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Wednesday, January 31, 2018

Oh Kenya, what next?

Yesterday Raila Odinga, the long-time politician (he's over 70 years old which is no small feat in this country) who was ultimately declared the loser in the presidential election held his own swearing-in ceremony as "the people's president".  He swore an oath to uphold Kenya's constitution, on a Bible, and gave a short speech.  President Uhuru Kenyatta who had been declared the actual winner after two full elections in August (the courts declared invalid) and October and was sworn in officially months ago warned that this alternative ceremony would be a treasonable offense.  Police were prepared with tear gas, security details the government routinely provides politicians were withdrawn, and three TV stations were shut down.  It looked like another day of disaster and violence was about to ensue as thousands and thousands of people gathered in the center of the city.

(photos from news sites still posting on line)

Instead, the day unfolded peacefully.  Raila's supporters cheered. The country had to admit that vast numbers of people are not satisfied with the politics.  Without police reaction, the violence was kept to a minimum.  Unlike the normal post-Raila event, there were no riots, no looting, no rocks and battles.  Kenyans turned out for a peaceful protest, and impressively did just that.

Still one has to wonder, what next?  It seems the government wisely decided not to provoke a confrontation that would escalate to bloodshed, and let the event occur then fizzle.  It seems that Odinga's deputy declined to show up.  Life went on.  Swearing oaths is an important cultural institution, with layers of meaning I'm sure I don't understand.  What does a deeply divided country do now?

Limp forward I suppose.  We still don't have enough staff.  Our hospital is running on less than half the number of nurses we should have.  Only one new doctor has been posted in spite of losing others.  Oxygen petered out on the weekend.  It's not clear whether our internship program will stay accredited.  Today we found that a little 8 month old girl who dodged AIDS from her infected mother inexplicably has a brain tumor.  There is always another sorrow which we are ill equipped to handle.

Kenyans excel in humor and resilience, and courage.  They will keep marching to protests, and keep plodding to work.  Here's to hoping they find ways to focus this activism on holding their elected representatives accountable, quashing corruption, and innovating solutions.  Oh Kenya, may justice be our shield and defender so we can dwell in unity, peace and liberty.

Sunday, January 28, 2018

The power of beauty

Like Job, we need regular infusions of wonder to counteract the despair of suffering.  God pointed Job to the beauty and mystery and majesty of creation as the only real answer to the deepest questions that Job's losses posed.  So if we could add one more lesson learned to the post below about walking with those in pain, it would be this:  look at the hippo.  Get outside, surrounded by trees and clouds, by flamingoes and zebra.  Or go to an art museum, or a concert.  Or enjoy Scott's photos (click on each picture to see a higher resolution version).

Walking with the suffering: some thoughts along the way

We face death and heartache every day.  Just for this week:  people we loved had surgery, went to funerals, found out about unexpected pregnancies and losses, faced false accusations.  My mom lost her best friend suddenly. A 35-year-old Serge worker (not in our Area) collapsed with a cardiac arrest and is still semi-conscious in an ICU in a foreign country where his wife and young children cling to hope.  A 39-year-old worker with another organization with whom our teams in Nairobi partner closely died in a paragliding accident in the Rift Valley; our colleague George led her memorial service yesterday even as his own family grieved.  Emergency trips to the USA for a stage-four cancer diagnosis in a dad, a funeral for a grandmother, a sickness in a child.  Another missionary doctor family (not Serge) left the field abruptly when their young daughter's abdominal pain turned out to be a widespread malignant tumor.  My intern yesterday felt ready to give up, he's exhausted and had had two babies die one after the other in the afternoon.  Our former Bundi team leader Travis heads for yet more invasive tests to enter an experimental trial for the metastatic colon cancer he's been fighting for years.   We sat with a hurting missionary whose deep personal pain just did not make sense to her.  And none of those stories are more than a few days old.

So the op-ed piece I read yesterday, written by Duke Divinity School professor Kate Bowler, caught my eye.  She writes from the place of suffering to talk about how people respond.  Her words are well worth reading as she grapples with the false prosperity-Gospel so popular in America and Kenya.  Here is a summary with our own thoughts included.

Don't minimize; Do acknowledge.  Cancer and grief and betrayal and loss feel so overwhelming, sometimes I know our first reaction is to cut the problem down to a manageable size.  Maybe we compare--sorry you miscarried in the first month but at least you didn't bury a baby after going through 9 months of gestation and a full labor and delivery.  That kind of thing.  We even do it in our own minds, trying to convince ourselves that we should't feel sorry because others have it much worse.  How can I complain that I miss my kids when I saw 3 out of 4 at Christmas and my colleague hasn't spent Christmas with his kids in 8 years?  So the first way to be helpful to others and ourselves comes right out of the Psalms--state the problem, cry out, admit the hurt, see the pain.  List the losses.

Don't build a box; Do embrace mystery.  The second response we often have to overwhelming sorrow is to try and get control. Develop an explanation.  This happened because that person didn't wear a helmet or get a vaccine or spend enough time with their kid.  That happened to them but I'm not going to let it come near me.  We build a box of logic, of cause-and-effect, of theological justification.  The entire book of Job pretty much consists of his so-called friends probing to find out what he did wrong to deserve such tragedy.  Or the people who bring the blind man to Jesus and ask, who sinned, him or his parents?  Over and over, God busts our boxes.  Job was more righteous than all around him, and God never actually explains Job's suffering.  We read some of chapter 40 in worship this morning.  God's only answer was:  would you condemn me that you may be justified?  Look what I made.  In other words, we have to embrace the mystery that suffering and blessing both come into our lives unexpectedly, that these are ways God disrupts our comfortable limiting explanations and reminds us that God is God and we are not.  Jesus answered the blind man's friends by saying, this happened to reveal the glory of God.  We pray honestly but we embrace the mystery that God's ways of working may not make sense to us.  Ever, or at least in this world.

Don't hide; Do practice presence.  It's hard to be with suffering people.  I lose multiple patients a week.  When it happens in front of my face, when the child is in my hands, when I hear the mother's wails, it hits me a lot harder than when the intern calls after it's all over.  Sometimes suffering feels contagious.  Sometimes we just don't know what to say. But the one thing some of Job's friends got right, like the women at the cross, was to just sit and mourn with him.  To be present carries great power.

Don't give up; Do point to truth and hope.  Related to hiding, as cancer or broken relationships or disabilities drag on, it becomes harder to hang in there with the sufferer.  And it's hard to speak the truth in love without sounding like we are minimizing or explaining away.  That's why this one has to come last, after naming losses, embracing mystery, practicing presence.  Only then are we ready to point towards redemption.  We do have some truth that we can share.  The arc of God's story stretches out of view, but we've been given some glimpses of the ending, and it is good.  Love is stronger than death.  God is working in all circumstances.  Nothing can separate us from God's love.  None of those statement imply that one must muster up positive prayers to generate the outcome they wish for.   But all of those statements provide a bedrock and a beacon to walk through the next day, and the next.  When we are suffering, we need to lean on truth and mercy, and sometimes we need others to remind us of those things.

Thanks Kate, and Travis and Amy, and parents of Kim, and many other saints, for bearing witness along your stony paths.  We need your voices.  Help us to listen, show us how to bear the cross, and lead us to resurrection.

Sunday, January 21, 2018

How we failed A.: a story of chronic illness in a resource-constrained place

We walked into the hospital last week for our first day back:  staffing changes, absent interns, the usual crowds and needs.  Scott was orienting new visiting residents and evaluating women for surgery and I was catching up on complicated patients and deciding on treatment plans, both of us distracted by also trying to pay attention to our visiting mom and to various team issues.  About half way through the morning I walked into one of our isolation rooms and nearly stopped breathing.  The 11 year old boy I saw sitting there truly looked like a skeleton.  His skin stretched taunt enough to see the shape of each bone. He greeted me in English and even smiled a little, and his mom said he'd had some mouth sores the last two weeks and lost a bit of weight because he wasn't eating, but now he was doing better.  No one could look like that in two weeks.  So over the next few days I learned his story. 

His story on this earth is now over, but I offer a few details in the hope that we can change the next story. 

A. was born with HIV infection, but he and his mom did not know that until 2010 when he was 4 years old.  About half of children who are born HIV-infected in Africa will progress to AIDS and die by the time they are 1 year old.  He was in the other half who struggled along.  So our first failure to A. and his family was that his mom was not diagnosed before or during pregnancy, so she took no drugs to prevent transmission of the virus to A.  Our second was that he was never screened after birth.  So by the time he was 4, this HIV infection had advanced enough that he weighed less than 20 pounds (9kg).  At that point he and his mom got the sad hard news of their trouble, and entered clinical care.

From 2010 to 2017 he went to clinic at least every three months.  I looked through pages of his notes.   He was prescribed anti-retroviral drugs, and Septrin to prevent infections.  He first had a blood test to quanitfy his viral load, the amount of HIV virus circulating, in 2013.  Why not earlier? Another failure of our world, that places like Naivasha with high burdens of HIV still lag behind places like America in availability of testing.  The tests are sent away, there is a lag time of weeks to months to get results, they are done infrequently. The test came back with terribly high levels of virus, meaning that his drugs were not working.  Kenya protocol requires that a child with a poor response to drugs be counseled for compliance and retested in 3 months and then changed to a stronger combination.  Instead he was tested once a year from 2013 to 2017, every time with sky-high unacceptable results.  But no changes made.  He was growing from 20 to 40 pounds (10 to 22 kg), getting taller, going to school.  So our system failed to realize this child had unchecked untreated HIV in spite of taking his medicine faithfully, and did not respond.

In 2017, his records show his weight dropping every visit.  From 22, 21, 19, 17, 16, 15, to 14 kg (40 down to 30 pounds).  Finally in November someone realized that his dropping weight and his high-viral-load results meant he should change medicines, and switched him to a regimen that should have been the first choice years and years ago.  But he kept dwindling.  By the time he was seen in January he weighed 12 kg, and then when he was sent to be hospitalized, 11.  That's 24 pounds as an 11 year old, the same as his weight when he was five, having lost HALF HIS WEIGHT in a year.  In spite of this someone checked a box on his record each visit over the last year saying "weight loss?" "NO".  Another failure.

After a lifetime of untreated HIV infection, after dwindling to a skeleton, after probably having HIV-associated malignancies and opportunistic infections running rampant, I saw him the last few days of his life.  We had treated his sores and we gingerly tried to re-feed him, offering limited calories through a nutritional milk that he loved.  His temperature remained cold, his labs were off the charts abnormal.  He needed an ICU and a miracle and we had neither.  Friday night my intern texted me to say that A. had died.

I believe A. is now healed.  That he has a seat of honor at the wedding feast of the Lamb.  That he's no longer hungry or weak or cold or in pain.  That the "all things new" promise of Revelations extends to him, right now.  I only wish it could have started 11 years ago.  Or before that.  That's why we are here, why we do what we do.  Bringing that all things new into this place.  Please listen to this Hillsong video of the song we played for church this morning, in honor of A.


Writing is in my blood, the desire to process, to share, to explore ideas, to shape memory.  But for the last month I have been unable, because the fullness of life itself has been too varied, to rapid, to overwhelming to leave time for thinking about it.  Christmas and New Years were, for us, a discipline of living in the present moment. 

The week before Christmas all our kids except Caleb arrived in Kenya, Luke brought Abby to brighten up our family, and we all went to a house on the coast of the Indian ocean that we've rented several times before.  Warm waves, fresh tropical fruits and fish, games of bananagrams, walks in the sand, snorkeling, it was a glorious four days.  Then we spent three days camping in Tsavo National park, celebrating Christmas in the wilderness, our stockings strung between palm trees and our tents overlooking a muddy river populated by crocodiles and hippos.  Dust and driving, elephants and gazelles, sunsets and sunrises, Christmas traditions over the campfire. 

That week of true holiday, in the holy-days sense of turning away from normal time and giving focus to the presence of God in tradition and in each other . . was truly refreshing.  We don't want to hide the fact that we take vacation, good restorative adventurous memorable days, boosted by the generosity of our moms.

Back in Naivasha we returned to work between Christmas and New Years.

Then we flew to London and bused on to Battle (site of the 1066 conquest of England by the Norman King William) for two weeks of Serge work--first a conference for all the team leaders around the world, then our usual semi-annual meeting of the Area Directors and Executive Leadership Team.  Seeing our East and Central Africa group brought us much joy as we ate meals together and held endless sidebar meetings.  We prayed specifically and earnestly for so many people and issues.  

As the meetings ended, we met Scott's mom Ruth at the airport in London for a two week visit, and flew back to Kenya together.  We've been back to work but also entertaining Ruth: seeing patients, having meetings, teaching lectures, making phone calls, interspersed with introducing Ruth to friends, going on a weekend overnight to a lovely lodge and driving in a game park seeing animals and birds.
At the airport
For once, Ruth can enjoy OUR cooking 
Watching the sunset in Naivasha 
Game driving at Lake Elementaita

So, in short, since mid-December we've been immersed in the lives of our kids, our teams, and one of our moms.  Meaning very little space in our conscious days has been left for writing.  Thanks for coming back to our site, and reading this far.  Thanks for the Christmas cards!  And we're back.