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Sunday, March 29, 2020

#COVID-19UGANDA day 8; on Fear and Charms and Ultimate questions

You know the "pan" is in pandemic when you find a diagram of the coronavirus on the wall of a home in Bundibugyo. I was intrigued by the personification of those eyes; the medical detail of the protein spikes; the smear of mud on mud to make it adhere.
The first sign made me assume that someone was doing a little teaching. The second and then the third made me curious.

Adherent to the front of the house, some kind of tag, warning, or an attempt to ward off the evil? I asked a lady I recognized who was greeting us, and she ran around the corner of her house and ripped the paper down, muttering something about the children, then turned to us and affirmed "Ruhanga enka."  Only God. 

We are all in this same boat. In Iran, we read today, a viral meme about whiskey-and-lemon as a cure for the common cold plus the confusing insistence on high-potency alcohol hand gel, in a country where alcoholic drinks are forbidden, has led to hundreds of people sickened and even dying from the ingestion of toxic industrial methanol.  The CDC had to warn Americans against purchasing an additive meant for fish in aquaria that contained chloroquine in the ingredient list, after reports emerged of toxic ingestions to ward off corona. We all want a way to feel safer. For many of us that's information. Reading the literature, checking the stats, examining who died and who did not, clinging to the reasons to assume ourselves into that 85% camp with an almost-assured recovery. For others the fear stokes latent anti-other feelings. Some African communities are threatening to harm anyone from other places, and we don't exactly blend in well. Some American states don't want anyone with out-of-state tags passing through. Yes we should respect the basics of hygiene and socially responsible (read, LIMITED), movement. Yes, we should embrace this season of the hibernation, the limit, the small. It is however heartbreaking to see the way that crisis reveals not only hidden generosity and goodness, but also darker realities.

But here on the edges, I can see the appeal of the evil-repelling charm, the bet-hedging poster. No one in this district is going to be on a ventilator, so if Africa follows trends of the North we could be looking at death we are helpless to prevent. Face to face with such realities, our neighbours aren't stockpiling toilet paper or calling 911. They are going down to the spiritual questions which matter. There is a new harm afoot, and how can we survive it. These are the questions that have faced humanity for millennia, though we do our best to numb them. Is God good? Does God care? And can that truth, if held, encompass the reality of COVID-19, or AIDS, or malaria, or war, or poverty, or corruption, or, or, or.. . . .?

Uganda's cases now number 30; all our neighbouring countries have slowly accumulating counts as well, except for a couple that are either very isolated or very reluctant to test or most likely, both, with zero. The five suspect cases from our hospital on Friday were all tested negative by Saturday night. So we still find ourselves in the peculiar position of brace. Of watching our families in the USA and UK become more and more hemmed in, surrounded. Of some of our kids working long hours in the hospital or garden; of other family members spending their days to protect the vulnerable by keeping our older or immune-challenged people set apart. While we wait for our environment to become like theirs, only without 90% of the response capacity.

In similar times, people of faith looked to the hills and asked, where does help arise?  And I think my neighbour already gave us the answer. Ruhanga enka. The maker of all things who never sleeps. Let's wash hands, and use every spark of wisdom to research better care, every spark of compassion and energy to save lives. Let's use all that God has given us to fight against not just this virus, but also fear and hate. But for now at least we have to do that while living in the tension that we can't control the story, but we know the one who is writing it can bring good yet. 

And while you're at it, remember the Psalms (like 121 above). This song echoes 126 (and Rev 21). I also keep going back to 46 and 23 and 27. And 42 with echoes of Jonah. Or Psalm 91. Post your favourite Psalms and songs for this time.

Saturday, March 28, 2020

#COVID-19UGANDA; end of week one, the paradox of weeping and truth

It is Saturday, and the weaver birds quarrel and chatter as they bustle about their nest colony in the royal palms outside the front door. Scott is sitting outside on our patio with a policeman. Because even though we don't have COVID-19 death yet, we still have death. We are not yet on lockdown here in Uganda, though now the country reports 23 cases. No public transport, even motorcycle taxis (bodas) are not allowed to carry a passenger, no school, no churches, no gatherings, no weddings, no funerals except 10 immediate family . . . but people can move to the market on foot for food, can greet each other with a wave and conversation. So we are still meeting as a team, with some small attempt at #social_space but a bit of inevitability too. Mostly we are a lower risk group, and the harm of complete isolation in a culture far from home at a time of world upheaval has seemed more risky than sitting in a circle to study the Bible and pray. So on Thursday afternoon, we had our usual team meeting followed by outdoor pizza making.  As we were putting pizzas into the oven and gathering team, we heard a massive shattering crash sound. Twice this week major branches have fallen from our mango tree (it's an old tree, this is a fruitful season, and as the rains return there is wind). So I immediately checked to see if a kid had climbed and fallen, or been smooshed. But Scott and Marc realized it was an accident on the road and went running out the gate. I was a few feet behind after stopping inside to grab some gloves.
All screening to take place in that tent before entering Outpatient Department

There was a motorcycle on its side, and many yards up the road, a young man lying on his back with a gathering group of onlookers. We checked his body, held his head to protect his spine, cleared his airway (thanks Kacie for running home to get a bulb sucker), protected him from being moved, assessed his neurologic status (NOT GOOD) while Marc cajoled the hospital ambulance driver into coming. There was blood, there was the eventual arrival of someone who knew his name, someone who could call for family, a wailing young wife, the police. There was the depressing reality of a hole in the back of his skull, and almost certain dangerous bleeding in his brain. There was a moment of prayer by our friend Asita who came by and we invited to intercede, loudly on her knees by the roadside, followed by a bit of hope when he seemed to start responding to us slightly. We eventually got him onto the guerney with his spine still protected, and off to the hospital. He died an hour later.

Nothing to do with the pandemic, but everything to do with the edginess of life here, being first responders to a motor vehicle fatality right smack in front of our house at a time when we are already on high alert and deep in grief. Seeing again the inadequacy of the health system.
staff meeting with #social_spacing

Friday morning, our hospital staff meeting was held outside, with us standing several feet apart, for better following of protocol. Two suspect patients had been admitted to the Ebola Treatment Unit, a tent set up 18 months ago in response to the Ebola epidemic boiling away less than 50 miles west of us. That had lead to general exodus. Maternity and Paeds still had half to two-thirds of beds full, but since we usually have ALL and many on the floor, it felt quite empty. I did a talk with all the patients to keep giving as accurate information as we can, to fight fear. Two young babies had lung findings and respiratory rates over 70. It is impossible to say if that is a coronavirus or some other virus. I was thankful for my mask.

And again, in the midst of all that, death came stealing. A newborn delivered at a smaller unit that morning, after 2 days of labor, limp and blue six hours later but still with a detectable heart rate. His young mom, first baby, laid him down wrapped up in the kitengi, hoping for a miracle. Scott called me to help and we did CPR together. No oxygen (!) but just bagging his little lungs and pushing his heart inside his little chest and a shot of dextrose and epinephrine got him pink and his heart back to normal. But his little brain was just as damaged as the motorcyclists I'm afraid. He was still alive on CPAP in our new NICU as I left, but taking infrequent gasping breaths. In both situations, almost no hope of recovery, but a kindness to still do SOMETHING, to put our hands on and give what care we can and minister the peace that the family did all they could.
Jessie and Kacie, nutrition program still goes on

Processing life during this pandemic is a constant, exhausting challenge. With our team, we agonize over policies. We delve into scriptures about prayer. We lament losses. We share where we are, knowing the next hour could bring a new level of restriction or danger. This takes time, so on Thursday after sharing I asked us to all pray ONE WORD for the person on their right, based on their expressed need. Many of those words were peace, surrender, courage, trust, flexibility, confidence, encouragement, awareness of beauty, be smart, resist pressure. My word was paradox.

Because like Jesus approaching Lazarus' family, I find this season to be a constant holding of tension. There is a genuine need for entering into our fears, lamenting our losses, naming the sorrow. When Jesus met Mary, he wept. No words. This is an unprecedented year in human history--we have had equally deadly plagues, but not with the global connectivity to experience not only our local trauma but stories and statistics from around the world. We have had dangers, but there were always places that offered escape and safety. So the first pole of the tension is to just settle into the hard reality of just how NOT RIGHT this moment is. But the second pole, like Jesus with Martha: we also need truth. I am the resurrection and the life, He said. Death is horrible but not the final word. Weeping endures but does, eventually, end. I don't know when that will be, or how, or what the next months will look like. But we keep trying to glean truth from God's promises, and truth from the medical studies, from colleagues, from discussion.

And at any moment, I don't know who is a Mary and who is a Martha. Who needs an ear and a tear, and who needs a verse and a policy. 
small gatherings outside shops

cocoa is becoming scarcer

when the storms knock the mangos down before they are ripe, making mango crisp is a taste of beauty

Milk and eggs from the market, walking up the road.

For my family in NC where evidently bread is now out of stock . . . we have bread!

Thursday, March 26, 2020

#COVID-19UGANDA; A complex emergency response day 5

Uganda cases are now14, out of 308 tested. We are still in the phase of only suspecting travellers, so if the coronavirus entered months ago and has been persistently and relentlessly spreading, we don't know. So far only one test has been done in Bundibugyo, and it was negative, so we have no idea locally either.

Five minutes ago, the third neighbour/acquaintance of the day came to say that they needed help. Food prices in the market shot up as soon as the first cases were announced. With borders closed, markets limited, movement discouraged, school children sent home, the average person here is not as concerned about dying of the virus as about going hungry. The main cash crop, cocoa, has already become much less valuable as European markets imploded. So our friends say, here we are at home, sitting with nothing, and not sure what we will eat. Uganda is a fertile country but also a crowded one. The average household here will be more able than most places to survive from a garden, from the land, but it will still be hard. Most markets have been closed down.

Every day, almost, the president speaks and announces new restrictions. Last night he canceled all public transport--all buses, matatus, bodas, trucks. Now motorcycles can deliver packages but not people. VERY FEW private cars exist, so this is an effective way to shut off movement. There are road blocks now set up between our town and the border. Questions are asked and the military is serious.

Our teachers spent the week working on take-home assignments to be distributed to our 357 CSB students tomorrow. They had a plan to go tomorrow to seven points around the district, and hand the hefty packets out to the students forced home a week ago. Only now everyone is afraid to do that, lest we be accused of causing unlawful gathering. The government did approve the plan to have teachers get radio time, but with transport shut down, even that might not happen. Wealthier elites will have TV and internet in the cities; our students will have nothing.

That is the floor, something that is usually covered with mattresses and mats and blankets and kids

Medical care continues, but as expected, patients are afraid too. Maternity was still full. Paeds was down to 100% full, meaning only beds and not the floor. And to add insult to injury, I saw the first case of measles in about six months. Last year this time we were in a major measles pandemic, but the concerted efforts of vaccination teams over the course of 2019 really made an impact. Measles is even more contagious than coronavirus, and deadly. In fact over 140,000 children/year have died of measles the last couple of years, due to failure to vaccinate. So far this year, 20,000 people have died of coronavirus. (Begging the question of, will everyone get a coronavirus vaccine if it becomes available, or not!? The COVID-19 risk to people under age 50 is probably similar to seasonal influenza; how many of those got a flu vaccine this year??).  My case yesterday was a 6 month old, meaning he had not yet been old enough to get the vaccine, and missed the special campaigns of 2019. His illness also means that there is active virus circulating in his community. So in the midst of COVID-19 preparedness and anxiety . . . we had to call for another team to go out and investigate measles.
Measles rash in an otherwise quite robust 6-month-old

Which illustrates the point of a complex emergency. COVID-19 is here, and it will cause harm directly to many people who will suffer. But it is also already causing collateral damage. How many malaria patients didn't get treatment this week because they were afraid to come to the hospital? How much will measles, or HIV, or gastroenteritis surge as all attention is diverted? How will the economic downturns translate into malnutrition, or domestic violence, or dropping out of school?

And while we track Uganda, and serve Bundibugyo, we also keep our eyes on the global escalation, remembering that the actual cases are probably 10x the confirmed cases (or more). So for our team, there are so many layers of trauma. Hearing and watching our community and friends suffer all around us. Working to prepare for the worst when we know how limited we are. The ever-present possibility of getting sick. Watching other Americans evacuate Africa (not now that it's all closed down, but a few days ago) and choosing to stay, then second-guessing that. Fielding well-meaning queries from family and friends who ask, so, if you get really sick what will happen, and not being able to give reassuringly confident answers. In the wee hours of the morning, thinking, what if I am the small percentage who needs an ICU, which does not exist? Or, how long can we manage if power, or banking, or markets, completely stop? Communicating with family and feeling their pain, jobs lost, restless isolation, canceled plans, looming worry.

These are real questions, and we are real people, who are in this global storm. Most of the times in our life, we slap a prayer onto what we subtly truly trust: the medicine, the expert, the evacuation, the plan. But there are sometimes seasons when our illusion of control is completely stripped away.  Preterm labor in a place that at the time had no capacity to care for a preem. Walking with a crowd of about-to-be-refugees towards the Congo border with gunfire behind us. Taking our temperature for 21 days in an Ebola epidemic where we had been exposed, and there was no option to leave. And now.  So what is our comfort? That the presence and good intent of God towards us cannot be interrupted by anything, not war, not disease, not edicts, not even death. And though I can type that as truth, I will not pretend that I can feel that in my bones at all moments.

Peter had to step out of the boat into the storm, God's people had to step into the Jordan and run towards the battle, to see the miracles. The ones who said, we can't put our children at risk (Num 14:3), did not live to see the promised land. So day 5, here we are, putting in a toe and holding our breath for the rescue.

Tuesday, March 24, 2020

#COVID-19UGANDA day 2-3; escalation and preparation

Our first confirmed case in Uganda was announced Sunday. Today we have 9 known cases, all in the capital. But since the extra 8 came from testing 35 more recent flight arrivals, if a quarter of the tests were positive we have to assume that hundreds have entered and the virus has spread. The chance that our cases from Dubai represent the absolute first cases to enter the country are vanishingly small. Kenya and Uganda are both awaiting the now nearly-daily addresses from our Presidents. We had borders closed, airports closed, churches and mosques and bars and schools closed. Kenya limited the number of people on matatus and buses, and locally our district pronounced only ONE passenger (in addition to the driver) per boda (motorcycle taxi). Today we expect more draconian rules. Meanwhile the worldwide exponential curve grows. The USA is filling with the red circles. Luke and Abby are working extra shifts. Jack's town is in lock-down, so he's writing his graduate school papers from his room. Julia is still allowed to work on her farm, which seems like a pretty essential service. Caleb is completing a language course today and in limbo with the army after that.

Day 2 out here in Bundibugyo started with a war council. On Friday, we had a staff CME, but the positive cases in Kampala over the weekend brought the reality home. Thankfully Dr. Ammon our medical superintendent and dear friend, who got a sponsorship to med school thanks to the post-Ebola scholarships, had started daily morning staff meetings a few weeks ago.
So Monday, we worked through a 6-part plan based on experience in Hong Kong and Singapore protecting health care workers. Wearing masks, hand hygiene, cleaning surfaces, triage, isolation with more extensive PPE for the suspect cases, keeping distance. Those six things we can do. I find that when I read what other hospitals are preparing, with advice like "you should have 10L/min flow of oxygen for every bed" and we have a total of about 20L/min for 24 hours in the ENTIRE HOSPITAL . . it does feel panicky. So we try to focus on the simplest measures. 

After the meeting, Dr. Marc organised final disposition of a medical supply container that had arrived more than six months ago. It was stuffed with lots of marginally useful items, but last week he found some N95 masks. Many, actually, and some PPE. That means that more than 2 years ago, God enabled a former missionary to prepare this container and it was sitting there at just the time we needed it. Pretty amazing.

Don't cringe if you're an infection control nurse but our reality is that we will wear our masks all day, not changing them, and take them off and store them with hygiene, and then re-use it for a week. Our reality on Paeds is that half our patients have respiratory illnesses, and zero attempt to limit their coughs. So we're wearing them now to get used to it. Half of me felt out of breath and suffocating as temps soar over 90 (no A/C on the equator, congested and stifling). But most of me felt relieved that I was not breathing in a corona soup.
While Marc was sorting and Jessie, Clovis, and I were seeing patients, Scott was pulled into a District response meeting.  Christ School closed Friday, so he came to the hospital to resume his long-delayed clinical life. Only to be diverted yet again into politics and leadership. (Below with Dr. Ammon and head admin Francis, keeping their #social_spacing)
For Bundibugyo, on a border, security is a primary issue, so the meeting with all sectors was a mix of medical and military.
The ward was still full, but full in a way that only maybe 1/5 of patients were on the floor and there were visible areas of floor with no patients. Meaning perhaps that people will start avoiding the hospital as the pandemic picks up. Which could be wise, but may be fatal. I suspect for kids we will lose untold numbers to malaria, sepsis, anaemia, other pneumonias and infections, diarrhoea and dehydration, untreated malnutrition, because the non-COVID health care will wane. We made a new diagnosis of HIV infection in a couple with a very sick baby. Getting people treatment for other fatal disease is still important. 

Patients like this one make me pause. Her respiratory rate was over 40, her saturations were about 90%, her breath sounds were decreased. Is this a run-of-the-mill virus or the new one? Will we ever know?  

After six straight hours of crouching and leaning, listening and writing, searching and explaining, everyone had been seen. We walked out into the blazing sun and washed hands in bleach, removed our masks and sprayed them with alcohol and put them in a bag, then washed our hands with bleach again.  Back to our house for another many hours of emails, texts, phone calls, a Serge emergency committee meeting by zoom, listening to concerns, praying with team mates.  

These are tense days. The weight of our zero-options existence seems to increase with every passing day's pronouncements.  Real prayer, writes Eric McLaughlin in Promises in the Dark, is fundamentally helplessness. I think we're really praying. now. Evacuation insurance doesn't help if the borders are shut. Knowing how to manage a ventilator doesn't help if there is no ventilator. We have some oxygen but it seems pitifully small. Yet we know that God can preserve our lives. We just don't usually feel like we need Him to, we usually feel like we're applying ourselves to that process. 

And we do get glimpses of why there is meaning and value in this season of risk. It is a privilege to stand with the least-resourced people on earth and fight a pandemic that affects everyone around the globe. It is encouraging to them to feel they are not forgotten or alone. Sometimes we actually offer something, like our stash of masks! Other times we just offer hope.

We may not be able to do this again very soon, but this was our team worship. We're basically a big family, and we took the 2 Chron verse seriously: we don't know what to do, our eyes are upon you. Like the original pray-ers of that prayer, we met the enemy with worship. This is what faith looks like where we are, on the edge. Helpless to stem the tide, but seeking the presence of God in the sea of uncertainty and glimpsing ways (masks! friends!) God provides.

And like everyone else around the world who has a phone, our days often end with a message or call with family, who are in more intensely affected areas and being very obedient quarantiners. 

Pray for all your medical workers and leaders; just the number of decisions and thoughts is exhausting.  Lord, have mercy.

Sunday, March 22, 2020

#COVID-19UGANDA day 1; May it be light and may we be light

In the few hours since yesterday's post, Uganda has joined the 169 countries around the world with cases of the SARS-CoV-2 induced illness, COVID-19. Our first identified case was a 36 year old Ugandan man who went to UAE (Dubai) on business and returned to Uganda ill. He was identified in screening at the airport, isolated, and tested.

While his test was still pending, the President instituted new restrictions. Borders are now closed. No passenger planes may land or depart as of midnight tonight. No one can ride a bus or a boda or walk or bike over a land border, or take a boat over the Lake borders. If you are in Uganda now, you are here for the foreseeable future. If you wanted to come back, it's too late. Cargo and UN movement only.

World cases now well over 300 thousand, with 14 thousand deaths.

Here is what we don't know: in most countries, the first identified case came when hundreds had most likely already been infected. Here's what we also don't know: how bad will it be, what will the hospital look like, how quickly will the commerce shut down, what will the security implications be? Salt prices doubled immediately. Cocoa prices are dropping with the lack of a European market. Security fired tear gas to disperse the usual market as a meeting place.

We are all in this together. The only way to get to the other side is to pass through whatever the next months hold, together. "Social cohesion with spacing" sounds better than social distance. 1 Peter 3:8 calls upon us to have unity of mind, sympathy, brotherly love, a tender heart, and a humble mind. Young people are restricting their freedoms, to protect their grandparents. Neighbours are looking out for their neighbours. Nurses and doctors are showing up for dangerous work, advocating, improvising. Creative people are reaching out on line to lead exercise classes or read books aloud. Pastors are preaching online.

And God's people are responding like they have for centuries. Martin Luther wrote in 1527 a very long letter answering the question of whether it was permissible to flee the plague.  In the middle ages, ships infested with flea-ridden rats were the globalizing force of trade and the vectors of plague, much as the incredibly connected airlines have allowed a respiratory virus to spread worldwide in a matter of weeks in our century. His letter is remarkably nuanced. Believers should not seek death; God has created each life and we are right to extend life to do good. He very practically recommends use of medicine, fumigation of housing, rest, and even avoiding places of illness where one's help is not needed. But that right is tempered by the imperative to serve one's neighbour. Love inherently carries the reality of risk. He writes that if it is possible to be more safe without hurting or abandoning others, we should, but then says:

Now if a deadly epidemic strikes, we should stay where we are, make our preparations, and take courage in the fact that we are mutually bound together.

 Social cohesion, resting on God's promises to care for us and showing God's mercy to all. Social spacing, to protect others as best we can. Social risk-taking if you are an essential worker, a first-responder, a health care worker, a farmer, a person who keeps electricity and water and fuel available.

These are sobering times, and incredibly complex decisions. We know that here in Uganda we are only at the very beginning of the exponential upswing the USA is now experiencing. This is one plague that you really can't flee; there is no place on earth likely to remain unaffected.

Our youngest, newest team member prayed this prayer, which I believe captures both the legitimate desire to escape harm and the determination to do good; much like "Lord I believe, help my unbelief" (shout out to Lindsey):
Lord, may the pandemic in our country be light.
And as it comes, help us to be light.

Saturday, March 21, 2020

We don't know what to do . . . COVID-19 and 2 Chronicles 20

Here are some words written several thousand years ago, but applicable today: "For we have no power against this great multitude (or virus) that is coming against us; nor do we know what to do, but our eyes are upon You."

When God's people were backed into a corner, with no hope, facing annihilation, this is what they said.

I don't even know how many times a day we have to make a major decision based on very little information, conflicting reports, impossible projections, with grave consequences. We don't know what to do. Or the times, here and there, when the weight of losses and the gravity of potential sorrows just feels overwhelming.

So here's what it's like at the end of the road this week, in one of the few countries left that has not yet reported a positive test.

We supervise 79 adults and 72 kids for Serge East and Central Africa. Two of our four countries have had low numbers of imported cases reported, two have not. Yesterday the US Department of State issued their most dire, war-like, travel warning ever: If you're an American on a trip, come home now. If you're an American that lives abroad, stay put and don't travel. Which means that there was a sudden calculation by and for 151 souls, do I live here or am I visiting? What is my risk? Should I leave? And these are not simple questions. A delay of a day could mean flights stop and borders close. We had already made sure our only over-65 people were off the continent, not because the rest of the world is safer, but because IF THEY were in critical condition there were NO OPTIONS for them to be in an ICU. But even younger people can have critical disease. Where do we say, your life is valuable, we want to protect you, it's our job to get you back to a place where the health system might be able to support you? And where do we say, your choice to shoulder this risk speaks of the Gospel to your community, and we want to allow you to stay in the long tradition of the church and pandemics? These are not simple questions. They have multiple right answers. We don't know what to do, our eyes are on You.

In most of our life here in Africa, we have a hidden privilege. When security deteriorates, when Ebola arises, when family at home is ill, when we are weary, we can usually pick up and take a break.  But not now. After 9/11 felt similar to this. It is a whole new level of faith to live in a place of poverty and margin, when you can't leave. Our colleagues are cognisant of the fact that if a treasured grandparent dies, if an adult child breaks a leg, if a two-year-old needs a special surgery, if any one of a thousand crises arise related to coronavirus or not, we most likely cannot go anywhere. Today my mom called with the news that my Aunt who is nearly 90 fell and hit her head and is in the ICU with bleeding in her brain. I hope I will see her again, but it is quite possible I won't. On that note, a shout-out to all our parents who are strictly quarantining. It is a tremendous relief to your distant family to know that you are sacrificing your freedoms, you are giving up movement out and about, to protect yourselves. We are so grateful. We don't know what to do, our eyes are upon You.

Usually, we live in rhythms. After a few months, there is a. break. We look forward to conferences or trips. The day to day slog of heat and need can be wearing, the distance gets draining. It is a whole new layer of difficult to not know when we might see our kids again, or our parents, or many others. Or even when we might see our other teams. Or get to a place with swimming or quiet. We don't know what to do, our eyes are upon You.

Africa is braced. Our country shut down schools, churches, bars, gatherings, sports. We spent time scouring up some facemasks and hand santiser.  I taught a CME for the hospital yesterday on the novel coronavirus. Teams are researching the best approaches. Our hospital set up handwashing stations outside every ward (since water and plumbing is not always reliable, these are refillable jugs). But once in side the ward, there is extreme crowding. All but two of our teams have a core of medical work. When the world stops moving, and people stay home, almost all of our missionaries in Africa are in a different category of essential workers. We are watching Italy on the news and wondering, if they had hundreds of deaths yesterday, how can we possibly not be even worse? Our population is malnourished. We have immune compromise from HIV, we have lung damage from TB, we have a high prevalence of malaria. We have about 9 oxygen cylinders, each of which will give a low flow for one patient for about 24 hours. We have no ICU. No ventilator. No oxygen plant. The ratios of health care workers to population where we work is among the lowest in the world. Options are so limited, for our neighbours, for all of us. We don't know what to do, our eyes are upon You.
These are the measures Uganda announced this week

This little can of water with a spigot is our defense against the pandemic

Collateral damage. This child from yesterday is swollen from lack of protein, a mom who was too soon pregnant again, no good food options without breast milk. When the pandemic hits, what happens to kids like this? 
Teaching CME. Everyone usually sits physically touching; it was our first time to space ourselves out like this. But this is a team who has worked through cholera and Ebola and untold crises. They can do it.

Christ School closing, all schools closing, hits Bundibugyo hard. Our students don't have internet access. There won't be online anything options. They are returning to homes which have no books, no electricity, perhaps even limited food. We struggle to keep up with the national curves even with all our school days; doing so with half the term canceled (or more??) will push us to the limits. The teachers are staying around to create a packet of work sheets since no one has texts. Monday Scott and Patrick will meet district leaders with a plan to teach on the radio, a gesture of good will, a way to come together in crisis and bless kids from many schools. With no church, no sports, no school, no books, few outlets, what will the impact be on this generation if this lasts very long? We don't know what to do, our eyes are upon You.

And so the days go, dozens of texts, hundreds of messages and emails, calls at all hours. Trying to stay alert and empathetic. Giving grace to various people in our orbit to make different choices. Wanting everyone to feel seen, cared for, supported. Then long days of the normal work of serving sick kids and their families. The disorienting feeling, is that cough evidence that the new coronavirus is already here? Is that fever potentially dangerous? Should I start using precious masks or wait? If we can barely make it through the ward where the patients cover not just the beds but the floor now, what will it be like in two weeks? In a month? We don't know what to do, our eyes are upon You.

In an era of distance, the group was giving me "roses", picking them from the air and throwing them to me to receive after teaching, rather than a clap our hand shake. 

We are praying for our world. For God's powerful rescue. For a 2 Chronicles 20 story, where we find out in the end that God was with us all along, that our worst fears are already defeated, that we are going to be all right. That in the end, because our eyes are on God, all shall be well.

Tuesday, March 17, 2020

The 80/20 rule of Coronavirus, Kindness, and antidotes to fear

As everyone but a dedicated hermit must know by now, 80% of people infected with Sars-CoV-2 aka the coronavirus that causes COVID-19, our pandemic respiratory infection, will have mild infections. It's the 20% who get the disease in older decades (like, gulp, ours) or who have chronic debilitating health issues, who get very sick.

I learned from my Kenyan colleagues, who are used to massive numbers of patients in the public health system, that as a doctor we need to find the 20% who are most sick and give them 80% of our attention. That is no less true now. MOST of our concern, effort, preparation, needs to go to our most vulnerable. In this year of pandemic, that means that 80% of us have to alter our behaviour to protect and love the 20% who are at risk. People are changing their lives, overnight. Giving up freedom. Travel. Habits. Churches and schools, closing. It's a massive effort by the relatively well to protect those most vulnerable should they become sick.

And some people are doing so in a very inspiring way. I love the videos of Italians, and Spanish people, on their balconies singing and clapping. They are social distancing physically, but not emotionally. Zion Williamson, the Duke basketball phenom who went to New Orleans, decided to pay the salaries of the arena workers whose jobs would be impacted by the shutdown of the basketball season. He's a 19 year old; his trajectory to wealth was so rapid he hasn't forgotten. Julia's church farm is providing food for people, and started a program to cook up large batches of nutritious broth. Luke and Abby had to give up their long-delayed honeymoon planned for April; Luke is back on straight night shifts next week for emergencies after having already put in his two-months of that in January and February, because that's what's needed as the health system narrows down its focus. Abby is working extra shifts, and both of them already have COVID-19 patients in their hospitals. Our moms are in isolation hoping as 80+ people to avoid the virus altogether. Friends are lamenting the loss of time with children or grandchildren, the honing down of wedding lists, the inability to celebrate milestones. Yet I see people posting ideas on how to help your neighbour, how to be grateful and generous which is an antidote to fear.

There is another 80/20 rule at play.  On a global scale, the poorest countries are those 20% vulnerable. It is not just age and pre-existing health conditions. It's other pre-existing conditions. Like poverty. Like a health system that doesn't even have ICU care or much in the way of oxygen. 155 countries are now reporting cases. Amongst the handful which are not? Uganda, and Burundi, two of the places we work. Yes, they are remote to get to and perhaps slow to receive travellers, but more likely they just don't have enough testing to really know what is happening. Interestingly there is only one state left in the USA without reported cases, West Virginia. On the WV:USA scale; or the Bundibugyo and Burundi : Africa scale, there are similarities. A study found that WV had the adult population with the worst health in the USA, so when COVID-19 hits, they will be severely affected with minimal resources. We anticipate the same here. No one knows the impact of HIV prevalence mixed with this pandemic. Or malaria, or malnutrition.

So here we are for a couple of days in the capital. (We were called to the State House's office on Land Matters because of the 6-year law suit trying to steal back land bought 20 years ago. That turned out to be an unpleasant morning of being told by a young lawyer that, and I quote loosely but sadly pretty accurately, we might lose our lives over this but hey everyone dies whether it's a bullet or old age, so just trust the courts. . . . the meeting was miserable but seeing the support of the community who sent multiple witnesses to explain how the mission's work was of value to them, and how they all feared the injustice being perpetrated, was pretty heartening.) Our couple of days here consist of scouring pharmacies and calling contacts who know the market from 25 years ago (no lie, the same guy who used to help us procure flour and rope and fuel when those were rare items today came up with some N-95 facemasks and hand sanitizer, no easy task when some enterprising person sold all of Uganda's supplies to China a month or two ago) for medical supplies. We're shopping but not for massive amounts of toilet paper (we LIVE NORMALLY in increments of months between access to groceries, so we generally stock up on peanut butter and beans and popcorn and cheese . . and one or two packs of TP). In between life-maintenance and medical-supply searching, we answer emails and talk to our people. We supervise dozens of adults and dozens more kids in four countries. Some are older than others, some are pregnant. Some are anxious. Many are health care workers. All of us have always had the sense that worse comes to worst, we can probably evacuate. We don't have that anymore. We are coming to new normals of facing an impending pandemic with inadequate supplies, of looking for weeks or months of being isolated from our origins. And the peculiar experience of being visibly indistinguishable from whomever brought the virus to our countries. We're in the guilty minority this time.

One more day and we'll head back. None of us know what the next weeks and months will hold.

But God does. We don't have ventilators or chest CT scans, labs or blood gases, high flow oxygen or access to tests. But we do have communities that would come to Kampala to testify for the good God is doing in our homes. We do have a genuine team of people in East and Central Africa sharing information and praying for each other. We do have some simple energy to care for the sick, to comfort, to support. We do have a few facemasks and bottles of sanitizer to stem the onslaught of virae. And we do have a promise, that nothing can separate us from LOVE.

This is today's paper. If our schools close tomorrow, please remember these kids will return to homes with no books. No computers. No online alternatives. They will not be fed at public lunch programs. They will be severely impacted.

All entrances in Uganda in the city look like this--hand sanitizer and warning posters.

The group that came from Bundibugyo to support us.

Kenya announced cases and a closing border but by the mercies of God this family was able to get from Eastern DRC where the Ebola epidemic is waning, to Kenya where they can more safely deliver a baby in May. Praying for them!!

Saturday, March 14, 2020

Pre-Coronavirus Realities on Friday the 13th

Friday the 13th, as America declared a National Emergency, our Serge organisation met to discuss travel policies, lots of phone calls and texts to make decisions and cancellations, the first case of COVID-19 in East Africa was diagnosed in Kenya in a person who had traveled from the USA . . . and life went on in Uganda. Meaning 8 am at the hospital, finding a young child who had been admitted the day before with a viral lung infection (presumably NOT coronavirus, there are so many virae), been on oxygen and convulsing overnight, and was now having intermittent agonal breaths. The shift had just changed, we did what we could which was not enough, and she died.  The morning staff meeting, the realisation that no other doctor was in the hospital today (politics, interviews, post-call exhaustion, planned travel). Bouncing between a packed ward and the newly opened NICU. Premature twins on day of life 3, doing what preterm twins do--getting jaundiced and losing a little weight but otherwise vigorous. But a baby admitted overnight whose mother had delivered a twin on the way to the hospital but not been able to get this one out. No records to say how long it took to get a C section or what the apgars were, but the baby was limp, blue on CPAP, with unresponsive pupils. Also dying.

Then back to the ward, facing what the records said was 81 patients but probably was more like 70-some, with what felt like no help. No vital signs charted. No one charting much of anything. Just bed to bed, mattresses on the floor, scribbling in exercise books, talking to parents, doing exams, making decisions, ordering labs and medicines, trying to find the sickest but salvagable. There was something about starting with two deaths and unexpected aloneness in the context of a pandemic that just threw me into despair. I texted a few team mates to pray. Scott sent back an encouraging message.  And by grace, we plugged on.

Once I just set myself to see the patients one at a time, to look at the little humans as humans and their parents as parents, to not worry about doing it ALL but just focus on doing the next thing, the day changed. I wasn't alone. There was a nurse in the injection room giving meds, and one in the office writing discharge papers. Later another came to help me get more kids on oxygen. Clovice our every-cheerful BundiNutrition aid was there, and even though he's not medically trained he's faithful and dependable, and recognized two of the sickest patients to call my attention to.

So here is a glimpse of rounds, on a normal day.

Typical section of the ward, when the beds fill patients just add mats and mattresses to the floor.

Ants enjoying the dripped IVF, evidence I suppose that the dextrose label actually DOES include dextrose.

Looking for lab results, discovered dozens from the last few weeks jammed into this drawer.

As if being under the Ebola into poster wasn't bad enough, this kid accidentally cut his heel down to bone FOUR DAYS AGO, came to the hospital two days ago and happened to get tested for malaria, which was positive. His hemoglobin was very low as blood poured out of his heel and parasites attacked what was left. Evidently his hand-carried record book got displaced, so until I found him bleeding away nothing had been done yet . . .

She survived malaria with vomiting blood, and a hemoglobin of 1.4 on admission (normal 12). In spite of exceptions like the kid above, we have made good strides on malaria and transfusions. Our nurses can inject artesunate (and ampicillin) and hang blood transfusions. Those three things save a lot of lives actually.

Malaria is so endemic that we try NOT to let anyone go home that was not tested. This boy was ready for discharge, his pneumonia better, but he had a palpable spleen. So I had to finally march him into the appropriate blood testing area and insist, and wa la, malaria. So he'll go home on treatment. Yeah.

More patients. At this point I was about half way through the ward. Malaria, malaria, malnutrition, sickle cell, pneumonia, lots of viral syndomes, abscesses, burns, hit-by piki, and so on.

Don't let sickle cell disease ruin your fashion sense. This hat and smile were so cute.

Sometimes a story just grabs me. A one-year-old wakes up screaming in his home at night, and the mom sees a big black snake. Snakes sometimes come into poorly sealed homes and look for warmth, and when you sleep on a floor mat . . .then the baby moves, the snake panics, and there is a bite. This child's arm was swollen and tender up to the shoulder and we could see the double fang marks. But by Friday she was much better and able to go home. The snake escaped, but hopefully that little reptile brain was scared enough to stay away.

Another fashionable cure. Little girls and spangles. Mirror image G?? 

This 7 year old is a twin, whom we have followed for several months. She has signs of Kwashiorkor (swollen feet and face, skin lesions, listlessness) which is not typical in her age group. Though she improved a bit on her first admission getting food and malaria treatment, now she has some pneumonia findings, so we decided to treat for TB. With an unaffected twin, it seems to be more than just hunger. 

The first NICU admissions were a set of preterm twins . . this one getting some natural phototherapy in his home made incubator (thanks Dr. Marc for all the work into getting this set up, and Kibuye/Tenwek/Caleb Fader for the incubator design). There was a bug floating in the CPAP but the baby looked great.

You might be surprised to know the typical topic of conversation these moments when I am trying to distract and calm an infant or toddler long enough to check their oxygen saturations and heart rate. The mother is usually saying something to the baby like "see your wife here? Are you going to marry her?" and we are all smiling because this is the normal way infants and grandmothers relate. I am not making that up. Literally many times a day I hear proposals from one-year-olds via their mothers.

This is the newest fashion trend sheet, I probably saw four on Friday. Sort of an American nod with the stars and stripes, but a few snowflakes for good measure and a global skyline.

And so we go. Examine, talk, think, write, make a phone call, check a dose, lead the patient to the nurse's room for a blood draw or injection if it just doesn't seem to be happening. On a good day, when someone is praying, I can make eye contact and feel empathy and take time to force my tongue into Lubwisi to explain, instead of rushing and feeling overwhelmed and frustrated. I try to go over the sickest patients with the nurses, to do some teaching. I make lists, and communicate with the doctors who might come over the weekend. It takes about 6-7 hours to get through rounds, meetings, treatments, etc. In between each patient, a generous splash of alcohol hand sanitiser.  We only have one oxygen tank and one concentrator. I have to choose which two of the four hypoxic patients get the oxygen. All of this is baseline. Before coronavirus.

We have three young boys with chests like this, consolidated pneumonias on one side. They are breathing at twice the normal rate or more. I can see their ribs as they work hard. This is before coronavirus, as far as we know.

Social distancing, hand hygiene, suspension of travel and gathering . . . these are methods to slow the spread of the pandemic so that the health system can adjust, can cope. But what if your health system already isn't coping?

Today's words from Deuteronomy. This is a global season of wilderness.  This is a time we can lean only upon God's provision. And this is a walk of faith that God will bring some good in the end.

This street sign is painted a few hundred meters down the road from us. "Born to win" street. Africa may not have resilient health systems, but we do have resilient people. And always, hope.

(And for another view of life in Bundi, read this blog about our Orphans and Vulnerable Children scholarship program. Or this one about cross-cultural realities from our BundiNutristionist.)