29 deaths in 28 days after 25 years: thoughts on burning out and smoldering on

October seemed so promising for the first couple of weeks, as we celebrated some encouraging discharges, some unlikely healing, some cheering morale.  But the nature of serving in a marginal place is this: even doing the right thing with all we have is often not enough.  Sure, scores of preemies have been discharged over the last weeks, and remarkable resuscitations have seen lives saved.  But the OB team had their first maternal mortality in months Friday evening, and the Paeds team has had a discouraging run of septic twins, severe asphyxia, an abandoned hypothermic baby found in the bushes, home deliveries brought in days later on the brink of death, tiny prematures born on the way, all not making it past the first 24 hours. I made a graphic for a lecture recently that described all the massive societal injustices that impact HIV prevalence and severity, and drew a tiny arrow to represent the medical impact of getting the medications right.  It helps, but it doesn't solve all the huge gaping wounds of poverty, violence against women, lack of transportation, inadequate staffing, corruption, and on and on.

As we passed our October quarter-century-in-East-Africa milestone, I've been thinking a lot about endurance and burn-out.  The years do not make one immune to discouragement, or confer the wisdom to not rail in the heart against a thousand frustrations.  A friend sent us an article about physician PTSD in the USA that described current medical life as "death by a thousand paper cuts", the idea that the accumulation of small constant assaults on your sense of purpose and joy accumulates to a career-ending level. Not everyone's story is the same, and longer does not necessarily mean better (and we would thoroughly encourage, actually for our organization, MANDATE, serious time for healing and reflection for anyone sensing such a loss of hope and vision).  But by grace and prayer here we are on a rainy afternoon many thousands of miles from our immediate family and if it is any help to those a few years behind, here are some reasons why.

1. Grace through you.  Your prayers. This has to be the top of the list.  A thousand may fall, but if God still has work to do in and through us, still has a path for us here, then here we remain.  That may sound like a sloppy syllogism, but deep down we have to humbly (Psalm 91) acknowledge it is true.  Many people do everything possible for a long and healthy cross cultural career and they are dealt an unsurvivable blow.  We have not been.
2. The Burning Paradox.  I think that most of us would assume that to prevent burn-out, we should turn down the flame.  However, a couple of weeks ago I read a thought-provoking article by a physician who suggested that delving deep into harder work actually might bring more satisfaction, which in the long run might keep you going.  Perhaps instead of turning down the flame, adding more fuel? I do think that for our particular wiring, being all-in committed to a team, a project, a patient, can paradoxically bring life. At various times for us, that has meant pioneering HIV prevention, innovative nutrition programs, investing in medical education, or perinatal care for maternal and infant survival. (below, a malfunction in the camp stove this weekend seemed to illustrate the point).
   
3. The Bigger Picture. Being part of an arc of redemption that extends through history, being a tiny footnote in a glorious story where all shall be well, all manner of things shall be well. We don't see evidence of this everyday unless we look very hard, but by faith we hold onto this truth.  
   
4. The Community of Colleagues.  We cannot overstate the uplift of a team, the life-saving attitude-rescuing essential of working in community.  Our fellow Sergers, our Kenyan counterparts, our daily interactions with trainees, the nurses, the neighbors.  Work for the common good, done with the and for the community, brings a sense of belonging. We are relational humans; and that human touch can make all the difference. A corollary to this is investing in younger people, in students particularly.  Passing on our gifts by creating a human bond while teaching.
   
5. Countdown against Futility.  Atul Gawande advises medical students:  count something . An act of measurement fights the temptation to believe all is vanity.  Change can be slow. We can lose sight of hope, and think nothing changes in spite of our efforts. So accumulating a few facts to the contrary can build a sense of curiosity, which is close to a sense of purpose.
6. The Leavening of Levity.  There is plenty in every day to mourn; it takes commitment to keep finding the humor.  But honestly the difference between a spiral of sorrow and a plodding resilience can be the ability to regularly see irony or absurdity, to not take ourselves completely seriously.  We need help with this sometimes.  But if you can't laugh at your own ridiculousness, it's time for a break. It's OK to acknowledge our mistakes, to even laugh at them. Which brings us to the final thought.
7. Rhythms of Sabbath and Festival.  The ancient culture of one day's rest in seven, three all-culture week-long assemblies laden with food and fellowship, still bears wisdom.  If we can't step away from work we start to imagine that everything depends on us.  Once we were asked to speak to young doctors and said, while you're in Africa, take your family on safari, even if people die while you're away from your hospital.  It felt a little risky to say that, but we still believe it is true.  We are not God.  When we unplug from duty and demands, immerse in beauty and quiet, we gain staying power for more good overall.  This is perhaps the counterpart to #2, a work-hard rest-hard philosophy.  This week we spent one night in a tropical rainforest, a small community-run campground, hiking in the mist, listening to birds.  Less than 24 hours, but it was another bolster of refreshment to return to the mess ahead.

I am well aware that even as we ponder the grace that has kept us thus far, we do not know what's around the corner. For this moment, however, these are the truths to which we bear witness.  They actually align pretty closely with our organization's core values: the big good-news picture, the foundational centrality of prayer reflecting unseen realities at work, embracing vulnerability, focusing on loving people. 

Tomorrow will probably bring a 30th death for the month.  It will probably bring some disappointment, some mistakes, something important we miss, some longing for those we love, some awareness of our weakness and temptation to hide or pretend.  But we pray for ourselves and those we supervise that tomorrow will also bring eyes wide open to the deeper realities, curiosity to investigate and delve deep, connection with others, and a few laughs. And a rhythm that paces us into the next 25.