On the first day of Christmas . . .

My God gave to me . . .

The FIRST GRADUATE from the post-ebola outpouring of funds to sponsor doctors in the wake of the loss of Dr. Jonah Kule.  Dr. Ammon Bwambale, a dear friend and man of God.

Two happy Myhres .. . Julia cutting the celebration pie made for Scott's happy news of passing his boards.  

Three tuneful carolers . . there were actually more but I felt awkward trying to photograph.  We went caroling on the Paeds ward one evening this week.  When we got to the Hark the Herald line that says "Light and life, to all He brings, risen with healing in his wings . . ", well, you have to cry or believe.  This is the place to sing that, with boldness or with trembling.  Much healing needed.  

Four strands of tree lights . . . Chinese imports to Uganda a couple years ago, that were wildly hypnotic and celebrated our first year with electricity from the grid.  I plugged them in this year and 2 of the 4 went POP!  SMOKE!  Severed the cord and blacked out the lights.  Frightening.  At least two still work.

FIVE in the FAMILY!

Luke is home!  Here he is by a lovely little tree we thought about harvesting, but it seemed illegal, probably planted by someone.  Instead we were able to cut our own tree in our yard this year.  We planted a row of them a couple years ago for this very purpose.  OK it is a bit spindly and sparse, but environmentally friendly to plant and harvest your own, right?  Here we are from start to finish:

And many other wonders of christmas, including:

Julia making a chocolate raspberry cake from a cousin's recipe

Starting on our annual puzzle, compliments of the Schubert family

Maternity Department winning the hospital's quality improvement honor!

The Christmas Tree on the Paeds ward always cheers me.

Great colleagues.

So thankful for visitors. This is Dr. Tina from NC.  Thanks to help, I've been able to bake and spend time with my kids!

Friends from Kijabe for a Christmas meal which must include chapatis and grilled meat and laughter and thankfulness for these people . . 

Lisa with shoes that light up and match the tree.  Made me happy.

And last, just for fun, a twin-yolk egg.  I have cracked thousands.  First time to find one.  Luke looked it up and the frequency is 0.3%.  Must be a good sign for the season.

Passed!

Wooooohoooooo!!!!!!!!!!!!!!!!!!!!!!!!!!

I (Scott) passed my Recertification Exam for the American Board of Family Medicine!

I'm a fully-certified Family Physician until 2023!!  Yay!

It's difficult to describe the burden that has been eased from my shoulders.  

It's been ten years since my last recertification exam.  Just to qualify to sit for this exam, there were hundreds of hours of "continuing medical education" requirements, on-line clinical simulations, and, of course, a $1200 fee which would be lost if I didn't pass.  And this is the same exam given to the 30 year olds just finishing their residencies in the USA.

Make no mistake about it, I am a highly functioning African doctor.  If you have malaria, dengue fever, schistosomiasis, cryptococcal meningitis or any of the other myriad infections associated with AIDS, or a baby in distress which needs surgical extraction… I can take good care of you.  But none of those things were covered in this 8 hour computerized exam.  Rather, I was pimped on diagnostic tests like d-dimer and BNP which I have never ordered, drilled on dozens of antidepressants I have never prescribed, and quizzed on medical problems which I never see in Africa (sarcoidosis?)… Not fair?  Well, yes, I'd say so.  

But when I saw this exam coming, in addition to laying out a brief study plan, I began to ask for prayer.

And this brings me to a moment of Advent reflection.  Bethany recommended an Advent devotional to us this year entitled Silence and Other Surprising Invitations of Advent by Enuma Okoro.  It's a daily devotional which looks only at the experience of longing, doubt, silence and seclusion of Zechariah and Elizabeth.  One of the first passages looks at Luke 1:10-13 where Zechariah enters the sanctuary… and behind him is a community praying.  The author stunningly captures the beauty and power of praying community…

Everyone understands the gravity and intensity of what it meant for the priest to enter God's presence.  Praying for one another can be a beautiful way of acknowledging the demands, perseverance, and vulnerability that authentic faith requires of us…

Zechariah approaches the Temple supported by a community of believers.  In an avoidable way he faces his task alone, coming before God alone.  But in powerful and mystery filled ways the prayers of the people outside the temple support Zechariah…

A believing community shoulders hope when circumstances seem hopeless.  A believing community speaks boldly into despair and longing and suggests that things do not have to remain as they are in the presence of a holy and imaginative God...

During Advent, as we wait for the fullness of God's promises in Christ Jesus, we are invited into humility and gentleness of spirit to whisper our longings to one another and to elicit a new depth of sharing with one another….Naming the ache of our yearnings is indeed faithful.  It opens wide the gift of receiving and embracing the prayers of others.

May we begin to look around and discern with wisdom the people in our midst with whom we can share this Advent invitation.  Who can help bear the weight of our longings, or whose longings can we help to bear, while still prayerfully hoping in the fullness of God's promises of abundant life?

So, I pause and thank the many of you who heard my whispered longing to be affirmed as a family physician.  

Thank you all for praying.

And I thank God for hearing your prayers.

Soli Deo Gloria.

This fragile anchor: a thrill of hope

A thrill of hope, the weary world rejoices . ..

I have been thinking about hope quite a bit, because it is a daily necessity for my job. And it is no small act of faith and the will to maintain hope, to renew the store of hope day by day. Hebrews calls hope a strong anchor that we must hold fast to.

To be a decent doctor requires one have hope that a patient will recover. When a mewling little blood-covered thin-skinned preemie is handed off to me to revive, I have to believe the baby has a chance to live as I work. When someone calls me to a code, or I decide to move a patient in to ICU who is slipping downward, I go into action with the hope they will improve. When I see brain-damaged kids in clinic who need adjustments to their seizure medications, I have to focus on the hope that they can learn and hear and speak and grow. When I admit a cute five-year-old, big-eyed and scared, with symptoms that could be cancer or TB, I have to hope for TB which is much easier to cure. Because I want them all to get better. And so many do. But not all. And sometimes the "not all" becomes a significant burden, a heaviness and weariness of loss and defeat. Last weekend I lost two children whom I had labored over intensely, whose mothers I had grown to care about. I had had hope, but those hopes were dashed, leaving flailing sobs and lifeless bodies.

If your child is sick, I am on your side, moving all the forces I can to ensure recovery. It takes a lot of energy. And I find that the energy is harder to generate without a strong sense of hope. The repeated losses erode optimism, make me cautious to invest my heart. Make hope hard. So that with the next one, I treat with a little more distance and doubt.

This is the reality, the context, of the holy night. Sin, error, and pining. Then something not done before, a God who is Spirit takes on flesh to enter the weary world, and throughout creation there is a rippling thrill of hope. Though Hebrews describes hope as an anchor, the faint thrill, the flutter of expectation, the almost-daring to yearn, rings more true. If this incarnation is fact, then there is nothing good which is beyond possibility. Impossible-odds recoveries, reconciled relationships, romance and progeny, feasting and fellowship and forgiveness, all move back into the realm of the probable.

So that the fragile little bodies with their fast heartbeats and cold hands become places where redemption can be seen, in real time.

I would like a thrill of hope for Christmas. A renewal of that dare-to-dream vision, that energy to push on.

The Right Setting for Christmas

Church was PACKED this morning because the national secondary school leaving exams are being marked by teachers from all over the nation AT KIJABE BOYS SCHOOL. I wonder if Kijabe's reputation as an enclave of holiness led to the hope that this would lessen chances of corruption. In Kenya you sometimes see signs that say "corruption free zone," which just goes to show you that the absence of such is noteworthy. I do believe in the spiritual nature of place; over time the presence of prayer makes some spots of ground more peace-inducing than others. But the fact that a hundred or so teachers would choose to come to church at 8:30 on Sunday morning probably bodes better for the hopes of transparency than the choice of venue.

Meanwhile, in Northern Kenya (Garissa) and in Nairobi (Eastleigh) explosions have led to deaths, terrorist acts designed to punish Kenya for involvement in Somalia. One was an IED in a bus, cowardly and cruel. Just now I got a US Embassy text warning that University of Nairobi students were rioting right down town . . "smoke in the air and rocks being thrown at cars " . . . However, lest we think of Kenya as inherently dangerous, we remember with sadness the one-year anniversary of school shootings in Newtown (near Luke at Yale) and the tragedy of the high school student who fired a gun in a school in Denver (near Caleb, but sadly also the school of one of our old friends and supporter's kids, who were present and shaken).

Also in church this morning, there were two announcements. First, we are instructed to bring our dogs tomorrow for rabies vaccination, because a rabid dog was reported in the area. Second, we were warned that the polio immunization campaign (Kenya is in alert mode due to cases imported from Somalia) is on hold due to the strike of the health workers. Rabies and polio, on our doorstep.

And speaking of strikes, in spite of the courts' declaration that the doctor/nurse strike is illegal, the health system remains crippled. Though I am thankfully off this weekend after a doozy last weekend, I've been in touch here and there. We're up to 34 babies in the nursery (designed for 18, and typically holding up to the low 20's), and we're being asked to make hard triage decisions. A 9 year old girl arrived with a femur fracture, still un-set a week later, because she had been in a hospital where no one was working. Every bed is filled, and every resource stretched.

And even the Kenyans are commenting on the weather, which is unseasonably wet and cold. We have had about ten minutes of sunshine ALL WEEK, I am not making this up, most of our clothes are on the porch trying to get dry in a fog. A recent New England Journal of Medicine paper noted that the number of weather-related aberrations and public health disasters had tripled since the 1980's. When the downpours here send rivers down the road, people begin to get nervous, remembering the landslides.

Corruption, bombs, riots, diseases, strikes, injustice, storms.

Just the right setting for Christmas, literally. Jesus was born into a time of political upheaval and danger, where the prevailing atmosphere made the longing for a Messiah more palpable. It is the people walking in darkness who see the light. At Kijabe on a Sunday afternoon in mid December, there is no veneer of tinsel and santa that obscures the raw reality of Christmas: the moment of change in the tide of the evil onslaught, the moment where God comes down into the fray. The tiny beginning of all things made new, of honesty, fairness, health, justice, compassion, peace for all people. Good news, which we must listen quietly to hear.

DUKE!!!

Julia got up with us at 6:30 and checked her Duke account, then emerged with the good news:  she was admitted early decision!  I am posting this in tribute of the CROWD of people who share the thanks for this event.  Truly the whole takes-a-village proverb is true for us.  We could never have reached the point of a third child accepted to University on our own.  First our prayer supporters who have kept us surrounded by grace for two decades.  A whole line of missionary teachers braved the spiders and malaria and heat and earthquakes to teach her to read, and spell (!), and sing, and add. She had brothers who passed down books, or who kept her on her toes and made sure she was safe in a very unsafe place. We had educationally-oriented team mates who took care of curriculum decisions.  Then when she was about 11 she transitioned to Christ School Bundibugyo where more teachers and coaches impacted her life, until we reached RVA mid-way through 9th grade (with a stellar interlude staring mom as the geometry teacher).  Here she has had mentors, sports coaches, disciplers, teachers, friends who have all encouraged her walk in faith.  When people from Bundibugyo look at our kids, they feel a part in the outcome, and that is just as it should be.  Julia is the person you want to be around: smart, pleasant, serving, persevering, responsible, and fun.  Way more so than we are, because of the influence of so many great people in her life.

Probably the most fun part of the day was the excitement her brothers showed:  they were genuinely thrilled for her, it was great to have that family phone-time of celebration!  And her grandmothers and aunts too.

Though we've known people from Duke over the years, it was not until we stopped by last Spring on our way down to visit family in Charlotte that Julia got a clear sense that this was the place for her.  She does not make decisions lightly.  We respected that assurance, and encouraged the early decision.  Duke has an overall acceptance rate of 5% (!!!) but applying early boosts that up to 25%.  This year they had record numbers of applicants, and took a smaller slice than ever.  We knew it was far from a sure thing, and trust that this is a door God opened for her to walk through.  They have given her a decent scholarship and some other forms of aid, which will help, though we are still working on the finances.  But most importantly, she'll be only a couple of hours from family.  Yeah!

Pray with us now for fellowship, good friends, mentors to respect, soccer, laughter, significant work that will bring out her gifts and bless the world.

Three down, one to go.

More seasonal signs: graduation, strikes, rain, Jamhuri, and cookies

December in Kijabe means rain, steady dripping cold rain punctuated by torrential downpours.  Sticky mud, sopping laundry, footprints across the floors, chilly nights.  Back and forth to the hospital in soggy shoes.  No sun.  The people that walked in darkness . . . becomes more real.  We are waiting for the hot dry wind to blow in, just like we used to in Bundibugyo. Waiting for light.

Last week I learned an important lesson:  Kenyan University Graduations are not for the faint of heart.  I had committed myself to attend Bob's, as a gesture of appreciation, friendship, and support.  My departure was delayed by the 6 am-ish appearance of a very very small preemie (660 gms) who needed intubation and surfactant and a central line, all procedures I happened to be the only one around to do.  But as I headed out, I texted and found out the ceremony had not started.  Great.   I made great time towards Thika (which is about 1.5 hours away) until a few miles out of town the six-lane highway slowed to a standstill.  Must be an accident, I thought.  But as the minutes ticked on, and on, I wondered.  I rolled down my window to chat with my neighbor struck-drivers.  Everyone around me was wearing suits and ties, and headed to this graduation.  The car next to me said to follow him, and he tried to get off for an alternate route, but it was just as plugged.  So we inched forward, literally.  It took about 3 hours to go less than ten km.  It seems that the university was graduating multiple years of students in multiple schools, and a single small road led in, absolutely jammed with thousands of cars.  I should have walked.  The next day my clutch quad was so sore I could hardly move.  At the three-hour mark I did finally park in the mud off the side of the road, and join the throng of pedestrians.  As per my odometer, the university should have been 1 km away.  But it was more like 3 or 4.  I walked and walked.  There were bodas and bodies.  People selling tinsel garlands and garish signs to place around the necks of graduates.  The crowds became so thick that walking was nearly impossible, and I still could not see the gates.  I called Lilian, Bob's wife, to say I had given up, and just then a man walked up and said "Dr. Jennifer?"  It was Bob's brother who had come to find me (not too difficult as I saw NOT ONE other white person in the thousands and thousands).  He body-guarded our way through the throng to the gate, where Lilian was standing.  Bob came out from the ceremony and I said congratulations.  I think it took between 5 and 6 hours to get to that point, and I had to turn around within minutes to get back (on a boda, weaving through cars and people on and off the road . . but that's another story).  I do love Bob and Lilian.  But I have to say I'm hoping Yale is a bit more organized in May.

Then a weekend of call, and what a call.  I kept a tally and was physically IN the hospital 26 of the 48 hours, besides phone calls.  The tiny 660 preemie thrived for almost two days, then crashed.  A toddler to whom I had grown attached, perhaps because it is December and his name is Emmanuel, died, a slow dwindle from an unexplained failure of his liver.  At one point I was masked and gowned putting a sterile line into the next preemie, then running up to resuscitate Emmanuel, then back to be sure the preemie was living, etc.  Thankfully I have a very cheerful Paeds resident from the States visiting for 2 1/2 weeks, and all the admissions and deaths and births and decisions are less stressful with company.

Then on Monday, we were greeted with the news that the entire medical community in Kenya was going on strike: doctors, nurses, pharmacists, lab techs, etc.  We were told to brace for the onslaught.  Seemingly overnight maternity began to burst at the seams--beds in the halls, in the nursing station.  Babies crammed in every corner.  By mid-week we were so desperate for space I pleaded with the hospital admin and got permission to turn the ICU room one into a satellite NICU--I fit four cots/incubators in there instead of one adult bed.  Triage and priorities, how to maximize life saving potential.  It seems that a December strike has become sort of normal.  Kijabe thankfully this time negotiated that our interns would NOT strike, so at least we are functional, just overwhelmed.  The bright side is that this week I have the biggest team of the year--3 visiting consultants and a resident, plus my colleague survived preterm labor long enough to come back to work.  All that help melts away over the next ten days, but for now the timing is good.

And as the doctors called their strike, the rest of Kenya celebrated 50 years of independence today.  Parties, speeches, and a holiday.  Which is why I only had to work a bit over two hours this morning and then came home, the first day since our kids got out of school that I've been (mostly) here.  A well-timed holiday, time to bake and decorate cookies with Jack and Julia (and a friend who had NEVER decorated a Christmas cookie in spite of living in this semi-American enclave most of his life), and even carol at a couple of neighbors, join friends for dinner, and a community Advent.  I suppose most of that didn't have much to do with Kenya's independence, but I can say the time off endears Kenya to my heart.  Perhaps Christmas Cookies and Jamhuri Day will always go together for us now.

And so December rolls on. We work, the kids sleep in, work out for next season's sports, plug through mounds of assigned homework for AP classes, watch football, and rest up from the long term.  I have a nagging guilt that I didn't come up with a plan that is unique or enriching or noble or anything at all other than hanging out at home, but I just have to trust that we're doing the best we can.  

Mercy, mercy

Mercy, mercy.

Jennifer writes about lots of tiny babies, but today let me share the story of a 57 year old woman I'm caring for on Kijabe Hospital's Womens' ward.  Mercy's her name.  

She came in with some diffuse respiratory symptoms: cough and shortness of breath for several months.  Let's call it a chronic cough.  Should she have come earlier?  Perhaps.

She underwent the standard work-up for her problem: complete blood count, chest X-ray, sputum examination - as well as a test which every patient get who is admitted to any hospital in Kenya: an HIV test.  Bang - positive.  Life-changer.  I have not gone into the details of her lifetime partners with her, but in most of the cases we see at Kijabe, women are married and faithful to their husbands - while men are out and about and inadvertently bring the virus home to their wives.  Don't mean to man-bash here, but those are the facts.

So, Mercy is very sick.  She has several signs suggestive of tuberculosis.  And she's dealing with a new diagnosis of HIV infection.  That's a lot to deal with.  She's got to be worried about the possibility that she might not live as long as she once expected to live.  She is dealing with denial, anger, or fear - or all of the above.  

So on Friday we were rounding and began to speak with her at the bedside.  As if things couldn't get any worse…she told us that she received news that her two sons who are in their late 20s got into a serious fight the night before…and killed each other.  My jaw dropped.  This is beginning to sound a lot like the Book of Job.  Debilitating and potentially terminal illness.  Estrangement from her husband.  Death of her children.  Not much left except for her house to burn down.

I stood at her bedside with my two medical trainees - silent.  What to say?  I tried to think of what to say.  I tried to express some words of consolation and encouragement.  Everything I could think to say just seemed so trite.  I really can't imagine being in her shoes.  Try it.  You have just been told you have AIDS and that your two sons killed each other last night.  Unfathomable.  

Well, I made an effort to console her in her sorrow.  Then she looked up and said, "If you put God first, then everything else will be OK."  No sobbing, fist-shaking, screaming.  Only quiet confident words of faith.  Very inspiring.  

That's my prayer when I face disaster.  No cowering, groveling, cringing.  Lament yes.  But hopefully, that howl melts with disturbing clarity into worship.

'Tis the Season of Beautiful Sorrow

Six years ago today Scott, Scott Will, and I were sitting at our table in Bundibugyo. The rest of the team had evacuated to Kampala a few days earlier, after the Ebola epidemic broke out, but we three stayed having already been exposed, to work.  It was night, and my phone rang.  I went out under the bougainvillea on the side porch to get better reception because I couldn't believe the message.  Dr. Jonah had died.  A tragic and sorrowful day in the history of Bundibugyo, and in our lives.  Today I was sitting in the NICU at Kijabe when my phone rang.  Melen and her daughter Biira were visiting Jonah's grave at Bundibugyo Hospital, and called me from there.  The years have softened the deep ache of that night, the disbelief, the shock, the heart-rending numbing wonder of what God was doing.  The years have shown us some redemption as a half dozen young people are following in Dr. Jonah's footsteps, the seed in the ground is now beginning to bear fruit.  But we still miss him, and no amount of redemption in this life completely erases the truth of that loss.  So for us, the season of Advent always begins with that beautiful sorrow, the mourning of a life laid down for the Kingdom, the longing for the no-more-tears of a New Heavens and a New Earth.

December is also a season of goodbyes and transitions.  Once again many of our colleagues are taking their annual leaves, migrating back to families upcountry or overseas.  School is out for the next month; Acacia baked her last batch of cookies (our first batch of Christmas baking) before her departure yesterday to spend Christmas with her family.  No decorations up in our house yet, though.  Just trying to survive.

With all the goodbyes, I am particularly thankful for the visitors who have come to fill the gaps.  Tonight we celebrated their kindness with some pizza. Drs. Keith and Lesley (left) are helping on Paeds, Dr. Sagar (left) in ortho, and Drs. Bruce and Rick (right) in medicine.  

'Tis a season of beauty in all the sorrows, and a hospital is a privileged place to spend Advent.  One of the devotions this week pointed to the God of the IMPOSSIBLE who brought a baby into a virgin womb, who redeems the world through suffering and glory.  Here is a tribute to some impossibles.  First, Pauline and her twin girls Malin and Erin.  They were 27-week twins, and it seemed to take forever for them to get off oxygen and be big enough for discharge.  But here they are today after a half a week at home, with mom transformed by civilian clothes and a huge smile:

Or dear Patrick, now improving with increments of strength and tone nearly every day, sweet and hopeful.  I remember his tears when he couldn't breathe or move, and so I delight in his smile now:

The aptly named Emmanuel is still battling those odds of impossibility, waiting for his miracle.  Pray for him.  He arrived last week jaundiced and vomiting with a severe hepatitis and failing liver.  While getting a CT in Nairobi he "complicated" and was rushed to nearby Kenyatta National Hospital in coma.  Overnight his parents watched other children die, and by morning they decided to escape by taxi, trailing his disconnected oxygen and holding his IV bag.  I moved him up to our ICU today with a heavy heart.  A few hours later, I was examining him and called his name, and his eyelids fluttered open.  His pregnant mother burst into tears at this little sign of hope.  Emmanuel, God with Us, needs God to show up tangibly and heal him.

And I may be in trouble for posting this photo, but this dear patient is closer to my heart than all the others combined and caused a fair amount of tears and angst this week.  My nephew Micah was admitted to the ICU in NC with a severe asthma exacerbation and respiratory infection.  We had all hoped he had outgrown this after some scary episodes as a baby.  I think for many missionaries, it is very very hard to miss supporting family in crisis because we are many thousands of miles away.  I'm thankful for cell phones.  But it's just not quite the same.  Micah has a precious gift of loving others, spontaneity, joy, a mean basketball shot and a passion for bacon and videos.  I'm so relieved he is well enough to be discharged today.  A season of cough and danger, and of healing.

OK a few more signs of the season.  Inexplicably, the maternity ward had EMPTY beds this week.  This does not usually happen.  My only explanation is that 9 months ago Kenya was in the throes of election anxiety, anticipating chaos, people traveling back to home areas, and, who would have thought, taking a pause on baby-making??

 And the season of college apps draws to a close as Julia submitted her final one tonight.  Prayers appreciated for her on Saturday as she takes the SAT one more time, quite late due to a clerical error which invalidated her registration earlier this Fall.

Advent at RVA means AP study.  RVA runs on a year round schedule which goes from early September to mid-July.  So when AP's roll around in May, RVA students have had two months of vacation that most schools have not.  Hence the habit of teachers to assign large loads of independent work over those two holidays.  Here are the station kids in BC Calc working on their problem sets together at our house.





This is our December of beautiful sorrows, mourning, hope, remembering, working, hosting, studying.  Waiting.  Trusting that love will break through.  And I truly do hope that we will get out Christmas decorations soon!