Coming Home, Take 2

You know, I'm always exhausted when it's time to go on Annual Leave. It's a lot of work sorting out the house and staff for other Americans to live in my house when I'm gone. I pack away the most valuable items, organize closets and shelves so there is room for another family's stuff, train my workers on new duties heretofore unlearned, try to get hospital maintenance to fix some of the broken items in the house (with a 1:5 success rate), move furniture around, stow away carpets since it will soon be the rainy season, pack our stuff, visit with our friends who want to say good bye, and clean a big concrete house. Btw, I will never own a concrete house.

The flight over the Atlantic Ocean was very bumpy. Usually that scares me a lot, but this time it didn't. It just felt like the Makwasa road, the road we have to drive when we want to go to the nearest city an hour and a half away. Truth be told, it was gentler than the road, because even though there were sudden movements, there was no jarring impact such as the potholes give a person. 

The children did great on the airplane. No vomiting this time. When Abigail fell asleep, I immediately noticed that her pants legs were pulled up. Tensing, I reached over to pull them down, but then stopped and relaxed. "There are no mosquitoes on the airplane to bite her," I reassured myself. That happened twice. It has become reflexive to always think of protecting the children from mosquitoes and malaria.

On the 16 hour flight from Johannesburg to Atlanta, usually the flight attendants become noticeably irritable with the passengers. This time they were all courteous the entire time. At the end of the flight, they took donations for breast cancer research. As we touched down into Atlanta. I started crying. I was trying to hold back, but I felt like having a good bawl session. This confused me. I stood up and stupidly went to tell the flight attendants that I appreciated how courteous they were during the long flight, and this is what happened. "I just want to thank you...sniff sniff...for how kind you all were...sniff, sniff, wipe tears...during that long flight. That was the first time...sniff, sniff, boo hoo..." A stewardess interrupted me, "Are you okay?" "Well, I'm feeling emotional," I wailed as she nodded and walked away. 

There were no car seats on the Super Shuttle, but the roads are so much more orderly here, and the shuttle so big... .

When we arrived home, the same home in which my children first lived, Abigail said, "I like this home better than the Malawi home. It's cleaner. And if I hit my head on this wood floor, it won't hurt me like the floor in Malawi does." This is the same little girl who, upon arrival in this home last year, said, "Dis not my home! My home Mawawi!"

Jedidah wanted to take a walk at 1:00 a.m. and I tensed before I remembered that I don't have to spray him first or say no. There are almost no mosquitoes here and definitely no malaria. Relaxing, I replied, "That sounds fun!"

A calorie conscious friend (that I love dearly) came over, and I don't know if any of you missionaries can relate to this, but I just wanted to give myself three or four days to eat freely, whatever I want! There is so much tasty food, so easily available, that is so much easier to prepare. I bought prewashed salad and carrots! I didn't have to haggle about the price of my avocados! My children begged for Taco Bell, and one day I bought it, but my friend was here when we arrived home so we didn't get to eat it. Then she and her children ate it! 

They ate my Taco Bell! 

They ate my watermelon! 

We have waited all year for good watermelon! Her children eat it nearly daily because they live in Southern California. I told her that we daydream all year for good watermelon, and that it was the only one we have purchased and just chilled, but it fell on deaf ears. That was hard for me, but good for me. We can buy more watermelon, and it is good to share even when we were not planning to...but I must say that a missionary salary is not extravagant! And when we come from a land of many limits to the land of freedom and plenty, there are a lot of expectations and many things we look forward to:

Like wearing pants!

Like dressing my children in white!

Like being able to throw away my ziplock bags!

Like having a real garbage can and garbage bags!

Like having a dryer to shrink our clothes back into shape!

Like having a shower!

Like the convenience of driving a few minutes on a good road with a car the works properly to a clean store that accepts credit cards when I need or want something today!

Like having no cockroaches in the house!

Like not having the stress of revolving the house cleaning around keeping cockroaches and mold out of the house!

Like being in my house without being asked for something 20-50 times a day!

Like having a chance to play crafts with my children!

Like crisp, sweet, juicy watermelon!!!

Today I enjoyed the deliciousness of just staying at home. No one has interrupted me once. The house and laundry are so easy to keep clean, food is so simple to prepare. The electricity and water work every time I need to cook or wash dishes or bathe children. I made crafts with my little ones for two hours and peacefully cuddled them when they fell asleep. And now I've had an hour to write about it!

Life seems so simple here.

I hope you appreciate what you have. It's not that way everywhere.

And maybe tomorrow we'll buy a Taco Bell bean burrito fresco again, and see who else we can share it with.

Surprise

Sometimes my job takes me by surprise. Like the time we were delivering twins and found
triplets. How those three triplets all weighing less than 3 lbs in the harsh African conditions
survived, and how just last week their mother and grandma “agogo” visited us at our house
looking very healthy and fat at 13 months of age. I really liked that surprise, and look forward to
surprises like that.

Unfortunately, not all surprises in my job are good. The other day I was called to see a little
18 month old baby who was struggling to breathe. His bed looked extra large next to his
small body with his mother snuggled next to him. Mom was quiet and sweet as almost every
Malawian mother I have met watching over their precious charge. The baby while not wasted
appeared chronically ill. It was not very surprising to find out that this child had HIV, and was
likely struggling with pulmonary tuberculosis. I wish it were surprising; it's not.

Another surprise is that in Malawi, there is a medical record system that is much more efficient
than in most developed countries like the United States where I come from. Patients carry with
them a health passport. It is a small book -- about the size of a real passport -- and serves as
a repository of all pertinent medical information. In one or two minutes you can review the sum
total of an individual’s interface with the health care system. I asked to see the mother’s health
passport book, knowing it would have more information. That is where I found what I did not
expect.

It seemed she had been diagnosed with HIV after she had delivered her child, and therefore
had not been put on treatment to prevent transmission to her child. In Malawi, there has been
a lot of effort to prevent congenital transmission of HIV from mothers to children by universal
HIV testing and treatment during pregnancy. Through national efforts, the rate of perinatal
transmission has dropped from 25-30% to less than 5%. Consistent with the African trend of
improved outcomes for people living with HIV/AIDS, these statistics give me hope that one day
this scourge will abate.

Unfortunately, my little patient and his mother missed out on all this. I continued reading the
story -- six months ago this quiet sweet 28 year-old mother of three had been diagnosed with
stage 4 inoperable cervical cancer. She would not have long to raise her children.

I have become a little bit “tough” after working in an environment where bad outcomes are more
common than we would like, but that caught me off guard. How in a short time this nursing
mother would be taken from her family by the sadistic synergism of two preventable diseases.
How her last to be born son was also suffering from a deadly combination of preventable
infectious disease. How if he were to survive this illness, for the rest of his life he will deal with
the stigma and consequences of having congenital HIV, and to face it all without that comfort
God has graciously given to little boys who deal with injustice...

I don’t think about all this when I see patients -- it would incapacitate me from a healthcare
professional to what I am right now -- emotions and tears. But the fact that I don’t think about it
doesn’t mean that it is not everyday life for these dear people. They are mothers and children
first, and patients last. I take off my white coat at the end of the day, they suffer. This story has
been repeated time and again in our villages.

Cervical cancer is the leading cause of cancer related death in Malawi. It is a sinister disease
that attacks women in their prime of motherhood. The pathogenicity and course of HPV (the
cervical cancer causing virus) in HIV is accelerated, and a cancer that would ordinarily take
decades to progress to a life-threatening disease, only take a few years or less. It is because
of this that our hospital has targeted cervical cancer as a top priority for prevention. Through a
simple screening technique called a pap smear, the rates of cervical cancer have been cut by
over 80% in developed countries. Malamulo Hospital is one of the only places in Malawi where
a pap smear program has been developed. With the help of Loma Linda University, the PAPS
International Team, the Coto Family, and the leadership of our previous Medical Director, Dr.
Cristy Shank, and our dedicated Malamulo staff we have to date screened almost 3000 women.

We have treated over 100 early cancers with minimally--invasive surgical procedures, and over
30 women have had a life-saving hysterectomy provided free-of-charge by our Surgeon Ryan
Hayton. Through what has been done in the last two years at our Women’s Health Center we
have saved over 125 mothers’ lives. How surprising is that?

The reality is that Malawi is a country of over 16 million with no fewer women than men. What
we have done is only little, and we would like to do more. We need to increase our capacity for
screening and treating women with early cancers. We need to train more cytotechnologists to
read the pap smears, and we need more supplies and equipment.

If you would like to partner with us, please pray for our work. We have given our work into
God’s hands, and we are dependent upon Him as He leads us forward. He knows no haste nor
delay or surprises, and we have seen His hand moving us forward.

“For we are God’s handiwork, created in Christ Jesus to do good works, which God prepared in
advance for us to do.” Ephesians 2:10.

If you would like to partner with us by giving, we request you do so by making your contribution through Adventist Health International with a note that you would like it to go to the “MALAMULO CERVICAL CANCER” project. Their website can be accessed at the following address: http://www.ahiglobal.org/main/main/

Today

Jamie took the children outside this morning to transplant tomatoes in the rain. Abigail came in first, covered in mud. I changed her into clean clothes. After two bowls of oatmeal with raisins and two Big Franks with ketchup, she was satisfied. The men came in and ate while wearing their muddy clothes. I washed the dishes in a tiny bowl of water, so they didn't feel really clean, and that made me feel a little grumpy. But then I was happy that we had water at all. I swept the floor.

"Baa, baa, baa, baa." Mama Sheep was bleating and stomping. It was a good day, because Jamie was home to take care of them this time! "You better go check on Mama Sheep!" I said. "She doesn't bleat like that unless there's something wrong."

He walked to the ewe, then ran away from her and then ran back to her. The next thing I saw was Jamie running, followed by three sheep! More ants! He planned for the sheep to run behind him to the backyard, but they had different thoughts. Spying the ripe papaya sitting on the front step that Jamie had picked that morning, they turned and started happily munching! When Jamie ran back from the backyard, there they were! He chased them away only to return to find the chickens claiming their share! Before they departed the front step, they left a deposit.

After putting Abigail to nap, I heard, "Cluck, cluck, cluck." Three hens were sitting in my dining room chairs! Grabbing a broom I shooed them outdoors and quickly disinfected the chairs and swept the floor.

Abigail awoke, and after she ate, three more hens ran into our house, with Jedidiah and Ellie the German Shepherd giving chase. Two went back outside, but the third one took off down the hallway, right into the children's room! She ran over all of my children's scattered toys and perched on top of their wooden kitchen. When I took her outside, there was Abigail, jumping in huge muddy puddles. I called her in and changed her clothes, again. And swept the floor.

Thankfully the water was flowing by that time and I began disinfecting toys. Then Jedidiah and his oversized puppy ran inside. Chunks of soil covered the floor and muddy paw prints marked a line to the dog food. Again, I swept the floor. The children took their baths.

Then Jamie came in, and the mud was from man-sized shoes and pants that time. I swept the floor. They ate supper while I sank into a chair with a headache.

Sometimes I just want to feel clean.

Our yard today

Welcome Back!

“Doctor, there is a patient in Maternity”.

It had been a good day of administrative discussions. As part of becoming the new Medical Director, I had spent the day catching up on the hospital business. We had wrapped up nicely by 5 pm. I had told my wife that I would be “home by 5:15”. She was obviously looking forward to it. 

“She is in labor, but the baby has no heartbeat”.

After the talks I decided to wander over to the Medical Ward as I had heard it was a “very busy day”. I hesitated as I thought about 5:15, but only being back in the hospital for a day, I thought I should at least show up to support our busy troops. I arrived to see a flurry of activity with our staff admitting, triaging, and treating multiple severely ill patients all at once. Our Clinical Officer was waving admission papers in his hand feeling the pull of multiple emergencies at once. A 29 year-old patient with hypoglycemia and alcohol intoxication had just pulled out his IV, and was about to seize and aspirate. He died a few hours later. 

“She is fully dilated, but having a lot of pain. The baby is not coming down”.

This story wasn’t sounding good. I looked around for a qualified delegate, but realized all hands on deck were busy. I reluctantly said goodbye to 5:15, and we went to see her together.

She was tired and pale. Her heart rate was fast, and blood pressure was low. She was tender in the middle of her abdomen, and while fully dilated, the baby was not coming. We discussed her. “Doctor, she is having strong contractions, if her uterus had ruptured, there would be no contractions”. That sounded reasonable, but something didn't make sense.

Uterine Rupture is one of the most feared complications of childbirth. It is also a leading cause of pregnancy-related death in Malawi. The most common risk factor is a previous Caesarian Section (which our patient had several years earlier).

I did an Ultrasound of the uterus. While I’m no expert at ultrasound scans, it seemed there was free blood in the abdomen. She needed a surgery.

In the Operating Theatre, her condition deteriorated. Heart rate going up, blood pressure going down; she was starting to get confused. Pulse 150. My pulse close to 150. We commenced the operation with a prayer for help. Blood gushed from the abdomen. The small rupture in her uterus had bled two liters into her abdominal cavity. An average human being has 5 liters of blood in their body. With the additional blood loss of surgery, she had lost at least 50% of her blood. We had 200 mls of blood available for transfusion (about half a pint). We started to give it. We removed the baby -- a perfect lifeless baby -- and proceeded to sew the uterus back together. Our Clinical Officer, Mikson, performed the surgery with skill far beyond his training. Jaqueline Uy, a Loma Linda University Family and Preventive Medicine Resident calmly assisted him in the procedure. I watched with admiration as the international team work to save a mother’s life.

Fortunately, we had the equipment to perform an autotransfusion of another 700 mLs of blood we could salvage from what she had lost.

The bleeding was arrested, her vital signs gradually improved. After thanking the team and ensuring she would be closely monitored all night, I started to head home a little after 8 o’clock. Her life hanging in the balance.

“5:15?”.

“I’m sorry”.

“You weren’t on call”.

Most developed countries have a maternal mortality rate of 20 maternal deaths per 100,000 live births or less. In Malawi the number is hard to know for sure, but is between 400-600. Easily 20-30 times higher than in the United States (which is far from the best in the world).

My children were energetically going to bed when I got home. “I was taking care of a mommy whose baby died”. I couldn’t help but notice how energetic and healthy they looked tonight. Jedidiah had lots of six year-old questions about how that was possible, and what we did about it. Abigail, our spunky two-year old, just got upset. “The mommy should have her baby. I want to pray for her.” She proceeded as only a sensitive angry two year-old could, “Dear Jesus, please help the Mommy that doesn’t have her baby. I don’t like that.  Amen”.

Hug your babies tonight; hug your mommies tonight. If you live in a country with good healthcare, thank God for it, and remember those who don't.

Ready to Return

It's time to go back.
Time to go back to...

fog that mysteriously rolls across the ground seconds before the sound of rain
squawing turacos in the brilliant orange flamboyant trees
chattering monkeys perched in the blue gum forests which rise like sentries amid rolling tea fields
chitenge clad women carrying baskets atop their heads with babies tied on their backs laughing together
the bleating response of goats to the goatherd's waved stick
rainy season's odor of decaying masuku fertilizing the tree from whence it grew
roller coaster pot-holed muddy roads
mournful wailing passing my house as another villager closes his eyes for the last time
jealousy and greed and entitled demands
missionary strife and discord
a battle that is more than flesh and blood

Thirty Something

I am thirty something.  We are an interesting group.  Most of us have moved from studying to working.  We are building our castles;  securing our posts.  Being fruitful and multiplying.  We are moving up the ladder, consuming anything that gets in our way.  

I’ve been told this is the age of competition--we are trying to prove to the world that we really do have what it takes.  Alexander the Great conquered the world by thirty something, Jesus of Nazareth conquered the cosmos by thirty something.  It can be a powerful time, but what am I doing?

I’m driving a borrowed minivan that has a squeaky belt, and when I pull up to church or the drive-thru I feel like I’m “barely squeakin’ by.”  Maybe its because I’ve gone to school for 24 years and my liabilities are still more than my assets.  Maybe its because I am really not sure where home is anymore, or if I have one...

“Store up for yourselves treasure in heaven… .”  Matthew 6:20

Growing up American, I have acquired an interest in the “American Dream”.  Its sort of natural, I suppose, and being thirty something, I should be well on my way.  I don’t need a mansion or a fancy car, but a comfortable house with lots of land in a safe neighborhood would be nice.  My family wants to be comfortable and safe.  

I’m not sure if it was the comfortable part or the safe part that led us to decide to work at a rural hospital in a developing country, but it didn’t really work out that way.  We had things stolen on multiple occasions.  We found a thief in our garage.  We had spotty water, a shocking stove, and a constant dribble out of our shower head.  My work consumed me in an often losing battle with suffering and death for which I spent most of my time feeling incompetent.  We didn’t feel comfortable, and my family didn’t feel safe.

We returned to the United States from our rookie year a bit disheveled in spirit.  The warm shower was so luxurious, and we reveled in a trip to Costco.  Its amazing how a short time in a different environment can make what used to be normal seem luxurious.  It felt so comfortable and safe.

Then a shadow blew over our path that led us to the doctor and a diagnosis which we did not want.  In a moment the troubles of life abroad paled in comparison with the reminder that our days on this earth are numbered.  My plans and possessions were all placed on the bargaining table.  All of my material worth was rubbish in my eyes next to the continued presence of my wife.  

“And this is eternal life, that they might know You, the only true God, and Jesus Christ whom you have sent.”  John 17:3

I used to think that heaven was a beautiful place.  I used to think I was somehow supposed to invest in heavenly commodities instead of the stuff of earth.  To use my earthly money to be “rich” toward God.  To “buy” heavenly stock with US dollars.  Unfortunately, my concrete materialism did not help me understand the treasure of heaven.  

“Thou shalt love the Lord thy God with all thy heart, and with all thy soul and with all thy mind, and thou shalt love thy neighbor as thyself.”  Matt 22:37

I have come to see heavenly treasure as relationships.  First and foremost living in love with God, and secondly our neighbors.  When this law is realized in us, we have crossed over from death to eternal life, and we are storing up treasure in heaven.  The goodness of God leads us to love others, and we make huge deposits into our heavenly account.  

As I sit here feeling a bit of a thirty something year old failure, its hard for me to ignore that the American dream kills heavenly treasure.  I think it must have been upright and conscientious leaders in Jesus’ day who for their safety and comfort killed the King on a cross of shame.  He gave up His comfort, safety, and so much more because He was the sum of heavenly treasure. He came to live an immaterial life to build a personal and eternal relationship with every willing human being, and to convince thirty something year olds that we can trust Him instead of money, or other worthless things.  Baal and Molech didn’t save many Israelites, and trusting money won’t save a single soul in post-modern America.  If the status of my bank account or portfolio means more in my life than a meaningful relationship with God, I am bowing low to the golden calf.  

As Jesus is the sum of heavenly treasure, my relationships are a share.  Investing in my wife and children with time and love is the most tangible way to invest in heavenly treasure.  I hope 2014 finds this thirty something year old male investing in God and family.  I hope 2014 finds the false security of materialism dethroned, and the King rightfully exalted in the lives of thirty something year olds all over the world.