paradoxuganda

What is It?

2012-02-05T11:34:00.001-08:00

This morning my reading fell in the book of Exodus, following a historical/sequential read-through-the-Bible in one year plan. Some background: such dramatic stories, but we often forget the years of less glorious preparation God puts His chosen leaders through. Joseph was a slave and a prisoner from age 17 to age 30, with no glimmer of assurance that he would ever see his family let alone freedom again. Moses was a third-culture kid who straddled two ethnicities and then was self-exiled into a third, managing livestock in the wilderness for his father-in-law when God propelled him to leadership. All through Genesis God upsets the normal order of the firstborn, raising up younger siblings to rule the older. And takes those leaders through long years of wilderness, conflict, alienation. Most of the time they had little to go on other than God's unlikely promise. It was a conditioning by service that strengthened them for the moments of truth.

The same thing happens to the entire nation of fleeing slaves, after four centuries of oppression they go out from Egypt "with boldness". Which lasts precisely three days. At every obstacle (which are admittedly quite frightening obstacles, facing annihilation between an angry pursuing army and a seemingly impassible sea, facing starvation and thirst in a hostile trackless waste) they immediately panic, and blame Moses, questioning his leadership. Why did you bring us here, you should have thought of this. Or worse, you purposely put us in jeopardy. Which had a slightly familiar ring to it as former remote-place leaders, when our team faced hard times. Why didn't we prepare better, anticipate, prevent?

And over and over Moses takes the issue straight to God, and over and over God patiently provides. Which brings us to today's story.

The people are hungry. And God sends food, in the form of a seed-like dusting of flour that can be made into bread, with a flavor of honey. When the people walk out the first morning and see this substance spread over the landscape, they say "What is it"? Which sounds like "manna" in Hebrew I suppose, because that is how the food gets its name. Manna is a skeptical question. It was not immediately obvious to the wandering hungry Israelites that this was food. It wasn't the answer to prayer that they expected. Provision, obscured.

I wonder how often I look at God's mercy and say, "What is it"? How often I fail to recognize the good in what God sends?

As we enter our second year at Kijabe there are still losses and questions that have not fully settled in my heart, and looking at this year with Caleb going one way and Luke another and balancing responsibilities, well, it looks about as appealing a gathering a seedy white ground-cover to cook with. Today I helped a visiting family medicine resident resuscitate a tiny preemie, put in a UVC, intubated, made decisions, set up a ventilator. I could not have done that a year ago. Progress? But then I returned in the evening to orient a visiting doctor with astute questions I couldn't answer, and happened upon the baby as he was deteriorating and failed to get the tube in again. Sometimes I get tired of always feeling like I'm catching up, not quite where I should be. Is this provision, this constant tension of more to know and do than I can manage? We lost the baby's mother. Is this provision, daily exposure to heartache?

For now Kijabe is my what-is-it. To taste the honey-tinged wafers one has to go and gather. This weekend we also spent a lot of time just being in community here. And it was sweet. Two couples whom we've met over the years, long-term Kijabe docs now departed to more frontier missions, were back to visit. A medical student whom we've been working with, processing and hanging out. Four other moms who help with class activities, baking about a thousand cupcakes and cookies for Valentine's sales, learning a little more about their lives as we poured batter and stacked cookies. Two families who have been here more than twenty years accepting our invitation to pizza and telling us some of their story. A friend we've made over the last year coming to us with a medical issue. My partner dropping by with precious Starbucks coffee. This is our community now, and I am growing in appreciation. What at first seemed intimidating and difficult to penetrate is now beginning to look a lot like a gift. I am thankful for these people, and the richness of our interdependence. It doesn't look like our old team at all, so it was hard to recognize the manna in this place. But it is here.

Jesus, of course, is the real manna. The real provision. And the real "what-is-it" as He consistently defies expectations. He wasn't recognized as God's gift when He was alive, and many of us stumble over they way he diverges from what we hoped God would do.

In 2012 I know we will be sustained by the daily freshness of God's mercies, however challenging they are to recognize. Praying we will all taste of the goodness.

Tribute to a Cow, DMC (1997-2012)

2012-01-29T05:07:00.000-08:00

We received news recently from Bundibugyo that our longtime dairy cow, Dairy Milk Chocolate (DMC) died.

"Where your treasure is, there will your heart be also." (Matthew 6:21)

We invested much sweat and money (for medicine, food, local labor) to keep the milk flowing from DMC's udders for the good of our children and our team over many years. Basic investment and return -- turning our money into fresh milk. But investing in a living creature has a consequences and I (Scott) have found that leaving behind my dairy cow was arguably the most difficult aspect of uprooting from our home in Bundibuygo. So, this week I traveled down memory lane revisiting the years with our friend and sustainer.

This story begins in the post-ADF war days of 1999-2000 when our mechanic (and farming consultant) in Fort Portal had some personal problems and needed to raise some cash. We had talked with him about bringing one of his dairy cows to Bundibugyo and this was an opportunity for him to make us good on our promise. So, Pat and I purchased one of his young cows for about $250. Pat chose the name based on the color of our cow which resembled Uganda's favorite milk chocolate bar. We gave him the money, but let him keep the cow since our pasture wasn't ready and the security of Bundibugyo didn't seem conducive to keeping domestic animals.

Several years passed. Our mechanic had improved his financial situation, but eventually cycled into deeper and more complex personal problems. At one point, this friend had lost everything (wife included) except his two children and DMC. It's the only thing he had to feed his two young children. At that point, I said "Keep the cow. It's my gift to help you sustain your family." Eventually, he turned his life around. His wife returned, he repented of the behaviors which led him into crisis and loss. But eventually he needed help to rebuild his business and re-buy a set of tools so he could begin to work as an auto mechanic again. So, he approached me (I had bought out Pat's shares because of her personal need for cash!) and asked me if I would be willing to buy DMC-- again!! I agreed - but decided that I wanted immediate delivery. I wanted my twice-bought redemption cow. So, we prepared: fenced the pasture, built a milking shelter, constructed a feeding trough and water trough, bought milking buckets and storage containers. No small additional investment. We took delivery of DMC in December 2005. She was giving milk at the time - for which we were so thankful. There's nothing like a bucket of warm frothy fresh milk which you've squeezed out yourself.

Things all seemed to be going well for several months, but the milk abruptly changed quality about eight to nine months after we got her. At one point it almost solidified in the bucket. About this time, Matt Alison and I undertook a bike ride over the Rwenzori mountains to Fort Portal, a blistering 100 kilometer ride. Halfway across the mountains, I called home on my cell phone. Julia answered, "Dad you won't believe it!" I'm thinking, what about me? Don't you want to ask Dear Old Dad how the brutal bike ride is going? Instead I patiently asked, "Julia, what is it? What happened?" She exclaims, "DMC PRODUCED!!" (translation: gave birth). "What!!!!" Long story short: Our mechanic had attempted artificial insemination the month before he brought DMC to Bundibugyo - but never told us! Despite her ever-widening girth, buckets full of custard-like colostrum in our milk bucket - we still never put it together -- until a calf popped out. Whoops.

We named that calf "Ghiardelli" - in honor of his dark chocolate color. We had no use for him (pasture seemed too small and I couldn't really imagine raising him for the purpose of steak) so we took him to our friend's farm in Fort Portal (after a few months of bottle feeding).

In order to keep milk flowing, a dairy cow must keep getting pregnant. Ideally, 6-9 months after her last calving, she's bred again. With no electricity and no cows in Bundibugyo, artificial insemination was not possible so we were forced to bring a sire. Our farming consultant in Fort Portal gladly sold us a stud who we named Sir-Loin. We hoped that his loins would procreatively keep us supplied with fresh milk - but without the same emotional attachment we had for DMC. We intended to let him do his work -- and then eat him. He was a good steer. Mean as all get-out. He got out of the fence a few times and ran down to Nyahuka creating sheer pandemonium. No one had ever seen such a strong and fierce animal. Unfortunately, he developed a joint infection which killed him before we could ever eat him. His daughter (and DMC's second offspring for us), we named "Truffle", for her swirling mixture of whites and browns.

DMC's next husband, came from a local herd. I was done with ridiculous cost and headache of bringing animals from Fort Portal. In my mind, we just needed a pregnancy - not a Kentucky Derby stud. On one of my local bike rides I spotted a healthy looking guy with Texas longhorns and a wizened shepherd. I sent my negotiator. For $15, we rented the guy for a month. We called him Shadow since he never left DMC's side. Insatiable he was. And effective. Nine months later DMC gave birth to "Oreo" (named for her black and whites sandwiched together).

Shadow did come back for a repeat performance this time with both DMC and Truffle. Polygamy is common in Uganda - and it was darn convenient for us. Mother and daughter delivered after we left Bundibugyo. Truffle continues the legacy of her mother providing milk and for the entire Bundibugyo Team.

DMC. Some called her "Dr. Myhre's Cow". In Uganda, DMC is also an abbreviation for "Dangerous Mechanical Condition" ("You see that DMC truck in Nyahuka this week…man, that muffler needed replacement!").

She was as gentle a milk cow that ever trod in Uganda. She was God's provision for us and to Him I am thankful for the privilege of having her.

the rest of the week

2012-01-29T04:18:00.001-08:00

The rest of the week, outside the NICU, music and community and sports and celebrations and just plain life. RVA choir sang this morning. Strong voices, inspiring song. You can see Caleb and Julia, but Acacia is in the front row of girls on the left that are perpendicular to our view. Caleb was asked to help lead worship for church today, with teacher/coach Ryan Dahlman and some other kids. He and we were thankful for this opportunity. I remember a little book I made the kids in poetry form: the Bundibugyo Bhana bhana (four kids) when Caleb was about 4, and described him as musical even then. He has taught himself guitar over the last few years. In the middle of the set of songs I started thinking about how much I'll miss him next year. Tears. Julia and Acacia went on a hike with me on Saturday morning, exploring a new path I'd been curious about . . .note Mount Longonot in the background. Note Acacia beneath a spectacular Acacia Tree. And by a dry river bed. The rains finally stopped in the last couple of weeks, and dry season blew in. The days are suddenly hotter, but the temperature still drops with strong winds at night. Amazing to me that we live in a place where we can walk out our front door and hike for an hour in relative wilderness. Girls' soccer season begins: two games for Julia this week, and one for Acacia. The Kijabe community's annual gathering to celebrate Dr. Ase Barnes' birthday, his 16th here at Kijabe and his 79th here on this earth. The Barnes leading Wednesday morning hospital chapel, singing in Swahili with the pathology and chaplaincy departments, accompanied by the accordion. I only hope that by the time I'm in my 8th decade I half as much fun and inspiration as they are. Ryan left this week, the little boy who almost died Christmas night, with TB and heart failure. Because his mom lives in a single room with four kids and an open fire for cooking, he could not have oxygen there, but transferred to a smaller clinic nearer his home. Pray for his lungs and heart to heal.

I've been thankful for a couple of times to pray with friends this week, to talk about life or hard things or decisions. To skype with Luke. To have pizza with our old friends the Chedesters, to create meals. To be more than a paediatrician, even though I love it, to remember there is more to the week.

Unsung Heros

2012-01-26T09:36:00.000-08:00

Today let us honor the unsung heroes of the NICU: the moms. I don't think I'd look as peaceful as Felister above if I was on my 52nd day of sleeping in a hospital ward, well, not sleeping much, because these moms get up every two hours and come into the nursery to feed their babies. Maxwell is almost ready for discharge. It has been a long push, and sometimes the last few days are the hardest! This is little Mark-Paul, who is only 3 pounds even though he was born at term. He was severely growth retarded. So his mom had to go through a FULL LENGTH pregnancy and delivery, and NOW has to stay as long as most preemie moms caring for him in the nursery. Brielle's mom is all smiles because her preemie has been a star--she's sacked out skin to skin after a feeding. This is one of the few couples where the young dad comes regularly too. I'm rooting for this little family. This baby's mom laid down her life, almost literally, to bring her into the world. Here she's being held by a nursing student, because her mom is in the ICU. This mom had such severe bleeding post-delivery that Scott got called in the middle of a not-on-call-night to help her, and he called in a general surgeon, and they called upon 15 people to emergently donate blood between about 2 and 5 am., including multiple nurses, students, security guards, one of the doctor's wives from home, and about 3 or 4 RVA staff. After two surgeries she was pulling through, but pray for Esther who is not out of the woods yet. She is a mother of four, including the cutie above. Her baby is a favorite in nursery as we don't usually have healthy term newborns whom we don't have to share with a mother, to cuddle and feed and love. Hannah Wangari is another miracle baby. This is the little girl born with gastroschisis, all of her intestines and stomach hanging out of a hole in her abdomen at birth. She is, so far, the only survivor of this condition at Kijabe and perhaps only the second or third in Kenya. Here her mom is attempting her first breast feeding after more than two weeks of tentative intravenous and slow tube feeding post-operation. Hannah's course has not been entirely smooth, and her mom seems depressed. Please pray for them. We are hopeful. This baby's mom was transferred urgently in labor to Kijabe when it was noted that he was lying sideways (not head down) in her womb, and she was in active labor a bit more than a month early. Scott did an emergency C-section that was pretty complicated, and Mardi resuscitated him back to life. Here he is in the blue glow of lights designed to bring down his levels of jaundice. His mom also had a hard time establishing feeding (not so unusual post-op). Her relief when his jaundice improved the next morning was a great joy to see. John is another cute little preemie with a bit of jaundice. His mom is reaching into his incubator to change his diaper and just touch him.George is pictured without his mom . . .because she was feeding his twin brother when I walked around snapping photos with my phone. George was the second, smaller twin, and he's had a hard week with a dangerous bowel infection. But he is greatly improved now, and his mom will have her hands full with two premature boys.

Sometimes I feel overwhelmed by coming up with three meals a day for four healthy kids who feed themselves at the table. Or unable to focus on questions about how to factor an equation or wither Iodine exists as a two-atom compound or what would be a good paper outline for the second battle of Bull Run. I am humbled to watch these women tirelessly caring for their babies around the clock, never sleeping more than an hour and a half, no privacy, wearing hospital gowns and eating from a trolley of institutional food, sharing a bathing area with 80-some patients on the ward, and with only a moderate hope that their baby can survive. Few families can afford to visit very often. These women form community amongst themselves in their shared suffering. And rejoice with each other, too.

Every morning I pray with them, that they will meet Jesus in this unlikely place.

So much of parenthood teeters on the grief of loss. This morning I read the beginning of Joseph's story in Genesis. This time Jacob jumped out at the end of chapter 37. "Thus his father wept for him." At that moment, with the torn and bloody robe in his hands, Jacob could only see tragedy and the end of his dreams. There was absolutely no evidence in this story to suggest that God would redeem Joseph's taunting pride and his father's favoritism and his brother's jealous violence and his culture's unjust slave trade to bring about the dramatic rescue of a civilization facing famine and a tribe facing extinction. Jacob had nothing to suggest any emotion other than despair. But his son was destined for greatness. I hope some of these moms have that sort of faith. And I hope I will have it too, next time my own children's paths look like they are dropping into a pit.

Here's to our nursery moms, and the painful joy of parenting.

Home Base

2012-01-22T04:03:00.000-08:00

in the last few weeks we've been blessed with a number of visitors. Africans always see visitors as a great blessing, and since my cooking is usually a topic of Swahili vocab and conversation with my teacher, whenever I say that we have guests he is exceedingly happy on my behalf. A family of missionaries in which the father was long-ago an RVA student coming to reconnect, kids who attend school coming a day or two early to get over jet lag, a single missionary from a remote and hard-to-live place coming for some family time, a family from a remote area of East Africa coming to investigate enrolling their child at RVA, a mom coming to check on one of her boarding kids, medical students and residents from the US coming to learn and explore and ponder their futures. Some of these have slept here, others we put up in the local guest house and just had over for meals. Many conversations, good meals, lingering, movies and games and fireside fellowship, tours and introductions, and some prayers.

I was praying with one of the long-term station women on Thursday, and we talked about this role God has given us in our lives here. The role of home base. Of safe spot to return to, to launch from. Of accessible food and medical care, of organized worship and recreation, of abundance of relationship. Kijabe and RVA are like the hub at the center of the wheel of missions in East Africa. People pass through because they have history here, or friends. Or because they're sick and need care. Or because their kids are here.

This is not always felt to be a very glorious role, particularly for the women who are mostly consumed with being moms. But I believe it is a crucial one. Because I've seen it, a good number of times, from the other side. We were once the people passing through. We first came here for safety when preterm labor threatened our baby, and stayed for a good delivery. We came here again in a time of war and upheaval and uncertainty and found a healing rhythm of work and community. We passed through other times to attend conferences and visit friends. And twice for life-saving medical care and surgery (Scott with a serious leg infection accompanying a visitor with an appendix disaster; and Jack with an incarcerated hernia). Until a year ago, Kijabe was a place whose existence allowed us to survive, and to continue living on a dangerous front line. RVA was a place which allowed our two oldest to progress further in school without having to return to America. The existence of this sprawling station with its resources was a safety net for us.

Now we are starting our second year here, appropriately, with a spurt of visitors who are using the net, touching the home base, as we once did. Now we're the people who provide the listening ear, the meals, the arrangements. It is different from the rest of our life in Africa, to be sitting on this breezy porch on a Sunday afternoon, undisturbed. To have a cold electric fridge that we just stocked with easily 15-20 different varieties of fruits and vegetables. To have a washing machine that churns out clean clothes for our travelers. To have heard a very good sermon in English with modern praise songs and American handshakes afterwards. To be able to send this post by a fast and fairly reliable internet connection.

In Genesis, Abraham and family were continually promised a land that they would use to be a blessing to others. A nation that blessed the nations. Kenya does flow, literally, with milk and honey, with dairy projects and bee hives. I still miss so much of Bundibugyo, but I do embrace the home base role, and pray that each person who passes through our life here will be strengthened and blessed for the journey.

A 24 hour life

2012-01-18T11:26:00.000-08:00

Evil feels triumphant tonight, or at least impotence and ignorance.

Twenty-four hours ago we were sitting around the table after dinner, serving tea. Our friends the Wrights had just pulled in from a long day's drive from Karamoja (Uganda) to visit, and our friends the Barnes had been sucked into the party when they walked by with a young premed student delivering Birthday invites. I had a page from the nursery to go over some labs, and was feeling pretty relaxed about the evening since things were going relatively well. Then a few minutes later I got the "999" page that means "RUN". I grabbed my coat and stethoscope and made quick apologies as I rushed out the door, trying to imagine which of the babies could be dying.

Into the humid warmth of the nursery, brights and steamy and slightly chlorinated, a jungly at-home feeling after rushing through the windy darkness of Kijabe. I see our medical officer and two nurses huddled over the resuscitation table, and quickly glance around the room to see which cot or incubator is empty. But it is a new baby, just delivered, pale and floppy and lifeless and bloody. Very bloody. Blood matts her hair, is caked in her ears, fills the suction catheter that vacuums her mouth. I hear quickly that she was born dead, with no heart rate or effort to breathe. But now a few minutes later her heart is beating strong, though nothing else seems to be happening. No flicker of movement, no flutter of eyelids, no gasp of breath. We dry and clean and suction and bag breaths into her lungs, over and over and over again, while her heart ticks steadily on. I get more story that makes me suspect she may be a bit drugged from pain medicine her mother got, and after a dose of a reversal drug she does start to breathe. In a full forty minutes though we're still floppy and in spite of lots of oxygen and help she is still blueish. And if she was just punky from her mom's medicines, what's the explanation for all that blood? I decide to intubate her to suction her airways better, and to try and improve her oxygen status. I'm still not confident about many of my skills, including threading the airway of a slippery (usually squirmy, though this baby wasn't moving) phlegm-filled micro baby throat. But by God's grace alone I get the tube in, and we suction some blood.

And so the first hour ticks by, and before too long the second. The baby is fighting a little now, moving her delicate arms. She never really responds the way I would expect to all the efforts we make. A fluid bolus seems to help. We check her blood count thinking that if this is HER blood she lost, she may need a transfusion, but she doesn't. Xray doesn't show any major lung problems, heart seems normal. I take time to go find her mom and bring her into the nursery to see her baby, whereupon she turns and puts her arms on my shoulders and sobs. I pray for her and stroke her back and try to sound hopeful, striking the right balance of sober and optimistic, your baby is very sick but so were all these others who are now improving. The mom names her Victoria. By ten pm we pack the baby into an incubator and wheel her up to the ICU to be kept on a ventilator, since she does not breathe well enough on her own to make it. I'm home before midnight, leaving her pink and restful, opening her eyes, and I hope over the worst.

By morning I've only had one call about her, and I am hopeful that whatever was wrong is getting better. Then another "999" during rounds, I run up to ICU where the staff has accidentally dislodged her endotracheal breathing tube. Not difficult to do since the margin between "in" and "out" is less than an inch. I briefly consider keeping her off the vent, she is doing so well, but then her oxygen levels drop, and I realize she's not ready. The medical officer tries to intubate without success and then everyone looks at me again, and I pray. This time Victoria is actively fighting against me. But I get the tube in again, and she's pink and as we put her back to bed, restful, looking at me. Labs look OK, and though I'm still puzzled by just what is causing her problems, i don't really mind not knowing if she's getting better. I order another xray to be sure the tube is back in the right place and go back to nursery.

(Where, parenthetically, I find a surprise 32 week tiny bright pink baby boy just born . . whoops, we are out of incubators, so he has to rest on the resuscitation table while the one available incubator is fixed).

Before another hour is up though, I am back to ICU where her oxygen levels have plummeted. I'm told the xray was OK but when I look myself I see a too-dark outline to the right lung. Her lung has popped like a balloon, leaving a rim of air between the lung and the chest wall that compromises breathing. And since we are pushing air into her lungs, we are making this worse minute by minute. I call the paeds surg team to put in a chest tube, and am poised to stick a needle in myself but they arrive just in time.

From there we never really regain our ground. Another couple of hours pass, the chest xray with the tube in place looks great, but the baby doesn't. Victoria is inexplicably dying.

I usually look forward to my Wednesday afternoon sign out to Mardi. Especially after being on call 3 of the last 4 nights. I try my best to have everything sawa sawa and ready to go. But today was not fun. I hung around an extra hour but Victoria only seemed to be getting worse, and then it was time for Julia's soccer game, and I left. Mardi messaged me not long after. Victoria was dead.

She lived a day. Not quite 24 hours, and I was with her a good number of those. More than her mom was. At first I wondered if we should even try to revive her, then I thought she would probably live and be fine, then I had no idea how to keep her alive.

Part of my heart knows that the quote below is true. Right, temporarily defeated, is still stronger than the apparent triumph of death. Victoria lives on, and waits for the resurrection. Her name reminds me of 2 Cor 15--where oh death is your victory? But I am wearied tonight by the lost battle, and though I'm thankful I was spared the final moments (thanks Mardi) it is still a sadness, hopes dashed. Her mother will grieve this in some part of her heart throughout her life; I will probably barely remember this in a month or two, as another hundred babies pass through my hands.

So tonight I honor one small life, a little broken body, a valiant struggle, and look forward to the place where death is no more.

MLK DAY

2012-01-16T11:12:00.001-08:00

"I believe that unarmed truth and unconditional love will have the final word in reality. This is why right, temporarily defeated, is stronger than evil triumphant." Dr. Martin Luther King

Quote for the day courtesy of our fellow-Africa-loving-Paediatrician Amy Long. Wishing I was at Luke's Gospel Choir Concert in honor of the day. Feeling a bit of temporarily-defeated-ness in the wake of a long weekend of call (Scott did 5 C sections in about an 18 hour stretch, I lost one of our NICU babies).

week in review

2012-01-15T04:08:00.000-08:00

Julia and the Varsity Girls' Football team, with Coach Dahlman. They had their first game this week, a loss to the Swedish girls. In spite of the 1 to 0 score, our team played well. And Julia played awesomely. Highlight of the week: Miss Larissa of South Sudan has stayed with us since Wednesday. It has been delightful to have her in the house, to feel like "team" again. You can see how happy Acacia is. I am thankful for her company, ideas, service, cheer, and general presence. Brielle sports her CPAP (continuous pressure oxygen circuit) which is held in place by the little pink knit hat. Charming parents anxious but happy, unstoppable labor, an active little preemie with a reasonable weight and a good prognosis. Hoping she will fight on through. Jack, exhausted with cheering, sinks to the floor in relief when Man U pulls out a victory over Man City. It hasn't been an easy couple of weeks for avid Man U fans, and the losses have taken their toll. Caleb's last step (??) in college apps, the ROTC physical fitness test. He did 57 pushups in one minute and then ran a mile and a half around the grass field in 9 min 6 sec, which is pretty good at this altitude. Here he is smiling with Coach Davis after the run. Miracle baby Wangari. Keep her in your prayers. No baby with gastroschisis has yet survived here, though we've tried to help many. The others have been born elsewhere, languish a few days with their intestines hanging out a hole in the abdominal wall, become infected and dehydrated and can not be rescued by the time they arrive. This baby was born here, and in spite of a harrowing first few minutes when we couldn't get her to breathe . . has done well. Her intestines are now back inside, and starting to work. I taught a conference on her case this week, and reflected on Psalm 139. Rugby tryouts have started a whole term early. Because the varsity team did not do so well last year, they have to play a relegation match this term, so the coaches are training with about 40 boys daily. Rugby is THE sport at RVA . . here is Jack, with the talented Howorth brothers, coming to eat pizza covered with mud . . Some of Caleb's senior guy friends (Titus and Aneurin are our guardees, plus Joop who is just fun) join us for pizza making at the end of the week. One of our other guardees . . Anna Rich . . also joins the party. It rained for hours and then cleared just as we were ready to cook, for a very fun evening. The power has been off most nights for random blocks of time. Caleb has mastered dish washing by candlelight. Sort of nice, you can't see the mess. Fridays the students gather outside during their chapel time for flag raising. Larissa and I went up to see the choir sing the national anthem in Swahili . . I tried to post the video but no deal. It was lovely. Perhaps you can make out Julia and Acacia singing alto, and imagine Caleb singing base int he back. This weekend Scott and I are both on call. Last night I sat with a tiny preemie who was dying, praying with his mom and watching his little heart slowly tick down to nothing. We had been rescuing him with less and less success all day, and by 2 am he had signs of brain death. Meanwhile Scott was doing two C sections. We both got home at the same time, 3 am . . And were both called from church this morning for this little pumpkin, a 33-week preemie whose mom was deteriorating dangerously. Scott did a C section and I whisked her off to be revived. Only she didn't need reviving, in spite of weighing 1.4 kg she was the most active, wailing baby I've seen all week. These two cuties were surprise twins--their mom delivered the one on the left and the paeds team was taking him to nursery when lo and behold another one came out. They share a cot warmer and are twice as cute as one alone. So another week goes by: death watches and celebrations, rescues and cheering, sweat and struggle, meals and messes. Amen.

Occupational Hazards...

2012-01-14T02:55:00.000-08:00

One of the inherent risks of doing surgery is potential exposure to patients' blood and body fluids. The Cesarean delivery is one of the bloodiest of all surgeries.

As Scott attempted to extract the placenta from HIV+ mother during a C-section this week, the cord tore and blood splashed up onto his mask and glasses.

Thankfully... -- it was cord blood which should be virus-free -- he doesn't think he got any fluid in his eyes -- the mom is on treatment so she should have very low virus in the blood.

However, please feel free to shoot a prayer up for his continuing HIV-free status if you think of it!

Mt. Kenya

2012-01-08T07:27:00.000-08:00

Between Christmas and New Year's our family hiked up Mt. Kenya. We reached Pt. Lenana, 16,300 feet, one of a cluster of craggy bare-rock pinnacles. Batian is a few hundred feet higher, but not accessible to non-technical climbers like us. Our route took us from the Northwest slopes, ascending the Sirimon path through the Mackinder Valley to the central peaks, then back down the eastern side on the Chogoria route past Lake Michaelson. We spent four nights on the mountain, three in simple wooden shelters with bunk beds, and one in tents at 14,000 feet of COLD. On our summit day we woke at 2 am for tea and biscuits, then hiked too fast so we reached Pt. Lenana almost an hour BEFORE the sun rose and waited shivering in the shelter of rocky crags until the light broke. That morning the clouds were below us, and nothing but brilliant stars above.

Four nights in the wilderness refreshes the soul, five days of strenuous hiking in the thin air of equatorial altitude hones the body, a week of family togetherness completely cut off from the world (no phone, no fb, no email) builds memories and togetherness. We went with a budget outfit of Kenyan guides and porters which turned out to be perfect. We drank mugs of hot sweet tea morning, noon, and night, and sometimes in between, which seems to be how Africans handle the low temps and high altitude. We marveled at the wildflowers, jumped over boulders, teetered on the edge of precipitous panoramas (I was later thankful that we ascended the final peak in the dark so I couldn't see most of the danger until the way down), laughed at the fat unafraid rock hyraxes, fed our crumbs to the mountain chats, shivered in our sleeping bags and ended up with sunburned faces and hands. The last morning we watched an elephant drinking from a watering hole near our cabin, while monkeys chattered in the trees.

Mt. Kenya is one massive rise, not the long convoluted range of the Rwenzoris. There were few bogs, and almost no mud, long spectacular views, more dry open scrub and a lot less jungle. There were also MANY more people. In a week in the Rwenzoris we hardly had contact with any other campers, unlike the couple of dozen at each campsite on Mt. Kenya. In the evenings we read aloud from "No Picnic on Mount Kenya", the true story of an Italian POW interned in Kenya in WWII who escaped the camp to climb the mountain and then turned himself back in.

It was a lovely way to spend the holiday. God often calls people up on the mountain when He wants to meet with them, wants their undivided attention. There is something to be said for the inaccessibility, the juxtaposition of danger and beauty, the rewarding effort, the perspective on life below, that makes mountain climbing an apt metaphor for a spiritual journey as well as an appropriate real physical location for divine encounter.

As we have turned the corner of our second year at Kijabe, passing our one-year anniversary on the 1rst of January, I hope I can hold on to the memory of the stark splendor and clarity of Mt. Kenya back down here in the Rift Valley of normal life.

Thanking my faithful and generous friends

2012-01-06T05:45:00.000-08:00

Luke stuffed his luggage on the way to Kenya with beanie babies. 162 of them, to be exact. And he brought me lots of cards from people who sent them. Vicky B, John, Susan, Ellie and Hannah P, Sarah E, Susan and Paul M, Elaine M, Sally V, Amy S, Debbie H, Dan, Erika, Daniel and Katerina C, I thank all of you. I found email addresses for some of you, but let me say thanks on this forum as well. And to whoever sent packages that Luke did not manage to keep the cards from. Yesterday we scoured craft markets for cute beaded baskets made by Maasai ladies. Tomorrow we start assembling the Valentine baskets which will encourage the students here at RVA as their parents will be able to send them, with notes. Fun stuffed animals, candy ferried by many of the doctor-visitors here, locally made African baskets, and a few fun goodies from the Nairobi grocery stores . . should be great. Thanks to the dozens of people who made this happen.

While I'm thanking, Heidi L and Julie S sent us packages (YEAH! Trader Joe's peppermint Joe's, and a puzzle!!) and Becky T sent a hand-made craft, and my mom's neighbors Victoria and Scott sent us a book and CD . . thanks so much for mailing and thinking ahead to bless us. And we had visitors from Baltimore by way of China, who brought Chinese oreos and cards and friendship and a New Year's Eve celebration. Grateful for their visit!

And I can't even begin to mention our families whose generosity made our trips to Samburu and Mt. Kenya possible.

I thought I'd get nice cards to send back with Luke to mail. I thought I'd write out lovely notes to everyone. But the truth is I didn't, and even if I had I don't have handy addresses for most of you. So please let this serve as a heartfelt thanks.

Below is Luke at the airport yesterday. I miss him so much already. This is a hard day here at Kijabe for me, some disappointments and just the heavy sorrow of another goodbye. So I'm obeying the Psalms and being thankful, hoping it lifts my heart (and if 162 stuffed animals and pounds of chocolate can't do that, I don't know what will!).

Strangers and Aliens and the End of Gloom

2011-12-26T03:12:00.001-08:00

There is a light. No matter how dark it might become, there is a radiance that will not be denied, that cannot be ignored. Prepare yourself for the coming of this luminous Presence. Get ready for the end of gloom. Is 42:16 http://www.d365.org/followingthestar/

If you know me you know that I love Christmas. It is a month-long tangible spirituality, anticipation and holiness, colors and tastes and music and memories. Over almost two decades we have developed a rhythm of traditions, from our families and from Bundibugyo and from Scripture and from experience. For me, at least, it was a blessing. But Christmas, the real Christmas, is a story about interrupted lives. Mary, interrupted by a turn-life-upside-down pregnancy. Joseph, interrupted by doubt and scandal. Their known world, interrupted by the chaos of a census, movement, displacement. The shepherds, interrupted from their duties by light and wonder. The wise men, interrupted by a quest, foreign intrigue, danger. Herod, interrupted by the threat of a new king. This was the theme of our sermon in church yesterday. For the first time I can remember, the Sunday School's presentation of the Christmas Pageant included soldiers marching in formation to genocide, and the main characters running out the side door, which African kids know too well. Our hearts keep trying to make order, safety, ritual, and yet the story is one of upheaval.

As newcomers to Kijabe, I felt this acutely. Trying to hold on to some of the things we "always" do, but in a new setting, with new people. A lot of that was good, and meaningful, and fun. Having advent with new colleagues, Kenyan and American and otherwise. Inviting friends for our White Dinner. Pulling out the old decorations in new arrangements. Less obligation, in some ways, brought more freedom. But in the few days before Christmas, a lot of that was hard too, and I felt the alienation of not being "home" in Bundi. In my old life our family would have taken little gifts to all the kids still admitted on the 23rd or 24th in the hospital, but here a major organized party went on the ward while I was stuck in the ICU struggling for a baby's life, and I didn't even know until I found all the balloons and stuffed animals that had been give out when I was on the ward that afternoon. In my old life we would have gone caroling as a team, but here we didn't find out about the caroling plan until a couple of hours before and it was too late as we had invited friends for dinner. In our old life we took beans and basins and practical gifts to each of a half-dozen neighbors and visited on Christmas Eve, so here I signed up to distribute Christmas gift baskets organized by RVA but our family inadvertently got dropped from the list (we could have just gone I know, but it threw us off, and it just wasn't the same as taking it to people we had known for years). All of the timing was just a little off, the services too early, the meals hard to work in. We ate our Christmas dinner with a family we had never met until that afternoon, at someone else's house. None of this is wrong or bad, people here were uniformly gracious, it is just the reality of uprooting and entering a place that has its own ways of doing things. Of moving from being the center of planning and instigating and creating, to being on the periphery of not-quite-keeping up with the established program. Compounded by working most of those days in a hospital where acutely ill children keep showing up regardless of the holiday, and being on antibiotics for a minor infection that I couldn't quite shake off.

So the words of Isaiah in the advent devotion called for faith, in a way that might not have been possible in a more comfortable setting. Get ready for the end of gloom. For a new thing God will do. For gifts He will send.

The real story is one of aliens and strangers and interrupted lives and making do. But also one of unexpected blessings, of inversion of expectations, of beauty in the strangeness.

So here are a few snapshots of Christmas, of moments that came as gifts.

Julia decided to make a wreath herself.

Christmas Eve dinner table, with the plates I found in a duka in Fort Portal once, who would have thought, all the way from China to Uganda to make an American table beautiful.

A fireplace, for the first time ever.

Best moment of Christmas: up on the soccer field at sunset, kicking a ball around, as rain swept over the valley and the dust and droplets lent a golden glow.

By Christmas evening there were four paediatric patients in the casualty department needing admission. After working with the intern and evaluating all of them, I went to do a final check on the ward, and thought I'd pop in and say Merry Christmas to my favorite little patient, Ryan, pictured above last week when he was feeling perkier. He has TB and his heart has not kept up with the damage to his lungs. He's moved from near death to pretty much alive over the last month. Only Christmas night I found him irritable and struggling to breathe. What!?! My greeting turned into an alarmed exam, and I found his heart much worse. A review of his medicine chart showed one of his essential meds had been mistakenly canceled. I got the nurse and we gave an emergency dose. It is a Christmas highlight because I think the Spirit sent me to his room that night, and I'm so glad, I doubt he would have made it much longer.

Second favorite moment: this morning, I went out to hang the laundry early, up because of various calls from the ward. And a flock of about 30 red-fronted parrots landed in our tree! They chattered and squawked, their beaks clacking as they fed on the tiny green berries. They've been here much of the morning. Luke set up the spotting scope so we could see their bright green feathers and red faces in exquisite detail. Christmas birds.

This is the bright red pullover and the silver cross Scott brought me back from his trip to America. I love both.

The Lion and Lamb

2011-12-21T10:39:00.000-08:00

In Samburu National Reserve, a Kenyan game sanctuary, the prophecy of Isaiah 11:6 was fulfilled about ten years ago. Jesus' reign is not complete, but in this instance a lioness adopted a young gazelle and raised it. Twice. What better place to spend a day or two before Christmas? But I get ahead of my story. What better way to really experience the anticipation of ADVENT than waiting an extra two hours for Luke to make his way off a late flight, last in line at customs from row 63 on the plane, and then talking his way through customs with a refurbished guitar in a box stuffed full of donated beanie babies? Here he is moments after arrival Monday morning: From there it was a couple of hours through snarled, agonizing, choking Nairobi traffic until we hit the open road and drove north to Samburu. All of our parents gave us generous gifts this Christmas, and this was how we spent some of it: 48 hours together, away from the rest of life, re-bonding and refreshing. Unlike our usual rough-it camping experience, we splurged on a tented camp recommended by our friends Anand and Sophia. We knew this was not a normal Myhre vacation when . . . We were following the rough trek to our camp, pausing to watch a group of elephants cross the shallow river, and around the bend we came upon a welcoming committee. Chairs, cool towels to wipe off the dust, cold drinks, all set up on the river bank where we could stop and watch the sunset before proceeding to the camp. Luke surprised us with a new safari accompaniment: the spotting scope. Binoculars on steroids. Luke can look at a distant horizon and pick out an animal, but the rest of us mere mortals need him to focus the scope to see much detail. It was a great gift! Here Julia tries it out on the veranda of the tent in the afternoon. Meanwhile Jack is cooling off in the heat of the day in a small dipping pool of COLD water. We went on the chilly early morning and late afternoon/evening drive, but mid day the temperatures soared. So each tent comes with it's on opposite-of-a-hot-tub. And our family all had good books to delve into in the heat of the afternoon. Lovely. Our final meal, breakfast this morning, on the river bank again. Any time you have four teens at a buffet you feel like you're getting your money's worth. We did actually see some beautiful views and animals, but those photos have to come from Scott. I only snapped phone shots at meals. A parting shot: Luke shows me that I can get in my own photos. We were only in the park a little over 36 hours, so we debated hiring a guide for game driving since our explore time was limited. But I realized that's not really our style. We aren't really out there to tally up the sightings. We're out there for the experience of wilderness and beauty. For the wind blowing in our faces as we ride out on top of the roof rack. For the way the sun lights up the post-rain grasses. For the spring of the spindly-legged gerenuk and the stately gaze of the oryx. For the family memories, the banter, the meals, the suspended time of being away and together. For all this I'm grateful. Tomorrow morning starts a stretch where we are "on" almost continuously 3 of the next 4 days, including 2 calls, one of which is Christmas. So this trip was a precious gift.

Christmas Prayer Letter for Downloading

2011-12-18T07:02:00.001-08:00

Merry Christmas from the Myhres and World Harvest Mission!

Some of you will receive a hard copy of this letter in your mailboxes in the coming week...

For those of you not on our mailing list or for any who would like to see the pictures in the letter in color...

Click HERE!!

Thanks for your prayers and parternship.

Kijabe pre-Kristmas News

2011-12-17T06:36:00.000-08:00

Moneys are browsing in the tree a few feet from my porch, the rain is drizzling down incessantly, the kids gave up on waiting for sun and went to play soccer anyway, Scott is on call but post-strike he has an INTERN, plus the rest of the world is not transferring patients our way left and right, so it's been relatively quiet. It's good to be home after several long hours sorting out both nursery and the regular paeds service this morning. One thing I do love about rounding on EVERYONE (OK I'm looking for a bright side here) is seeing the very baby who I despaired of living, now thriving. So nice to greet Dancun and his mom today. He's out of the incubator and starting to breast feed, happy and growing, and a few weeks ago I didn't believe he'd survive the night. We have a whole room of little oxygen-dependent heart-defect babies who are hoping for surgical sponsorship from a German charity (see http://steeres.com/ "A tale of Two Hearts" and http://www.helpachild.de/de/hilfsprojekte-/medsoforthilfe). Our ICU baby is coming back to life too, and his neighbor is much better once we figures out his severe electrolyte deficits. Now I have been plowing through a month or more of flagged emails, the up side of being made immobile by having my hair braided. If it turns out I'll post a picture.

Most relieving news of the last few days: Caleb has officially completed his college applications. He hit the submit button. From our human perspective, it is done, and all goes into the black box of God's will and human random choice and the beating of butterfly wings in China that will somehow determine the next phase of his life.

Most exciting news: Julia got to fulfill her goal of learning to ride a motorcycle, thanks to the cheerful can-do kindness of another station family, who took her with a handful of boys out to the airstrip to practice.

And most meaningful news, we had a lovely evening with our Medical Officer Interns. We had planned a pizza evening for them on the 16th but with the strike we weren't sure it would really happen. I think it was God's timing to bring us all back together. Six of the seven were able to come (one didn't get away from call at the hospital). I realized once again what a great group they are. Intelligent, game, hopeful, curious, seeking. I have to say they made some very good pizza, catching on quickly. They were, of course, rather late so it was dark as we finished. Then they came up with a couple of very active laughing dancing sort of games, almost giddy with the freedom of a night off, lots of food, the end of the year in sight, rest from their ten days of strike. We lit advent candles and focused on Zechariah 4, not by our might but by the Spirit, God bringing victory from the day of small things, very appropriate to our work. The evening ended with mutual thanks. I guess we're old enough to be their parents which was how they categorized us, and I was complimented by that. As we miss Bundibugyo, these evenings with our colleagues at Kijabe are very sweet to me.

And most anticipated news: Luke is, even now, in his organic chemistry final exam. In a few hours he'll be DONE with the first semester of his sophomore year, and boarding a plane for Africa.

Snickerdoodles and CPR

2011-12-15T10:05:00.001-08:00

That could be the title of my life, I guess. In the last 24 hours (I am not making this up) our life has included the following disparate moments, often within the same hour.

Bedside with Ryan, a nearly two-year old twin whose TB-filled lungs caused his heart to fail and nearly cost him his life. After a month in the hospital he is smiling, reaches out to shake hands, precarious, his spindly legs splayed out, not yet catching up to his largish head. Tremendous progress, but he is still oxygen dependent. Sympathizing with his patient mother, who cares for him day and night, we begin to discuss plans for home oxygen. I mention, as a last minute thought, that the oxygen can't be in a room with a flame, so they will have to keep Ryan separate from the kitchen. Oh, wait, she begins to balk, in Swahili. It turns out that this lady, her husband, and her four children all live in one room. They cook and sleep and exist in it. She can't cook outside, because the wind causes the fire to burn down too quickly, wasting precious fuel. She decides that since her husband has taken the other three kids up-country to the grandparents for Christmas, she really doesn't need to get home until it's time for the older children to go back to school, so she'll stay as an inpatient praying for Ryan's improvement. What an impossible dilemma: breathing or eating, one twin or the other.

And then I'm home for a couple of hours, making Snickerdoodles in my safe and efficient oven, in my 8-room house for six people, with my thriving healthy kids. Mixing brilliant red and green food color, rolling in the cinnamon sugar, fighting off snitchers.

Because yesterday evening, the annual Kijabe women's cookie exchange occurred. I had kind of been feeling like we were among the only ones left here, but last night one of the dorm apartments was packed with RVA women and girls, all bearing plates of every variety of cookie, sipping coffee and juice, greeting. I think it is the first time I've ever been to one of these, and as one might expect this event has a long tradition and a specific sequence and plan. You basically take home as many cookies as you bring, but an assortment. It was a good thing I brought Julia because just when it was time to collect on the goods, I got paged back to the hospital.

And a few patients later, only an hour after the cheery companionable atmosphere of women in red sweaters, a buzz of chatter over the strains of Christmas music . . I was kneeling on the floor of maternity responding to a complete cardiorespiratory arrest in a post-partum woman. I happened to be closer than Scott so got there just as the nurses were realizing that the springy mattress made resuscitation impossible and we all pulled the heavy lady, thin mattress and all, onto the floor. Just as I was wondering what the adult dose of epinephrine was and how long my arms could keep up the chest compressions, lo and behold, an INTERN showed up. The strike was CALLED OFF AGAIN and unlike 99% of the doctors she was not waiting for the morning but came straight in to take call. We took turns ventilating and compressing until Scott arrived and intubated the lady, but in spite of everything we were unable to bring her back. So there we were on the floor, kneeling around the body of this woman, in a crowded passageway in full view of a handful of other patients. She was unmarried, had delivered a baby with severe malformations who came to Kijabe for surgical care, and while here she developed what was probably a pulmonary embolus. Scott had to go tell her hysterical sister who was caring for the baby. Tragic.

I was home a few hours somewhere between midnight and 4, replenished my energy on Christmas cookies and tried to sleep a little, though we both got numerous pages. Our spastically blinking blue tree lights are a beacon in the dark when running back and forth in the wee hours. Scott left for an emergency C section (his third of the day I think) a while before I was called back to see a shriveled jaundiced little baby I had admitted a few hours earlier who was basically dying. I spent the rest of the night trying to stop that process, as it turns out, unsuccessfully. Intubation, bagging, xrays, labs, fluid bolus, an epinephrine AND a dopamine drip, ICU, but he still didn't make it. He was also a twin, the firstborn in a hospital without a handy doctor, he was born unattended and probably suffered some damage even then. A week later he was infected and gasping and his heart just gave out. He was another victim of the strike perhaps, both at his birth and in the many hours visiting three hospitals before finding care at Kijabe.

Back home (hooray for Thursday and Mardi!!) I make tea, notice the milk is sour, know my kids and Scott are about to wake up hungry, and remember a great oatmeal muffin we used to make from the Jane Brody wedding-present-cookbook-before-I-could-cook-anything era of food in our lives. I find the recipe on line, use the sour milk and oats and dried blueberries to make a double 24-muffin batch that three teens completely consume within two hours. We linger at the counter together, spreading on butter and locally made jam. Big treat of the morning: the annual Schubert Christmas package. Julie grew up as an MK and she gets it. She finds a puzzle for us every year, and sends it in time to reach before Christmas. Something about the continuity and thoughtfulness of that is so reassuring.

Meanwhile Scott is up and out and back on the ward while I stumble through a Swahili lesson. He checks on his middle-of-the-night C-section patient, who was HIV positive, which always makes surgery a bit more risky and tense for the surgeon. As they chat he asks the baby's name. Shekinah. Intrigued he asks her how she chose that name. And then has one of those "you aren't in Bundibugyo anymore moments". She replies, doctor, don't you know that's Hebrew for the transcendent presence of the Glory of God. He asks her where to find that in the Bible and she replies, google it. Really.

The afternoon is devoted, at long last, to Caleb. Who is one essay away from finishing and submitting applications to 8 universities for Engineering programs, in case he does not get into the Air Force Academy. Scott, Caleb, and I all sit by his computer as he uploads answer after answer that he's been working on for weeks, checking through one last time for spelling and commas and missing data. Caleb's humor in the whole process has us laughing a lot, which is remarkable in our sleep deprived state, I think with every step closer to done his burden feels a little lighter. He's a remarkable kid, with some very solid and meaningful statements about life. Each school looks better than the last. Soon it will be out of our hands, and in God's alone. I notice that the more he writes, the better it gets, the later essays being the best, which makes me a bit more of a believer in English classes.

Back to the hospital one more time at dusk, to visit my house-worker's sister-in-law who burnt both legs badly when she accidentally spilled a jiko full of burning charcoal on them. I am wearing loose running pants and tennis shoes and have my hair in pigtails. No white coat, no stethoscope. I truly think for a moment as I walk in the gate, no one will recognize me, I look just like all the other visitors. Oh, then I remember, I'm white. So much for blending in.

Patients and packages, death and muffins, hospital and family. All mixed together hour by hour in a messy paradox of life. Snickerdoodles and CPR.

THE STRIKE IS OVER

2011-12-15T09:55:00.001-08:00

Poetry or prayer, who can say, but we are all happy to have our interns back. I wish I saw more good coming out of this for Kenya, for the doctors themselves and more so for the poor whom they serve. But we're glad it is done, and hope not to experience that kind of stressful stretch again soon!

How the Strikers Stole Christmas!

2011-12-13T11:39:00.000-08:00

(or tried to. The story isn't over, and I'm too tired to finish the poem, but this first part goes out to all my colleagues at Kijabe)

All the docs at Kijabe were working a lot

But the ones living just East in Nairobi were NOT.

Those doctors were on STRIKE! For the whole Christmas season!

Now, please don't ask why, No one quite knows the reason.

It could be their income left their budget too tight

It could be, perhaps, they weren't treated quite right

But I think that the most likely reason of all

May have been that their vision for health was too small.

But whatever the reason, their salary or their dues

Their posters and slogans made Kenyan news.

They sat in their homes with stubborn strike frowns

While the docs at Kijabe ran themselves to the ground.

For every doctor there hustled, doing more than their share

To handle the patients who came seeking some care.

They were hanging IV lines 'til casualty was all clear

Though Christmas was nearing, it was practically here.

The government held meetings while the patients kept coming

The poor people suffered while protestors marched drumming.

Oh to find some way to regain those employed!

For tomorrow they knew all the sick girls and boys

Would wake bright and early and rush OPD

And then, oh the noise, oh the patients to see!

Every one, young and old, from the greatest to least

Would expect to be treated, cured, and released,

While normal folks sit down to a great Christmas feast

The Kijabe docs will cover for their colleagues to the east.

Yes, they'll keep working, on the worst tasks of all,

From paperwork to surgery, on the tall and the small

They'll stand together, united, to each other clinging

As beepers alarm and phones keep on ringing

And maybe, just maybe, they might even sing!

Because in the end, this frustrating strike thing

Must eventually end, and then, how they'll sing!

Why for nine straight days they've put up with it now.

Kenya must stop this strike from continuing. But how?

Advent Week 3

2011-12-12T12:40:00.001-08:00

Advent looks back to the incarnation, Jesus' entrance in human form upon earth. And it looks forward, to Jesus coming in power. As we've gone through the first two Advent Sundays, we have read Scriptures on these dual themes of "came" and "will come".

But this week we turned out attention to the present continuous tense, the way that Jesus is currently coming. Now. As in Matthew 25. As in, "I was . . . you did it to me."

We had our Paeds team over, the very people with whom one would want to ponder this present reality of Jesus as he appears in our current lives. And we read one of my favorite books, Papa Panov's Christmas, a Leo Tolstoy retelling of a simple shoemaker who looks for Jesus on Christmas day and realizes he saw Him in the poor and needy and hurting people who came to his shop.

It was lovely to have a house full of friends, American and Kenyan and Canadian. To have a beautiful spread of cookies. To play and sing carols, to light candles, to talk and visit. I miss the bustle of being the social center of a team.

But more than the atmosphere, I needed to be reminded of the message. As the strike drug on, I spent 11 hours of Sunday in the hospital (almost the whole day, except the hour and a half of our party!). I needed to think of the next person, and the next, as Jesus, however unlikely. A little boy found naked, cold, unconscious by the roadside by a slightly inebriated man who dropped him off at the casualty department as a dead body, but who later warmed and woke. Hours later his family found him. It seems he is a mentally retarded child with a convulsion disorder who had been locked in the house while his mom went to get milk, crawled out the window, and decided to try and walk to see his distant grandfather. The police were involved by this point, and we appealed to the family to support this mother, and watch this boy. . . . . A nearly two year old who had lost a third of his body weight in the last few months, received terrible medical advice from a district hospital, and whose mother persisted in thinking that there must be something else she could do for him . . . a toddler whose mom also abandoned her admission at a government hospital after she saw no improvement in days of admission, and had seen no doctor the entire time in spite of the serious diagnosis of meningitis. . . kids with vomiting, with dwindling, with cough. . . a little preemie who just tried to give up on life as his fever spiked up and he lost the drive to breathe, requiring hours of resuscitation including a couple of rounds of CPR until the nurses had an important observation about some missed medicines that helped him pull on through.

All of these kids, and more, were Jesus at Kijabe yesterday. And until he comes in power, we will continue to meet him in these unlikely powerless people and places.

Christmas Tree

2011-12-11T03:20:00.000-08:00

Yesterday we put up our Christmas Tree.

You might think that after 18 years in Africa we would have succumbed to the convenience of an artificial tree. And this year, I did wonder why we were stubborn purists on this matter. But we've always had a live tree, or something close to a tree, and it has become a matter of tradition now to search for it. One year we were nearly arrested, so the process is not always straightforward. After that I planted enough for the coming years myself in Bundi, but those are now long gone. So here we were in Kenya with no real plan. There was definitely a bit of reluctance/anxiety/doubt as we all piled into the car. I had asked two Kenyans and one missionary what they have done, and was told all three times, oh, just go into the forest. So we looked for a good spot to try that.

Kijabe sits on the edge of an escarpment that is topped by National Forests planted with pine trees. But these are huge 30-50 foot tall trees, with long straight trunks in endless dark rows and scraggly needles way up at the top. And it would be unwise, not to mention illegal, to cut them. We did cruise along the road looking for perhaps a younger tree which had chanced to grow right on the road edge, but no luck. So we ended up hiking a short ways into the "quarry", a ravine of public land nearby where rock is quarried. The sun reaches here, so the floor is covered with bushy vines and scrub, including some cedar trees. None of them have anything close to a traditional Christmas tree shape. Most were scraggly, one-sided, bent, multiple-trunked, too large, or on a cliff edge. But we did find one semi-promising specimen. Caleb gamely chopped it down, and Scott and he added in some branches of equal height from a few other cedars.

We loaded our branches onto the car and brought them home, at least feeling less guilty since we had not really chopped down a full tree, so re-growth would take place. And while cruising the national forest we bought 3 seedlings so we can try and grow something more shapely for the next few years, or at least have a net re-forestation impact. No one questioned or threatened us, thankfully. At home we realized our ceiling is barely 7 feet tall. But we pushed all the various scraps together, secured them to each other with zip ties, set them upright in a bucket of bricks and water, strung on the lights, and added our ornaments.

Resulting in a festive display. Our tree lights are from Kampala, when electricity came to Bundi two years ago we went wild and bought four strands of the tackiest blinking spastic colorful lights you can find. Our ornaments are numerous, collected over many years. Some from our childhood, most bought here and there as we traveled, memories of trips, or home made by our kids. Our tree itself smells of fresh cedar, and splays out in awkward and scraggly directions. I like to think of the whole thing as exuberant.

It would be easier, and more attractive, to have a tree we assembled from a box. Or to drive to a lot where trees are lined up, grown in neat rows, manicured to prescribed shapes. Somehow this expectation of perfection is so much a part of modern culture. But I like our tree. It is fresh and real. It does not conform to expectations. It is not afraid to push out in various directions, or to blink in blue.

Christmas, as in the real Christmas, was a lot about making do. Making do with a less-than-ideal shelter, with an improvised cradle, with cast-off rags for clothes. And all those things were made beautiful and infused with meaning. Our tree reminds me of all this, of the boldness of pulling things together and declaring them beautiful. Of our whole life, which involves pushing the edges, looking for beauty in the ashes, creative adaptation of our home culture to new places, the melding of the old and the new. Of a God who does not require us to be the perfect uniform shape and height, but whose grace pulls us in just as we are and adorns us with lights and jewels. I'm thankful for our little tree. Just hoping it holds up 'til Christmas!

Doctor Strike Day Two

2011-12-07T04:12:00.000-08:00

Scott and I both opt to begin the day around 7:30, checking on critical patients before rounds. Which is a good thing, because we're almost immediately called about a transfer from Naivasha. A strike-effect, a very sick baby lands our way. Throughout the day the combination of an increase in patient volume (one man went to ICU after 36 hours of bouncing from one non-functional hospital to another after his road traffic accident) and the considerable decrease in functioning work-power.

This cheerful little girl spent over three weeks on our service, as the TB therapy finally kicked in and she began to come back to life. This was her first day without an oxygen mask on her face, and I just had to take her photo. Though the endless stream of malnourished, dwindling, gasping, struggling little people can get depressing, the wonder of watching most of them move from lethargy to life makes it worthwhile.

My team is down to Lillian, the Clinical Officer who works full-time week-days in Paeds, and me. The strike is harder on people like Lillian than anyone else. Our 20-ish patient service used to be shared between her, a medical officer ntern (doctor) and one or two clinical officer interns, who would all review some of the patients and present them, or follow up labs, or write up new admissions. Now she tries to come in early, too, to see as many patients as she can, and we review all of them and then finish up together. Lillian is bright, caring, cheerful, competent, willing . . everything you would want in the person you spend most of your days with. So one of the blessings of this strike is working with her. After rounds we go to the Maternal and Child Health clinic where we see patient after patient again. And keep checking in with ICU, casualty (emergency), nursery, the floor. I'm called to private clinic to see a sick missionary baby, and to the neurosurgical ward to help with a deteriorating four year old. It's non-stop.

In the late afternoon I find out that one of the preemies in nursery has dangerous levels of jaundice and needs an exchange transfusion. This baby temporarily dies while we are putting a line in her umbilical vein, requiring CPR. I try and explain what's happened to her anxious parents. Then the charge nurse and I begin the tedious process of removing her blood volume and replacing it twice over, a teaspoonful (5 ml) at a time. After a short time the line fails to work and I am rescued by the ever-patient paeds surgery resident, who helps me replace it. At first I am relaxed and chatting with my nurse about Christmas but the baby once again begins to have a falling heart rate, and it takes all our care to keep her alive through the procedure. My advent devotions pointed out that if Jesus could come to Bethlehem, God can show up anywhere, so we should expect him in the hard places. Once again the exchange transfusion reminds me of a crucifixion, a small innocent person spread out and pinned down, lots of blood, what looks like murder and turns out to be life-saving.

I hand the baby over to the nursery nurses several hours later, because at the last minutes of the exchange the OB nurses want me in the operating theatre, where Scott has gone to do a C-section. It's about 8 pm. A small perk of shared OB/Paeds call is we keep meeting over babies. This time the mom has failed to push the baby out and the baby's heart rate is falling. Scott extracts her surgically, untangles the umbilical cord from around her neck, and hands her over to me.

Another perk of no interns: the happy moments are mine alone, a healthy baby who could have died and is now squalling and strong. But no time to linger, the preemie in the nursery needs more support post-transfusion, and another baby keeps forgetting to breathe. Then I remember that hours ago I'd been called to go to an admission in casualty.

This is our most interesting patient of the night, a six-year-old Maasai boy who was perfectly normal and well until a couple of days ago, when he began to bleed. in his eyes, his gums, his skin, his vomit, his urine, his stool. Being from Bundibugyo my first thought is ebola, and my second was along the lines of the ER docs that he had leukemia. But he just wasn't that sick. His platelet count turned out to be 1000, which is a half a percent of normal. Frightening. But the words ITP popped into my head, hopefully from the Spirit, and I decided to gamble on treating him for an immune disorder. We admitted him for a blood transfusion and steroids and protection from trauma, hoping he can avoid bleeding somewhere critical like his head before his platelet count recovers. Saw a couple more kids there, one in severe heart failure for admission, one who had swallowed a ten shilling coin, which is smaller than a dime and worth about that much.

Then back to the operating theatres, where Scott was doing another C-section. This mom had had a previous c-section, and now was carrying twins. She was supposed to deliver at the district hospital, but due to the strike was sent here, which likely saved all three lives. She had massively dilated blood vessels covering her uterus and could have bled to death.

Instead she had two identical boys. Lovely.

Earlier in the day I passed a visiting prayer warrior, Jeanne B, in the hall. We first met umpteen years ago when we were working at Kijabe temporarily, because she comes with her retired pathologist husband for 3 months every year. She said, "How can I pray for you today" and I said "pray for my attidtude". So this photo is for Jeanne, I snapped it in the theatre dressing room on the way out, because I know her prayers were with me.

One admission to ICU, and back to see the sickest patients in ICU, Nursery, ward, last check-in at Casualty and then, just after midnight, I came home. Scott had been able to help the kids with dinner hours ago, but not eaten, so they left us each a nice plate of spaghetti and green beans and salad, and we sat down to eat our first meal since breakfast.

Jack graciously waited up for us and watched football on TV.

By 1 am we're both about to sleep, for a short while. I get paged to nursery, but the competent charge nurse tells me the xray I ordered earlier can wait for review in the morning. I want to hug her. We sleep. At 2:30 Scott gets called back for a couple of middle-of-the-night hours to care for the mother of twins whom he ends up admitting to ICU, and I spend from 5 to 7 am trying to keep the baby from Naivasha, and my two ICU patients, alive.

When I realize it is 7 am, I opt for a quick trip home to shower and have tea. And as I walk out of maternity, this is the sky I see. It's still raining most of every day, but glimpses of sun and sky are appearing.

And so Day 3 begins, back before 8, for the usual chapel, rounds, C-sections, admissions, babies, consults. I do appreciate the medical officer interns, it is NO PICNIC to take call without them. I remember being in med school and residency 20 years ago, when days like this one would be common and constant, and no excuse for not working full-out the day after. Only this time I have kids whom I miss, and whose feeding and care I have to still ensure through phone calls. Oh, and I'm a few years older I suppose. But thanks to the attitude prayers, I found a lot to enjoy in those intense 24 hours. Because the public medical system serves the poor, they are the ones who truly suffer from this strike. I'm just missing a little food and sleep, but not my life.

Dec 4th

2011-12-04T05:42:00.000-08:00

Four years ago on this day, Dr. Jonah Kule died of ebola. We were in Bundibugyo, and he had admitted himself to Mulago Hospital in the capital, where he had gone to pick up his daughter from boarding school before he fell ill. He died alone, in a tent pitched on the hospital grounds for isolation, with his last words being that no one else should die of this terrible disease, and that he was now going. That is a long story for another time, but suffice it to say that that night when we got the call from the MSF team that night, in the darkness of pre-electricity Bundibugyo, we were stunned, grieved, frightened, bewildered, numb, disbelieving, crying, despairing, praying, a gamut of emotions. Standing outside to maximize the weak cell phone signal, talking to the doctors, then being the ones to call and tell his wife, all of us in tears, Scott and Scott Will and later our neighbor Tibererwa, recounting how this happened. And wondering, what was God doing. How could He allow such injustice and suffering.

Tonight we sit in cold soggy Kenya, just below the equator, with unseasonable rains drenching us, waiting to hear if the Kenyan doctors will all go on strike at midnight. There are issues of justice and corruption here as well, though a strike seems like a far cry from a doctor who laid down his life to serve the sick. We hope that the government will negotiate and avert the collapse of the public hospital system. If they do not, we will find ourselves being the only functioning hospital in the district, working without any of our interns and some of our consultants, and adding onto our already-stretched capacity the overflow of patients who can not find care in their usual places.

Two thousand years ago, God chose to show up in the darkest time of the year, in obscurity, and in danger. One of my advent meditations pointed out that He did this to show that if He can be present there, in Bethlehem, He can come anywhere. To Bundibugyo during ebola, to Kijabe during a doctors' strike. Because our hope is not in God changing our circumstances immediately, but in God Himself. In His ability to bring light into the darkness, redemption into death. Unlikely though it is, it is in these places of dense night, of loss, that we find Him choosing to be with us.

I talked to Dr. Jonah's wife Melen on the phone today. She is a strong and admirable woman who has endured too much. Yet the nursery and primary school she founded are thriving. Her oldest daughter is entering her last year of high school. Her son, born after his father's death, is a joy to her. Five young men are now in medical school because of Jonah's death. Three have written to us in the last week with good news of classes passed, of learning, of eagerness to serve. Our team in Bundibugyo works hard, too hard, to keep that small light burning. But they have moments of beauty too, of connection, of redemption. Because we are still in the story, we can't fully make sense of today, or of the 4th of December 2007. But if we look all the way back two millennia, perhaps we begin to see that the light shined in the darkness, and the darkness could not overcome it.

Beanie Babies Batch one

2011-12-03T09:38:00.001-08:00

Luke reports that we now have 13 beanie babies--3 from friends in NJ and this box which arrived from CT. THANKS!! Just a reminder that he flies out on the 17th, and he has to figure out his packing, so it would be nice to get any shipments by the 15th, which is 12 days from now. Children in Kenya will be very happy. We're aiming for 50 . . .

Caught in the turbulence

2011-12-01T22:36:00.001-08:00

Scott brought back from his meetings a thought provoking book called The Meeting of The Waters, 7 Global Currents that will Propel the Future Church, by Fritz King. In the introductory chapter he describes two classic missionaries meeting at a guest house, two contrasting models of missions. The first is an older lady who has spent her entire life with a remote people group, rarely traveled back to America, had given up everything. We honored two couples and two single women who were just like that this past week at the AIM conference. They were retiring after 30 to 43 years of service in Africa. They had pioneered remote stations, translated books into local languages, established schools, weathered wars. They bore up under whatever life brought their way with very little outside help. They were grey-haired sturdy survivors with practical shoes, quiet and unassuming, faithful servants for the duration. One had come here as a little girl in 1946, a trip which took two months on a boat in those days. After a few years in Tanzania her parents left due to health reasons, but she returned as a young woman in 1968, was married in the RVA chapel, and the rest is history. These are the heroes that drew my heart towards Africa as a girl. They are the generation that laid down their lives and did the right thing, year after year, without fanfare. I didn't even know any of these people, but the standing ovations at their retirement brought tears to my eyes.

The second missionary in King's introductory chapter is a 30-something guy who is multitasking on his cell phone and computer, has left his family in America while he checks out a project run by local leaders that his church supports. He has a career, but is arranging to take two years to spend overseas lending his skills. This is the new generation of missionaries. The break with their formal life is less abrupt, more fluid. They set boundaries and have high expectations of personal development, exercise, protected family time, organizational support and responsibility. Travel and communication lend connectivity, educational levels are high, they are task-oriented generally, outcome-focused, and missions is an important part of their life, but not their whole life. We meet amazing people like this here too. Skilled doctors donating a month, or six, or more to boost services and education. Teachers, engineers, artists, contractors. People with the funds and vision to start and orphanage or foster micro-enterprise, who will leave it within a few years in local hands.

As I finished the introduction and started into the book (I'm only a third of the way through) I had sort of an "aha" moment. When the two rivers flow together to create the Amazon, there is a stretch where their waters flow in parallel, then a period of mixing and turbulence. And we are squarely in that turbulence. With 18 years in Africa behind us, we are a bit past the half-way mark towards the classic old-time missionary life. This is who we expected to be. And this is why over a year out from Bundibugyo, I have to keep remembering the very specific ways God led us, and convincing myself it is right to be here at Kijabe. On the other hand, we carry iphones and text our son in America, we travel, we access grant funding for projects, we connect with the national health system. We're now working at a hospital that was founded upon the classic missionary model, but is largely staffed by more modern types. When I look at the December call schedule, we are 2 of about 5 missionary doctors with more than a decade behind us, the rest of the 30-some names on there are either short-termers or young Kenyans.

So we're in an in-between generation, uncomfortable not living up to the heroes of the past generation, but not really fully able to buy into the ethos of the new generation either. I guess that's OK, to be Hebrews 11 pilgrims and strangers. Being securely settled in one group is not our goal. I hope we can be part of the melding, the settling out of the streams to honor what is best in both. Combining longevity with innovation, relationship with technology, perseverance with enabling nationals. Maybe because we're spending our first Christmas in this new place, it's a good time to reflect.

World AIDS Day, Dec 1

2011-11-30T11:54:00.001-08:00

This morning our HIV-AIDS team at Kijabe Hospital led chapel. This year's theme, ZERO. Zero new infections by following the ABCs of Abstinence (unmarrieds), Be Faithful (marrieds), and Condoms (those who can't manage A and B). Zero stigma, because stigma hurts people, keeps them from seeking care, drives the epidemic. And Zero preventable deaths, because infected people should have access to medicine. Watch this compelling video and think about it. http://youtu.be/vKdgF7DHTG0

Complicated

2011-11-30T11:28:00.000-08:00

It's 9 pm, and we just cleaned up from a pretty delicious dinner whose preparation was interrupted by two trips to the hospital, which makes the whole cooking scene a bit more challenging. The first call was to attend the death of a very sick preemie whom I had left only an hour before, knowing he was dying. After 48 hours of an all-out effort, his vital organs were failing and we knew we were at the end of the road. I had made the always-agonizing decision to accept that he was dying, and tell the parents. Francis was in the ICU right next to his mother, whose life he saved by being born too early. She suffered from a life-threatening complication of pregnancy called "eclampsia", which can only be cured by delivery of the baby. So this doctor had to make the difficult decision of taking the baby out of the mother way too early, or risking the mother dying and leaving behind her other two children and husband. Francis' life was only about 72 hours long. But I think this was the right decision.

The second call was much more fun: the Kenyan lady who runs the "Supa Duka", the one-room everything-you-really-need small store in our village, had just delivered a strapping healthy baby boy. We are always called for C-sections, but this time there was nothing to do other than admire the lovely boy.

And while I was in the nursery, I checked on Dancun, the little boy whom I agonized about a couple of weeks ago, an HIV-exposed 28-week preemie who nearly died that night. He's now a "feeder and grower", a seemingly healthy little speck of a baby, who in spite of starting out similarly to Francis has miraculously lived. And I ran into Scott in the operating theatre, who had just finished his fourth or fifth surgery for the day, a woman whose ectopic pregnancy had ruptured her fallopian tube spilling two litres of blood into her abdomen. Thankfully her life was saved.

Which was a nice end to three solid days of nonstop work. Well, not exactly end, but at least it's in sight tomorrow morning.

Let's see, the last couple of days included a little boy with an rare congenital syndrome called Pierre-Robin, the usual parade of malnourished marginal toddlers and their desperate mothers, another boy with meningitis, preemies, two kids with severe heart lesions, a girl with damaged kidneys after an infection, the amazingly improved and nearly-healed baby born with part of his intestines missing as well as the one who had hemorrhages in both lungs, quick consults for rashes including chicken pox and fungal infections. And most distressingly, an 8 year old deeply jaundiced with a liver mass that turns out to be lymphoma, a cancer that could potentially be treatable. Only we need to get him to a hospital with an oncologist and chemotherapy. Which requires a lot of money. Which his Maasai father thinks he can manage by selling off his cows. Meanwhile we are starting chemotherapy at Kijabe and hoping we can keep him alive long enough for the cow market to come through.

The sheer breadth of pathology on this service always surprises me. One can spend all day, non-stop, from bed to bed, to ICU, to nursery, to the clinic or the emergency room, conferences and meetings, and then back around to all those places again, without a moment of down time. Yet the doctors in Kenya have threatened to strike on Monday, Dec 5. Meaning a barely-survivable day could get lots worse. Kijabe hospital without any functioning Kenyan doctors is unimaginable.

When a patient dies, the nurses use their own creative verb, saying "he complicated". It's an interesting take on death, as a complication of life, or of their disease. Or does it mean that the patient has made our life or our job more complicated? Difficult, confusing, complex, interrelated, entangled. Not the ending we all planned. Life as a doctor here is just that, complicated. The clues to a disease are often obscure, the labs unreliable, the history vague. Understanding the thoughts of the parents who come looking for an easy fix adds another layer of complication. And sorting through all of those layers with the pressure of time and people waiting complicates things further.

Hoping that no more patients complicate tonight.

Light shines in darkness

2011-11-28T20:28:00.001-08:00

Here is one more Advent site, thanks to counselor Susan S here at RVA. A daily devotion is posted, including scripture, prayers and a meditation. The site is:

http://www.d365.org/followingthestar/

Below the short thought on Mark 13:24-27

Many of us carry the false assumption that the goal in life is to be happy. That is why so many people around us mask their struggles and claim a false sense of happiness. Doesn't God want us to be happy? God cannot intend for us to be in darkness, depression, despair.

Mark tells this story so we would not forget that darkness cannot stop God. Mark calls us to be honest. Yes, there is darkness. It hurts when someone close to us dies. Our hearts break when a friend abandons us. The pressure to succeed smothers us at times and we don't know if we will ever see the light of day. The one who comes may come right in the midst of that darkness. Darkness does not stop him from making all things new. True, the one who comes may not bring simple happiness. The one who comes will bring meaning.

Michelle Thomas-Bush

Advent

2011-11-27T04:10:00.000-08:00

Today begins Advent, a season of preparation, repentance, anticipation, and party. I've been looking for some resources to celebrate with our family, and here are a few I've found.

1. Advent Conspiracy: Worship fully, Spend less, Give more, Love all. http://ac.wcrossing.org/default.aspx?page=3684

And here is their 2011 short video on youtube: http://youtu.be/9IN0W3gjnNE

2. Daily Scripture readings from the Anglican Book of Church Order: http://www.crivoice.org/advent2.html

3. A booklet of Advent readings and meditations from my friend Bethany's church: http://fairmount.liberti.org/advent/

If these don't come up as links, then copy and paste into the browser (sorry!!).

Unexpected Cost

2011-11-26T11:03:00.001-08:00

6:30 a.m., a light rain in the chill of the early morning, and a dozen bleary-eyed students balancing stuffed duffels into the back of a van, heading home. Yesterday they did the traditional end-of-term countdown, and were released to clean up and pack. By this morning the bustling boarding school was nearly empty, eerily quiet and damp. I help Acacia load her suitcase, checked her passport, her money, her phone. Then a big hug, and I'm standing back by my car holding in tears that rise and surprise me.

When we agreed to bring our friends' daughter into our home, I thought about a lot of things. Whether she would be too homesick. How she would find the volume and pace of our family in comparison to hers. Whether she would find friends, or regret not living in the dorm. Whether we would thrive together. How the sibling relationships would work out. It is an awesome responsibility to parent someone else's child, and I expected some sense of relief if we made it through our first three months relatively intact.

Instead, I felt only grief. Another precious person to hold and release. Another important relationship that has huge gaps of space and time. Another piece of my heart sent away. Four kids were going to leave our home eventually, and now we have to survive five.

Be careful whom you love, or just let the cost sink in and hurt?

stuffed-animal-love

2011-11-25T01:26:00.001-08:00

As Thanksgiving turns to Christmas Consumption, and we read of people flocking to Walmart and the Malls .. . here's an idea for de-cluttering. Would you like to pass on some of your small stuffed animals, beanie babies or about that size? The sophomore class at RVA (which we help sponsor) does an annual Valentine sale to raise money for the class. We're in charge of creating gift baskets which parents can purchase for their children as a reminder of their love while separated far away at boarding school. I know my kids have been very attached to stuffed animals, particularly in stressful times of life. So along with candy, we thought it would be fun to include a little stuffed animal in the baskets.

If you want to donate some of your slightly used but still lovable animals for this cause, mail them by Dec 10 to Luke who will fill his luggage with as many as he can to transport them here:

Luke Myhre

PO Box 201510

New Haven, CT 06520-1510

If we get more than 50, we will pass them on to the children at the hospital. Thanks so much. No doubt the suite of guys at Yale will get a kick out of this influx into their dorm too.

Thanking Whoever . .

2011-11-23T11:09:00.000-08:00

. . out there sent up some specific, directed, effectual prayers between late-Monday and mid-Tuesday.

Because we were enveloped in a cloud of grace. I picture this like the glory-cloud that fills the temple, the palpable presence of God. Monday night, I was on call, only I didn't get called. At all. This just does not happen. When my alarm went off at 6 I sort of panicked, the way you do when you're a young mom and your baby never cried all night. I had left two babies intubated in the ICU and the ICU ALWAYS CALLS. I got out of bed and re-checked the call schedule, and only then did I realize that the ICU doctor on call was one of the few who handles paeds cases (much better than I do I might add). And the intern I was on call with is extremely competent, so she just messaged me in the morning about what she'd done overnight. Wow. Then I went to work and discharged 6 more patients, in addition to the 9 from the day before, with only 1 admission, bringing our service down from 24 to 10. When we have 24 patients, you really can't even eat lunch or go to the bathroom, it is nonstop. When we got down to 10, I actually took my medical students to the cafeteria for chai and had personal discussions about paediatric medicine and their lives. An idealistic consultant moment. Then I went to the office to check on next month's call schedule and found out I was NOT ON CALL for Christmas, and it looked great. One of my patients whom I've cared for his whole life, Bedan with major malformations, smiled at me. He is much better and ready to go home, and sat in his bed beaming from his little yoda-like face. This was not my typical day at the hospital.

Then I got home and found out the best news of all: Caleb was nominated by one of our VA Senators for the Air Force Academy. This senator received 740 applications, offered about 30 interviews (Caleb's was by phone last week), and then selected 10 for nominations. Only one of those ten will be appointed by the academy, so he still has some odds to beat. But this was a huge relief, to know he still has the chance. (He has not heard from the other Senator, or our Congressional Representative, or the Vice President, so if any of those also nominate him his chances go up). About 4000 kids are nominated and 1000 admitted in a given year. He's such a great kid, I see deep things happening, and I hope for the best for him, wherever that is.

And did I mention that my Kindle, which had been in a deep unresponsive coma which I feared would be fatal, revived after my neighbor advised me to hold the on switch over for a full 15 seconds? And this happened later, but still counts in the tally of super-thankful: Julia was chosen for the Varsity Girls Football (soccer) team, and Acacia for JV. This is huge.

By Tuesday evening, going up the hill to the jazz band concert with Caleb after having actually managed a creative and nutritious dinner ON TIME for the whole family, I thought, someone is praying, and why do I ever worry?

Which was, of course, a short-lived triumph. Because that grace-cloud did not last very long. In the last 24 hours, life settled back a little towards normal. That beautiful call schedule, it turns out, had to be totally changed when other doctors objected to being on call Christmas, so now Scott and I are (though we're working out a way to share so others take Christmas Eve and Boxing Day). Internet issues slowed me down, went to watch soccer scrimmage and ended up with a student with a broken arm, fighting general single-parent tiredness, one kid forgot to turn in homework, another bombed a test, finals-week edginess as everyone struggles to get things finished.

Yes, my thankfulness is very fickle. Just like the Israelites. God might part the Red Sea one day, but the next I'm ready to complain about food. A 24 hour stretch of an amazing series of things-going-right is quickly forgotten when I get back to a normal day. You'd think I would be on a faith high over that senatorial nomination for weeks, instead of worrying about the next nomination or application.

I suppose I'm learning that thankfulness is a daily discipline. Like manna, one day's does not spill over to the next. I think that a "series of fortunate events" will inspire me towards perpetual thanks, but it doesn't. I have to be thankful again the next day, and the next, even when (especially when) the circumstances are less ideal. Perhaps if days of triumph worked thankfulness in us, God would give us more, but He knows that we haven't changed in several thousand years, and no matter how richly He blesses us we still have to be prodded towards thankfulness.

But I'm still grateful for whoever prayed, and would welcome you to do so again.

Worth

2011-11-21T08:04:00.000-08:00

A week goes by, and the baby who barely lived through the night and upon whom I gambled the $200 surfactant treatment, thrives. (see http://paradoxuganda.blogspot.com/2011/11/who-is-worth-it.html) Here he is with a morning yawn as his smiling mother gets ready to feed him through the tube. He's gaining weight, off of oxygen completely, and behaving like a reasonable preemie. I admit I did not expect him to make it this far. But God thought otherwise. He still has a tough life ahead, even if he escapes infection he will have twice the normal chance of dying here, and he will lose his mother before he grows up. But for the present moment, they are a happy pair. This is Tume, the severely malnourished 9-year-old girl who was transferred from NE Kenya with TB, a dislocated hip, sores where her fragile skin had broken down as she lay immobilized in bed, and allergic reaction to her drugs. Two weeks ago she was not moving or talking, let alone smiling. Now she's up with a walker, coloring pictures, and chatting. Progress. But something about the poignancy of her "Prom Queen" shirt tugged at my heart. Her mother is also HIV-positive. This girl's challenges include eventually being orphaned, and possibly being lame. A bit far removed from some other distant little girl whose cast-off shirt seems shallow and vain in this context. Yet I hope Tume feels beautiful too, and loved and admired in the same way the prom queens do. And guess who is going home today? The little girl who stopped breathing in casualty just when the power cut off (http://paradoxuganda.blogspot.com/2011/11/high-and-low.html). It was a rocky course in the ICU but she's no longer convulsing, perkily alert, and possibly healed. On a long Monday it is good to be thankful for those who DO get better. And to be thankful for prayerful blog readers.

Wandering the hospital with my IPhone, and pondering

2011-11-18T00:10:00.000-08:00

This is my first full-Swahili patient visit. Our MCH (Maternal and Child Health) clinic bursts with charts, especially on Mondays. While I would like to stay free to consult on the patients already screened by the interns, clinical officers, or medical students, they sometimes get bogged down and I reluctantly pick up a chart on my own and at least try to get started before calling for translation help. I'm embarrassed by my stumbling slow progress. But for many reasons, not all of them noble, I just haven't invested the time and effort I should in Swahili. I do work with an excellent language helper two or three times a week, but I must be one of his more disappointing students. So this week I really celebrated when I called this baby back to an exam room, had a conversation about her condition with her mom, and finished the whole visit with no English and no help. I have to admit it was the simplest patient of the day. She was healthy. Her mom was returning for a check up after an admission to the hospital, and answered "no" to all my limited "Is she vomiting" type questions. I have far to go, but I'm still thankful for this baby step. Charity narrowly survived severe dehydration this week. I found her on Monday morning, having arrived in the middle of the night. When her sodium came back as 191 (almost the limits of the machine) I transferred her to the ICU for management of her fluids. She was also in kidney failure. But a few days later she is greatly improved. Her mom lost her previous baby to the same problem exactly a year ago. Pray for her. In today's political climate, I'm not sure just why a parent would choose to name their child Gadaffi, but this diminutive twin enters life with the burden of a very low birth weight, a need for a skin graft to heal a terrible IV extravasation burn from another hospital, and an ominous name. This darling little girl, Karen, was my patient months ago when she was transferred to our NICU for the expert care of our surgery team after being born with a developmental defect in her perineum-no rectal outlet. I remember how hard it was to get her to gain weight post-op, and when I last saw her she was scrappy and scrawny. In spite of a dangerous gastroenteritis and bacteremia with high fever a few days ago, she's healed and perky and almost ready for her next surgical step in creating a functional perineum. This is Bedan, who I posted pictures of months ago. He was born with a front0-nasal encephalocele and mid-facial cleft (his face was split open from between his eyes down to his lip, with a balloon of brain-lining-tissue and fluid bulging out). After a month or more in the NICU our surgeons were able to piece his face back together, and he returned this week for the next step in his reconstruction. He's about tripled in size as his mom feeds him well! Unfortunately he came with a bronchiolitis, a temporary lung infection that would have made his next surgery too dangerous, so it had to be delayed. His mom was abandoned by her husband after she delivered such a deformed child, so she struggles to get help to pay for his medical expenses. But she's a brave and dedicated lady doing a great job.

These are all kids who remind me that what looks like a disaster often turns out to be an amazing story of healing, or love, or something else intangible and important. Our moms' prayer group guide this week included this paragraph, even more poignant in light of the top news story out of Penn State football: " Where they (our children) have been the victim of evil, I pray that You would heal, restore, and lift them up above it. Bring good out of it. Just as You raised up Joseph to save a nation after evil plots on his life were carried out, I pray You would raise up our children to great things in spite of the evil perpetuated on their lives. In the meantime, enable them to navigate through this time and find “grace in the wilderness” Jer 31:2." What a powerful reminder that God is at work even when the hard realities of a fallen world impact our children. Whether it is having an application denied, or being born with brains bulging from one's face, or being abused by supposedly responsible adults, our kids suffer and our hearts ache, but we cling by faith the the story of Joseph, that evil can be transformed to bring good.

Grit / Glory

2011-11-13T04:03:00.001-08:00

I'm a mom who prays for Glory.

And unlike one of my friends, who responded to her son's match-winning glory goal as an answer to her prayer, my prayers along these lines don't seem to get the answers I would hope for. It isn't very noble, but in my heart I've struggled with that.

This weekend I started to get a glimpse, that while I'm hoping for glory, God is working on grit.

Caleb's final game of his high school career was Friday afternoon, the Semi-finals in the Association of International Schools of Kenya league. It was an exciting match, extremely close, with passionate fans and reversals of fortune as one team went ahead, and then the other. We ended regulation time 2-2, but then the opponents scored in the first five-minute OT period. In spite of losing, it would have been a memorable end . . . except that Caleb hardly played. Perhaps he would not have been subbed in at all if the other boy who plays the same position hadn't chosen to leave the field, winded or mildly injured I'm not sure, and the team and coach yelled for C to go on. But within a few minutes the other boy had recovered, C was off, and that was that. He's fast, smart, accurate in passing, dedicated, tireless, but not as physically large as the other boy, and the ability to overpower, push, and take hard shots from far out is highly valued on the team. So in key games like this, he sits on the bench. I felt bad for him. But that was just me. After the game, Caleb has two comments. One, an admiring observation that the boy he "competes" with for the position played so well, had a great game. And two, that he really loves his team. No complaint, no bitterness. Once again I needed to learn from my kids. I've been hoping for that moment of glory, the goal scored, the key pass, the unforgettable save. Instead Caleb has learned a lesson in team support, good attitude and perseverance. I also found out yesterday he applied to manage the girls' varsity team, a big time commitment to a sport he won't even get to play, hopefully to spend more time with his sister if she is chosen. Another sign that he supports the coaches and the program. He was also inducted in the NHS this past week, after being rejected 3 times he went ahead and applied a 4th time. That boy has grit, and that grit will take him further in life than a glorious reputation.

Jack's final game was glorious, for the team at least. They thought they would not make it to the play-offs, but scraped by. Then they won semi-finals, and on Saturday won the JV-level finals for the league. The coach had even commented that he hoped Jack would score a goal on his dad's birthday . . and he came so close, we all jumped in the air cheering, until the ball bounced off the post at the last second. Once again it was his friends who got the glory. Each game that Jack plays he comes away more determined to improve. He watches football whenever he can, thinks about it, talks about it, practices. He has three more years to develop in size, speed, pubertal mass, skill. Maybe a bit more success this early on would boost his confidence, but it might have also taken the edge off his drive to improve. He does not yet have the grit that Caleb does, but I hope it is developing.

A couple months ago Scott came across a NYT article about a school in NYC that is trying to redefine success in terms of character development rather than test scores. They looked at characteristics that predicted future competence, and the first one was just what I've been talking about, grit. Grit that comes from struggle, from some experience with failure and disappointment.

And as I've pondered all these things in my heart, a Bible story came to mind. I'm not the only mother who would like to see her sons pushed ahead, recognized for the amazing people that they are. In Matthew 20, Zebedee's wife puts her request in to Jesus, that her two sons be honored with high positions in the Kingdom. I'm sure that's the same thing I pray. Jesus answers that the path to glory takes serious grit. Can they drink the cup of wrath, pain, judgement on behalf of the world? Can they bury themselves, even die? In the Kingdom reversal, leaders are servants, who seek sacrifice not glory. Glory is a consequence of faithful perseverance, not a goal.

I doubt I'll ever be cured of praying for people to make the team, pass the test, get the SAT score or college acceptance. But I'm beginning to suspect that there are more important prayers as we put our kids in God's hands, prayers He's answering even if I don't really have the courage to pray them. Caleb has been teaching us this since he was a fetus with his life on the line, but I guess 16 years haven't been enough to really get it.

Praying for grit, and trusting God for glory.

Who is Worth It?

2011-11-11T00:30:00.000-08:00

Last night I had only been asleep a little more than an hour when my pager went off. 1 a.m. We have a 28-weeker in the nursery, please come.

I arrived to find a pink little infant boy being assisted with his breathing, as his tiny rib cage pulled hard to move air into his not-ready-for-this-world lungs. He was tiny but kicking. We've seen smaller, but few survive who are this young (28 weeks) here. His HIV-infected mom had been seen a few days ago with serious bleeding, but refused admission. Instead of the therapy that might have prolonged his 6+ month (28 week) gestation to a survivable 30 . . or stimulated the development of his lungs . . she went home and perhaps expected death. Last night she returned in late stages of labor and popped out a reasonably sized (1270 grams) 28 week boy.

A boy who proceeded to not cooperate with the program of living. An all night struggle. The parents said they could not afford the treatment (surfactant), about $200, which replaces the lung lining that is not yet developed in this stage. So we tried him on our bubble CPAP, oxygen and pressure to open lungs and help breathing. But he did not do well, and his xray showed significant respiratory distress syndrome, so after 2 hours I decided we should just give the surfactant anyway and dip into our Needy Children's Fund to cover it. This is not an easy decision as the funds are very limited, and using them on one baby means we won't have them for another. So I had to struggle: was this baby a good choice? Might he survive? It is very very hard at 2 or 3 in the morning, alone, to weigh this. I think it was his little kicking feet. He seemed to be a fighter.

Nothing is simple, I intubated him but thought I'd tape the tube in and get an xray, which led to the tube coming out, which led to more attempts and having to stop and resuscitate him several times, and help from a friendly anesthesia nurse who happened to be in for another C section in the middle of the night (bless Lucy). We gave the surfactant and he seemed to respond, his oxygen sat level was over 90 (good). Somewhere in there after attempting IV's in all extremities and finding the veins too fragile, I put in an umbilical venous catheter for the first time since residency (quick review of procedure in Harriet Lane and then forge ahead).

Ah, I thought, this has been a long night, the intern was busy elsewhere so I ended up writing up all the notes too, and by 4:30 I was walking out the door, tired but at least I felt we'd done something (evaluated four other sick babies over those hours too, several who were critical inpatients and one new admit).

Home, the prospect of almost 2 hours of sleep, climb into bed, pager goes off immediately, stat page to nursery. Seems the preemie didn't respond well for very long. Same trek, full moon, mysterious clouds, sleepy guards, back to the nursery. We checked everything we could, bagged some more, tried to get an ICU bed, but there was none available. In my heart I didn't think he was a good choice for the limited ICU resources either. 28 weeks, four days at home with mom bleeding, no steroids, poor response to surfactant . . . so with a heavy heart I brought the mom in to see him for the first time, in case it would be her last. We stroked him, and watched him struggle with oxygen sat levels down in the 70's. Not good. I pulled each nurse aside, explained what had been done, asked if they had any other ideas, and made the hard decision for the team that we had reached maximum effort. Now it is in God's hands, I told them and the mom. Meaning in God's hands to die, I thought, though I prayed that he would live. We started calling the chaplain. I left at almost six, the full moon not quite setting, the birds beginning to stir. There was nothing else for me to do there, and I wanted to be home when the kids woke up (only one parent now, Scott is en route to WHM meetings in America). As I got them breakfast almost an hour later I called the nursery, a little surprised not to have been called back to his death, but realizing he might hang on for some hours.

How is our preemie? Oh, he's fine. What do you mean, fine? Well, his sats are over 90%, and he looks comfortable.

This baby may or may not survive in the long run. He has far to go. Is his life worth $200? An all-night effort? Is it worth that even if he doesn't live more than a day or two? Did I make the right decisions? One can always choose life whole-heartedly, but in a limited-resources setting one life might cost another. He is occupying our last incubator. The next baby might not be able to get the surfactant because he did. I might have caused his parents longer agony and larger bills, which in this HIV-positive family might impact the health of the three children they already have.

When I put him in God's hands, I didn't really hope for a lot. God doesn't always plan things the way I do, and my prayers have become less certain of their outcome. God's hands did not imply that I was, or am, sure of his survival. But God knew our limits, and with at least our one available incubator and medicine and oxygen and tests and warmth, I think we were meant to offer all we had. Perhaps it was a widow's mite that will be multiplied to life. Perhaps not. This baby's worth is equal to mine, or the President's, or the richest man alive, so we trust that if God does not heal him now, it is not a matter of being unworthy, but a matter of mercy and a better plan.

High and Low

2011-11-08T11:08:00.001-08:00

High of today had to be assisting in the delivery of a baby in the front seat of a matatu parked in front of the hospital . . alerted to the evolving scene as I saw another patient in casualty but heard the screaming mom outside, who just couldn't make it those last few yards inside. I took the blue baby girl and RAN all the way to the nursery, but by the time I got there she was crying, and all was well.

The rest of the day blurs together: rounds, teaching, notes, labs, run home to start some bread dough, consults. The usual, as Kijabe is a mecca for the floppy, the weak, the neurologically devastated, the wasting away. More seizures and poor growth, calculations and xrays. Low is that Scott is on call for ICU, but all 4 patients there are pediatric, so when he got called in the middle of dinner I ended up leaving our 7 guests and 4 kids to fend for themselves and joined him for a few hours, as he intubated two critically ill babies and we sorted out their therapy. Then the real LOW came in precisely the same spot as the high, 12 hours before . . standing by the same bed . . admitting an 8 month old with intractable seizures, maybe a viral encephalitis. As I talked to the intern the nurse said "Doctor!" and we looked at the baby, who had been in respiratory distress, and now completely stopped breathing. Flat. Still. Nothing. The intern reached for the ambu bag (ventilating equipment) and I reached for the baby and at that very moment the power went out. Completely. Pitch black nothing. I fumbled in my pocket for a tiny flashlight I carry, tried to get the mom to hold it so I'd have hands for the baby, she was in hysterics and unable, I grabbed the dad's hands and showed him what to do, and at that moment the power came back.

High number two: came home just now to find the girls had washed all the dishes and put everything away. I love boys, but tonight I have to say, hooray for girls.

Specialization is for Insects

2011-11-07T12:09:00.000-08:00

Monday on the Paediatrics Service (since Mardi just posted an appeal for visiting volunteer docs, here is the 11 pm off-the-top-of-my-head recap of what came across my service today, just to whet the appetite): rickets, malnutrition, tuberculosis, pneumonia, more pneumonia, gastroenteritis, more gastroenteritis, chicken pox in a burn patient, hypernatremic dehydration and septic shock, renal failure, recurrent pyelonephritis, question of sexual abuse, precocious puberty, increased intracranial pressure with impending herniation, probable cerebellar tumor, colic, seizures, more seizures, heart arrhythmia, meningitis, bacteremia, diaper rash, viral hepatitis. And an email introduction of an admission tomorrow with TB osteomyelitis.

So when, at 5:30 pm in the casualty department, I was giving the intern on call instructions about an admission I had just evaluated and how to call me with issues, he looked at me and said "But Dr. Jennifer, you aren't on call" and I could have hugged him. I was so in the groove of all day and night Sat, Sun, and Monday, it hadn't occurred to me that I was no longer responsible. I walked home in the deluge of rain (courtesy of my chivalrous 16 year old who showed up with an umbrella, either hoping to extract me for getting dinner or just being a gentleman). Who knows what tomorrow will hold.

a typical Kijabe weekend

2011-11-06T09:00:00.001-08:00

S t r e t c h i n g days and nights at the hospital. This is our monthly weekend on-call. The paeds service suddenly ballooned to 40-plus patients, half NICU and half older babies and children on the Paeds ward. Just when we lost our visiting professor and when our Kenyan paediatrician colleague took a week off to teach elsewhere, of course . . . And hardly any of these kids are straightforward cases with solvable problems. My head is still spinning in spite of hours reviewing and examining them yesterday and today. Thankfully we're on call with two bright and competent interns. So when one called Scott at 2 am for help with a breech delivery, and the other called me twenty minutes later just saying "please come", we knew we were in trouble. A mother trying to deliver twins, first one became lodged bottom-first, compressing the cord in a situation that could easily have ended in death. Scott managed to wrest the baby out, though he broke the baby's arm in the process, a small healable price to pay for survival. Unfortunately the delay before he was called meant the baby had suffered a prolonged hypoxic period, and he was floppy with no effort to breath for a long while, later developing convulsions. His prognosis is guarded. But after that Scott and Dr. Anne whisked the mother into the theatre for a C-section to deliver the second baby, just as the womb almost ruptured. This baby was also blue and limp but responded to our efforts and was crying by the time he was a few minutes old. Our work-life has diverged from each other so much since Bundibugyo, it was kind of nice to be working together, even though it was from about 2:30 to 5 am.

Guests. A pleasure to welcome our friends who are now living on the coast, and have two boys our boys' ages. They started off relatively close to us in Uganda all those years ago, and we've crossed paths repeatedly over the years. In a place where we generally feel like the "new" people, it's nice to have history with someone. Nice also to have their boys drifting in and out, making pizza together or waffles, giving us that team feel that we miss.

Games. Jack's last JV football game, a 1-1 tie, good effort but not quite enough to make semi-finals. Acacia off to a game in Nairobi, victorious, and Caleb to a draw. And cheering for Julia in her last Bball game of the term, a decisive win over a team with a 6'5" Sudanese 13 year old . . . I'm so thankful for sports for our kids, especially for the girls, promoting a healthy self-image, exercise, friendship, teamwork, fun, belonging. Kudos to Mr. Gonzalez, Mr. Davis, Mrs. Chedester, Mr. Hazard and Mr. Dahlman, who have coached most evenings and weekends for the last few months. Coaches are our unsung heroes.

Events. Caleb taking SAT subject tests, all attending the high school drama "Death on the Nile" based on an Agatha Christie book, baking brownies for Julia's class to sell at intermission, working on maintaining our database for patients, planning for visiting doctors, coordinating upcoming meetings, thinking through protocols and improvements with other doctors, editing essays, washing dishes, coming up with meals, washing clothes, getting them out on the line in brief respites of sun and pulling them in ahead of squalls of rain, all has to be fit in around the hours in the hospital and calls on the phone.

Family. Ruth's 79th birthday. Luke suffering recurrent debilitating back muscle spasm and pain from the injuries he incurred on his motorcycle accident this past summer. Feeling regret that we miss important life milestones, and impotence to help those we love.

Burdens. Bearing the sorrow of kids who aren't coping. Mostly other peoples' whom we see in the clinic, and listen to, and pray for, and ache over. There is a high cost to this life, and much of it is borne by our children.

Rejoicing. The best for last: a very very generous and faithful friend, who has supported BundiNutrition heavily over the years, decided to step in the gap for Christ School this year. Please thank God, and pray for this family to be blessed with the same measure they are pouring out for us. This gift and other responses to the recent appeal reassure us that in spite of opposition and set-back and disappointment, God still has plans to use CSB for the Kingdom. A key family whom the Johnsons had hoped to work with mutually decided their gifts would fit better elsewhere, which was a huge loss all around, so this unexpected bounty of provision was well timed.

That's a taste of a Kijabe weekend. Driving rain and moments of golden sun, premier league football on the television, Caleb and a handful of RVA students singing the Hallelujah Chorus with the local church choir in worship this morning, greeting hospital friends on the road, pondering management of a syphilitic rash or an obstructed bowel, gathering a gaggle of 10th grade girls for cookie baking, trying to think clearly in weariness, this is life.

HELP! End of year crunch time at Christ School - Bundibugyo

2011-11-03T08:03:00.000-07:00

Travis and Isingoma have been crunching the financial numbers at Christ School this week.

As most of you know, World Harvest Mission subsidizes the operating expenses of Christ School each year in order to keep tuition fees affordable for the average subsistence farmer of Bundibugyo District. On average, WHM helps to raise about $50,000 per year to help cover the basic costs of running a boarding secondary school - namely, paying teacher salaries and buying food for the students. We operate on a shoestring…our average teacher salary is something around $175/month and we feed each of our students for less than $1/day.

Unfortunately, in 2011 we had a major donor default on major pledge. We don't blame the donor (he has promised to contribute in the future), but we are left with a significant gap in 2011.

Travis and Isingoma are estimating

that we need

about $12,300

to finish 2011 at Christ School -Bundibugyo in the black.

(that means paying the final month of salaries to our teachers!!)

WOULD YOU CONSIDER GIVING TOWARDS THIS CRITICAL NEED?

CLICK HERE TO BE TAKEN TO THE WHM DONATION SITE FOR CHRIST SCHOOL…. Any amount, little or large, is appreciated. Thanks so much.

the weight of a Wednesday

2011-11-02T12:25:00.001-07:00

Esther, floppy as a fish, dressed in blue, with sparkling brown eyes that follow our movements, a babbling tongue. She's a normal 1 year old mentally, trapped in a body that barely moves. Her mother died giving birth, so her stout and steady, coarse-featured competent grandmother stepped in to rescue her. For a year she's been feeding, bathing, carrying this child, who grew in size and responsiveness but never managed to hold up her head, to sit, to play, to crawl. As a last ditch effort, her grandmother accepted money from a friend to travel across the country to Kijabe, determined to hope. Instead she ended up with me, hand on her shoulder, as she wiped the tears subtly with a blanket edge, then broke down in sobs. Esther seems to have a form of muscular dystrophy, and is unlikely to survive very long here. She will never do very much. I hated watching this dignified older Kenyan lady sob, hated being the one to bring her dream of cure to an end. But I stood there and talked and then prayed, because it is important for the family to understand the truth.

An hour later, a hyper little two-year-old flitted around the outpatient exam area. Who would have guessed that she was brought here to rule out rape? I couldn't find any definitive signs, and as time went on it became clear that the mother and father were separated , and the rape accusation was actually directed from her to him. We could not untangle the truth. In the end we called in the police-based child welfare officer to ascertain the safety of sending this little girl home. I'm afraid this country will not protect her, or the many children like her. That she'll be abused by those whom she should be able to count on for sustenance.

Same room, another hour or so later, I was called by our clinical officer for help. As soon as I opened the door the stench almost knocked me over. Incontinence of stool and urine, chronic and powerful. I tried to breathe shallowly and appear unaffected. The 3-year-old little boy smiled at me, disarming, charming. He has been having seizures for the last couple of months, getting more and more frequent, and now has a staggering gate, loss of speech, and inability to control his excretions. We fear a brain tumor, and arranged for a head CT. When I examined him his pants were chock full of pasty overwhelming stool, and soaked with urine. His mom was dressed poorly and I suspect just too overwhelmed to keep him cleaned up. I'm sure Jesus would have put this sweet little boy on his lap.

Back to the ward, where baby Mercy waited for the results of her bone marrow biopsy. She is a diminutive 4 1/2 pounds at age 2 months, tiny, curly dark hair and huge eyes. She has many anomalies, at least two of which could use immediate surgery . . only she has very few platelets, so no one wants to take her to the operating theatre for fear of bleeding her to death. I was pretty nervous about poking a needle into her bone as well, but she survived that. For someone with a long list of problems (cleft palate, heart defect, ano-rectal malformation, microcephaly, not to mention anemia and low platelets) she looks pretty cute and cuddly wrapped in her blankets.

All of these children have potentially disastrous, lethal prognoses. All are oblivious, mentally intact, eyes seeking out contact, face ready to brighten and smile. And when they do, all give my heart a tinge of grief, a sigh under the weight of this world's sorrow.

We have plenty of other kids too, malnourished and dehydrated, oozing pus from a huge scalp incision, incessantly convulsing, breathing too fast, languishing with fever. This week however I feel the burden of those who trust, who look me in the eyes, who try to connect. Who hope for help in this world. And who probably won't linger long.

Sunday Contrasts

2011-10-30T12:38:00.001-07:00

Yesterday we spent in the misting rain, shivering at times, cheering most others, back and forth between 3 football (soccer) games for Jack's JV and 5 for Caleb's Varsity in the annual RVA football (boys) and basketball (girls) tournament. It is a community event, with seniors selling grilled burgers and chicken and pizza and salads, parents meeting up with kids and old friends, faculty mingling. The best moment for me was Caleb scoring the tying goal in the first round against the team that won the whole tournament in the end. The final game came down to overtime and then a penalty shoot-out, which we lost 3 to 2. But it was valiant and muddy and crazy and tense. And followed immediately by Acacia's pizza party for a handful of her classmates, celebrating her 14th birthday. A great thing to be able to host this with Karen. Due to rain we had to be mostly inside, but the girls' chatter and the candles on Karen's home made apple pie were cheery. At Acacia's request, Karen and I made a breakfast this morning of crepes with strawberries and whipped cream, before they went off to Nairobi for the day with family. I love our blended family here, the extra mom and dear friend staying under our roof, the shared Bday fun.

About the moment the party was all over Scott starting shivering, and within the hour he was knocked over by some infection. The last few days (weeks? months?) really wiped him out anyway, a complicated patient with unusual neoplastic tissue only a few weeks post partum, a difficult surgery, and then a long hard phone call which was the culmination of a week's worth of sorting out a conflict. I think his body was just over-the-limit, so when an infection hit, it hit HARD. He's not spent a day in bed like this in ? I can't remember. So he missed the early morning visit to plant a tree with our friends who lost their baby. I sort of invited myself when I heard they were commemorating her birth and death, and they were gracious to let me come. After days and days of rain there was a moment of sun, fresh earth, a simple scripture, tears, memories. As we talked it struck me that I was glad to be there on so many levels. As a fellow mom who lost three babies of about the same size, the lonely mourning of miscarriage now shared. As a doctor, closure to walking through this week with the frightening bleeding and shock and transfusions and ICU. But mostly as a person who misses the intimacy of our small team, someone peripheral to the massive intricate complexity of Kijabe/RVA, in this small moment we were able to delve deeply into a life, and I'm thankful for that.

Birthday and burial, all within the hour. Life is so like that. Sickness and crepes. The clouds part for a few hours of sunshine, and then return. A toddler giggles as mourning parents weep. All true no matter how incongruous.

Prayers for Scott's healing appreciated. I am just emerging from almost two weeks of intestinal issues, still not sure if the disease or the cure caused the most problems, but it wasn't pretty. Hope he doesn't take that long to improve . . . we need him.

Things that make me happy

2011-10-28T21:19:00.000-07:00

It is raining, incessantly, the kind of build-your-ark drenching that leaves us with a muddy floor, damp clothes draped over chairs, and a harrowing ride back from the airport last night as many cars stalled in the gushing rivers that flooded Nairobi's streets. ( You have to be in a foot or two of water on a major highway, being sprayed by trucks, slipping in the dark, to realize how important it is to think through where all the water which falls should go, and how important engineers are!). Rain does NOT make me happy. But it makes everyone else happy. Thankfulness for the rain is the first phrase out of everyone's prayer mouth this week, Kenyans, missionary kids. They get it, that we need this moisture to eat, to survive. I am cold, and would like to see the sun, and dreading standing in the rain to watch soccer all day and to cook pizza for Acacia's party tonight. But I dutifully put rain first because it makes Kenya happy. This is the spread of loot from Dr. Raymond, visiting paediatrician from Alabama who has been a voice of wisdom and stability working in our department this month; Dr. Lesley, Mardi's friend visiting from Australia for two weeks; and Dr. H who could not come this time but sent a suitcase with others from Europe! We now have some really important life-saving items like ambu-bags for infants and preemies, oxygen tubing, specialized IV lines. Some donated, some bought at these doctors' own expense. Mardi and I spread it all out and divided it up and delivered it, Christmas in October. One thing that REALLY makes me happy is that my dear friend Karen came to visit. A perk of holding her daughter hostage I guess. Yesterday she and I took a long walk, then later slipped into 7th period choir class to listen to Acacia (top left), Julia (a few girls down the back row) and Caleb (with the bass section in the middle of the back) rehearse Christmas music for their concert in late November. Glorious. This rug makes me happy. We had a disintegrating cheap mat in the bathroom, until I was craft shopping with my Mom on her way to the airport yesterday, and found this cheerful rag rug. It is heartening to see the colors with the blue bathroom walls, and step out of the shower onto it. And while I was buying gifts to send back to my sister, niece and nephews, my mom insisted on buying me this necklace. Note also the warm red hoodie, and three layers of clothes. Skyping with Luke was the most cheering part of our evening. We miss him so much. It makes me happy to just see his face in his dorm room, hear about his Gospel choir concert and organic chemistry and plan to meet his RVA friends in NYC this weekend. His news: winter arrived. New Haven is COLD. The seniors working together is another fun sight. I spent last evening with Julia's class, but snapped this as I looked for Caleb to hand him a sandwich because he missed dinner. The girls have given him a note of encouragement with his number (8) for the tournament today. He worked for about four hours after his game last night, then got up at 615 to work two more before the tournament today, all on the food that the seniors sell to raise money for their end-of-the-year class trip. Not sure when college apps fit into all this, he's exhausted. This bright knobs always make me happy, when the roaches are running off the kitchen counter I try to focus on this little spot of beauty. My mom sent these months ago, but these remind me to be thankful that she made it back safely to the USA after a month in Kenya.

Two views

2011-10-26T11:39:00.000-07:00

Some evenings I can wrest a half hour or more in between work, scrambling to see games, a quick check of email, preparing to cook dinner, folding laundry, clean up. So when I can, I love to go for a short run or walk with Star. One of our favorite routes is directly across the field in front of our house, catching a path that leaves the station houses behind and meets a relatively flat old road or railroad cut, to the airstrip. It is a gravelish path, used lightly by foot traffic from the valley up to Kijabe. Yesterday as we jogged along, I was struck by the different views to my left and my right.

To the left of the road, the trash dump for the station. Heaps of garbage, columns of smoke rising from the attempt to burn the trash. An old man was picking through the pile, looking for anything useful. And between the road and the dump, a ditch filled with grey, bubbly, putrid water, the effects of sunless days and drenching rains. The stench is nauseating, the view distressing. A stray dog lopes through.

To the right of the road, however, eucalyptus bushes lend a balancing fragrance, with their silvery-green leaves and exotic scent. The valley falls away over boulders and acacias. In the distance, the sun filters through clouds, a golden light on the tops of mounts Suswa, Margaret, and Longonot. The horizon is endlessly far away, hazy and beautiful.

One path, but two views, both real.

And as I jogged along, it struck me that this is a picture of life. As we move along our path, we can look left or look right. We can see the putrid or the sublime, because both are there. Neither should be ignored, but there is some choice involved in which way we spend most of the time looking. And I've been looking left too much.

Looking left, my heart sinks when a kid misses a deadline for a school event, sits on the bench for a game, does not get invited to participate. But if I looked right I'd be thankful for school even if we are at times peripheral. Be thankful for a season without injuries, even if playing time has been disappointing.

Looking left, I feel inadequate and incompetent in my work and in most of life. Looking right, I'd be grateful for the blessing of being around people who are smarter and more experienced than I am. To the left, another baby with incurable complicated heart disease, who will die sooner rather than later. To the right, a child whose bone marrow aspirate showed his cancer was cured.

Looking left, my heart protests the way God allows suffering in the lives of people I love. Looking right, I see the privilege of walking through a hard and dark valley with friends this week.

Looking left, I am tired of the intestinal parasite that has wiped me out, as well as the toxicity of the cure. Looking right, I realize how great it is that no one else in the family got it.

Looking left, the tension of living in a country on the edge, tense, unstable, wondering when the next grenade will be launched. Looking right, the reality that life goes on almost normally.

This month started with an absolutely life-draining, mistakes-made, non-stop call weekend. I think I started looking left then, and now three weeks later I've hardly appreciated the view to the right. God sent my mom to organize my kitchen and play games with my kids and cheer us on. He sent two visiting doctors to allow a little breathing space in life, mentors, gift-bringers who have taught and supported in amazing ways. He sent friends to fix our car. He sent us a weekend break. Bethany reminded me that praise and thanks are instruments of war. That when we're under attack, the way to survive and emerge is by remembering thankfulness. By looking to the right. How many Psalms are written just this way? A lament of left-ward looking, true, painful, and then a transition to look rightward and remember that which is also true and beautiful, even if distant.

Pray that as we plod along this road, we'll balance the left-view of the trash dump by taking long right-views of the sun on the valley.

Kenya at War

2011-10-22T05:53:00.000-07:00

Kenya invaded Somalia this week, and President Kibaki officially declared a state of war. It is a peculiar war, waged by Kenyan military across their border in cooperation with the weak government in Mogadishu against the kidnapers and insurgents who control much of the territory in between. The reality of this is pretty far removed from idyllic Kijabe. Pretty far, but not completely. Today as I walked to the market with Acacia, I saw police stopping and checking vehicles as they approached the hospital. Our neighbor pointed out that one was wearing blue flip-flops with his blue police uniform which cut into the intimidation factor a bit. Emails are circulating about security awareness, because Al-Sha_bab has threatened to bring their campaign of terror and bombs to Nairobi in retaliation. This station has a history of angelic protection from attack during the Mau Mau uprising decades ago (Mau Mau who were later captured reported turning back from attacking missionaries and children at the school, because of the strong perimeter of military they saw, when in fact there were none). So one could look at it either way: a dangerous spot as the largest concentration of American missionaries in East Africa and the perfect target for anti-USA or anti-Christian terrorism . . . or a very safe spot protected by God Himself.

In other news today, Burundi was named as the most corrupt country in East Africa. Our new team has their work cut out for them, Every step of their work, from building houses to getting vehicles to approving curriculum to rehabbing the hospital to sourcing clean water . . will be met with the obstructing frustration of inefficiency and bribe-seeking. Uganda has cracked down on anti-government protestors again, even as a hundred US military "advisors" landed to assist in the capture of Joseph Kony, murderous and deluded leader of the LRA. Our Uganda team is back in business, with new team mates Josh Dickenson and Pamela Stephens. Josh was an intern with us who went on to finish a PhD in Engineering in Florida. And as soon as he landed he was swept up in trouble-shooting diminished water flow in the pipleline that provides tens of thousands of people with life-saving clean water. As soon as the Johnsons landed they were sick, a key CSB donor landed unexpectedly early for a visit, and another team mate had an injury requiring stitches, so it's back to the usual push. Pushing for the Kingdom, and being pushed back.

Please pray for peace in Kenya, for protection from terrorism. Pray for courage in Uganda, and wisdom, and provision as our team puts their shoulder to the plow, as our CSB students and friends take their life-determining national exams. Pray for vision and growth in Sudan as our team hosts 5 businessman interested in micro-development.

Pray for our family too. One more week with Grammy, Caleb feeling the crunch of application deadlines, some disappointing grades and games, some very heart-rending patient stories, all felt more acutely by me because I'm muddling through an unpleasant case of dysentery for the first time in over a decade (just after I told a new missionary that I eat freely when we're out in Nairobi and never get sick . . . ).

One can be lulled into the protected beauty of this place, of a structured hospital, of competent colleagues, of seemingly normal teen life and school, and forget that we are living in a war. Right now, both spiritual and literal.

More Photos, Grammy and Julia at Kembu Cottages and Farm

2011-10-20T11:15:00.000-07:00

Celebrating Cultural Diversity

2011-10-20T10:29:00.001-07:00

Today was a Kenyan national holiday, Mashugaa Day, formerly Kenyatta Day, for remembering the heroes who fought for independence and established this country. RVA takes the opportunity to celebrate "Multicultural Day", which is the 4th of July and Halloween and Thanksgiving all sort of rolled into one. Probably the highlight of the program was a traditional Korean Fan dance, performed by twenty or so young elementary-aged girls, only a fraction of whom were actually Korean. Imagine butterflies dancing ballet. The Parade of Flags: the students of RVA carry passports from over 30 countries. The student who has been at RVA the longest from each one is honored by carrying that country's flag to the front of the auditorium, and giving a greeting in the local language, while the audience cheers. It was pretty amazing to see the students transformed by their national costumes and languages, and to realize the richness of this place. USA, South Korea, and Kenya pretty much brought the house down. The language classes also come forward in groups and present a song, skit, reading, etc. in their language. Above you can see Acacia, Julia, and Caleb all looking quite animated while singing in Swahili. Caleb and his good friend Titus performed a humorous song, about being a "Mujungu" (foreigner) in Kenya. They sounded really good together, and the song was hilarious. If you use your imagination, you can see Jack in the back row far right with all the French classes singing "Blessed be the Name of the Lord" in French. After the program, the students divided into four teams (red, white, green, black the colors of the Kenyan flag) for relay-type games. Somehow the amazing food service coordinator Mrs. Janet Adkins manages a feast for all after the games, chicken and ribs and corn bread, eaten on the lawn in front of the school. Chatting after lunch. Grammy and Caleb in front of Kiambogo, the original RVA building. The entire student body lined up in the gym, mimicking the arrangement of colored stripes on the Kenyan flag. Not pictured: there was a girls' basketball game, where the jazz band played in all the intermissions and time outs, which felt very much like the pep rallies and games of my high school days. And the evening ended with fireworks as the stars came out over Upper Field. Real fireworks. Impressive popping sizzling exploding bursting colors. The entire school community was sitting in the bleachers, a boom box was blaring Souza marches amplified by a bull horn, and we oohed and ahhhed as the fireworks lit the sky. The theme of the day was God's Kingdom is here and includes all of us . . . it truly was a day to realize that in Heaven we'll be standing next to kids from Ethiopia and Brazil and China and the Netherlands, just like we were today.

A Tale of Two Hospitals

2011-10-17T21:53:00.001-07:00

In the massive, sprawling, congested city of Nairobi there are two hospitals. There are actually many hospitals, but these are two of the most well-known, and since they host he only two paediatric residency training programs around (there is a third program in Eldoret at Moi University) they are the two that I've wanted to visit. Since we have a visiting paediatrician in October as well as back-up from another visiting med-paeds ICU doctor, we came up with the grand plan for the three long-term Kijabe paediatricians as well as our colleague who runs the Neonatal community health program here, to take a field trip. Together.

So yesterday Mardi and I set out in the mist at 7:30 to drive into the city, where we met Immaculate and Mary (who live in Nairobi). It was an 11-hour eye-opening day.

Our first stop was AKU, as upscale and private as it gets in Africa. This is a hospital where one needs a culture-shock debrief to leave the doors and re-enter the rest of the world. It was established by a wealthy Persian hereditary prince, as part of the world-wide foundation that promotes development in the name of that particular branch of that particular religion. We were treated royally as well: greeted by the department chair, hosted to tea and sandwiches, invited to interact with all available faculty (all Kenyan, young to middle-aged, professionally styled, friendly), then given an extensive tour highlighting such technological wonders as the completely digital radiology department, nuclear medicine scans, well-equipped intensive care, state-of-the-art linear accelerator radiation therapy, carpeted luxurious hotel-like super-private wing where all the diplomats stay. The Paediatric ward is new, bright, sunny, clean, creative, calm. They have about 25 beds, with probably 20 kids. The neonatal ventilators and monitors were state-of-the-art, and only two babies had the full-time attention of a nurse and a doctor. The clinic has huge exam rooms, and a handful of well-dressed babies waited to see the consultant. I felt like I could have been in any suburban high-quality American hospital. This program takes 3 or 4 residents per year, who are paid to work there. The only drawback for them is that the patients are all private so they are superseded by the private consultants to care for them, and the spectrum of disease can not include much that is common and poverty-related, because only the wealthiest Kenyans (or best-insured) can get in. These residents already rotate at Kijabe for their surgical month, and we will now be on the lookout for improving their general paediatric experience while they are there as well. We've referred a couple of patients back and forth, and it was good to find out about the wealth of subspecialty consultants there. But few in our population would afford care at AKU.

From there we fought traffic (actually it was surprisingly not bad) across town to Kenyatta Hospital, the massive historic public institution and main teaching hospital for the University of Nairobi (medical school, nursing school, clinical officer school, public health). Multi-storied, with dark stair wells, marginal cleanliness, obscure arrangements, a bit of a prison/institutional atmosphere, and CROWDS of patients. The architecture was reminiscent of Mulago and Mwanza, I wonder if they were all constructed in the peri-independence colonial days of the early 60's, with open-air halls and central courtyards, unpainted grey-yellow stone stucco, formidable. We sat in on the weekly Paediatric teaching conference, which was amazing, led by a personal hero of mine Ruth Nduati who proved that bottle-feeding HIV-affected infants was MORE DANGEROUS than exposing them to potential HIV infection through breast milk. She is the department chair, and brilliant. Here they take 25 or more residents per year, who sat in a steep lecture-hall with it's old furniture and peeling paint. After the rounds we met a neonatologist (both she, the chair, and another lecturer were 50-something sorts of well-established academicians) who took us to see the newborn nursery and intensive care. The space was brighter than I expected, and reasonably well equipped, with again the same amazing modern ventilators (only 3 of 7 functional) and monitors. But 75 babies were crowded into what should have been space for less than half that many. In the incubator room for the preemies, the babies were turned sideways to fit two or even three in each plastic box. Mothers stood shoulder to shoulder with their hands through the little doors doing feedings. Every inch of the other rooms was cluttered with cots, chairs, parents, files, etc. Sometimes there are up to 20 students as well. We had a good talk with the charge-nurse about the challenges she faces. From there we toured one of the four Paediatric general wards, each with about 50 beds but bursting with a hundred or more patients. Again the bright yellow paint, oxygen, IV tubing, etc showed a fairly functional and active system, but the place was packed, room after room with more than one patient in each bed, milling parents. One lady ran up to me smiling and at fist I thought she was mentally a bit off, but then I realized she was the mom of a patient we referred a couple of months ago who was still languishing in a forgotten corner. My guess is that the over-taxed residents focus on the sickest handful, and the vast majority get little attention after admission. The consultants round only two mornings per week and then they only see 5 or 10 or 20 of the hundred inpatients. The emergency room was lined with waiting patients, but there seemed to be an excellent triage system in place, and a very sick child was receiving oxygen by face mask with a paediatric resident attending to him. Patients pay small fees at Kenyatta, but for EVERYTHING, from a bed to a dressing to an injection to a medicine. Overall the costs probably end up similar to Kijabe or a bit lower. If you have a competent aggressive parent who can advocate and navigate and has a bit of cash on hand, Kenyatta has the expertise and resources for some of the best care in Kenya. But for the masses of the bewildered poor, it probably turns out to be a frustrating and overwhelming place, easy to slip through the cracks.

I don't think there could be two more different hospitals in the same city offering such similar services. One is all about money, modernity, efficiency, customer satisfaction, excellence. One is all about inclusion, the public good, stretching resources, making do, thinking nationally. Both fill an important niche. But you can probably tell my heart is with the latter. It would require a strong heart to work there, because I'm certain that death is common.

Week in Review, Part 3--the Big Picture

2011-10-07T11:02:00.001-07:00

If you've persevered through all the family happenings and medical crises of the last week, bless you for reading. The last thread of the week though was a national level meeting of the Kenya Health Task Force, convened by our American Ambassador Scott Gration, in order to cut mortality in Kenya by HALF. By the end of NEXT YEAR. Which does not sound very possible, but I have to say his opening speech was both inspiring and impressive. This ambassador grew up in Kenya with missionary parents and even went to RVA for a while, and his wife spent most of her childhood at Kijabe. They are ideally placed as Americans who know Kenya, the language, the people, the issues, the dreams, and can connect Kenya's community with both the American government (i.e. money and power and influence) and with outside charitable organizations (i.e. skills and dedication). This is the same effective triangle of action that our famous Hopkins public health professor, Carl Taylor, wrote and taught about. A cooperation between local communities, government, and NGO's, driven by actual data and need, taking advantage of the unique gifts of all three.

So in the middle of this wild week of intubating babies and baking birthday cakes, I found myself as Kijabe Hospital's Paediatrics representative to the Let's Live campaign, sitting around a table with Kenyan professors and ministers brainstorming on how to improve immunization coverage, or new ideas for training doctors, or innovations in the treatment of malnutrition. We focused a good bit on the neonatal (birth to age 1 month) mortality rate which has barely budged in the last decade (33 to 31 per thousand births) and accounts for almost half of under-five deaths. It was stimulating to sit in lectures once again, to ask questions, to meet interesting people at tea and lunch from all areas of Kenya's health system. And in a week in which one of those 31 per thousand was not a mere number but a gut-churning reality, it was also a relief to look at the big picture view of where this country is going in health, and feel encouraged that bright and ambitious and capable people are dedicating their lives to see change.

Week in Review, part 2 - Challenges

2011-10-07T11:01:00.003-07:00

Because life is always that way. A celebratory week can not just be savored, it has to be wrested from the thorns. From the Fall, the curse meant that we could live under the vine and fig tree, but only at the cost of the sweat of the brow. We could commemorate the joy of 15 years since bringing forth a particular child, but only in the context of mourning for others.

Last weekend, the first two days of October, and by the end of them I thought I might need the rest of the month to recover. There are call days, and there are call days. This one did not start off too badly, rounds were reasonably efficient, and I ran up the hill to the school to watch the boys play soccer. At the very moment that Caleb scored the opening goal of the match, my phone rang from the ICU asking me to come for a little neurosurgical baby who had "coded" on the floor and been temporarily revived and transferred up to intensive care. And that was pretty much the last free and happy moment of the weekend, and beyond. It all runs together now, but I will tell you a few stories.

"Baby of Carolyn" lived her whole life in this week I'm reviewing. I was with her at the moment of her birth Saturday, and the moment of her death at 4:40 this morning. It all started when her mom was transferred into Kijabe from a smaller clinic, bleeding and leaking amniotic fluid, with a supposed 30-week pregnancy whose fetus measured smaller than that and with a dangerously falling heart rate. Her husband did not feel he could afford an emergency C-section or intensive care that might be needed for the baby, nor did he think the baby could survive, so they refused at first to sign consents. Which left Scott, on OB call, and me, on Paeds, standing in the labor room calling our medical director and executive director for ethical advice. Within a few minutes we got permission to insist on trying to save the baby, even if the hospital would be left with the bill. And within a few minutes after that Scott was extracting the baby girl surgically and I was coaching the intern through a resuscitation of her tiny limp blue not-even-gasping form. She began to breathe with help, pinked up, moved. She weighed 840 grams. Things were going as well as one could hope with such a distressed preemie until I intubated her for the first dose of surfactant, a soapy coating that preemies lack in their lungs. I put the tube in too far (easy to do in such tiny babies) so that it lodged in her right mainstem bronchus, and the intern assisting me gave the first few breaths with nervous vigor (also easy to do in this stressful situation). I was listening for breath sounds and watching the monitor, and neither looked good, and then I looked back down at the baby and nearly died of shock and dismay when I saw that I had given her such a severe pneumothorax that air tracked up and ballooned under the skin of her neck. I called our excellent anesthesia and surgical attendings for rescue, certain that I had killed the baby. It was a terrible hour, but they were able to place a chest tube and re-intubate and stabilize. I took her to the ICU (my second newly ventilated patient of the day). It was a long weekend with her, trying to keep the tube in place, following xrays, managing her fluids and tiny initial feedings, comforting her mom. And throughout the week, I had hope. Even when I happened to be the one who found her when her tube was out, who set her up on CPAP, and who ended up with her all night the last day of the struggle, when her heart was failing, her kidneys were failing, and we ultimately failed to save her life. On Saturday we had made the difficult decision to choose to go all out to give her a chance; by early Friday morning I had to make the much more difficult decision that we had done everything, and lost this battle. She had not taken a breath, moved, opened her eyes, made a drop of urine, all day, and even intubated and pushing in the breaths we could not get her saturations over 50% (normal is 90-100%). I stopped pushing and just put her back on oxygen and within two minutes she was dead. Her mom, achingly, thanked our team for trying, and said this was God's plan. Which is on a certain level true (Job says the Lord gives and the Lord takes away, blessed be the name of the Lord) but on another level is not, the cosmic struggle of good defeating evil means that babies like Carolyn's should linger into a full earthly life as eternity reaches down into their time.

It was a week for complex patients. Another baby, Samuel, was admitted over the weekend, transferred from another hospital where he'd been treated for pneumonia and had not really healed. HIs chest xray showed a discreet pulmonary mass, which by CT was later confirmed to be a rare congenital malformation. But that did not explain his extreme cyanosis; he was BLUE, and not that uncomfortable about it. So we got an echo in Nairobi which showed complete transposition of the main blood vessels leaving his heart. The blood which should flow to his lungs for oxygen flows to his body without much, and the blood which comes from his lungs just keeps going back there, two parallel independent loops. Needless to say he can't live long like this, but we hope that he'll qualify for surgery with a visiting team in November. I snapped his photo when his mom dressed him in a shirt labeled "Special" to remind us that his anatomy is not a mistake, God can take this problem and turn it to good.

Then there was the little girl with pneumonia who got worse and worse, as her infection spread into empyema, pus in the lining of her lungs. As well as the neurosurgical patient whose wound may have been infected with tetanus, she lies in constant spasm. Or the previously normal 8 year old boy whose week of fever and headache progressed to intractable seizures, whom I found admitted to our service with classic signs that his swelling brain was about to push down through his spinal cord into his neck. Another trip to the ICU. Or the infant we had sent home from the ICU a few weeks ago who returned with a big mass in his abdomen, which turned out to be his bladder, obstructed and damaging his kidneys. Or the HIV-exposed baby who was dwindling not from the infection but from hunger. Or the Maasai boy whose bizarre symptoms Mardi linked to sampling local mushrooms. And on and on.

Somewhere in there we also had a visit from a family from Germany, whose adoption of two Haitian children led them to establish a charitable foundation to fund projects for needy children. Though we had never met we bonded quickly over the stories of these patients, and it was a privilege to connect Simone with our Paeds ward chaplain Mercy. Mercy meets with and prays with every family on the ward, and through her loving care hundreds if not thousands of people have encountered Jesus in life-changing ways. She'll be able to help identify patients who truly can not pay even the nominal fees charged by Kijabe, and connect them to Simone's group in hopes of allowing more children with anomalies to access surgery, more families being crippled by expensive bills to break out of the cycle of poverty.

And I haven't even mentioned the national meeting for health in Kenya, which will have to have a separate post.

Birthdays, grandparents, donors, visits, meetings, severely ill patients, calls in the middle of the night, tubes and blood, oxygen and labs, cooking and more cooking, travel and hosting and plans, dishes and dirt, recoveries and tragedies. And not a lot of sleep. In the context of a minor cold and just not feeling very physically well myself, I think this was one of the most challenging weeks since we arrived in Kenya. I end it tonight, tired, and sad about Baby of Carolyn, relieved to take a weekend away from the craziness, and a bit drained of optimism.

Week in Review, Part 1 - Celebrations

2011-10-07T11:01:00.001-07:00

In the theme of thankfulness, let's start with a couple of family highlights.

First, on Monday, Grammy arrived in Africa. This is her sixth visit to the continent in the 18 years we've lived here, 3 alone and 3 with my Dad. Scott and I took a taxi ( a separate story, but due to a mishap while changing the oil, we were without a vehicle, until a servant-hearted and capable friend at RVA fixed it on Wednesday; I would mention his name but he's very humble about it, and he might get inundated with mechanical problems if we make him famous . . . ) down into the city Monday night, and waited for her flight. Which was a bit delayed, and then waiting for her handy walker to be unloaded delayed her further, until we were beginning to worry. Never fear, she had befriended multiple people on the flight and got a Kenyan airport worker to help her with her bags, talked her way through customs with two humongous pieces of luggage stuffed fully of goodies for us, and briskly made her way out into the waiting crowds in her bright pink sweater, more-slender-than-years figure, and trademark sliver-white hair. She'll be with us for the month of October.

Secondly, on Tuesday, Julia turned 15! What a lovely young lady she is, smart, capable, helpful, willing, determined, loyal, loving. She sets her own pace and has her own style, athlete and scholar, loving dogs and crochet, books and flowers and cows and bugs, friends and soccer and piano and choir. She decided to invite her JV soccer team (from 2nd term) to come for pizza, so in the less-than-two-hours between the end of Basketball practice and the mandatory study hall time for dorm girls (no exceptions for Bday parties I'm finding), we had to squeeze in 14 girls making and eating dozens of pizzas. Lots of laughter, creative toppings, hot fingers, excited conversation. We all called out our top 15 things we love about Julia as we baked and ate. As darkness fell the girls poured inside for a 4-layer cake and ice cream, then we sent them back to their dorms with bags of goodies. Julia, a blessing in our life and family that none of us deserve, yet none of us would want to live without!

Thirdly, on Wednesday, because our friend fixed the car, and because I was able to get out of a meeting an hour early, we converged upon Rosslyn (another international school in Nairobi) to cheer on the teams. It was a privilege to watch Acacia in her first-ever-in-her-life athletic competition, first team event, in her uniform, giving her all. Though her team does have a long way to go. . . Jack's team also lost Wednesday, though by a narrow margin. Julia was the only winner but her team played at a different school, so we didn't get to hear that until later (and in the week-in-review theme, her team also won a whole JV tournament last Saturday, they have really come together as a team and are doing quite well). Caleb's team was resting until Thursday when they played the Prison Guards. No, that's not a euphemistic name for a school team. It is literally the young adult men who have jobs guarding at the maximum security prison in Naivasha. His team had previously gone TO the prison and played the prisoners themselves, so I guess the guards wanted their shot. In spite of being much younger and not quite as strong or fast, the RVA boys endured and emerged victorious, 3 to 1. Caleb sent in the corner kick that resulted in one of those scores, and played hard and well the whole game. With every game we get to see I remember that it is a privilege not a right, that I never saw Luke play a high school sport, that these hours are the most focused live-in-the-moment hours of our life. When we stand and cheer, it is all about the kids and the day, the sun and the breeze, the excitement and encouragement. We're not on the way to something else, we are THERE.

Which brings us to today, when the family spun off in several directions for the long weekend. Julia's birthday wish was to take Grammy to see our favorite Kenyan spot, Sunrise Acres, near Eldama Ravine, the cozy basic camp-like cabins on a dairy farm in the highlands. Acacia went to visit her aunt, uncle, and cousins who work at a Christian University in Nairobi. Jack and Caleb flew to the coast to visit a family there whom we have been friends with over many years. This was planned long before the recent kidnappings, travel warnings and restrictions in that region, so we let them go ahead on faith, but deep down wish they were at arm's reach. And as we take a short weekend break we miss Luke all the more, this is a setting which should include him.

By any measure a full week, with the comings and goings, games and tests, celebrations and meals. But this was only half of the week, or less. On to part 2.

Parenthood, via Abraham

2011-09-29T22:38:00.001-07:00

"Before Abraham sacrificed Isaac, he laid himself on the altar - by obeying God."

by Ferenc Visky (Ferenc Visky (July 1, 1918 - October 5, 2005) was a minister in the Hungarian Reformed Church in Transylvania and a leader of evangelical revival in Romania who spent several years in prison under the Communist rule of that country.)

"Take your son... and sacrifice him as a burnt offering."(Genesis 22:2)

God speaks to Abraham and requires something from him. Abraham thinks of everything, except the fact that he has a God who asks something from him.

Nobody is aware that God can also ask for things. People like to ask for things and they like God to give. God asked Abraham to sacrifice his own beloved son and with it, He asked everything from him.

When I was deported together with my seven little children, the eldest of whom was eleven years old and the youngest only two, my biggest concern was not that all our possessions had to be left behind, that the door was closed behind us and that we would not return. The one thing I worried about was the seven little ones. What would become of them? Who would feed them and look after them?

Abraham obeyed and laid his son on the altar, though he did not know God's purpose. He only knew God Himself, for he believed Him and loved Him. Before Abraham sacrificed Isaac, he laid himself on the altar - by obeying God. Because he sacrificed himself first, he prevented the sacrifice of Isaac.

I knew I had to do the same thing. I cried for my children, but I had to lay myself on the altar first. And there, in that fateful situation, I experienced a miraculous surprise. Jesus had been there before. He did His Father's will and so I found that He was there when I was prepared to sacrifice myself and it meant salvation for me and my children.

Don't try to find an excuse when God takes you to the altar, for it is there that He Himself is waiting for you - in His beloved Son.

This is one of those passages that keeps coming up as a theme in our lives, an uncomfortable one, one I'd rather skip over. The most consistently impossible challenge of faith and missions is that of parenthood, of putting our children into situations that seem like an altar, a knife, rope, and bewilderment. I spend a lot of energy feeling like a bit more organization, better feeding, alertness to opportunity, push for language acquisition, more consistent family devotions, more effective prayer, will somehow shield them from the altar. Ferenc Visky and Abraham bear testimony that by asking us to place our children at risk, we are placing our very hearts on the altar. No wonder we balk. But the good news is that God is there. So for all parents of kids at boarding schools, parents of kids who feel lost and out of place, parents of kids with marginal health, parents of kids whose future feels uncertain and threatened, parents of kids who have been teased or isolated or excluded, parents of kids who are taking their own steps of sacrifice and faith . . . remember Abraham.

Walk in the manner worthy of the calling

2011-09-28T12:51:00.001-07:00

Our chapel speaker this morning read from Ephesians 4: I therefore, as a prisoner of the Lord, urge you to walk in a manner worthy of the calling to which you have been called . . .

And he used as an example Wangari Maathai, who died of cancer this week at age 71. She was a called woman. Here is one paragraph about her life:

"After graduating in 1959, she won a scholarship to study in the US, as part of the "Kennedy airlift" in which 300 Kenyans – including Barack Obama's father – were chosen to study at American universities in 1960. After further study in Germany, she returned to a newly independent Kenya in 1966, and five years later become the first woman in east and central Africa to obtain a PhD from an African university. There followed a tumultuous personal and public 40 years in which she ran the University of Nairobi's veterinary department, was imprisoned several times, stood for president, became a minister and won the Nobel peace prize. . . By this time, the Green Belt was flourishing. What began as a few women planting trees became a network of 600 community groups that cared for 6,000 tree nurseries, which were often supervised by disabled and mentally ill people in the villages. By 2004, more than 30m trees had been planted, and the movement had branches in 30 countries. In Kenya, it has become an unofficial agricultural advice service, a community regeneration project and a job-creation plan all in one." (The Guardian, http://www.guardian.co.uk/world/2011/sep/26/wangari-maathai?intcmp=239)

Wangari Maathai saved some of Kenya's most important forests, because she understood the link between the environment and freedom, between environmental degradation and poverty. She was willing to risk her life, endure beatings and hardship and loss, to stand for what she believed in. And because she did this, an entire new generation of Africans will live better lives.

Wangari Maathai knew her calling, and lived with a passionate single-mindedness that blessed the world. What Kenyan 3-year-olds that I'm treating will be the next Nobel Peace Prize winners? And how can we as missionaries, parents, doctors, live with the same all-out dedication to our calling?

weekend, weekstart

2011-09-25T11:25:00.000-07:00

It's 9 pm on Sunday, and I am very happy to be writing this from BED, the end of a long week, with another one starting too soon. For this hour, though, the cares of Monday are still a sleep away, and I am thankful for this cozy room as the wind whistles down the Rift outside. I confess to ending this week in a bit of a funk, physical (minor viral thing) or emotional (RVA nurse Loren Harrison's sudden death from a hemorrhaging aneurysm in his brain while on a six-month USA stay) or spiritual (allowing the demands of life to eat away at rest and reflection). One of the many small beauties to spring from the blood-soaked soil of Loren's death was a long conversation with another teacher who had been widowed in similar circumstances a few years ago. She told me that God had prepared her heart by leading her to focus on the discipline of thankfulness. So that even hearing about her loss and pain years later, the primary message she communicated to me was thankfulness, for her husband, for the way he died, for their life, for God's mercy. It was very inspiring and convicting in the midst of feeling rather down myself to hear this from her. Today at Loren's service one of his friends read the verse in Proverbs "a merry heart doeth good like medicine" (which Kay Meyer cross-stitched for us years ago) and spoke of Loren's cheerful attitude as the medicine he tirelessly gave his patients. So at this moment let me be thankful. Thankful for life here, for cheering at games as the sun sinks glowing over the Rift Valley. Thankful for Julia the sparkling hostess of our 10th grade Caring Community (monthly small group of students to feed and love), as we produced dozens of pizzas and engaged them in a Cranium game, and popped M and M's and chatted and prayed. Thankful for the 30-some kids who showed up for a prayer breakfast Friday morning, sincere and open. Thankful for the RVA community, as they came together for the memorial service, which was just the right paradox of mourning and celebration. Thankful for teachers like Mr. Batterman volunteering to coach, and doing so in a positive way. Thankful for Mr. Crumley and the choir singing this morning. Thankful that Caleb finally got a chance to lead the weekly fellowship group Koinonia on guitar. Thankful that Caleb and Jack made it through another weekend of games without being seriously injured. Thankful for our old neighbors the Riches lingering over Sunday breakfast and talking about kids and life, thankful for the connection of relationship that goes back more than a decade. Thankful, along those lines, for Anna and Jessica who pitched in with our group on Saturday night when I was almost too tired to stand. Thankful for Sarah and Nathan who took a train up from NYC and spent the day with Luke, a taste of "home" as he put it. Thankful that Caleb is another step closer to finishing his USAFA applications (and trying not to think that then we have to start the "regular" admission parade). Thankful that I'm living with my kids, and heard 3 of the 4 sing in choir this morning. Thankful for an evening jog/walk with Acacia, out on the lip of the valley, with scrub and birds and quiet. Thankful that Scott washed the dishes tonight. Thankful that we got Luke on the phone. Thankful for my washing machine that is churning through the second installment of the weekend's accumulated mountain of dirty clothes (I do love that machine). Thankful that a week from tomorrow we'll be collecting my mom at the Jomo Kenyatta International Airport. Thankful for my happy dog, who gains such satisfaction from any little jog. Thankful that God gives HIs children sleep.

Contrast?

2011-09-22T23:06:00.001-07:00

Our first famine baby to reach Kijabe. Drought and war have interrupted the tenuous cycle of survival in NE Kenya and across her border in Somalia. Food prices have risen dangerously across the region, even though we are a decent distance from the most affected areas. But this week, in the wee hours of the morning, an aid agency dropped this tiny malnourished 3 month old off in our casualty department. Ayub was born in our neighboring chaotic country, 8th child in the family. Three had already died in their first months of life, so this time when his parents saw that he had a defect in his spine and was frail, they decided to trek to Dhaddab, a huge refugee-camp-tent-town on the Kenya side of the border. He was hospitalized there and then transferred to Kijabe wasted, infected, pencil-thin, and irritable, with pneumonia on top of his neurologic and nutritional issues. We stabilized him and began to uncover his underlying problems, which have affected his brain and make his prognosis very poor. But no child should die of hunger, and feeding is one thing we can do while we wait to see what God will heal in the rest of his body.

In contrast, a few meters away, five hundred bright promising multinational children study and play, learn and grow. This is Julia's class last week, and this morning about 30 of them showed up at our house for prayer and cinnamon rolls (a holy combination). They are the future of Africa, and our world, kids with hearts for the poor and with the physical and mental advantages to effect change. At first glance the gap between an RVA student and Ayub seems to be an immeasurably impossible chasm, and we walk the edge between these two worlds, back and forth, hour by hour.

And yet there is a common thread of experience which ties us all together, that of suffering. I think the strong turnout this morning was related to the tragic events of the week at RVA. One of our student health nurses, Loren Harrison, father of 8, died Thursday morning. He was in America this term for a short HMA while his 4th kid started college (3 older are fairly grown, 4 younger are students in elementary to high school). Sunday he had a headache and collapsed, and it turned out that he had massive intracranial bleeding from a cerebral aneurysm (abnormal blood vessel) that had been a dangerous silent threat and then finally burst. In spite of being near a good medical center in MN for care, in spite of being only 51, his life on this earth ended on Thursday. Loren was a man of constant good humor and cheer, who stood in as a father and strength for countless sick students as he worked here for the last decade. This is a small and close community, and such a loss reverberates throughout the students and staff.

We read Romans 8:17 this morning. As heirs of glory we are also heirs of suffering, walking the same path that Jesus did. It always comes as a surprise that godly people who serve others would suffer, even die. Yet if this was required of Jesus, how can we expect anything less?

So today as we prayed for the kids, and as I watch Ayub's mother stranded in this unfamiliar hospital days from home, surrounded by people whom she can not understand at all, I can only ask that the suffering brings us nearer to Jesus, makes us more aware of where He walked, and more complete in Him in the process.

ANNOUNCING. . .

2011-09-21T12:58:00.000-07:00

. . . World Harvest's newest team, to go with our newest field of Burundi. Today the new team was approved as a group: John and Jessica Cropsey (ophthalmologist and teacher/administrator/mom) with children Elise, Micah, and baby-on-the-way; Eric and Rachel McLaughlin (family medicine and OB/GYN) with children Maggie and Ben; Jason and Heather Fader (general surgeon and teacher/mom) with children Anna and Abi; Alyssa Pfister (Internal Medicine/Pediatrics); and Carlan Wendler. That's 15 new family members in one day. Very sweet. We are incredibly thankful and blessed that God has intertwined our paths, for the world's good and God's glory.

They will now be in a couple of years of support raising and language study before arriving in Burundi to focus on medical care and education in 2013. Get to know them on their blog, and join us in praying for them: http://mccropders.blogspot.com/

I MISS MALARIA

2011-09-20T11:46:00.001-07:00

Who in her right mind would miss a disease that ranks as one of the number one killers of children in the world? Me. I shouldn't, I feel guilty about it, but I confess that I do.

Malaria is deadly. But it is also quite concrete. It can be seen under the microscope. It has a known course, and a cure. A child with malaria can look like death and in a few hours look pretty normal. Malaria is an enemy one can grapple with. We aren't always successful, but we often are. Patients and parents understand it, and want the treatment. You don't have to convince or cajole. The drugs are available, relatively cheaply, and the turn-around is quick.

Which is in contrast to the average Kijabe Paediatric patient, who is complicated and for whom we seem to do little that is dramatic. When I heard that our new admission yesterday was "a 15 month old with diarrhea and dehydration" I thought, great, something we can treat. But of course he had that on top of a progressive depressing divergence from normal developmental milestones, a history of TB with a pericardial effusion, a Rickets-related cardiomyopathy, overall marginal nutrition. This morning he was barely moving, just this side of coma, and we re-checked his potassium level which had fallen from 5 to 2.2 since admission (bad) from his copious stool. The one patient on our service who may have actually come with malaria (from a distant low-lying town) was only here because he also has spina bifida, a VP shunt, a deep pressure ulcer awaiting plastic surgical repair. One of our patients was missing this morning, a darling little 4-year-old girl in a pink headscarf (already) who had come from ICU after being stabilized for new-onset insulin-dependent diabetes. Not the easiest place in the world to raise a diabetic child, but thanks to Mardi's contacts we had a donor who was willing to fund her glucometer and care. Only it seems her father and his relatives did not deem her worth the effort, because about an hour after a long conference convincing them to stay, they ran away with her, and left the bill.

Because we're a referral hospital, and because we have excellent surgeons who are game for attempting the impossible and taking on desperate cases, and because simple things can be treated more cheaply in government health centers, Kijabe is a magnet for the complicated. And often a place where we fail to substantially alter the course of a disease or disability. A place where we bump (crash) right up against our limits.

Which is my real problem, I know. I like to see cures. I like to fix, restore, redeem. It is more appealing to deal with problems we can label, to engage in battles where we can fight back.

Jesus had compassion on the poor, the blind, the lame. I suspect that most of my patients are not so different from those that thronged to Jesus. He healed many, but I don't think he "fixed" everything. The final putting-all-things right still eludes us. The people of the Kingdom are tough cases, complicated, marginal, hungry, lagging, peripheral. Being at Kijabe immersed in these very people should be a taste of Heaven. In fact it just reveals to me that I don't particularly love the needy so much as I love being able to do something about their need.

So pray for people like me, who miss the curable malaria cases, and resent the sense of ineffective futility when confronting our daily stream of those who will never be particularly healthy or smart or strong. Pray for compassion to trump frustration.

thoughts at the end of a long day

2011-09-15T13:16:00.000-07:00

Here we are in Africa, safe and sound, while our extended family battles the elements. My mom's basement flooded for the first time in her 35 years living in that home, after torrential rains in Virginia, something like 15 inches in a few days. By the time she discovered the problem extensive damage had been done, a lifetime's worth of saved memorabilia, boxes, papers, photo albums, clothes, christmas decorations, all damp and moldering, some ruined, some salvageable. She also had some disappointing zoning/financial news about property my Dad left her with rental income to sustain her. So pray for her. Thankful that our dear church friends and neighbors have helped her carry and sort the junk.

Scott's sister and family are in Norway for a year, something like a working sabbatical. So his parents went to visit, and took a cruise ship up the coast. But today their cruise ship caught fire, evidently an explosion in the engine room killed two crew members and several others were burned fighting the blaze. All the passengers were evacuated by lifeboats, wearing life vests. We saw the photos in the news. We've been able to get through to a hotel where they have been taken, but have not talked to them yet. Norway is having a very bad year, and our parents must have been rather frightened. All of their luggage is still on the burning ship.

Luke talked to Marine recruiters visiting Yale this week, and they told him he could sign up for a free helicopter ride. So he did. A 15 minute flight over his school, the city of New Haven, the ocean, with him in the co-pilot seat. Pretty effective recruiting . . and pretty cool opportunity, even if he did miss one class in the process, and even if helicopter rides are a bit dangerous. I've been thinking that if you raise your children in a war zone, and they repeatedly hear gunfire and have to lie on the floor until it stops, and the soldiers they see are good guys protecting them from rebels who have killed people they know, you can't be too surprised if they are attracted to serving in the military. Particularly if tuition is involved. Only we learned today that the Marines don't pay for med school because they don't have doctors, which seems kind of crazy, but I guess they use Navy physicians, or just tough it out.

In a day where almost everyone I love was in danger in some way . . it was good to pray with the Moms In Touch group here, a handful of moms of college-aged kids praying for them and their schools. I appreciate the fellowship of maternal worry and joy.

And my last thought for the day, I really like RVA students. I'm glad I get to see them in clinic every Thursday, and at other times for acute illnesses or injuries during the week. I like teens in general, the way they are finding their way through this world, learning and experimenting and watching and being, seeing things with fresh eyes, challenging. They are interesting. And RVA teens are even more-so to all that. These kids are courageous and creative. Sometimes they are vulnerable and lonely. They are a unique breed, passionate about justice and Jesus and bush living and art and culture, driven to excel because they have purpose, but also still kids who miss home and long for wholeness and peace. I like cheering at their games and listening to them explain their travails in the examination room. I like the taste of the big picture of all that God's people are doing in countries all around us, as I hear from their kids. Of course there are a handful of RVA students I like best of all, my own kids, including the indomitable Acacia.

Reminders of War

2011-09-11T13:04:00.000-07:00

Ten years ago today . . . we were in Bundibugyo, the day seemed normal, until friends who were tuned into the ubiquitous local-language radio station told us that America was at war. In those days we had no cell phones, infrequent and poor communication. I remember wondering, was this the beginning of the end, a massive world war that would erupt. On one hand we felt safer in Bundibugyo than our relatives near Washington DC. On the other hand, it was unsettling to imagine all our known world disintegrating, not knowing what was happening to our extended families, feeling stranded. And we were pretty conspicuous as the only Americans for many many miles in any direction, in a district already known for rebel activity from an Al-Qaeda trained group. It was not until weeks later that we saw the unbelievable images that everyone else watched on September 11th (sent on VHS tape in the mail from friends). We did have a satellite radio and I remember all gathering to listen, and to pray. But for once, we were in a SAFER part of the world.

Ironically, today on the 10-year anniversary, a google-alert popped up in our email. Wikipedia added an entry today on Bundibugyo ebolavirus. What appropriate timing, linking disasters. All the world ebola epidemics combined have not killed as may people as 911. Yet the two, 911 and ebola, have much in common. Unstoppable, random, destructive violence, frightening in its sheer evil.

On this day, it is hard to deny the existence of evil. And even harder when one spends the entire day battling it. 4 am, beeper goes off, power is out, stumble through the house to find a light to see what is happening . . 6 am phone rings, our tiniest preemie is not breathing. I spend several hours hovering over this 1 1/2 pound fragility, and call everyone I know for help, and end up jamming the smallest endotracheal tube I can through his tiny glottis with some damage. I pretty much give up on a happy ending to this story, bring his mom in to hold him (another lady with no living child after several pregnancies), and then for want of anything better to do put him back in his incubator on oxygen by cpap as I rush off to another critically ill baby in the casualty department at 9. This new child consumes the rest of the morning, stridorous, cold, shocky, poorly perfused, marginal. Thankfully there is an ICU bed, and as I'm reviewing his very abnormal labs that don't quite fit together and make sense, I wonder if he has congenital adrenal hyperplasia, and look up the treatment. I pass back by nursery and the tiny preemie is, miraculously, still alive. Off to the ward to check on those patients, back to ICU, back to nursery to see a newly admitted baby who sucked in a bit of meconium in the birth process, and just as it looks like I might get to go home we get a call that the OB team is taking a 32-weeker to C-section. The mom is in her 4th pregnancy after 3 early losses, and now she's in labor, with a foot presenting. I watch the intern struggle (and I mean struggle) to extract this baby (it turns out the mom has an anomaly of the uterus) and by the time he pulls this girl out she is limp, pale, lifeless. By the time we start to give her breaths we lose her heart rate. I don't think I can face another desperately bereaved mom. But a few minutes of CPR and we have her back, and we set her up with all available therapy. It's now 3:30 and I have yet to drink, sit, eat, or take a personal moment since dawn. Meanwhile Scott plows on through his call too, intubating a trauma patient, consulting on the unstable adults. A lot of evil out there today, grabbing at defenseless babies and elderly refugees alike.

So this evening, in an hour of quiet between running back and forth to the hospital and giving minimal attention to kids and dinner, I pause to remember 911. And to remember, we are in a war, a war against evil, not against people of any particular ethnicity or cultural background. A war against the evil diseases that plague our patients, not against the patients themselves (though we can feel beaten down in weariness by this time on a weekend call). Grant W from WHM posted a link to a Christianity Today article by Russell D. Moore, called the Gospel at Ground Zero. In it Moore argues that the legacy of 911 is the reality of evil, the insistence that we not gloss over it or package it in muted form:

Where there are no demons, we demonize. And without a clear vision of the concrete forces we as the church are supposed to be aligned against, we find it very difficult to differentiate between enemy combatants and their hostages.

The Scriptures command us to be gentle and kind to unbelievers, not because we are not at war, but because we're not at war with them (2 Tim. 2:26). When we see that we are warring against principalities and powers in the heavenly places, we can see that we're not wrestling against flesh and blood (Eph. 6:12). The path to peace isn't through bellicosity or surrender, but through fighting the right war (Rom. 16:20).

Saturday on the Rift

2011-09-10T11:03:00.001-07:00

The weekend, and not a moment too soon.

First, a story of the kind of miracle that happens at places like RVA. And more often than we notice, I'm sure. Today was outreach day, where groups of students go out into the community to serve in various ways, from orphanage visits to trash pick-up. One group planted trees and was attacked by a swarm of bees. I talked to the nurse who received them back in the infirmary, and she estimated that at least 15 girls and both staff members accompanying them had multiple stings, some up to 20 on one person. BUT . . . the only two kids who were not stung were the only two kids with severe allergy to bee stings.

Julia and Acacia also planted trees, but in a different place, at a primary school in old Kijabe town. Which is pretty cool for at least two reasons. Acacia planting acacia trees in her new home country of Kenya, and Julia planting any trees anywhere because she has a particular affinity for trees, and has read Wangari Maathai's autobiography (amazing Kenyan woman who won the Nobel Peace Prize for the Greenbelt Movement to reforest Kenya).

Caleb's varsity soccer team went to a prison in Naivasha and played a match against the inmates. Which seemed to be fun, though I'm just glad that no one was injured, as I think of grown men and a walled compound and a dirt pitch . . . Jack's JV soccer team stayed here and played against a team from the on-station Moffat Bible College, young African aspiring pastors, which is sort of an ironic contrast to the prisoners I guess, and afterwards they had lunch together. JV won 4 to 2, with Jack scoring both of the second half goals. Which is sort of amazing because he was clearly frustrated with himself and not playing his best first half, and Scott gave him a half-time pep talk. So I guess it shows that Scott knows how to give half-time pep talks.

Scott and I are both on call, and paediatrics has been eerily calm. Scott however is covering ICU as well and though the day was quite reasonable he's dealing with a victim of a road traffic accident now. His highlight today was sending home a young woman after a month of antibiotics cured her of a brain abscess incurred when her husband tried to kill her with a machete. Our 650 gram 25-week preemie is alive and breathing, and today started on the whopping amount of a half a cc of milk every two hours. Interesting case of my week, a 3-year-old who was admitted with ascites (fluid in the abdomen) that turned out to be secondary to abdominal TB, and a 6 year old who was admitted multiple times in his life for vomiting, whom I didn't take seriously as he looked quite well until I SAW the basin full of fluid he threw up ... who turned out to have lived all those six years with an intestinal malrotation. Thankful for our paeds surgery partners!

And this week, we are glad to be safely in Africa rather than DC! My mom has had an earthquake, a hurricane, zoning issues which threaten her livelihood, then massive flooding that seeped into her basement for the first time ever, not to mention the high alert for terrorist attacks tomorrow. Kijabe seems rather calm by comparison.

Lastly, we made pizza in our new oven Friday night. A few neighbors stopped for tastes as they walked by, and we roped one young lady in for the evening, plus our WHM team mates Jessica and Anna, so it felt almost like a Bundibugyo evening. Only cold. And no obekekuni. As we always say, there's a reason a hundred missionary families live here, and one in Bundi.

After an spiritually and emotionally draining week, I'm thankful for the weekend, even if we are on call. And Man U is winning to boot.

Unanchored

2011-09-08T23:45:00.000-07:00

I am tempted to delete the post below.

Because at 3 this morning, I was awakened by a phone call. The intern said, "I have some sad news from nursery". In my bleary state I thought he said some sodium results, since the only unstable baby was a dehydrated one . . But then he went on to tell me that Shunetra had died.

Yes, Shunetra, the poster child of hope.

Dead.

I was stunned, unbelieving, speechless, and grieving. By the time I walked over to the hospital the chaplain had also arrived, and I heard Shunetra's mom Esther weeping as soon as I opened the door to the maternity ward. I went straight to her bed and hugged her and started crying myself, while the calm and sober chaplain Sylivia sat on her bed and rubbed her legs. The first words from her mouth were, between sobs, "I thought I was a good mom, but why did God take my baby?"

Why, indeed?

Why did she lose her first child as a stillbirth at 8 months last year? Why then did she have severe complications and have to deliver this one at 7 months this year? Why did she spend over two months (almost three) in intensive care with this baby, hoping against the odds? Why did she come so close to victory, only to have all her dreams snatched away at the last moment? Shunetra was allowed out of the NICU to stay on the maternity ward with her mom on Monday. She was officially discharged on Wednesday. She had stayed two extra nights because she couldn't pay the balance of the bill not covered by her insurance (nearly 3 months of intensive care and surgery had come to over 3 thousand dollars, of which 2 thousand was covered . . which I'm sure one could spend in one day of NICU in the states, but here it's a lot of money, and we were contacting a charitable group in Germany who sometimes helps kids like this). She was full of plans and dreams, ready to take this precious baby home, ready for a new life as a mother. Now she has lost it all.

Esther is a high school teacher. She is articulate and competent. She was fully committed, unwavering. She bought her own thermometer to monitor Shunetra's temperature when she moved out of intensive care and had less nurse supervision. She knew what she was doing, after those months in the NICU day and night she had experience, and she saw no signs of illness. Shunetra breast fed avidly at 10 pm, had a normal temperature, a diaper change, and fell asleep, so Esther did too. It wasn't until she woke at 1 am and realized the baby had not cried as she always did at midnight, that she realized anything was wrong, and by then it was too late. When she ran hysterically with the baby into the nursery, the nurses report that Shunetra was cold and stiff and long dead.

If there is anything to be learned from Job, this is the time to apply it. Esther is a modern day Job, a righteous woman, who in spite of faith and hard work and encouraging others and prayer, lost all that was precious to her. I should have sat in silence for a week, but on the relative scale of my life, it was about an hour, of tears and listening. Then what could I say? We can't explain God. He allows suffering that we would not choose, that makes no sense to us. If there is anything we can see in Shunetra's death, it is the enormous horror of Evil. Evil with a capital E, Evil that stalks the innocent, that sucks life, that disrupts and steals, that then whispers doubt and blame. Satan, not God, attacked Job and now Esther, and there is no glossing over the putrid terrible reality of this wrong.

God did not block this particular move in the battle for the world. So we cry and ask why, as Job and David and many others have done.

After the why, then what? Job said "I know that my Redeemer lives, and in my flesh I shall see God." There is nothing to justify or soften the blow, but there is still truth. Truth that this is not the end of the story. Truth that Shunetra and Esther will be seated, in new incorruptible flesh, at the banquet of the Lamb, reunited and whole. Truth that the God who allowed this death also allowed the death of His own son, because Evil is that pervasive and terrible, that costly to conquer. Truth that God is God, and we are not. That His ways can not be boxed and categorized neatly according to our sense. That in this world we see the weak and innocent pay dearly, but that there is more than what we see.

Esther will go home empty-handed, bruised and beaten, devastated. Perhaps in a year or two she will risk breaking her heart for the third time, perhaps she won't be able to. It is actually the second night this week that I've gone in at 3 am for a non-revivable baby, the second time we've been unable to rescue one living child for a multiply-bereaved mother. We will push on day after day, fighting back, but I have to be honest in saying that that anchor of hope feels too light to hold anything in place today.

For we who for refuge to Jesus have fled (Heb 6:18).

The weight of hope

2011-09-08T11:15:00.000-07:00

I don't think of hope as a weighty substance. Perhaps courage has weight, or determination, or even passion. But hope sounds ephemeral, fleeting, insubstantial, tenuous. So the verses we read in prayer meeting this morning jumped out: we have this hope as an anchor (Heb 6). Last month we rode a traditional wooden dhow through the Indian ocean surf, anchoring off an island for lunch, and near a coral reef for snorkeling. The anchor involved was solid, barnacled, a definite substance, straining the muscles of our crew-man as he threw it over the side. The weight of it carried it down to the ocean floor, and our attachment to it held us in place. Instead of drifting with the tide we remained secure. We couldn't see the anchor anymore, but it did its work below the surface of the ocean.

So tonight I'm thinking more about the heaviness of hope. Hope as a solid, tangible thing, a thing of weight and drag, to hold onto, in the currents of life. A thing that pulls on our hearts steadily, unseen, keeping us from wandering, attaching us to the Rock.

In fact, I think hope weighs more than most of my patients do. Today Shunetra was discharged from the hospital. She came into this world precipitously a couple of months ago, less than two pounds. There was not much to anchor her to this world other than her mother's hope. I remember meeting her mother pre-delivery to explain what we could do in the nursery, she was admitted with life-threatening complications of pregnancy, and had to be delivered before both she and her baby died. She had no living children, this was her last chance. We gave the baby everything we could, but her prognosis looked soberingly grim, and I remember her mother's tears. But this lady also had hope, and one day I met a group of her friends who had come to pray through the nursery windows. Shunetra was not a star preemie. Most things that could go wrong, did. One night I was on call, and I spent hours in the NICU with her on a heated bed, giving her artificial breaths, hoping she would live. I hated to face her mother if she died, but I pretty much had resigned myself to that. After many attempts at reviving her, she was not really responding. So I prayed aloud with the nurses over her one last time, and said we will resuscitate her again, and if she doesn't start breathing, we will have to let her go. And then, miraculously, she did. All night, one hopeful breath after the other. That wasn't her last brush with death, she also had surgery on both knees for infections (she must be one of the tiniest ever in the orthopedic surgery theatre). But that mom's hope anchored Shunetra firmly to life, and she fought on and on, all the way up to a whopping four-plus pounds, ready to face the world outside.

Tonight hope, in my mind, weighs four pounds. And as I pray for my own kids I ask for this kind of hope to anchor their souls and mine. To be a tether in a choppy world where it is too easy to be pushed far out to sea, or thrown against the rocks. Compared to Shunetra they look amazingly solid, but in my heart I see the gaping future, the uncertainty, the danger. The desire for friendship, the quiet perseverance through hours of work, the plodding, the work of fitting in and making friends. And the imminence of each leaving this harbor, the nausea of being out in the wildness of the storm and holding on for dear life.

Let me stay anchored to hope.

the facts of life, and death

2011-09-07T12:33:00.000-07:00

FACT: Most of the dangerous places to be a less-than-five year old child are in Africa. FACT: Though Africa represents about 15% of the world's population, more than half of all childhood deaths occur here. FACT: Almost all of these deaths are preventable with good maternity and neonatal care, a few antibiotics, clean water, mosquito nets. FACT: Jesus cares about the least of these. Hard to remember sometimes in the thick of it, like at 3 am this morning when I was awakened to assist with the anticipated delivery of an extremely premature baby. He came out mottled and stiff, dead for some hours. Which is sad enough, only this was this mom's third pregnancy, third C-section, and third dead baby. FACT: The infants cry out for justice, God is listening, and that's why some of us end up where we do. I think there's room for thousands of more pediatricians in Africa. Come.

to Joanna and Grammy

2011-09-04T11:18:00.000-07:00

I take zero credit for the crafting soul of this child . . Joanna taught her to crochet, and today she used the last of the yarn we brought from America making this scarf. Just in time for a cool rainy night. Julia is also holding a stuffed-animal ladybug she made, which she named "Judy" in honor of Grammy, and is to be a gift for a friend tomorrow. Before Luke left she made him a new crocheted cap, which will be essential in surviving the winter at Yale. So thanks Joanna, and mom can you bring more yarn???

slow thanks

2011-09-01T23:26:00.000-07:00

Slow, and thanks, are two words that sifted into consciousness at our field retreat. Being present in the here and now, and thankful for it. So in a week of a bit of chaos (ten living in our small house, fifteen one day, new books and notebooks and pens and classes times four high-schoolers, covering extra work in the hospital due to colleague sickness, keeping up with bread production and food preparation and laundry for the crowd, Caleb trying three nights to skype interview for the Air Force Academy before it finally worked, feeling like the emails are out of control so I counted one day's worth last night and quit at 132, new students with new health issues and the usual fevers and injuries and rashes and worries, trying to connect with one kid on the other side of the world, you get the picture) I am pausing this morning to remember slow thanks.

Jen G posted a quote on fb: what if you woke up tomorrow and only had what you gave thanks for today? Sobering. Thanks was the theme of my devotional reading this morning, too. So I am reminded to be thankful, for this cup of warm milky Kenyan tea, for this comfortable peaceful home, for four kids off to class this morning with brains and book bags tumbled full of integers and English essays and Swahili vocabulary. For Luke getting into a required but full English seminar. For Julia and Acacia joining Caleb in choir; 51 new kids tried out for limited spots. For Mr. Crumley, the choir director, whose pastoral heart draws, as evidenced by the fact that about 1/5 of the high school is IN choir and another 1/4 would LIKE to be. For Jack and Caleb surviving the first round of cuts in soccer tryouts, again 60-plus boys all trying their hardest. For coaches who enable three teams for boys' soccer and girls' basketball, meaning my kids and others have an opportunity to learn and run (and I mean run, Caleb has placed second amongst the 11th and 12th graders in the 1 to 3 mile runs, and Jack also placed second amongst all the 9th and 10th graders!). For the Massos' courage and sacrifice, leaving their daughter with us, a holy privilege, deeply serious. For our WHM colleagues spending the month at Kijabe, the ever cheerful can-do Miss Anna substituting in World HIstory and Government for a teacher who is missing the first few weeks of the term, and the tenderhearted Dr. Jessica who not only kept a newborn alive with expert resuscitation while she called me to come in the early morning hours but then donated her own blood to save the life of the post-partum bleeding mother. For connection with God's Kingdom in scattered outposts of Africa as parents bring their children here, for our tiny supporting role in this complex picture. For my partner and friend Dr. Mardi, whose wisdom and work means I have time to inhale, to ponder, to thank.

And time to slow down. Another theme of our meditation was to live in the present, not to treat the present as a temporary anomaly between what is past and what will be. My reading this morning brought me to Exodus 24 again, a really remarkable chapter, particularly after actually visiting Mt. Sinai and thinking about the feast for the seventy elders, the substance of the heavens paving stones to the Throne. And the six days of thick cloud that preceded Moses' encounter with God. Dan remarked that sometime in his life he hoped to spend six silent days waiting for God to speak. I tend towards a frantic pace, cramming and quick, as if that would then buy me slow time later. But I need to grasp that this is the life we have, currently, not as a next-best-thing to what was, or a get-yourself-ready for what will be, but for NOW. Some of my favorite hours of the last year have been spent on the sidelines of sports matches, which sound rather trivial in the big picture of eternity and the relentless battle for the restoration of creation. But I think those hours are precious because they are rare slices of the present. When we cheer our kids, we are there, not thinking about the past or future, fully engaged in the here and now, enveloped in a community doing the same. Along with meals, slow fellowship of the table, and worship, these are the places that the pace of real life (eternal life) breaks in.

There will be many moments in the next week that will be hurried and worried. I'll be faced with a long list of patients or be pushed to action by a breathless baby; I'll be multitasking in the kitchen to pull together sustenance before some scheduled event. But this morning I am practicing slow thanks. Which is, in the end, merely another way of saying faith. Remembering that more action from me, or better ideas from me, are not needed, because God is in control, and all manner of things shall be well.

Putting faces to the facts

2011-08-28T07:22:00.000-07:00

Kijabe Hospital Paediatrics . . children come from nearby villages or from neighboring countries, some with major surgical problems that can not be treated very many other places south of Cairo or North of Johannesburg. Some come with the same issues that kill most children in the world: hunger, socially non-coping parents, exposure to lethal infections, poor quality water and food and education. And many come without the resources to pay for their care, even though that care is offered at about 1% of the cost of similar care in the States. Since this is a not-for-profit hospital belonging to the Africa Inland Church, we seek to help all of them, while still paying our Kenyan staff and maintaining a decent facility. Which is easier said than done. So some years ago other missionary physicians started a "Needy Children's Fund" to subsidize the care of select patients who were so poor they couldn't even afford the minimal fees charged by Kijabe. Here are a few of the kids we've helped with that fund this week. The first is a 16 month old girl with Kwashiorkor, peeking around her mom's shoulder as she rides on her back, similar to my patients in Bundibugyo. Malnutrition, a mom that weaned her too early and was unable to provide enough food, a father who seems to be at odds with the rest of the family. A treatable condition that is too often fatal. The second is a 10 year old boy who had been progressively more and more tired, unable to play and run like he used to, until in the last two weeks his whole body began to swell up. He was in heart failure, and we subsidized his referral to a cardiologist for an echo in Nairobi which confirmed that he was born with a major structural heart defect (common AV valve). The cardiologist helped us get him on a good combination of medicines, and he left feeling MUCH better. The third is a 3 year old who came in with a bad cough and was found to have TB, which lead to the diagnosis that she and her mom are both infected with the HIV virus. Now they are being treated for TB and AIDS, and what would have been a few months' decline until death can be redeemed into a decade or two (or more?) of life. All three of these children would have been dead within a few weeks or months without treatment. All three will have ongoing challenges, but left improved and hopeful. If you are interested in contributing to this fund, follow this link to: Kijabe Hospital Needy Children's Fund You will have to type "For Needy Children's Fund Kijabe Hospital 70351" in the comment box to be sure the money goes directly to help children like this. As you do to the least of these . . . I think Jesus thanks you.

TRANSITIONS

2011-08-28T01:42:00.000-07:00

Transitions. Again.

Goodbye to Luke, he walked through the airport security alone, again, this is now beginning our fourth year of sending him to another country from the rest of the family for school. At 18, he's already walked this path many times. My confidence in him carries me through the airport scene, where we all stand huddled in Maasai blankets peering through the glass. But when we get home and he's not there, it aches. And when we hear that he was singled out for security checks, had his trunks pulled and opened on the tarmac in Istanbul with Turkish airline officials brandishing his Maasai swords and him explaining that they are "cultural artifacts", we're glad for his poise but sad that he was in that situation (images of a Turkish jail . . . ). And when we get a facebook message from a friend and my mom, who drove him back to Yale from DC, we're so thankful for their care, but sad that we aren't the ones helping him settle into his new dorm, or anywhere available as he's told to brace for the hurricane and stay in his dorm today.

And hello to Jessica, Anna, and the Massos. Dr. Jessica from our Bundibugyo team is here for a month at Kijabe to gain experience in OB, and Miss Anna is here to substitute teach at RVA. The entire Masso family is here to settle Acacia in as a new RVA student. As Anna pointed out, it was like a Bundi Saturday night, tacos at the Myhres with a dozen at the table. We are blessed to be here in missionary central, a place where others from our teams can come for specific boosts. This morning we all attended chapel together, filling a whole row of the folding chairs. Mr. Crumley the chaplain brought us God's word from 1 Samuel, the story of Hannah, who gave her child up to the Lord. Another paradox of faith, that those who lose will gain, that life comes from death. The call to missions is fraught with so many goodbyes, such transition and loss. What kind of God would ask that of us, he queried? The God who went through the same thing Himself, the God who works all things for the good of those who are called, the God who will bring us all back together for eternity and wipe every tear.

We hold to these truths by faith, in the storm of transitions.

TIA

2011-08-23T11:03:00.000-07:00

African travel veterans we are supposed to be, but somehow there are always more adventures out there.

Unmarked roads, for one. It is much easier to find your way INTO a city than out of it. We made one wrong turn in Mombasa and within a minute were on a road that ended in a pile of trash and then the bay. Whoops. Near Nairobi there is NO SIGN coming from the east to find the international airport. You have to notice the streetlights (which are rare) and then make a U turn over the median of the divided highway to get there.

Curious police. We were only stopped once yesterday. I expected the fake radar gun and a charge of "overspeeding" which happened to us some years ago in about the same place (the police then tell you that you have to appear the next week in court which of course no one driving from Mombasa to Nairobi can conveniently do out in the boonies, so they hope you'll offer cash). This time the policeman didn't even say hello. As soon as Scott pulled over he said "American or Britain?". Uhhh, American, Scott said. "Oh, Obama!" The policeman smiled, looked in our windows to break the boredom of his day, and waved us on. One of the few times it pays to be an American and not a former colonial.

The ferry. In the middle of the old city of Mombasa, a channel, a finger of the bay, divides the road. It is not a huge distance, a reasonable bridge would suffice. But there is no bridge. There are a handful of old chugging ferries. Long lines of cars. Hordes of pedestrians. Vendors selling trinkets and ground nuts. A roadside fish market. Beggars. A steep ramp onto a flat steel boat. A glance at the pontoon-like safety devices hanging up on the rails. Keep the windows rolled down in case we have to swim out. We are inches away from the matatu beside us, and a smiling German girl whom we had seen passing something out to locals on the ramp now hands us a stack of evangelistic tracts in Swahili, through our window, which feature a verse about lust. She has determined we are missionaries and tells us to hand them out to others ourselves.

The trucks. As we near the edge of the city, we stop behind a congested line of trucks, the two-lane road at a standstill in our direction, though vehicles come in the other. We think there must be an accident. We wait. We wait longer. Inches of progress only. All the non-truck drivers are pulling out onto the sandy, dusty shoulder on the wrong side of the road, driving against oncoming traffic. If you can't beat 'em join 'em. We finally abandon all traffic etiquette scruples and jolt over the road margins. There is no accident. There are hundreds of trucks, lined for a mile or more, inching along through the congestion of the port.

Rest stops. There are none. We pull off into the scrub. Not much shade from the unlikely portly baobob trees. The only bathroom in hours is to hide in the bushes. We pull out the pb sandwiches I made that morning, and eat them with tepid water and cold apples and salty chips. Yum.

Sightings: elephants ambling away from the road, zebra, baboons. Near the end we see a small herd of wildebeest, stamping and restless. We reach the Masso's (Michael's parents) as dusk deepens to dark. Thankful for a place to get out of the car, stretch, eat, sleep briefly.

Goodbyes: up at 3 am for the final hour into Nairobi to the airport by 4. We left the warmth of the coast and didn't unpack in our few hours at the Massos, so we're chilled by Nairobi night-time coolness. And at Jomo Kenyatta Airport, non-passengers stand OUTSIDE. So our kids wrap up in the Maasai blankets we had for camping. Jack doesn't even have shoes. We watch Luke through the glass, as he goes to the check-in counter alone. Beside us thin young Somalis stack the ubiquitous cheap plaid plastic zip bags stuffed with who-knows-what for the flight to Mogadishu. I remember the time I flew to America after evacuating from war, and my checked bag was a cardboard box tied with string. Really. With used clothes that were donated to me out of pity. That seemed worth checking on an international flight. Luke comes to the window and says goodbye through the glass, and we linger until he disappears. Until Christmas. Sadness.

Efficiency. 3 am is a painful time to start the day. But it has its rewards. We hit the center of Nairobi just before 5. It is quiet, the streets are uncrowded, and the original massive Nakumatt Mega is open 24 hours. So Julia, Scott, and I all push a cart and we load them with a couple months' worth of shopping. We're like war-scared refugees, we can't quite believe that we live an hour out of Nairobi instead of Bundibugyo, so we still shop as if we won't see civilization for the near future. Peanut butter and toothpaste and dish soap and butter enough to outfit several families. By 7 am we have crossed the city and are emerging out the other side just as traffic starts to snarl. And just as Java House opens, so we stop for a hot breakfast, hungry 4 hours into our day.

Home. It does feel like home, now, particularly after being away. Star. Kijabe is cool, greener than we left it, damp. It takes most of the day to unpack, sort, clean, wash. But in Bundi it would take me most of the week. It is good to be back, to cook and wash dishes, to answer the phone, to be still. This is Africa, and home is not to be taken for granted. We are missing Luke terribly, we are missing the dear friends we just retreated with, we are missing Bundibugyo. But we embrace this place and time. Which is a lot easier to do with a washing machine.

tides

2011-08-16T00:19:00.001-07:00

The ocean recedes, rhythmically. The tide is going out, slowly, stepwise, leaving a flat white stretch of sand.

This week has been that for us. A quiet declining tide, washing away long nights of anxious call, sadnesses of bereaved mothers, months of separation as a family, and a year of extreme change. 12 1/2 months ago we left our home in Bundibugyo, with the life, ministry, friends, purpose that had fallen to us there. In this year Scott transitioned to a new role as Field Director, our first kid went to college, we traveled through months and miles to visit countless people, we moved to a new country, fixed up and furnished and entered a new house, started new work, and have studied a new language. Like a high tide, this year has churned up a lot of sand and seaweed. It's murky. That's a lot of transition and loss and recovery. A lot has been great, cheering kids from the sidelines of their games rather than from a poor phone connection a continent away, re-learning so much of medicine that had lain dormant and musty, being blessed by the community and atmosphere at Kijabe. So much has been hard, watching the team we love struggle with unexpected sicknesses and loss of personnel and cutting back of programs and feeling unsupported, holding on to kids through disappointments and struggles, saying more goodbyes. So we really needed this low-tide break, these accumulated days of sun and breeze and quiet. No agenda, no projects, not really accomplishing much. Reading, sleeping, swimming. Emptying. Letting the crashing surf of this year ease back. Creating a space.

On Thursday we will move from this rented house to the small cottages we booked for our whole East Africa Field. And I think it will be time for the tide to turn, to begin to come back in. So we are praying that the space created by this week of rest will be filled with God himself. Not with plans or worries or strategies, but with His presence. Please pray that for us, with us.

just another day in paradise

2011-08-12T23:41:00.000-07:00

The click of palm fronds in the ocean wind, swaying branches silhouetted, dark and papery against the bright day. A misting rain moves in, and out, leaving damp tiles that steam in the sun. Fishermen push heavy wooden canoes through the shallows, bumping over the waves of a receding tide, to reach the rich waters as dawn breaks. The thin dark arc of monkey's tails as the shy group of sykes brushes through trees, pausing to pick fruits. Thick adobe walls, brick floors, grass mats, pillows, thatch roof, dark shutters open to the fresh ocean air, house on a coral cliff, outside and inside blending without barrier. The smell of sea foam on sunscreened skin. The soft give of sand. The sweetness of coconut rice, the creaminess of a seaweed sauce, the firm chewiness of octopus, the charcoaled flake of grilled snapper. Books, more books.

Yesterday, trip to Shimoni, people milling about the cement pier, the piles of vegetable oil and plastic cups being loaded onto a huge wooden dhow. We board a small creaking swahili fishing boat, the motor sputters to life after the captain pulls an extra spark plug out of a plastic bag of greasy miscellaneous parts. We leave the harbor heading for a protected reef, the boat rising and slapping against the churning water, which gets rougher as clouds gather. Our little crew scrambles to pull a tarp out and rig it over the mast as we huddle, chilled, wondering what in the world we got ourselves into, the sea tossing our small boat, then we pass through to cloud-filtered sun. Two kids pale and queasy; two unaffected. Then we are there, anchoring near a small atoll, pulling on flippers and masks and snorkels, slipping over the side of the boat into the aqua water, bright blue. Beneath the surface, another world. Purple and golden corals, lumps and fans and lace and castle, mushrooms of rock. A school of mustard-colored sleek fish disperses and re-forms. Every color, every size, every pattern of creature darts around. Long sleek, thin; fluorescent blue on emerald green; yellow stripes and black spots. Floating, drifting, kicking, chasing, the bubbling effervescence of someone else's fins kicking. Julia pulls my arm to point out sea turtles, two, gracefully and slowly flying through the waters. The boys dart down to touch an octopus which has retreated into a cave. Later three dolphins swim through, playful, glimpses of silver fins. Back to the boat after two hours of swimming over the reef, another moment of doubt as the dhow teeters aground in shallows, we wait for the rising tide to allow our return.

Paradise is in the setting, but moreso in the wholeness of being together, time to discuss majors and futures, applications and ideas. Time to rest. A Sabbath from the agendas and demands of others. Sunrise on the flat roof patio, prayer and scripture. Late evenings watching a video as the moon shines on the water. Very thankful to be here.