Bee calm

The swarm of killer bees mysteriously moved on after a day in the mango tree.  Not sure what they're looking for, but hopeful that they find it far from our home.  Our workers and friends are relieved, too.  We've heard of them killing goats by stinging, so we were a bit worried about Star whose house is directly under the mango.  But before we could form a plan of defense, they left.  However, within hours of their departure a major caterpillar migration ensued.  These are toxic-haired little beasts that we have learned NOT to touch at all costs, as they raise welts on contact.  Dozens were crawling up the sides of our house last night.  Makes the roaches and mosquitos and obukuni (midges) seem rather benign.  

you know you're in Africa when . . .

You're washing dishes and hear a peculiar almost electronic hum, but there are no electronics around, so you walk out to see what is happening and notice the air around the mango tree thickened, wavy, shimmering with a cloud of thousands of bees . . a colony has moved in, a huge mass of bee-bodies forms a dark growth on the trunk today, a deathly danger.  This is not a few bees pollinating flowers, this is a hostile takeover of the mango tree.  Which is usually infested with fruit bats, by the way, and has been declared off-limits to our kids since ebola was linked to bats . . not to mention that previous climbs have resulted in broken arms. In Africa the back yard is not necessarily a benign place of refuge.

You're biking down the sandy damp road to work and almost wipe out because a black hairy pig decides to trot across the road, taking no heed of down-hill bicycle speeds, and then stops squarely in the middle to root out an interesting smell.  Thankful the brakes work!

You're counting your blessings because the ward had only two patients overflowing onto the floor after filling every bed, and no one died all weekend or all morning, and the two nurses on duty actually came to work and were less than an hour late, and the theatre nurse was actually present running the charcoal pressure-cooker sterilizer so that there is hope the burn patient will get his dressings changed today, and everyone waiting for consultation had straightforward issues like malaria and pus-ridden skin.  A good start to the week, in spite of it being a Monday.

You're invited to a meeting with the member of parliament who also happens to be a Minister in the Education department, and spend the entire morning waiting for the big man to arrive, knowing that the hundreds of other people also waiting mean your chance of actually connecting with the MP is slight, but the fall-out of being seen leaving is also potentially harmful, so you're stuck.

You're awakened every morning by the new Nyahuka taxi, which finds it essential to gather customers by beginning to blare it's horn every 90 seconds from approximately 4:30 to 6:30 am, a marketing ploy that does not seem to be impacted by the fact that NO ONE comes to board at 4:30.  Remember that none of our houses have window panes, just open screen, so outdoor sounds are not muted at all.  Some of us are distant enough that it is merely an annoyance, but for those closer to town it must feel like a traffic jam in the driveway every morning.

You're preparing to cook and remove approximately a quarter cup of grass, dirt, sticks, and two live worms from the two cups of beans from the market.

You look at the clear morning sky suffused with pink, shiver a little in spite of being on the equator, and know that by noon it will be intensely hot and by 4 pm it will be raining.  Every day.

You see more smiles than tears from people around you, whose lives you could only barely imagine living, they take it in stride and still find the humor.  Humbling and amazing.

Occasional thoughts (2): communalism

The same book referenced below (Foundations of African Traditional Religion and Worldview, by Ysusfu Turabi) shed light on a conversation with our students.  Today is "visiting day", when parents are encouraged to drop into the school grounds (preferably with food from home) and see their kids.  I got up early to bake cinnamon rolls, boil eggs, and brew chai so that we could attend chapel at CSB and then invite our five boys to a brunch picnic.  After discussing the recent Premier League football standings and news of everyone's family, the topic turned to a long and convoluted story about roll calls, dorm duties, jerry cans, accusations, and the discipline master.  The details are a bit obscure, but the bottom line is that the two boys who are responsible as leaders in their dorms debated quitting that role, because they are blamed from above, and scorned from below.  Sigh.  

Turabi looks at human relationships from an African standpoint on four axes:  harmony (the ultimate value is to live in harmony with the spiritual and physical world, not to obey some transcendent rules of right/wrong), spirit (meaning is found in pragmatic interpretation of spiritual matters), power (seeking survival by manipulating the dynamism of the universe for your own ends), and kinship (pursuing harmony and meaning and power are all done in the context of promoting one's own family/clan).  

So in this context, how do teenagers relate to their dorm mates?  Well, they don't want to create enemies.  This is not a question of truth, or right.  For them it is a question of survival, of staying out of trouble, of keeping harmony in relationship.  I didn't have much to say, other than go to a trusted staff member regularly, don't let things build up, lead by example, and pray.  Perhaps if these kids learn to lead in their dorm, the ripple effect in decades to come will change leadership in Bundibugyo.

Occasional Thoughts (1): spiritual arbirtrariness

A few weeks back we entitled a post "arbitrariness and stress", about the experience of crossing borders and being stopped by police where the rules are unwritten and unclear, the response variable, the potential for disaster ever-present.  Once again this week Scott had to spend three hours in unmoving traffic crawling through Kampala in order to take Melen and her three youngest children to a medical conference where Dr. Jonah's memory was being honored.  Due to situations beyond his control, he reached Kampala at dusk, and due to our friendship with Melen, he had to persevere into the heart of the tangle of the city.  And due to our truck's ever-tricky electrical system, the lights were once again on the blink, brights only and then only if held manually in the flash position on the steering column.  So with three small tired children, in the dark, on Kampala's uneven potholed narrow unlit over-used streets, he had to endure hours of  creeping forward while holding on the brights, while every other driver yelled and cursed his bright lights, and any random policeman could have extended the three-hour torture to an all-night police-station escapade.  It was rather frazzling.

I picked up a slim book that is proving to be a treasure:  Foundations of African Traditional Religion and Worldview by Yusufu Turaki.  And I realized this morning, that those hours of traffic torture are a window into the every-day every-hour experience of many Africans.  Because besides benevolent and evil spirits, they also perceive a that all of creation is "infused with . . impersonal power" which can be used "for both good and evil.  The existence of wicked human beings and wicked spirit beings, who also have access to mysterious powers, makes life full of uncertainties--rife with unpredictable wickedness and and evil and dangerous to human beings.  Thus traditional Africans who  believe in the impersonal powers feel they are at the mercy of benevolent or wicked users of these powers."

So I suppose it is a good thing for us to enter into the experience of unpredictable malevolence.  We are so used to a world that contains some order, some limits, some laws, some assurances and protections, that it is not until we are in the dark of night in a city of dangers that we can glimpse the world view of our neighbors.

And it makes the good news that much better, that the Creator is not only benevolent (willing good towards us) but also imminent, involved, and interested enough to take part in this world "densely populated" with spiritual beings and forces.

The Truth Will Make You Free

This phrase popped up in our kid cartoon movie last night (Meet the Robinsons . . ).  But Jesus actually said it first, in John 8 . . . the topic of our weekly team Bible study this week.  Truth is not a very American PC topic these days I suspect, and it is not very central to African thinking either.  Expediency would be more to the point.  So it was interesting to study this chapter on Thursday with our team, and again on Friday with the Health Center staff.  (Yes, I did it twice, because I can only lead and prepare so many meetings a week . . .and God was still working on my own heart from this story anyway).  The pithy statement about truth is preceded by the dramatic encounter between Jesus, a ready-to-stone mob, wily political agitators, and a woman who had been caught in adultery.   To a Ugandan audience, the communal response to adultery, the idea of involvement in marital conflict and negotiation of penalty, the way a new leader challenges authority, and the scene of it all playing out in the public market space, makes perfect sense.  One nurse actually admitted to helping stone a suspected rebel once.  So the story was very relevant, very alive, the discussion very participatory.  No one particularly sympathized with the victimhood of the woman, and one man in particular who hails from a law-oriented world religion was quite offended by Jesus' refusal to condemn her.  But before I could say anything to that, another participant from the same religious background stated:  "But Jesus came to SAVE sinners, didn't he, so it makes sense that he would forgive."  Wow.  We talked more about the way Jesus transitioned the law from being an external set of rules that protected community cohesion to an internal code of character and conduct, a matter of the heart.  And this is the scalpel edge of truth:  only in a confrontation with the judgement and love of a person such as Jesus can the kind of heart change occur where a woman does not just become more careful in her adultery, to not get caught, but actually chooses faithfulness.

And me?  I realized I would like to SEEM loving, more than I actually want to BE a lover of people.  I want to SEEM wise and trustworthy, more than I want to put in the sacrificial time to BE those things.  I want my family and team and neighbors and coworkers and supporters to FEEL cared for, whether or not I actually AM caring for them. I don't want to be publicly caught out in my selfishness, more than I want to root it out of my heart.  It is the kind of subtle distinction that needs the freeing light of truth.  Jesus stoops, writing in the dust, aware of the implications, not forcing His opinion, but offering that freedom.

East Africa's "Perfect Storm": HOLD ON!

From a news report yesterday:  

The African continent is no stranger to humanitarian disasters. Climatic changes, war, financial hardship and infrastructural chaos seem to regularly take turns in plunging one region or another into desperation. The latest crisis is centered on East Africa, where countries such as Uganda, Ethiopia, Kenya and Somalia are currently experiencing a 'perfect storm' of suffering.

These countries and others in the Horn of Africa are facing a combination of below-average rainfall, the prospect of serious crop failures, increased instability through regional and civil wars, and the overburdening of less severely hit areas through the displacement of populations.

A report by the United Nations Food and Agriculture Organization (FAO) also warns that an already serious food insecurity situation in the region could worsen. The FAO report ominously predicts that if El Nino, the oscillation in ocean temperature which usually brings heavy rains towards the end of the year, delivers as expected, floods and mudslides could add to the misery by wiping out existing food stocks, killing livestock, damaging infrastructure and making thousands homeless.

This is sobering news for running a school as food prices double, for managing nutrition programs as patient loads multiply, for living in a jungle on a mud road as floods threaten.  We are warned by the FAO to plan ahead.  If the World Foot Program and the United Nations can't manage to get enough food or stop the conflicts, I'm not sure how we're supposed to solve these problems locally.  I suppose bearing witness to what we see, giving what we have, and praying.

homework

A massive rain storm swept in this afternoon, catching me at home between hospital rounds and chapel.  After half an hour of relentless pouring, I realized I was NOT going to make it to chapel.  So I embarked on lingering homework, updating the simple database of HIV exposed children that I try to keep.  These are the kids who come to clinic, or to Kwejuna Project quarterly gatherings, where we can follow-up their testing.  The denominator is problematic, because only the children who survive long enough to see me, or whose mothers are motivated to come regularly, are counted.  The sick kids are probably over-represented in those that seek care.  But I still found the big picture rather interesting.

There are 286 kids, from age 2 months to age 15 years.

73 are infected, which is 26% overall.

Of kids born in the last 3 years 30 of 216 are infected.  That is 14%.  (More reflective of PMTCT, the Prevention of Mother To Child Transmission, since the older kids are in our care because they are SICK not because their moms were screened).

PMTCT is supposed to cut transmission rates in half.  Again, the math is not perfect, but the general trend there looks good.

Of the 30 kids infected in the last three years, it struck me tonight that 10 were born in the time of ebola.  It looks like a 3X risk for infection between Nov 07 and Mar 08.  The health care system, particularly PMTCT, essentially stopped functioning in that time.  Our numbers are not high, but that's a pretty dramatic rise in risk in a very defined time period.

I keep the list so that when these kids show up on the ward or in the clinic, where the medical records are almost always NOT available, I can quickly find out their status.  It is a list for reference, but when you look at it for trends, I think it encourages me that the medical effort is accomplishing something.  Though there are also reminders of our failures.  At least 7 have died.  As I type in data I can see some toothy skinny smiles and some plumping-out cheeks in my mind, more than just names and test results, these are nearly 300 human beings who did not choose to have their existence defined by a struggle with AIDS.  

Never too old for homework.

snapshots of a day

Three hundred chicks, in a mud-walled and screened shelter, Jack helping our agricultural extension workers under John's supervision to vaccinate them all, the future of egg-protein for malnourished kids.  Dusk falling, the charcoal glowing in small screened towers to keep the chicks warm.  Three weeks old and so far 100% survival.  No small miracle.

The two widows of my late neighbor, knocking in the afternoon, we sit on the porch, they reminisce and we all shake our heads to realize that their son John and my son Luke will finish high school this coming year, when it seems they were just playing trucks in the sandpile together.  They ask for ibuprofen for their aching backs, but I know the visit is not about the ibuprofen, it is just a check to be sure we're still in relationship.  My heart aches for the way their husband's clan disinherited them, and how hard they have to work now to survive.

Another knock, on the hospital store room door as I'm getting on my doctor-coat and preparing to begin the day.  A father holds a bundled child, having just arrived from who-know-where, and says the child is very ill.  As they all do.  But I tell him to lay the child down on a bed and begin to examine him.  The hot little body is too still.  No heart rate, no respiratory effort, vacant eyes.  He died sometime along the way.  I tell the father, who quickly re-wraps the body to walk back to wherever he came from.

Blue suede shoes, Israeli Birkentsock-type sandals, appear on a patient's dad.  Unusual, not just because of the style choice, but because the very same shoes were stolen from Heidi's house months ago.  I confront the man, who assures us he bought them in the Mpanga market in Fort Portal (3 hours away by car, who knows how much time it took the thief to unload them there).  Heidi wisely decides that she does not particularly want them back off this man's none-too-clean feet.  We laugh.

Greens, dark for the mountain tops, bright for the trees, a palette of shades for the landscape, as Pat works on her mural covering one whole wall of the Paeds ward, a touch of color and beauty and entertainment for some very sick kids.

Guvena Yona, the name on the immunization card, of a 3 year old admitted over the weekend, a child from our own village whose parents I know . . then I remember that he was called "Governor" after his political ancestry, but "Yona" because his birth was the late Dr. Jonah's first C-section when he was posted to Nyahuka Health Center.  Dr. Jonah saved his life, and his mother's life, but lost his own.

Chocolate zuccini cake, my mother-in-law's recipe, for no big reason.  We had zuccini from Kampala, and a precious can of cream cheese frosting from our summer of visitors.  So an hour of stirring and grating and mixing and baking, in honor of my family.  

Hands slapping, we play Speed Uno (taught to us by Lydia Herron years ago), which is hands down (ha) the best cross-cultural game ever.  My CSB/hospital mixer attempt for four young staff who are far from home turns out to be a lot of fun, laughing about how each was shocked how FAR away Bundibugyo is, sharing stories from our days and prayer requests.

The good news that Caleb's arm has healed enough to remove the plaster cast!  He calls from the hospital, cleared to resume full football privileges wearing only a splint.  We rejoice.

A moaning woman and a pool of blood, the midwives ask me to call Scott, who brings down the portable ultrasound and diagnoses a placental abruption and a dead baby . . . but still in time to save the mother's life.  Scott calls the surgeon in Bundibugyo town and we help arrange her transfer.  A few hours later we learn that the fetus was removed by C-section and the mother is recovering well.

A soberly distressed nurse tells me that a doctor from Kampala has arrived and wants to see me.  I am called into an office like a mis-behaving school child, as the imposing man chides me.  Why have we started so many children on anti-TB therapy?  I guess our disproportionate numbers got noticed all the way up the chain and he was dispatched to bring us in line.  Just then Kagadisa shows up for a medicine refill.  I call him in, and show his records, how this child was dying and now is alive and thriving.  And I begin to explain why we suspect the diagnosis on so many kids, though we aren't always right, we see lots of response to treatment.  So just possibly it is not Nyahuka that is OVER treating, but the rest of the country that is UNDER treating.  What starts as a hostile lecture ends as an interested and collegial discussion of TB diagnosis, and as he departs, the official doctor promises to come back and study this further.  Amazing.

Another day in Bundi, snapshots of sorrow and tastes of victory.  And cream cheese frosting.

One step forward, two steps back...

Occasionally, the stars align...and the health care system in Bundibugyo works.

Today, I (Scott) received a call from Jennifer who relayed a request from the chief midwife at Nyahuka Health Center that they needed an urgent ultrasound, because they could not hear the fetal heartbeat of a mother in labor. I biked down with my trusty SonoSite 180 in my backpack, the noonday sun blistering hot. In the delivery room, I began to unpack my ultrasound while the tiny mother began to climb onto a step stool to get on the delivery table. Ker-splash. At least a liter of bright red blood splashed out between her legs onto the white tile floor. Yikes. She began to scream and cry. There's really not many possibilities medically speaking here. The placenta has separated from the uterine lining before the baby is born (placental abruption). I quickly got her onto the bed and confirmed with my scanner that the baby was indeed dead and that the placenta had indeed separated.

The midwife mobilized the family who mobilized a pick-up truck. I called the medical superintendent of the hospital who prepared the surgical theater. So, she was loaded into the back of a truck and rushed over 8 miles of the worst road in Uganda to the District Hospital. Within an hour, she had a Cesarean delivery and her life was saved. She could have very, very easily bled to death.

Not every anecdote from Nyahuka is so happy. Amon Bwambale, our clinical officer from Nyahuka who is now studying medicine at Kampala International University is on break between first and second year and returned to work (!) this week. He joined us for dinner this evening and during dinner we went around the table sharing "highs and lows" of the day. Amon described how frustrating it has been this week to see patients, diagnosing and prescribing, but the cupboards of the health center are empty of drugs for outpatients (note: World Harvest funds the drugs and supplies for pediatric inpatients only). Outpatients are instructed to go to the private clinics and purchase the drugs which have been prescribed in NHC Outpatient Clinic. The reality is that most patients proceed to purchase one or two capsules of an antibiotic or antimalarial, an inadequate approach to nearly any infectious disease. Many of them return to outpatient in worse condition than when they were initially seen.

Exhilaration...frustration...frustration...frustration.

Paul Miller in his book A Praying LIfe reminds us that "God wants us to come to him empty-handed, weary, and heavy-laden." (p.54). I think we qualify. Let's go.

frozen chickens

When we moved to Bundibugyo, we joked that we would stay here until frozen chickens came to Nyahuka.  This was a way of gauging development:  a place with electricity, and enough development that there were people around who were willing to pay for their chicken to arrive dead, plucked, and in a bag rather than running out the door.  It was also a way of saying, we may stay here forever, because the idea of a shop with a freezer seemed impossibly remote, and by the time it came there would be other needier places to go.  Well . . . . drumroll . . . the power lines which we've watched go up this year, are, as of today, CARRYING ELECTRICITY.   Scott just came back from dropping friends off post-dinner, and announced that the transformer is humming and AN ELECTRIC LIGHT IS SHINING IN NYAHUKA.  Amazing.  Hard to imagine or predict all the changes this will bring.  We aren't leaving yet (!) but the frozen chickens can't be far behind.