rotating header

Monday, November 13, 2017

Running with the zebras

This is the image that popped into my mind as I sit here in my laundry room/side porch/office at sunset, trying to communicate what the last week+ has been like.

We're the donkey, a hopeful but plain work-horse sort of creature, not the fastest or most glamorous, usually reliable and at times cantankerous.  But we live amongst the zebras in their spectacular wild glory and community, and we run along trying to keep up and join in.

Critical, complex medicine:

A week ago we did our monthly call at Kijabe, which is always an exhausting mixture of high-intensity medicine and deep reconnection with people we respect and admire.  It's not easy to oscillate between extremely-low-resource and moderately-low-resource, between chaotic-vague-diffuse-responsibility and emerging-organized-high-standards.  So like the little donkey, we trot along behind the Kijabe experts doing the best we can to fit in and help.  The baby above actually came from Naivasha in an ambulance as we drove over in our car, needing emergency surgery.  He survived that but sadly died later of an overwhelming infection that started at Naivasha.  We are thankful to not only contribute to Kijabe, but for the resources that we can access there for our patients.

Regional Diplomacy:

The day after finishing our two-day Kijabe work, we drove up to Chogoria hospital where we've been working for months to iron out a good Memorandum of Understanding, a sort of contract for our missionaries to serve the hospital.  Over the course of a couple of days we led six different meetings, each averaging a couple hours, with various partners.  The purpose was to bring clarity to responsibilities and allow for a peaceable and unified way forward.  This is the future of medical missions: several NGO's partnering with a completely Kenyan-led hospital, learning to flex cross-culturally with them and with each other.  Messy and good, and potentially amazing.  

Post-strike escalating care:

Back to having nurses, two per ward instead of one, shifts actually covered, people with experience.  YEAH.  But once the word went out that the strike was over, the patients flocked in.  Back to two babies in many of the cribs and most of the incubators.  Back to crazy flows of admissions and deliveries, rounding on 40-60 complicated patients.  Back to the saddest and poorest cases, families with AIDS, working women who deliver premature babies waiting for the bus, children abandoned, children abused, children malnourished, the kind of patients who were not accessing private care for the last five months but just waiting or dying at home.  This past week as the strike ended and patient numbers climbed also coincided 3/3 of my doctor co-workers being sick at some points.  And we found that it has taken a week for the returning nurses to get back mentally as well.  So it was a little crazy. 

Teaching, teaching, teaching:

We have two medical officer interns (doctors who finished med school, doing a 1-year rotating internship), five clinical officer interns (finished a PA type course, doing a 1-year rotating internship) who spend 3 months at a time on Paeds, plus students from schools around the country that show up unannounced for a week or a month at a time.  The end of the strike coincided with the 3-month slightly-staggered rotation of the interns.  My last day with some of them is pictured above.  We both spend a lot of our time teaching on rounds, and giving more formal presentations as well.  It's amazing to see them grow in their ability to give good care.  

Life tasks:
This laundry made me happy, because while I saw torrential rain during rounds after having put it out that morning before work, by the time I got home in the late afternoon the sun had dried the clothes again.  In the midst of all our patient care and teaching and administrative work and travel, there is also the challenge of renewing our work permits and having enough food and maintaining a home.  This week a HUGE HUGE sink of my time and energy went into the final points needed on my five-year cycle of staying board certified in paediatrics.  I should have put up a photo of my pulling out my hair.  Talk about a donkey among zebras, my life just does not fit their categories.  I thought a project I had done for Quality Improvement would be an ace in the hole to meet some requirements.  The American Board of Pediatrics did not agree, and I was pretty stressed out by the prospect of failing to meet the deadlines because I had waited too long.  Thanks to good ideas from others and a lot of work, I managed to jump through the final hoops and pay my massive amount of money and get my letter.  Set 'til 2022.  

Local Fellowship:

We have, over our year+ in Naivasha, been drawn more and more into our local church, the Naivasha International Fellowship.  Scott led the service this week and I play the keyboard for worship a couple times a month.  The women meet for Bible study when I'm working, so I rarely get to do the extra things, but there was a one-day retreat on "Transitions" on Saturday.  This group represents a deep treasure of life experience, and it was a privilege to join in on the trust they have built and listen to their stories of struggle and grace.  On that day I was really a stray donkey, and so thankful to have the herd welcome.

In the hospital, too, we've been trying to build relationships with our co-workers, so we took a couple hours out of our Saturday evening to attend the wedding reception of a young doctor.  It was raining.  We figured out we had to put money in the proffered envelope to go up and greet the newlyweds (the donkey/zebra effort to blend). The MC picked us out of the crowd (surprise) and announced us as guests from Scotland (Scott=Scotland I guess).  

Gold Friends:

And saving the best for last, we celebrated Scott's birthday this weekend too.  The Massos and Bethany came for a sleep-over birthday party . . a lovely dinner, gifts, cake, and the next day Scott and Michael did a bike-ride while I went to the retreat and Bethany got some work done in quiet.  It is a real gift to spend time with people whom we have loved and walked through hard valleys with for over 20 years.  On Scott's actual birthday, Sunday, we even had a true Sabbath of our favorite stroll through the local game park.  

That last photo was part of the wedding decor, but a fitting end to the week.  From posing as ICU docs or international negotiators, to balancing American board requirements and Kenyan red tape, to relaxing with dear friends and figuring out the cultural nuances of weddings, there is no donkey I'd rather trot along with amongst the zebras.

Tuesday, October 31, 2017

500 years of protest

Today marks the 500th anniversary of a German priest, Martin Luther, famously nailing his 95 theses to the church door in Wittenberg.  He had encountered God in fresh ways, and sought to reform the church by calling people back to a teaching that we receive grace freely from a generous God rather than earn it stingily from a reluctant one.  In the process of sparking debate and pushing for change, however, the political and religious movements of the day carried his ideas into a massive fracturing of Christianity.  Much good ensued, such as Bible translations into heart languages rather than only Greek and Latin.  Much pain, warfare, and division also followed.  Having grown up Protestant, however, one hardly notices the word root is "protest".  Our narrative feels more like the true faith standing firm in the face of unreasonable opposition than like the vilified footballers taking a knee, or civil rights protestors marching through southern towns.  Can faith and protest go hand in hand?  Is is sometimes necessary, even heroic, to be fissiparous? (A word levied at our Kenyan president in an editorial this week . . and one that applies frequently to politics).

This is more than a theoretical question for the cross-cultural missionary.  How do we choose what to protest?  When do we work for slow change from within, and when do we pull out the hammer and nails and say "I cannot do otherwise, here I stand, may God help me, Amen, " to quote Luther?

Protest comes pretty naturally to me because I generally assume I'm right.  It's not lovely, but it's true.  For instance, I had to re-admit an 8 month old who caught a very bad viral croup on our ward because she sat on a bed with her mother for a MONTH due to an unpaid bill.  I'm sure that's not legal in America and I think it's probably not legal in Kenya either, but it is a very common practice.  Once someone leaves the hospital, there is not really a system to track them down for payment.  Health care in government hospitals is heavily subsidized, but very sick complicated kids can run up bills of ten or twenty or even a hundred dollars if they stay long enough, since the public hospitals are allowed to levy small charges for the food distributed to the caretaker parent, or for linens or certain tests.  The kind of desperate people who come here often have little family support or communication.  Sadly, their relatives might prefer to leave them stranded for days or weeks (or months) rather than come to their aid with money, and the longer they stay and eat, the more their bill accumulates.  It's a complicated cross-cultural catch-22 for which I am ill equipped to make solutions.  If I hand over money, then theoretically the word will spread and no one will pay (or so I have been sternly told).  If I ignore the practice, then patients sit there for dangerously long periods exposed to new diseases (not to mention the mental health impact, or the fact that they take up valuable bed space).   I used to just call and bug the social workers until they waived bills, but now a new system was announced involving charge nurses for each ward.  Oh, wait, there is a NURSING STRIKE still, and no charge nurses.  So typical me, I protested.  Which got me absolutely nowhere.  I should know by now that you don't win hearts and change minds by pushing people.  You have to come alongside, listen, find common ground, negotiate, be patient, pray.  Sigh.

On the other hand, there must be times when protest is necessary.  When a teacher at a school we were helping lead seduces a pupil, or beats one, we have definitely drawn a line . . .  but even then, I've seen that if we do it with a high and heavy hand, we drive other staff to sympathize with the perpetrator (since the illegal activities are actually culturally common), but if we spend months and years modeling a different approach, give background, allow for discussion, put responsibility in our partners' hands, eventually they come through in a way that is more effective and sustainable.

Still struggling, I guess, with the Jesus who brings true peace at a price, and the Jesus who did not hesitate to bring division too.  No easy answers in the tradition of protest.  I'm not sure Luther would be thrilled to see the state of the church today, but I suspect he would have been proud of Wilberforce protesting slavery. 

So pray for the church to have true unity in things that matter (as in John 17), and for people of faith to use discernment in working for change in ways that are generally respectful.  And that we would all know (and have courage to act) when the loving thing to do is to say:  here I stand in protest.

Friday, October 27, 2017

And In Kenya, Keep Holding that Breath

Yesterday, about half of Kenyans went to the polls.  The election that drew 80% of the electorate in August only attracted 48% (or 34% from another source) in October.  Since the almost-half who voted for Odinga in round one were enjoined to boycott, and since people are weary and cautious and losing faith in the system, that makes sense.  Naivasha was quietly normal, with more shops open than in August, more trucks moving, more patients pouring in.  It's hard to gear up for the end times twice in a quarter.  We bought some canned beans, topped up our phone charge and fuel tanks, but life goes on.  

With a vengeance, it turns out, that little notice that went out about our hospital with his handful of nurses and NO INTERNS and as far as I can tell only one out of an assigned dozen junior doctors plus Scott, me, and three clinical officer interns, being fully operational for the first time in 5 months of nursing strike . . . well that timing was a bit insane.  Scott's doing 3-4 surgeries a day and rounding on all patients and backing up a growing number of deliveries.  I've spent the rest of the week scuttling around doing vital signs and physical exams and writing notes and orders and trying to hold all the kids and babies in one piece.  I started today by drawing 15 tubes of blood and doing an LP, so I could get results by the time I finished rounds.  Between 6 and 7 pm tonight, Scott saved a mom who was near the tipping point of seizures and death from pregnancy-induced hypertension by doing a risky C-section, and I would like to hope I might have also saved a baby who came with meningitis and got stuck with only me to figure it out, get an IV, do labs, and push antibiotics.  Which was the exhausting close of an exhausting day.

And meanwhile the election is not over.  Four counties had such protest, with police firing guns and tear gas at opposition enthusiasts with their rocks and arrows and crowds and taunts, that polls could not open there yesterday.  So they get a delayed second chance tomorrow.  Meanwhile the IEBC reads tediously hour after hour the votes as they are reported.  "Shockingly" the incumbent president leads with 96% of the vote, and the opposition who withdrew announced that their supporters should resist and disobey government at all levels.  Which some did by burning down a school in a poor neighborhood of Nairobi, hurting mainly themselves.  A handful of people have died, more have been wounded.

It is, in short, a mess.

On election day, my devotional reading fell on the end of Luke 12.  Jesus says "Do you think I have come to bring peace?  No, rather, division!"  That jumped off the page, a jarring shock.  What about the "Peace on earth" message of his birth-night?  I've been thinking about that over the last two days.  As in many things true, one must grasp paradox.  Yes, Jesus' birth was an unprecedented historical foray of the Divine into human flesh which set in motion the love that conquers death, the advent of true peace.  The kind of peace that comes because evil is swallowed up, because tears are no more.  But in the near term, Jesus does not advocate for a false peace that consists of ignoring injustice and forcing everyone to just stop striving and acquiesce.  No, the very presence of goodness seemed to bring the powers and principalities to a dither of rage, a crisis of political proportions in the Roman empire and the Jewish resistance, a crisis that resulted in Jesus' death.  Even followers were divided as some longed for a power-driven top-down Kingdom of God on earth (and on through the ages of Crusaders right down to many "evangelicals" today) . . while others embraced the slow quiet dark ambiguity of a spreading movement of personal transformation leading to community.  Resurrections, in real time pointing to end-time.  Still, division persists in the age of incomplete justice, because it is the only way to stand apart from systemic evil.  But peace is coming, full restorative just peace, peace on earth.  

Praying Kenya, and Uganda and Burundi and South Sudan and Congo, and America and the world, get to see that soon.

In Memorium: Charles Mujungu

This morning we received some very sad news, that a friend of ours from Bundibugyo died during the night.  Charles Mujungu was about 19 when we met 24 years ago this month.  His father had died, his mother had returned with a fatal disease to live with her relatives, Charles had a wife and young daughter already and no way to support both his own family and the siblings his father had left behind. So a relative of his, who worked for Betty Herron, asked her to find him a job, and as the newbies in the district we were the natural choice.

24 years ago in Bundibugyo, there was no power and no running water and no indoor plumbing.  We lived in a house made of mud bricks with a tin roof and cement floor, and our major luxury was that we collected rain water from our gutters for washing and bathing.  Given the fact that we added three more kids in the first four years of living there, Charles was essential to our life.  He washed clothes, swept floors, watched kids, taught us some Lubwisi, shopped in the market, and eventually managed our household, making delectable home-made tomato sauce, baking bread, pasteurizing milk.  He held our kids' hands as they learned to walk.  We walked with him through the death of one of his brothers, and his mother, both of whom we tried to treat and ended up mourning and burying.  We went to traditional baby-naming ceremonies at his house, had his family over for many meals, and shared holiday traditions.  His wife became a Christian in our house.  We watched his kids grow, and one of his younger brothers became one of Luke's best friends.  

After we left for Kenya, Charles developed an aggressive and difficult to manage form of diabetes.  Though we visited over the last 7 years and tried to help him with medicines and encouragement, he wasted away.  These photos are from a year ago when we last saw him, in his home with his wife Oliva.  The baby Jack he once carried now dwarfed him in size.  Though Charles was only in his early 40's he seemed frail.  About five days ago we had news he had been hospitalized.  We spoke on the phone with the doctor, another dear friend who has followed in Dr. Jonah's footsteps and is now the medical superintendent of Bundibugyo Hospital.  He was personally attending to Charles, but from the photos he sent we realized that a diabetes-related infection had progressed beyond the point of healing.  Charles was too weak for an amputation, so they tried wound care and antibiotics, but he died within a few days.

Our relationship with Charles was not always perfect.  But we had a sense of true community and mutual interdependence that comes when one family (us) consists of bumbling strangers who need a lot of help and advice, and the other (Charles') consists of resilient insiders who were pummeled by poverty and disease.  When we heard this morning that he had died, I wept.  I wept to lose a person who intimately lived my children's childhood as much as any other human on earth.  I wept to lose a person I had known for 24 years for better and for worse, when by worse we mean as hard as it gets.  I wept because the world is so not fair, when a formerly vigorous man wastes away because of a disease that should be chronic not quickly fatal.  

Pray for his wife and children, for the cousins and the church and our kids and the many people who are grieving tonight.  I like the top photo, one I caught as we sat down in his home to greet him last year, with the light on his face through the open door.  This life of clay and sorrow is not a closed box, there is a door that opens into something glorious whose radiance lights our way.  

Wednesday, October 25, 2017

Kenya Elections Tomorrow

Yesterday I was in Nairobi to accompany a Serger who absolutely needed to be there for important reasons in spite of the unfortunate timing, and the juxtaposition of normal bustle with a tense inhale was palpable.  Riot police in their camo, helmets with visors, boots and clubs lingered on the corners.  But hundreds and thousands of people did what they always do:  hustling down sidewalks, in and out of banks and shops, selling newspapers, attending meetings, boarding buses.  We waited to cross a street as a brightly painted (Minion theme no less) bus pulled up with rowdy youths hanging out of the windows blowing whistles, shouting, singing, clapping, but that's all the protest we saw.  Later on the news there was a photo of the same road, near the same time, a few blocks away, where police were using tear gas to disperse demonstrators, but we had no problems. 

Which is a picture of Kenya in general.  Mostly normal life, poised for disaster.  The tense inhale means schools have shut down until January, except for seniors who take a grueling set of national exams.  People have migrated and re-sorted themselves into tribal areas of safety, piling onto matatus to go stay with grandparents.  All of the medical (doctor) interns and medical officers (like residents) have disappeared, leaving two junior clinical officer interns and a few consultants to stretch coverage for the whole hospital.  On the other hand, I saw vendors spreading their used clothes out for sale on the roadside after a rain, boda drivers hustling for passengers, construction workers hammering on a roof, welders creating and fixing something.  The poorest people stay put, and keep trying to make a day's wage for food.  Only those who have fixed salaries withdraw to places of perceived safety.

And whoever we are, we're wondering, what will happen tomorrow?

According to the electoral commission chairman Chebukati, the show must go on.  According to the Supreme Court where a last-minute appeal was filed to stop it, they wanted to hear the case but failed to get a quorum, so could not rule.  According to the main opposition candidate, he's not participating but only asking his supporters to protest and not taking responsibility if things get out of hand.  According to the police, they are ready to protect voters.  According to the drivers tasked to deliver ballots, there are already burning-tire road blocks and threats of violence in opposition stronghold areas like Migori county which will make it impossible to get the polling stations ready in time.  According to the Nairobi City Council, the gathering crowd in Uhuru park downtown who expect the opposition leader Odinga to appear and speak, have gathered illegally.  According to the supporters of the incumbent, this is a constitutionally required step and the results will be valid.  According to the watching world, that seems hard to believe.

Kenya, like America, has been increasingly polarized by power-grabbing men who play on fear to garner votes.  Kenya, like America, is overwhelmingly populated by people who love and sacrifice for their families, enjoy their relationships, work hard to get ahead in life, keep their heads down and hope to remain unscathed by this passing storm. 

Please pray for Kenya tomorrow.  I honestly can't see a clear solution.  Just ask God to show mercy to the vast silent majority and give people courage to resist the temptation to slip into violence.  Ask God to bring evil into the light.  Ask God to preserve the lives of the poor, the sick, the marginal people who just want a government that gives them justice.

someone whose life depends upon a just government supporting health care

the hospital gate, on the day of calm before the storm?

Best surprise:  even though today was a last-minute declared holiday and all our trainees had departed, my fellow consultant Pediatrician showed up and we divided and conquered the work of our usual team of 12

Intern skill #1--straight pins and paper scraps, organizing lab reports and Xray requests on the files.

Intern skill #2--when your patient who is very very sick with probably TB has still not received the medications prescribed two days ago and the nurse going off her shift shrugs that she'll sign it out to the next shift, you go find pills in outpatient pharmacy and bring them back

Intern skill #3--getting our sickest patient on her OWN oxygen concentrator instead of splitting the flow to share with a half dozen others in hopes it will help.  Pray for baby S.  I don't know if she'll make it.

Scott is in for his third emergency surgery since morning.  
All our teams have prepared to hunker down.
Thanks for standing with us.

Wednesday, October 18, 2017

The Path of Wonder, and The Path of Suffering

This quote from the book on the Trinity I am sloowwwllly reading has stuck with me for at least a week, so it's worth sharing.  The author talks about how difficult it is for us to cross over from intellectual affirmation of doctrine to grasp the mystery of "deep calls to deep" (Psalm 42), and hold onto both aspects of knowing God.  Then he says:

"I might be oversimplifying, but I think there are basically two paths that allow people to have a genuinely new experience:  the path of wonder and the path of suffering."

Wonder:  awe, admiration, reverence, beauty, marvel, astonishment, mystery.
Suffering:  distress, pain, agony, torment, grief, loss, aguish.

Paradoxically paired, these two states break us out of our struggle to control, they both put us in a place of vulnerability.  They are not opposites so much as intertwined partners, descriptors of the human state in a unfathomably vast and intricate universe that is also dangerously full of hard sharp edges.  We are small, real, loved, uncertain.  Which is often the place where we can perceive, no grasp the presence of God in newer and fuller ways.

And paradoxically paired, wonder and suffering are like two arms holding our home, two parentheses surrounding our lives.  Naivasha, Kenya, Africa are the places of wonder and suffering.  We returned 9 days ago.  The last week+ has been a blur of both.  Five days at Naivasha, two at Kijabe, one of Serge-admin-calls-followups, and one of rest.  Rounds, lectures, emails, bedside teaching, unpacking, cleaning, listening, supporting, meeting, planning.  Right back into the thick of life.

Wonder:  the pounding afternoon drenching of rainy season, the suffusion of pink in the evening sky, the cheer of neighbors and friends in spite of uncertain futures, the embrace of truly wonderful team mates and friends, the simplicity of our own home, the growth or our garden with its soft bright leaves of spinach and cilantro, the privilege of hosting overnight guests more than half our nights back already, the grace of giraffe and pelicans and eland and jacaranda.

Suffering: the three babies who succumbed to curable problems this weekend, the baby with brain-damage from a difficult delivery after his mom was turned away from private hospitals for lack of funds, the 270+ Somalis killed by terrorist bombers in their own capital Saturday just to our NE, or the 46 Afghan police officers killed and hundreds wounded in two similar attacks by their own version of terrorists targeting their own people today (about 180 km south of our 2nd Lt), the wearying reality that next week's elections will likely mean another slow-down shut-down of medical services with potentially nothing resolved, the ongoing nursing strike in Kenya, the tension of working in a dysfunctional system and knowing when to bite our tongues and when to call out evil, the holy sorrowful moment of telling a 16 year old high school student the story of John 9 because the baby she just had was born with no brain . . . wanting her to know that this is not a punishment but for the mysterious glory of God in her life.

Walking through wonder, walking through suffering.  Pray that we would walk into mystery, into knowing deeply the God who is for us, with us, and so far beyond us.

Monday, October 09, 2017

The Threshold Between Worlds

(written from the plane on Sunday) Last night, as I lay awake in the airport hotel in London, the word that came to mind was liminal.  The vague hovering outside of time and between spaces, the threshold from one thing to another where you might still be present in both, but not in either fully.  Two am in an island city, a few miles from an airport, 8 time zones from departure but still two from arrival.  A few hours of sleep having taken the edge off of exhaustion, a body confused into thinking night is day. 

And as I thought about that space that is neither here nor there, and the dis-ease of occupying it, the fading of what came before and the uncertainty of what lies ahead, I realized that the pause in travel between continents and social classes that characterizes our life parallels the space we walked with Scott’s dad over the last two weeks.  Liminal.  The threshold between the his four-score and five in once fit and then aging flesh plus once brilliant then increasingly troubled mind and his eternity as part of the new creation whose arc is ever upward.  We watched him withdraw from one and cross to the other and wish we knew what he struggled to tell us he saw or thought.  The valley of the shadow.

On a God’s-eye scale, this is more than a short walk through a low spot, this is the tale of our lives on earth.  We live in shadow, seeing through a glass darkly the outlines and reflections of glory that was, is and shall be.  

For us the transit back to Kenya carries some of the same loss as death.  Our trip to California was wrapped in weighty sadness, but not without its blessings too.  We had an unanticipated few days with two of our four kids.  We had weeks with Scott’s family.  We had Oceanside bike-rides and carrot cake and grilled salmon.  We had old photos and memories and hugs.  I feel even more acutely the departure from Julia who celebrates her 21rst birthday without us as we travel, and Luke who bravely strides into his own life calling.  The ache of the absence of Caleb and Jack looms as a darker shade in those shadows.

We recited Psalm 23 at Dave’s memorial service, a passage so familiar one can forget its power.  Our liminal life plays out in the valley of the shadow of death, but even here the poet claims to fear no evil.  It’s hard to grasp that such transitions from one world to the next, be it Earth to Heaven or California to Kenya, are the very place where God comes to set the feasting table.

A glimpse of that came a few hours before the restless 2 am thoughts.  London, neither old home nor current home, a threshold place between them, offered us an overflowing cup Saturday night.  Thanks to Serge social media we realized that one of our sister teams had planned a 5-year-anniversary celebration dinner for a church they had birthed.  At the last minute we contacted our friends and were embraced by their community.  Candleight and sparkling cider, immigrants and children and homeless people and students and artists and unlikely edge-people who had been gathered into a fellowship.  An hour of celebration and good food, slideshows and prayers.  Even in transit, the presence of God in God’s people.

Death makes me tired, tired of living apart, tired of the scattering and constant transition that the missionary life holds.  Tired of living on the threshold between worlds, never fully part of any.  Yet this is the cross.

A cross rearranged becomes a doorway.  Would you pray for us to hover there in the shadows of both worlds, and invite others to the party?