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Tuesday, March 24, 2015

Depth of Field

Most cameras, and I, can not focus simultaneously near and far.  I have to choose a certain depth of field, and my attention goes there.  The last couple of weeks I feel like I've been zooming the lens in and out and in again.  

Most of the day and every four or five nights the focus is tight, and specific.  Tiny little lives that struggle.  Lungs that aren't filling with air, blood that teams with harmful bacteria, intestines that aren't digesting milk, skin that is broken down or infected.  My patients weigh anywhere from 900 grams to a few kilos.  They are jaundiced or febrile or anemic or dehydrated, and they can't ask for help.  So it is my job each day to plunge into a sea of chaotic activity and sort out the serious problems from the distractions, to insist on attention to detail, to calculate and palpate and think and work.  To organize my team, to listen to their presentations, to check their plans.  To respond to emergencies, and teach.  We've been extremely crowded, wedging 28 babies into space meant for just over half that number.  We have an outbreak of a bad bacterial septic infection spreading.  It's been intense.  But I like the tight focus, the immediate crisis, the hands-on problem.  These babies are precious, and their moms are heroic.  Here is my view:

But the last two weeks have also required a zoomed-out focus, the panorama, the big picture.  Our team in South Sudan left under pressure of illness and rumor of war.  Our team in Bundibugyo has faced public pressure on the school administration, an unexpected resignation, loss which changes personal plans.  We are in discussion with multiple colleagues who are discouraged and in need of hope.  We are deeply involved in plans for our regional leadership training and then retreat, a 10-day stretch of ministry for six teams in four countries that begins Saturday.  Preparing schedules, thinking through content, meditating on talks, praying for each person coming.  This is big-picture stuff, the why and how of the Kingdom come, the survival of vision and purpose.  I invited a hundred people to a Serge party and desperately want God to meet them there.  This is one view, with parts of two teams over for dinner and prayer:

Both are the real work of the reversal of all that is wrong with the world.  Both are opportunities to pour our souls out on behalf of fragile people.  Both call for the Spirit's power.  For wisdom.  For perseverance. For patience and kindness and hope.

But it isn't easy to keep focusing in and out, to hold the full depth of our East Africa field in view all at once.  Yet Jesus does this, knowing each sparrow of a preemie whose little heart tires out, and knowing the major political forces at work between warring clans or the life-trajectories of dozens of intersecting people and families.

Tomorrow is my last day in the NICU for a couple of weeks; Thursday I fly down to the coast to meet Heidi who has been a rock of can-do organization these past months as we have planned these retreats together.  We have Friday to finish up all the details for both retreats.  Scott flies back to Kenya and meets Jack late Friday night, and they arrive at the coast with all the others on Saturday.  He has finished quarantine, and our two-month separation is down to just under 4 more days.

Pray that all these babies would be healed and strengthened and thriving as I go and leave them in the hands of a visiting Canadian paeds NICU fellow.  And pray that the last preparations for the retreat would fall into place so that many weary and hurting missionaries would meet Jesus.  And lastly pray that Scott and I would be unified in the counsel and leadership we need to bless our field, at all depths.

Monday, March 16, 2015

Death in Liberia

Many of you received an email update from me in Liberia in which I asked for prayer for Bosco, a young man who sustained burns to 70% of his body surface after the generator he was filling with gasoline exploded (he was filling it while it was still running).  

I received an email from one of the doctors still working at ELWA Hospital sharing the sad sad news that Bosco died on Sunday morning.

Even at the best medical center in the USA, his prognosis with such extensive burns would have been about 50-50.  But he survived for six weeks.  And we all thought he was through the worst of it all.  

His wife was truly amazing - Felisha.  She never left his side.  She never complained.  She would help him get into a big tub of warm water every morning and slowly peel off the sticky gauze dressings so that clean ones could be applied.  This was a pain-filled, revolting task.  There was a putrid odor that filled the room from the wounds.  She cooked every day for him on the sidewalk outside that little room.  And she always smiled when you came in the room.

I shared in the task of applying the daily gauze dressings.  I would lay the sterile gauze on so gently after applying a thin layer of Silvadene - and he would still wince from the pain - but not complain.

I discovered that he was a Chelsea football fan at one point and brought him news of one of their winning games.  It’s the only time I saw him smile.

I feel so so sad for Felisha and his family.  They were all so hopeful.  

It’s easy to shrug it off and say he lived longer than he should have.  He didn’t have a chance.  But I was with him and he was so alive so hopeful for so long.  

I offer this little piece of cyberspace as a memorial, a remembrance to a courageous and perseverant man whose life was cut short.  The Old and New Testaments are full of reminders to Remember.  I remember Bosco.  He death leaves a void, a hole, a gap which shall never be filled in the lives of his family and friends.  I pray that his family will be reminded of the Big Picture, of the Resurrection, of the Hope to Come - but I’m sure that seems very very distant at this dark hour.

Sunday, March 15, 2015

In like a Lion, out like a Lamb?

March has been one angry lion so far, ripping into our Serge field.  The month started with two funerals for close family of Sergers.  Then a medical evacuation, and soon after a political one as the peace accords in South Sudan faltered and rumors of conflict abounded.  Every few days it seems we have deep conversations with Sergers who are wondering if they can make it, life is just so hard.  Evil abounds, and last week threats and pressure caused our beloved head teacher at Christ School to resign, probably a victim of tribalism and greed.  His loss to our team there is huge.  Our teams live on the hot and dusty edges, where there are dangerous thieves, fatal diseases, needy demanding people day-in and day-out, bugs in your food, conflict with others, and the chronic background sadness of being lonely for loved ones and familiar places.  We endure separation and danger and then at some point it becomes just too much.

For me, the battle is up close and tactile, and sometimes all-night.  One call this week, amongst the 50 or so kids I was covering on our three services were a list of diagnoses so long and diverse you can't even make this stuff up:  a congential brain tumor, a teenage schizophrenic, a toddler with a perforated esophagus leaking into his lungs after swallowing a caustic chemical, a baby of uncertain gender due to an enzyme mutation that affects hormone production as well as life-threatening fluid and salt balance, several new spina bifidas, meningitis, TB, a kid with AIDS who had been doing well but came in respiratory distress, tiny premature babies, the usual malnutrition.  Yesterday on Saturday I went in at 8 am and did not stop until Sunday 2:30 am except for a quick "lunch" at 4ish.  We admitted seven new patients, including two babies with critical brain-damaging levels of jaundice that have to be treated with an exchange transfusion, in which we remove and replace the entire blood volume of the baby twice over, a little bit at a time, which takes HOURS.  Another baby who had lost almost 1/3 of his body weight in two weeks of not feeding, leading to kidney failure and labs that were off the scale.  And for good measure, a 28-week 930-gram premature delivery to a mom whose first two pregnancies ended in deaths in utero.  She's so far tiny but pink and fighting.

March has been, in a word, relentless.

This morning, as I struggled to stay awake after going back in to the hospital briefly, I thought about the Lion and Lamb image.  All through the Old Testament, God uses the Lion as a way to describe his own chosen rulers, and Himself.  A ruler, who can rend judgement in no uncertain terms.  Unpredictable.  Frightening to those who do evil, which on some level includes all of us.  CS Lewis used these passages to develop the character of Aslan, who is most decidedly NOT safe, but GOOD.  Then 1 Peter speaks of the devil as a lion on the prowl, seeking whom he may devour.  So as we go through these trying circumstances of sorrow and harshness and loss, we sense the lion tearing in.  Only we don't know, is this God allowing suffering for ultimate redemption, or Satan attacking?

Or both?  March is a picture of the span of redemption.  It comes in like a lion, with judgement and fear.  But goes out like a lamb, because the lion ultimately wins not by ripping apart the enemy, but by becoming the lamb of sacrifice.

May we see the rule of the Lion of Judah, won by the bloody helpless death of the Lamb of God.  May we fight injustice with the dangerous teeth and courageous zeal of the King of the cats, but be willing to suffer the consequences with the humility and voluntary brokenness of the smallest of lambs.

Thursday, March 05, 2015

Post-Liberia Quarantine - not quite jail

I did my homework and I planned to isolate myself in my parent’s home in California for 21 days following my service in Liberia.  I chose to come to the USA because Kenya wouldn't allow me to come back and because I know almost everybody treated for Ebola in the USA survives. However, I wasn’t expecting the level of intense scrutiny and enforcement from the Federal and State authorities which I’ve experienced.  

When I arrived at San Francisco airport on Tuesday evening, the Immigration and Customs Officer nearly gasped when he read “Liberia” on the list of “Countries Visited” on the form which I had filled out.  He immediately picked up the phone calling his supervisor.  “Is Liberia one of those countries where they have Ebola?”  He then looked at me and said, “We need to take you to Secondary.”  We walked down a long hall while he insisted a half dozen times that “this is really routine”, “they just want to ask you a few questions”, “this won’t take long”, “you are going to be just fine.”  His level of anxiety was starting to stress me out.  

I was ushered into a small room, given a mask to put on my face, and asked to wait.  A mask, really?  Ebola is not an air-borne disease - so I put the mask on the desk and waited.  After a half hour with no information, a Senior Immigration entered.  “You just came from Liberia?  And you didn’t pass through one of the five designated Ebola Screening airports (JFK, Dulles, Newark, O’Hare, or Atlanta)?  That’s not suppose to happen.”  It happened.  I had purchased my own air tickets - in separate purchases.  The first piece was the Brussels to Monrovia leg.  I had to get that in place before I could figure out the rest of the complicated travel.  My itinerary ended up looking like: Nairobi-London-Brussels-Monrovia-Brussels-London-SanFrancisco.  Kind of crazy - but it worked.  Despite not being a designated screening airport, the San Francisco Immigration Dept did manage to get the job done.  They had a prepared packet from the CDC for travelers returning from an Ebola-affected country.  It included a “symptom-checklist” and a digital thermometer.  We then went through the detailed symptom review with a CDC doctor from Atlanta by conference call, took my temperature, got every possible contact and address from me and after about an hour, I was released.  My was the lone bag left, sitting by the quiet conveyor belt from the London flight.

While in the car on the way home, I was contacted by the California State Department of Health who informed me they would be calling me in the morning to set up our Quarantine Process.  Finally reached Mom & Dad’s home late in the evening.  First time I have ever come home and not been able to hug my parents.  My dad gives the biggest hardest bear hugs to welcome me home - but not today.  During dinner I got another call from the CSDH because they wanted to give me a special number to call in case I developed a fever overnight.  “Don’t call 911.”  Those First Responders are not prepared to handle you.  Call this number and we will send a Special Team if you get symptoms of Ebola (read: Hot Zone Space Suit-clad Team).  You’ll be taken to the University of California at San Francisco which is the Regional Designated Ebola Treatment Facility.  OK.  (Gotta remember to take that malaria prevention medicine, I thought, because any fever is going to be a disaster).

The next morning I was called by a Public Health Nurse representing the California State Department of Health.  Yet another hour of questioning and explaining of the context of the situation where I worked in Liberia.  Then…4 hours later the doorbell rang and the Director of the San Mateo County Department of Public Health came to serve my “Quarantine Order”.  This was a legal document stipulating the very specific terms of my Quarantine Period.  No public contact of any sort.  I may not go anywhere where people gather.  No shopping, no restaurants, no church, no theaters.  No public transport of any kind: train, boat, plane, subway. I may leave the house only to go for solitary exercise.  And I must check in by Skype twice a day: 9am and 4pm.  During that time, the public health nurse will watch me take my temperature with the digital thermometer - and I will show her the reading on the Skype camera.  And report if I have any symptoms consistent with Ebola. Violation is punishable by stiff fines and/or  jail time.  Enforced by the Sheriff of the County.

The Director (a doctor), told me that there are currently about 1400 “travelers who have recently returned from the Ebola-affected region” who are currently being monitored and in quarantine in the United States.  Of that group about 95% fall into a “Low Risk” category meaning that they were not involved in any patient care.  I’m in the “Some Risk” Category (the other 5%)  which includes those that worked in an Ebola Treatment Unit or provided general medical care in a non-Ebola setting.  The “High Risk” Category is for those who have had a known body-fluid exposure from an Ebola-infected patient.  The “Low-Risk” group reports their temperatures but doesn’t do it in the Directly-Observed-by-Skype method which the “Some Risk” does.  Many of the “High Risk” workers seem to be admitted to a hospital for testing and observation.

So, this little vignette certainly serves to illustrate that the CDC has their game on. They are super-organized and super-serious.   I didn’t really expect this level of intensity in my post-Liberia monitoring.  Is it onerous? Not really.  Every person has treated me with kindness and respect.  The San Mateo County Public Health staff have expressed their appreciation to me personally for my sacrifice and service.  Of course, it might feel a bit more oppressive were I not staying with my parents who live two blocks from the Pacific Ocean and pamper me as if I was their only son.  Three weeks of jail = three weeks of rest.  And I got three free digital thermometers courtesy of the CDC. 

Wednesday, March 04, 2015

Leaving Liberia

After a month in the sweltering heat of Monrovia, Liberia I’m bundled in my fleece watching jumbo jets rise into the gray sky over Brussels.  Monrovia seems a distant, ethereal memory already.

Sometimes over meals at home, we go around the table sharing “highs and lows” of the day.  That seems a reasonable way to structure a few reflections on this past month:


- To the best of my knowledge, I did not ever touch a patient with Ebola.  While I did have the opportunity to tour the largest Ebola Treatment Unit (ETU) in Liberia - “ELWA-3” managed by Medicins Sans Frontiers —  I did not go to Liberia to work in an ETU.  I went to support the transitioning weak medical system with general obstetric care. I also ended up covering the whole hospital for general medicine and pediatrics on my call days.  We know from experience that the hidden collateral damage of every Ebola epidemic arises from the fact that hospitals just shut down in order to protect their staff.  The result is that children die from malaria and women die in childbirth.  I did quite a few C-sections - all good outcomes - to that end.
One of the OB wards

- I relished the opportunity to work at ELWA Hospital.  Jennifer visited ELWA way back in 1982, when she was in Liberia for the summer with InterVarsity’s Summer Mission Program.  As mission hospitals go, it’s been around a long time (1965).  It’s a shadow of its former glory though.  The Liberian Civil War of the early 1990s took a devastating toll on the facility.  It’s in pretty bad shape.  The good news, though, is that Franklin Graham, the head of Samaritan’s Purse International Relief came for a visit, was completely appalled at the condition of the place, and committed SP to building a new hospital.  They are 75% of the way into a $3.5M hospital construction project.  It’s going to dramatically transform ELWA into a new era.  But the real treasure of ELWA Hospital is the spiritual heart of the hospital.  The whole staff meets daily for a half hour of singing, Bible study, and prayer.  Their bedrock and strength is God’s Grace and Love.
With Dr. Jerry Brown, TIME Magazine Cover Star

- Working with some of the most courageous people on the planet…the Ebola Fighters.    ELWA Hospital was among the first hospitals to establish an isolation ward for Ebola patients (an ETU).  The hospital closed for a brief two weeks in August after three American missionaries were infected with Ebola, but Dr. Jerry Brown insisted on re-opening the hospital because pregnant women were going to the personal homes of ELWA’s midwives in order to deliver their babies.  Dr. Jerry Brown appeared on the cover of TIME magazine regaled in his Tyvex suit and goggles because he bravely treated Ebola patients when no one else would.  But there are many many others.  Nurses , midwives, lab techs, janitorial staff all came to work at significant personal risk, because they believed it was the right thing to do.  So far close to a billion dollars has flowed into Liberia from outside donors.  The ELWA staff have been promised “hazardous duty bonuses” by the government (approx $300/mo x 6 months for the midwives), but as of this writing, not one dollar has been received by any ELWA staff.  Are they on strike?  No they just keep working.  
With my team of midwives


- The heat.  

- The poverty.  Liberia is a hard place.  The soil is sandy and there isn’t much that grows there except palm and rubber trees.  It’s billiard-table-flat so the country has no ability to generate it’s own power from hydroelectric.  When we flew in over the capital, Monrovia, I was shocked at the darkness.  A capital city immersed in darkness?  No grid electricity.  The country runs on generators.  Liberia also has the poorest physician-to-population ratio in the world. (50 Liberian doctors for 3.6 million people before Ebola).  Doctors fled in the civil war - and of those that remained, some died in the fight against Ebola.  Life was a struggle before the war, before Ebola, and now everything is broken.

- The threat of Ebola.  While I feel confident that I didn’t actually come into contact with any Ebola patients, every patient we saw was screened for the possibility (temperature taken, symptom checklist reviewed).  Everything we did was viewed through the lens of Ebola.  Almost everyone has malaria which means that many, many patients arrive with fever.  We tested many for Ebola.  We worried about Ebola.  We wore impermeable gowns and gloves for every patient encounter.  Thankfully the NIH Ebola Lab was actually on the ELWA campus so the wait for an Ebola test was never more than 24 hours.  In the last week of my work, there was only one new confirmed Ebola patient in the whole country.  That was encouraging, but the fact that in that same week, Sierra Leone had 65 and Guinea had 33, was disconcerting.  Until all three countries are Ebola-free, none of these severely affected countries can really relax.

- The deaths.  I saw a lot of people die this month.  Most heart-breaking were the preventable deaths.  A newborn developed tetanus four days after birth because his mother was not properly vaccinated and died a horrible death of spasms and respiratory paralysis.  (Did the mother fail to understand the need for vaccination—or was she afraid to come to the hospital because of Ebola?) An 8-year old died of rabies after being bitten by a stray dog.  I poured myself into the care of a 16 year girl who had severe and protracted menstrual bleeding for over two years.  After hormonal therapy failed, we began to think she might have had an inborn blood clotting disorder.  She was in-and-out of the hospital over three weeks of February during which time she received twenty units of blood.  We finally decided that it would be life-saving to remove her uterus - but the father refused.  She died the next day.  I went to my room to weep alone.  The incomprehensible senseless deaths just weigh you down.  The death of a healthy 16 year old girl.  The death of a healthy newborn for lack of a tetanus immunization.  Doctors who die from Ebola.  Our dear friend Dr. Jonah died from Ebola back in 2007 leaving five girls and his wife pregnant with their first boy.  In our human understanding, there is no way to justify these things.  While there can be beauty from ashes and fruit from the seed which dies, the fact remains that Death steals Life that it does not own.  We have six new doctors in training in Bundibugyo who were sponsored in the aftermath of Jonah’s death—but Melen is still a widow and his only son is still fatherless.  While I have been freshly struggling with the tragedy of such pointless, inexplicably wasteful deaths, I suppose that is some small way I must admit that is only in this suffering, in wading through this wilderness, that I seek and search and cry to understand the Mystery.  And as I ponder the Infinite, squinting through the tears, God is there.  And He defies Explanation.  Here is where the Psalms of Lamentation abruptly switch from wailing to worship, from agony to faith. The alternative is bitterness and despair—and I refuse to go down that path.

It’s been a long road, this path to Ebola-Land.  Jennifer has paid a high price, keeping all the balls of our Kijabe Life in the air in my absence.  Doing all the cooking, hosting house guests, taking extra hospital call, caring for the dogs, teaching our Senior Boys Sunday School, handling a bevy of crises among our Serge East Africa Teams.  She’s been burning the candle at both ends and in-between.  I’m thankful for her and miss her desperately.

Now I’m putting even more distance between me and Jennifer as I head for California to hole up and wait 21 days to make sure I don’t develop Ebola.  I never did go “skinny dipping in Ebola juice” as one of our oh-so-compassionate blog commenters suggested that I do — so I doubt it will be a problem.  I will be taking my temperature twice a day and calling it in to the California State Health Department.  I’ve not missed a dose of my malaria medicine, so I’m hoping that I don’t get any fevers at all.

Thanks so much to all who prayed and continue to pray.  And give.  We are your hands and feet.  Thanks for your partnership.

Tuesday, March 03, 2015

Two Funerals, and a Birthday

There is a song that came out right around the time of Ebola Bundibugyo, with the line, "like a swing set in a graveyard, like a bloom in the desert sands . .  love is gonna break through".  A poignant jarring juxtaposition, that highlights the paradox of redemption, where life is breaking in and overcoming death.

Today, two of our East Africa Serge colleagues attended funerals for close relatives.  Our hearts are with them, as they worship and mourn.  Faith in the hardest moments of life is real faith.  Heidi L has been caring for her mother for a long, heartwrenching, often beautiful, mostly ordinary moment-filled final year of dying from ALS.  Lesley S was shockingly and suddenly bereaved of her 24-year-old sister due to a car accident.  Both of these women missed years with their nuclear family because they have been working for transformation and hope in distant, hopeless places. For both the deaths are terrible, and too-soon.  And both are spending today in the emotionally overwhelming process of closure and goodbye with their USA community and family.  Both are places I would have liked to be today.

However, instead, I was grinding my way through call and then a busy NICU day with a sometimes-bewildered and fairly inexperienced intern team.  Scrambling to see patients in private clinic and RVA clinic too.  All with a goal of getting home to prepare for a 17th birthday party for Jack.  So this evening while my friends were waking up in the USA preparing for funerals, I was sliding pizzas onto paddles, setting out sodas, passing out party whistles and cake.  Celebrating.  Jack is a hard-working kid, smart, sociable, insightful, loyal, with a sharp wit, good humor, fast feet, and sheer speedy strength.  Tonight we had a pizza party, which is a beautiful way of honoring a person just for being who he is.  I am so thankful for him, and for the community of Senior Boys (our Sunday School) who came to celebrate with him. We ended the party praying for him, and I was thankful to know my son has friends who are asking God for closeness and wisdom and guidance on his behalf.

Two funerals and a birthday party. The context of darkness, which sets the stage for light. The real reminder that life breaks through death, that birthdays will overcome death days.

Meanwhile Scott is on an airplane high above both funerals, making his way to California for a 3-week be-sure-you-don't-have-Ebola incubation before he can return to Kenya.  And our school in Bundibugyo faces serious threats once again, possibly related to greed (for our land) and tribalism.  Anyway, please continue to pray for our friends, for those who mourn, asking for comfort.  For the Kingdom to break through, in love.

Sunday, March 01, 2015

The suffering of the poor, grace at the fray

This past week was one I would not care to repeat, and am glad to leave behind.  After a relatively good first three weeks of February in ICU where uncharacteristically everyone got better and left alive (and where I was tempted to feel competent for a moment, fatal mistake), suddenly the deaths mounted.  We lost seven patients on our three Paeds services, and all but one were either my patients/former patients, or dying on my call coverage night.  Two were excruciating decisions that we had come to the end of care for unsurvivable conditions, which is a very weighty burden especially when not everyone feels the same.  Two were similarly severely impaired by chronic medical problems and malformations and though we were giving our all in ICU, after multiple resuscitations (including the classic heart-shock-paddles for one) we had to admit defeat.  One was a newborn that I just walked in on in the final moments, but had been delivered too early, and my role was just to back up one of my partners in the last moments. Those five were exhausting but I can live with the decisions and accept our limitations.  The other two, however, really hit me hard.  One was a 9 month old with spina bifida and pneumonia, who came in severely anemic with a failing heart and shock.  Not a great prognosis, but she actually improved for several days.  Her initial blood culture showed on the third day that she was growing a gram negative rod (bad bacteria) in her blood, and since we have many resistant ones, I changed her antibiotics.  Only it turned out that my choice was the one she was resistant to, and by the time the lab reports were final, she was deteriorating fast.  She turned the corner towards death so quickly and decisively, and I spent a long night trying to control spiking fevers and falling blood pressures and low oxygen until she succumbed.  But the hardest of all was J, the 15 year old girl we prayed for a couple weeks ago.  Her apparent brain tumor had turned out to be tuberculosis, and I was practically dancing with that result because she could be treated and cured.  After a week in the ICU she moved out to another floor, and I heard she was slowly improving.  She emerged from her coma and begun to talk a little, and even walk.  In fact she was being discharged when someone noticed that her spinal fluid was leaking from her surgical site, and decided to order a head CT.  So Thursday, prior to being discharged, she was sent in an ambulance with a nursing student down to Nairobi, a stable improving patient.  It's not clear what happened but her mom gave a history that she got an injection of something that "calmed her down".  All we know is that after the CT, on the way back in the ambulance, she stopped breathing.  And in spite of the efforts of the nursing student, bumping on our horrible road in the ambulance with a dying girl, she arrived with no pulse and cold not be revived.  

And that was the hardest of all.  I ran into her mom in the hallway later, and she hugged me and cried.  I have a child who is 16, nearly the same age.  Losing a baby is terrible emptiness and robbed potential, but losing a teen, someone you have known and watched grow, must be nearly unbearable. Particularly after we all thought the danger was past, and whom we expected to recover.  I felt deflated, punched, sorrowful.  Devoid of words.  And I was only the doctor, not the mom.

And the rest of the week wasn't much better.  Scott's 15 year-old bleeding girl in Liberia died after her family refused surgery.  Two of our Africa-based team mates lost close relatives:  Heidi's mother died of ALS just like my Dad did, and Lesley's 24-year-old sister died in a car accident driving home from a final family dinner with them.  We have a family of six from South Sudan who evacuated for medical reasons, as it turns out multiple large kidney stones causing months of pain.  One of the three remaining missionaries there injured his back, resulting in phone calls and considerations of security and evacuation, though in the end it seems muscular and he's staying put.  Accusations exploded against our school in Bundibugyo this week, with politically slippery types trying to agitate against our administration.  Kids at this school, RVA, are also tired in that mid-year slump where exhaustion sets in, and not a few have had to have compassionate leaves for mental and spiritual health reasons.  All of these situations have weighed on our hearts and filled up my hours in a week with 4 call nights and 3 extra guests spending the week at our house, with little sleep and lots of meals to coordinate and serve. I had two projects due as well, which meant that every moment was a push.  And did I mention the car trouble, or the sick dog?

So this weekend I wondered, what was God doing this week?  Why was it so hard, so full of death and defeat, so discouraging? 

And that brought us to Sunday, and Psalm 22.  Jesus quoted this song on the cross, the cry of the heart when one feels forsaken.  "I am poured out like water . . my heart is melted like wax . . my strength is dried up . . ".  The psalmists describes being utterly weary and surrounded by enemies.  Which pretty much sums up this week.  

In the middle, the Psalm transitions to faith.  "But you, O Lord . .have answered me."  Right in the middle of all the painful chaos, this promise:  "For he has not despised nor abhorred the suffering of the poor; neither has he hidden his face from them; but when they cried to him he heard them . . The poor shall eat and be satisfied."  All this because "The kingdom is the Lord's and he rules over the nations."

Terrible things happen in this broken world.  Seven bereaved mothers.  Bleeding.  Stolen breaths. Cars screeching off the road.  Hateful rumors.  Bad choices of antibiotics.  The psalm acknowledges this, and yet still holds onto two things:  God sees and hears and speaks, he enters and embraces us right in the midst of all this.  And God rules, his reign is slowly and surely setting all things right.

Wright calls this "something that doesn't cancel out the suffering, but that seems to grow out of it. . . These verses reach out, like the two arms on the cross; and they reach up, like the sign of the kingdom, pointing to the heavens.  You can't split them off from the long, dark pole of the cross.  . . they are the fruit of the suffering."  He writes of rescue and justice leading to worship.  All pivoting on the cross.

So I am praying to notice the God who comes to the poor in their suffering, the subtle ways He shows up to love and to rule.  Looking for signs that the world is being set right.  And as hard as this week was, it would have been a lot worse if God had not orchestrated a calm, competent, thoughtful, friendly visit from Dr. Becca Cook the very worst week of the year so far, and the very week when two other staff were gone.  I am thankful for ideas and companionship on the late night code runs, the early morning vent adjustments, the agonizing decisions.  

She was an RVA grad and fabulously successful academically, but more importantly has a heart for the poor just like Jesus does, and it was good to have her around.  

And once you start looking for God's mercy and rule, you see glimpses all over.  Here is our team community this week, expanded by Ann's parents and the Wallaces:
 And this morning, even though it was supposed to be an off week for Sunday School, all of my group chose to forgo extra sleep and come.  Love these guys.
 An impromptu party to watch England vs. Ireland rugby, when my pot of soup kept on giving and we all ate and cheered.
 Saturday I got to ride the bus with the team and watch basketball, and my favorite player, #11.
 And this smiling face and ginormous cookie awaited us this evening, a reminder that Jack's birthday is only 48 hours away.
 And we made it past the half-way point, the 29-day 29-day split of this separation which came yesterday.  Scott has now been gone more days than days that remain until his return.

Pray that we would keep grappling with faith, keep believing that the suffering of the poor is not forever, not in vain, not forgotten.  That God's mercy and reign keep moving in.  That the glimpses of community and refreshment this weekend will carry us through another week, even if the deaths pound on and the unraveling continues.  That there will be grace at the fray.