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Tuesday, February 28, 2017

Lent 2017

Our Lent started early and is stretching indefinitely on as a season of longing, and some minor deprivations, but the church's season of reflection and preparation begins tomorrow.  Forty days using physical reminders (fasting, or prayer, or readings) to shape a spiritual longing for the resurrection.

"The sacrificial season of Lent is a time for us to purposefully go deeper with Christ through reflection, action and renewal. Its structure offers practical ways to increase our devotion and love for Christ. If the church is indeed a hospital for the sick and wounded, then it follows that Lent is its yearly physical and annual tune-up. Lent has been observed by the vast majority of Christians since the earliest days of the Church. It’s a time to cleanse our wills, realign our spirits and strengthen our dependence upon God. It’s a period of genuine repentance, of concentrated reconciliation with others, of fasting from all that distracts us, and recommitting our lives to Christ in love and service."

Here is the Lent (and Advent) site from Biola we have come to love, combining Scripture, art, music, poetry, and insightful meditations.  We're also reading John for Everyone by NT Wright, part of his New Testament for Everyone series.  Our normal Bible reading come from the Church of England's Common Worship Lectionary App so we're reading the commentary on the John passage of the day.

This year the parallel to Caleb's push through Ranger school, and Luke's intensive month preparing for Step Two medical boards, and our long season of strike-related work, plus Jack and Julia's normal challenges of University . . . make 2017 Lent even more meaningful for our family.  We're designed to integrate our bodily experiences with our spiritual growth.  Lent and Advent celebrate the incarnational truth of our embodied souls.  

Join us and most of those who have followed Jesus over two millennia as we prepare to celebrate the resurrection.

Kenya Doctor Strike Quote of the day: Not Normal

This was from a text from a striking Kenyan doctor, a very young one, who believes in the cause but it getting tired of the stalemate:

"Yes it is hard on everyone.  But what's even worse is the fact that it's slowly turning into normal.  That we act like everything is fine, which isn't the case."

AMEN to that.  The chronic crisis becomes the new normal.

The possibility of a solution this week is looking dim.  But I haven't given up on a dramatic 11th hour rescue.   So keep praying.

Once again the sheer volume of work can make one feel like drowning.  Just when I thought I was getting back my intern IV skills, I was 1 for 3 today, and the two babies I kept blowing up veins on had already been poked over by the day nurse who was feeling sorry for me and tried to help.  I had two pretty sick admissions on the Paeds ward so I left for a while, and at the end of the day remembered I had to go back to do those IV's.  So I trudged in and started gathering supplies, then I looked over at one of the incubators just as the evening nurse seemed puzzled on why I had come back.  She had put in both IV's.  I actually hugged her, right there.  That's how tired we feel.  It probably scared her but she smiled.

Not long after we got home, Scott got called back because even though he's not technically on call tonight the person covering was not comfortable doing a C-section in a lady who'd already had three prior ones (too much scar tissue makes it really hard), and there was no possibility of referral.  So he went back and did it as the most experienced on the team now.  He's done about 65 since mid-January.  Which makes sense with a 10-15% rate and 500 deliveries a month and him doing the vast majority of the coverage.  No maternal deaths (except a couple of dead-on-arrival but not much we can do about that) we thank God, and only one surgical site infection which is also pretty remarkable.  My outcomes are not nearly so nice, so it helps to celebrate his.

Pray the country would not become complacent in accepting this broken system as inevitable.  Pray we would continue to build trust and relationship because we are needy and dependent.  It is no fun to need help, but it is a way to connect.  Pray for the confidence to go to Congo, Uganda, and Burundi.  And pray for those Burundi visas.  Thanks.

Monday, February 27, 2017

Kenya Doctor Strike, losing track of the weeks, but finding holy moments

And so the days go by in a blur of exhilarating craziness and dreary defeats.  The futility of pouring one's soul into one admit after another that dies.  The humbling realization that trying to hold up this service by pushing on through day after day does not guarantee better care than the mediocre chaos that preceded the strike.  Glimpses of victories.  Squeezing in the rest of life mostly between a late dinner and midnight, calls, emails, work.  Trying not to think more than a day ahead, even though that means we are no doubt very frustrating to the people we are supposed to be visiting for supervision, encouragement, and exploring opening a new team/field in March.  As in next week.  And mostly, in case you don't have time to read this ramble, realizing that the relational depth we are plumbing with God and humans is the real story, as lives come and go.
(going home tomorrow, day 51 of life, a 27-week preemie survivor)

It's hard to think back more than a few days, too much water under the bridge.  Saturday started out with my usual peek into Newborn Unit before heading to ward rounds.  Nurses seem to be doing CPR.  I walk all the way in and find a very mottled, dead baby with zero response.  As soon as I help they leave me to do the chest compressions and ventilation alone while they get the medications I ask for, and some information from the file.  Mom had just come in to feed and found the baby dead. A full term infant who aspirated meconium at delivery, but as per the file had been breast feeding and stable.  It is my first time to see this baby, and it's too late.  There is no reviving her, dead too long.  Thursday I had almost the same experience, I was examining one baby and looked over at the one sharing his bed . . who was grey and lifeless.  That one I got back with CPR and meds but not for long.  After an hour or so the responses become less and less, until there was no heartbeat at all.  Two in three days, both good sized term babies admitted the evening before, dead in the morning.  Either their critical condition and hypoxia were not recognized (since we have only 1 monitor to spot check 20-30 babies, that's understandable) or they crumbled from a rising overwhelming infection, or choked on a feeding?  It's a depressing way to start the day, comforting a grieving mother.  But there are probably 40-50 patients a day to be seen, examined, touch base with the parent, write for adjustments in treatment, draw labs or review results, discharge a half dozen and admit another half dozen.  So we go on.

But the frequent futility puts that puzzling book of Ecclesiastes into perspective.  So much seems to be in vain.  Still delving into Keller's Every Good Endeavor, trying to embrace this season and what it has to teach us.  Not just a temporary insanity to be muscled past, but an invitation to shape our work as God works.  For wholeness and newness and beauty, requiring sacrifice . . . but not necessarily demanding tangible results.

Because I want those tangible results, which in my work's case are actually lives.

Could it be that God is offering glimpses of something bigger?

A few hours later, I'm looking at a baby who has been with us all 37 days of her tiny preemie life.  Many of those days have been tenuous but on Saturday she's plunging downhill fast.  Her heart is beating at an unsustainable 225 beats a minute, and when I first check on her her lips look blue, confirmed by oxygen saturations of 77% (should be high 90's).  Her blood shows signs of another mounting infection, even though she's barely been off antibiotics more than a few days in her life.  An x-ray seems to localize the source to her gut, necrotizing enterocolitis, a dire complication.  My kind Kijabe friend what's app group responds to my enquiries with advice and rising alarm.  She may need surgery, which at this strike moment would not be available anywhere else but Kijabe.  But her mom has no money or insurance, her dad is unsteady with alcohol, and I'm afraid to put her in an ambulance looking so unstable.  Fluids and antibiotics and by mid afternoon she's marginally better, so with the gracious invitation of Kijabe's generosity we risk the ambulance ride kangaroo-style (on her mother's skin for heat).  Before she leaves, all the moms are in the unit feeding, and this baby is such a precious little long termer that I decide to ask them all to pray with me for her, explaining in my halting Swahili the problems.  We pray, I am feeling pretty emotional, then open my eyes to find her mom with tears streaming.  That, I realize, is a holy moment.  What it's all about.  The community of mothers, praying.  The teamwork of the public and mission hospitals. The mother of the sickest baby sensing God's provision, presence, support.  Running to the end of our resources, and desperately asking for survival.  And all that for something so small and fragile as a 3-pound baby.  We load her into the ambulance with our last tank of oxygen, and I hear later she's made it just in time.  The infection is indeed serious, but we have hope she will make it.

About 5 pm, thinking my semi-off Saturday couldn't get much worse, my hand is literally on the exit door with Scott when a midwife runs out to ask us to come see a mom 28 weeks pregnant with triplets.  Sometimes it's so crazy you have to laugh or scream.  Really?  She's in active labor.  We recruit one more nurse to double the Newborn Unit night staff, start assembling three oxygen delivery systems (tricky since we are out of tanks completely, so it's beg and borrow enough concentrators) as the babies start coming.  Scott ferries them from the delivery room to the Newborn Unit.  The first two are identical girls, sharing a placenta, 820 and 960 grams. They are followed by a big brother.  I line them up and keep passing the bag with oxygen to inflate lungs up and down the row until the nurses can get the CPAP's bubbling.  It's after 6 when an angel of a CO pops in, this young woman has miraculous IV skills, and as I'm preparing a little surgical procedure for 3 umbilical lines she just slips in hand IVs.  Hooray.  Teamwork.  Another holy moment, three tiny lives holding on because of two nurses, a clinical officer, and me, helping each other.

Sunday . . . Scott's in at 4 am and 6 am for emergencies; I'm early to church to practice for helping with the worship team.  As soon as the service is over we head as quickly as we can to Nairobi.  The day before, our dear friends' father had been admitted to the ICU at one of the best private hospitals. Michael and Karen are there with Michael's mom waiting, while his dad goes into surgery for a triple coronary bypass after a devastating heart attack.  The senior Massos had recently retired from a 15+ year term of service teaching at a Christian University in Nairobi and founding a home for street boys on the side, but were back to sell their house and transition to more of a frequent shorter term pattern of ministry.  We sit outside the operating theatre as the risky surgery goes on, sharing some stories and memories and Psalms and prayers with the family and a handful of Kenyan adults who were once in their program.  As the hours go by, and the report is only "we're trying to get him off the heart-lung bypass machine", we all become more and more sober.  Finally about 5 pm the surgeon comes to the door of the theatre hall, and beckons Michael and his mom.  He looks tired. The setting is surreal, through a cracked door, he tells us that Mr. Masso is dead.  Sobbing tears, disbelief.  Holding onto each other.  More scripture, and prayer, and a raw sorrow balanced by the truth that this dad lived life fully and well and died in the midst of doing exactly what God called him to do.  It is dark as we finally head home with Karen, still communicating with family over the globe.  The day is unbelievably draining, but holy as well, cutting to the core of family, of love, of friendship, of faith that stands in the room with a dead body hating death and separation, yet says goodbye knowing we will be reunited.

Monday, back to the hospital, an emaciated child, another with the listless swelling of chronic malnutrition.  Two of the triplets have died but the tiniest one fights on.  Tubes of blood drawn, listening to lungs, palpating, thinking, empathizing.  Scott pushing to get emergency c-sections done, made doubly difficult sometimes by the foot-dragging of others.  Hour after hour, again the day slips away, and I walk back onto the ward one last time to deliver a lab result I've just checked, when I hear a nurse talking about intubation and see a clinical officer intern trying to do CPR.  It's a 2 year old with severe burns, and there goes another couple hours of maintaining his airway and breathing while we sort out a way to send him to the ICU at Kijabe.  Once his heart nearly stops.  He'd been treated overnight at a small private local clinic, not a good idea, since he's nearly un-save-able by the time he arrives.  And while I'm bagging his lungs with oxygen, I hear from Scott that there's a mother in labor with a premature baby with a prenatally diagnosed intestinal obstruction.  You actually couldn't make up this much crisis if you tried.

So what is bigger than a few saved lives?  Perhaps it is building trust with coworkers I used to command/ criticize, learning to value cooperation and acknowledge how much we need each other, which has the potential to save many more lives.  Perhaps it is living a small glow of light that says God is present, even on dark days of a father's death, a child's burn, a baby found without breath.  Perhaps it is faith to believe this is not all in vain, even when it looks that way.

Please do pray.  It would take a miracle to end the strike this week.  We are supposed to leave for Congo, Uganda, and Burundi on Sunday.  We feel very conflicted about walking away.  Our hearts mostly want to keep at this work. But we also have committed to other work.  Pray for wisdom.

Sunday, February 19, 2017

Kenya Doctor Strike: on gardening, and thoughts of the heart

Some days I think of this as my garden.

Rows of babies, growing.  Attention to the watering and weeding, the IV's and Ng tubes and fluids, the blood draws and (yes it's true) lancing abscesses and exams.  The temperature regulation.  The atmosphere, just enough oxygen, not too much. 

And every day, the weights, looking at who is growing and how much.  When they hit 1600 grams they move into a crib under the heater, when near 1800 into the cribs in the next room.  Tonight I noticed we're back to doubling up babies in the cribs as we hit 31 babies admitted.  There was one nurse on duty.  So we each fed one of the twins whose mother bled to death in an ambulance on her way being transferred from a government clinic with no doctor.  Another strike fatality.  Three babies like that in the nursery now, only a tip of the iceberg of strike-related maternal mortality.

The steamy heat of the Newborn Unit and the rows of growing little beings . . . and my daughter's passion for soil and plants, had put this analogy into my mind this week.  So this afternoon as part of a mostly sabbath day (before problems pulled me back in anyway) I was reading Tim Keller's Every Good Endeavor, and this paragraph on work as cultivation jumped out:

We are to be gardeners to take an active stance towards their charge.  They do not leave the land as it is.  They rearrange it in order to make it most fruitful, to draw the potentialities for growth and development out of the soil.  They dig up the ground and rearrange it with a goal in mind:  to rearrange the raw material of the garden so that it produces food, flowers, and beauty.  And that is the pattern for all work.  It is creative and assertive.  It is rearranging the raw material of God's creation in such a way that it helps the world in general, and people in particular, thrive and flourish. 

Active stances, aiming for thriving and flourishing.  Yes.  

This period of work intensity on the one hand, and trying to understand the motivations and goals of the strikers on the other, pushed me to Keller's book.  Also Romans 8 came in my Bible reading today, all creation subjected to futility, waiting for hope.  A lot of my days seem subjected to futility. How can my work become more like God's, creative and assertive and perfectly producing goodness, instead of falling hopelessly short?  How can I invest my heart and soul into this little garden without losing sight of the real Gardener when too many deaths lead to discouragement?  

And how do my Kenyan colleagues see this whole thing?  I can't fully answer that (comments welcome) but I've come to see a few things.  For most Kenyans, equality of sharing, fairness, a wide and inclusive disbursal of resources is a high value.  For them the strike is about rectifying the government's refusal to share the national bounty.  They look at the corruption and say, why shouldn't we get more out of these jobs?  The fact that people are dying is not seen as so directly related to their work.  People die all the time, and the forces which cause that are not always considered to be under our control.  There's a certain amount of fatalism here.  So while I agonize because I feel like my job is to keep the patients alive, even though almost every day I fail, I am not sure my colleagues overestimate their power or responsibility in the same way.  So they don't necessarily directly connect their strike to the poor outcomes.  In fact I think many see the strike as a way to get more resources not only for their pockets but for the hospitals (even though only 2 lines in the 27-page CBA really talk about this, I do believe that it is on the heart of the best docs).  Most people are more motivated when they feel less futile.  Me too.

Please to pray tonight that the strike will end.  And that more strikes will be averted (mission hospital nurses threatening at midnight tonight, similar disgruntled dissatisfaction with obscure accountability of resources and a sense they have been short changed; government nurses threatening to re-strike March 3.) . But while you're at it, pray that we grow in a godly view of work, and understand this culture's views with grace and empathy as well.  

Here's someone who would like all of us to work with heart and passion and skill, as human beings tending God's garden!

Saturday, February 18, 2017

Kenya Doctor Strike week 11: same tune, another verse . . . bearing witness

This strike may feel like it's been a lifetime long, but for some that is literally true.  The baby above I transferred to our nearest mission hospital the day before the strike started in December . . . and she not only survived but thrived, back for a check-up visit with her mom.  If she had not been shuttled between Naivasha and Kijabe, two places trying to offer a safety net of emergency care, she would not have lived.  So today, let us bear witness.  This is what health care looks like.  A fragile life plumped out, a mother and her smile.

The small successes help us make it through the week, week after week, as the strike drags on.  The union-leaders were arrested briefly, sparking a call for all mission/private hospitals to join in closing down.  A few of the biggest Nairobi for-profit places did a slow-down, saying appointments were canceled and doctors were at a "meeting".  The jailed leaders were released pretty quickly, but no word on change.  The public, resigned as always to a harsh world with little guarantee, trudges on, making do.  The complexities of the situation make negotiation extremely challenging.  A government steeped in accusations of graft lacks the moral footing to speak for the poor, or justify failing to meet the rather dramatic promised perks (massively increased salaries and allowances, loans, training positions, funding for research).  County governments hide behind the National leaders claiming impotence; and vice versa, all the while continuing to gather in their own benefits as the public institutions crumble.  A health care profession who has now turned a blind eye (some very painfully and reluctantly, others with a conviction of the righteousness of their cause and their entitlement to a richer life) to un-marked thousands of deaths nation-wide keeps digging in as the stakes become too high to turn back.  The clinical officers and nurses who try to hold up a minimal net of care are blamed by the doctors for disloyalty or overstepping bounds, unappreciated by the public who continue to suffer, and taken for granted by the government who has failed on more promises to other categories of health care workers as well.  Rumors of more strikes to come.  Bitterness grows.  The narrative becomes more and more about money, about broken trust, about deserving better.

The dry-season air snaps like a tinderbox.  It feels edgy and explosive.

Today, as I was examining patients and writing notes in the room with the sickest babies, an unfamiliar nurse entered the unit and chatted with our nursing staff for ten or 15 minutes, in one of the outer rooms.  Surprisingly after a long friendly visit, they then brought a pink blanket bundle in to my room and announced 'we have an admission for you, a preem.'  I brought the bundle to the bed and opened it, to see a grey stiff little premature boy, his arms and legs extended in a hypoxic seizure.  He was deathly cold, not breathing, but a heart rate still present and low.  His mother had had a complicated pregnancy in Nakuru, the county seat of our county, a much larger town.  She went into labor at 29/40 weeks, landed at a private clinic and delivered this baby at 6 pm the night before, but there was not a single place in this major town that would agree to admit this baby.  The small private hospitals all said they were full, the public hospital was shut down, a pediatrician could not be found, any private clinics functioning said they didn't take preems.  He was left on the only source of oxygen overnight in the operating theatre, and then this morning someone in the family figured out Naivasha was open, so put him in a blanket and an ambulance and drove him out to us (about 2 hours).  It took me a long long time to ventilate and oxygenate and warm and treat him back to life.  I don't know if the damage was too great, for too long, or if he's a fighter looking for a miracle.

So, bearing witness once again, this is what a strike looks like.  

A vulnerable boy, born 11 weeks too soon, no room at any inn.  Finally and desperately brought to our public hospital, because we have one courageous director who is trying to be compassionate and moral in the midst of crisis.  For every baby that finds us, how many die in their village, or on the way?  Dozens?  Hundreds?  More?

For every emergency Scott has responded to, late night bellies full of blood from a ruptured tubal pregnancy, mothers with a womb starting to tear from a labor that is obstructed, babies whose brains are starved for oxygenated blood . . . how many don't make it to any care at all?  He just rushed back to do his 51st surgery since we returned in January.  This is just one smallish place.  Multiply that by hundreds of towns all over Kenya where those 50 life-saving operations aren't occurring.  Surely the toll is in the thousands by now.

And even though we are working at a punishing pace, we can't always be there, and we can't save everyone even when we are.  I lost a 660-gram 25-week baby girl, though she stayed with us about 24 hours.  Her peculiarly bruised head raised questions of whether she was the second baby this week who came out unexpectedly alive after attempted abortion, to desperate moms.  The staff tells me that another who died after coming in floppy, seizing, in kidney failure from dehydration, exposed to HIV, was born after two unsuccessful attempts to abort earlier.  We sutured up a 1 1/2 year old who had been raped by her step father.  We are working to revive a 10 year old with AIDS and neglect and hunger.  Passion to stand against this tide of sorrow, compassion to touch and comfort in this flood of woe, should be the essence of medical care in Kenya.  Evil is out to crush the vulnerable.  It is only by a consistent word of truth, a conscious effort to not love our own lives too much, that good pushes back (Rev 12:11).
So, as we plod on into week 12 . . please keep praying.  Revelations 12 carries the image of a baby-swallowing dragon, a mom in labor.  It's more than a fanciful dream; it is what we see every day.  By pitting one group against another group, the dragon fills its belly.  

What would healing look like?  Leadership that operates with such integrity and accountability, it can be transparent.  Decisions about salaries and infrastructure and oxygen tubing and clean water that are made based on common good and justice, not personal or tribal or class ascendency.  Scores of young people who enter this profession, and stay there, learning from each other, motivated because they can actually do some good.  Willingness to work, hard, and rest, regularly.  Teamwork and respect on all levels.  Innovation and hope.

Pray we live to see the day, or at least the first tinges of rose on the clouds of that dawn.

Tuesday, February 14, 2017

Dear Dr. Oluga: I stand against your arrest, but I stand by the patients

On Monday, the seven leaders of the Kenya Medical Practitioners Union who are leading the strike into its 11th week were arrested and taken to jail.  Today the Kenya Medical Association, in conjunction with many other professional associations for Paediatrics, Surgery, etc., announced that as of midnight no doctors in any facility, even private or mission, should offer any service for 48 hours.  Where is justice, and how should we respond?

Dear Dr. Oluga-
I saw your photo yesterday in the paper, standing strong and confident in your cause as you were led to jail.  You look just as I remember you in your internship, late nights standing in the halls of the Kijabe Hospital operating theatres, waiting to teach you to resuscitate a baby being born by cesarean and in the meantime talking about life.  You were ambitious and passionate then, and clearly not much has changed.

While I admire your tenacity and agree with much of what you fight for, particularly in regards to holding the government accountable to promises and seeking better facilities, equipment, medicines, supplies for serving the public, I will still be going to the hospital tomorrow.

Mass action of a strike, a protest, a slow-down, a refusal can be legitimate ways for the disempowered to collectively find enough power to get the attention of those who control their lives. This is particularly effective if a work force shuts down profits in such a way that their rights become a matter of importance, for instance miners walking out of a mine until safety issues are addressed.  The mine starts losing money, and the bosses come to the table, both sides compromise and life moves forward.  This is most certainly NOT effective for public doctors in Kenya, as you've shown over the last 11 weeks.

Mostly, because of the gap between who you want to punish and who you actually are punishing.  The strike of doctors in public hospitals hurts the poorest segment of society.  Pregnant women.  Premature babies.  HIV-affected families.  Injured pedestrians.  The elderly.  The rural and resourceless.  These people have no power to supply your demands.  Yesterday I found myself kneeling on the gurney to desperately perform CPR on a woman who delivered her baby at home, and bled to death.  Today I took care of her orphaned infant girl.  And a baby whose mother was turned away from a private hospital because she could not pay for a cesarean, even though her cord prolapse was a matter of immediate life or death.  These people are the ones suffering, and their suffering has increased exponentially over the course of this strike.  They don't blame you.  Even though they scrape by on less than 10% of the current lowest intern salary, they do not begrudge you your double or even triple target. But as paradoxically sympathetic as they are,  they can't increase your salary or supply the hospitals with gloves.

In some political systems, you might hope that the more the people suffered, the more political pressure would come to bear upon the government.  In Kenya, this does not seem to be happening.  About 36 hours before your arrest, after 2 1/2 months of the chronic humanitarian emergency this strike has sparked, a politician of the highest rank pulled into our town with his retinue, to campaign and register voters.  The suffering throngs lined the roads cheering.  NO MENTION of the crisis was made in the speeches; no questioning or accountability from the masses.  They will vote for him again, because they are ethnically loyal, and hopeful of benefit.  The politicians will not suffer.  When they get sick, they take public money to fly to South Africa or India.  They don't depend on your services, so they are unharmed both politically (because they still get their votes) and physically (because their medical care comes from outside this system).

Fred, I think we both know that a large part of the problem here is the devolution of health care from the central government to the counties.  In fact it is quite confusing, if the central government can't fulfill the CBA because the power has devolved to counties, isn't your strike against county governments?  Shouldn't they be the ones at the table?  Or the ones deciding on your arrest?  Something is very wrong with this picture.  I am guessing that somewhere far from Africa, someone with money and power dreamed up decentralization as the answer to corruption.  If Uganda, or Kenya, or who knows how many other places wanted aid and investment, they had to shift responsibility downward, closer to the ground.  What sounded good on paper backfired.  It turns out that under devolution, corruption has flourished.  The local pressure for favoritism and profit has been stronger, and scrutiny more difficult.  The counties and the ministry have swallowed health sector money like there's no tomorrow.  We need people of integrity to trace the money flows, people with a commitment to the common good to work at fair but not extravagant salaries, people with technical expertise to upgrade the infrastructure.

Striking is not making that happen.  Throwing you in jail is not making the problem go away either.  Everyone is losing right now.

But while you battle it out, there are lives that can't wait for your solutions.  I have critically ill children whose lives depend upon the substandard but sometimes-adequate care we can provide.  And I can't morally walk out on them, not even to show solidarity with you.

I hope you'll understand, and look for some alternatives.  Focus on standing up for the poor.  Talk about justice.  Pray and consider what Jesus would do. He turned over the money-changer tables and shook up the powers that be.  But he also refused to be crowned king, and laid down his life for others.  I can't tell you how to solve this, but I know God can lead you to hold onto your ideals with humility and to re-evaluate a road that will lead to true and lasting change.  No government can stand indefinitely against truth, fairness, and care for its people.

Believe me, working at the pace of a combined intern, MO, and consultant for this long has been draining.  I truly hope that you are released immediately, and that you and the government settle on terms that bring the doctors back to work.  We miss you.  And that when you do come back, your zeal will lead to a prioritization of good care for those who need it most.  There's no salary or promotion that will lead to a more satisfying life than simply being the healing hands of Jesus in the hardest places in Kenya.

Thanks for listening,
Dr. JM

Sunday, February 12, 2017

In this world you WILL have trouble

Two days ago we hoped that would be the last post on the Kenyan Doctor Strike.  What was I thinking?  The stalemate continues, and no one knows when it will end.  So tomorrow we start week 11 of this chronic crisis.

While we need prayers to continue for the hearts of the government to change (last night, after working another horrific and long day, we tried to get groceries but the whole town was shut down as people thronged the streets for a triumphant political rally as the motorcade of the President swept into town . . . and all I could think is, why are we cheering?  Where is the protest?  Doesn't anyone care?) and the hearts of the doctors to change (to their credit they've backed away from the massive salary boost and settled for a smaller one . . . but this weekend same as last one the person sharing calls with Scott simply didn't show up, perhaps fear of safety if caught working by the union, so mothers with potentially fatal complications were sent away in labor), what I know that I most desperately need is for MY HEART to change.  

Because feeling tired erodes my calm acceptance of the situation, and turns me mean.  And self-righteous.  And critical of those who seem to be making things worse.  Help! (The xray is a baby with lungs full of meconium, which is a nice word for poop, and symbolizes the suffocating feeling of the atmosphere of frustration, the need for a clear breath and a clean heart).

It's all about expectation, as Scott keeps reminding me.  Saturday I was under some illusion that perhaps a weekend day could be shorter.  That the two clinical officers who said they would be there to help me would actually do so.  But one had been re-assigned and one had a family member sick, and by the time I walked in to find that the 3-death day was actually a 4-death day, and that another baby had taken a plunge for the worse and needed urgent attention, and as I was working on that one I noticed yet another new baby who was purple and not long for this world, and the oxygen tubing was leaking, and the IV pump we got to work a few days earlier was now not functional. . . all I could do was work steadily to squeeze oxygen into lungs, calculate new antibiotics, listen, prod for IV's, fill syringes for blood tests, organize the two overwhelmed nurses to address the sickest priorities.  Mid-day I did get some help, but it still took 6-7 hours to sort everything out.  I left with the two newly-discovered critical infants both much better, called in about them during the night, but this morning found out both had died.  It feels discouraging and futile.  Today Scott is sorting out chaos, and about to start a C-section on a woman with her 10th pregnancy, whose uterus may already be ruptured.  It doesn't look good.

I am a fighter by nature, and I don't usually want to give up.  But at this moment, it looks very tempting.

So the daily Bible readings jumped out, as they sometimes will when one is desperate.

First was from Genesis 3-- I will greatly multiply your sorrow and your conception, in pain you shall bring forth children . . . Cursed is the ground for your sake, in toil you shall eat of it all the days of your life.  Both thorns and thistles it shall bring forth for you . . In the sweat of your face you shall eat bread.  Why do I expect things to flow, to work properly, to be rewardingly successful?  This world is broken, and putting it right takes serious push.  Your hands get scraped by thorns, sweat drips in your eyes, and conceptions multiply as most end in sorrow.

Second was from John 16--In this world you will have trouble (as in Genesis 3 above).  BUT BE OF GOOD CHEER.  I have overcome the world.  And there is the place it all hinges.  In the depth of this muck, you can still have cheer.  NT Wright comments "It's all happening because, with Jesus' death and resurrection, a new world--the new world--is indeed being born.  This is what John wants us to grasp.  This isn't just a matter of Jesus saying 'there's trouble coming, but it will be all right afterwards'.  It's a matter of seeing that when we find ourselves, a few chapters from now, at the foot of the cross, and then when we find ourselves after that with Mary Magdalene in the Easter garden, we shouldn't miss the significance of these events.  They are not merely strange, shocking and even unique.  They are the visible sign that God's new world really is coming to birth.  . . Somehow, even in the worst that is to come, the disciples can have a peace that will carry them through.  This peace doesn't come from a detached, philosophical attitude.  It isn't a matter of saying, 'Oh well, these things happen.'  It isn't a shrug of the shoulders resigning yourself to the world being a nasty place and there being nothing much you can do about it.  It's a matter of standing on the ground that Jesus is going to win--indeed, that here he claims to have won already.  'You'll have trouble in the world; but cheer up, Ive defeated the world!'"

So pray we could stand on the ground that's already won, that we would work with the courage that all tears will end.  Pray against a hardening of the heart, that says, oh well, babies die.  Pray against an anger at others.  Pray for the resilience to love, even now, even here.  Pray for good cheer.

If you read this far, here's some cheer, the best name I've seen on an admission list all year:  Lucky Pizza.  Truly.

Friday, February 10, 2017

Kenya Doctor's Strike Week Ten: A possible end in sight, and reflections on what we've learned

The strike that seems to never end has some glimmers of hope over the last 24 hours.  The doctors have signaled their willingness to accept a less than 300% salary increase if the government also addresses promotions, education, working conditions, and staffing.  It seems a Human Rights commission in Kenya is mediating talks now.  Which is good, because many humans have had no right to a safe delivery, a bound up wound, a course of antibiotics, or anything else for the last 2 1/2 months.  Pray that the government and the union respect each other and follow through on their compromises.

For the rest of us, the end, if it comes this next week, will be none too soon.  We are tired.  For six of those ten weeks (subtracting our trip to the USA for Christmas/Serge meetings) we've been acting as intern, resident, and attending on Paeds/Newborn Unit/OB for our local sub-county government hospital.  Rounding on every patient on our services, writing dozens of notes a day, routinely doing about five admissions per day, every blood draw, every conversation with relatives, many IV's.  Trying to teach the nurses and the limited clinical officer coverage. Working 6-7 days a week and some evenings and nights.  Our colleagues have been pushing themselves hard at mission hospitals with increased admissions.  The entire public health system cannot shut down without consequences, and even with extra efforts those who are standing in the gap can't do so indefinitely at this pace.

Today was a 3-deaths in 24 hours day, topping off a 6-deaths in 5 days week.

So while I and others feel totally spent, I've also been reflecting on how these six weeks give me insight into the life of our Medical Officers in rural hospitals, the bulk of Kenya's health care system.  Young doctors finish their internships, and then get posted all over the country.  And perhaps some of them feel like I do right now.  Here are what I see as the biggest challenges:

  • Being the only one.  Always. No sharing the burden, no input on hard calls.  When you take a break, you do so knowing that people will die, no one will stand in your place.
  • Being pounded by death after death, and acuity beyond your expertise.  The people who come to public hospitals have complicated and advanced problems.  They are the school kids hit by a car as they walk home, left with a skull fracture in a coma.  The nearly-40 mom who finds herself pregnant after raising a family, and struggles to have enough milk to breast feed, bringing in a severely (30% drop) dehydrated baby.  The 3-year old whose mother waits until hours from his death to finally come to the hospital, and get the diagnosis that they both have AIDS.  The 14-year old who gets pregnant at school, and whose illegal abortion attempt results in a live crying preemie that gets brought in.  The mom with a 6-month old coming from the western regions to look for work, bringing a severe case of malaria with her.  The women with no prenatal care, who carry in preemies they deliver on the way.  And on and on, all of the above just from the last few days.
  • Being innovative with what you can manage.  Like today, holding tubing under water looking for leaks and taping over them, to improvise more CPAP set ups because I had 4 preems at 28-30 weeks all on this breathing support.  No functional thermometer one day, no xrays the next, and on and on.  And I have oxygen (most of the time) and lights (better with a new generator) and more supplies than most.  For the real upcountry medical officers, it's draining to always lack the means to do what you know you could.  
  • Daily doubting your own competence and feeling like giving up, when another baby dies.  The evil in this world seems to have no end (technically we know it does, but that's by faith not sight) and an extension of it is the self-condemnation of failing another family, or the lethargy of steeling your heart against caring.  Even after 2 1/2 decades, I have found this very hard.  It reveals some ugliness about wanting to feel like it is ME who makes a difference.  It's a real struggle.
  • Being far from family, for most of them, and us.  Which makes the loneliness of the posting more acute....
Yes, there are also some great things about this work.  There is a satisfaction of giving care that no one else will give.  And if you can look at the 82 babies who went home alive in January instead of the 11 who died, that's hopeful as well.  There is the intellectual stimulation of a wide variety of cases.  There is the direct contact with allied health colleagues, and with families.  There is the personal challenge to learn and improve.  

But some days all of that doesn't feel like much.  Even though it's been a challenging time here during the strike, I have hope that it will end next week.  If I was a Medical Officer in Turkana, I'd be going on like this all year.  Or two.  Or three.

So I'd like to think about some of the things that keep us going, to share now while we're in the thick of it, as a way to think about perhaps reaching out to this group of young doctors in the future.
  1. Community.  The last couple weeks as I've felt overwhelmed, I made a What's App group with the Kijabe Paeds docs.  Some offered advice.  Some offered sympathy.  Some both.  A particular shout-out to Mardi who has been a great sounding board.  I know the MO's who graduate from Kijabe often text Ari.  That's a great ministry.
  2. Lament.  It's good to take a few minutes with a grieving mom.  To acknowledge it is hard for us too.  And wrong.  Here's a beautiful post by Mardi with a poem commemorating the lives that pass through our hands.  The Bible is full of honest lament.  Don't cover up or accept the injustice and sorrow, name it.
  3. Big-Picture Thinking.  Today as I was bemoaning the rash of deaths, I decided to go through the death registry and the admission registry.  The denominator is so often forgotten.  It is much easier to see the failures, the bad outcomes, the miseries than to remember that 8-10 go home well with a life ahead for every 1 who doesn't.  Scott has had super complex patients (severe near-eclampsia had a blood pressure of 200/130 as he started one case, a placental abruption that could have been a disaster, ectopics, a ruptured uterus, preterms, postterms,etc.) but in spite of 10 weeks of strike we haven't had a maternal death.  That's something.  Numbers can feel heavy, but in fact numbers can be a great encouragement. (And individuals can too . . the photo is a severely malnourished child, who after weeks finally had the gumption to play peekaboo and smile.)
  4. Goals.  Something to look towards.  I think an internal Kenyan medical conference by Kabarek Family Medicine for the upcountry MO's would be amazing.  A way to share experience, not feel alone, and see potential for further training.  
  5. Sabbath.  Like our life in Bundibugyo, this phase of work intensity makes Sabbath sweet.  It requires some tolerance of not being able to help everyone.  But that's part of the point of Sabbath, to remind us that we are not the ones saving the world, God is.
Hoping this is the last "Kenyan Doctor Strike" post.  If not, I guess we'll have to come back and take our own advice.

Tuesday, February 07, 2017

24 years of wonder

On a snowy morning in Baltimore, 24 years ago today, Luke made his debut appearance.  It was a bit touch and go, and he was almost a month early so whisked off to an incubator temporarily, but within hours he had the family in his thrall, where we've been ever since.

So today, a Happy Birthday shout-out to our oldest, the little LAMb who grew into lion size and strength.  Thanks for being YOU.  Insightful, confident, questioning, creative, energetic, passionate, fiercely loyal, wildly fun, wrestling with reality, faithful, honest, never-a-dull-moment you.

You're a great brother.

A great friend.

And a great son.  We love you.

Saturday, February 04, 2017

Kenya Doctors' Strike Week Nine: The Short Life of Baby Blessing

Imagine yourself in S's life, which is what story and empathy and being human are all about.  

S is 27 years old, and in her 6th pregnancy.  The first four pregnancies all ended in sorrow-a miscarriage at 3 months, then still-births or immediate-deaths at 5, 6, and 7 months of gestation.  She had one live baby after that who is now 2 years old, but after all that loss she feels the strain on her marriage of what is perceived to be her reproductive failure, and she was eager to have another.  Being Rh negative and high risk, she started going for prenatal care to a church hospital.  But Thursday night, suddenly, labor pains started.  She had only completed 26 of the 40 weeks a baby needs to grow.  She and her husband got a vehicle to take them towards the hospital, but the baby was born on the way in the car.  So they stopped at the first place they found, another church-based hospital near the highway that is only equipped for very basic care.  They wrapped the baby in blankets, put the mom and baby in an ambulance, and sent her on to her original destination, about five miles further on.  The ambulance pulls in, but the staff comes out to say that there is no room at the inn so to speak, all the incubators are occupied, so they never even get out of the ambulance.  This church hospital like most "private" but outreach-oriented places in Kenya has seen a 50% increase in admissions.  They are stretched to the bursting point, and have made the agonizing decision that they will not admit beyond their bed capacity, which would put the patients they already have at risk.  It's widely known that Naivasha is one of the only government facilities trying to stay functional, so they are told to go try there.  By the time they arrive it's about 2:30 am.  The baby is cold, gasping for breaths.  Nurses set to work warming him and starting CPAP.  All the incubators are occupied here too, but for better or worse they have no limits on capacity.  He seems to respond for a few hours.  

I arrive Friday about 8-something whisking into Nursery with efficiency, because I have some sick babies, some high levels of jaundice, and I've prepared all my paperwork and blood tubes the day before for getting samples to lab early.  If I can get the blood in by 9 and start rounds, there's a chance I can see the results by mid day in time to make adjustments to therapy.  The night nurse is just leaving, and casually mentions there's a new 1 kg baby who she's been resuscitating, but his oxygen saturations are in the 40's % (normal = 90-100%).  I hear the weary defeat, and while I wish she'd called, they know and I know that I can't come in every day and every night, so I feel like they shield me especially when it looks hopeless.  26 1/2 week babies have a very low survival anywhere but Kijabe, probably Tenwek, or a large Nairobi private expensive hospital.

Nevertheless, this little guy has a heart rate and responds to touch and my efficiently anticipated Friday goes out the window.  It takes me almost a full hour to persistently and gently bag the saturations up over 90.  His lungs lack surfactant, a lubricant that keeps them open, and with the low oxygen levels the blood vessels in the lungs also clamp down.  It seems miraculous when they somehow open after all the effort, and he gets pink.  A nurse has tried an IV but his veins are like strands of hair, so small, that even that effort has left his arm badly bruised.  Umbilical catheters are not really done here, but remembering "improvise" we find a pair of sterile gloves and open the package for our operating field, open a sterile blade and a suture that was in the cabinet, and a sterile ng feeding tube.  I swab his abdomen with betadyne and hope for the best, because he's now over 8 hours old with no fluids, no dextrose, no antibiotics.  Turns out it is possible to suture and to place a line with only your fingers in sterile gloves (no instruments).  Now we give the dextrose and antibiotics and put him on CPAP with a heater near by.  It's now well into the morning, and I notice that our nurse is all alone with this sick baby and about 20 others.  

Because the nurses have gone on strike too.  They had come back based on promises from the county government that did not materialize by the end of the month of January, so they didn't show up Friday.  Meaning only a contract (temporary) nurse covered the unit alone.  The mom who came from Nairobi to get her C-section for her preem who had stopped moving much (after losing a baby last year in the same scenario) can read and write, so she takes over weighing all the babies and recording their weights.  It's a crazy day, back and forth between the Nursery and the ward.  By 4 pm we hear that the nurses will return, so the wards won't be totally empty at night.  Whew.

Somehow the tiny, early premature boy plugs along through the day Friday, and the night.  His saturations stay at 98-100% in spite of very immature stiff little lungs.  His mom S., who had been counseled that he was dying, gets a little bit hopeful.  She names him Blessing.  Which just goes to show that there are people in this world with faith greater than we can imagine.

I've texted with the lone night nurse so I know he's still alive as I arrive Saturday, and I'm starting to hope too.  Maybe he'll be a fighter.  Surely the dramatic turn of yesterday morning means something. But this morning he looks cold, with a heart rate in the 90's which is rather low for someone this size.  Being on a non-functional resuscitation bed covered with blankets next to a heater (see top photo) just isn't working well.  Our three incubator choices are underheat, no heat, and overheat.  I choose overheat and we move babies around.  But when he's put in the incubator, his condition plummets.  Again I bag, but this time in an hour he's barely touched the 90 range once.  I ask his mom to put her hands on him for warmth and prayer.  We stand side by side, me leaning into the incubator trying to keep oxygen going in and out of his lungs, watching the numbers on our single monitor.  This mom asks about any medicine that can help, and we talk about her sending someone to Nairobi for surfactant, which I might be able to find a way to give (again, the moms who meant to go elsewhere but land at Naivasha are quite different from the vast majority who get care here, for whom a $130 vial of surfactant would be over two month's of income, impossible). There are a couple of moments when I think we might make it . There is another when I am completely alone with the babies, and I lean my head down on the incubator and cry a bit, I am so tired.  I go for an hour and 45 minutes with diminishing returns.  This would be her fifth loss, and I want to give it our all, and yesterday the baby responded, but today I feel punched back by evil.  Finally about 11:30 am, mom has gone to rest, and I give up.   The sats have sunk into the 20's.  His brain is almost certainly not recoverable now.  The lone nurse (no strike today, but only one working) puts the CPAP back on.  Within five minutes, he's dead.

Baby Blessing might have lived if the strike was not on.  His mother might have had closer follow up.  She might have reached her better hospital sooner.  When she did reach, they probably wouldn't have been so overwhelmed, they would have had space or made space for one of their own prenatal-care patients.  Our NSCH would have had more nurses, and interns on call.  His life was a long shot, but his death was certainly hastened by the strike impact.  And he happened to be living within an hour of the limited available care.  If he'd been born beyond the small radius of accessibility to a church hospital or the minimally functional Naivasha or Nakuru, he would have died the first night, which must certainly be true of multiple preemies per day over the rest of the country.

S. cried when we told her, but she also expressed her trust in God.  The death, for her, like many women here, is only one part of a larger picture of expected fertility, family pressure, a sense of failure and desperation.  My nurse was excellent, counseling her to rest, to take time before getting desperately pregnant again.  We both talked about our own losses and families and ages at delivery, which gave her some hope.  As defeated as I felt when Blessing died, and the rest of the day's work loomed still ahead, even I felt better after praying with the nurse and the mother.   I had so wanted God to intervene, to dramatically save this boy, because his mom had been through too much grief.

And, if I'm honest, because I needed the emotional boost too.  It's been a death a day this week.  A severely malnourished child with previously undiagnosed AIDS.  Another baby with AIDS.  A toddler with the severe viral syndrome we're seeing.  Another preem born before getting to the hospital, cold and septic.  Blessing.  Others who are alive are scarred forever.  We had a baby abandoned in the market, two babies starving at their mothers' empty breasts, a 9-year-old beat so badly by her teacher that she couldn't move her arm, a 5-year old raped by her stepfather.   In the news another child to our north was "caned" by the teacher then the whole class was enjoined to beat her, to shame her inability to read, and she actually died.  It's a broken world out there.  The government is paying themselves salaries that are more than a hundred times higher than the parents' of my patients, and can't come to a solution for the public health system.  The doctors refused a major raise, holding out for the tripling of their salaries.  

How does one live in such a world?  

My Bible reading this morning took us to the close of 1 Corinthians.  Paul writes, "come, Lord Jesus."  We ask for God's merciful presence right here with the suffering; we ask for God's justice to shake up the principalities and powers that wield evil broadly and to sanctify our own evil hearts.  And while we wait for that coming, here is Paul's advice:

Keep alert, stand firm in your faith, be courageous, be strong.  Let all that you do be done in love. 

Those are words to live by. Please pray we would be alert to God's mercies, see that His goodness which far outweighs the sorrow, like the baby below who is peacefully sleeping and growing.  Truly the vast majority of our patients have happier stories.  Pray we would stand firm in faith when every day carries uncertainty of what we will face and with how much (or how little) help.  That we would be courageous and strong, like our Ranger School son who made it through the first (and hardest) week.  Months still to go though.  And mostly, that all we do would be done in love.  Not for political statement or for stubborn duty or for personal satisfaction, but for love of God and His world.