On Fairy Tales and Kenyan School Books

This week we progressed through some Bible stories, medical role plays, and the children’s school-book “Mama Mwizi.”  The title is a dead give-away that this isn’t a sanitised American politically-correct story where our minds are broadened to accept any lifestyle choice as legitimate, and where everyone ends up friends.  If you aren’t up on your Swahili, the translation is basically “Mrs. Thief.”  Two children are left home alone on a Saturday while their parents travel to a party (which in Kenya would be an all-day affair).  Their father gives them strict instructions to not open the door to anyone they don’t know.  But they venture out to spend a dime on candy, and on the way back fall victims to a well-planned scam.  A car slams to a halt and an apparently pregnant woman is shoved out the door.  She lies helpless, crying as the car speeds away.  The gullible/tenderhearted children help her to her feet and as she wails of injury, they escort her to their rural home.  One runs to find the taxi-driver in the village to take her to the hospital, and the other runs to find a local nurse for advice.  Meanwhile the woman calls on her accomplices to come to the house with a lorry, and they systematically empty the contents of the home, from the radio to the clothes to the furniture and appliances.  The shocked parents return to a ransacked, empty house, followed soon after by the kids, the nurse, and the taxi driver.  Luckily the thieves have been stopped by the police not far away for a “random” shake-down, and when they can’t show the police any receipts for the items in their truck they are apprehended.  The story ends with the goods returned, and children sobbing in front of an angry father, who lectures them for disobedience and then cancels his promise to take them to the game park in the future.

Perhaps this sounds harsh for a 1st or 2^nd grade picture book. 

But the plot reminded me of many fairy tales, where disobedient children run into potentially fatal consequences.  In the old days, and in modern Kenya, the point of these stories was not to calm or delight or broaden the young minds who read them.  They were/are cautionary tales in a world filled with danger.  A child could not be assumed to avoid some of the world’s harsher realities, like lying thieving con artists, or child traffickers, or HIV.  So obeying some rules could be life or death.  Bad things, really bad things, happen.  Kindness is not always rewarded. 

Our generation tends to trivialize evil, to deny any such category, or to glorify it, or to spew it forth with such repetition we become numb.  Our story lines become cartoonish, with self-absorbed angsts and occasional unavoidable random misfortunes.  Or become prurient. But we need fairy tales, where creepy goblins lurk and where witches cast spells and where choices must be made.  And where all of the evil has not been explained or tempered into a bland universe of shades of grey.

Truly terrifying evil on the order of a Biblical universe with hellish beings has some merit, though it is most often relegated to the fringes of horror movies and paranormal books.  I think David Mitchell and Cormac McCarthy write evil properly.  Small doses are all I can take, for sure, sort of like immunisations, to help us make sense of the Cross.  True confession--besides Mama Mwizi, this is on my mind because a friend who shall remain unnamed got us watching Stranger Things.  We're a few episodes in, and I can't vouch for the whole series, but it is truly terrifying in the Fairy-tale genre of other-wordly evil creeping into a small-town late-70's looking place that reminds me of my childhood.  This thoughtful essay about another movie I haven't seen grapples with the same phenomenon, finding truth in fictional horrors, and the way such stories help us live in South Sudan (the author of the essay just evacuated from there to our former church in Baltimore) or treat malnutrition or counsel the sorrowful.  It's a reason I liked the Hunger Games series as well:  adolescents conscripted to fight on behalf of corrupt all-powerful regimes sounds awfully close to real life.

So if you're an 8 year old in Kenya, you better know about thieves and scams and the importance of locking your door.  And if you're a middle-aged doctor in Africa, you might need some TV series and novels that take evil seriously.  And if you're thinking of giving the next book in the Rwendigo Tales series to someone you love, be warned that rebels and abduction and human trafficking make an appearance.  Evil is part of all these stories, but not the end of any of them.

Angel-Vision Goggles

This haunting photo was posted by our photographer friend David last week, from a National Geographic site.  It immediately conjured images for me of Mt. Doom in Mordor, the smoldering hours and days after the ring was destroyed.  The cost of redemption cannot be denied in this scene.  The landscape, eerily devoid of life.  The embers still glow, the merest hint of the raging fires that once spewed forth.  The world is saved, the fire quenched . . . and yet the world is ash, the work of rebuilding looms so large as to seem impossible.  Certainly the main characters in the final chapters bear scars that attest to the reality of the battle, even as they turn their attention to pints and songs and love. 

So I went on line to find out where the photo actually came from, and the Lord of the Rings connection was not far off.  This is a mountainside which once seethed in the unstoppable flames of a wildfire.  Now it has ben tamed by firefighters and God and time.  The war is won, but the battles continue.  Mopping up any sparks that threaten to accelerate.  Then replanting.  Rebuilding.  Reclaiming.  Restoring.

Perhaps if we had the ability to put on something like night vision goggles, only they were angel-vision goggles, the world I normally see (Mt. Longonot from the Sorley's porch) like this:

or this:

Would be revealed to ACTUALLY look like the National Geographic photo above.

Revelations 12 gives the angel-goggle view of history.  Our world, scorched by the dragon’s destructive hate, pauses, pulled away from the brink of immolation by the blood and innocence and love of a child.   The sparks still smoulder, the pain of that costly battle still extracts a toll.  But the restoration has begun, and God’s people plant the Rift full of acacias and olives and wildflowers once again.   

First Day of School Pics

Perhaps this isn't the photo you expected?  Keep reading.  Late August, always a time that turned our focus back towards school, now fills our Facebook feeds with smiling children perched on front porch steps, toting backpacks or lunch bags, dressed to face the new year.  Little "L", above, is no exception.  She's 6.  The photo on the right if from fb last week.  The one on the left is her about a week after she was born here at Kijabe.  She had hydrops fetalis, meaning a severe heart failure and swelling of her whole body in utero.  The mortality rate even in the most modern hospital is over 50%, and can be up to 98%.  We struggled with her pleural effusions (water in lining of lungs) for weeks, and after too many chest tubes to count the paediatric surgeon got down to the last chest tube in the hospital, and we knew this was it.  If she needed another, she'd die.  But against all odds, she not only survived but is a cute, smart, normal 6 year old going to school.  I guess if I had more former patients whose parents posted on fb (not exactly my usual population) I might see these miracles more often.  But L's photo this week made me very, very happy.  Happy for my Kijabe colleagues who worked so hard 6 years ago and still do.  Happy to see this story unfold.  Happy that NO ONE who watches L walk into her first days of school would every dream of her nightmare appearance at birth, her weeks on death's doorstep.  Mardi hunted down the old photo, and so we get a time-lapse of redemption.  

The next photo you'll have to imagine.  Just up the hill, 4 young men the age of my own college kids have started Bible School at Moffatt.  They are studying Counseling, and Community Development. And they are another snapshot of redemption.  Because their entire life has been spent in civil war in South Sudan.  A few months ago they were facing bullets and starvation.  LAST WEEK they were shot at by thieves on the way to the airport for this course.  They have all lost family members.  Their life experience is nearly unimaginable.  But after our team had to evacuate, they did not stop trying to help the people they had grown to love.  Yes, there are thousands and millions more who did not get to escape.  But for these four, a season in a country at peace, at a school, amongst people like the Massos who care about them, getting counseling themselves from our excellent and skilled Bethany, studying the Word of God, gaining skills they can take back . . . surely this is another first-day-of-school snap where the smiling faces represent triumph over very dire circumstances.

And lastly, two more first-day snapshots close to my heart.  You'll notice a theme:

Jack returned to Duke for his sophomore year in Engineering; Julia was being dropped off in Washington DC where she will launch Saturday into a 3-month 3-continent comparative global health study abroad.  They both flew into Charlotte a week apart, and my 80-year old mother drove them each to their programs and helped them settle in.  They've been seriously ill in their childhoods, though not as sick as baby L.  They've been shot at in their childhoods, though not as many times as the South Sudanese Bible students.  But even for them, the first-day snapshots show a smiling and comfortable facade that would belie the struggle and trauma they have seen.  They are embarking upon challenging semesters, with parents 7000 miles away, which is never a small thing.

I could go on and on, Ivan starting a bachelor's in nursing in a new University, Katuramu waiting for the Ugandan MOH to settle on internship arrangements, Luke plugging through his Neurology rotation, Caleb spending hours in 100-degree heat learning to fire a machine gun, Biira the daughter of the late Dr. Jonah starting a law degree, Noah my nephew starting college, Tanya my Kenyan colleague's daughter entering British school for two years because of her dad's surgical training.  So many kids stepping into places they have never gone before, with no assurance of success, but with hope.

So this first-day-of-September, let us salute students everywhere who have overcome some steep challenges.  Who have perhaps left their families or countries.  Who have physical or mental or emotional hurdles most of us can only imagine.  Students whose smiles and health seem to blend in with the crowd, because we may not know even a tiny portion of the struggle that has brought them to this point.  It is the very poignant cost of their progress that will make them great, I know, but my heart wishes I could smooth each of their paths.  

Choglorious

The last three days we’ve been at another historic mission hospital on the eastern slopes of Mt. Kenya, founded over a century ago by Scottish Presbyterians.  Chogoria is the site of our newest Serge Kenya team.  We were asked to recruit doctors there to support the Kabarek University Family Medicine Residency Program.  Relatively few doctors in Kenya have the opportunity to go on for a “master’s” degree (residency) after their internship.  Yet these young men and women, after a 5-year post-high-school combined university/medical degree program and a 1-year internship are expected to manage all-comers at hospitals, from an ectopic pregnancy surgery to outpatient diabetes care to critically ill newborns to a hernia repair.  It’s a lot to expect, so the Family Medicine residency here (unlike the USA which is more outpatient and primary-care oriented) gives the trainees four more years of mentored experience and intensive discipleship to prepare them with the skills and character to lead in managing a district-level health team as hospitalists and administrators.

  

In Chogoria we collaborate with the Presbyterian Church of East Africa which has hired some solid Kenyan consultants in Family Medicine, Surgery, and OB, and the World Gospel Mission who sent an Emergency-Medicine trained former-military couple to lead the team (currently on a year’s sabbatical).  Our Serge contribution consists of three more families:  Jason B (med-peds) and Ree’l (business and admin); Derek W (PA) and Lauren (nurse); and soon-to-arrive Larry S (family med) and Beth (lawyer transitioning to advocacy work within the church).   Our team teaches not only the residents but a couple dozen clinical officer (PA) and medical officer (doctor) interns, plus two recently-graduated doctors.   They provide patient care, supervise rounds, prepare lectures, ponder protocols, trouble-shoot equipment, help with budgeting and quality improvement, reach out to the community in Bible clubs, and generally model what it means to be a follower of Jesus in the context of the needs in a small town in rural Kenya.

This work grew out of the trip Scott, Jack, and I made to Chogoria a year and a half ago, with our team on the ground now for less than a year.  So a visit this weekend was an opportunity to witness the early stages of collaboration and to encourage our young team members.  Thanks to Karen M they spent their first few months in the same Swahili program we are currently using, enabling them to bond with the culture and place and lay a foundation for relationship.  Some of the very deteriorated housing has been rehabilitated to the level of livable.  Now they are into that sticky phase of plunging into all the beauty and dysfunction of a rural hospital in a poor place. 

 The highlight of the time was definitely just connecting with the families.  If being a team leader is a bit parental (in the healthy sense of leading, setting direction, fostering the gifts of those we led, lots of meals and late night talks and trips and fun, daily presence, being responsible/blamed, etc.), being an Area Director affords the taste of the grandparental life stage.  We show up intermittently bearing a few gifts, marvel over cuteness and growth, get hosted and served meals, listen and pray and offer perspective and praise, then try to direct some resources where needed.  It’s actually pretty fun.

 

Church, a picnic by the shared neighborhood rope swing, an afternoon prayer time for God’s work in this place, dinners and evenings with each family, hikes into the forested ravines, and then hospital rounds and meetings.  It was a “Choglorious” weekend (Lauren taught us that adjective).  And by Choglorious, we don’t mean perfect.  There are bumps galore.  Interns who so want to be helpful and positive that they may think or wish they checked a lab or did a history when in actuality they are making it up.  Antibiotics that aren’t given, machines that are broken, labs that are unreliable.  People whose plans change, who leave or never show up.  Salaries that aren’t paid.  Theology that veers dangerously towards the “health and wealth” heresy.  Yes, this team has some serious work ahead. It's a climb steeper than the actual physical rock scramble (note all the kids on backs) we did Sunday afternoon.

So what does “Choglorious” mean?  I think it takes the word “glorious” and gives it a Swahili relative prefix, “cho”.  Meaning, glory in the relative position of the here and now.  Glory that God is working in the dust of Kenya.  The glory of preemie twins basking in the warmth of an NICU that looks almost more biblically stable-ish.  The glory of a worshipful voice in spite of a static-laden microphone.  The glory of thriving children whose friend and activity horizons are rather limited.  The glory of a 17-year-old AIDS patient who landed in a bed where a caring and competent med-peds doctor will think through his care and give him the best shot at survival.  The glory of collaboration, imperfection, tiny steps towards quality improvement.  The glory of the word made flesh, right here in Chogoria.

 

(A few more fun photos, from several of our phones):

A fresh voice from med school: LUKE MYHRE

Clearly the last few weeks of intensive Swahili and repeated transition and goodbye have taken a toll, and blog writing has lagged for me.  If you're on our prayer e-mail list you should have heard from us a couple of times in August (email me if you wanted to but did not).  

Last week Luke was on break from his 3rd year of UVA Medical School and took time to write his family and some friends a thoughtful, reflective email about his experience thus far.  With his permission, here are his thoughts.  He can use your prayers as well, so read and remember him.

The date is August 18th, I'm at a suburban poolside outside of Boston visiting my roommate's family, a 90's summer playlist is booming and we have officially completed the first half of our third year at UVA medical school. This is our week to sleep in, spend time outside, and let the minutes trickle by without panicking about tomorrow's responsibilities. 

We are only a fraction, a sliver, of our way through medical training. Already thoughts of specialty choices, residency programs, MPHs, and research opportunities, loom. For all practical purposes we are the bottom of the food chain. We hold the retractors, we fax requests for medical records, we call family practices to set up appointments, we wait our turn to listen to the pneumatic lung or a mitral murmur. 

In the last year, however, a crucial line was crossed. With the advent of our first board exam, pure theory was exchanged for the gritty mess of the wards. Flashcards were replaced with scrawled patient notes. We began scrolling through the EPIC medical record system instead of question banks. Late nights at the library fell way to shifts scuttling around the Emergency Department. The shift from wide eyed trepidation to undeserved confident swagger is already underway. 

It is hard to avoid the cliches, to bring a fresh perspective to a profession packed with sharp and insightful minds... but wisdom from the mouth of babes, right? 

Two experiences stand out, as book ends. 

The first, in my first month, the beginning of a life. My first day on the labor and delivery service on the eighth floor I scrubbed in to my first cesarean section. One of the most common surgical operations worldwide, it is a dramatic decision, a rescue mission. Armed with forceps, clamps, scalpels, and scissors, we slice and tear through each layer of the abdomen (carefully delineated in every medical student's mind: skin, superficial fascia, deep fascia, anterior rectus sheath, rectus abdominus muscle, transversalis fascia, extraperitoneal connective tissue, peritoneum, uterine wall ). There is no subtlety, little delicate detail. Surgeons make a small incision in the muscular vascularized wall of the uterus, insert two fingers, and literally tear it open. I was engrossed in the anatomy, the blood, the different tools and techniques. The amniotic sac burst in a literal flood of fluid, latex hands plunged in to the muck struggling to get a hold. Out of this chaotic mess emerged perfection. It's ironic, in retrospect, to be so unprepared for a moment that I knew was coming for hours. I shouldn't have been so taken aback. So overwhelmed. But I was. 

My left hand supported the baby's neck while I dried him off, wiping some of the vernix caseosa from his eyes. I was thankful for the surgical mask, because the thing is, I couldn't stop smiling. I think I would have laughed out loud, from relief and joy and sheer wonder, if it wasn't for the stern surroundings.

From many waters came a mind and body that fit in the palm of my gloved purple hand. 

The second, in my six month, a life already ended. I was on call for internal medicine with our team: student, intern, and resident. We were given the responsibility of admitting new patients, and manning the code pager (auspiciously lined with red warning tape). When the pagers went off, I wasn't even sure I was supposed to follow- they were normally just drills and medical student's usually aren't in the inner circle know-how. The room was a logistical and moral mess. Nurses and techs fumbled at both arms to put better lines in the patients vessels, one doctor had started CPR, my resident stood at the foot of the bed shouting instructions. You could taste blood and feces in the air. I primed bags of blood by pumping the cuff (inflating a bladder that would force the blood through the tubing into her system at a much higher rate than gravity would normally allow) while they gave multiple pushes of epinephrine and slapped AED stickers onto her chest. She was too big for most nurses to get any leverage with the chest compressions, so I stepped up to help, rehearsing the rate, depth, and placement, desperately acting like I had done this before. Each compression made a ripple spread out from her sternum, the sheer volume of fat between my palms and her heart absorbing the majority of the force I pressed down with. After my two cycles, an eternal four minutes, and 400 compressions, I called out a thready pulse in her left radial artery. Her eyes rolled back in her head in pure terror. Her heart started to beat again, but after we handed her off to the intensive care unit team, she died. My own heart hurt.

Both, moments of emotion and blood, flirting with the fine line between life and death. The first, an example to emulate. A decision to act, to intervene, to yank an infant out of it's suffocating prison of muscle and fluid, as it's heart dropped to dangerously slow rates. A nonpareil glimpse into the potential of every soul. The second, a lesson that still weighs on me. A futile shot at an impossible chance, a failure to foresee a very real possibility (I later learnt her heart stopped because of massive blood loss into her bowels- she was known to be in awful health and unstable, and was only 'full code' because her family had not accepted the harsh realities of her current state). We filled her last moments with pain, we smashed ribs and bathed her brain in adrenaline to keep her tissues oxygenated for a few extra minutes. I don’t think we are very good at knowing when less is more. 

This time, for me, is not necessarily about making a difference. I am often a wallflower. It is about learning. We learn medical technicalities- drilling drugs and differentials in every free moment… But I’m also feeling out the edges of my own personality, charting the spheres that augur 80 hour work weeks. 

I've learned that I don't shy away from a challenge. Even wallflowers need to speak up if they want to get their hands dirty in the muddle that is health care. Sometimes you wish your means justified the ends. I've learned that I truly enjoy the mystery medicine, the complex web of physiology and morals. I've learned that one of the few things I fear most is mediocrity, that I'll strive for my utmost wherever I end up.

I'm frequently asked what specialty I plan to pursue: what kind of doctor do I want to be? The only answer I have now, is a doctor who is committed and faithful, one who seeks to liberate the oppressed, one who works so others may live, who sacrifices for those he loves. 

I'm impossibly far off, but I'm raring to go.

Pray that God would give me love for all. May he be with you.  

in Love,

Luke.