressful stretch again soon!

How the Strikers Stole Christmas!

(or tried to. The story isn't over, and I'm too tired to finish the poem, but this first part goes out to all my colleagues at Kijabe)

All the docs at Kijabe were working a lot

But the ones living just East in Nairobi were NOT.

Those doctors were on STRIKE! For the whole Christmas season!

Now, please don't ask why, No one quite knows the reason.

It could be their income left their budget too tight

It could be, perhaps, they weren't treated quite right

But I think that the most likely reason of all

May have been that their vision for health was too small.

But whatever the reason, their salary or their dues

Their posters and slogans made Kenyan news.

They sat in their homes with stubborn strike frowns

While the docs at Kijabe ran themselves to the ground.

For every doctor there hustled, doing more than their share

To handle the patients who came seeking some care.

They were hanging IV lines 'til casualty was all clear

Though Christmas was nearing, it was practically here.

The government held meetings while the patients kept coming

The poor people suffered while protestors marched drumming.

Oh to find some way to regain those employed!

For tomorrow they knew all the sick girls and boys

Would wake bright and early and rush OPD

And then, oh the noise, oh the patients to see!

Every one, young and old, from the greatest to least

Would expect to be treated, cured, and released,

While normal folks sit down to a great Christmas feast

The Kijabe docs will cover for their colleagues to the east.

Yes, they'll keep working, on the worst tasks of all,

From paperwork to surgery, on the tall and the small

They'll stand together, united, to each other clinging

As beepers alarm and phones keep on ringing

And maybe, just maybe, they might even sing!

Because in the end, this frustrating strike thing

Must eventually end, and then, how they'll sing!

Why for nine straight days they've put up with it now.

Kenya must stop this strike from continuing. But how?

Advent Week 3

Advent looks back to the incarnation, Jesus' entrance in human form upon earth.  And it looks forward, to Jesus coming in power.  As we've gone through the first two Advent Sundays, we have read Scriptures on these dual themes of "came" and "will come".

But this week we turned out attention to the present continuous tense, the way that Jesus is currently coming.  Now.  As in Matthew 25.  As in, "I was  . . . you did it to me."

We had our Paeds team over, the very people with whom one would want to ponder this present reality of Jesus as he appears in our current lives.  And we read one of my favorite books, Papa Panov's Christmas, a Leo Tolstoy retelling of a simple shoemaker who looks for Jesus on Christmas day and realizes he saw Him in the poor and needy and hurting people who came to his shop.

It was lovely to have a house full of friends, American and Kenyan and Canadian.  To have a beautiful spread of cookies.  To play and sing carols, to light candles, to talk and visit.  I miss the bustle of being the social center of a team.

But more than the atmosphere, I needed to be reminded of the message.  As the strike drug on, I spent 11 hours of Sunday in the hospital (almost the whole day, except the hour and a half of our party!).  I needed to think of the next person, and the next, as Jesus, however unlikely.  A little boy found naked, cold, unconscious by the roadside by a slightly inebriated man who dropped him off at the casualty department as a dead body, but who later warmed and woke.  Hours later his family found him.  It seems he is a mentally retarded child with a convulsion disorder who had been locked in the house while his mom went to get milk, crawled out the window, and decided to try and walk to see his distant grandfather.  The police were involved by this point, and we appealed to the family to support this mother, and watch this boy.   . . . . A nearly two year old who had lost a third of his body weight in the last few months, received terrible medical advice from a district hospital, and whose mother persisted in thinking that there must be something else she could do for him . . . a toddler whose mom also abandoned her admission at a government hospital after she saw no improvement in days of admission, and had seen no doctor the entire time in spite of the serious diagnosis of meningitis. . . kids with vomiting, with dwindling, with cough. . . a little preemie who just tried to give up on life as his fever spiked up and he lost the drive to breathe, requiring hours of resuscitation including a couple of rounds of CPR until the nurses had an important observation about some missed medicines that helped him pull on through.

All of these kids, and more, were Jesus at Kijabe yesterday.  And until he comes in power, we will continue to meet him in these unlikely powerless people and places.  

Christmas Tree

Yesterday we put up our Christmas Tree.

You might think that after 18 years in Africa we would have succumbed to the convenience of an artificial tree. And this year, I did wonder why we were stubborn purists on this matter. But we've always had a live tree, or something close to a tree, and it has become a matter of tradition now to search for it. One year we were nearly arrested, so the process is not always straightforward. After that I planted enough for the coming years myself in Bundi, but those are now long gone. So here we were in Kenya with no real plan. There was definitely a bit of reluctance/anxiety/doubt as we all piled into the car. I had asked two Kenyans and one missionary what they have done, and was told all three times, oh, just go into the forest. So we looked for a good spot to try that.

Kijabe sits on the edge of an escarpment that is topped by National Forests planted with pine trees. But these are huge 30-50 foot tall trees, with long straight trunks in endless dark rows and scraggly needles way up at the top. And it would be unwise, not to mention illegal, to cut them. We did cruise along the road looking for perhaps a younger tree which had chanced to grow right on the road edge, but no luck. So we ended up hiking a short ways into the "quarry", a ravine of public land nearby where rock is quarried. The sun reaches here, so the floor is covered with bushy vines and scrub, including some cedar trees. None of them have anything close to a traditional Christmas tree shape. Most were scraggly, one-sided, bent, multiple-trunked, too large, or on a cliff edge. But we did find one semi-promising specimen. Caleb gamely chopped it down, and Scott and he added in some branches of equal height from a few other cedars.

We loaded our branches onto the car and brought them home, at least feeling less guilty since we had not really chopped down a full tree, so re-growth would take place. And while cruising the national forest we bought 3 seedlings so we can try and grow something more shapely for the next few years, or at least have a net re-forestation impact. No one questioned or threatened us, thankfully. At home we realized our ceiling is barely 7 feet tall. But we pushed all the various scraps together, secured them to each other with zip ties, set them upright in a bucket of bricks and water, strung on the lights, and added our ornaments.

Resulting in a festive display. Our tree lights are from Kampala, when electricity came to Bundi two years ago we went wild and bought four strands of the tackiest blinking spastic colorful lights you can find. Our ornaments are numerous, collected over many years. Some from our childhood, most bought here and there as we traveled, memories of trips, or home made by our kids. Our tree itself smells of fresh cedar, and splays out in awkward and scraggly directions. I like to think of the whole thing as exuberant.

It would be easier, and more attractive, to have a tree we assembled from a box. Or to drive to a lot where trees are lined up, grown in neat rows, manicured to prescribed shapes. Somehow this expectation of perfection is so much a part of modern culture. But I like our tree. It is fresh and real. It does not conform to expectations. It is not afraid to push out in various directions, or to blink in blue.

Christmas, as in the real Christmas, was a lot about making do. Making do with a less-than-ideal shelter, with an improvised cradle, with cast-off rags for clothes. And all those things were made beautiful and infused with meaning. Our tree reminds me of all this, of the boldness of pulling things together and declaring them beautiful. Of our whole life, which involves pushing the edges, looking for beauty in the ashes, creative adaptation of our home culture to new places, the melding of the old and the new. Of a God who does not require us to be the perfect uniform shape and height, but whose grace pulls us in just as we are and adorns us with lights and jewels. I'm thankful for our little tree. Just hoping it holds up 'til Christmas!

Doctor Strike Day Two

Scott and I both opt to begin the day around 7:30, checking on critical patients before rounds. Which is a good thing, because we're almost immediately called about a transfer from Naivasha. A strike-effect, a very sick baby lands our way. Throughout the day the combination of an increase in patient volume (one man went to ICU after 36 hours of bouncing from one non-functional hospital to another after his road traffic accident) and the considerable decrease in functioning work-power.

This cheerful little girl spent over three weeks on our service, as the TB therapy finally kicked in and she began to come back to life. This was her first day without an oxygen mask on her face, and I just had to take her photo. Though the endless stream of malnourished, dwindling, gasping, struggling little people can get depressing, the wonder of watching most of them move from lethargy to life makes it worthwhile.

My team is down to Lillian, the Clinical Officer who works full-time week-days in Paeds, and me. The strike is harder on people like Lillian than anyone else. Our 20-ish patient service used to be shared between her, a medical officer ntern (doctor) and one or two clinical officer interns, who would all review some of the patients and present them, or follow up labs, or write up new admissions. Now she tries to come in early, too, to see as many patients as she can, and we review all of them and then finish up together. Lillian is bright, caring, cheerful, competent, willing . . everything you would want in the person you spend most of your days with. So one of the blessings of this strike is working with her. After rounds we go to the Maternal and Child Health clinic where we see patient after patient again. And keep checking in with ICU, casualty (emergency), nursery, the floor. I'm called to private clinic to see a sick missionary baby, and to the neurosurgical ward to help with a deteriorating four year old. It's non-stop.

In the late afternoon I find out that one of the preemies in nursery has dangerous levels of jaundice and needs an exchange transfusion. This baby temporarily dies while we are putting a line in her umbilical vein, requiring CPR. I try and explain what's happened to her anxious parents. Then the charge nurse and I begin the tedious process of removing her blood volume and replacing it twice over, a teaspoonful (5 ml) at a time. After a short time the line fails to work and I am rescued by the ever-patient paeds surgery resident, who helps me replace it. At first I am relaxed and chatting with my nurse about Christmas but the baby once again begins to have a falling heart rate, and it takes all our care to keep her alive through the procedure. My advent devotions pointed out that if Jesus could come to Bethlehem, God can show up anywhere, so we should expect him in the hard places. Once again the exchange transfusion reminds me of a crucifixion, a small innocent person spread out and pinned down, lots of blood, what looks like murder and turns out to be life-saving.

I hand the baby over to the nursery nurses several hours later, because at the last minutes of the exchange the OB nurses want me in the operating theatre, where Scott has gone to do a C-section. It's about 8 pm. A small perk of shared OB/Paeds call is we keep meeting over babies. This time the mom has failed to push the baby out and the baby's heart rate is falling. Scott extracts her surgically, untangles the umbilical cord from around her neck, and hands her over to me.

Another perk of no interns: the happy moments are mine alone, a healthy baby who could have died and is now squalling and strong. But no time to linger, the preemie in the nursery needs more support post-transfusion, and another baby keeps forgetting to breathe. Then I remember that hours ago I'd been called to go to an admission in casualty.

This is our most interesting patient of the night, a six-year-old Maasai boy who was perfectly normal and well until a couple of days ago, when he began to bleed. in his eyes, his gums, his skin, his vomit, his urine, his stool. Being from Bundibugyo my first thought is ebola, and my second was along the lines of the ER docs that he had leukemia. But he just wasn't that sick. His platelet count turned out to be 1000, which is a half a percent of normal. Frightening. But the words ITP popped into my head, hopefully from the Spirit, and I decided to gamble on treating him for an immune disorder. We admitted him for a blood transfusion and steroids and protection from trauma, hoping he can avoid bleeding somewhere critical like his head before his platelet count recovers. Saw a couple more kids there, one in severe heart failure for admission, one who had swallowed a ten shilling coin, which is smaller than a dime and worth about that much.

Then back to the operating theatres, where Scott was doing another C-section. This mom had had a previous c-section, and now was carrying twins. She was supposed to deliver at the district hospital, but due to the strike was sent here, which likely saved all three lives. She had massively dilated blood vessels covering her uterus and could have bled to death.

Instead she had two identical boys. Lovely.

Earlier in the day I passed a visiting prayer warrior, Jeanne B, in the hall. We first met umpteen years ago when we were working at Kijabe temporarily, because she comes with her retired pathologist husband for 3 months every year. She said, "How can I pray for you today" and I said "pray for my attidtude". So this photo is for Jeanne, I snapped it in the theatre dressing room on the way out, because I know her prayers were with me.

One admission to ICU, and back to see the sickest patients in ICU, Nursery, ward, last check-in at Casualty and then, just after midnight, I came home. Scott had been able to help the kids with dinner hours ago, but not eaten, so they left us each a nice plate of spaghetti and green beans and salad, and we sat down to eat our first meal since breakfast.

Jack graciously waited up for us and watched football on TV.

By 1 am we're both about to sleep, for a short while. I get paged to nursery, but the competent charge nurse tells me the xray I ordered earlier can wait for review in the morning. I want to hug her. We sleep. At 2:30 Scott gets called back for a couple of middle-of-the-night hours to care for the mother of twins whom he ends up admitting to ICU, and I spend from 5 to 7 am trying to keep the baby from Naivasha, and my two ICU patients, alive.

When I realize it is 7 am, I opt for a quick trip home to shower and have tea. And as I walk out of maternity, this is the sky I see. It's still raining most of every day, but glimpses of sun and sky are appearing.

And so Day 3 begins, back before 8, for the usual chapel, rounds, C-sections, admissions, babies, consults. I do appreciate the medical officer interns, it is NO PICNIC to take call without them. I remember being in med school and residency 20 years ago, when days like this one would be common and constant, and no excuse for not working full-out the day after. Only this time I have kids whom I miss, and whose feeding and care I have to still ensure through phone calls. Oh, and I'm a few years older I suppose. But thanks to the attitude prayers, I found a lot to enjoy in those intense 24 hours. Because the public medical system serves the poor, they are the ones who truly suffer from this strike. I'm just missing a little food and sleep, but not my life.

Dec 4th

Four years ago on this day, Dr. Jonah Kule died of ebola.  We were in Bundibugyo, and he had admitted himself to Mulago Hospital in the capital, where he had gone to pick up his daughter from boarding school before he fell ill.  He died alone, in a tent pitched on the hospital grounds for isolation, with his last words being that no one else should die of this terrible disease, and that he was now going.   That is a long story for another time, but suffice it to say that that night when we got the call from the MSF team that night, in the darkness of pre-electricity Bundibugyo, we were stunned, grieved, frightened, bewildered, numb, disbelieving, crying, despairing, praying, a gamut of emotions.  Standing outside to maximize the weak cell phone signal, talking to the doctors, then being the ones to call and tell his wife, all of us in tears, Scott and Scott Will and later our neighbor Tibererwa, recounting how this happened.  And wondering, what was God doing.  How could He allow such injustice and suffering.

Tonight we sit in cold soggy Kenya, just below the equator, with unseasonable rains drenching us, waiting to hear if the Kenyan doctors will all go on strike at midnight.  There are issues of justice and corruption here as well, though a strike seems like a far cry from a doctor who laid down his life to serve the sick.  We hope that the government will negotiate and avert the collapse of the public hospital system.  If they do not, we will find ourselves being the only functioning hospital in the district, working without any of our interns and some of our consultants, and adding onto our already-stretched capacity the overflow of patients who can not find care in their usual places.  

Two thousand years ago, God chose to show up in the darkest time of the year, in obscurity, and in danger.  One of my advent meditations pointed out that He did this to show that if He can be present there, in Bethlehem, He can come anywhere.  To Bundibugyo during ebola, to Kijabe during a doctors' strike.  Because our hope is not in God changing our circumstances immediately, but in God Himself.  In His ability to bring light into the darkness, redemption into death.  Unlikely though it is, it is in these places of dense night, of loss, that we find Him choosing to be with us.

I talked to Dr. Jonah's wife Melen on the phone today. She is a strong and admirable woman who has endured too much.  Yet the nursery and primary school she founded are thriving.  Her oldest daughter is entering her last year of high school.  Her son, born after his father's death, is a joy to her.  Five young men are now in medical school because of Jonah's death.  Three have written to us in the last week with good news of classes passed, of learning, of eagerness to serve.  Our team in Bundibugyo works hard, too hard, to keep that small light  burning.  But they have moments of beauty too, of connection, of redemption.  Because we are still in the story, we can't fully make sense of today, or of the 4th of December 2007.  But if we look all the way back two millennia, perhaps we begin to see that the light shined in the darkness, and the darkness could not overcome it.

Beanie Babies Batch one

Luke reports that we now have 13 beanie babies--3 from friends in NJ and this box which arrived from CT. THANKS!! Just a reminder that he flies out on the 17th, and he has to figure out his packing, so it would be nice to get any shipments by the 15th, which is 12 days from now. Children in Kenya will be very happy. We're aiming for 50 . . .

Caught in the turbulence

Scott brought back from his meetings a thought provoking book called The Meeting of The Waters, 7 Global Currents that will Propel the Future Church, by Fritz King. In the introductory chapter he describes two classic missionaries meeting at a guest house, two contrasting models of missions. The first is an older lady who has spent her entire life with a remote people group, rarely traveled back to America, had given up everything. We honored two couples and two single women who were just like that this past week at the AIM conference. They were retiring after 30 to 43 years of service in Africa. They had pioneered remote stations, translated books into local languages, established schools, weathered wars. They bore up under whatever life brought their way with very little outside help. They were grey-haired sturdy survivors with practical shoes, quiet and unassuming, faithful servants for the duration. One had come here as a little girl in 1946, a trip which took two months on a boat in those days. After a few years in Tanzania her parents left due to health reasons, but she returned as a young woman in 1968, was married in the RVA chapel, and the rest is history. These are the heroes that drew my heart towards Africa as a girl. They are the generation that laid down their lives and did the right thing, year after year, without fanfare. I didn't even know any of these people, but the standing ovations at their retirement brought tears to my eyes.

The second missionary in King's introductory chapter is a 30-something guy who is multitasking on his cell phone and computer, has left his family in America while he checks out a project run by local leaders that his church supports. He has a career, but is arranging to take two years to spend overseas lending his skills. This is the new generation of missionaries. The break with their formal life is less abrupt, more fluid. They set boundaries and have high expectations of personal development, exercise, protected family time, organizational support and responsibility. Travel and communication lend connectivity, educational levels are high, they are task-oriented generally, outcome-focused, and missions is an important part of their life, but not their whole life. We meet amazing people like this here too. Skilled doctors donating a month, or six, or more to boost services and education. Teachers, engineers, artists, contractors. People with the funds and vision to start and orphanage or foster micro-enterprise, who will leave it within a few years in local hands.

As I finished the introduction and started into the book (I'm only a third of the way through) I had sort of an "aha" moment. When the two rivers flow together to create the Amazon, there is a stretch where their waters flow in parallel, then a period of mixing and turbulence. And we are squarely in that turbulence. With 18 years in Africa behind us, we are a bit past the half-way mark towards the classic old-time missionary life. This is who we expected to be. And this is why over a year out from Bundibugyo, I have to keep remembering the very specific ways God led us, and convincing myself it is right to be here at Kijabe. On the other hand, we carry iphones and text our son in America, we travel, we access grant funding for projects, we connect with the national health system. We're now working at a hospital that was founded upon the classic missionary model, but is largely staffed by more modern types. When I look at the December call schedule, we are 2 of about 5 missionary doctors with more than a decade behind us, the rest of the 30-some names on there are either short-termers or young Kenyans.

So we're in an in-between generation, uncomfortable not living up to the heroes of the past generation, but not really fully able to buy into the ethos of the new generation either. I guess that's OK, to be Hebrews 11 pilgrims and strangers. Being securely settled in one group is not our goal. I hope we can be part of the melding, the settling out of the streams to honor what is best in both. Combining longevity with innovation, relationship with technology, perseverance with enabling nationals. Maybe because we're spending our first Christmas in this new place, it's a good time to reflect.

World AIDS Day, Dec 1

This morning our HIV-AIDS team at Kijabe Hospital led chapel. This year's theme, ZERO. Zero new infections by following the ABCs of Abstinence (unmarrieds), Be Faithful (marrieds), and Condoms (those who can't manage A and B). Zero stigma, because stigma hurts people, keeps them from seeking care, drives the epidemic. And Zero preventable deaths, because infected people should have access to medicine. Watch this compelling video and think about it. http://youtu.be/vKdgF7DHTG0

Complicated

It's 9 pm, and we just cleaned up from a pretty delicious dinner whose preparation was interrupted by two trips to the hospital, which makes the whole cooking scene a bit more challenging. The first call was to attend the death of a very sick preemie whom I had left only an hour before, knowing he was dying. After 48 hours of an all-out effort, his vital organs were failing and we knew we were at the end of the road. I had made the always-agonizing decision to accept that he was dying, and tell the parents. Francis was in the ICU right next to his mother, whose life he saved by being born too early. She suffered from a life-threatening complication of pregnancy called "eclampsia", which can only be cured by delivery of the baby. So this doctor had to make the difficult decision of taking the baby out of the mother way too early, or risking the mother dying and leaving behind her other two children and husband. Francis' life was only about 72 hours long. But I think this was the right decision.

The second call was much more fun: the Kenyan lady who runs the "Supa Duka", the one-room everything-you-really-need small store in our village, had just delivered a strapping healthy baby boy. We are always called for C-sections, but this time there was nothing to do other than admire the lovely boy.

And while I was in the nursery, I checked on Dancun, the little boy whom I agonized about a couple of weeks ago, an HIV-exposed 28-week preemie who nearly died that night. He's now a "feeder and grower", a seemingly healthy little speck of a baby, who in spite of starting out similarly to Francis has miraculously lived. And I ran into Scott in the operating theatre, who had just finished his fourth or fifth surgery for the day, a woman whose ectopic pregnancy had ruptured her fallopian tube spilling two litres of blood into her abdomen. Thankfully her life was saved.

Which was a nice end to three solid days of nonstop work. Well, not exactly end, but at least it's in sight tomorrow morning.

Let's see, the last couple of days included a little boy with an rare congenital syndrome called Pierre-Robin, the usual parade of malnourished marginal toddlers and their desperate mothers, another boy with meningitis, preemies, two kids with severe heart lesions, a girl with damaged kidneys after an infection, the amazingly improved and nearly-healed baby born with part of his intestines missing as well as the one who had hemorrhages in both lungs, quick consults for rashes including chicken pox and fungal infections. And most distressingly, an 8 year old deeply jaundiced with a liver mass that turns out to be lymphoma, a cancer that could potentially be treatable. Only we need to get him to a hospital with an oncologist and chemotherapy. Which requires a lot of money. Which his Maasai father thinks he can manage by selling off his cows. Meanwhile we are starting chemotherapy at Kijabe and hoping we can keep him alive long enough for the cow market to come through.

The sheer breadth of pathology on this service always surprises me. One can spend all day, non-stop, from bed to bed, to ICU, to nursery, to the clinic or the emergency room, conferences and meetings, and then back around to all those places again, without a moment of down time. Yet the doctors in Kenya have threatened to strike on Monday, Dec 5. Meaning a barely-survivable day could get lots worse. Kijabe hospital without any functioning Kenyan doctors is unimaginable.

When a patient dies, the nurses use their own creative verb, saying "he complicated". It's an interesting take on death, as a complication of life, or of their disease. Or does it mean that the patient has made our life or our job more complicated? Difficult, confusing, complex, interrelated, entangled. Not the ending we all planned. Life as a doctor here is just that, complicated. The clues to a disease are often obscure, the labs unreliable, the history vague. Understanding the thoughts of the parents who come looking for an easy fix adds another layer of complication. And sorting through all of those layers with the pressure of time and people waiting complicates things further.

Hoping that no more patients complicate tonight.