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Saturday, August 01, 2020

Systems and Powers: #COVID-19UGANDA day 134

Monday, Wednesday, and Friday we spend the first 30+ minutes (OK who are we kidding it is often an hour) of our hospital day in an outdoor, socially spaced, all-staff morning report. Twice in the last few weeks we've spent an extra all-day meeting for government and partner planning on health, education, care for children. Every day we have people coming to talk to us, or we are interacting as we work and move. And IN EVERY SINGLE CASE we are the only people from beyond the borders of Uganda in the conversations, which means we are always listening and learning and processing and comparing. We are always running a little behind the curve of a dynamic system of beliefs, habits, values, history, proverbs, language, culture. Then many evenings we are viewing through the window of CNN or newspapers back into our birth culture, watching testimony before Congress, or reporting on protests or the pandemic. This week there has been a slew of live-coverage from Congress. Again we are outsiders by location, slightly out of step and behind the dynamic curves of popular opinion. But in both cases, I would say our off-balance not-belonging can be a strength as well as a weakness. Because we can bring a fresh view.

So when Attorney General Barr said that he did not believe there was systemic racism operative in our criminal justice system, I immediately applied that to the kind of systems-thinking we try to do in medicine in Africa.

When problems arise, the human tendency is to look for the person to blame. Bad outcome of treatment? Well, whose fault was it?

But while it is important to hold people accountable to do their jobs, most of the real progress in improving care and reaching goals comes from thinking about the system that is functioning to produce the results that we see. For instance, here are some of the problems we have been present for discussions of this week:

  • A child dies of severe anaemia from Sickle Cell, because there is no blood in the blood bank to transfuse them.
  • Teenage pregnancies are on the rise during lockdown, and we're all realising that many girls are safer in school than at home.
  • An infant is still born because the nurse called the doctor to do a C-section, but he did not answer his phone, and so she waited for the next shift in the morning.
  • Rats are eating the hospital register books and plaguing the operating theatre because they are attracted to placentas left in buckets.
  • A two-year-old comes in with an abdominal stab wound inflicted by his own father who was high on a substance and mentally ill.
  • Alcohol and marijuana are in our markets because the parliament gets income from this business.
  • Artesunate, a key malaria drug, is out of stock because people believe it is so powerful that they sneak into maternity ward and copy the name and file number of patients so they can go to the dispensary and fraudulently take it.
  • Before all schools were closed, teacher absenteeism was rampant because they take loans which they cannot repay on their salary so are constantly working other jobs.
  • Government staff do not respect their supervisors because their salaries come via bank transfer not tied to performance.
  • Coronavirus deaths are now three in the country (extremely low, but the beginning of the wave) because people have stopped wearing masks and distancing.
  • Families complain to the police when their daughters are enticed into sexual relationships as teenagers or even younger, but as soon as the threat of action generates a financial settlement from the seducer they drop the case.
  • Medicines are out of stock because the national supply chain is months behind schedule.
  • A friend has to move out of his paternal home because his alcoholic brother keeps beating up the friend's wife when he is at work, and the family cannot send this alcoholic brother away.
  • Another friend calls a community meeting because the neighbours have blamed a death on the statement "you should take her to the hospital; if you don't she might die" , attributing that statement rather than the delayed care as the cause of disaster.
  • A neighbour limps in with snakebites because the local house construction has many gaps.
  • The school gets a 2.4 million shilling water bill (almost $700, or more than 30x normal) because of a shoddy repair five years ago that has now allowed thousands of liters to silently leak into the ground. 
  • We are on our last tin of therapeutic milk, because our district relies on UNICEF supplies that do not reflect the reality of the need.
  • Food production is inadequate for our district, because people planted so much land in cocoa over the last two decades to make some cash, at a ratio that benefits the buyers and leaves the small holders with hunger.
  • A baby dies because his exhausted mother is over 40 and on her tenth delivery and she just can't summon the strength to push him out.
  • A rape case is not followed up because the family can't pay the extortion required to get all the forms filed with police and medical reports.
  • With primary elections approaching, people are warily testing the winds to figure out who will win, because the voting is done publicly by lining up for your candidate. So what is meant to quell rumours of ballot box stuffing becomes, in peoples' hearts, a fear that they will be punished for supporting the wrong person (whoops, your name was deleted from the payroll, spend a few months with no salary to try and sort that out).
  • The further from town a school or health center is, the less likely it is to be fully staffed, because as people move up in education and responsibility they want to live more centrally with access to shops and power.

It is exhausting to generate a quick list of items we have been presented with in just a week, let alone months and years. I am not making any of these up, and I know I'm not remembering many. Pretty much any of those issues could be traced to an individual who cut a corner, took a bribe, failed to show up, made a bad decision, committed a crime. But the fact that they happen, over and over, is bigger than any one individual. They are part of systemic injustices that have brought pain and suffering into Bundibugyo for centuries. The Bible speaks of the world (the fallen state of everything from the coronavirus to flooding), the flesh (our own sinful desire to promote ourselves at the expense of others), and the devil (principalities and powers in the unseen realms bent on evil and destruction). These are seen in the objectification of women, the colonial systems of administration, the removal of resources, the corruption in allocation of services, the extreme fear of the spiritual powers, the personal conflicts, lack of agency, lack of trust. None of the solutions are simple. We can exterminate a few rats or buy some milk or boxes of medicine or pay for some court cases . . but the real solutions require generational changes in values and habits. They require hearts for serving others, access to adequate food and information, dependable safety nets. 

Which is, of course, why we are here for the long haul. In the meeting of the district committee on orphans and vulnerable children (OVC's), I noticed that amongst the two-dozen people in the room were two young adults who had received OVC scholarships at Christ School. OVC's who were now planning for the care of OVC's. This kind of change takes time, lots of it. But it is happening. The people of this district are resilient and committed, patient enough to listen to a dozen sides and opinions, willing to sacrifice and wait, willing to pitch in and change.

So Mr. Barr, let us respectfully disagree.  The broken world, self-absorbed human hearts, and evil intentions, permeate every part of our globe. Our problems in America are not just a handful of agitators or trigger-happy outliers. Change in the USA and in Uganda both require some deep works of the heart, some careful attention to policies, some just allocation of resources.

Today I finished my read through the book of Isaiah. The prophet is writing at a time of danger and upheaval, and I imagine his audience felt something like we do in 2020. And much of what he has to say relates to big-picture, large-scale, national systemic transformations. Yes there is talk of individual piety, it is never either-or, always both-and. But let's not forget that God works through people for peace to cascade in like a river that carries life to all.

Thursday, July 30, 2020

Rookies of the Year, COVID-19 edition (Uganda day 132)

When COVID exploded last Spring, our Area of Africa was not immune to the impact of altered plans, closing borders, mounting worry. Quite a high percentage of our workers had structured Home Assignments (the 1 in 5 plan for furlough from the field to report to supporters and reconnect with family, pursue professional development, take Sabbath rest) around the rhythm of our quadrennial all-Serge conference. When that gathering was wisely canceled, it was understandable that many would still opt to return to North America to wait out the wave of uncertainty.  These decisions are complex and varied, with no two stories the same, vulnerable people, needy relatives, medical high-risk conditions, burning-out souls, longed-for plans, and on and on. Everyone did the best they could to walk by faith and act responsibly.

But today I want to thank and honour the three 20-something single women in our Area who decided to stay.
Why Jesus Chose Mary Magdalene to Proclaim His Resurrection |
The history of spreading the word that Jesus conquered death begins with a single woman, Mary Magdalene in the garden around the empty tomb, taking the risk of soldiers and controversy to perform the hands-on inglorious task of embalming. And throughout the story of the reversal of evil in our world, we see the marginalised and vulnerable moving into places of risk and need, usually without much fanfare or stories. From Clara Barton to Helen Roseveare the good news has traveled on the feet of women who chose paths that put them at odds with their peers and the expectations of their culture.

That history continues today, and though the word "missionary" may conjure up for you a middle aged man with a seminary degree, in reality the demographic includes a disproportionate number of spunky young women.

Back to our three rookies-of-the-COVID-year.  

Lindsey in Uganda has spent the COVID season so far finishing out a school year teaching kids, including accelerating the program when one family decided to depart early because of the pandemic. While "summer" is supposed to be a restful break for teachers, she spent June and July supervising a total overhaul of the 25-year-old school building, flushing out rats and snakes, repainting walls and shutters, having cabinets built, sorting through accumulated mouldy supplies, commissioning curtains and rugs, landscaping and rearranging. Her most proud accomplishment of COVID though is creating a pathway for about 70 pounds of curriculum (books, paper, supplies) to be shipped to a country with closed borders. We aren't quite sure how she did it. But this week she drove the 8 hours to the chaos of the capital and claimed the haul.
Lindsey with the curriculum in her back seat. NO SMALL JOY.

Emilie in Kenya is the ONLY member of her team left, besides the leaders.  She has joined them in discipling coaches through their Ambassadors Football program, pouring multiplicatively into Kenyan coaches who can then become positive role models and Gospel influences for youth in the city's informal settlements. Because of the economic impacts of the drastic shutdowns in our region, she and her team also raised funds for food packages to help their coaches survive. Her room-mate had to leave the country unexpectedly too, so she is now facing her summer's most challenging task alone: preparing to be the main support for her leaders' family as they prepare to deliver their third baby in Kenya instead of back in America with their own family's support.  Third baby means there are two other toddlers in the mix.
This is Emilie (far right) last year; she's said goodbye-for-now to everyone else in the photo

Maike in Congo is literally the ONLY member of our Serge team left, though she's on a hospital compound with a few other missionaries. She has continued to provide nursing care in maternity and the intensive care area, mentor youth in Bible study, and raised funds like Emilie to support the stranded families of Bible School students. When a local militia attacked the military nearby, there were some tense hours. Many of her neighbours fled into the "bush" then slowly returned in fear. Maike and her colleagues perceived the need for trauma healing, as this community has faced so much insecurity and disease over the decades. So she facilitated a workshop to begin that healing and reconciliation process.

This is Maike's photo from the reconciliation exercise last week, giving grievances to Jesus to be buried at the foot of the cross.

At Serge these are just three of the MANY women of faith. Would you pray for them in a special way? The rest of us have some automatic proximal family with whom we live even when we miss our families of origin. We have some ability to process, or just other humans with whom to share car maintenance and cooking and make weekend plans. The loneliness of lockdown intensified the sacrifice; yet we need their invaluable contributions. And if you'd like to be in the running for next year's rookies-of-the-year (we have several on the way . . ) send us a message.  

PS read this fast, because I did not ask any of their permission to use their names and photos, so I may be in trouble soon and have to take this down.

Saturday, July 25, 2020

Running in the Dark: #COVID-19 UGANDA day 127

When we moved back to Bundi 1.5 years ago, I started running in the dark. It's too hot and humid to go later, and too public to run in the daytime while attracting "mujungu! mujungu!" frenzies from children, unwanted attention, traffic to dodge. Plus to be at the hospital by 8 while living on the equator where the sun sets and rises at 7, means that fitting in exercise, a Bible and prayer time, breakfast and hygiene requires a start in the dark. Once COVID hit, Scott started joining me, since he could no longer take strenuous distant bike-rides in the limited-movement lock-down. We step out into the cool morning darkness in a time I call star-fade, as the background subtly greys and the flickers of starlight disappear pre-sunrise. We take our dogs on their leashes, and carry a small torch (flashlight) which illuminates the pavement a few feet at a time. 26 1/2 years ago when we arrived, this would not have been possible on the treacherous muddy potholed track, but now our road is smoothly paved with a helpfully reflective white painted line on the side, and a wide verge. We are rarely passed by more than a handful of motorcycles or trucks, and we usually encounter less than ten other humans also out moving on foot. Frogs complain until we get too close, then are silent until we pass. There is one very alert rooster that always squawks.

When running in the dark, seeing only the next few seconds of roadway, the path gives one the illusion of being straight and level. So it always strikes me when I later drive in the car, how many dips and curves there are. Our road is quite good . . . but it does have to bend to the reality of being situated at the base of the third highest mountain range in Africa. There are ridges that fall down to creeks, contours that cause the road to wind. In the daylight, particularly on the way back from Town, one can note the overall trajectory, the bird's eye perspective . . which shows that our distance is not a straight line at all.

But in the early morning, it is all about plodding ahead, taking the next few strides.  

When we moved back to Bundi 1.5 years ago, we had no idea what those 1.5 years would hold. We were plodding a few strides at a time. We thought we were coming for a few months to fill a gap in leadership. It looked pretty reasonable, as far as our little flashlights could project. If we could have seen the near-implosion of the school as an unstable teacher instigated riots, or the decision of some key team members not to renew their terms or to change their foci, or the impact of this pandemic on our capacity to move, would we have had the courage to come? Maybe not.

Yet here we are down the road in 2020, which is one big blind curve. Not the story we thought we were choosing. Somehow we expected this phase of life to be one where seniority had some perks, where we could somehow hold together the needs of our octogenarian moms and just-launched young adult children with the forward progress of eleven teams in five countries. We thought we'd do that by perhaps living near an airport, having a base but frequently in motion. Instead, it's been 127 days circumscribed routine (minus three to camp and pray recently!), with no clear end in sight. In other words, exactly what everyone in the world is facing. Being in one place and staying there. Seeing patients, again and again. Attending meetings with spacing, eking out the same small palette of culinary options, music, clothes, interactions. Yes we are still thinking globally and dreaming beyond, but we are at this moment deeply rooted.

And the surprise is this: darkness is a mercy. 

We do not know how 2020 will end. It doesn't look good for anyplace right now. Uganda has locked down more effectively than most, but we've recorded our first death this week. The whole world is addicted to the reality-TV of America, us included, with astronomically increasing sickness, violence between groups stirred up to fear and hate each other, and a flare for turning things like wearing/not wearing a mask into a litmus test for righteousness. When healthy 30-year-olds die of this virus, we are reminded that while a fatal outcome is unlikely for most of us it is certainly possible for any of us. We can't see the road very far ahead. We can only see the immediate next steps. We wear our masks and wash our hands, greet from a distance and avoid most activities. We read and pray and treat and hope. We prepare Bible studies and medical teachings, reports and letters. We mentor and supervise. We listen and intercede. A few steps at a time. Until one day we realise: this road is actually good in many unexpected ways. We are in the home have had for more years of our lives than any other, the home we helped build, the home where we raised our family. We are working with young people whom we care about deeply, being invited sometimes into their hearts, their marriages, their dreams. We are helping a team carry out a vision we were part of setting in motion. We get to see the decades-long arcs, not just the moments. We get to learn to be elders, a base that allows others to thrive and embrace their own callings. We get to talk to our kids and moms and sisters sometimes, not enough but we do appreciate that technology that did not exist when we started.

Faith is a run in the early morning darkness, a commitment to move ahead without knowing exactly where we will end up. Faith is work, and a work-out, a necessary precursor to arrival and rest. Whether this stretch is a 5K, 10K, a half or whole marathon, or an ultra-marathon, we can't say. But that is the mercy of God's mystery.

Thursday, July 16, 2020

Humbly Hastening Righteousness? #COVID-19UGANDA DAY 118

First, the weekend was exactly what we longed for. A spot of untouched rugged beauty, wild animals just living their lives wandering by, an unexpected respite of wind and cloud that gave picture to the Spirit's refreshment, books to read and prayers to offer sitting in camp chairs which we moved to catch the shade of a cactus. Remembering redemption, and how it comes in hidden slow ways. And just to keep us on our toes, the challenges of reality: encountering a whole new kind of tiny stinging ant that swarmed under our clothes when we inadvertently washed dishes on their territory, a lone pesky hyena that kept wandering back after being chased away with rocks and a panga and in his curious boredom chewed through our tire cover and gnawed on our tea pot at night. And, the requisite car issue. We went on one game drive (it seemed superfluous asa the the game kept coming to us, why go to them, but we do love the motion of the savannah and looking for lions . . ) in which we're pretty sure we were the lone visitors in the park (the lodge was closed, so only campers and we didn't see any other campers).  So when we ended up on a newly graded track in the rain . . and the black topsoil turned to slick muck that quickly filled our tire treads and left us fishtailing like we were driving on ice, and we ended up in a ditch, we were envisioning being stuck for hours. We chopped small branches from nearby clumpy brush to get some traction (while keeping an eye on nearby buffalo) and the 4WD mercifully got us going our first try. Yeah. The highlight of the weekend was perching our chairs on the roof rack and watching an elephant circle our camp, spraying clouds of dust on his back. We saw easily over a hundred elephant and buffalo, and dozens of warthogs, waterbuck, kob. Not to mention 3 lions and 9 giant forest hogs. Ever since we really READ Job, we have embraced the concept that God's answer to suffering is to go look at creation. So we are grateful for the time we could do just that.

We packed up camp in the rain Monday morning, which means we actually just threw the wet tent and muddy tarps into the car for later cleaning/drying/sorting. A real blessing on the way back was the opportunity to have a leisurely porch lunch with the Fort Portal team, recounting griefs and blessings. They are our neglected stepchild, independent strong women who rarely ask for attention and for whom we are grateful but wish we had more to give. That time was a good choice with some consequences of a rushed minor re-supply shopping time in order to beat the curfew and return to Bundi.

Which brings us to the last 48 hours. If you put down your work for a weekend, it gathers strength to pounce upon return. Hundreds of emails, a few meetings, some brewing issues, heart-to-hearts, a flurry of cleaning, visitors ... .plus the news that we were to appear for an annual District Health- NGO Coordination meeting on Wednesday with reports on our activities and plans for the year. A late night Tuesday creating a presentation, an early morning Wednesday unsuccessfully trying to push through rounds (I think I rounded and wrote notes on about 10 patients out of 80-ish), and then we were called and told to get to the meeting.

All masked, socially spaced at tables, open windows . . . still odd to be in a meeting these days. The district health team was joined by another dozen or so representatives of the NGO's focused on health, all Ugandans and mostly NOT from Bundibugyo who work for major organisations. Person after person put up impressive, articulate slides, with tables and work plans, goals and dates, numbers and percentages. Pathfinder has a five-year 11-district USAID grant to improve access to family planning that involves universities, research, highest levels of government. Save the Children procures mama kits (delivery packages of helpful items) and supplies village health teams with basic medicines, but also heavily facilitates the work of the district health team in supervising and planning. World Vision has an ongoing project in one area of the district that includes peace-making and literacy activities. Baylor University employs a team of data gatherers and analysts to make sure HIV/AIDS care is evidence-based, up-to-date, accessible, monitored. As the hours went on with these presentations, all with their slick urban representatives, their impressive funding, their buzzwords and acronyms, personally I was feeling more and more like a failure. What are we even doing here? And how does all this heady office-based assurance match up with what we see on the ground actually happening? I started googling the budget sizes of these organisations. Wow.

We were called up last. While Scott connected the computer, I had a Holy-Spirit moment. Instead of trying to look just as competent as everyone else, I was able blatantly say that we are NOT equal to them and to just reflect thanks to them all. Save the Children and World vision are 2+ billion dollar organsations; Pathfinder and Baylor are 50 million dollar enterprises. Meaning they are all 25-1000 times larger than Serge. And what I saw was, everything they are doing here, we were struggling to start nearly 30 years ago. Community health teams with Dan Herron, immunisation outreaches, the Kwejuna Project that initiated HIV testing and care and mama kits and safe delivery capacity,  BundiNutrition that educated and provided food for kids, education with CSB, kids' outreaches, relief after war, epidemic response. It used to be us, and the government, pretty much alone. So what a blessing that now there are multiple organisations with more funds, more personnel, more expertise, investing here! It's not our territory to defend, it's our home and family to rejoice in the opportunities. We are nobodies, who made simple attempts and began some good works, that we now have the joy of seeing grow beyond anything we could have accomplished. After that we made our presentation, admitting our limited capacity, but connecting our work in the hospital, nutrition, water, relief, sponsorship to build up the
health of this place.

Then we sat down, and the whole air of the room changed. Immediately the local-Bundibugyo person running the meeting transformed the fact that we went last from "now that the major people are done we'll get to World Harvest" to "you know in African culture, the elders speak last, so we saved Dr. Scott and his wife for last." It's as if our sincere acknowledgement of how far we have come together with recognition of the incredible input from everyone allowed us all to stop trying to impress and to just relax into nostalgia. And perhaps as the lone foreigners in the meeting, by not taking a superior role we let everyone just breathe. Or maybe it was just the importance of history, so the few who knew us were then empowered to remind the others of our long shared experience. As the meeting closed the local leaders were (verbally, in a COVID - friendly way) embracing our presence. It was very sweet.

God answered my question, what are we doing here? Mostly, just. being. present.  Getting older, and remaining. In an almost simple monastic way, doing hands-on care that people with less training or experience could do but doing it alongside them even when it is long and tedious. Sometimes speaking up for justice. Sometimes pulling in research or ideas from outside. Sometimes carrying the memory of what has and has not worked, or of how far we have come. Sometimes praying, and noticing that God brings in Save the Children and Baylor. Sometimes pushing the younger people forward, with boosts of advice or help or visibility.

I am sure the weekend of peace set our souls up for the unexpected day of collaboration for District Health. This morning, the phrase I read in Isaiah 16 jumped out. Isaiah is pronouncing judgements and warning of dire days, but then speaks of shelter, a throne established in mercy, One who seeks justice (v. 5). That one will sit on the throne in truth, "hastening righteousness". God is going to put this world right, including destroying COVID and racism and poverty and cruelty and oppression and everything that is NOT RIGHT. In the meantime, we're about hastening that right-ness where we can. Getting a jump-start on preventing AIDS or feeding the hungry or proclaiming the Kingdom. Yesterday was a glimpse of how this team has been doing that since the late 1980s and how the pace and scope of change has accelerated. Now we have the opportunity to be back in this fray to protect the gains from being lost to the difficulties of 2020. Here we go.

Thursday, July 09, 2020

111 Days: #COVID19Uganda helps us embrace our limits

It turns out, our wall is at 111. The morning started with a bat swooping in the dark around our heads in the bedroom, a court case to attend that continues a 6-year protracted attempt to take away food garden property from our school, pushing back against some rash decisions, meeting with people, preparing studies, working, juggling, listening. Phone calls, desperate "I have no food for my kids" letters. We truly love this place and believe in the life God has given us here. The pressure of ever-increasing work with ever-decreasing resources has felt heavier and heavier.

So tomorrow afternoon after work, we are retreating to the wilderness for two days. Prayers appreciated that we will find God's presence in ways that restore and encourage us to go on. Thanks. And that our team will be healthy and safe, various simmering crises will take breathers, various colleagues will be blessed.

Wednesday, June 24, 2020

The complexity of doing good: #COVID-19UGANDA day 96

Some things may seem simple: a 1 year old with severe malaria, whose blood cells have been destroyed by the parasite, needs rapid attention. An IV, some highly effective medicine, a blood transfusion, monitoring. Maybe IV fluids if the blood sugar is low, or a seizure medication. But what happens when there is no medicine, no IV fluid, no tubing to carry the blood from a bag to the patient, no tube to hold a blood sample to measure the amount and type needed? What happens when there isn't even a malaria test? Step in with resources and even-out a bit of the world's injustice. The 1 year old had no option about being born in a malarial jungle, about the poor drainage around a house without windows or screens allowing mosquitoes to feast. The 1-year-old didn't choose parents who can't afford to get care anywhere but the public hospital, didn't choose to be a baby during the COVID pandemic when government medical stores are depleted, supplies are months late in arriving, transport to another hospital nearly impossible.

In fact in Bundibugyo we've been studying this problem in health care capacity-the pandemic's impact on health worker burn out, sickness, fear; the lack of supplies and diversion of resources to other places, the stress on marginal health systems; the hesitation of the population to seek care as frightening messages roll out about coronavirus, the ban on public transportation, the curfews, the falling economy, all making care difficult to access.  It's a perfect storm we've seen before with Ebola, only this time the winds are pounding globally. We actually have some pretty good data that the potential collateral damage could be greater than the viral damage (as it has been for Ebola), with years of improvement in maternal and child health lost. Quite possible bad-case-scenario (I won't say worst-case, because these are mathematical models of reasonably possible events and 2020 keeps throwing us curve balls), both maternal and child deaths could increase by 38-44% this year. That would be over 2 million extra dead children.

We know that some basic interventions: food for malnutrition, antibiotics, medicines that stop blood loss in labor, a clean delivery environment . . . can prevent much of this slide. A few hundred dollars of such basics serves more than a hundred people. In fact I suppose that many of the 2 million plus lives that the COVID impact will cost could be saved with less than 8 million dollars' investment in the right places.
So the responsible thing, the just thing, would be to use all possible means to shore up the systems that are crumbling, to invest in medicines and food and vaccines that can save lives.

Which is what we do here routinely, and way moreso the last few weeks. Bundibugyo Hospital has a solid team of leaders, and we are privileged to join forces with people who are concerned about how to improve our quality of care. How to stay ahead of the problems. How to work together.

But yesterday, I saw that a meeting for the Paeds ward staff had been called. I texted the in-charge nurse to see if I needed to attend since it was during a time I usually focus on my other jobs (as team leader and area director).  Olupah said, come, and as I respect her, I did, even though the meeting was quite late and long and torpedoed the entire day. I'm so glad. What I learned in that meeting was the complex other-side of assisting the desperate. Even an infusion of a few hundred dollars worth of malaria medicine and vitamins can lead to relational fallout. Though our leaders are people of impeccable character and strove to direct every extra vial to the right place, others around them questioned why the medicines were locked in a cabinet with limited access. Suspicions arose. Were we favouring some staff who could profit? Was that bulky shoulder bag because of a dirty uniform being taken home to wash, or stealing medicine? I was floored, and sad, to see the people we trust and respect suffering for their responsible and helpful actions. But that was nothing compared to the actual misery that she, and others, had experienced as the gossip escalated and accusations festered. Similarly this year, the government sent a belated bit of their Ebola windfall cash to our hospital since we were actually on the border and prepared for cases (in spite of dozens and dozens of alerts and tests here, NONE of the Beni-based 2018-20 epidemic crossed this border . . . it's less than 50 miles away!!).  That Ebola money led to a lot of discord, questions, accusations, mutiny. In a culture that values equality above most other goods, anyone perceived to get benefit is isolated and vilified as a suspect. In fact at various points I was ready to throw my hands up and decide it was better to just not try to help.

However, the lesson in this kind of situation is to sit back and watch the cultural experts do their thing. This is why we are only part of the partnership. We have access to resources, to donors, to vehicles, to planning and resources. But we don't have the patience, depth, moral authority, capacity to solve widespread jealousy. Thankfully, our Ugandan partners do. I watched as everyone had their say, as the skilled leaders listened, as the conversation turned to ways to bring in help with accountability, as agreements about keys and documentation were reached, as the end note was celebratory and thankful.

So we live to work another day. Another box of emergency medical supplies. Before we could even get it unpacked, Scott was sending me a nursing student on the run to get a blood transfusion set to save the life of a mother with post-partum-hemorrhage. I found one of our malnutrition patients barely arousable with a low pulse, and the immediate ORS and antibiotics (which he had not received in the days prior due to cost) will hopefully save his life.

Doing good is complex. Unintended consequences abound. Being willing to be inconvenienced, to change, to grow, means we can always learn more. Always do better. We can never assume our interventions, from scholarships to peanut-butter paste, will bring unadulterated joy. But giving up, running away, are cop-out reactions. Instead we are called to keep engaging, inviting the feedback, becoming real partners in a shared endeavour.

This is our life: every week or two waiting for the latest rules. This time we got two big releases: in spite of being a border district, public and private transport is now allowed with limited passengers.  Wooohooooo.

However, CSB and all other schools cannot open. The country wide policies are the same: we still have a curfew, no churches, no gatherings, we are enjoined to stay home, to keep distance, to wear masks, and only limited shops are open.

Saturday, June 20, 2020

The Preacher of Futility: #COVID-19UGANDA day 92 and the relevance of Ecclesiastes

Yesterday, I hit the proverbial wall, after finding a pale, stiff, low-oxygen, responding-only-to-pain child correctly identified as the sickest on the ward and in need of attention . . . but due to a broken system of overlapping cracks had been admitted 24 hours before and still not received any dose of malaria medication for her heading-towards-fatal disease, had not been transfused, had an IV that had filled her tissue with fluid, had no antibiotics given. To be fair, we get dozens of kids a day, literally admission rates always double-digits and often over 20, most of them with malaria. Our ward is a tangled web of blood transfusion tubing. I always find a few kids with vital signs and diagnoses that should land them in an ICU. A few hours into the mess I can barely remember who is worse off than whom. And most days Scott finds his proverbial hundredth sheep where an intervention saves a life or two, and I plod through everyone to make a careful list of the top ten sickest and what they need so the nurses and whatever student or volunteer is hanging around can focus. We look at starving children and go into fixing mode with calculation and instruction. We make a list of out-of-stock essentials and procure a few hundred dollars of medicine or transfusion tubing or tape or whatever is missing. We try to connect with the government, the referral options, the system above and beyond us, to be a voice for those who can't. We revive whom we can and teach a little as we go and accept the imperfections dissolutions and disasters. Most days this is enough.  Most days. I don't know why but yesterday morning, after our 1 kg preem kept stopping her breathing overnight, the sickest malnourished child with the hemoglobin of 2.0 still withering, and this new admission looking like she was within a half hour of death from a preventable and treatable disease, it was suddenly just too much. None of the staff on the roster (2-3 nurses per day shift, 1 on nights, for 60-80 patients) had arrived. I walked out into the hall to start looking for someone to call. The charge nurse Olupah walked in from the opposite direction, arriving, and said, how are you doctor. I said, not OK, and she looked so genuinely alarmed and concerned that I just burst into tears.
Olupah doing her usual 

I not a big crier, doctors never cry here, staff are not emotional, which is 99% of the time good and necessary way to cope with this reality. But she whisked me into a side room and closed the door and gave me a huge hug before I could even object to COVID spacing. . . . and it was so genuine. We both talked about what was breaking down, where the issues were, and what needed to change, landing on the delays from lab (which is inundated with patients and not keeping up) and the tendency towards passivity when the in-charges are not present.  Just a few minutes. Olupah is a shining star in a sea of sorrows, and I'm grateful for her.  I composed myself and wiped off my face and went back out to battle.

And it was a battle, hours of it, with not a ton of victory.
Next patient after the above story, 2 yrs and 2 months old, 11 pounds and that includes edema, abandoned by his mom due to marriage conflicts and finally in the care of a paternal grandmother who noticed this was not OK.

Thankful for the clinical officer student who was running back and forth to lab for bags of blood.

Only patient I've had rocking a mask . . .

Meanwhile in theatre, a remarkably efficient C-section for cord prolapse that ended with a perfectly good baby.

Standing room only? not really even room to stand.

One of the tiny lives that breaks one's heart.

In my read-through-the Bible, yesterday and today covered the whole book of Ecclesiastes. Not a place I often land, but what a relevant book for this time and this mood. The words of the Preacher, it begins, the reflections of a man known for wisdom. Chapter 8 ends with a discourse that sounds amazingly relevant: the consequences of a good life and an evil life do not stack up the way we expect in a just world, because the sentence against evil is not executed speedily. Expecting to equilibrate good with reward (or evil with punishment) is futile. This leads the Preacher to two conclusions. One, similarly to the book of Job, the work of God is mystery. Two, the best we can do then is to live our lives doing meaningful labor in which we find some satisfaction, and to enjoy the present food and company, marriage and meals. 

That's pretty much it. On the one hand, relish lament and mystery: Sorrow is better than laughter, for by a sad countenance the heart is made better (7:3) . . . On the other hand, do and enjoy good: nothing is better for a human than to eat and drink and for one's soul to find good in one's labor, to look for the beauty God put in the world and embrace the longing for eternity God put in our hearts (2:24, 3:11-13)

Sounds pretty simple. Most of the time we can get it. Name the losses. Don't put God in a box. Create community, cook meals, find humour, celebrate the little glimpses of goodness. Accept our limits. Don't give up. 
This shirt epitomizes party in the miasma of malaria. Enjoy the food and the babies in spite of all the mess.

And as if Ecclesiastes wasn't quite enough, Bethany's book was excerpted in a magazine this week prompting me to re-read a chapter this morning I needed to remember. Then Lindsey on our team sent me this quote from a book I have yet to read, This Too Shall Last (Ramsey): "Walk into the barren, empty places of your pain, because this is where God will fill you with himself. This liminal space is where we hate to go but where God is always leading us. Don't run from what does not make sense or try to explain it away. Dissonance is the birthplace of all abiding Christian hope. Embrace mystery as the place God dwells. Embrace your suffering as the paradoxical place where you will be made whole."  That's the surprise of the Gospel right there, the cross leads to resurrection, suffering is integral to the process of glory.  Also any quote that combines liminal and paradoxical pretty much sums up all that is important about life.

So the day after Juneteenth marches, the day that coronavirus cases are again rising, the day that holds neighbours knocking on the door to explain their hunger, and most of our closest relationships stretched thin over miles and days. . . Let's stay in the dissonance a bit longer, looking for God.

PS. Not to be emotionally manipulative sharing a low point, here is some data on COVID-19 and Africa. The Lancet put out a paper this week with various mathematical models of what the impact on children under-age-5, and maternal (the two biggest sources of lives lost prematurely) mortality will be.
Baseline deaths are too many, but most scenarios show a significant increase. And interestingly the main solutions in the accompanying tables are readily purchasable items: food, antibiotics, oxytocin.  Sometimes we feel a little guilty for propping up the failing system with a bag of medicine vials and IV tubing and a load of our BBB paste. Then we read the actual data and think, this is the labor under our sun, to which we are called. Peanut butter and artesunate and blood and a quick dose of a medicine that contracts the womb, that's about the difference between life and death. So if reading this kind of hard story leaves you restless yourself, by all means look around locally and get your hands into protests or poverty alleviation. But you are also welcome to join us in the BundiNutrition (food) or BundiMedical (medicine) funds.

Monday, June 15, 2020

We interrupt 2020 to bring you a reminder of JOY: Abby Myhre

One year ago today, Abby Myhre officially became Abby Myhre as she celebrated her birthday, and her wedding to Luke, on the beach in Nantucket.

Which means that no matter how stressful any year is, every June 15th we get a double reason to thank God for creating Abby, bringing her through the first two decades of life in a loving family with a heart of faith, a great education, and a zest for life, intersecting her path with Luke's and therefore our family's, enabling them to persevere through further training and times apart and then to envision and pull off a fabulous feast to celebrate their vows.

And in 2020, we truly need this little glimpse of grace not-long-past, grace still reaching us.

A year into their as-long-as-we-both-shall-live: a new apartment, a new puppy, a new job for Abby post-fellowship, new friends and church, new opportunities to lead and serve, new strength as Abby is training for a triathlon. The delayed reception happened in November, the delayed honeymoon planned for a simultaneous vacation week in April is still on hold because travel was shutting down and they both knew the responsible thing to do at that moment was to be all-hands-on-deck as the first wave of COVID hit. We don't know when we will see each other again, when we can be on the same continent. But in these lonely and uncertain times we are glad that Luke and Abby have each other. We would gladly give up our visit certainty just to see them together.

Today is a picture of life on this earth. So many things are broken and wrong, hateful and unjust, sick and sorrowful. As I ran this morning, I was thinking of how 2020 started off as such a hopeful year at CSB, how our momentum was going to open a new chapter. How we were going to build things, welcome people, have meaningful gatherings. Instead I was passing the garden where a court case drags on and precious lumber was just stolen, past houses where kids are missing out on a year of school life. To prepare to say goodbye to two team mates who have been a huge boost and blessing to all of us. To go to a hospital where tiny kids are dwindling with TB and AIDS and a host of other terrible things, where there's not power to run the machines, where we just lost an adult with "acute bronchitis" but didn't get a coronavirus test in time. But in spite of all that, all day today I am thinking, but Abby. We have a daughter-in-law. We had a wedding. Grace drops good things in from the unseen realm where all is healing, justice, beauty and voila we receive better than any of us deserve.

So Happy Birthday to Abby! Happy 1rst Anniversary to Luke and Abby!