Sudan Mission Trip: A meningitis post by Dr. Clarke

Thursday, July 14, 2011

A meningitis post by Dr. Clarke

8 July, 2011

This was a “meningitis” day. About 2.5 months ago we started having a series of cases of meningitis, or at least what we called meningitis based on our most educated guess. We diagnosed a case, then Across in Adol diagnosed three cases, then we had several more. At the Ministry of Health meeting in April we told of our findings and we also heard from Yirol that they had made definitive diagnosis of N. Meningococcus meningitis in three cases. We had 6 by that stage. In 2007 N. Meningococcus caused an epidemic across Sudan that left thousands dead, including some very close to the Akot family. The conventional wisdom is that the epidemics come every three to four years. I felt we were on the cusp of another epidemic. Our case number eventually rose to 15, but we have not had another case in several weeks, making it look to me like an aborted epidemic.

As evidence of a possible epidemic increased, I sent word out for prayer and for intervention. I think we got a good deal of both. God turned back the pestilence He sent against Israel at the pleading of David (II Sam 24), and I believe and will continue to believe that God spared us this epidemic because of the prayers on our behalf. Two specific things I asked for as the epidemic loomed were the Meningococcal vaccine and a counting chamber so that we could make a definite diagnosis of meningitis. A recent team from St. James Church in Richmond got us both, and today we used them both. We had a child come in obtunded with backwards (opisthotonic) posturing. He had a large spleen and was test (+) for malaria, but he had not responded as well as we would have liked by last night, so Elijah started him on Ceftriaxone. I felt this was a good time to get a more definitive diagnosis. The father agreed to a lumbar puncture (spinal tap), so I did it. I have done many, but not for several years, and my holder was inexperienced, and the child was 5 years old, so I sedated with ketamine. The procedure went well and there were no cells, so we could feel good about stopping the Ceftriaxone and continuing the Quinine.

Almost immediately after that, I traveled to Atiaba with Mary Agum to vaccinate the Hope and Resurrection School against Meningococcus. Though we were leaving after the

time I told Marcelina to expect us, I tried to think through all the things we would need. I got the vaccine and the diluent. We have a cold box for transporting the vaccines and I got that. I got the syringes for giving the vaccine and the cotton soaked in methylated spirits to clean the skin before administration. But once we got there, we realized two important items I had forgotten: larger syringes to mix the vaccine and a sharps container for the used syringes and needles. We got around the first by opening the vaccine bottles with a knife and pouring the diluent into the powdered vaccine.

The day actually went well with no real problems, but a few surprises. The biggest surprise to me was the amount of fear the injections caused, even among the boys. I have spoken about the bang, the state of nirvana or disassociation that these young boys go into as the one who administers the cuts walks around the circle sharpening his blade and looking for any signs of fear. I could never go through that ritual, and there was a time in my life when I hated shots about like these men did, but I was surprised at not only their fear, but also the fact that they were not embarrassed to show the fear in front of the girls. At that stage of my life I still was not fond of needles, but I would have more successfully hidden my fears if there were female classmates around. Several times I joked that I would have to get Mary Agum wielding the knife and killing any who showed fear. Strange, but they did not seem to enjoy the joke as much as I did. Overall it went well. Because of the unrest in the area, many of the students were not there. I have not decided if we will offer a make-up day for those students. I was pleased, however, when members of the community of Atiaba were asking if we were going to offer the vaccine to them. I told them our basic strategy is to get the schools in the area first, then open it up to the people in Akot, and then Atiaba would probably be our next stop. They were pleased with that approach.

As a child of South Carolina, I have always sympathized with governors faced with making the call for forced evacuation of the coast as a hurricane approaches. There will always be those who criticize you, particularly if you call for an evacuation and the storm is not as severe as predicted. That is how I have felt with this “epidemic.” I am glad to be wrong. I do not want hundreds dying. Fortunately, the vaccine is good. Everyone who receives it should be protected for the next 10 years or so, and possibly for life. What if there is never another epidemic? Well, it would be a great blessing to Africa if those epidemics quit, but there is nothing to give us that kind of confidence. If what I have been told is true, that the epidemics occur only during the dry season, then the onset of the rains may have ended or greatly diminished the epidemic. If that is the case, there is a good chance the epidemic may reappear when the rains cease. So it may well be that what we have had was some advanced warnings of troubles to come, and so vaccinating the school aged children is still doing is good, even if not so pressingly urgent as I once thought.

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Dr. Clarke Macintosh's Journal

Rakchok

1 June 2011

Today I drove back to Rumbek to pick up a visiting team. We are glad to have visiting teams come in. First of all, they have traveled a great distance at a great expense to do something for the people of this area that probably coincides with some of our aims, if not directly with our goals. We know that the needs of this area far exceed what we can do, so it is good to have our brothers and sisters in Christ come along beside us to do some of the work. But this team I particularly wanted to meet because they were some of the “old timers” (those who had been doing something in Akot before me) whom I had not met. Darryl and Jennifer Ernst were the driving force behind the start of Hope and Resurrection (H&R) Secondary School in Atiaba. I was excited to meet them because they had the vision and drive to set up a secondary school in our area, and the fruit of their vision is coming forth. This year, H&R will graduate its first class. More than that, however, H&R is already being talked about as possibly the finest secondary school in the Lakes State. On a more personal note, all the hospital staff who know Darryl and Jennifer had always spoken of them in very complimentary terms, so I was looking forward to meeting them. As par for the course, the leaving this morning was difficult. We had our heaviest rain of the season last night, thereby cancelling devotions, so I decided to make rounds before starting out for Atiaba. But as I was making rounds, the requests started rolling in. This sister needed to be taken to Rumbek. Civicon had a truck that quit functioning and needed us to tow them to their headquarters. So by the time I got on the road, it was later than I intended. Also the rains took their toll on the road, so going was slow. Though from a crops standpoint the rains have just started, from the perspective of the roads, it appears that the rains have been established for months. Already, whatever scraping they did from Malek-agok to Rumbek has lost any benefit. The potholes may not be quite as deep as they were, but they are plentiful and are expanding and deepening rapidly. By mid-July it will be a complete mess. And I was transporting some patients to Rumbek (patients recently diagnosed as HIV (+) and going to start therapy), so there were some stops for them and other delays. We arrived shortly before noon, but I needed to get some funds out of the bank, so that delayed us another 45 minutes. Finally the last passengers had exited and I was alone, headed to the airport. I ran by Dalbit to see if any diesel fuel had arrived. No. Disappointing, but no tragedy. We have some barrels at the hospital, so we will have to use our stores until the next shipment arrives. So I hustled to the airport where the ALS staff informed me that the plane would arrive shortly.

There is utility to the little signs at the airport, but I had not made one. I sent an email telling Jennifer to look for me in my tan cowboy hat, but I think she did not get it until after her arrival here. I stood as conspicuously as I could, hat perched appropriately, but no group joined me. Therefore I took the initiative. There were many kawajas on that flight, but my eyes fell upon a likely group and I approached them. Fortunately Jennifer had seen my picture and the connection was made. Airports are always a hassle, and one curve they throw in Sudan is to charge an airport entry fee (in addition to your fees for your travel visa). The charge is 84 NSP (New Sudanese Pounds). They will allow you to use American, but the rate of exchange they give you is far from market value, so it is always better to have pounds. Of course, there are no places to exchange money in two the Sudanese airports I have visited, so my stash was all the more valuable. We went into the market, exchanged some money, bought a few items and returned home. We had discussed whether we would stop at a couple of places, including H&R, but it was still unclear to me (the one in the lead) what our plans were for the school. The plans were soon made evident. About 3 kilometers from the school we spotted a gathering in what looked to be the H&R school uniforms. As we neared, they struck into song. As one group finished, another began. For 15 minutes I-40 was blocked (well the one car that came during that time eased around the students) as they celebrated the return of their benefactors. We piled out, searched for cameras, and basked in their rejoicing. After the hit parade, we headed back to the school. Our celebrants had to walk behind us, but they did it without dampening their spirits. They arrived at the school, dancing and singing and celebrating again. There is real appreciation in the gift of Hope and Resurrection Secondary School. The teachers rehearsed this with the students, but the students feigned nothing. Their heart-felt rejoicing was evident to all and I rejoiced to share the moment with them.

2 June 2011 I had seen this mother before and knew her to be a bad asthmatic. She came to me with her two children. The first was the younger. According to the mother, she was 6 months old, but the child weighed less than 5 kg (11 lbs). The mother is quite small, less than 5 feet, but this child was too small for genetics to be the answer. She had a history of chronic cough that worsened with breast feeding. The head was disproportionately large compared to the body and the fontanel (soft spot) was as opened as a 1 month old. That suggested serious malnutrition. Her chest was full of wheezes and crackles that improved but did not go away with inhalers. My diagnoses were asthma and gastroesophageal reflux disease (GERD) and I started some appropriate medications. But I was also convinced there was some degree of starvation in this picture, I also wanted the mother to add medida (porridge) to the child’s diet both to help with the reflux and to get some calories into this child. The older sister had much the same story. She, too, coughed all night and was worse after eating, and her diagnoses were the same. She was small, but not as tiny as the sister. The problem with my plans was that the mother had no medida. She had no flour. She had no food. Indeed, her milk supply had begun to dwindle because of her poor diet. The husband was around, but had no means of helping her. The mother had already been seen by James, but seemed to be having some significant breathing problems. When I looked at her “book,” I did not think the problems had received the attention necessary, so I examined her myself. She had diffuse wheezes and crackles that improved marginally with inhalers. That actually gave me an opening. I admitted the mother to receive appropriate medical therapy, but also to get some nutritional support for her and her children from the hospital.

My larger concern is how often this same story is being repeated. This woman is not starving; the children are not yet ready for posters for save the children, but they are all very hungry with few options. Moreover, the medications will be far less effective because this woman cannot follow my advice of adding porridge to the child’s diet, thus improving the nutrition and reducing the reflux. Both of the children are likely to die if they contract malaria, much less meningitis. In reality, it is impossible to address the medical needs of South Sudan without simultaneously helping them nutritionally.

South Sudan is a fertile land with a favorable climate. If the separation goes smoothly and South Sudan builds some infrastructure and there is appropriate development, South Sudan could become the “bread basket” of Africa. But that is a long way off, and the rains are late this year. The suffering is already started and will be intense before the ground nuts are harvested (3 months away). And if we do not get the seeds for the fast growing (3 month) sorghum, we are going to be facing some bad times this winter. Think of this family and pray for South Sudan.

3 June 2011

We were finishing clinic when a man forced his way in and told Rose, “My wife is bleeding in Makur-agaar.” They had been footing from Atiriu, about 15-20 kilometers away, but she suddenly bled a lot more and could not go any farther, so he was sent for help. I could tell from his looks and his description that the case needed immediate attention. So I left Dr. Rosy to see the remainder of the patients and I went to get the LandCruiser. I did force myself to think. A bleeding woman probably means either delivery or an abortion, so I grabbed our TBA (traditional birth attendant) kit. I also thought that she might be in shock, so I grabbed some Ringer’s Lactate and a couple of IV catheters. I passed several would be hitch-hikers that I might have ordinarily picked up, because I felt the urgency of the case, though Mary Aleck, one of our TBA’s managed to flag me down and catch a ride. Before we got to the area I consider Makur-agaar, the husband pointed me over to a group alongside the road. There were several people there, but none look like ER material, but then someone pointed out the patient. She was stretched out under a Nima tree wrapped in blood stained garments. The temperature had to be over 110, but she was cold and clammy. Her pulse was 150 and though she was not completely out of it, she was not very interactive. She had massive clots between her legs. It looked like an abortion (i.e. miscarriage, not anything induced); clearly she was in shock. I got Mary Aleck to hang the IV fluid in Nima tree and I ran in a catheter in her right arm. I do not know if it was the pain or the fluid, but after only a few hundred milliliters she was somewhat revived and able to be assisted into the car. We put her in the back with the fluids hung from the ceiling. Bumpy roads are a nuisance in South Sudan. Dr. Rosy virtually refuses to get into the car because of the toll the bumps take on his back. But when you speak of an acute abdomen or an evolving abortion, the pain can literally kill you. Despite the IV fluid bottle swinging wildly overhead and the swerves necessary to avoid the already treacherous mud holes, the patient lived through that ordeal as well. We transferred her to a bed and opened up the fluids. Her blood pressure at that point was 92/54. I found a gown and her mother cleaned the blood from her. After the second liter of Ringers, she was coherent and had urinated.

Shock is where the intravascular volume is insufficient to perfuse vital organs. There are several mechanisms by which this can occur, though for our patient, it was the blood loss of the abortion that caused the problem. The diagnosis of shock is usually obvious. The treatment of shock is not cutting edge. It does not require great knowledge or skill. But it does save lives. You do not have to be brilliant to do the work here in South Sudan, but the work is important and it does save and change lives. I know that others could do it just as well as me, but I feel privileged to be a part of the work.

4 June 2011

It was shaping up to be a typical Saturday. After rounds, a friend said I needed to see his wife, leading to a dozen or so “walk-ins,” including two abscesses, one of the hand and one of the foot. I successfully avoided a couple of people who claimed to remember promises that I almost certainly did not make, but then the children of Gabriel Amat came to me. Helena Ding, Gabriel’s wife, needed me to take her to Makauc to get her sorghum and millet. That was a semi-promise (meaning I will if I can) I did make and it was time for me to fill it. So I gathered my things and started out. When I reached the house, she was not ready to go, but let me be fair there. For two weeks she had held onto the semi-promise with no fruit to show. It took about 20-30 minutes to get ready, and by that time Gabriel had joined us and we set off. We first went to Gabriel’s house in Makuac to gather some utensils and weather-proof sheets. While there, I was served lulus by a few different people. I like lulus and I ate half a dozen, but you can get too much of a good thing and I started declining. Then we traveled a short distance to a neighboring tukul. I got the impression that the tukul belonged to a monydit who was family, but I was never clear on the subject. Both of the tukuls were the two level variety, and this time the women took the sheets and went inside the large storage bin upstairs. Soon they emerged dragging the sheet full of sorghum. Sorghum looks like something out of a dried flower arrangement. It is a stalk usually broken off at 3/4^th foot and hundreds of bb-sized white/brown/red balls cover it. The grain is beaten off with the first few strokes of their pounding when it is time to eat it, but until then it remains on the stalk. I am a bit slow on the uptake at times, so when they pulled the sheet of sorghum to us, I thought we would lift it and place it in the pickup bed. Wrong. We dumped the sorghum into the bed and returned the sheet. The next grain in the sheet was millet. Millet reminds me of corn without shucks and with severely undeveloped kernels. We were starting to get an idea of the appropriate technique of transfer from second level to pickup bed. There were several sheets of millet to transfer, and we were on the last when Helena Ding came down. A large scorpion stung her on the foot. I saw in her the evolution of the pain I felt when I was the recipient. She seemed rather matter of fact when she came down, but within a few minutes, she was showing more anguish. One of those with us tied a ribbon of cloth about her leg and Gabriel got a bit of diesel fuel on a stick to apply, though I saw no relief in Helena’s body language. We had virtually an entire pickup bed of grains when we finished, and we tied the sheet over them before leaving, because it looked and felt like rain was imminent. But what dominated the trip home was concern for Helena. She was a picture of writhing agony. There was no position of comfort, and periodically she would get stiff and then deflate, but there was no relief. We passed their home and drove straight to the hospital. I injected 5 ml of Lidocaine 2% into the tissues around the sting and went off to complete a few necessities before taking her home. When I returned, her agony was still evident. This time I injected 10 ml of half Lidocaine (fast acting) and half Bupivacaine, a longer lasting local anesthetic. We drove to the tukul, transferred the grains to their new storage facility (Helena’s tukul) and left. Helena was still in pain, so I got some meds to her through Gabriel and I hope she will recover quickly.

Any way you look at it, it is tough being a Dinka. Gabriel and his family are more fortunate than most. They appear to have great food stores and relatively comfortable homes. But they needed help to get the food where they could use it, and scorpions are always ready to rain on any parade. Yes, they do seek our help (read handouts) and they are wasteful, but they rarely are discouraged, despite the odds arrayed against them. I admire their courage and resilience.

5 June 2011

I was sending some overdue messages to headquarters when Daniel Ayuik asked me to step out. “There is an obstetrical emergency in Makur-agaar and they need your help.” I have learned some skepticism about the wolf calls, but OB is different. I know that far too many babies are delivered at home with tragic outcomes, and I know OB is an area where a few minutes really matters, so I quickly gathered what I needed and headed out. Daniel and the man who had come to get me were in the front seat. Before I left, Isaac Mayen warned me, “I hear the road to Makur-agaar is really bad right now.” I was prepared for that. The rainy season is officially upon us. The roads were already bad, but the last two days have seen torrential rains. To add to the tension, the winch on the LandCruiser does not work, so if I get stuck, I will be digging myself out. And the sun was rapidly setting, so I was dependent on headlights to give me a sufficient view of the situation and decide which alternative looks less treacherous. Several times I had to leave the road because the lake before me looked impassable, but such treks also have their dangers. The first time I ever got stuck I was swinging wide to avoid such puddles only to find soft mud and a sink hole, so I no longer consider swings onto the “shoulders” an easy alternative. A couple of times I stopped to try to get a better appraisal of the side, trying to avoid the side where the ground looked more like the “slough of despond” (Pilgrim’s Progress, John Bunyan). I was in 4-wheel drive the entire trip, something I rarely do, but I thought the roads warranted the precaution. We arrived intact. I was greeted with the news that the baby had just died. I hurried into the tukul. Dusk had ended and it was dark: the only light was a torch. Mother was like the usual Dinka mother in tukul births I have attended: squatting, a blue strip of cloth tied around her waist kept her from being completely naked. She was in no distress, but was dejected. I asked to see the baby and made the mistake of putting my stethoscope on the child’s chest. The heart was still beating. The heart was slow and the remainder of the child’s body lifeless, but the child was not dead. So I stretched out over this mother and started doing mouth-to-mouth resuscitation on this child. And the heart responded. The heart rate quickly rose to 150, but there was no visible change. I vigorously dried the child. I slapped his heels and rubbed his back. Nothing. I quickly returned to the mouth to mouth. The sight must have been ludicrous. It was certainly gross, and I am not a “nasty-nice.” I am kneeling on a dirty, blood smeared sheet, leaning across a naked lady doing mouth to mouth resuscitation on this limp, rag-doll like child that everyone else in the tukul has pronounced dead. I would give a series of breaths, stimulate the child, and listen to the heart. The heart was beating well, but there was no other sign of life. Daniel Ayuik said, “Doctor, I think,” but I cut him off. “You do not know anything and neither do I” I yelled back at him, frustrated that this child would not breathe, that these people were so resigned and unresponsive, that they had not come to the hospital to have this baby who would now be alive, that I had driven out in through treacherous roads only to witness the dying embers of life in this precious child. I called for a dry sheet. I tied off the oozing umbilical cord, I spit the grime out of my mouth that I had gotten from the child’s dirty face and I kept breathing. Why would he not respond? He was cold, so I placed him between his mother’s breasts, but she was totally detached. I put the stethoscope in the ears of two of the bystanders so that they could hear that the heart was beating, that this child was alive, but they treated the experience as something of mild interest instead of a life and death situation. I started thinking about what I needed to help this child. If I only had some oxygen…if I only could intubate this child…if I had some glucose to give him…if I had only gotten there a few minutes earlier…if…if…if. I quit while there was still a heartbeat. What were the chances that I could convince someone else to take up the task of resuscitation while I drove him home? What would the outcome be of this child who had an APGAR of 2 thirty minutes after birth? They had been right all along. The heartbeat was a technical phenomenon. In truth, this child was dead before I arrived. I was the only one who did not recognize the facts. But I do not want to get to the place where I recognize such a death. It is only as we refuse to resign such children to their grave that we will start saving them. When I gave up, I was furious with the people and with myself. I covered the baby, stomped out of the tukul and promptly stepped into a large hole and almost fell on my face. It was a fitting exit. And we still had the treacherous road ahead. The mother opted not to return with me, which was probably a wise decision. I came home, flung my filthy clothes into the sink and retired, utterly undone.

“Moses My servant is dead; now therefore arise, cross this Jordan, you and all this people to the land which I am giving to them, to the sons of Israel” (Josh 1:2). Joshua faced an impossible task, yet God was with Him and Israel drove out their enemies. We, too, face an impossible task in Sudan. The odds are too great; the obstacles too numerous and strong, and too often, the people are indifferent. But there is a heartbeat here, and I am not the only one who hears it. We lost this child, but by God’s grace, I believe the prognosis of South Sudan is much more favorable. And we cannot give up while the heart continues to respond.

6 June 2011

Sexually transmitted diseases (STD) are common and often amusing. Whether in the US or Sudan, it is common to find the patient somewhat evasive about symptoms, origin, and often about the real reason they are seeing us. Today we had a follow-up for a meningitis case, though he was about 2 weeks late in his appointment. We had been a bit uncertain if this 31 year old man had suffered from Typhoid fever or meningitis, though we thought the latter and his follow-up seemed to confirm meningitis. He still had severe headaches and neck stiffness, though neither anything to compare to what they had been. He also had some constipation that we treated along with the headache and we sent him home. The next patient was a young woman with all the cardinal signs of STD: vaginal drainage, abdominal pain, prolonged period of no conception. We told her we would treat her with her husband. Experience has taught us that if you treat the wife with the promise that the husband will come, he never shows, so your treatment was not only wasted, but also contributed towards emerging resistant organisms. She said her husband was here. It was our meningitis patient. Apparently he was convinced that the meningitis was healed and saw no need for the kawaja to tell him what he already knew. At least our treatment inspired enough trust that he did return with a second problem, though he was too embarrassed to admit it when we saw him. We treated both of them. Later we had a man come in because his penis was swollen. He said that he had been just fine until the night before when he slept with his wife and now his penis was swollen and painful. That is very quick for an STD to work, and I suspected irritation rather than infection. I questioned him about other sexual contacts and about the timing. He soon recalled that he slept with his wife three days earlier, but the swelling of his penis was the night before. He adamantly denied any other contacts. He brought his wife along, called her into the room and then left, giving us the opportunity to obtain a confession from her. She was a young, pretty, shy girl. I asked her about pain in their time together and she denied it. She denied any discharge or sores, but she was very concerned because they had been married two years without conception. She confessed to a liaison with man she had hoped to marry before she was given to her present husband, but denied any contacts since. A quick inspection verified the lack of sores, and the husband was brought back in. Mary Agum started asking him some questions. Gradually it emerged that he had not been quite as faithful to his wife as previously advertised, and that he had contact with some extramarital acquaintances a couple of weeks before. Our treatment was the same as it would have been without the confession, but a bit of his righteous indignation evaporated.

Though I still maintain that revenge, an unwillingness to forgive, is the worst problem in South Sudan, promiscuity ranks high. New cases of HIV are being unearthed weekly. The reason HIV has not already become a major problem in our area as it is in much of sub-Saharan Africa is because of our relative isolation, not our sexual practices. As HIV is introduced, and it is here, it will become an epidemic unless current practices are drastically changed. Please pray that the gospel will take hold in people’s lives before AIDS ravages this land.

7 June 2011

I saw a patient in follow-up from an abortion (miscarriage) last week. She has two children at home, but lost the third child early in the pregnancy. Hers is a common problem in Sudan, probably for a number of reasons. First of all, miscarriages are relatively common anyway. One benefit of the legalization of abortion has been that we recognize the pain associated with the loss of a child, whether the abortion is spontaneous (as it invariably is in South Sudan) or induced. But in South Sudan where approximately 1/3 of the women between the ages of 15-40 are pregnant at any given time, a normal incidence of abortions would still be fairly frequent. Second, the women are “nutritionally challenged.” Their diets are relatively poor; if they have had numerous pregnancies, they have literally sacrificed their bodies for their children. They have almost no nutritional reserves and their iron stores are usually depleted. Third, the women work all the time. One of the main reasons why we keep women in the hospital for a few days after the threat of an abortion has passed is for them to rest. Shortly after returning home, they will be carrying water and chopping wood, and not uncommonly, the abortion threat that seemed on the verge of passing returns and is completed. Our patient returned for follow-up as scheduled, but she was still having a bit of bleeding and some abdominal pain. On her exam, there was a significant mass in the right side, about midway down, measuring 6 x 6 cm. It was mobile and slightly painful. It did not appear to be connected to the uterus. I think it is an ovarian tumor, probably benign. It reminded me greatly of Rose Paul’s tumor. It also could be an amoebic cyst and I put her on Flagyl to see if it would respond.

Rose’s tumor had a happy ending in all ways but one: because of the risk of recurrence, they ligated her fallopian tubes (she had her tubes tied). Rose has six children, though the first died of meningitis. But given her preference, she would have several more. Most Sudanese women feel the same way. My patient today is married to a fairly important man in the community. If this turns out to be an ovarian mass, he will have the resources to get her to Juba and pay for her surgery. No one can face surgery as though it is no reason for concern, and the anxiety is much more understandable in Sudan. But I think the biggest cause of consternation for her would be to lose the ability to have more children. I hope that does not occur.

8 June 2011

A three month child was brought to us a few days ago, and it did not take a master clinician to see that this child was very will. He had a fever 39.5 C (103F), had wheezes and crackles throughout the chest, and had a large spleen (6 cm). I did not think him more irritable than the fever should cause and he followed my keys, so I did not think he had meningitis. I diagnosed him with malaria, asthma, and pneumonia and started him on ACT (artemisin combination therapy) as well as Amoxicillin and asthma therapy. On rounds the next day the nurses informed me that the child’s respiratory status worsened and they changed Amoxicillin to Penicillin and Gentamicin. The fever was down a little and the child looked better, but the following day the child looked worse and the fontanel was full. We switched him to Quinine for possible cerebral malaria and to Ceftriaxone for possible meningitis. The child improved marginally if at all. The nurses raised the question of HIV. I said for them to test the mother, but they opted to test mother and child. The mother was negative, but the child was positive. How do you make sense of that? It could be that the tests were wrong, either the mother was a false negative (the test was negative, but she has the disease), the son was a false positive (the test was positive, but he does not have the disease), or he contracted the disease another way. We are hoping he was a false positive, but we are suspecting that in a disastrous attempt to help this child, the parents bought some medication and then injected this child with a contaminated needle. I want to scream, “How long will you be so foolish? How long will you keep killing those you love in your tragically misplaced zeal to help them?” If true, he is the third child affected in this manner that we have discovered. We have to wake these people to the disaster ahead.

9 June 2011

“Etu Brute? Then die Caesar” (Julius Caesar, William Shakespeare). I understand the pressure the guys who are close to the kawajas feel all the time. People in the community see the kawajas as having all things at their fingertips: unlimited money, power, fuel, vehicles, resources. So they are constantly being pressured to get us to do things for them. Johnson, one of the executive chiefs of the area, has been pressuring my friend to get me to drive him to Pacong and retrieve his belongings. I never said that I would, only that I would consider it, but in the Dinka realm that translates into a promise. His wife had been coming to the clinic to sit outside to pressure me into taking her. So last Sunday I had run out of good excuses for denying her and told her I would take her, though I wanted to rest for a few minutes prior to going. After about 30-45 minutes, I went out to find her and fulfill my obligation, but she was gone. I felt, more than ever, that all obligations were finished, but then my friend came to me again today saying that the man was pressuring him as to when I could take him. Since it was just past 4 PM and I had only one obligation, I told my friend I would take the man after I completed the errand. I took Hunter, a visiting medical student, along to get some exposure to the area. I did have to push things to get people moving so that I could fulfill my obligation, and then I was told of another part of the executive chief’s plan I needed to fulfill: go get his wife and bring her along. The house was close and I made it clear: she comes right away or I leave. And she came fairly promptly. We got back to the market and I asked my friend point blank: “Once I get to Pacong, is the house right on the main road, or do I have to still go a long way?”

“It is right on the road, only 5-10 seconds.” I have learned over the years not to trust Dinka estimates of time or distance, but this was my good friend, and I felt certain that he would tell me the truth. I figured that if the tukul was that close, we could be back on our side of the river before dark, and that was important because the road is much better on our side of the river. I concluded that I was going to continue to receive pressure from this man until I went, so today was as good a time as any. We made good time getting to Pacong. I was even beginning to hope that we might make it back to Akot before dark. Johnson pointed to the turn off, a “road” that ran by the ECS church of Pacong. It was one of the churches built by Samaritan’s Purse (SP). SP has committed to rebuilding all the churches in South Sudan that were destroyed by Khartoum in the war, a huge undertaking that has blessed many. I figured Johnson lived near the church. Wrong. We kept driving. Getting directions from Dinkas is a challenge. I think it is because they so value being cool. They like to answer in the positive with a minimal lifting of the chin and an almost inaudible clicking of the tongue. The negative response is a brief showing of the tongue between the teeth. They give directions in an equally subdued manner. Johnson stuck his hand out the window and moved his fingers a maximum of 2 degrees to indicate the direction. I was in no mood for his James Dean impersonation. “Tell me where to go,” I half shouted at him. We went barreling on for about 25 minutes until he finally said, “There is the house.” We still had to circle around to find the path in. There was no way we would get back to Akot before dark, but the river was still a possibility. The plastic chairs were pulled out, but I nixed that idea. “No one sits down. Everyone helps load the truck and we get back on the road quickly. Everyone responded, and even Johnson helped a little. We loaded up the truck in about 10 minutes, and I was still hopeful. Then Johnson pointed to another tukul some distance away. I needed to take them there so that he could drop off his ox plow. I did not see a good path in that direction and his statement seemed non-sensible, but I went ahead again. Hunter and I unloaded the ox plow while the women gathered more belongings and Johnson disappeared. Everything was loaded, but Johnson was nowhere to be found. “Where is Johnson?” I asked and motioned. No one knew. I had enough. “Ena ci jal, mit thioga.” I am leaving now. The women signaled for me to wait, but I refused. No, I was not going to wait. I was tired of waiting. I was tired of being lied to, particularly by my good friend. It was 7:15. It would be dark in a few minutes, so I left. I was actually fairly proud of myself for being able to discern the tire tracks out (I thought it would reduce the drama of my exit if I got lost and had to go back to them to help me find my way out). The light was starting to fail by the time I reached the main road. It was after 8 when we got back to Akot and we still had to take the wife and things back to Tin-Machar. The wife was unable to help direct us to her home, but she directed us another friend’s house and we unpacked her belongings there. I was tired of the whole thing, but most upset about the lie from my friend.

10 June 2011

Mary Agum pressed me again to help her get her sorghum and millet for planting. There is no question that it is time. Indeed, there are many of us who think the slow growing sorghum will not mature before the rains end. I had put her off a couple of times, but it was time to help, and I had no conflicts, so I agreed. We have a visiting team from America who are fun and adventurous, so I invited them to come. All but one took up the offer. So we first drove to Mary’s home. There was a bit of a delay as everyone wanted to see Mary’s tukuls and visit with her children, but soon we headed out to find the young man who could direct us to the place where she had her grains. (I do not know this, but I suspect that Mary and her husband, who have been in Uganda for three years, had to purchase some grains for planting, so she knew the general location, but did not really know the house where the grains were located). Anyway, that necessitated another stop and some more interactions while the young man was located. Then we got on the road to Marial-bek, which runs through Makur-agaar. I had been on that road recently and found it treacherous, but this time we were traveling during the day, so picking the best routes was more feasible. There are a few guidelines for traveling the roads of Sudan. Probably the most helpful rule is to look for tracks. If someone has come before you on a particular side of the pool and there is no abandoned vehicle or signs of being dragged out, there is a good chance you can make it as well. Second rule is that if you can keep two tires on fairly solid ground, you probably can make it through. Third rule is to go for the gentler slope. Fourth is to avoid the grassy areas in the puddle. Fifth rule is to maintain your speed if at all possible. The last rule will help keep you from getting stuck and will make the trip more exciting for those who are along for the ride. We had a number of rather deep and wide puddles, but typically had some routes of by-passing the more treacherous sections, making the trip exciting without excessive risk. We made it to the tukul housing the grains. There was not an adequate path to the tukul itself, so we parked on the road. The seven tins of sorghum had been put into two sacks, one holding the main load. It was surprisingly heavy, and the truck was a couple hundred yards away, so it took a united effort to get it there. The children were fascinated. It is probable that they had seen kawajas before, but very unlikely that they had ever seen this number, especially so close. The children were flocking around all the kawajas, touching them, fascinated by their skin and hair. Some women were dancing around as others brought some more of the grains from a nearby tukul. I was enjoying myself, but I was unsure how the visitors felt. I asked Caroline if she was okay. “I have seldom had a better time in all my life.” I was greatly reassured and seemed to see the same emotion registered on all the kawajas. As I was driving back through Makur-agaar, there was a single branch across the road that had not been there before. I road over it with no difficulty, but a man came out flagging me down. He informed me that the path I was driving on was not a road and that I needed to go a different direction. It is true that there are three paths through that particular section. One is very bad. It is full of deep holes that make it uncomfortable even during the dry season and quite treacherous during the wet season. There is a second that is also in poor condition, though not really treacherous. And there is the one I was traveling, which is by far the best and the one I have taken preferentially for at least the last year. So when the man informed me that the path was not a road and I could not use it, I informed him that it was indeed a road and I had every intention of continuing to use it. There is no eminent domain in South Sudan. People feel that they have the right to close a road at anytime or do whatever suits them, irrespective of the needs and desires of the community, though they are the same ones who will be calling on me to drive some impassable route to serve them. I drove the remainder of the way without incident, returning back to Mary Agum’s tukuls with all present and accounted for, though two Dinka girls who were cultivating an area near the market chastised me for following the route I had taken when leaving because they were extending their area of cultivation into the part where I was driving. I ignored them.

So how was the trip? It was a great trip. You will not last long among the Dinkas if you cannot deal with ambivalent feelings. I will not give in passively to stupid road closures, but what stands out about the journey was the excitement of the families in seeing kawajas, the fun of the team bouncing over back roads and through puddles that SUV drivers in America can only dream about, and the satisfaction of delivering seeds for cultivation to the home of my friends. There will always be selfishness and unreasonable acts, whether in the US or Sudan, but the good of what we are doing far outweighs the occasional bad experiences.

11 June 2011

Yesterday Gordon Mayom came to warn me about some unrest in the area. I am not wild about the currently in vogue definition of insanity, but it does seem to me that after years of repeating the same stupid mistakes, people would catch on to its futility. Yet two nights ago, really in the morning hours of yesterday, some Dinka Agaar from Paloc and Pecam (actually a long way NW from Akot) raided some Dinka Atuot in Pandit (east of Akot), killing two men and rekindling the unrest. Gordon advised me to not go out after dark, so I was not pleased with Samuel Mathiang came to me as I was finishing supper with a request: the pickup from NPA was driven towards Aluakluak (and Pandit) and was now stalled. Would I go and help them start the truck? I considered telling him to wait until the morning, but I thought the pickup would probably be destroyed and the man’s life might be in danger, so I reluctantly agreed to go. Samuel was clearly frustrated by the stupidity of the driver. He was sent to gather some firewood. We are not talking about hardwoods blazing on the hearth; we are talking about the basic cooking power. I have gathered firewood for our hospital many times without ever losing sight of the hospital, but this man had stalled out the pickup 6 kilometers from NPA, his base of operation, and was traveling towards the unrest. On the way, we passed many families who were leaving their tukuls in the bush and coming into the market of Akot to protect themselves from the marauders. I had to agree that the man was foolish. Samuel said the man may lose his job for his stupid decision. That is certainly his call. I wondered if the man was somehow itching to be involved in the skirmishes. Whatever his motivation, it was foolish and had little to do with gathering firewood. When we got to the truck, it was off the road in a small gully. By the looks of things, I suspect he stalled the truck seeking to climb over the ridges of the gully. I turned the truck around as they got out their chain. I am not overly fond of pulling another car, particularly with a rope or chain. Any slackness means there will be a grating sound and the sensation as though a giant dentist was seeking to extract your chassis. We successfully pulled the truck onto the road. I was instructed to get the car going fast and he would pop the clutch and seek to start his car. I nixed that arrangement. I suggested instead that I push him. You may ask, “Why not simply jump the car off with cables?” I know this NPA car. Whatever the problem, it is far beyond the simple remedy of jump starting. I did jump start a car earlier in the day, but we did not even go through the motions with this one. Instead, I opted for a rear approach. I do not care for this approach either, but it is far less hazardous. The NPA truck has no back bumper, but it has been pushed started so many times that the tailgate looks like someone pounded it flat from a rolled piece of metal. Our pickup has a large guard, almost like a “cow-catcher” on the front of a locomotive, so the potential for disaster was less. The key to the rear approach is to slowly make contact and to smoothly accelerate until you are up to speed. The dangerous time is if they pull away and then stop in front (hence the pounded metal appearance of the tailgate). We went through the procedure with no disasters or success. Eventually we decided that my AAA role for the evening would be as a tow truck. Again a smooth, steady acceleration is key and we seemed to be going along fairly well at a blazing 12 kilometers/hour until we came to the speed bump. I made every wrong decision. I almost stopped as I shifted to first gear and then hesitated as I cleared the embankment. Each mistake was greeted by the dental tug and wrenching sound. I did a bit better by the second speed bump and by the end was getting the feel for how to negotiate these three foot mounds. Of course, I will forget the lesson by the next time I am called upon. I pulled them into the NPA compound.

“Chief Dut is over there,” Samuel Mathiang informed me. I have always liked the chief and went over to speak to him. We speak of the sword of Damocles, and Chief Dut certainly rules under one. He is a good and wise administrator for our people. One of the two men killed in the raid was a good friend of his, and Chief Dut had several of his cows stolen in the raid. But he was staying in the NPA compound with his family because he understood that the marauders would love to kill him to even the score, though Dut had nothing to do with the raid and condemned it thoroughly. He did not seem overly worried about being forced from his home or the dangers he face. We chatted for a bit and he gave me a platter of fried fish that I ate with relish, though in the night I was troubled with some heartburn. This whole episode made me think about the enigma of the Dinka people. The chief was absent from Akot virtually all of last year because he was afraid that the soldiers in Akot might still be trying to even the score and take a pot shot at him. Now he is again away from his home because of others who seek his life. “Be strong and courageous” says the Lord to Joshua (Joshua 1:6). They are necessary characteristics of all good leaders. I pray that Chief Dut will have them in abundance.

12 June 2011

Rose keeps a child, Mary Abyea, who is Paul’s niece. She has recently reached a milestone: she started her menstruation, thus making her, in the Dinka mindset, eligible for marriage. She has lived with Paul and Rose for about 4 years and is much closer to both of them than either of her parents, but her father, who mainly played the role of sperm donor (he is the kinsman redeemer, the brother of Paul’s sister’s husband who died, but he has had virtually nothing to do with Abyea or her mother since conception). Now, however, he wants some cows when she marries. Paul and Rose were objecting, wanting Abyea to finish school (as she wants), but lately their objections have been more tepid. They are concerned that Abyea may be out one night and get raped, and they do not want the family to hold them responsible if such a thing should occur. I asked Rose, “What is the penalty for rape?”

“Two cows. One cow to the parents and one to the government.” She told several stories she knew first hand. Recently a young woman was walking in Maluel, near Rose’s home, and an officer in the SPLA came up to her. He had tried unsuccessfully to woo her earlier, but this time he found her walking alone from her home to another tukul and tried to force himself on her. She was neither small nor weak, and she was fighting him off, so he called four soldiers to hold her down while he raped her. The court told him to marry her, but she refused. The court fined him one cow for her parents and one for the court. The other soldiers were not penalized because they said they were following the orders of their commander.

Another story involved Nyanapen, a woman who had been hired to teach in the Living Waters School. She was coming back from her home in Yirol and stopped to spend the night with her uncle Agany. Several men grabbed her and carried her to a tukul and intended to rape her, but her uncle found out and ran to the house and called the police. Meanwhile, Nyanapen fought bravely and resisted the men. The police came and the men came out. Nyanapen refused until her brothers came and took her to Yirol. Her family sent her to Kenya to continue her education. She gave up her teaching job.

Rose had her own experience. She was at home in Miridi. There was a big man in the SPLA named Atem. He had tried to woo Rose, but she was not interested. One evening she went to the store to buy bread and was coming home when Atem and several men grabbed Rose. She screamed and cried and bit and fought for all she was worth. For a time, no one came to help her. She grabbed on to poles, but the two main soldiers trying to drag her away were hitting her arms with the butts of their rifles until she let go. But when she let go with one arm, she grabbed something else with the other. All the time she was screaming and crying at the top of her lungs. Then a neighbor who knew Rose and her family heard the commotion, got into his car, and sped over there. He chased some of the men off. When he saw Rose, he slapped her and asked her what she was doing with those men, but she was hysterical by that time and could not answer. Finally he took her home and told her parents to let her sleep. The next morning Rose was able to tell them the story and Atem was put in jail.

“Wash yourselves, make yourselves clean; remove the evil of your deeds from My sight. Cease to do evil; learn to do good. Seek justice, reprove the ruthless, defend the orphan, plead for the widow” (Isaiah 1:16-17). I hate the revenge in South Sudan, but I suspect that one of the root causes is a weak to non-existent judicial system. Where there is no justice, vigilantes will rise up. This is not a liberal or conservative issue. We should all be working for and praying for justice in South Sudan. There are certainly plenty of problems in the US judicial system, but the faults lie mainly in the execution of justice. The laws and system to defend the innocent and prosecute the guilty are there. I hope one day we can say that about South Sudan. It will never be perfect, but I hope someday the penalty for rape will be higher than one cow.

13 June 2011

One of our patients on the wards is a 7 day old with meningitis. We have had a fair amount of meningitis lately, and I have reported several cases, but this one tells much about the Dinka culture. This child was brought to us at 4 days of age, but with a history of being sick for three days. The three days prior to coming to us were spent seeking “traditional cures.” They took the child to the witch doctor. Fortunately, this time the witch doctor was merely ineffective. He did cost us precious time, but at least this time he did not stab the child in the head and turn a bad situation into a hopeless one. The patient was brought to the hospital in the evening. The nurses started him on Penicillin and Gentamicin, and the fever promptly broke. However, the child did not really improve. He could not nurse. Coma scales are for older patients, but he would have been in a moderately deep coma. The following day he was no better and his fontanel (soft spot) was fairly tense. It had been full the day before, but I thought Pen and Gent decent drugs for the presumed pathogen, Group B Strept. But now I was not as confident. I changed his antibiotic to Ceftriaxone and we added some hydrocortisone. I was more convinced that this was meningitis, but I wanted to confirm that we were pursuing the right rabbit. A visiting medical team from St. James Episcopal Church in Richmond, VA has brought us all kinds of good things to help our hospital, including a counting chamber to give a more definitive diagnosis of meningitis. It took a bit to get everything arranged, but I thought I finally had. Francis and I spoke with the mother and she was in agreement, but as we were leading them away, the sister-in-law spoke up. We should wait for the husband. After this woman probably joined in the chorus pushing this mother to the witch doctor, is she going to disrupt everything again by some outdated, chauvinistic custom? Apparently so. The lumbar puncture (spinal tap) was postponed until the dad arrived, which he did not do, and so it will probably never be done. That is no tragedy, though I would have liked to have the confirmation. By this morning, the child was clearly better. The fontanel was softer and he was nursing well. But as we made rounds, I heard a virtual brawl out on the stoop because the same sister-in-law was demanding that Francis pull the NG tube. When we finally got to the patient on rounds, it turned out that he had received very little via the NG the night before and was nursing more vigorously, so we elected to pull the tube and see how he would do.

This sister-in-law is a microcosm for Sudan. She feels justified in demanding things from us for free, though she and her family were more than willing to give goats and other things to the witch doctor for ineffective or even murderous therapy. She sleeps on our beds, eats our food, and then obstructs the care we offer. It reminds me of the way the government treats NGO’s. We pay the exorbitant fees for licenses and travel permits to have the privilege of assisting their needs. It is strange. Instead of feeling a sense of gratitude and obligation, they see those who have come to help as deep pockets fit for pinching. The truth is I like this woman, just as I like the Dinkas. She seems to be a caring mother, nursing her child as she assists our patient and her baby. She is pretty and pleasant at times in her interactions, just as the Dinkas can be caring and gracious people. I overrode Francis and let her stay on the condition that she cease being so disruptive and abusive of our medical staff. We will see what happens with her. And we will see what happens with South Sudan. For a country that has been at war for 40 of its 55 years of existence, South Sudan does seem to have a peculiar relish of conflict and a poor way of responding to the kindnesses offered to it. I hope that will change when the new nation comes into being, but I see nothing upon which to build that hope. Still, the needs are here and we have the means of helping them, so we will. Why? Because we are far less deserving, yet God never gave up on us, though the provocations were severe.

14 June 2011

We had a woman come to us at what we judged was approaching term (around 36 weeks) with abdominal pain and some bleeding. She was from Paloc, a village almost directly north of us that is a short distance but a long drive away. The road is rough during the dry season and virtually impassable during the rainy season. After a couple of days, the bleeding stopped, but her pain persisted. Now abdominal pain during pregnancy is ubiquitous, but this lady’s pain was different. As she spent more time in our hospital, it was clear that she had either a very big baby or two (it was before our US machine arrived). The other thing that stood out in her exam was her uterine artery sounds. We listen for fetal heart sounds every day on our pregnant women, and often we hear the uterine artery. It is much slower than the fetal heart sounds, and therefore easily distinguished. But her uterine artery sounds were different. They were very loud and a there was a continuous quality to them (called a bruit), much like certain heart murmurs. At first I ignored it, but the quality was so different from every other woman I have examined that I noted it and had everyone listen. She was around for weeks and we became very familiar with the sound. She would go into labor every 2-3 days, but the pains faded quickly. She was a funny woman, and we all enjoyed having her around, but it did feel strange. Her BP was good, the bleeding had long ago stopped, the pain was a bit worse than usual, but there was nothing solid keeping her in the hospital. However, we simply did not feel good about her going to Paloc, because we thought the chances were high that she could not make it back to the hospital in time and we felt uneasy about this delivery. The mother had 4 children already, but I think she sensed something concerning about this pregnancy as well, because she did not try to persuade us to send her home even though we did nothing that she could not do at home. After weeks of this, she found a home in Akot where she could go and left us, but came back for the delivery. Caroline, a visiting nurse, was present at the delivery as were the nurses and the TBA (traditional birth attendant). Shortly after the baby was born, there was a gusher of blood and clots. She received 4 liters of Ringer’s Lactate. When I saw her the next morning, she was “as weak as rainwater,” very tachycardic (high heart rate), but she was alive and had urinated, a favorable indicator of intravascular volume (the volume of fluid in the circulatory system). She will need some aggressive iron supplementation and some more days of recovery, but I think she will recover. The baby (one) is large, but not excessively, and is healthy.

I believe that the strong bruit we heard represented an abnormal connection between the placenta and the uterus. In many ways, the placenta is virtually an arterial-venous malformation (AVM). The intimate connections are critical for the child to survive and grow. Nutrients and oxygen diffuse from the mother to the child, and waste products such as urea travel the opposite direction. I think that the connection between this placenta and mother, though, was pathological, too much of a connection, explaining both the bruit we heard while the child was growing, the marked pain this woman had, and the severe blood loss during delivery. I am convinced of this: had she delivered in Paloc or along the way, she would have died. We second-guessed ourselves multiple times about her long stay, but her difficulties seem to justify our approach. Shock is still a killer, even in the US, and a frequent offender in Sudan. And for myself, when I hear that bruit again in another pregnant woman, I will deal with the mother very cautiously.

15 June 2011

In medicine, there are many times when the patient feels as though he has lost control. That is true in the US as well as Sudan. Even in our sophisticated society with medical exposures on TV and magazines continually, when you are the patient, there is the feeling of getting swept downstream and having no options but to go with the flow. Those feelings are exaggerated in a population that is in transition from traditional care (witch doctors) to modern medicine, and that has none of the media exposure to help cushion the confusion or answer their questions. The child with meningitis (13 June) was the center of more controversy today. Three days ago, the child was virtually comatose. He would not suckle. He did not interact with his mother, much less the doctor. He had been on Penicillin and Gentamicin, but we changed him to Ceftriaxone and added hydrocortisone. He has responded well, given how ill he was, but he is far from recovered. The fontanel is still quite full, but not tense like it was and the fever is gone, he is sucking well and making positive eye contact. We are much more encouraged than we were before, but the child is still very sick. In American terms, he has moved from critical to serious. One of the reasons he was so sick initially is that the family delayed 2-3 days bringing him to the hospital. But the father, who probably more responsible than anyone else for the delay in coming to us, now has decided that the child is sufficiently improved to be able to go home. In his defense, there have been some problems in the area. He is Atuot from Agany. The recent attacks on the cattle camp in Pandit (11 June) has everyone worried. The Agaar are worried that the Atuot will mount up an attack on Akot, though none of the culprits were from Akot, and the Atuot are worried that they could get caught up in some counter-action from the Agaar. Therefore the father wants to take the child home and get out of the Agaar territory. Viewed in that light, his request is reasonable. The problem is that we do not have medication by mouth that will complete the treatment. I heard about this today on rounds, and then the father came to me while in clinic. I may have been too rough on him, but I felt I needed to be blunt. I told him that the child was improved, and we were pleased with how he has done the last 2 days, but that the child was far from cured. I think if this child completes therapy, there is a good chance he will turn out normally, though there are certainly no guarantees. But I told him that if he takes the child home today, he might as well dig a hole and bury him, because it is a virtual certainty that he will die. I assured him that we would keep his wife and child and all family members with him safe. In the end, he decided to leave the child with us. I know that he might still change his mind, but I hope not. I think this father really cares about his son and wants to express that in every way possible, but if unguided, his love could kill this child. I am hopeful that we have dodged that bullet, but we shall see.

16 April 2011

I have often commented to the Dinkas that their culture is probably much closer to that of the Hebrews than my American culture. I think of marriages. Weddings were huge social events, particularly when prominent families united, as we see in Matt 22:1-14. It is very similar in the Dinka culture. One of the things I am discovering the hard way is that the promise of marriage and the actual event may be miles apart. In the fall, I drove twice to Billings to support the wedding of Isaac Mayom, yet after five months that marriage is still in limbo. I am not strongly opposed to arranged marriages. When parents or relatives who know the two potential partners well and decide for the interest of the bride and groom that they would suit one another, I suspect the outcome will be more favorable than in the US where dating is the standard modality. But here in Sudan, the chief determinant is the dowry. Isaac has been able to bring forward the requisite number of cows for the wedding to take place, but the parents of the girl have had other offers. This is their chance to get rich, so they push the issue for all it is worth (literally).

Yesterday Gabriel Amat asked me to accompany him to the wedding of his niece (his sister’s daughter). He wanted us to leave at 8AM. Saturday is my day for washing clothes, so I wanted to complete that before we left. I had several interactions that further delayed me, but we left our compound about 8:15. Rosy was with me, as well as Angelo, Gabriel’s nephew and cousin to the bride intended. We picked Gabriel along the way instead of at his house and I thought we were golden. However, Gabriel still wanted us to pull into his house. Nothing there was even approaching readiness. After about 40 minutes of sitting, the party indicated they were ready to depart. The wedding was to be held in Makuac. The flexible boundaries were in play. I have been to Makuac many times, but we drove twice as far as I expected. Yet despite all the delays, we arrived at the appointed time (at least by African standard), but there was no gathering. As we struggled to find some shade, we were quickly informed that the celebration had been put off until the following day. The information was not well received, for it put a lot of people into difficulty. Several argued that the hosts should proceed, including the two older sons of Paweer, grandfather of the bride and one of the leading men of Akot’s olden days. I have conflicts for tomorrow and will not be able to make it. Some of those who rode with us will stay at the sister’s home, but many headed back with us and will find it difficult to get back. I cannot decide if this is a “power play” or if there was a significant reason for the delay, but I am convinced this will not earn many brownie points.

Ironically, as the afternoon was progressing, Isaac Mayom approached me about transporting some of the wedding party to Tin-Machar. It appears that the power play by the Billings family has backfired. Isaac is from a prominent family, and there has been some intermarriage in the past, so the wedding had to be viewed favorably by all the Dinkas. It is conceivable, but unlikely, that the girl had serious reservations about Isaac. By far the most likely reason for the interminable delay was that the father and uncles wanted more cows, and now they may have lost out of the bargain. I am glad to see Isaac moving on and I hope this wedding will go smoothly and quickly. And I hope the same for Gabriel’s niece.

17 April 2011

Lately our hospital has felt like an OB ward and level 2 nursery. We had one lady with intrauterine fetal demise (her child died in utero). We had some discussion about the best way to deal with this situation, but reason finally prevailed. She was induced into labor and had the child, though dead as anticipated. Still, she did not have sepsis from the dead child, nor did she have a C-section. She went home well. She will spend a few weeks grieving and therefore not having relations with her husband, and then she will begin again as though nothing has happened. We had another child born alive 5 days ago, but after a day, she had fever. In the US, she would have had a “sepsis work up” including a spinal tap, but that is not possible here. She always nursed well despite the fever. We have treated her with oral antibiotics. The most common cause of neonatal sepsis is Group B Streptococcus. Typically the child gets colonized with the organism in passage through the birth canal. Once full-fledged sepsis is established, IV antibiotics are required, but we have adopted this intermediary step out of convenience. We keep the child in the hospital. If the child is getting worse or quits nursing, we proceed to IV meds, but this child has done well. Another day or so and she will be discharged. We had a mother come to us because her uterus was so much bigger than her dates would suggest. She had been diagnosed with polyhydramnios, meaning too much amniotic fluid. We entertained the idea of twins and did not make a definitive statement one way or the other. We did give a shot of steroids to prompt maturation of the surfactants in the child’s lungs. The mother stayed with us for several days, but then insisted on going home. She delivered twin girls at home, though one was dead. The living one is quite premature, around 30 weeks, but in no respiratory distress. We are giving her nasogastric feedings (a tube through the nose into the stomach). Mother is expressing her milk and we infuse 10 ml every 3 hours. We are hopeful she will do well. Indeed, we are hoping she will do as well as Apet. Apet means premature girl (Mapet for a boy). Apet was born 5 weeks ago, probably more premature than our more recent addition. We have fed her via the tube since that time. We kept putting her to the breast to encourage suckling, though she was far too small to survive by that means. Currently she is nursing 2 out of three feedings (the 3^rd is dripped, now at 38 ml) and she is up to 1.3 kg. We realize that this child still has innumerable obstacles ahead of her, but we are now expecting her to live and go home soon. A month ago the odds were clearly against her. Now I would say she has a 50-50 chance of reaching 5. And those are good numbers in Sudan.

18 April 2011

We had a Shakespearean discourse on rounds today: Much Ado About Nothing. Two days ago an 18 yo girl came to us with burns. She had been preparing Seco, the local alcoholic brew, at home. I have seen the process. There are several large pots of water over the fire and the brew is placed into one of them for several hours. That is just one step of the procedure (overall it does not sound too complicated), but it is a pertinent step for her situation. One of the boiling pots of water was put on the ground and she backed up and sat into it. I tried to get some idea of how much sampling of the Seco she had been doing prior to the incident, but I was unsuccessful. There are things patients, whether American or Dinka, will not tell the doctor no matter how confidential. Besides it was not really all that pertinent to the question at hand. She did not have a seizure (that is a very pertinent question to all burn patients in Sudan), so whether it was simple clumsiness or clumsiness enhanced by alcohol really did not matter. She had second degree burns over her buttocks and slightly up her back. When we rounded yesterday she was lying naked on her abdomen, her burns upward (as they should be). Today when we rounded, she was lying under a tent of sorts, but still in her birthday suit, and she felt some freedom to be on her side. The burns are superficial. She should heal well, though dressing with Silvadene is important to reduce the risk of infection. I asked about her home, figuring that if she was from Akot, she might go home and return for dressing changes, but she lives in Thon-Aduel, about 25 kilometers away, so that is impossible. I then raised the question about how she was able to go to the latrine; she has a dress she slips over her for her walking. Elijah was concerned that she needed more clothing, and that it was inappropriate for her to lie there naked. I suggested that she get one of the toga-like wraps that a lot of girls, particularly at the cattle camps, wear because it would be easy to slip on and would not cause too much actual contact with the burned areas. But as we talked, I looked at her countenance. It became obvious that we were a lot more concerned about her modesty than she was. And that, after all, was the issue. She clearly had less pain with the burns open to the air and no cloth touching them. So there was no reason for the significant ado about the nothing she was wearing.

The issue with exposure within the Dinka culture attracts a lot of attention (pun intended), yet it seems to be much more of a kawaja issue than Dinka. Less than 20 years ago everyone here was naked all the time, so in reality clothing is in a bull market. It is still very common for children to be naked and breast exposure is essentially accepted by all except kawajas. The age group where breast baring is most common is in the older women who have no illusions of using their lack of attire to attract masculine attention and who would wonder that anyone even noticed. But even in the less than 2 years that I have been here, shirtlessness is less common. As interaction with the rest of the world increases, nakedness will become rare. I suspect that in another 20 years, nakedness in Sudan will become as rare as it is in Kenya. I will argue vehemently that the shirtless Dinka woman has significantly less intention of attracting male attention than the American woman showing cleavage. It has nothing to do with morals; it has everything to do with mores. In other words, this is a cultural issue. It is perfectly consistent for a Dinka woman to worship God in the morning and to go shirtless around any number of men that afternoon. So the issue is with us. Therefore, we will let the girl decide in what manner of dress she is most comfortable, and we will make adjustments in our own comfort level.

19 April 2011

I traveled to Karic today in search of bamboos for various members of the community. Bamboos provide much of the structure of the roof of the tukuls, but they do not grow in our area, so the people are dependent on outside shipments. And because the rains are imminent, the pressure to find the bamboos increases. I traveled with Angelo and Maker, but they had been charged with obtaining several more bundles. At Karic there was a pile of bamboos, some in bundles, some loose. The men started walking around the bamboos like me at a used car lot, trying to look knowledgeable, but afraid I will be had. This or that pole was excluded and a more suitable one substituted. Their purchase was large, given the number of people for whom they were buying, so Angelo tried to push the seller to give them a free bundle or discount the price slightly. He did neither. I told Angelo that was Economics 101: supply and demand. The rains were coming, everyone needed to finish their tukuls and there were not enough bamboos around for everyone. The man did not need them as much as they needed him. Indeed, the bamboos they were rejecting would eventually be sold to someone because of the need.

Knowing less about bamboos than I do about used cars, I made no pretense at shopping or decision making. Instead, I do what I do everywhere: talk with the children. I was shaking hands and playing with the boys when I noticed a shy boy about 4. He had heavy purulent drainage coming from his right eye and the eyelids were swollen and puckered inward. He had trachoma. Trachoma is a horrible disease. After repeated infections, the eyelids are permanently turned inward so that the lashes that are to protect the eye become rakes to burrow into the sensitive cornea. It is painful and eventually results in blindness. At the stage where I saw him, the little boy probably has been infected more than once and is a risk for blindness, though with proper treatment it can be avoided. He could receive Chloramphenicol eye drops and follow. If the lids are truly turning in after that treatment, I could help. The eye team from Tenwek taught me how to do the release of the scarred eyelid last March and I could do that surgery for him. It was with those things in mind that I brought the boy closer to me to have a better look and be sure that I was correct (I think I was). But the child was embarrassed by the infection and by the attention I brought to it. He shied further away from me. He was wearing a pullover with hood and tried to hide the diseased eye behind the flap while looking out with the good eye. He did not hate me. I could see that he liked being around the kawaja, but he did not want any attention to that eye.

Jesus gave some great invitations, but they always necessitated the responder to see his need. “Come to Me, all who are weary and heavy laden, and I will give you rest” (Matt 11:28). “If anyone is thirsty, let him come to Me and drink” (John 7:37). This child has the same problem that most of us do: we cannot admit our need. There are usually several reasons. We like to think we are strong and can overcome the problem through our own efforts. We think we will be rejected if we come, particularly if we come without anything to barter. “Nothing in my hands I bring; simply to Thy cross I cling” (Rock of Ages, Toplady). It is so ironic. If the child could somehow be persuaded to come, he might respond to the antibiotics and even if he needs surgery, there is every likelihood that he will respond well and keep his vision, but if he does not come, pain and blindness are almost certain to follow. And we are the same way. If we can just admit our need and trust His heart, Christ will provide all we need. “‘Come now, and let us reason together,’ says the Lord. ‘Though your sins are as scarlet, they will be as white as snow; though they are red like crimson, they will be as wool. If you consent and obey, you will eat the best of the land, but if you refuse and rebel, you will be devoured by the sword.’ Truly the mouth of the Lord has spoken” (Isaiah 1:18-20). O Lord, give us ears to hear and hearts to understand.

20 April 2011

I had just finished the afternoon clinic and was seated in my tent when a distressed acquaintance (I know his face, but not his name) approached, together with Abraham Laat for interpretation. The uncle of my close friend Mayek Biljok had fallen from a tree and broken his back. He needed to be transported to the hospital. We are the closest alternative to 911 here in Akot, so I thought the request reasonable and quickly headed out in the pickup. We had a few passengers join and exit before we arrived, but no one thinks in terms of seconds making a difference here, so the stops did not cause my escort undue stress. We picked some family members who were nearly distraught, though I am fairly certain they had not seen him. Information travels in the Dinka hotline quickly, especially bad news. I was traversing paths for foot and two wheel vehicles, so I had to thread the needle between stumps and holes all the way. We disembarked upon arrival and Mayek’s sister repetitively threw herself down beside the old man in paroxysms of grief. Still working on the theory that a few seconds will not change the outcome, I did not run to the bedside. I let the grieving women (and a few men) form their enclosure and then I gently wormed my way to the man. I was actually fairly relieved. I saw him moving both legs.

Dinkas do not value a systematic approach to patient care. My concern for this man was his spine. As soon as I reached him, it was obvious that he had shattered his shoulder blade (scapula), but there is not anything we are going to do about a broken scapula except stabilize the arm. I started pressing the spinous processes down the vertebral column, but everyone was telling the stupid kawaja that the problem was in the scapula, not the spine. After about the 20^th interruption, I stated adamantly that I did not care about the scapula, but I was very worried about the spine and needed to evaluate it. There was some moderate tenderness in the lower thoracic, upper lumbar region, but the pain was not nearly as intense as the scapula, so I was encouraged. On pressing the sternum, I felt crepitance, but his breath sounds were equal. His R chest was hurting, but he had crackles in the L chest. I then obtained the history that he had been sick with fever and cough and concluded that the crackles were pneumonia and not related to the fall. He had some moderate swelling on each side of the spinal column in the lumbar region, but no neurologic losses that I could appreciate. We started back to the hospital. I am always amazed how many people who have never driven a car want to tell me how to drive. “Just go slow.” “Be careful.” I wanted the man to sit in the front, but he complained so vehemently that we put him on a mattress of sorts in the truck bed with 20 attendants, mainly female. We arrived intact, though after several stops for appropriate grief demonstrations. After getting him to a bed, I had to worm my way to the bedside, but my findings did not change.

Though he has no neurologic deficits, I am concerned that he may have suffered a spinal contusion and so we will treat him with some Decadron. I am convinced that the crackles are not related to the fall, so I will treat that finding like pneumonia. I am concerned about his abdomen. An old man with that much trauma and pneumonia is unlikely to be able to tolerate food, so I put him NPO (nothing per oral). Despite the grief, I think this man will do fairly well, though I suspect he will be with us for a while.

21 April 2011

Lactose is the main sugar in milk, both human and cow. Lactase is the enzyme that breaks lactose into simple sugars that can be absorbed into the intestinal villi, the finger-like projects that increase the surface area of the intestines and thus enable us to absorb more of our food. Lactase is produced at the tips of the villi. It is therefore not uncommon that a gut injury, such as a prolonged diarrhea, will cause sloughing of the villi and a secondary lactose intolerance. In the US, your Pediatrician recognizes this and prescribes a lactose-free formula (such as soy) to allow a period of recovery. This also happens in adults. In my last trip to the US, I had the pleasure of experiencing this malady. The treatment is simple: avoid milk for several weeks. An alternative is to buy lactase in the drug store and add it to the milk you drink. The problem is much more serious in Sudan. You cannot run out to Wal-Mart and get some Isomil, much less the lactase. Moreover, there is a love of milk here. At the cattle camps, milk is the primary food group for every age. And mothers exclusively breast feed their babies for the first year of life if not longer. I am sure that the scarcity of food was part of the reason for this rule, but it is almost universally obeyed. It is not at all uncommon for an 18 month old child to continue on the breast as his only source of food.

On the ward we have a 10 month male who was admitted with asthma, pneumonia, and sub-acute diarrhea (5 weeks). He has responded to our treatments, but he continues to have loose stools and to be in a lot of pain. I raised the question of secondary lactase deficiency, and mother agreed that it was likely. She said that every time she nursed her child, the diarrhea worsened. I suggested yesterday that we try to get the child to take oral rehydrating solution (ORS) to spread the nursing about a bit. The child refused the ORS. I suggested medida (porridge). But the child is whiny and clingy and reaches into his mother’s blouse to pull out his comfort. If I am right and this mother weans him, either permanently or for a short stay, he will recover. But that means standing up to this whiny mound of jello and refusing to give him the breast. And of course, the child thinks the mother has ceased to love him, for she refuses to give him what he most treasures. That takes resolve on the mother’s part not to give in, but it is in the best interest of the child. We will see how she does.

22 April 2011

“All authority in heaven and on earth has been given to Me. Go therefore and make disciples of all the nations, baptizing them in the name of the Father, the Son, and the Holy Spirit, teaching them to observe all that I have commanded you, and lo, I am with you always to the end of the earth” (Matt 28:18-20). I say that most Americans misquote the Great Commission because they leave out the start. But how am I to make disciples? How can I persuade men to die? How can I get men such as the rich young ruler to see their need of a Savior? The answer simply is that I cannot. If the Holy Spirit does not do the work, no one will come to Christ. But Jesus sends me out not in my own power and ability, but under His authority. It was His authority that chased out demons, withered fig trees, raised from the dead. I go carrying His badge of authority and knowing that He will do the work; He just calls me to be obedient.

Authority is a great theme in the Scriptures because it is so important. The one man who seemed to really impress Jesus in all of Israel was the centurion who understood authority’s ramifications (Luke 7:1-9). But I always thought his statement to Jesus was insightful. “For I also am a man under authority.” I would have expected him to say, “I am a man with authority,” but he does not. He also seems to understand that Jesus is sent under the authority of the Father, and we know that is true. The point is that a man understands authority first by serving under it and later by having it. The man who rises in the ranks can become Maximus, the great general, whereas the one who claims authority without learning it is Comitus, the usurper and regicide (Gladiator).

We have had a crisis of authority here in Akot. One man who is my close friend has sought to exert authority without ever being under it. In some ways he is a wise and mature man, but he has a blind spot with respect to authority. We have some Americans visiting with us who come with the authority of the church and the checkbook. As my appeals to this friend have not resulted in any yielding on his part, he will now be forced to learn authority by being under the authority of others, even some he sought to elevate himself over. It will not be a pleasant lesson. I am hopeful, however, that it will be a good one. I am praying that God will use this in his life to show him his error and bring him to the point of repentance. And I firmly believe that if he will learn, he will become a much more useful man in God’s kingdom than he has been to date. Please pray with me.

23 April 2011

“God moves in a mysterious way His wonders to perform” (William Cowper). Today was a strange day, filled with mystery and potential for good or bad. The day before, the interaction we had with my friend mentioned above went as poorly as I had anticipated, though he did hear us out and did not walk out prematurely. He adamantly refused the position offered to him, though in many ways it was the same position that he had officially had before. What he accurately saw was that there would be those in authority over him, and he thoroughly rejected that plan, though that was the only position we would offer him. We did pray for him and give him 24 hours to reconsider. This morning, as Bill Deans, Bob Claytor, and I were leaving to go to Maluel, Abraham returned. His countenance was lifted. He said he had reconsidered and would accept the offer. I had little doubt that reality was dawning on him. Though his rivals would make more than him, he would still be handsomely compensated, at least by Sudanese standards. I consider myself a realist when considering human motivation. God is utterly unselfish; man is not. Man is motivated to do what is in his best interests. I believe Jesus speaks to that reality when He tells us “store up for yourselves treasures in heaven where neither moth nor rust destroys and where thieves do not break in and steal” (Matt 6:20). He does not tell us to work because it is the right thing to do or because it makes you feel good. He calls us to seek delayed gratification, seek the better later; He does not call us selflessness, for we cannot do it, but we can learn to look to Him as the rewarder that really matters. So though I was aware of Abraham’s mixed motives, I was very pleased to see him humble himself in that manner.

We also had unexpected guests. We were already hosting six good friends of Akot Medical Mission, six people who have committed their prayers and finances to being a part of what God is doing here. But early in the afternoon I met someone I had talked to before, but had never met. Kimberly is the head of MWP, a group that at one time considered assuming control of this hospital, though those plans fell through. But in the process of the plans failing, relationships were hurt. She was unaware of the group that was here, but since the plane taking her to Bahr el Ghazal brought us some supplies, she came to meet me and the other members of the hospital staff. That meeting between two who had not enjoyed their previous interactions was awkward enough. The plans were for the plane to drop the medications and refuel and continue on to Bahr el Ghazal, but the plane developed problems shortly after taking off and had to make an emergency landing. By the grace of God no one was hurt. However, Kimberly and her group were forced to spend the night and interact with the groups here.

“A new commandment I give to you, that you love one another, even as I have loved you, that you love one another. By this all men will know that you are My disciples, if you have love for one another” (John 13:34-35). God is into relationships. He desires a relationship with men, and He wants His children to have relationships with one another. Abraham hurt some relationships by abusing authority; now he will have to learn authority properly and seek to mend relationships with his brothers. The leaders of MSI and MWP were forced to be in close proximity and be cordial. I would love to be able to say that the story was over, that Abraham learned to be under authority and that there was complete reconciliation between the leaders of MWP and MSI, but I would be lying. However, it was a start. I believe that God’s brought this about as if to say, “That is your brother in Christ; you cannot simply walk away, even if there has been pain.” At the end of the time, there was still much to be done, but a new beginning has been launched. Let us not kick against the goads. Cordial is not intimate. It does not fulfill Christ’s commandment, but it is a step. As with Abraham’s relationship with the Dinka Christians here, there is a long way to go. Maybe I am unrealistic, but I am encouraged. “A battered reed He will not break off and a smoldering wick He will not put out until He leads justice to victory and in His name the Gentile will hope” (Matt 12:20-21). I see the hand of God in the events of today. I am praying that they will bear fruit that glorifies God.

24 April 2011

Happy Easter! The churches in Sudan swell in attendance on this day, much as they do in America. Along with Judy Doll and Dr. Rosy, I attended church today at the Baptist Training Center. The numbers there were fairly small, though we had three pastors in attendance.

As usual, I was asked to preach. I read the Easter story from John 20, but told the “other resurrection story,” the story of Lazarus found in John 11. That, too, is a great story. It struck me in my preparation that Jesus referred to Himself as The Resurrection even before Easter. But what really struck me was that resurrection stories always come out of pain. Martha and Mary suffered those days preceding Lazarus’ death. They grieved as they laid him in the tomb. When each of them says, “If You had been here, my brother would not have died,” they are exposing the tragedy that has befallen them. Jesus’ resurrection came in the midst of pain: His own intense suffering, the suffering of the disciples as they despaired over His death, the suffering of the Father has His plan is fulfilled and the perfect intimacy with His Son is broken. Yet out of the pain arose the great victory. On the contrary, the enemies thought they had the upper hand, yet their trump card was turned on them.

God’s plans for good usually wind through paths of pain before bringing us to what He has in store for us. “Humble yourselves in the presence of the Lord, and He will lift you up” (James 4). We see His pattern very clearly in the two resurrections. We want clear sailing, carefully charted courses that are laid out before us and over which we have approval. Those are not His plans for us. We trust Him even when our world falls apart, and somehow He makes it come together for good. Jesus loves the title of The Resurrection because it is our ultimate hope, but also because it is His pattern for us. Happy Resurrection Day! Happy Easter!

25 April 2011

Trees are an important part of South Sudan. Even during the dry season, we have trees offering shade and beauty, and often food (such as with the Mango or Lulu trees). North Sudan has almost no trees and they are right to be envious of our trees. The giant, beautiful mahogany tree out front defines our waiting area. Most of the churches in the Akot area are log-benches set up under a tree. During Anyanya (the war of northern aggression) the Sudanese Air Force targeted trees for their bombings, so the people learned to leave their natural allies and lie down in the fields when the bombers approached. So trees are an essential part of the landscape of South Sudan. But falls from trees are a significant cause of morbidity (injury) and mortality (death).

A ten year old boy came into the clinic with his L arm wrapped in cloth, supported by his R hand. With him came the distinctive odor of Pseudomonas (if you want an idea of that smell, take a whiff of some old tennis shoes). He was in obvious pain and had a lot of fear. I was told that 2 days prior to the visit he fell from a tree and that a piece of the bone stuck through the skin. He was taken to the local bone setter and had the bone set, but now he was sick and in pain. The child was miserable. Given the choice, he would have opted for a treatment from equine medicine: shoot the horse. Just unwrapping the arm intensified the fear, pain, and smell. Under the wrapping was the usual “cast” of the local bone setter. Do you remember the when you built a miniature house and yard and constructed the fence from Popsicle sticks? The cast looks like that fence, only it is bamboo sticks strung in wire. For this boy, the cast had two effects that affected him oppositely: it supplied support for the shattered bone, thus reduced his pain, but it was an unyielding stricture against the swelling, making the pain worse. I located some of the new material that we have received for splints. It is simple but brilliant. It is a metal mesh covered with soft, water proof material that can easily be bent to the shape of the extremity needing support, but then offering good support once in place and wrapped by an Ace wrap. I shaped that into the form needed to help this boy and then quickly put it under the arm as I removed the “cast.” That allowed us to examine the arm without shifting the broken fragments of bone and thus intensifying the pain. On the palm side of the arm there was a purulent appearing sore that was a 2 x 3 cm oval and from which the smell was the most intense. On the dorsum of the arm was an area of swelling and fluctuance that was intact.

The boy weighed 25 kg, so I gave him an injection of Ketamine 50 mg and let him calm down. We kept him quiet and I saw another patient in the clinic. By the time I returned, he had the typical Ketamine stare that says, “I see you; I know what you are doing, but I do care.” I injected the Lidocaine and opened the area. I did not find pus. The “weak blood” of necrosis poured forth. I put him in the hospital for IV antibiotics of Gentamicin and Chloramphenicol. The next day the nurses unwrapped the wound and opened up the area proximal (towards the center) from the palm. A lot of pus and even some bony fragments exited. After two days (today) in the hospital, he is much better. He is afebrile. The swelling in his arm is about half of what it was. He slept last night and is eating fairly well. It feels as though the ulna (the bone from the elbow to the little finger side of the hand) is shattered. The drainage has subsided, but not completely.

This boy has a long course ahead of him. Best case scenario for him is weeks of IV antibiotics, months of casts/splints, and a weakened but functional arm. More likely scenarios having him keeping the arm, but losing virtually all function in the arm. And he will be on oral antibiotics for months. But I am hopeful that this arm may recover to a large degree and remain somewhat functional. We will see.

26 April 2011

I have never liked good-byes. I guess that goes along with being a rut man. I want everything to stay as it is. We have had a good team in. In was an interesting team, brought about by the hand of God. Some of its components did not seem to fit together, yet it seemed to work. Indeed, one of the great blessings was that there were those who would not have chosen to be together, yet steps towards mending of those relationships were taken. It was a courageous team. There were some difficult problems that needed to be addressed, and they did it. At the same time, it was a gracious team. They were ready for reconciliation, or at least taking steps in that direction. They were quick to perceive good steps, even if the same person had a hundred stumbling steps around the same time. Some strained relationships were completely reconciled. In others, the first steps were taken. And it was a fun team. We laughed, told jokes, acted spontaneously, enjoyed one another. So it was hard to take this team to Rumbek and send them flying. At the same time, I was sending Rose away. Her last trip home was to identify the body of her eldest child who died of meningitis four years ago while away at school, and her mourning then was cut short because she had to rush back for her oldest girl, Nyanakot, who also meningitis (she was treated at AMM and lived). So it felt like a double whammy sending her away for 2 weeks.

Will there be good-byes in heaven? We are told there will be no more tears. Since adolescence, I think I have cried at a high percentage of departures, so either they will be less painful or they will cease. I hope it is the latter. I want to get to heaven and stay home. I want us all to be together. I want to be gathered in the Father’s house, enjoying Him and His children. I think it will be exciting but comfortable, familiar yet challenging. It will be like the best of family holidays. I want to sing songs and swap stories of His grace in our lives and fall before my Father in worship. I think heaven will be homey, yet anything but boring. Maranatha—come quickly Lord.

27 April 2011

The Dinkas in general have a low body mass index (BMI) and low blood pressure, neither of which is true in the American Black population. It could be genetic, as the Dinkas are quite underrepresented in the America, but I think it is more environmental. Most Dinkas eat two meals/day or less and meat does not figure prominently into their diet unless there is a celebration of some kind (marriage, holiday, etc). Many of the more affluent Dinkas tend to be obese and the obesity related diseases follow them. Recently we have had several patients with more typical Internal Medicine (IM) in America diseases. One of our higher ranking policemen has been seen several times lately with asthma, gastroesophageal reflux disease (GERD), and hypertension. One of our best drugs in our limited armamentarium against hypertension is Atenolol, a long lasting beta-blocker, but there is a relative contraindication for that drug in asthma, so we are treating him with Enalapril (an ACE inhibitor) and diuretics. The man has quite a paunch, making me wonder if Dunkin Doughnuts are the chief culprits for similar issue in America, as it is widely assumed. Because of his position, he has refused admission to the hospital, but we have gotten things under somewhat better control, though his blood pressure (BP) is still not good (156/108). If we can keep his reflux under control, his asthma should become less of a problem, and maybe we can try the Atenolol.

The second patient is the biggest woman I have ever seen. I met her a couple of weeks ago when I helped her son deliver some timbers to their home. Her sons are all 8-12 inches taller than me, but none of them are as tall as their mother. She is pushing 7 feet tall and 200 kg. She is a very nice lady, though she gave me a flash back to my 7^th grade. In my hometown, the churches sponsored socials, events where records were played loudly and everyone danced. Standing over in the stag line, I received a summons from Tonya. Tonya was a beautiful girl, but she was very tall and had blossomed early, whereas testosterone was something I was still hoping would enter my life. I answered the summons, as I did want to dance, but it turned out to be a slow dance. The potential for enjoyment was high, but I felt much more like Madonna and child rather than a dance partner. And I would have had the same experience with this lady today. A few days later she was in the hospital with vomiting and fever. She was improving on conservative therapy until yesterday when she started having pain in the L leg. Her calf was warm compared to the other side and though the calf was the most intense point of pain, she was tender all the way up the saphenous vein. I am fairly certain she has a blood clot, a deep venous thrombosis (DVT). Unfortunately we do not have heparin or Coumadin. We started her on low dose aspirin and antibiotics. Today she seemed less tender in the groin region, which is the dangerous part, at least for pulmonary emboli. But I expect her to stay with us for a few more days.

Our third IM patient is a 60 year old woman with chest pain radiating to her neck and L arm. It could be “the big one” as Fred Sanford used to say (Sanford and Sons), but her pulse was relatively slow and her heart exam unremarkable, except for the BP, which was 185/95. She also had a history suggestive of GERD. I did admit her, but I am hopeful that if we can control the BP (this time with Enalapril and Atenolol) and GERD, her chest pain will resolve. If it does not, she will be in trouble, because we do not have many more options, but I am hopeful.

28 April 2011

Yesterday in the afternoon I started having some grumblings of GI malcontent. I had a couple of fairly rapid descents upon the cho and by the third time I knew that the night time would be challenging. It was. The distance from my tent to the cho is relatively modest, but in the middle of the night it seems like a marathon. I do not know how often I made that journey, but it was more often than I wanted. So when my alarm went off, I was not thrilled, but I got up anyway. However, about an hour into my study I gave up the ghost and went back to bed. It was a wise decision. I immediately fell into a deep sleep interrupted only by some more “calls to the rear.” So when it was time for devotions, I opted out. Dr. Rosy called me a few minutes later to inform me that they were waiting for me, but I told him of my decision. What I really wanted to do was sleep, but the concerns of the Dinkas for me quite overwhelmed me. Several friends came in and prayed over me. Even the women came into my tent. That was very unusual. They would have never considered coming into my tent otherwise, as it would be breaking social taboos, but my illness gave them permission. They were touching my arms and saying “atoic” (fever) and generally seeking to make me more comfortable. Elijah came in and prescribed medicine, delivered it, and offered to start a drip. “I was sick, and you visited Me” (Matt 25:36). I did want to sleep, but I enjoyed being fussed over. Who doesn’t? How practical and joyful are His commands for us.

29 April 2011

I remember reading in the James Herriot books about the time when the sulfa drugs came out. Some calves had the scour and all his remedies had not worked, but he had just gotten in the sulfa drugs and was anxious to try them. The farmer was somewhat reluctant because the necromancer gave slightly more money for live animals, but James was so adamant that the man consented. James came back the next day and thought that the calves had died anyway because they were no longer in the stall, but they had completely recovered and were among the rest of the herd. Such amazing things happened at the time of the introduction of antibiotics, and so they were dubbed “Wonder drugs.” But that was 70 years ago, and though we still have effective antibiotics, they almost never work that quickly.

A two year old girl was admitted two days ago with high fever and watery diarrhea for 5 days, with the diarrhea much worse the last 12 hours. I started the child on Chloramphenicol thinking this was typhoid fever. The response has been good, but not amazing. The fever is down, but still present. The diarrhea is much less. But the father is insisting that I treat the child for malaria. I have taken tests in continuing medical education that insist that malaria does not cause diarrhea. I am fairly certain that they are wrong. Diarrhea is not one of the cardinal signs of malaria, but it is seen fairly commonly as an associated finding. The reason I do not think this is malaria is because we are still in the dry season. I have not seen mosquitoes around. If there are no mosquitoes, there can be no malaria. I did hedge and add Amoxicillin as well, though I doubt that is as likely to help as the Chloramphenicol. I think the reality is that we are a victim of our own success. People, whether in the US or Sudan or wherever, want to get well now. If the medication is not working fast enough to suit them, they begin looking for an alternative. A wise doctor will reconsider his steps. He will think about what has happened and compare that to what he expected to happen. Is the patient truly doing better or not? If not, why not? Is it the wrong diagnosis? Is it the wrong treatment? Is the medication getting into the patient? Or has there just not been sufficient time? Right now the diagnosis still seems appropriate. We have expanded the treatment some, though not dramatically. I want to give it more time before making drastic changes.

30 April 2011

Sometimes the simple tools are the best. I trained in an era when meningitis was a relatively common diagnosis. I made the diagnosis many times and it was always what I was fearful I might miss. Because of vaccinations for H. influenza, Streptococcus, and Meningococcus, it is very conceivable that a doctor, even a Pediatrician, could go through his entire residency without seeing a cause of meningitis, but I do not remember a month of ward or ER duty without a lot of cases. I always found that one of the best tools for evaluating a child for meningitis is car keys. In those bad old days, the peak age for meningitis was 8 months, so using things like confusion and altered consciousness that the books recommended were useless. And bending the neck of any child will cause them to cry. What I found to be the most helpful signs were unusual irritable and refuse to bend the neck on his own. So every time I went into a room with an irritable child with fever, I took out my keys and started rattling them before the child’s face. Almost always, the child became fascinated and his eyes were locked on the keys. So as I continued to rattle, I lowered the keys down to the point that the child needed to bend his neck. If he bent his neck and continued reaching for the keys, I felt meningitis was unlikely. I did a few other things, but if he would not lock in on the keys or would not bend his neck, he usually ended up with a lumbar puncture, and many of those ended up being meningitis. On rounds yesterday we had several irritable children. Two of the children followed the keys into their laps. I looked in their ears and they both had ear infections. A third child had fever at admission, but the fever had resolved, yet the child was still remarkably irritable. I pulled out my keys and his eyes did lock in, but he would not bend his neck, though I tried several times to get him to. I was unwilling to call him meningitis at that point, but I told the nurses to keep an eye on him. That afternoon he spiked a high fever and was quite stiff. The nurses, appropriately, started him on Ceftriaxone and he was much better and far more relaxed this AM.

At clinic today, Andrew Marial, one of my good friends from ACROSS, came to inform us that in a relatively near village they had made the diagnosis of meningitis in three children. None of us have confirmed the tests using a lumbar puncture, much less through culture, and one of the most common signs (petechiae [small nonblanching red dotes on the skin]) is invisible in Dinkas because of the color of their skin, but four cases of meningitis in one day gets your notice. Then Gordon Mayom told me a young boy from his church started with fever and “joint pains” (body aches), progressed to a headache and neck stiffness and died the same night. The most common organism in the epidemic form of meningitis is Meningococcus. It is also the one that is most common in adults, and it is the most likely to result in death. It is almost undoubtedly the organism that claimed the life of our beloved Rose’s eldest child when he was away at school and which her older girl contracted while Rose was at her eldest’s funeral (she was brought to the hospital, was treated and lived). That was in 2007-8, when a large epidemic swept through Africa, as tends to happen every 3-4 years, so we think we are on the cusp of another.

Last time we intervened with the Meningococcal vaccine, and though the hospital was swamped (by report, I was not here), our deaths were relatively few compared to much of Sudan. We are trying to get in the vaccines and prepare our medical supplies now. Please pray for us.

April 1, 2011

I was recently out for holiday for a couple of weeks. Samuel Maker was restricted to the old pickup that needed the correct part (he had purchased the wrong part, hoping to make it work, but it did not). So for the last two weeks, there has been no one to help the people haul building materials. Meanwhile the rainy season has been drawing near and the repair and building of the tukuls needs to be complete before the rains come in earnest. Therefore once I was back and the pickups repaired, Samuel and I have been running continually trying to help the people get their mudbricks, bamboos, and grasses to the site of construction. I spent most of the day in that kind of activity, but Angelo still had some bamboos that needed collection from Warliet, so Samuel agreed to take him. It was around 6PM, but there should have been enough time to accomplish the task before night fell. I went to the kitchen to get a bite to eat and to read and suddenly Angelo was there. “Are you back so soon?”

“We did not go. The soldiers commandeered the truck and Samuel is taking them to Rumbek.”

I got Angelo to repeat what he had said so that I could be certain, and then I began to rage. We have worked hard to cultivate a relationship with the SPLA, but here they showed themselves to be difficult partners. We have had our standoffs. But this was different. It sounded as though the order came from higher up the chain of command. Samuel and Angelo had explained that the pickup belonged to the hospital, but that did not deter the soldiers, so I changed and went out “armed for bear.” Angelo was trailing me. I was muttering to myself and fighting the entire SPLA single-handedly with no weapon. I was magnificent. About half way there I noticed that I had taken pathways that were not as familiar, so I was glad that Angelo had kept up and could direct me. As we continued onward, I was able to get a bit better look at myself and I had to laugh.

The irony of my situation dawned upon me. In my devotions, I have completed Matthew and have started a study of James. The section for that morning was “This you know, my beloved brethren. But everyone must be quick to hear, slow to speak, slow to anger, for the anger of man does not achieve the righteousness of God” (James 1:19-20). In my mind, I saw my righteous indignation carrying all before me, subduing all into a quivering mass and achieving a new level of respect for the hospital in general and me in particular. But as I continued to walk, I realized the improbability of that dream.

We walked to the police station. My initial thought was to walk to the SPLA commander, but Angelo informed me that the commander was at the police station. As we neared the station, we saw a small bus pull away. “I think that is the commander and his people.” It was. By the time we arrived, the soldiers and the upper echelon of the police were gone. The man in charge was friendly (I had cared for him in the hospital), but could not tell me why the soldiers had taken our car or who had given them the authorization. My attempt at intimidation via my righteous indignation fell flat. He informed us that his superior had gone to the barracks and would probably return in a few minutes, so we waited until dark and then found our way back to the hospital. When we arrived, we were told that Samuel Maker had returned. His fuel had run out on the airstrip, but he and the vehicle were fine.

“Never take your own revenge, beloved, but leave room for the wrath of God, for it is written, ‘Vengeance is Mine; I will repay,’ says the Lord” (Rom 12:19). I have preached on that enough. It is about time I believe it.

2 April 2011

About two months ago, Justin Machar was bitten by the love bug. He had been emailing a girl he met with the Nehemiah Teams orientation and at my encouragement had written her a letter “to push it to the next level” (You’ve Got Mail). Haley wrote back that she appreciated the letter and would respond, but before she ever did, Amy wrote him. Justin and Amy had been in seminary together and dated for a while, but she gave him the “it’s not you, it’s me” line and it ended. But just as Justin was waiting to hear from Haley, Amy wrote to tell him that she had been thinking about him and that she had been wrong in her assessment of their relationship. Suddenly Haley was no longer an issue. I urged a measured response, but Justin had always thought Amy was the girl for him. Now that she saw it, he was not going to play it cool. The one obstacle between them and the altar, as far as he was concerned, was whether she could live in Sudan, as he felt God’s call to continue here. He told Amy how he felt and that she should come and see if she could live in Sudan. She asked what kind of clothes to bring. She met us in Nairobi just after Justin’s pack with our most important things (including an engagement ring) was stolen. Never one for half measures, Justin bought a replacement ring while in Nairobi.

Back in Akot, things did not look so promising for a few days. Sudan is a tough place to live and Amy felt it for a bit and made it plain to Justin. Also, I think the gravity of the decision they were making hit them both. But as the week went on, Amy warmed to Sudan, lost her reservations about Justin and Justin reheated towards her.

About four days ago, Justin was bit by a different kind of bug on his calf. Rarely can I identify an insect by its bite, but I usually can recognize complications. I have commented on how rapidly superficial infections here become abscesses. Justin asked me to look at the bite two days ago. He had a 10 cm area of warmth and induration surrounding the bite. I started him on some Cloxacillin right away. But it continued to get warmer and deeper.

Tonight was Amy’s last night in Akot. Tomorrow Justin drives her back to Juba to fly back to the US. I knew that if Justin’s plans progressed as anticipated, he would pop the question, so as they came in for some more beans and rice, I looked strategically. On her left ring finger, Amy was sporting a white gold and Tanzanite ring. I whispered to her that I noticed something new and she blushed. It was a fun evening. We joked with Amy and finished reading aloud The Horse and His Boy (The Chronicles of Narnia, C.S. Lewis). But then Justin asked me to look at his leg again. It had become angry and fluctuant. So after supper, I incised and drained the area. There are a lot of worse things that can occur than a simple incision, and Justin handled it well. Still, I doubt many have had their proposal accepted and their calf opened on the same evening. Both bug bites had come to fruition on the same evening.

3 April 2011

I have been surprised how often I find significant pathology that is incidental. I have gone driving somewhere and stop at a house only to find a child with a large abscess on the neck (I encouraged them to come to the hospital and have it drained, but I am fairly certain that they never did). We continually have patients who are visiting someone in the hospital and then come to us because of pathology that turns out to be important. We have a premature child who is being fed via a feeding tube. She has been with us a month and probably will be for at least that much more. Today her grandmother came to me with complaints of R breast pain. It turns out that she has been having drainage from that breast for 8 months. On exam, there are no lumps, but she has a bit of tenderness at 10 o’clock. She also has fairly large (1x1 cm, two of them), non-tender nodes in the R axilla. Her left axilla had some small nodes and the breast was normal. With massage, some serous fluid came from the R breast.

In the US, she would be scheduled for a mammogram for this week. Drainage from the breast, particularly from one, is cancer until proven otherwise. But that is in the US where even relatively small towns have oncologists and no one is truly far from state of the art treatment for cancer. That advance puts added pressure. No one wants to miss cancer at an early, more treatable stage. In South Sudan, even Juba does not do oncologic chemotherapy. Well, I know that they do not treat prostate cancer, so I am assuming that treatment for cancer is generally unavailable. I will treat her for mastitis, an infection in the breast, and see what happens. I will also make contact with Dr. Mergani in Juba to make sure my assumption is correct.

4 April 2011

I spent several years in academics, and I remember that I often felt the most pressure when examining the child of another doctor. On the one hand, you wanted to identify with the doctor, to let them know that you felt a kinship with a fellow practitioner. On the other hand, they came to me for my expertise. I use to say something like, “I know you are a doctor (or doctors) and you know a great deal, but I am going to treat you like any other parent and explain things simply and completely.” The risk of not treating that patient like any other is that you end of performing poor medical care. I remember an incident from my residency years when the wife of a doctor was allowed to push in labor much longer than the usual limits. When they finally did the C-section she had uterine atony (complete loss of tone in the uterus), almost bled to death, had an emergency hysterectomy and was on the ventilator for days.

We do not have many other doctors in Sudan, but I found myself today in a somewhat analogous situation. Nyanapen is a girl in her late teens I saw today in the clinic. She was pretty and articulate. She had finished secondary school in Uganda. And she was modest. That is not to say that Dinka women, on the whole, are not modest. They are. Yes, it is common for them to be bare-breasted, particularly at their homes, but that is not considered immodest. They are very reticent to be exposed from the waist down. And this girl, who was not married, was particularly shy. However, she had a swelling below the waist. She initially described it as in the buttocks, but then as Isaac got more history, it sounded more and more like a hemorrhoid. And she did have some constipation. I was about to assume it was a hemorrhoid and not expose her, but something she said made me uncertain, so I asked if she would mind if I looked. She was willing, but again so modest that she did not want to lower her skirt on the table. She got down on the floor, on hands and knees, before lowering her skirt. That, of course, meant I had to join her on the floor. Medicine is an elegant profession. It turned out that she had a perianal abscess that clearly needed drainage. That, of course, presented other problems. She had on a nice skirt that was likely to be ruined if not removed. I went to the ward and got a sheet. Actually I asked Elijah for one and he yelled to Monica, “Malilah.”

“Malilah means sheet?”

“It does in Dinka. In Kiswahili it means prostitute, so be careful how you use it.”

I took the sheet and some pads back to Nyanapen. She undressed from the waist down except for the sheet. She could not be seen by anyone but me, but, of course, that was distressing enough. However, fairly quickly the most severe discomfort was pain, not embarrassment. I have incised many of these, and hers went about as well as any, but it is an extraordinarily sensitive place. The Lidocaine instillation to numb the area just about did her in. The actual incision hurt very little, but the blunt dissection did. Still, about 20 ml of pus was drained, so she should feel much better. Now her only dread is that when she returns in 2 days, the modesty issue will have to be pushed again as the wick is pulled and the bandage changed.

5 April 2011

I have always been a soft touch. Here in Sudan, that is a problem because the problems are so deep, so real, so numerous. Right now the push is for school fees. Everyone knows school is costly. There is some hiding of that fact in the US because the fees come indirectly if you are in public school. Actual costs are quite high, and actual expenditure/student is higher in many public schools than in private, but the costs are paid in taxes. That is not true in Sudan. Each student has to pay his own registration and uniform fees (school uniforms are virtually ubiquitous in East Africa). But the costs are modest. Until the senior year, when the added costs of the national exam (somewhat equivalent to the SAT) must be borne, school fees are around 160 NSP/year (slightly more than $50). Unfortunately, though that is next to nothing in the US, it is a difficult fee for many to raise. Part of that is the parents are still trying to understand how education will help them, particularly when the student is in secondary school. By that time, the student can read, write, and speak English. Those are far beyond most of the parents. And the parents need the child now. The sons can work the gardens and daughters can get married and bring in some cows. Therefore there is little motivation for the parents to fund “higher education.” I have had a number of Dinkas approach me about school fees this week. Many of them will have to miss the upcoming year if there is no provision for their school fees found.

I am torn. I see the benefits of forcing people to discover the reality of their own resources and utilize them instead of looking for a handout. And I know that Dinkas, like Americans, would much rather spend their money on things that bring immediate gratification rather than putting it aside for what is truly important. But many of these approaching me are orphans or come from destitute families so that 160 NSP is truly out of reach. My plan is to give as many as possible the fees, as long as my funds hold out, but then make them pay back half the fee in monthly installments of 10 NSP. Almost everyone can achieve that. It is not as good as making them come up with half the money before the rest is given, but I think it can truly help meet their immediate needs and teach them responsibility. It may not be the best approach, but I think it is a good and will meet the immediate need while forcing them to make their own provisions and sacrifices for themselves.

6 April 2011

Gideon came into my room to tell me of an amusing patient he was referring to me. Gideon is quick to refer (sometimes I suspect he refers anyone who would require a physical examination) and some have been quite amusing, but this one would not be. “I am sending you a 60 year old woman who went through menopause, but then started having her period again.”

I thanked him for the referral, but I did not think it would be funny. When a woman starts bleeding a significant time after menopause, it is almost always cancer. But worse news was that I had heard back from Dr. Mergani in Juba. He agreed with my assessment about the woman with the breast drainage, but told me that they do not do chemotherapy in Juba. The way he worded his statement made it clear that they were not doing chemotherapy for any cancers. Thus unless this woman had some extraordinary source of money, this would mean her death.

The woman was a cheerful soul. I got some more history with the help of Rose. She had been through menopause about 14 years earlier. I asked her if she and her husband still had relations. She burst out laughing. Her husband was now dead, but they had not had relations for years before his death. “If he was alive, I could ask him what he wanted for breakfast, and that is about all. I could not even suggest that we have relations.” She was not bitter. She was chuckling as she said it, as if she were saying to herself, “These kawajas do not understand anything.” Her exam was unremarkable. I did not do a pelvic. For that to be of any help, I needed to be able to send a cervical smear to pathology. And even if I made a definite diagnosis, we had nothing to offer her.

I explained to her that she did have cancer. At first she did not understand, but she caught on quickly. “Well, when I saw the blood, I knew it meant I was going to die.” There was no protest, no self pity, no denial. Death is an ever present reality in Sudan. I gave her some Diclofenac for pain and explained that she would probably have more pain in the future. “We have stronger pain meds we can give you in the hospital. We will be here for you.” She thanked me, but I suspect that is the last we will see of her. Dinkas deal with their own mortality well, including the pain. I cannot help but admire their courage.

7 April 2011

Peanuts, or ground nuts as the Dinkas call them, are a hazard to the airway. I have pulled several out of the noses of children who presumably shoved one up the nares for safe keeping. But in my former life as a Pediatric Pulmonologist, peanuts were the most common foreign body in the airways. That is why your doctor recommends your child not be given peanuts until about 4 years of age.

I saw a 1 year old child this morning that was normal until he was eating some ground nuts and choked. Since that time, he was having difficulty breathing. It was very noticeable as he sat quietly nursing. When I examined him, he had inspiratory wheezes throughout the chest, but the noise was the same in all areas of the chest. That was actually a good thing. It suggested to me that the ground nut was in the upper airway (in the pharynx above the vocal cords) rather than below, though it was still possible that the ground nut was in the trachea. It took the child to the procedure room and inserted a Foley catheter (like the ones used in the bladder) through the nostrils, first the right side and then the left. Once it was clear of the nose, I pushed 3 ml of air into the catheter tip and pulled it back, with the idea that if the ground nut was in the esophagus, we would pull it back to the oropharynx (mouth and throat) where he could cough it out.

The results were one horrified and furious child. I did not retrieve the ground nut. But later as the child calmed down, he seemed to me to be breathing easier. The mother did not see any difference, but when he was nursing, there was no sound. My hope is that we were able to move the ground nut from the pharynx down into the esophagus and that he swallowed it the rest of the way and that the residual sound (because I still here the sounds) is from inflammation and swelling where the ground nut was earlier. My fear is that this is a tracheal or bronchial foreign body, but if that is the case, we are going to be in trouble. To remove a foreign body from the airway requires a rigid bronchoscope, usually performed by a Pediatric Surgeon. There is no such animal in South Sudan. I am more hopeful for this child than for the woman mentioned above, but the reality is that if this is a tracheal or bronchial foreign body, this child is either going to die or be sentenced to a long trying ordeal. And I will be sentenced to know what to do, but have no ability to do it.

8 April 2011

I just had a little cold, but it was Thursday, antenatal clinic day and there were not a lot of referrals coming my way, so I decided to go back to my tent for a bit of rest. When I came back, Gideon spoke to me about the referral he sent me, the boy with the swelling of the leg. I went and spoke with Rosy, the new physician here. Rosy was born in Ethiopia, was raised in Somalia and went to medical school there, received some training in Rome, worked for a number of years in Canada, and now is back in Africa. We talked over the patient. He is a 14 year old boy with swelling in his leg for one week. The father said that his son became sick while he was away in the cattle camp, and that is why he was so ill. He also said that 4 years ago the child had a similar problem, except that it was far worse and required drainage of pus from the leg in two spots.

The patient was lying on the bed in obvious discomfort. He was wearing a jalabia, the man’s dress of Arabic origin. He was prepubertal. I saw definitive proof of that as he lay there. His left thigh was at least twice the circumference as the right. He also had three old wounds on the lower portion of the thigh, one of which was draining foul smelling pus, but the major swelling was in the upper thigh. It was tense, warm, painful. There was an area of fluctuance. Rosy thought we might put him in the hospital for a few days and then drain the pus, but I thought it was ready for drainage today, so we proceeded in that direction. The child was fairly anxious, as well he might be, so we gave him Ketamine for sedation. When I instilled the Lidocaine, I aspirated the area and got pus, confirming my plans. After cleaning the area, I made a small incision (1 cm) and then used scissors to sharply dissect downward. I did not have to go too deep before a fountain of pus spouting 6 inches high erupted. Normally I am digging to find the pus pockets. Today I used the hemostats to hold the edges of the incision apart and let the pus continue to flow out. Altogether I would estimate 2-300 ml of pus was evacuated. I then performed some blunt dissection to find any more pus pockets, thus endearing myself to him all the more. When I finished, there was still a fair amount of swelling in the lower thigh, but I suspected that the pus had been under enough pressure that it dissected down tissue plains and I think it will eventually flow out the incision along the wick I placed. The smell was almost undoubtedly Pseudomonas.

We tried several times to elicit a history of a fracture or gunshot wound, but the father adamantly denied it. Still, given the history of the previous infection in the same thigh 4 years ago, I am convinced this is a chronic osteomyelitis. We did admit him for IV Chloramphenicol and Ceftriaxone and oral Flagyl. Once the acute infection is over, we will need some chronic therapy. I will follow the recommendations of my sister-in-law, the Orthopedic Surgeon, and keep him on Septrim for many weeks following the hospitalization.

9 April 2011

We have had one good rain, but the rains have held off for the most part, giving the villagers an opportunity to complete their building before the rains come. The walls of their tukuls are mudbrick that is then plastered over with mud that turns stone like in the baking sun. However, just like the ground here that seems rock like until the rains come and change the hard as brick roads into swamps, the rain disintegrates the mudbrick walls, particularly if it lands on top. Hitting the sides, the rain bounces off. Hitting the top, it puddles, softens, destroys. Therefore it is imperative that the grass roofs get finished before the rain starts in earnest. Last year my good friend Abraham Laat had finished his tukul except for the door, but he did not want to sleep there until the door was put in place. The soldiers came and took his grasses, and then the rains destroyed his very nice tukul. I was sick. So I know what the rains do to tukuls that are not protected. Therefore I am trying to help as much as possible. I finished rounds and decided to exercise. I had not exercised in three days because I had Strept pharyngitis, but I felt better today. About half way through, Joseph Mading came to me asking me to fulfill a promise I made to Gordon Mayom. Gordon’s tukul was recently burned by a fire that got out of control (to me, that seems common here), so he has repaired the walls and has to redo the roof and needed some grasses. At the moment, he was in Uganda retrieving his family, so it was essential that the roof be finished before the rains came. I completed my exercises and then took the truck out to the market to find Joseph. In the meantime, another two friends approached about their building supply needs, so by 10:30 my dance card was filled. We started towards Makoltit, the village beyond Tin-Machar. The supplies for my other two friends were in differing directions, so only Joseph Mading and I were in the pickup initially, though that changed when we reached the donkey at Tin-Machar. There was a wedding party there, and when they saw us, they flocked to the pickup. I guess I should have been offended that they presumed upon my offer, but in truth I was glad that they knew that if I had room and was going in their direction, they would be welcome. Moreover, a wedding party is a fun group. They are always singing and everyone greets you as you pass, so their joining us was a great treat. I have been in Akot long enough that there are few who have not at least heard about me, but the farther from Akot I range, the less that is true. In Makoltit, some of the boys knew me, but the family whose home was our destination did not. Still, they were warm and gracious.

I love and respect Dinka men, but Dinka women are something else. I have heard people complain that Dinka men are lazy. Well, compared to Dinka women they are, but compared to Dinka women, ants are lazy. Compared to Dinka women, humming birds just loll around. Dinka women are happy, strong, constantly working. When we got to the place where the grass was being sold, the woman of the house climbed up to the second story and started hurling down the grasses, making sure that they landed on the cut end so as to tighten the bundle. The grasses are not particularly heavy, but they are bulky. She acted as though she was tossing pebbles. We gathered the grasses and a few passengers and headed for Gordon’s home, dropped the grasses and returned to the market. Joseph left and John Mabor got into the pickup. We drove to Akot Primary School (not far) to pick up his poles (tree trunks with a Y fork at the top for supporting the roof). We loaded those and headed back to the market, looking for the third appointment of the day, Gabriel Matur. Gabriel lives near Gordon and suffered the same fate, so he is also rebuilding. He and John had similar material requirements and needed to go to the same place, so I was hoping we would accomplish them together, but Gabriel could not be located. We traveled to John’s home, unloaded the poles, visited with his wife and children for a short time, and Gabriel drove up on a piki-piki (motorbike) with a friend. Gabriel and John talked briefly, exchanged some money, and Gabriel took John’s seat. We were heading west. The main road from Yirol to Rumbek upon which Akot lies I have dubbed I-40, for it is one of the chief east-west arteries in South Sudan. It has alternated between a bone rattling, axle challenging ride of the dry season and the Molasses Swamp capturing unsuspecting vehicles during the wet season, but now it is being redone. The plow and scraping machine had almost reached Akot when we left; the steam roller was just up the road. Gabriel said he hoped that we would find the needed timbers in Atiaba, 8 kilometers away, but there was the chance we would have to go as far as Pan Awach (about 30 kilometers away) to find them. Two months ago I would have balked. Indeed, I did with one of my close friends. But now the road is a pleasure to drive. I was in 5^th gear. Until now, I had only used 5^th gear in that truck on the airstrip. We were sailing along between 65-80 kph (40-50 mph). Atiaba had nothing. Neither did Karic or Thon-Aduel, but I did not mind. This was easy driving. We crossed the Bahr Naam on the make shift bridge/causeway and I noted, to my dismay, that nothing had been done to repair the old bridge. The causeway is fine during the dry season, but will be washed away during the rainy season. I know that is only my opinion, but since I have seen the water higher than the causeway, I feel fairly confident in that prediction.

On the other side of Pan Awach, we found a house selling the timbers. The advertisement was a stack of them leaning against the tree outside their home. After pulling in, we were greeted as though we were doing them a great honor. And, as usual, they were thrilled and amazed at my puny efforts at speaking Dinka. The problem was that they had enough timbers for Gabriel, but not for John. Gabriel asked what we could do. We asked them if they knew of anyone selling more of the timbers. Maker, a boy of around 12, said he knew and volunteered to ride with us there. The father came as well. I was afraid we were talking about another 10 kilometers or so, but a couple hundred yards up the road we followed a path to another home. There again we were treated as royalty. As we stood outside the pickup conversing, primarily in signs, offered his daughter to me in marriage and I in signs accepted. She laughed. We all laughed. Marriage is both one of the greatest events in Dinka culture and the standing joke. Pretty young girls are constantly offered to old men like me or to young men like Justin, and you can see in the girl’s face that the joke is not as funny to her as to the others. Every girl needs to feel she is attractive, and I think Dinka girls appreciate having a kawaja treat them in that fashion. She did not really think I was going to marry her, but she was pleased by my response. Maker said he wanted to go to Akot. At his home, his parents consented, so we headed back.

On the Akot side of Karic, we found an NPA pickup truck on the side of the road. NPA is one of our nearest neighbors. We helped push the truck to start, but without success. Then we decided it needed to be towed to Atiaba. The problem was that the truck was headed in the wrong direction. Again we pushed the car through a three point turnabout, only to hear the unmistakable sound of a rapidly deflating tire. They suggested pulling it anyway, but I knew that would be miserable and would ruin the tire and maybe the rim. Their spare was flat. But we had a spare, so we used it. We had to get the truck off the road because there was traffic, heavier than usual because the road is good. But that meant backing the truck down a steeply sloping shoulder. They suggested using the winch, but I did not want to risk fouling the cable. We tried some rope. It was looped 4 times but not twisted, so as I tried to pull the pickup up the shoulder, each of the four strands broke in sequence as they bore the weight. I found a wrapping strap and that worked. NPA had promised a woman and her children a ride to Akot, so we let them ride in the bed of the truck. We reached Atiaba with no problems. Gabriel and I found some bamboo poles and loaded them in the back. Then our NPA friends asked us to pull them all the way to Akot. I think we made a fine sight. In the lead vehicle there was the lone kawaja with two other front seat passengers. In the bed, there were 25 timbers about 12 feet long exiting along the rear, and on one side four bundles of 10 fifteen foot long bamboos and about 7 feet in the rear the companion vehicle connected by orange packing straps. I had gloried in our speed before, but now we were crawling again. But it was fun. We drove through Akot and got to NPA. It was now 4 PM and I was a bit blown. In the village, others need my assistance, but I said I need lunch first. I drove Gabriel to his home and picked John and drove him for his deliveries in Mayom, but then the pickup would not start. It had happened like that recently and Samuel Maker found a disconnected wire. I was sure it was the same, but I did not know how to correct it, so John, some young boys, and I footed back to hospital. That may seem like a bad ending to a good day, but it was not. All along the way, I was greeted and given water and mangos. In fact, it made me realize how fortunate I am to be in Akot and to be able to help these needy but appreciative people.

10 April 2011

Last Sunday, Gabriel Amat asked if I would meet him at a new church dedication and preach there. Most South Sudanese churches are trees with benches under them and this one would be the same, but they were excited about the opening of a new church. It would be at the end of the airstrip, so walking distance and in an area with which I was fairly familiar. I gladly consented. He reminded me of it a couple of times during the week, and we settled on 7 AM for the time of our rendezvous. I am an early riser on weekends as well as weekdays, but I am a rut man. I stay in my routine. Moreover, the power ran out on us prior to my alarm, though my watch alarm kept me from being too late. Still, I had barely eaten and had not showered or shaved by 7AM, so I was hustling around to get ready. Rosy, our new MD from Ethiopia by way of Afghanistan, Italy, Canada, Kenya and now recently in Sudan, accompanied me as we set out around 7:30. Jacob Majak met us at the gate. Jacob is somewhat like me, spending about half his time in the ECS and half in the Baptist’s camp. I figured Gabriel sent him to get us to the church and that Gabriel would stay to meet Bishop Isaac. The drums, a sign not of native unrest or war, but of church, at least here in Sudan, were playing in the right area. I was half afraid that we were so late that Gabriel may have handed over the preaching responsibilities to another. I needn’t have worried. We came to a Lulu tree with 6 double rows of benches and four occupants, two of whom were the drummers. I sat down to outline the sermon that I had reviewed in my mind, but had yet put to paper. Over the next half hour, people started straggling in, though I started hearing some mildly troubling reports of Gabriel going to Makuac to conduct a wedding. I had attributed his tardiness to Bishop Isaac who usually had Gabriel meet him and conduct him to the church, but then Jacob informed me that the Bishop was not coming this week, but next week. Over the next hour, we sang songs. I joined in the one Dinka song I know, so they sang it several times. I was impressed that several of the young teenagers were leading the singing for various stretches. Finally when Deng Ater, the church founder, took control, we started moving through the ritual.

They asked me if I had reading for the day. I did: James 2:1-13 and Matthew 6:9-15. Deng Ater read one section. He read in Dinka, so I can say nothing about his accuracy, but he seemed to read well. (That should not surprise me, as he is an educated man and in the government payroll. That is the place to land if one is to be successful in Sudan. The Dinkas joke about the political stomach, but most of the few fat men in Sudan are in government; virtually all the obese women are married to GOSS men.) Then I got Jacob to read and could see that he struggled. That should have alerted me, but it did not. I told the story of the lord settling accounts with his servants (Matt 18:21-35). Jacob translated. I would say about 30-40 words and wait. Sometimes there was no response at all. Most of the time, a series of English words around 20-49 in length resulted in 2-3 Dinka words. I realize I can be wordy, but Dinka is not that condensed. He was not understanding me, or at least he could not translate in that manner. We went on that manner for about 10 minutes, with everyone looking a bit lost. Then Deng Ater took over, told the story up to that point (I presume he did a good job; he seemed coherent and the interest improved.) So he translated for me for the remainder service. We ended up having a good service.

As Rosy, Jacob, and I were leaving, one of the ladies I knew ran after us and compelled us to stay. I was hoping it was just for chai, though I had no reason for such optimism. Eventually it came out that the woman of the house had run to the market for food. That presented several problems. First, I did not want to eat their food. We have plenty and they do not, but their rules of hospitality dictate generosity even when they can ill afford it. Second, we had already been there four hours and I had things I needed to do that day. There are no meals ready to nuke in Sudan. After chai and small talk for about an hour, I got Jacob to beg for pardon, but we had to be released. The women reluctantly agreed. We started walking back, but when we had gone but a little ways, we met Ayen, one of the women of the church, coming in the opposite direction with food balanced on her head. I know that the balancing on the head is a common sight, but I often am amazed watching them. Ayen made it clear to us that she had food so that whatever release we had managed to obtain was nil and void, so we turned back with her. On her head, she was carrying a pot about 16 inches in diameter, maybe 14 inches high, topped by a lid and the brightly colored crocheted doily that all the women seem to have. She had a kerchief, but did not have the roll so many use. She was walking over very rough, uneven ground as rapidly as we walked, yet her hands never went up to the pot, either as she approached or walked with us. I made a comment about it and she laughed and started running for a few paces. The food itself was standard fare: goat meat in soup (broth) with noodles, and two stone cooked rolls. I liked it very much. I also appreciated the fact that no utensils were offered. I may have a lot to learn in my language skills, but I can eat like a Dinka. Why mess with spoons and forks when you have ten fingers? We were released afterwards with a good heart.

11 April 11

John Mabor played on my sympathy cords again. He wanted me to drive his relatives back to Paloc. Paloc is not a skip and a jump, nor is it a good road. But he told me his relatives had come to Akot to buy some flour and staples for the children because the children were hungry, but she had been in Akot for almost a week without finding any means of transporting the grains, so she was considering walking back to Paloc empty-handed. I could envision the scene. At first the children would be overjoyed to have their mother back, but within hours, they would be crying to her about how hungry they were and why could she not have found someone to bring the grains? So contrary to my better judgment, I agreed. I had also agreed to help Gabriel Matur take some poles out to his tukul where several members of the congregation had agreed to help him construct the tukul if the components were there. If the road to hell is paved with good intentions, the signage is provided by half truths. Gabriel told me that the poles were just behind the ECS church. What he meant was that if we took the road that ran by the ECS church, about a kilometer into the woods, we would find them. He also assumed that I knew we needed to transport the rest of his bamboos which were not terribly far away, but did need to be gathered and transported. So what I thought would take 15 minutes took an hour, so we were around 5 hours after the meridian when we departed for Paloc, a time that assured a return in the dark. Even in the dry season, Paloc is a tough road. We were constantly leaving the main little path to by-pass an area so chewed up by some unfortunate LandCruiser stranded in the last rainy season that it was still not fit for travel. In broad daylight I had difficulty in determining the road more traveled, so I was concerned about getting back late. We did pass a group of baboons, and right afterwards a little boy going towards them, so I asked if the baboons ever attacked. Never. If cornered they were very dangerous, but if given a means of escape, they would flee, even from a small boy. After a bit over an hour, we began to get into some of the homes of Jubilee, the village near Paloc. I remembered well the small church we visited when up for cattle camp 6 weeks earlier and the nearby donkey. There was no one at the church, but the women, of course, were at the hand pump gathering water. Shortly afterwards we came to John’s mother’s home. There was no thought we would just pass it by, being pressed for time. She would know John had been there and would have been insulted. We did keep the visit short, but one of the ladies obtained a promise of going back to Akot with us. There was no reason to take an empty pickup back to Akot. We arrive in Paloc and had to stop in the town center under the Abyea tree to greet the community leaders. I have been to Paloc several times now and many of them have come to the hospital for treatment, so there were many I recognized and all greeted me heartily. After about 15 minutes, I suggested that we continue on, but not before another lady obtained the promise of transport. Though we were in the village center, we still had another 15 minutes of driving to actually get to the home of the relatives, much of it over paths that had never seen any vehicle with four wheels. And, of course, there were two more stops with their greetings and obligatory seating. We finally arrived at the destination, but of course needed some more sitting time. It was after 6:30, meaning we had another hour of light. Two more people begged rides. We retraced ourselves to the next to last stop, but had to wait there another 10 minutes for the riders to arrive, though it was not because of slackness on their part. I looked with dismay at the house from where the two travelers originated, but was told the paths were not good to there. Having traversed paths they thought good, I waited, though impatiently. But as I looked, I saw them leave their house with their possessions on their heads and virtually sprint to the pickup. Precious minutes of sunlight were wasted, but not because of laziness. After that, we made our biggest mistake. We drove back to the Abyea tree and stopped. We might as well have shouted that we were giving out money. People came flocking to the pickup. I shouted at John to control them, but I have noticed that Dinka men have a tendency to get into intense conversations away from the scene of action at vulnerable points. By the time I got his attention, a pecking order had already been established and the one woman who had asked permission was excluded. I was furious, but there was nothing to be done. Had I forced a man to give up his place for the woman, she would have suffered for it later. We still had the one other woman waiting for a ride. John mentioned that to me as we neared his house, the reality of the consequences of his neglect falling upon him. I was still fuming and told him he could make a space for her in the back or she could miss like the other one we promised. Somehow she did get on.

Dinka men are great conversationalists. I have never been in the presence of two or more men when there was the awkward silence, the lull in the conversation that could not be bridged. Even when they have just met, they get into intense conversations quickly and they continue until they are forced apart. The man who had climbed into the seat beside me did not introduce himself. I therefore concluded that I had met him earlier. How well he and John Mabor knew each other was unclear, but I had to force John to break from the conversation so that he could see where we were and help guide the way back. The last half of the trip was in the dark and was mildly harrowing. Around every curve I felt lost, yet before I really appreciated it, we were back in Akot. By that time, John Mabor’s nieces and nephews were eating some of the grains their mother had brought to them.

12 April 2011

Yesterday on rounds there was an old man admitted by Gideon. He had been sick for several days and had gone to the market for some kind of treatment. When he received it, he suddenly became much worse. He could not swallow and was choking on his secretions. He had a high fever. On exam his tongue was markedly swollen and occupied most of his mouth. He had crackles in his chest (an area called the lingula). His blood pressure was low and his heart rate was high. I suspected him of having anaphylaxis (the severe allergic reaction) to whatever it was he took from the market), pneumonia, and probably pharyngitis. We gave him some epinephrine and Promethazine and the swelling in his tongue reduced. We gave him IV fluids and he did urinate once. Today on rounds he was not dramatically better. His tongue was markedly smaller, but he was still breathing rapidly and he was still fairly unresponsive. We gave him steroids and started running in more fluids. I switched him from Penicillin to Ceftriaxone because of the possibility that the medication that he bought from the market was Penicillin, so we could possibly be worsening the anaphylaxis as we treated it.

I don’t like doctors, either. I readily understand why people try all sorts of things to get out of having to go. But we run into so many complications of self treatment, the worst being the child who did with AIDS she contracted from her parents using a dirty needle to administer Penicillin. We are making progress in winning the people’s confidence, but in a culture that understands little about medicine, their confidence in us may keep them away from treatments that would otherwise kill them.

13 Apr 2011

People my age and older can remember the polio vaccines were introduced. I remember standing in line at Concord Elementary School to get my sugar cube with the attenuated polio vaccine (the Sabin vaccine). People of all ages were in that line. The Salk vaccine, the injection of kill virus, had been introduced earlier and offered some protection, but the epidemics of polio in the 40’s and 50’s were still recent history, so cooperation was not an issue. No one wanted polio for themselves or family, and we had one of the most rapidly successful programs ever, essentially eradicating polio in one generation (compare that to small pox, where it took over 100 years after the vaccination was discovered until eradication). In the US today, if someone has a case of polio, it is probably an older individuals who had polio as a child and who get the late phase of the illness, almost a relapse, though it is more autoimmune than infectious. If I ever saw a patient with the paralysis of polio I did not recognize it, but I see it all the time in Sudan. Abraham Chol is a good friend whose right leg is extremely weak compared to the left, his good leg. Maker rides one of the bicycle wheel chairs that allows him to propel and steer with his arms, because he is paralyzed from the waist down from polio. The youngest I have seen with polio was 5, indicating that our pushes for eradication are working. At present, according to Ann Buff of the WHO/CDC, there are 4 countries that still have endemic polio and South Sudan is one. Therefore a group of WHO/UN volunteers came to the hospital to observe the eradication program first hand. I was glad. The vaccinators have been working hard to train and motivate the workers. Those originating from our hospital have been enthusiastic about their work, going into the community and trying to hit every tukul. I remember the goal in the US being 70% catchment. Because of “herd immunity” it was estimated that if 70% of the people were vaccinated, 100% would be protected. The enthusiasm of the vaccinators makes me believe we will get numbers in line with those desirable figures. I proudly wear my polio eradication hat and shirt. I hope I will be able to say I was in Sudan when polio was eliminated. I have too many friends with polio sequelae. I hope no more are ever infected.

14 April 2011

I was in a foul mood at the start of clinic. There was a patient on the ward whose child died in the womb, an unpleasant issue for everyone. We attempted to induce labor yesterday without success, partly because the mother complained so much as the dose of oxytocin increased. She was not sick, but there is a relatively short period of grace until she is at risk for sepsis from the dead child and I felt like we were approaching that time, so I wanted to push things a bit. The husband wanted his wife transferred to Mapuordit, which we agreed to, but then he felt it was our responsibility to get her there. I did not see it that way. Then I found out that the woman with severe hypertension (185/105) never went to the wards. I am not sure what happened to her. Then there was a boy we picked up last night who fell from a mango tree and struck his head. He had a large goose egg on his forehead, but he was not confused. I put him in for observations, but his parents decided to take him to someone who would do something for him. I felt like I had made three good decisions, but had been thwarted by the superior medical knowledge innate to the Dinkas. As I was still trying to calm myself down, Martha Adongwei walked into the clinic. She was about 60 years old and turned a deaf ear to Rose who told her to wait to be called. She pointed to the orange shirt I was wearing. She informed us that the worms inside her were biting her heart and it had turned that color. She told us that she could not see out of her left eye, but that she had quadruple vision in the right eye. She had multiple other colorful complaints. When Rose asked her age, Martha declared that she was very old, “over 10 years old.” I was still trying to finish up the patient who was supposed to be in the room, but to emphasize her description and to insure her place in line, she removed half her clothing.

Typically when someone her crowds in front of others, it is a man, usually a prominent man such as the paramount chief or head of police and the people accept it as normal. Martha was allowed her place because of her audaciousness. She clearly had a cataract in the left eye and possibly in the right. I think her orange heart disease is gastroesophageal reflux, and I thought amoebic disease and parasites also probable. But what I really thought was that she made my day. My irritation turned to amusement. I look forward to seeing Martha Adongwei again.

15 April 2011

I am a twin. I think I have mentioned that before. My childhood memories are all “we” not “I.” One of my more frequent memories was weeding the garden. I am sure it did not occur nearly as often as I remember, but it seemed to me that every time we asked our mother for permission to go play baseball or participate in any other critical function, she sent us to the garden to weed first. Scott and I would complain bitterly to each other about the unfairness of life and swore fealty to garden-free living as adults.

Because of that experience, I have often wondered how to motivate children to work. I think of Tom Sawyer and his tricking his friends into whitewashing the picket fence, but I do not such an approach would work repetitively. It is still the end of the dry season here and everyone feels the push to complete their building projects. I was helping Gum Ater haul his mudbricks to his new tukul, and there were a lot of bricks to move. He and I were working and were joined by some adolescents, but a high percentage of the work was done by young boys. That has been true at most of the mudbrick movings that I have attended, and I have participated in a lot. The work is not easy. The bricks themselves weigh about 4-5 kg each. They are often fairly firmly attached to the ground. You have to be careful as you move them, for scorpions lurk under the bricks. I killed about 4-5 today. (I am usually the one who kills the scorpions if I am around, because I wear shoes. If you step on a scorpion wearing sandals, it will find a way to free its tail and sting your foot.) There are almost always some abraded fingers or toes from stacking the bricks or having them topple over on you. So why do the little boys do it? Part of it is to be with the men. John Eldridge likes to say that manhood is bestowed through other men (Wild at Heart). The boys like me because I like them. I see a little one carrying a brick alone or see one of the slightly older boys struggling with two bricks at a time, and I always say, “Aparak” (warrior, strong man) and they always laugh and appreciate it. But I saw something fascinating at the end of the day. After we finished, I was about to run on, but Gum stopped me. Ayen Ater, his sister and host of the post-moving events, had prepared tea. But as I looked over, all the little boys were gathered around and Ayen fed them ugali and okra soup. And the boys were sopping it up. Try that in America. Try getting 12-15 boys to work for two hours with the promise of rice and gumbo. They would be expecting money. If food, maybe pizza, but preferably something not nutritious. I was impressed. They worked hard and they ate hard. And they will be ready tomorrow for the same kind of outing if we have one. They are good boys.

1 March 2011

Dinkas have a flare for the “dramatis persona.” I have trouble counting the number of times I have seen patients carried in by a half dozen caregivers, all anxiously expecting the patient to give up the ghost at any minute, and then to find the patient’s examination completely normal. So when this monydit was helped into the room by his wife yesterday, I was not overly stressed. But after a few moments my stress level increased. I had trouble palpating (feeling) his humeral artery and could not get a blood pressure initially. When I did get a reading, it was 55/38, which is okay for a newborn, but distressing in an older individual. After a quick exam, I sent him to the hospital for fluids. He had a history of fever, copious diarrhea, and vomiting and I suspected Typhoid fever. We gave him fluids and Chloramphenicol. This morning after devotions, he was seated on the sidewalk. He needed some help getting up, but looked much better. Our cooks made him some medida (porridge) so that he could eat something. About halfway through clinic this morning, Francis came to me concerned about the man and wanted to expand our coverage to include Metronidazole (Flagyl, for amoebic dysentery). I agreed. Then at noon today I was told he died quite suddenly.

This afternoon I was summoned by Peter Makoi, the guard, saying a monydit was sick. I came out to the front of the hospital to find a man semi-conscious with the stench of diarrhea, bees buzzing around his hindquarters. He had been sick only a day with headache and fever, then started with abdominal distension today and vomiting and diarrhea. We carried him to the ward and started IV fluids. His exam was unremarkable. This temperature was 39.4C (103). His blood pressure was fine and the remainder of his exam was normal.

I have been seeing cases I thought were Typhoid fever, and I am fairly confident that is what the first man had and the second has, though I did hedge my bet a bit on the second and started the Flagyl right away. The rainy season hits us with its malaria. The dry season gets us with the dysentery. The abscesses are a continual source of amusement. It never gets too dull around here.

2 March 2011

I admitted a 25 year old male recently. He came to me with swelling of the left thigh and fever for a day. He denied any penetrating injuries recently, but he did have a severe break over a decade ago. He broke his femur (the bone in the thigh) and it was a compound fracture (the bone fragments stuck through the skin. The bone was set by the local bone setter and the young man did well until 2 years ago when he developed some swelling much like what I saw and had pus in his leg that had to be drained. The area was warm and fluctuant (soft like fluid) so I did open it, though I did not find pus. I placed a wick and admitted him to the hospital on IV Cloxacillin (an old drug in the US, similar to Methicillin which people know only because of the Staph aureus that is resistant to it [MRSA]) and Gentamicin.

He did well. His fever was down by the next day. The swelling was significantly reduced. He had a little bit of pain at the site of the incision, but nothing deep. We kept him in the hospital for 2 days of IV meds and discharged him on Ampiclox (Ampicillin and Cloxacillin).

I have a sister-in-law who is an orthopedic surgeon. It is good to have an expert in the family. Because of the fact that the bone exited the skin, I strongly suspected chronic osteomyelitis (bone infection). But there were some things that did not seem to fit. How could he go 8 years with no problems? How could he not have pain and fever between episodes? But the expert thought chronic osteomyelitis was the diagnosis (what else would fit?) and that the relatively benign course was not that atypical. She also gave me some tips in handling the problem. Like I said, it is good to have experts in the family.

3 March 2011

One time Francis, one of the nurses here, and I were discussing what to do when patients came in with ill-defined complaints and non-clarifying exams. We decided that we could always treat with iron and Mebendazole. Virtually everyone in South Sudan is iron deficient and most have intestinal parasites.

I had a 22 month old boy come to our clinic today. His symptoms were vague. He had been lethargic for some time, and when we pointed out the evidence of anemia (pale conjunctiva, nail beds, and tongue) she said he had been like that for 3 months. The child was sullen. He did not make eye contact or smile, but he also did not cry. He was small, his abdomen was distended, and he had multiple small lymph nodes in all the usual places.

I put this child in the hospital to start on iron and Mebendazole, but my concern is that he has leukemia. He is at the right age and would probably have a relatively good prognosis if he was taken to a pediatric cancer center. It is ironic that a simple blood test would tell us all we need to know. If his platelet counts are normal, then this is just “run of the mill” anemia. Anemia can arise from poor nutrition (probable in this case), infections (particularly intestinal parasites and malaria). It is very possible that he could have had malaria before (3 months ago) and had insufficient iron stores to regenerate the red blood cells lysed during the infection. Without the test, our best way to determine what is going on is to treat what we can, observe the patient for response, alter our therapy appropriately, and be content to say we have done all we could.

Addendum: With iron, Mebendazole (for parasites), and Ducolax (for constipation), the child did very well. He stayed in the hospital about a week, but went home looking and feeling much better. Are we now certain that this child does not have leukemia? No, but we are encouraged.

4 March 2011

We had an interesting array of patients today mixed in with the regular complaints. I was asked to see a little girl today with an abscess in her right labia majora (part of the vulva). I have quit being amazed at when and why and where abscesses arise in Sudan and have concluded that it is another part of the difficulties of being a Dinka. I am not one to overuse Ketamine. Often we just hold the child down, instill the Lidocaine, give it some time and open the abscess. But as an American, I have had enough psychology to tell me that such an approach to a little girl’s private area might have some long term ramifications. So I did give her Ketamine. She was not completely out. She objected to both in instillation of Lidocaine and the incision and drainage itself. The difficult part of the procedure (besides the fact that the new packet of blades does not fit our scalpel handles) is that after the pus is gone, there are still hard areas that need to be explored and evacuated, but that adds to the trauma for the child. I believe she will do well. Shortly after that we had a woman come to us about 5-6 months into her pregnancy with bleeding. Threatened abortions (miscarriages) are one of the most common reasons for admission to our hospital, and many do well, but this one would not. The uterus was hard and I could not find the child’s heartbeat. I suspected intrauterine demise. When I checked later, she had delivered a dead child. We have done that a fair amount, and it is always sad, but better than having to be transferred to Mapuordit for evacuation of the uterus. Dinkas grieve appropriately, but their grief is brief.

I also removed a ganglion cyst from the hand of Kana, a 10 year old child of a friend of mine. I got some tips on the procedure from my sister-in-law, though I do not think I “did her proud.” Ideally there should be a long enough incision and enough exposure for the cyst to come out, but I made a relatively short incision (about 3 cm) and between that, the poor lighting and my inexperience, I got into the cyst and left it rent from stem to stern, but did not really remove it. That means there is some risk of recurrence, though this should be more effective than the “Gray’s Anatomy” method (have the person place their hand on the table and whack the fire out of it with a large, heavy book, such as Gray’s Anatomy). I did use a combination of Ketamine and Promethazine plus a carpal tunnel block to get her still and decrease the pain and she did well. Finally, given our less than sterile environment, I instilled some Gentamicin into the wound bed to decrease the likelihood of infection. As we were taking Kana to the ward to allow her time for the Ketamine to completely wear off, Jacob told me there was another one I needed to see. This was a soldier who had been jabbed in the mouth with a spear. I have watched the way Dinkas play and suspect that this was not malicious. The wound was in the corner of the mouth, crossing the lips and going into the inner side of the cheek. He was also hit in the teeth of the lower jaw, and wanted me to remove two of them, though I felt the likelihood was that the teeth would recover. I refused. I did close the laceration, however, and felt good that it came together well. That is particularly important at the lip. It is strange how much scars at the lips affect us. If that “vermillion border” is not smooth, we almost always notice it. You never are certain how something will turn out, but I pleased with the way he looked as he left.

There are some disadvantages of being in South Sudan, but the advantages seem overwhelmingly more. I continue to be amazed at the variety of experiences, medically and otherwise, I have the privilege of participating in since I have been here. It is a great calling.

5 March 2011

Another privilege I have had is participating in has been teaching in the Bible School here. Justin Culp (Machar is his Dinka name) is working with e3 to establish a Bible Training Center here in Akot. The reality is that I have never had any formal training in theology or Bible, but I have been a student of the Bible since becoming a Christian in my teens. Also, I have had the privilege of sitting under a large number of really gifted preachers from whom I have learned much. That would not be sufficient in the US, but this is Sudan. In the fall I taught much of the Old Testament Survey course. I also taught Matthew and Acts in the New Testament Survey. I am just finishing a study of Matthew and it has been one of my most rewarding studies. But this week I had the chance to teach Galatians. The Bible Training Centre for Pastors book, our curriculum guide calls Galatians “‘the Magna Carta of Christianity’ and ‘Christianity’s Declaration of Freedom.’” I know it was Martin Luther’s favorite book. My daughter is with World Harvest and that ministry takes much of its Sonship course directly from Galatians. Therefore to teach Galatians was an honor. The book has several themes. Paul is establishing his authority as an Apostle, not an easy proposition, as he was not one of the followers of Jesus during His earthly ministry. But it was critical to be able to take his stance against the Judaizers who had followed Paul’s missionary journey to Galatia and sought to destroy it by adding to it. But that brings us to the major theme of Galatians: our salvation, from justification to sanctification to glorification is by faith. The Judaizers said that the Galatians needed to hedge their bets. They needed to add circumcision and keeping the Law of Moses to the merit of Christ if they would be sure of their salvation. But Paul makes it clear that the addition is really a subtraction. But by seeking to add those works, the Galatians were not doing the one work God calls us to do: believe. My obedience, therefore, is not to earn me status with God, but rather to reflect my gratitude to Him for the work He has accomplished on my behalf. I remember how freeing those words were to me as I went through Sonship for the first time. I saw that same attitude reflected in the faces of the men who were in the study. We were supposed to cover Galatians in a day. I made it half way through the first day. By the end of that session, 13 men were participating. There was not another day for me to finish Galatians on the schedule (we meet on Monday, Tuesday, Wednesday to accommodate the schedules of the men), but over half came back on Thursday to hear the remainder. Galatians is a great book. It so clearly states our position of faith, our adoption as sons, our freedom in Christ. What a privilege to teach those things to my Dinka brothers.

6 March 2011

When do we quit extending grace? Like so many issues dealt with in Scripture, there appear to be some contrary advice that, I believe, in truth balance one another. I am saved by faith alone (Eph 2:8), yet faith without works is dead, being by itself (James 2:17). With respect to extending grace, we are told on the one hand that our extending grace should be infinite (Matt 18:22), but just above that we are told that if the erring brother refuses to listen to the church “let him be to you as a Gentile and a tax collector” (Matt 18:17).

One of my best friends here is wrong, but he cannot see it. He has had conflict after conflict with various members of the churches in the area, but he always sees it as their problem. Indeed, he thinks he is Moses and they are the Israelites rebelling against his leadership. I confronted him fairly bluntly today, but he still thinks the reason I cannot see that he is right is because I do not know the Dinka language and customs sufficiently. That is true, but when everyone who does know the culture consistently says the problem is my friend, the odds are they are correct. This friend may end up losing his position if he cannot be brought around by another method, but I hate contemplating that decision. Please pray for us in this struggle.

7 March 2011

Today I did not preach at the ECS church. I talked with Gabriel Amat, the pastor and he asked me to preach. I did prepare a message for the people that I thought would be appropriate. But as I was heading out, I was interrupted by Joseph Apec. Joseph and I have had a “mixed” relationship. He is the coordinator for the Ministry of Health for Rumbek East County, our county. He lives part time in Adol, but appears (at least by my unscientific observations) to spend most of his time in Rumbek. Since getting to know Achol Achol, the Director General of the Ministry of Health in Rumbek, we have been signed up to receive medications that come regularly from the Government of South Sudan (GoSS) in Juba. The problem is that only recently (the last 18 months or so) have we emerged as one of the major providers in health care in the region. And before I got to know Achol Achol, what we did in Akot went fairly unrecognized in Rumbek, but now we are known. The medications from Juba have been delivered to and stored in Adol at the Across compound. That would be fine, except that Joseph has never given anyone in Adol authority to hand out our medications. Last week I was notified that the medications had come in and that most centers had picked theirs, but we had not. The one informing me was a friend, so in the politest tone I could manage, I responded that it was difficult for me to pick up medications in a timely manner when I was never informed that they were coming. This past Thursday I was told that I could come to Adol either Thursday or Friday to pick up the medication for Akot. I finished clinic and headed for Adol, but when I got there I was informed that Joseph Apec had left and I could not get the medications. We made many attempts to work through this problem without success. I was able to procure some IV fluids (which we desperately needed), but I made no progress on our meds until Leeanna, a close friend from Across, suggested that they talk with Joseph Apec and get the meds and deliver them to us on Saturday, because they were already coming to Akot to meet an airplane. When Andrew Marial and the team from Across arrived on Saturday with the meds, I was hoping that resolved the issue, at least for this month. But on Sunday morning, Joseph was at my door. We talked about the issue of picking up medications for a while. I stressed that I knew he was busy in his job, and therefore it made more sense for him to delegate the task of signing out our medications to one of the health care officers in Adol. He finally agreed. He also took me to task for not attending the month health care provider’s meeting, but I countered with the fact that I had gone to Rumbek the first Friday in January and February, the days designated for the meeting, but it was not held. I did receive notice in February the day before that the meeting would be the second Friday of February, but it was too short notice to be able to respond. Joseph also wanted us to fill out a weekly review of certain diagnoses made and to bring them every week to Adol. I asked about scanning and emailing, but Joseph wanted one of our staff to ride his bicycle there (about 20 kilometers one way) every Saturday. I initially balked at this, but said I would attempt to get it done. He held the carrot of a new bicycle for compliance. I thought about riding to Adol myself for a new bike. Finally he wanted to see the ward. That went fairly well. Both Francis and Elijah remembered Joseph well and our time on that side was cordial.

I have always been frustrated by pompous stupidity. It is ironic that I find myself in Sudan, for pomposity is state of the art here. Two major things associated with the supplies and medication distribution out of Rumbek have “frustrated the hound out of me.” The first was that Joseph would not delegate his authority so that someone could sign out the medications to me or my representative. I hope that has been resolved. The second is that though we are in essence the hospital of Rumbek East County, we are not acknowledged as such by Rumbek because we do not have a lab. There is one designated hospital in Rumbek East County, in Billings, but that hospital went under 8 years ago. So supplies that we could really use are taking up space in Adol, and we are forced to buy our own or do without. I hope maybe I can tactfully address that issue on our next meeting.

By the time Joseph left, Gabriel had already procured a substitute preacher. But I enjoyed the service nonetheless.

8 March 2011

Fungal diseases of the skin are somewhat difficult to diagnose and treat. My experience, both in the US and here, is that over diagnosis is more common, but under diagnosis is also common. One of the most common over diagnosis is calling nummular eczema ringworm. Nummular eczema is common, though not nearly as commonly recognized. It is small patches of dry crusty lesions on dry surfaces such as the forearm or anterior thigh. Generally speaking, fungal diseases prefer wet damp areas. We had a man come in today with a rash for 7 years that was a simple jock rash (tinea cruris). He had intense itching on the scrotum and thighs. On Dinkas, it is somewhat tough to see the areas of redness, but he did have a border and pimply rash in the usual places. Tinea cruris can be treated with topical drugs. But usually when ringworm is diagnosed, it is the nummular eczema and there are multiple lesions on dry skin. One of the confusing things is that they get better when treated for fungal disease, but that is because of Vaseline in which the medicine is suspended. I recently saw a good case of ringworm on Gabriel Amat’s child Micah Mabor. The one lesion had been there for months and was getting larger. He responded promptly to the Clotrimazole.

Another presentation of fungal dermatitis is “athlete’s foot.” That is when the fungus grows between the toes, usually starting towards the outer toes. There is maceration (soft soupiness, like when a scab sits in water), itching, and smell. It is common in the US because we wear shoes and our feet sweat. Dinkas almost never wear shoes. Their biggest problem is severe drying of the heels and soles, with cracking. Our providers love to give fungal medicines for that, but it is ineffective. What is needed is oil or Vaseline, and sometimes treatment for secondary bacterial infections.

There are fungal infections that will not respond to topical therapy, particularly of the head (tinea capitis) and nails. Both are common here. The tendency is to use topical therapy (anti-fungal creams) and occasionally it works when the lesion is very small, but usually on the head and always on the nails, Griseofulvin is required. I saw a woman today with severely roughened hands. I had seen her two weeks ago and told her to wash her hands and put oil on them (Vaseline is not available). Today she returned. Her hands are better, but it was time to deal with the nails. Two of her nails were thickened, brittle, dark. I started her on Griseofulvin, but warned her it would take a while (2-3 months).

I struggle with how much to tell our providers. They have been here a long time. They are starting to emulate my prescribing practices, so I hope that I can make a difference in this area without causing them to become too discouraged.

9 March 2011

Today I joined the 700 club. Not that one. Today I helped move 700 mudbricks. I have not gone into great detail about the construction of tukuls. They are completely constructed of locally available materials (locally meaning in Sudan, or even in the Lakes State, but not necessarily in the vicinity). There are wooden poles terminating in a Y (from the nearby bush) that go outside around the tukul and support the roof. The roof is constructed using bamboo poles (I am unsure of their origin) and grasses (fairly local). The walls are made of mudbrick. Though there are certain impurities that enter the making, such as straw and grasses, there is no attempt to add anything but mud (unlike the Egyptian bricks). I think a particular kind of mud is necessary, and you need water. You also need something with which to cut the bricks, like a spade. The bricks are cut in rectangular shape, with an attempt (and close approximation) of uniformity and then left to dry. Often the place for cutting and drying bricks is far from your tukul, but when the Dinkas leave them, there is no concern that someone else will take them. Everyone knows their bricks. I estimate that the bricks weigh 2-3 kilograms each. Therefore after the bricks are sun hardened, there is the issue of transporting them. I realize that I am introducing a foreign element into the Dinka culture. How have they moved those bricks in the past? What is going to happen if someday we are not here and there is no one to help them? I understand those concerns, but to me seeing someone in need and having the ability to help them and ignoring their need is to say to them “be warmed and be filled” (James 2:16). I had arranged with Jackson Dut to help move some of his bricks after clinic. Jackson is a good guy. When I first moved here, I was trying to play some volleyball, and we became friends during that stage. Later I found out that he is a teacher at Living Waters School. I got the pickup and transported some things to the market for Abraham Maper and was looking for Jackson without success. So Abraham suggested that we use that time to help transport his bricks (he had two hundred he needed to move to a tukul he is building in the market). I agreed and we went to his stash of bricks, loaded them up and moved to the market. As we were completing that task, Rose came to me to get help transporting the well repair team to Malual, her home. I have put a temporary hold on well repairs until the community leaders uphold their role in the arrangements, but I cannot let principal stand in the way of Rose and her family having water. So we loaded up the tools and headed to Malual. I was helping repair the pump when we found a pipe that was disconnected (probably rusted through the threading). That meant that we needed to return to the hospital, gather the spare pipes and return. On the way, we met Jackson Dut. So we gathered the pipes, picked Jackson, and returned to Malual. We dropped the pipes and went to Jackson’s brick stash and collected his which amounted to 500.

I have done a lot of mudbrick transporting, particularly this year. I have had various roles in the loading and unloading of the bricks. Often the majority of the help is from the little boys who just come and volunteer their services. I have done a lot of the stacking of the bricks in the truck (you need to be somewhat compulsive if you are going to get a full load). And I have done a lot of the toting (usually 3 at a time, which impresses the little boys). But Jackson’s crew won the prize. One guy was tossing the bricks and another would catch them and put them in place. I was impressed. I became one of the tossers during the unloading. To get the 500 bricks in two loads, we needed to go higher than the pickup walls. I did some neat pyramiding of the bricks to keep them stable. We had one near fatality when one of the tossers decided to toss to my receiver just as I was in the motion. I still had enough control to guide it away from him. The brick did not even break. It was a fun time.

I am sure some missiologists would disagree with my involvement in these activities, but I think I am on safe ground. “Do you know what I have done to you? You call Me Teacher and Lord, and you are right, for so I am. If I then, the Lord and the Teacher, washed your feet, you also ought to wash one another’s feet” (John 13:12-14). How will they know the love of Jesus unless we show them?

10 March 2011

We have had a relatively young man on our ward for a couple of weeks now. He came to us after a fall from a tree. We have been hard pressed to understand what he was doing up the tree. We have a lot of falls from the boys. Even the women occasionally are in the trees cutting firewood, but men are rarely in the trees. Moreover, from the sound of things, his fall may not have been accidental. By description, he was high in the tree and fell straight backwards, an unusual but not unbelievable story. Whatever the cause, he landed on the lower part of his back and on presentation could not urinate and his left leg was very weak. He had to have a urinary catheter placed. I saw him the next morning on rounds and immediately suspected a spinal contusion, a bruise of the spinal cord, if you will, and started him on injections of Dexamethasone for three days. He showed modest improvement at that point, but was unable to urinate when the catheter was pulled. Elijah felt that he had some resistance when trying to replace the catheter, so I suspected urethral edema (from the presence of the catheter) and we restarted the Dexamethasone. Far from what I anticipated, he started showing more improvement in the strength of the left leg. After a bit more than a week, the left leg was almost as strong as the right. On rounds today we were making plans for another attempt to remove the catheter. We are all amazed at how he is recovering.

Though we have lost our fair share of patients, we have had a lot of amazing outcomes. I would like to attribute that to diagnostic and therapeutic brilliance, and we have tried to approach our patients logically and physiologically. But we have had a lot more success that we should have had. I believe God has blessed us and honored our prayers for the patients. Tenwek Hospital has the motto: We Treat; Jesus Heals. I am tempted to plagiarize. There have been too many times when we had no idea where to turn, yet the patient recovered. Why some and not all? Why us at all? There are a lot more deserving hospitals around, but God has enabled us to do a good work here. And to paraphrase a familiar quote, I would rather be blessed than good.

11 March 2011

Injuries to the finger nails are common. If you think about how often our hands are put in harm’s way, the frequency makes sense. Most common are the subungal hematomas (the blood under the nail). All that is needed is a needle through the nail to drain the blood and usually they well. But a fairly common one, though much more severe, is the avulsion of the nail. I took care of one during the evening last week and a man came to see me today having caught the tip of his middle finger in the hand pump. The presentations are stereotypical: the hand is held up and away, the fingers are splayed, and the offended finger looks like a bloody pulp. The last thing that patient wants you to do is examine the injury. Therefore I start by getting them to soak the finger in antiseptic solution and then I do a digital block (injecting Lidocaine at the sides of the base of the finger). After giving it a few minutes, I was able to see the avulsion: the base of the nail was out of the nail bed and there were some lacerations to the cuticle through which it had escaped. The first thing I did was drill some holes in the nail to evacuate the blood there and to prevent there being another reason for the nail to come off. I repositioned the nail back into the bed, sutured the two lacerations to give some support to the nail staying in, and bandaged it with plenty of Bacitracin ointment.

The reality is the nail will die. It will start looking better and about the time it looks like it might truly make it, it quickly lifts off, but that is because the new nail has grown underneath and replaced it. So why not just cut the nail off. It is simpler to remove the nail, but that leaves the nail bed exposed. That can lead to drying and damaging the bed. Plus the finger is much more normal, much less painful. I think it is worth the extra effort. Here in Sudan, an exposed nail bed would probably be more likely to get infected, giving another reason for this approach.

12 March 2011

After a prolonged time in Sudan (by kawaja standards), altered plans (originally we were going to Egypt), Justin Culp (Machar) and I headed out for Juba on our way to some time out of Sudan. Once settling on Mombasa as our destination, we looked for the cheapest way out of Sudan and to the Kenyan coast. Mombasa is a port on the Indian Ocean. It is Kenyan’s busiest and most famous port. I look forward to swimming in the Indian Ocean. That will make me a three ocean swimmer, which I presume to be fairly uncommon. We originally decided on riding the bus from Rumbek, but that is not cheap and is much slower. Once we found a place to keep the car, we decided to take Justin’s car and we will leave it at the Juba office for Mission Aviation Fellowship (MAF).

We did not travel alone. When Rose Paul, the Ms. Everything for our hospital, was found to have an abdominal mass, we took her to Rumbek, and there I met Dr. Mergani Mohamed, an OB/GYN at Juba Teaching Hospital. I found another patient, Nyanamut, this time a 14 year old girl with an abdominal mass and I started talking to her months ago about traveling to the teaching hospital in Juba. When we decided on taking the car, we informed her family and she and her father accompanied us. There was another girl, 10 years old, who also had a mass and I also wanted to bring her, but the family did not show up in time. Nyanamut and her father spent the night in our ward, shared some of our oatmeal, and were ready to go at the designated time. (Actually I delayed us about 30 minutes, but we were pleased to get on the road by 7:30).

On my only other trip east, I spotted some unique wildlife and we had the same experience this time. I have seen several mongooses (? mongeese), but had my best view of one today because after scurrying across the road, he stood on his hind legs and watched us. He was about 30 inches in height with an equally long tail. He had stripes regularly dispersed on his brown-gray torso. And we saw 6 (at least) eagles. I referred to them as bald eagles before, but I did notice that the white extended past the shoulders onto the chest and the tail was white. Several were in trees not far from the road, but one was on the ground not ten feet from us. We also saw some baboons, though that is a common enough sighting not to elicit further comment.

Nyanamut had a difficult trip down. The road from Akot to Yirol is worse than towards Rumbek, necessitating many swerves and causing severe bouncing. That soon elicited motion sickness. I have been a great sufferer with motion sickness all my life and can sympathize. It is conceivable that the oatmeal in the morning was the offending agent, but I am fairly certain it was the travel. About every thirty kilometers we had a repeat performance until we found some soda.

My only other time to Yirol was during the rainy season when water was up to the road on both sides as far as could be seen and the river we crossed before reaching Yirol was impressive. Now there is no water along the roadside, though there are innumerable tuffs that look like giant toadstools that formed little islands when the water is up. The river is reduced to a small stream. Last time I traveled we were met by hundreds of fishermen returning with their catch; today the road was fairly deserted, though we were much earlier. Even the cattle camps were relatively deserted (I presumed the cattle have been herded towards more water).

After Yirol, we turned south towards Juba. The road was surprisingly good for a while and we were zooming along at a record breaking 80 kilometers/hour (50 mph). That, of course, could not last, though we made good time during those stretches (excluding the puke stops). The land is much drier and there were few trees. There are some small mountains around Juba, but the city itself is large and dusty. There are, however, paved roads, the first I have ever seen in Sudan (South Sudan is reported to have the least paved roads of any country in the world, but I know now that there are some). We stopped first outside Juba to visit Nyanamut’s uncle, a high ranking officer in the SPLA. After a brief interaction with the family, he and a woman (I think his wife) joined us and we proceeded into the city.

Juba is a city. Rumbek and Yirol were the only two large towns I had ever visited in Sudan, but Juba, though small by American standards. There is much construction of roads and buildings. I think it is clear that Juba is preparing herself for becoming the capital of the new nation of South Sudan.

We did find the Teaching Hospital of Juba. Dr. Mergani had left by the time we arrived, but he promised to see the patient the next day. We made plans for a rendezvous with the family on our return from Kenya and checked into the ECS guesthouse.

13 March 2011

Travel for the next 36 hours started well and ended poorly. We drove to MAF who were very welcoming. They included us in their devotions and prayed for the hospital and for our time out. They not only graciously allowed us to park our car there for 2 weeks, but sent a driver to take us to the airport, thus saving us cab fare. We arrived in plenty of time at the Juba International Airport (not nearly as large as Greenville-Spartanburg Airport). We boarded the plane just a few minutes late and arrived in Nairobi around noon. The smooth flow ended there. First, we had arranged a driver to pick us up at the airport, but I suspect the driver went to Wilson (our usual place of landing) rather than Jumo Kenyatta where this plane landed. About an hour and several phone calls later a driver did show up, but (as we were to find out later) without a key parcel. We were philosophical. We were on vacation. Besides we still had over 6 hours to make our connection at the rail station. Our drive to the train station was uneventful. We arrived 5 hours early, check a couple of bags, and confirmed our tickets for Mombasa. We were on the schedule, but our tickets were not there. Hakuna matata. We had five hours before the train left for the agents to get our tickets to the train station. Justin and I went to have a cheese burger and check some emails. Justin did a bit of shopping and then we returned to the train station with 1.5 hours to go. No tickets. Now it was no longer early. A few phone calls later we found out that the tickets were with the driver who was supposed to pick us at Jumo Kenyatta and now said that there was no possibility of getting the tickets to us before the departure of the train at 7PM. Meanwhile the train billeters were adamant that we could not go without the ticket. Eventually they gave in and wrote a letter explaining our situation after the driver assured them he would have the ticket there in the AM. It is important for our return. We will see.

For the most part, the train ride was fun. For movie buffs, this is the same train that Karen in Out of Africa took. I was told that at one time they served meals on fine china and used nice silverware for the trip. That is no longer the case. As we were getting settled into our bunk, the bellman came through ringing for supper. We sat down and Don and Gabriel were force ushered into our table. We had a great time. Don is an Aussie working at a refugee camp in Kenya near the Somalia border. Gabriel is a Kenyan originally from Mombasa but now living in Nairobi and headed to the coast for vacation. But we all enjoyed each other. We might have done it longer except that the bellman rang for us to leave. I have slept well on trains before, but whether it was the temperature or the tea (unusually strong) or the rough ride, but I aroused frequently through the night. Still we had plenty of time and even on those sleepless nights, we actually do sleep more than we think, so I did not fret. The bellman brought us to breakfast with a less convivial couple and the problems began. I noticed that we were stopped for longer than needed. I could not figure out why breakfast should halt the train’s progress. But then Godfrey, the train manager, announced that a train ahead of us had jumped the track and we would be delayed over an hour. It was significantly over an hour; indeed, it was slightly over 3 hours (but who’s counting). But we met Paul, a Brit working at an orphanage near Nairobi and Katrina, a German doing similar things north of Nairobi. The children from the Taro station were crowded around the train. Many of the people were throwing money out of the window, inducing near riots. I enjoyed my usual interactions of shaking hands and teaching them to do high fives. Finally we did get rolling and pulled into the station some 4.5 hours later than scheduled only to not find our driver. An hour later, he did show up and got us to the hotel about 6 hours after we had hoped. But we are here.

14 March 2011

Mombasa is located in southeastern Kenya. But as we were passing through the land on the train, there were comparisons with Sudan that were inevitable. First of all, children are children. As the train passed through, the children came out to wave at us, much as the children in Sudan come out to wave at the cars that pass through the village. To the best of my understanding, this train passes every day in each direction, but when the train comes, the children are excited. The adolescents feel the need to be somewhat cool and often are a bit embarrassed to wave, but will respond if I initiate the contact. In each of those, the Kenyans and Dinkas are similar. But the dress was different. It actually struck me that we saw no naked children. There are varying degrees of exposure in the older children in Sudan, but it is almost a given that at every tukul, every group that runs out after the car yelling, “kawaja, kawaja” there will be several of the younger ones with the essentials uncovered. I did not see that once in Kenya. A second thing stuck me was the homes. Similar to what I had seen in Bomet last year, the homes almost without exception lacked running water and power. But the homes were more stable, more permanent than in Sudan. There were a number of homes with grass roofs, but about an equal number with the corrugated metal roofs, whereas those are exceptional in Sudan. There were many of the homes constructed with the mudbricks similar to those from Sudan, but there were also a number made with bricks that had been fired or stones cemented together, whereas those materials are almost exclusively found in the homes of some of the “very rich” of South Sudan, usually government officials. There were many similarities, however. There were the ubiquitous women carrying the jericans of water on their heads. The children were not naked, but their clothing was not fine. There were fewer flip flops and more substantial sandals, at least at our prolonged stop where I had more leisure for observations, though there seemed to be just as many who were barefoot. Like in Sudan, the children wanted us to give them something, but they were content to have an acknowledgement that they were people, that we liked them and wanted to interact with them.

I watched the people throwing money out of the train window and I was reminded of missiology. You can interact with the children without giving them anything and in truth they like it. You offer them money or candy and they, of course, respond, but it is actually somewhat degrading for them to fight for coins or candy. They do not know it innately, but they prefer to look you in their eyes and touch their hands. And in missions, the people really prefer it for you to be with them. If we are going to make a difference, we have to be with them and touch them, not throw money at them. I am no expert in missions. I have done it a short time and not very well, but I know being with them, among them, involved with them is important. Hauling mudbricks around is nothing profound and does nothing to impress mission committees, but I think it is what Christ would have us do.

15 March 2011

As a three ocean swimmer, I want to give some impressions of Indian Ocean. When I came down the path from our hotel to the ocean, it was obviously at high tide. There was a ribbon of white sand covered in sea weed. And the water is hot. Until this week, I had experienced the Atlantic, primarily in SC, where the Gulf Stream keeps the water fairly warm, and the Pacific at Anaheim and Malibu, where the water is uncomfortably cool (Anaheim) and painfully cold (Malibu). But I had no idea an ocean could get as warm as the Indian Ocean is in Mombasa. Secondly, the salinity (salt content) is much higher. I did swim a fair amount. The water is pretty clear and blue, but there are almost no waves. Along the shore are tons of vendors, though some are unique (like camel rides). And you are inundated with hawkers who try to convince you they are your friends and want to make your life and time in Mombasa better, whereas the truth is you represent money.

Today when I came back to the shore, it was obviously approaching low tide. The water had receded 300 yards and there was a sandbar visible that earlier was covered. The shore was not like the South Carolina coast at low tide, however. There was a ton of actively growing seaweed and a low film of water punctuated by pools containing various sea creatures. Justin filmed a live star fish trying to get away. I saw a 3 foot eel. There were some brownish red sea cucumbers (I think) that initially looked like snakes, but had the villae at one end surrounding what we thought to be the mouth. They did recoil upon being touched. There were some other plant-animals of a different color that were similar, but who played host to black mollies with a couple of stripes down their dorsum. There were numerous fiddler crabs and several sand crabs that have a barnacled shell and the ability to blend in and rapidly dig into the sand. And we found the shell of a creature in the sand dollar family with the five pointed star on an oval shell.

As usual, for much of the time I was a lone mzungu (kawaja) among a multitude of blacks, and as usual, I felt safe and welcome. I bumped into a few as I swam, but none took offense. Many of the children were interested in looking at a mzungu. I remember when the South Carolina coast was segregated, so I am pleased each time I go there and find black families mixing in along the beach and feeling welcome there. I am proud to be a South Carolinian, though our segregated past remains an embarrassment to me and most of my fellow Carolinians. But if there was any problem with whites in Mombasa, it seems long past. However, in no possible stretch of the imagination do I blend in.

16 February 2011

Daniel Deng is a 36 year old man with elephantitis: blockage of the lymphatic drainage from his left leg. The most likely culprit in Daniel’s case is a filarial infection. Lymph vessels (lymphatics) are miniscule, but they are important. The circulation of blood through the body is a relatively complex process. Before Harvey (I think in the 1500’s) blood was thought to slosh around, as there was no obvious connection between the arteries (vessels carrying blood away from the heart) and veins (vessels carrying blood back to the heart). Of course, now we know that there are capillaries, exceedingly small vessels going between the arterioles (small arteries) to the venules (small veins). But in truth, the process is much more complicated than that. Capillaries are quite porous. Most of the non-cellular components of blood and even some cells can actually leave the capillaries into the tissues (some of the larger, more complex proteins cannot leave under normal circumstances). The efflux (leaving of the vessel) and influx (returning) of the water, electrolytes, proteins, and even small cells (lymphocytes) is dependent on various factors: blood pressure (arterial and venous), oncotic pressure (the pulling of water and electrolytes back into the vessels by proteins), tissue pressure, gravity, temperature of the tissues, etc. And the reality is that some of the fluid, proteins, and even some cells exit and do not return to the capillaries. These form the lymph fluids. The lymphatics gather the fluids together and course back towards the heart where they are reunited with the other blood components. Along the way, the lymph fluid passes nodes where B and T cells can be stimulated to provide immunity. Lymphatics are easily overlooked or forgotten until you find a patient like Daniel Deng.

From the knees up, Daniel is perfectly normal. Indeed, he seems fairly fit and bright (at least his English is pretty good). His right leg is normal, but from just below his left knee to the top (dorsum) of the feet, there is more and more swelling. He has had some severe infections at times. Currently he is stable, but such swelling is painful, risky, unsightly, and itches. Unfortunately there is no cure. Treatment involves wrapping the leg to increase the tissue pressure, thus pushing the fluid back inside the blood vessel, elevating the leg as much as possible, and treating significant infections as they arise. I gave him some Ace wraps, and I hope to get him some support hose from America. We cannot correct this (I think that is still true in the US, and I know it is in Sudan), but we hope to control it instead of it controlling Daniel.

Speaking of Daniel Deng, I heard something today about the derivation of Dinka. Deng, by the way, means rain, probably signifying that he was born when the rainy season began. In the late 19^th century the Arabs were seeking to control all of Sudan, so all the traders had to be registered. One of the traders from South Sudan had been staying at the home of a man named Deng Kau. So when the Arabs asked him, “Who are your people?” he answered, “Deng Kau.” The Arabs took that as the name of the tribe, not a person, and started calling them the “Dengka’s.” Later that was shortened to Dinka, the name by which we know them today.

17 February 2011

In the last group of journal entries (12 Feb 11), I talked about a child with gastroesophageal reflux disease, asthma, and a broken arm. He was brought back by his mother yesterday sans cast. I got a bit angry. I was proud of the way put on that cast and here it was less than a week later and she removed it. I thought to myself, “Well, that arm can just grow deformed.” When I asked her why she took it off (she soaked it and unwrapped the cast) and she said that the child was beating his arm and crying, so she removed it. She said it was an abscess. I thought to myself, “It is a broken arm. His older sister was carrying him and fell with him and broke the arm. How would you get an abscess from that?” But then I got off my high horse and examined the child. The R upper arm was indeed quite swollen and now was very warm. Moreover, the end pieces of the humerus (called the condyles) seemed to be in place and were not that tender. I asked mother again how this happened and the story was repeated: the 6 year old girl was running with the baby on her shoulders and trip and the child landed on his right arm. There was nothing that poked into the arm. As I further examined the arm, there appeared to be an area of fluctuance, indicating pus. Therefore we took the child to the procedure room. After a Lidocaine injection, I aspirated and got back thin blood, a sign of necrosis (cell death). I incised the area and explored, eventually releasing about 20 ml of pus. The child was miserable during the procedure and for a while afterwards, but then later he was using the arm fairly normally and was not upset at all. He slept well last night.

Mechanisms of injury tell us a lot about what to expect. Some months back we had a man here in the hospital that was in a car wreck. He smashed into the dashboard, breaking some ribs, and we were watching for the hypoxia that followed from the lung contusion and transported him while he was still stable. I think understanding how the injury occurred and thereby anticipating the subsequent problems is important, but it should not make me ignore what is before my eyes. Fortunately I did listen to the mother and reexamined the child soon enough. I still do not understand how he got an abscess there, but I did drain it and I think the outcome will still be favorable.

18 February 2011

About 4 months ago, on one of my innumerable journeys to Malual and the home of Paul Mayol and Rose, Rose asked me about Kuot. Kuot is Paul’s nephew (his brother’s son) but he has been living with Rose and Paul since before I came. He was sick and was seen at the hospital (not by me) two days earlier and was diagnosed with malaria and treated as such. It made sense. It was the middle of malaria season and he had fever, headache, abdominal pain. But when I looked at him, his right tonsil was swollen and had significant exudate. And he had large, tender lymph nodes at the angle of the jaw. I was confident that he had Strept pharyngitis, a common problem that can result in many of the same symptoms as malaria. More than that, it was a victory for completeness. I am sure there are some arguments for a “focused exam,” that is only looking at and examining those areas directly pertinent to the patient’s complaint, though I think the main argument is that it is quicker. And here was an excellent example of the inherent dangers of narrowing in too quickly on the presumed diagnosis. It took some restraint not to bring this case to the notice of all the providers, but in the end, I did restrain myself. Kuot was treated with Amoxicillin and did very well.

Sabita Paul Mayol, Rose’s younger girl, came to the clinic today with fever and difficulty swallowing and on exam she had the large, red tonsil with a sore, enlarged and very tender cervical (neck) adenopathy. She was the fourth family member since Kuot to be diagnosed. That, too, is not unusual. Strept is a very contagious infection. But Rose was clearly frustrated by this recurring problem. I started asking about their routine around meals. Everyone has their own plate and utensils, but they share a common cup. That is very much a Dinka tradition. At every gathering, the cup is brought forth and one after the other takes of the liquid and then passes it back. I had to get use to sharing water bottles and cups at the meals and other times. It is almost a sign of brotherhood. But I suspect that at Rose’s home the cup has become the perfect fomite, the nonliving transmitter of disease. I also treated Sabita with Amoxicillin, a fairly standard drug, and I instructed Rose that they should stop the sharing of the cup. That is a bit tough for Dinkas, but I am convinced that unless they stop this sharing, the Strept will never leave their home. Something needs to be done to interrupt these continual re-infections that are inflicting their household.

19 February 2011

“God sees not as man sees, for man looks at the outward appearance, but the Lord looks at the heart” (I Sam 16:7). The passage is about Samuel anointing David as the future king. God sent Samuel to Jesse to anoint one of the brothers, and Samuel was certain Eliab would be the anointed one because he was tall and handsome, but God corrected him. Today I had two patients that were troubling, because one looked horrible by outward appearance but has a good prognosis, whereas the other looked pretty good, but has a poor prognosis.

The first one mentioned was actually my last patient for the day. She is a 2.5 year old who reportedly had a single blister on her neck 4 days ago. That may be true, but it is a bit hard to swallow. She is small and fairly miserable at this point. All over her scalp she has this golden crusty exudate, probably occupying 20% of the scalp surface. But then you get to the neck, chest, and axillae and it is really bad. There is virtually no normal skin. The crusty exudate covers all. She cannot raise her arms without severe pain. The rest of the skin was mildly involved, with ruptured blisters over her abdomen, legs, and arms. She was fairly cooperative with the exam because she did not want to move. She was the most pitiful looking patient I had seen in some time. Fortunately, she has a severe form of a benign disease: impetigo. She looks to have a combination of Strept and Staph, the two most typical culprits in impetigo (the golden crusty exudate is typical of Strept; the bullae or blisters are typical of Staph). I thought at first she might have something underlying the infection to get it so badly, such as Varicella (chickenpox), but as I examined her more closely I decided that was unlikely. She could have an underlying immunodeficiency, but that would more typically lead to invasive disease. This was still superficial, though very widespread. I gave her an injection of Gentamicin (a good Staph drug) and started her on Keflex and will see her again in the AM.

The second patient came with swelling in the supraclavicular (over the clavicle or collarbone) area for two months. He had no pain or fever. On his exam, he had two separate nodes about 8x8 cm. He had another 5x5 cm node under the angle of the jaw on the same side. On the other side were several 3x3 cm nodes in the supraclavicular area. He had two 1.5x1.5 cm nodes in the L axilla. His spleen was about 5 cm below the ribs on the left. I believe this child has lymphoma. What we need to confirm that diagnosis is to remove one of the nodes and send it to pathology, but that is beyond the scope of medical care in Sudan. We can treat, but the results are bad. A course of high dose steroids often will put the child into remission for a short time, but that treatment reduces the chances that the child would respond to chemotherapy, should the family be able to take him to a center for such treatment. I instructed the dad to go home and consider his options. I am afraid that at the end of the day, he will take his Prednisone and get that blimp of a response, feel better for a couple of months, and then he will relapse and die. There are many hazards of living in South Sudan, and there are frustrations of practicing medicine here knowing that you cannot offer a child such as this the best treatment available.

20 February 2011

We at Mustard Seed International have been conversing with another potential partner in our work here, Life in Abundance. I met two of their staff (Anteneh [Ethiopian accountant] and Kefa [Kenyan medical officer]) last Friday in Rumbek and invited them to come to Akot, and they came at my invitation (actually Kefa and Zacharias [Sudanese pharmacist]). Unfortunately when they came, we were still in the midst of clinic, so we sent them to get some tea and wait for us. When we finally finished clinic, we shared some red beans and rice with them, and a few minutes later we were heading out to the airstrip. AIM (African Inland Mission) Air had moved some things around to find us 400 kg of space on their DC3. Justin organized the order in a day. MEDS (Mission for Essential Drugs and Supplies) had rushed to fill an order in half the time usually needed. AIM Air even worked around a mix-up in the destination (to MAF [Mission Aviation Fellowship]) and found enough space for our whole order (635 Kg). So it was incumbent upon us to quickly unload the plane and get the DC3 back on it flight pattern. Kefa and Zacharias acted as though there was nothing they would prefer to do than help unload a plane in the blazing Sudanese sun. It took about 1.5 pickup loads to get the meds back to the hospital. Justin (thank God for someone organized) checked off the meds while Kefa, Zacharias and I spent an hour or so putting the meds on the shelves in something resembling order. After finishing, Justin was headed to help a friend move some mud bricks (to construct the tukul) and, being a host with limited skills in entertainment, I headed us back to the kitchen for more tea. It was then that I was reminded of a promise to loan two barrels and take some photos of the family of Gabriel Amat in Makuac. I asked Kefa and Zacharias if they would like a trip into the bush. They were not only willing; they were enthusiastic. In Sudan, the challenge of getting through the swampy puddles in the road during the rainy season is replaced by the bone jarring ride through sun bake canyons of car tracks in the dry season. And Kefa and Zacharias were in the back with the barrels, but they seemed to enjoy the ride. We took one of the barrels to Debora Yom’s tukul, met her pregnant wife, and then on to Gabriel’s home.

Debora’s wife deserves at least a side comment. I had heard about this arrangement before, but only recently got the “full skinny.” Debora is a widow. Her husband was a practicing polygamist, as most Dinka men are. Debora had 4 daughters, but no sons. Therefore she has married this young woman, and Isaac, the son of one of her husband’s other wives, has taken on the burden of impregnating Debora’s wife, in the hopes of producing a male heir. She is a young, pretty woman in the advanced stages of pregnancy. Soon we will find out if Debora has a male heir, and after the nursing is completed, Isaac’s duties will resume.

We went on to Gabriel’s tukul where we were greeted by half of Makuac and shown our seats of honor. Helena Deng, his wife, prepared us some lovely millet ugali and some ground nut and okra soup to put over it. We took tons of pictures featuring everyone there, including Gabriel’s family. By that time the sun was getting low, so we headed back over the same bone jarring trek. To complete the day, we gave Kefa and Zacharias some more red beans and rice. I was thinking to myself that I had done little to entertain or impress these visitors, but as we broke up the meeting and headed towards the showers, Kefa said, “Thanks for a great day of sharing the heart.” I believe I could learn to work with a man with that kind of attitude.

21 February 2011

I am old enough to remember standing in lines at Concord elementary school with all ages of people from the community receiving the oral polio vaccine. That proved to be one of the most effective medical programs ever instituted in our country. Polio came in epidemics in the US leaving death and crippled victims in its wake, but the oral polio was so effective that polio is virtually eliminated in the US. That is not true in Sudan. Every day you encounter multiple people with some form of disability. Many are war injuries or injuries from overly vicious play, but many are polio victims.

Maker Amer is one of those. I am making a presumption, but he does not have the spasticity in his legs that would be expected from cerebral palsy. His legs are very weak, but not flaccid as I would expect from severing the spinal cord. So I assume he had polio. He has a wheelchair bicycle. It has the crank of a bicycle, but it is high, and there are rods instead of peddles. He churns the crank with his hands to get wherever he needs to go. He remains independent despite his disability.

Maker wants to build a new tukul. There are wooden poles, bamboo poles, and grass needed, but the most basic building material is the mud brick. Uniform (relatively) blocks are cut from the appropriate mud banks where there is water (to soften the clay) and arranged to dry. Everyone in the community knows whose bricks they are and respects their property. Maker is in the unfortunate majority who cut their bricks in one place and build their house in another. When Maker asked me to help him move his bricks, I agreed. Sadly, I agreed too often to help people do things so it was some time before I could help Maker. I came to him one evening to move the bricks, thinking a pickup load would do it. It made a dent in the work, but there were still many more bricks unmoved than moved. A few days later I went for a second run and the remaining bricks were noticeably less, but still very noticeable. So my entertaining of Kefa and Zacharias included them helping me move some bricks. We ended up moving 3 more loads. Again the guys did not complain, but joined in the community. At church this morning, Maker offered special thanks to God for providing a means of moving his bricks, and he particularly thanked the three of us, including two people he had met for the first time when they were moving his bricks. Fittingly, part of the sermon topic for the day was on being servants. The men from Life in Abundance demonstrate that very well.

22 February 2011

Akolde is a beautiful child. She is about 12 years old, has a fun personality, a great smile, and epilepsy. When she first came to us, she had been having multiple convulsions daily for years, yet she seemed bright and friendly. We have increased her medications slowly and she has responded well, often going several months between seizures. Today when she came in, she was having difficulty answering my questions about her medications, particularly what meds she has been taking. Her older sister was with her, and they were trying to construct some history when they gave up the ghost and told the truth: she had been out of medications for 7 weeks and had been having 2-3 convulsions daily since running out. They had gone to Aweil when the medications ran out. Aweil is a long journey away, probably two days by matatu. I thought initially that the explanation lay in their distance from the hospital. But then they told me that after a week they returned to Akot. The family had been here for 6 weeks, yet did not return to the hospital for more medications. Akolde had been having 2-3 convulsions every day because her father would not allow her to return to the hospital and get the medications. It was not that he would not bring her; he has never brought her. She is perfectly capable of coming to the hospital alone, conveying her own symptoms and reporting how she is doing, and getting the proper medications and taking them. This was not that he was so swamped that he could not bring her. For whatever reason, he would not let her come and receive the medications that controlled her epilepsy.

I was furious. I admitted Akolde to the hospital and sent word by the older sister that I would not discharge her until the father came and we explained to him the necessity of the medications. But I was worse than that. I told the sister that if he was in America, he would be arrested and sent to jail for the neglect of his daughter’s health. I do not want to start a war with this man. But I do somehow want to shake him, to wake him up to the fact that he is not the center of the universe and that his daughter’s health is important, more important than his convenience. Maybe this was a control issue. But I know this: with two relatively simple old anticonvulsants, Akolde’s life was turned around. And I will do whatever I can to make sure she can continue on those medications.

23 February 2011

Two days ago I was supposed to meet Angelo and help him transport some poles and grasses to start rebuilding his tukul. Instead, I found Mary Aleck whose 20 year old son Marial reportedly had severe diarrhea and vomiting, making him too ill to come to the hospital. I picked up Marial and brought him back, but on exam I noted that his sclera (the white eyes that prompts our fire) were yellow. I was alone with him, and his English is little better than my Dinka, so I put him on some IV fluids, suspecting that instead of the usual pathogens, we might be dealing with Hepatitis A. Hepatitis A is a relatively benign disease. In the US, the main reservoir is in children who are almost never ill with the disease. Even when adults contract the disease, it may last several weeks, but the prognosis is good. Worldwide mortality for Hep A is less than 100/year. The next day, however, I had a translator with me, so we probed further. He had been jaundiced for months. That suggested a more severe form of hepatitis, such as Hepatitis B. There are marked differences between the two diseases. Hepatitis B is dangerous. It can and often does cause liver failure and death. It usually causes a chronic infection, such as this young man was demonstrating. There is also a marked difference in transmission. Hepatitis A is fecal oral transmission. Someone in the restaurant has it and is not very particular about hygiene and the next thing you know, there is a minor epidemic and the health department is recommending that everyone who ate at that restaurant get the immunoglobulin injection (which in my opinion is worse than the disease). Hep B, however, is transmitted through contaminated blood (transfusions), contaminated needle (accidental sticks or sharing needles) or sexually. Since blood transfusions basically do not occur in South Sudan, I suspected it was either contaminated needles or sexual contacts. And the modes of transmission for Hep B are identical to those for HIV. We do not have the capacity to check for Hep B, but we do for HIV. Unfortunately, he was positive.

We have had our HIV (+) patients before, but no one this closely related to the staff. Marial has lived much of his recent life in Rumbek. According to Rose, he is not respectful or careful. If I had to put my money down, I would bet on him getting the disease from a prostitute. But as visits to the madam appear to be a fairly regular occurrence, there is not a lot of comfort in that fact. The plague of Africa is here. Over a year ago I warned the staff that HIV was here and would do what Bashir could not achieve. Unless their sexual practices changed, HIV will devastate our country. I will warn them again. Please pray that they will hear and heed the warning while there is time.

24 February 2011

I have always liked surgeons. During my residency at a children’s hospital, I went out of my way to get to know the surgery residents rotating through and I had a good relationship with the attendings. As a second year resident, one of the surgery residents showed me the proper way to place chest tubes, and I continue to use the method he showed me throughout my career. Steve Golladay was the senior surgery attending at our hospital and he showed me how to reduce an incarcerated hernia.

We all have an idea about hernias. We know that they are bulges where they do not belong. Almost all the children here in Sudan have umbilical hernias, a protrusion at the belly button, but they are almost always benign and almost never need surgery. Inguinal hernias (in the groin area) are the most common significant hernias. They can affect females, but they are much more common in males. There is a difference between boys and men with respect to hernias. Men generally have a direct hernia. They have torn through the tissue separating the abdomen and groin and the intestines pour through (that is why they are associated with intense straining). In boys, however, the hernias are usually indirect. The testicles start in the abdomen (about where the ovaries are in girls) but then migrate through the femoral triangle and into the scrotum. In boys hernias usually come because the pathway did not close completely. But whether direct or indirect, the results are the same: intestines end up where they do not belong, in the scrotum. Often they will emerge when the abdominal pressure increases, as when the child cries or strains to pass stool, but then may go back into the abdomen when the increased pressure passes. Quite often, the parents will report having seen the bulge, but it is not there when the child is examined. Indirect hernias like this can close on their own, but in the US, the recommendations are for surgery because of the risk of incarceration or strangulation. Incarceration means the hernia has gone where it is not suppose to be and will not leave. Strangulation means that the blood supply has been compromised. Strangulation can lead to death of the herniated organ (usually intestine) and so becomes an emergency.

I saw a 7 year old boy today with “swelling of the testicle.” It is almost the exception, but he did have his book, his medical record, and I saw where I had seen this child about 7 months ago, told them that he had an inguinal hernia, and referred him to Mapuordit for surgery. But the family had never taken him. They said that the swelling in his scrotum had been continuous since December. On exam, the child had a huge bulge in his left scrotum. It was fairly tense and was painful to touch. But this was a Dinka man, despite his years. I had him lie on the table, pull up his knees, and I went to work reducing the hernia in the manner Golladay had taught me. The problem in a hernia is like the Keystone cops going through the door: the opening is small and not everyone can fit at once. Therefore, you pull the mass of the hernia away from the opening and massage a small amount through. The process is usually slow and somewhat painful. And in this child’s case, I would think embarrassing. It took about 15 minutes of pulling and pushing until the hernia was reduced. By the time I completed it, there were probably 10 women in the room carefully watching the proceedings. Dinkas are not Americans. Most children have publicly displayed their wares for the first 5-7 years of life. If this child was embarrassed, he never let on. He was in some pain, as demonstrated by the tears welling up in his eyes, but he never cried out, complained, or even resisted me. At the end, you could not tell he even had a hernia. But I stressed to the mother how important it was that she take him to Mapuordit rather than chancing that the hernia could come out, become incarcerated and then strangulate. That could cause his death if neglected (as this one had been). And I am convinced he will grow up to be a fine Dinka man.

25 February 2011

A couple of months ago I started with Peter Malual to go to the cattle camp for church, but a flat tire interrupted our journey. I approached him again about going and he recommended a whole weekend up in Paloc, so Justin and I joined him this weekend. It actually coincided with a church opening celebration in Paloc, so it seemed to perfect time to go. The road to Paloc is treacherous in the wet season, but merely rough in the dry season. Justin volunteered to drive, which was good, because the nurses were exchanging today (Samuel was going out after his two months and Elijah was returning). We saw several groups of baboons and a number of guinea fowl, but little else in the way of wild life going up. Actually, as always, there were a number of beautiful birds.

Paloc is permanent community that also hosts a cattle camp. That is the exception. Cattle camps are usually in the wild. During the dry season, they are near the water so that the cattle can eat and drink. As such, they are the Wild West. They have their own laws, they carry their own guns, and they have their own sense of justice. Since cattle are essentially the currency of Sudan, the cattle camps have been powerful institutions. Until recent times, all the leaders of the community came from the cattle camps. Since John Garang, the SPLA (Sudanese People’s Liberation Army) and SPLM (Sudanese People’s Liberation Movement) have been the source of national leadership, and it is very recent since the educated became the community leaders. Indeed, the issue is not resolved in most places. I have seen many cattle camps, but I have not stayed in one before this weekend.

We arrived at midday. Justin came over with the Nehemiah teams going to the cattle camps, arranged to have Peter Malual as the missionary to the cattle camps, and knows many of the leaders. Therefore I was in his shadow the whole weekend. We arrived and they were all glad to see Justin, and thereby welcomed me. Normally Justin and Peter would set up camp right away, but things were a bit more complicated by the celebration of the church opening. Therefore we got to the cattle camp, parked the car, were greeted by many and then sat there for a bit. Justin asked if I had a story to tell, and I told the story of Jesus confronting His disciples with the question, “Who do the people say that the Son of Man is?” (Matt 16:13-20). We talked about the nice but inadequate things people had to say about Jesus. They said He was John the Baptist resurrected. They said He was Elijah or Jeremiah or others of the prophets. I talked a bit about the way many Americans look at Jesus, as a good man, a great moral teacher, a wonderful example, a martyr. But then Jesus turns the tables on the disciples, asking, “But who do you say that I am?” And Peter answered with the great confession that Jesus is “The Christ, the Son of the living God.” That is the only accurate and the only acceptable answer. But upon receiving that answer, Jesus immediately starts talking about His death (Matt 16:21-23). We must recognize Him as the Christ, the Messiah, but we must also join Him in His death and His resurrection. He is our example, but first of all, He must be our Savior. It was a good group and they listened well.

I then suggested that, as we had some free time, we should go to the lake. This is the Lakes State. During the rainy season, I had seen the water flooding most of the plains, but nothing that I would call a lake. Peter Malual was joined by his uncle (who is actually younger, a not unusual occurrence in South Sudan) and they assured us the lake was 30 minutes away by motorbike. I knew without question that Dinkas were not good at estimating time. I think if you asked a Dinka how long it would take him to walk to Uganda, he might say 8 hours. As we wound down this road, it was evident that 4 wheeled vehicles rarely made the journey. We saw many hippo tracks along the way. Justin “threaded the needle” frequently and had to stop and create new roadways around trees not infrequently. About an hour into the trip he was looking at me with that, “You had to ask to go to the lake” look. About 1.5 hours after the journey began we pulled up to some trees and could see the lake. We were warmly greeted. I know that we are not the first kawajas to see the lake, but not a lot have. We started towards Lake Nyibur. After a short distance, it was boggy and we had to take off our shoes. We got into dugout canoes and Peter’s uncle poled us out into the lake. It was impressive.

I am from South Carolina and grew up going to the coast. My grandfather use to take us back into the marshes during high tide. I felt like I was experiencing something from my childhood. Instead of the marsh grasses, the reeds grew up along the river/lake bank, but looked much the same. The dugout had that mildly feculent smell that so many who are not from the low country find offensive, but which makes South Carolinians drool for oysters, shrimp, crab. The inlet where we arrived opened on to this great lake or river (I could not tell). In the distance was the opposite shore lined with palm trees, again much like the palmetto trees from home. The uncle polled us about 45 minutes until we arrived at a solitary palm tree. That was actually the place called Nyibur. From a distance we could see the children playing and swimming in the water. We were hot and tired when we arrived, so we quickly joined the children. A number of adults under some trees a bit more removed from the shore came out to watch us. I have not had a good swim in a long time, so I swam out to the middle of the lake, but the people started waving me back, and I returned. Later I was told that the hippos sometimes came to the middle of the lake. I would like to see a hippo, but not from that vantage point. I was also told later that there were many crocodiles along the shore, but I figured if they left the children alone, they were unlikely to go for me. We returned to the shore. The people had never met me, but they gave us fish (I think they were lung fish) caught that day, grilled on the coals, the scales removed by the young boys. It was great. They offered me salt and I should have taken it. I thought I did a pretty good job of picking the meat off one fish, and I even ate some of the “lungs” the orange fat tissue that grew under the meat, but then I passed it back to Peter who made a meal on what I had left. We drove back to the church and shared a meal with them before setting up camp to end our first day in Paloc.

26 February 2011

Awaking in cattle camp is unique. First of all, through the night you are assaulted by various noises. The bulls bellow. I was convinced by the sequence of the bellows that they bulls were seeking to add to their numbers, but Justin says he thinks that has more to do with the rumination, rechewing the food in the cud. There was also the dancing. The drums were beating and the cries of the dancers took up a large portion of the night. Still, I slept well overall. The full moon shone into the tent and I was convinced the sun was up, so I got up, only to find I had awakened at my usual time, but without my usual activities. Where could I go to read? I went back to sleep until the sun really rose around 7. When I got out of the bed, the camp was bustling. There is a strong hierarchy within the cattle camp. There are a few families attached to the camp were usually associated with the highest men of the camp. The Aparaks, the strong, young unattached men, are numerous and appear to be in charge, though they do answer to the head men. The Aparaks drive the cattle and tell others what to do. There are lots of young boys associated with the cattle camp. They do the menial chores. But the group that most fascinated me was the young women. They did all menial tasks of the young boys: gathering the fresh dung (with their hands) and throwing it into piles, spreading the piles with forked sticks to let the dung dry. After the dung is dried, they put the dry dung on the piles of burning dung that provides heat (not needed) and smoke to drive away the insects (strongly needed in the rainy season, but not a particular need now). They start the process before the cattle move, and continue until the dung is properly distributed after all have been driven to their grazing land. I witnessed something I had heard about but not seen before. One of the cows started urinating. A young girl ran to it with a container and caught most of the urine. Subsequently the urine was used to wash the bowls and containers and their hands (usually followed by a final rinse of water). I guess after the dung it really did not matter.

Justin got out the kerosene heater and heated water for coffee. Some things are essential. We also had some instant grits and tuna, the breakfast of champions. Then we set up the medical clinic. We took some rope from the car and the one cot we were not using and started seeing patients: Peter was translating, I was examining, and Justin was handing out medications. We saw about 60 patients that morning, but the line never seemed any shorter. We were supposed to go back to the church for lunch, so Peter took down the names of those waiting in line. There were another 40. We also saw about 10 during the lunch, so it was a busy day. We returned from our lunch of chicken and fish (it was great) to a place with a bit more shade for the afternoon session. There was a fair amount of asthma, though mainly we saw back pain and diarrhea. There was no privacy. Throughout the time we were constantly telling the people to move behind the ropes, but the next thing we knew they were inside the ropes sitting on the cot. I brought a fair amount of medications and they covered most of what we needed. I had not planned on the small children (at a cattle camp) so I brought no liquid meds, but we were able to get the doses down to the size needed. I came prepared for lacerations, abscesses, scorpion bites but returned having opened one abscess near the lake. I also came prepared to treat a lot of sexually transmitted diseases (STD’s). I treated one older couple from the community. Included in that treatment is an injection in the buttocks. The wife allowed the exposure without concern, but the man was embarrassed. After seeing about 50 patients that afternoon, we closed down the clinic, though many were disappointed at our brevity.

That evening Justin Machar (the black bull) led a Machar around the camp, repeating the song about the bull to the great amusement of all the Dinkas. There were a few feats of wrestling between Machar and some of the Aparaks (Justin won them all). I probably could have joined in, but they accepted my explanation of monydit (old man) as a sufficient excuse. Again we turned in fairly early.

27 February 2011

I fell asleep fairly quickly, but during the night I was awakened by the drums, shouting, and dancing. I had seen some of the cultural dancing in Akot, but I wanted to see the cattle camp version. I came out of my tent and one of the older ladies (though still probably in her thirties) motioned me over to the dance and I went. As I walked up, several of the Aparaks came at me as though with their weapons. I cowered, and they laughed. There were many more boys than girls. In the middle were two men beating on a drum with one wide end and one relatively narrow end. The men were hopping backwards and typically in every cluster of 4-5 men there was a young lady doing the same steps. I was encouraged to join in. Dancing has never been my forte, but I can skip rope, backwards if necessary, so I thought I would fit right in. The young boys howled with amusement at my dancing. I was semi-associated with a couple of women. When the music ended, they tried to show me the rhythm that has evaded me for fifty years. Needless to say, at the end of the dance, I was not a proficient. But I did enjoy myself and the next morning, they looked at me with more kinship than before.

Sunday morning was like Saturday. Cows still need to graze and dung still has to be gathered. The people were hoping we would have another medical clinic, but experience has dictated that on leaving day, you pack up quickly. We did have church and it was good. The same cot served as the pew for the Aparaks. Some mats were the seating for the boys. The girls continued to work. Peter started with several Bible stories and the people participated fairly well. Then Peter asked if I wanted to say anything. I talked about faith. I quoted Eph 2:8-10 and then told them the story of Naaman (II Kings 5). Naaman, the Aramean army commander, had leprosy. The Hebrew slave girl told her mistress that the prophet in Israel could cure him. The king of Aram sent a message to the king of Israel asking him to cure Naaman accompanied by many gifts. Exasperated, the Israeli king tore his clothes, protesting that the Aramean king was seeking to provoke war, but Elisha the prophet heard and sent word to the king. “Let him come to me that he may learn that there is a prophet in Israel” (II Kings 5:8). Naaman started towards Elisha, but the prophet sent instructions. “Go wash in the Jordan seven times” (II Kings 5:10). Furious, Naaman was returning to Aram when his servants persuaded him to obey the prophet. “If the prophet had commanded something difficult, would you not have done it?” After washing in the Jordan, his flesh was restored like that of a young boy. God calls us to the difficult task of faith, having nothing in our hands that earn us status with God, trusting only in His mercy and love.

I was impressed with the attention they gave. The boys and Aparaks took in every word. Even the girls stopped their work and listened and reacted to my antics (I am fairly animated in the telling). The cattle camp is the Wild West. The principal players are far from innocent. But there is a spiritual hunger there. I am planning on going back when the opportunity arises. As I was leaving, one of the Dinka women said to me in broken English, “I love you.” There were three young girls standing with her. I said to her, “I love you,” and gave her a hug. The girls reacted predictably, as though I was making a move on her, so I said it to each of the girls. I am sure that professions of love were not alien to them, and almost invariably connected with pressure for sexual favors, but they need to hear of the One who truly loves them.

28 February 2011

Our challenges here are not all medical and they are not limited to the cattle camp. A few hours after arriving back from cattle camp, we had a meeting with some of the principal men involved in the Baptist ministry here. One of my 2-3 best friends from among the Dinkas was in clear and significant error. I had tried for a while to give him the benefit of the doubt. I had confronted him directly about some of the issues, and specifically warned him about something I heard he was contemplating, trusting that the Holy Spirit would use my words and the Scriptures to convict him, but he went ahead. He had threatened to go to the community about some church issues, and I confronted him with I Cor 6, but he went ahead. He saw himself as being right, being persecuted by the others, and he was destroying the body. We had to meet with him. It could have gone better. He felt that I had betrayed him. All these men who had been his brothers in Christ he now was convinced were seeking to destroy his reputation. He even had me read Nehemiah 6, comparing the actions of brothers who were seeking to persuade him to see his error to Sanballat and Tobias who were seeking to ambush Nehemiah. In the end, he demanded that if we reinstated a teacher he had replaced (for no reason), we had to put it in writing and everyone needed to sign their names to the document. Even then, he would not remain for the closing prayer. Here is the letter we composed.

Meeting of the Christian Leaders of Akot 20 February 2011

Purpose: To address issues dividing the church

Attendance: Clarke McIntosh, MD, Justin Culp. Gordon Mayom, Samuel Maker, Joseph Mabor, Abraham Maper Maker, Peter Malual, Chadrach Chol, Isaac Bol.

The meeting was opened by prayer, Chadrach Chol leading.

First item of business was the recommendation that a committee of seven church leaders be established for the resolution of church problems. This was prompted by reports that Abraham Maper had taken church matters to the community leaders. I Cor 6:1-8 was read by Justin Culp. In the discussion it was pointed out that this had also been the desire of Mark Kissee, former missionary with the International Mission Board (the mission organization of the Southern Baptist Church of North America). After much discussion, the issue was decided by 8 to 1 vote in favor of forming the committee. A subcommittee was appointed, consisting of Gordon Mayom, Samuel Maker, Chadrach Chol, and Isaac Bol to recommend 7 people of godly character and in good standing in the Baptist Church of Sudan to fill those positions. It was also agreed upon with an 8 to 1 vote to amend the constitution of the Baptist Church of Sudan to include the formation of this committee as a means of solving disputes within the church.

The second item of discussion concerned the removal of Joseph Mabor from his position of teacher at the Abundant Life School and replacing him with John Chol. The facts of the matter, as revealed in prolonged discussion, are that Joseph Mabor was approached with the idea of joining Peter Malual as a missionary to the cattle camps. He initially expressed some interest, but when given time to contemplate the decision, decided against the position in favor of remaining in his position as a teacher at Abundant Life School and the pastor of Mayom Baptist Church. Abraham Maper, thinking Joseph had given his final consent, hired John Chol to teach. (John had previously been considering going to the cattle camp as Peter’s partner). After hearing extensive discussion on all sides in this matter, the committee voted 8 to 1 in favor of reinstating Joseph as a teacher in Abundant Life School in the position he formerly held. It was also decided that John Chol could be offered either the position in the cattle camp ministry or to be a teacher in the Living Waters School in Malual.

There was sharp discussion and disagreement. Prayer was offered by Clarke McIntosh, though only after Abraham Maper left in anger.

The closing prayer was offered by Isaac Bol.

In Christ,

_____________________ ______________________ _______________________

Clarke McIntosh Justin Culp Gordon Mayom

_____________________ ______________________ _______________________

Chadrach Chol Abraham Maper Maker Samuel Maker

_____________________ ______________________ _______________________

Isaac Bol Peter Malual Joseph Mabor

1 February 2011
Like catfish, abscesses seem to thrive in every culture and every climate, though we seem to have an inordinate number here. Rose Lou is a 19 year old girl who came to us with marked swelling of the right hand. Her fingers were curled because she could not straighten them, particularly the third and fourth fingers. She said it started three days earlier, though I would have guessed before that time. The dorsum of the hand (the back of the hand that we are supposed to know so well) was markedly swollen, but not at all tender. The palm was so not very swollen except at the base of the 3^rd and 4^th fingers (middle and ring). Each of those fingers was very tense in the proximal (closest to the palm) segment. As I pressed other areas, there was significant pain, but not as severe. She had some small nodes in the axilla (arm pit). The fact that the nodes were not larger supported her story that the infection was not of long duration.

Because she was in so much pain, I tried both a carpal tunnel block with Bupivacaine and a digital block using Lidocaine. I may have been smart to use Ketamine. She seemed pretty tough at first, but when I attempted the Lidocaine instillation, she was uncooperative. Initially I thought I would need 4 separate incisions, but when I opened the proximal segment of the 3^rd digit, a river of pus ran out. That finger holds a small volume, so I suspected a connection to the palm. I explored that area through the first incision and more pus was removed. I repeated the same procedure on the 4^th digit and released some pus from there as well, though not as much as the first one. I instilled some Gentamicin into the incisions for a couple of reasons. First, Gentamicin is a fairly good drug for Staphylococcus aureus. It also works well in direct contact with the tissues. The concentration is very high (thus increasing the likelihood that it will kill the bacteria), but the medicine gets only a very small amount into the blood stream (its main toxicity is the kidneys). I placed wicks in each incision and admitted her to the ward for IV Gentamicin and Ceftriaxone. I was pleased to get by with two incisions rather than the four I initially expected. But I cannot help but wonder why she had these in the first place.

2 February 2011

I had another wedding experience recently. Weddings are the social events of the year in South Sudan, particularly when it is a wedding involving a prominent family. A different Abraham Chol came to me recently. This Chol is part of the Sawat clan, the deputy Paramount Chief in the area. He asked me to help transport the bride. She was in Tin-Machar and the wedding was in Akot. I suffer through a number of miscommunications here. Much of it is my poor Dinka skills. Some of it is undoubtedly the poor English skills of the Dinka speaking to me. But I cannot help but feel some of it is mild deception, white lies. I was initially under the impression that the bride was in Akot and needed to be transported to Tin-Machar. I am sure that was just miscommunication, because the reverse was true, and that did not matter. Chol then told me that the bride lived near the donkey, the water pump, in Tin-Machar, a spot with which I was very familiar. But we passed the donkey and kept going. Then he asked me if I knew where Abraham Maper lived. I affirmed. The house was there. But we passed Abraham Maper’s house and then the church and kept going. We went to Makoltit and passed the church there and kept going. Finally we arrived at the destination. There was only one problem: no bride. And no bridal party. I sat there for 30 minutes, but there was no scurrying about, no bad feelings for having brought me out for nothing. The little Dinka girls were cracking the ground nuts and staring at me. After their initial greetings, the remainder of the household ignored me and acted as though there was nothing unusual happening that day. Thirty minute later I decided I had waited long enough. Chol had already been hinting that the wait might be long and would it not be better to return later. “What time will you come back?”

“I will not come back. They asked a favor and I did it once. I will not do it again. If they cannot be bothered to get here while I am waiting, I will not be bothered to come back.” The next day towards evening Martha Yom Maker approached me, wanting to me to take her to the wedding. She could have gotten there easily; she wanted me to come. So I did. Abraham Chol was there, confirming my suspicion that this was the same wedding. I had a good conversation with Abraham Maper, but mostly I just sat and observed. I did exchange greeting with several monydits who made me feel like a parapuol (young man) and I let the children rub the hair on my arms and legs. As evening fell, I returned home. Last night, Abraham Chol again approached me. “The bridal party needs to return home.” I objected slightly, but I know there is a lot of stuff that needs transporting. And what is a ten minute drive for me is an hour walk for them. And I think about why we are here. Am I here to get a hospital going in the direction it needs to go? Am I here to preach? I think the real reason we are here is to demonstrate the love of Christ in word and deed. The people need the gospel. They have heard it, at least in part, but they need to embrace it, to come to know Christ, to be transformed. For that to happen, the Holy Spirit must change their hearts, but I make myself most useful in that process by servant leadership. If I am not serving the people, how will they see the gospel? If I shield myself from the people and give only what is convenient for me to give, how is that like Christ? I agreed to go. When I arrived, 40 people needed transporting. Chol said, “I am afraid we will need two trips.” Of course in America, 40 people means 8-10 cars are needed. We got about thirty in the first trip, but we could not squeeze them all (and I am literally talking squeeze). So I made another. My mood even lifted and I joined in some of the singing, repeating sounds I did not understand to the amusement of my passengers.

Today Abraham Maper told me that in the negotiations he spoke up for me, declaring that I should receive a goat as an honorary member of their family. If all goes well, it will come my way. That means I have 5 (soon to be six) sheep and a goat towards my son’s dowry. It was not such a bad deal after all.

3 February 2011

A few days ago a pregnant woman came to me with a history of leaking fluid for four days. On her exam, I estimated the gestation to be about 32-34 weeks, so we gave some steroids (Dexamethasone) to try to increase the maturity of the surfactant system. Premature babies die for a variety of reasons, but one of the main reasons a child this far along often dies is that the surfactants in the lungs have not properly formed. In science class, the lung is fairly accurately portrayed as a bunch of small balloons at the end of a straw. However, if you constructed such a system perfectly and then had repetitive influx and efflux of air, you would find that the distribution of air would not remain uniform. Some of the balloons would get overly inflated, while others would get no air. The reason is the physics of a balloon. We have all experienced that difficulty getting a balloon to start inflating, and then the relative ease once the inflation starts. Surfactants change the nature of the “balloons” (air sacs called alveoli) in the lungs by reducing surface tension and thereby allowing the uniform expansion of alveoli and distribution of air. It is another great example of the intricacy of our design and the proof to the receptive mind of a Creator. Premature babies, like Kennedy’s child, lack a mature surfactant system and therefore get into respiratory distress syndrome (RDS) and die without some fairly heroic efforts that are unavailable here. However, steroids (the most commonly used one is Betamethasone) can cause the surfactant system to mature, so that at relatively mild prematurity RDS can be avoided.

The mother was in the hospital for several days, giving the Dexamethasone a chance to work. The leaking of the membranes appeared to stop a couple of times, but then returned. Two days after she was admitted, she had some labor pains and the nurses gave her some Ventolin and Phenobarbital to stop the labor, which they did. But there comes a point where the risk for infection becomes greater than the risk of prematurity. We started her on Amoxicillin and decided not to stop her labor again if it began. Three days later it did start and she delivered. The child was about the maturity we had estimated. He had some respiratory distress, but I believe that was from pneumonia, because he improved with antibiotics. If he was going to develop RDS, we should have seen that in the first 8 hours, but a day later, he looked pretty good.

The immaturity of the surfactant system is the most dramatic deficit of prematurity, but it is far from the only one. Another one that is greatly impacting this child is maturity of the gut and the sucking response. The child has the inclination to suck, but coordinating the inflow of milk and breathing has become a problem. We put a tube into the stomach, but that comes quickly back up and chokes him. The nurses had to resuscitate him several times yesterday. In the US, we would pass a tube into the intestines and feed him continuously. That is a simple issue in the US, but we do not have the technology, and after all the questions and struggles, that could end up as his death sentence. What a pity.

4 February 2011

After exercising yesterday I was sitting in my tent reading and I watched such a typical Sudanese scene. There was a young lady walking around the square of walkways that, to a large degree, defines the courtyard of our compound. She was in the hospital with her small child who has profound anemia and an acute infection that tipped him over, possibly Typhoid fever. He was quite ill initially, but now is recovering. They had been in the hospital for about 4 days, and I am sure that the mother just wanted a little space, a little breathing room, a chance to think instead of just reacting to his needs. But as she walked down the sidewalk, her naked son walked behind her crying. He did not want her to have the chance to collect her thoughts. He wanted to dominate her thoughts and keep her for himself. Several times she stopped, spoke to the child, and then walked on. Each time the child stood for a moment or even turned around, but within seconds, turned back around, held up its arms and started crying and running after his mother. They turned the corner of the walkway in front of the kitchen and the mother was walking along with the child, holding his hands. By the time they reached the generator room, she was carrying the child. There is a great possessiveness of the babies with their mothers. If a mother comes to the clinic to be seen bringing her child, I encourage them to get someone outside the room to keep him because otherwise I will not be able to examine the mother because of the child’s protests. And the mother’s breasts are his possessions. He feels complete right to reach into her blouse and remove the breast for his use. He clings to it in triumph as he satisfies his hunger.

There is a desperateness that is far more than the separation anxiety of American children. It is as though the child realizes that soon his mother will no longer belong to him. Soon he will be weaned; soon the mother will be pregnant again; soon he will be sent to his grandmother’s home and be truly separated from his mother for months. For the mother, there is no relief except in the community. She can talk with other mothers as they collect water, grind the grains, clean, care for the children, cook the meals. There is no daycare. There is no Curves or bridge club or tennis. Yet there seems to be real joy, true contentment, with their lot in life. Except for those few times when they have just got to get away and have time for their own thoughts for a brief period.

5 February 2011

I saw a child again today. She is the niece of a friend. She started having skin problems when she was about 1 week old: blisters on the places where she lay. She is now close to three and has suffered with this problem all along. I saw her a week ago or so and put her on antibiotics and she improved, but she has chronic scarring. And even as she improved, she developed new blisters on the bottoms of her feet from trying to walk. She also has problems with her gums.

I believe she has epidermolysis bullosa (EB). EB is a genetic disease. Her form is almost undoubtedly the autosomal recessive form. Dominant means that one of her parents would have the disease; recessive means that neither has it. Also recessive diseases, in general, are more severe than dominant. (If it is fatal, it virtually has to be recessive or it would die out). Autosomal means that the gene is on one of the 22 non-sex chromosomes rather than the X or Y chromosome. We have no therapy for EB, but we are not alone in that. Unless there have been a dramatic break-through, EB is incurable. In the US, the children can be helped more than we can help here, but the severe forms usually are fatal, typically from infection. I gave them a tub of Silvadene to apply to the ruptured blisters to reduce the risk for infection and we will treat with antibiotics only as needed.

We talked about the transmission of this disorder. This mother has five children, though the first two were by an earlier marriage (and therefore not really at risk). The three older children and the one younger all appear not to have the disease. I explained that with every birth with her and her current husband, there was a 1:4 chance of EB, but the reality is that if she has 10 more children, all of them could have it or none of them, or any number between. She sat musing over the information and then stated, “Then I will not have any more children.” That is never easy to say, but far harder here than in the US. Women love having children. Most want 10. She is by no means lacking at 5, but she was also not done. How her husband will react is uncertain, but her reaction told me she understood what I was saying. I have dealt with many parents whose children had severe, often fatal recessive disorders. Most choose the path this woman took. I think it is the best one.

6 February 2011

As I was walking to the ECS (Episcopal Church in Sudan), I met Manasseh Meen Malou and Jacob Maker Majak. Both are important men in the community. Both of them had fairly large homesteads consisting of several tukuls that were burned out during the unrest last year. Both of them were now making plans to rebuild and move back to the Akot area. I thought back over the past year: how badly it started with the fires and unrest, how many things had taken place with the first elections ever and now the referendum essentially completed, with only the announcement pending. Everything feels right, in place, moving forward. I was reminded of the scene in While You Were Sleeping when the son comes to his dad and the father says, “There are times when everything seems to come together and everything is right,” and the son replies, “This is not one of those times.”

Today I completed my study of Matthew and I preached today on the Great Commission. But preceding the Commission, it appears like it is one of those times when everything has come together. The disciples were with Jesus for 3.5 years, and despite their professions, they still did not really grasp who He was. He had warned them for weeks repetitively that He was going to be arrest, humiliated, crucified, and that He would rise from the dead. The disciples, in Jesus’ time of need deserted Him and not one of them remembered about the resurrection. But now they had obeyed His instructions to go to Galilee and now they were with Him. Now they understood. He truly was God. They came to Him, even with some persisting doubts, and they were removed and the disciples worshipped Jesus. And I believe that had we asked them, they would have declared, “This is all we want.” They no longer cared about the overthrow of Rome or being the greatest among the apostles or having the position of honor. All they wanted was to be with Jesus. But it was not to be. Jesus was with them several times. Paul tells us He appeared to over 500 men and women (I Cor 15:6). But the time of rejoicing had not arrived. Instead of just letting them enjoy the moment, Jesus commissions them for greater work and more service. The day of rest and enjoying Him will come, but not yet.

“All authority has been given to Me in heaven and on earth.” It is ironic that most American Christians, when quoting the Great Commission, leave out this part. It is the heart of the commission, the basis upon which He is sending us. Why in the world should I be here in Sudan? I do not blend in. After 1.5 years, my language skills are still very poor. I am starting to get a grip, an understanding about the culture, but my understanding is still very rudimentary. On what basis do I have any hope of doing anything of lasting value here? I have hope because of Him. Jesus has all authority in heaven and on earth. There is nothing He cannot do. He gave His Apostles the power to heal and perform miraculous works. He could still do that if He chose. The Holy Spirit goes at Jesus’ beckoning and ravishes the hearts of men. I cannot be persuasive enough to bring men into the kingdom, to cause Christians to put aside their pride and objections to one another and become united, but the Holy Spirit can use my poor words to do great things. Small wonder we are so quick to resort to gimmicks and one time prayers. We do not believe Jesus’ assessment. “‘How hard it is for those who are wealthy to enter the kingdom of God! For it is easier for a camel to go through the eye of a needle than for a rich man to enter the kingdom of God.’ They who heard it said, ‘Then who can be saved?’ But He said, ‘The things that are impossible with people are possible with God’” (Luke 18:24-27). We are convinced that if we do the right thing, say the right words, live the right way that we can force the camel through the eye of the needle. It cannot happen. God must do it or it will all be counterfeit.

“Go therefore and make disciples of all the nations.” On the basis of the fact that I have all authority, “Go.” If we understand the first part, the rest follows. If we do not, we are in for frustration. Christian bookstores are full of treaties describing programs and ideas to enable us to do the impossible, and we have learned to fake it well. The megachurch movement is a testimony to that fact. But God is not mocked. Indeed, I think He anticipates our reaction. He does not tell us to go and fill up the churches. He does not tell us to go and get decision for Christ, to plant new churches. He tells us to make disciples. The continent of Africa is a testimony to the truth of Christ’s assessment. Bringing about the gospel in Africa is impossible with men. I know that in Kenya and Sudan, and I suspect in all of sub-Saharan Africa, 80% of the people profess to be Christians, but the fruit is not there. Africa is dying from AIDS because of our promiscuity. In Rwanda there was the horrible genocide. In Kenya, church members hacked fellow congregants to death because the election did not go to suit them. In Sudan the cancer of revenge and unforgiveness is destroying this country. We have churches under every tree, but many of the pastors never show up and the vast majority of men on Sunday morning are in the market, not in the churches. Jesus calls us to make disciples even though He knows we cannot do it. Is He mocking us? Does He castrate the gelding and then command it to be fruitful and multiply? No!!! He wants us to look to Him, to go out in His authority. We are to be obedient and look to Him to do the work. I think of the conversation I had yesterday with Abraham. Should I come down hard on him and force him to change his decision about Joseph? If Abraham is going to become the leader we all hope he will be, the Holy Spirit needs to do a work in his life. I can force some outward conformity, but I cannot change his heart. God must do that. We are to preach, pray, and show forth some example of discipleship; God must do the work of making disciples or it will not occur. We also see that God is sending us to all the nations. Missiology orthodoxy today says that I need an exit strategy. I need to come in for a time, empower some nationals, and get back to America. I totally agree that, by God’s grace, nationals need to be included in the work we are doing. But why should I be heading back to America? By all accounts, America has more doctors and preachers than we need. If I live another 50 years, Sudan will still be lacking both. I feel no compulsion to comply with missiology orthodoxy.

Since disciple seems to be a key word in this commission, Jesus gives us at least two characteristics of what constitutes being a disciple: identification and obedience. Disciples are to be baptized, to identify with us. They are to be baptized “in the name of the Father and the Son and the Holy Spirit.” Here is an important aside. This is one of the few places where we see the Trinity actually named and grouped together, but I think it is compelling. If the Holy Spirit was not of the same substance, He would not be included here. I believe it speaks to the humility of God, the contentment of the Holy Spirit that the One who inspired the prophets and apostles to pen the Bible did not make sure He got more credit. He rejoices to see the Father and Son glorified. When Jesus speaks of the Holy Spirit, He speaks of Him in glowing terms. “But I tell you the truth, it is to your advantage that I go away, for if I do not go away, the Helper will not come to you, but if I go, I will send Him to you” (John 16:7). We are to baptize, to bring the sign of the covenant to bear on all who believe. In America, and even in Sudan, that is not such a big deal, but in the disciples’ day, receiving baptism was rewarded by being cast out of the synagogue. Today, in Muslim and communist countries it is still costly to identify with Christ. And there is the necessity of obedience. “Teaching them to observe all that I commanded you.” Jesus does not give us the option of just making converts. There is no place in Scripture that gives us any assurance that those who are not obedient derive any benefit from praying a prayer. All the promises are for those who obey His commandments. Therein lies the problem. I can get hundreds of professions of faith weekly by handing out slips of paper to those coming to the clinic, but I cannot change their hearts to make them obey. Only the Holy Spirit can do that. Jesus anticipates this problem as well. “And lo, I am with you always, even to the end of the age.” Liar, liar, pants on fire. Jesus knew full well that His ascension was only a few days away. Yes, but the Holy Spirit would come. The Holy Spirit is with us, doing the impossible work through us. He is with us now and He will remain with us until the Great Day of the Lord. Maranatha. Even so, come Lord Jesus.

7 February 2011

“I think I can safely promise, ma’am, never to dance with Mr. Darcy” (Pride and Prejudice, Jane Austen). We who have come to love Elizabeth Bennett over the years have to smile at our heroine’s statement, for we know that she will not only dance with Mr. Darcy (reluctantly at first) but will in the end fall in love and marry him. The issue is not the fickleness of Ms. Bennett, but rather that she has pronounced judgment too soon. Elizabeth is enchanted by Mr. Wycombe and despises Mr. Darcy, but by the end of the book, her judgments are “right the opposite.” I have had a Pride and Prejudice experience of that sort lately.

In my last group of journal entries, I wrote about a friend of mine who had beaten a pregnant woman. It disappointed me greatly, but when I sat with him, I heard a very different story. My friend had allowed this woman and her husband to build their tukul on his land, though he made clear that the arrangement was temporary. But lately there have been several episodes where he has regretted his decision. Several things have been stolen in a manner that pointed to them. His sister, who lives nearby, was beaten by one of the men in the house. So he decided that it was time for them to move on. Not surprisingly, they were not thrilled with his decision. According to my friend, she came by and was abusing him and he fought her off fairly gently. She then threw herself to the ground several times and tried to maintain he abused her. There is, of course, no way to be certain what happened, but on my examination of her, the only point of significant pain was in the right rib cage, a point very unlikely to be hurt if someone is hitting another (the right arm naturally protects the area), but a prime area of injury when one is thrown down (either by another or throwing yourself down). There was a time when the husband vowed to kill my friend and my friend was brought before the courts, but all charges were dismissed and the husband seems satisfied. I am uncertain where the truth lies, but I suspect it is closer to my friend’s story. I was very relieved to find out that the damning story is probably false.

I had another friend prove to be more of a Mr. Wycombe. He came to me at one point and we discussed hiring him. Indeed, at the time I thought the decision had been made, but then he just quit coming, so I assumed he felt an obligation to the people he had been serving and stuck with that job. We remained on friendly terms despite the slight. Recently he started coming around quite often. Later he was in the hospital here. After that he started telling me about how unfairly he had been treated by his former employees. “They are not Christians.” He told me that because he was sick and unable to report to work, they had fired him. I know his former employers fairly well and was surprised to hear his accusation. I wrote them to tell of his illness and to try to intervene on his behalf, but then I found out he had been dismissed before his illness occurred. He had not been reliably at work. Though he was warned and admonished, he persisted in his pattern and they had no choice but to fire him.

“Shall not the Judge of all the earth deal justly” (Gen 18:25). Abraham is seeking to persuade God not to judge Sodom and Gomorrah if there are a number of righteous men. He starts with 50 and whittles it down to 10, but we know that there were not even 10 righteous men in Sodom and the city was destroyed. “But when the Son of Man comes in His glory and all the angels with Him, then He will sit on His glorious throne. All the nations will be gathered before Him and He will separate them from one another, as the shepherd separates the sheep from the goats” (Matt 25:31-32). We should seek to exercise judgment correctly. As I am learning, it is important to hear all the facts before coming to a conclusion. On a more personal note, there will be times when we are falsely accused, when the truth does not come out. Justice cannot be perfectly carried forth in this life. Fortunately, there is a final judgment and He will judge justly. Many will be shocked and dismayed, but none will have any room for complaint.

8 February 2011

I was talking today with Rose and she told me the story of her courtship. Rose is in many ways the heart of our hospital. She guides the cooks and cleaners in their work. She manages the stores in the hospital and goes with us to Rumbek to buy the supplies at the best cost (much better than kawajas would get). But Rose is not a Dinka; she is Mauro. But I loved her story and thought I would pass it along. It came up because after 15 years of marriage and 6 children, Rose has never met her in-laws.

She and Paul, her husband, met at church camp. Paul is a smart man and quickly discerned what a fine woman Rose is. She was the more reluctant one. She did not want to marry a Dinka. But Paul was persistent and eventually made her willing, so he showed up at her parents’ house, and when her parents came to the door he introduced himself. They invited him in, though he made no show of his intentions. Rose was called to come to the room and was asked if she knew him. She said yes, she did know him and gave the circumstances where they knew one another. The rest of the meeting was spent with Paul answering questions about his family. At the end, they gave Paul permission to see and talk with Rose, but only at certain places and times. It was always during the day, not at night, and never alone. After several months of this, Paul was able to report to her parents that he had succeeded in winning her affections. Therefore there was a gathering.

On the appointed day, there were 10-12 representatives from each side of the marriage and the two prospective partners. Then a friend of the family comes in and starts making small talk. He talks about how much he loves this family and reminisces about the various experiences that he has shared with the family. Then after a bit he looks across the table and says, “But I do not know these people. Who are they?” That is the cue for the prospective bride to introduce her prospective husband and his family to the guest. Rose said that the pressure was really on and the introductions are supposed to be long. The bride is expected to stumble over her words and be nervous. After she gets through her part, the groom is called upon to state his purpose for being there and intentions. The groom needs to be ready to speak up and deliver a succinct message. Then the couple are sent away (to opposite areas) while the families discuss the couple, get to know each other more fully, and agree upon a dowry. The Mauro dowry is much more reasonable than the Dinka. For the beautiful daughter of a prominent Dinka Agaar, the groom’s family may be expected to pay 100 or even 300 cows, but for Rose the dowry was 10 cows, twenty goats, and a few pounds. Also the groom’s family is not expected to feast all the members of the bride’s relations for days. A small meal for the intimate family is sufficient. Unfortunately for Rose, the representatives of Paul’s family did not include his parents, and she has never traveled to Bor, Paul’s home. She was planning on a trip this March, but one of the prominent uncles in Paul’s family stopped her. He is a colonel in the SPLA and could not be spared at that time, so he insists that she wait until he can go to the home place and prepare everything as it should be to receive her.

9 February 2011

My first clinical rotation in med school was OB. One of the first patients I was involved in was a C-section. The resident, intern, and I guessed at the weight and I won. I think that was about the last time my transabdominal assessment had any strong correlation with reality.

We had two patients on the ward recently. One came in with labor pains. Actually, she had back discomfort, identical to the presentation of her last child. What struck me was how large the womb was. Not only did the fundus (the top of the womb) reach the top of the abdomen, but it seemed to stand out amazingly. I heard the heart beat of one. The patient’s mother asked if she could be having twins, and I said it was very possible. By the next day the pain had subsided, but the mother lived 10 kilometers away, so she ended staying in the hospital until she delivered one male child, though the biggest Dinka baby I have seen. Francis joked that I was worse than Bill Deans, our erstwhile leader who rarely sees a pregnant woman without predicting twins.

The second mother came in with leaking membranes. I guessed about 34 weeks gestation, so we gave some Dexamethasone to mature the lungs. Two days later, on the same night as the other, she delivered a small but healthy boy. Francis thought that the child was term with intrauterine growth retardation (IUGR). To me the child did not look wasted enough to be IUGR. I think he was more than 34 weeks, probably 35-36. It is entirely possible that his lack of any respiratory distress was from our intervention, but he did look older than 34 weeks gestational age. There were two more deliveries that night and a couple of threatened abortions, so our wards felt like an OB ward.

The good news is that deliveries are happening in our hospital. A year ago we were averaging less than 5 deliveries/month, so to have 4 at one time was remarkable. The bad news is my skill needs to rise if my predictions are going to help anyone.

10 February 2011

Last night as I was getting into bed and preparing to watch the concluding scenes of Seabiscuit, Monica Akoi came to my tent. “Barten.” (Come here or follow me). Monica is a TBA (traditional birth attendant), so I was expecting some OB problem. But when I followed her to the ward, there was an SPLA soldier sitting there. His head was wrapped in a red and blue shiny shirt and when that was removed I found a 15 cm laceration. The problem was that as I started to ask about how this occurred and when, it became obvious that these men understood neither English nor Dinka. My Arabic is limited to a few phrases that the Dinkas have incorporated into their language, but I took reassurance because the medical issue was so straight forward. I have always enjoyed sewing lacerations: you accomplish something while putting your mind at rest. I took him and his entourage (8-10 soldiers) over to our procedure room where the lighting is not as far from adequate as the foyer of the ward.

The procedure itself is so straight forward it is not worth recalling. I did inject him with Lidocaine 2%, soaked it a bit in Povidine, and closed it with 2-0 silk. The scalp is extremely vascular. There are many vessels in the skin and skin is relatively tight, so when a laceration opens the scalp, the vessels are virtually held open and so a lot of bleeding occurs. So when I injected the edges of the laceration, fresh bleeding was inevitable. Before I knew it, it was running down his face. Some pointed it out to me and I gave the patient some gauze to dab it away.

Whether it was the lack of language skills, their fear of the situation, the horror of seeing the blood streaming down their colleagues face, there was not a sound in the room. About 20 eyes were glued to the laceration. The man had been struck on the head with a stick, so the edges of the laceration were not sharp, so I took more tissue with each bite of the suture to pull it together. The main problem was the lighting. With barely enough light for most seeing the laceration, it was almost impossible to see the suture against his black skin for tying the knots. I pulled one suture out searching for the free end. But what amused me during the suturing was the complete silence. I was reminded of a James Herriot episode (All Creatures Great and Small) (I think) where he had sampled one of his client’s homemade wine and they had gotten carried away. By the time James was contacted to go to another call, he was “three sheets to the wind.” The people upon whom he was calling were complete teetotalers. He found his voice only worked at a whisper, so he whispered and everyone else was silent. I thought about that episode as I proceeded in utter silence, as though I was performing the most intricate of brain surgeries. When I finished, a few words of appreciation were said, but even as they left, they were silent. And that is highly unusual for Dinkas or the SPLA.

11 February 2011

A five month old boy was brought to me in pretty bad shape. He was wheezing, coughing, vomiting, running a high fever. Mother told me that before he got sick this time, he used to cough every time he nursed. In addition, he was miserable because his big sister (5 years old) had been running with him on her shoulders and fell, breaking his arm above the elbow. We put him in the hospital.

Sometimes having an order overlooked can prove the point. I suspected GE reflux with aspiration and asthma. I ordered omeprazole as well as Salbutamol and Beclomethasone inhalers and oral antibiotics. My nurses were convinced that this was pneumonia and started him on IV antibiotics, but overlooked the order for omeprazole. They did splint the arm which improved the child’s disposition greatly. But on the third hospital day, the child was not improving very rapidly. I reviewed the meds on the child and discovered the oversight of the omeprazole. By the next day, the child was dramatically improved. A couple of days later he was ready for discharge, but the splint was proving inadequate. I promised to cast the arm, but forgot that afternoon, so I did it the next day.

We still use plaster of Paris, which is pretty fun to use. All our rolls were 8 inches wide, so I had to unroll it and cut it in half. I remembered to get a catheter to put in the cast to give some protection against cutting off the blood supply if swelling occurred. The child was miserable as I held the elbow bent, the thumb up, and shaped the cast around him, but as soon as I let him go, he was happy as a clam. In America, this child might have seen a pulmonologist or allergist, a gastroenterologist, and an orthopedic surgeon. But on the field, he saw me. It was fun being able to address all this child’s needs.

12 February 2011

I saw a 6 month-old named Thon with a problem with his testicles. There is some humor there if you know Dinka names. My Dinka name is Mak Maker Majak. Mak for McIntosh. Maker is a black and white bull with the back (or abdomen) white. I was dubbed that by Abraham Maper Maker. But then I came up with Majak. My father is named Jack. Therefore his Dinka name would be Majak, or at least Majak is the closest bull name (it is the red bull with white sides). The second Dinka name always your father’s name. The irony is that these “bulls” are all really steers. They are all castrated. The male cow that is not castrated is called Thon. So here is a boy named for the true bull, the noncastrated variety, and he comes to me with testicular problems. I guess you have to stay among the Dinkas for a while to find that funny.

The mother says Thon has intermittent swelling of the testicle on one side, sometimes lasting as long as a day. He also is having some difficulty stooling, forcing him to strain to pass the stool. His exam was completely normal, including normal male genitalia with no swelling. What do I think and what do I do?

I think this is a perfect history for a hernia. It is almost undoubtedly not the testicle that is swelling: it is the intestines following the track established by the testicles in their descent. In utero (in the womb) the testicles start in the abdomen, about the place where the ovaries are in a female, but then they follow a course that goes wide (to about the inner third of the thigh and then from there into the scrotum. In a fair number of boys, the track does not close completely, and so, like with Thon, when the pressure in the abdomen is increased, the intestines will follow the same track. The danger is that if the intestines go down and do not go back up into the abdomen, they may swell and get stuck (incarcerated) and may even lose their blood supply (strangulated). There is a chance, actually a good chance, that the track will eventually close up sufficiently that the intestines do not continue to go out. In America where we have great anesthesia and highly skilled surgeons, the risk of strangulation typically outweighs the risk of surgery. It is not that clear in Sudan. I told the mother to seek medical help for any swelling that persists over 2 hours. I also put him on Ducolax, a laxative to make the stools softer and so decrease the straining of stooling, and thereby give us more time for the track to close on its own. This called an indirect hernia. It is not caused by a tear, but rather the persistence of the track, as opposed to the direct hernia found in older men. (The direct hernia is unlikely to heal on its own). If he presents with an incarcerated hernia, he has to have surgery, but I am hoping he may grow out of this.

13 February 2011

“If you ain’t John, I’m gone.” Many of us remember the story of the man spending the night in the house haunted by ghouls. Each apparition exceeds the previous one in horror, and as it leaves, it asks, “Are you gonna be here when John comes?” So after the most horrible ghoul imaginable asks the question, the man abandons the house exclaiming the opening sentiment.

Sudan is always hot. I think most days top 100F at some point, but in the last few days, you can feel a change. At church in Tin-Machar today, Gabriel Makur admonished the people to come early so that we would not be running into the real heat of the day. And when the Dinkas start talking about it getting to be too hot and making plans around the heat, you know it is hot. For the next two months or so, we are going to see some real heat.

Today I told the story of Abraham offering Isaac up as a sacrifice (Gen 22). The readings were Matt 7:7-11 and I John 2:1-2. From the I John passage, where we are told that Jesus is our Advocate with the Father, many Christians have gotten the mistaken idea that while Jesus loves them, the Father tolerates them for Christ’s sake. But the story of Abraham and Isaac gives us the best perspective from a human standpoint of God’s emotions around the redemption. Yes, Isaac must cooperate. Most authorities think that Isaac was probably an adolescent at the timing of this offering, so Abraham would have been 115 or so. Clearly had Isaac chosen to oppose Abraham, he would have succeeded. So it is with our redemption. Jesus has the right and authority to stop the process at any time, but He submitted to the Father’s will. But what rips out our hearts in this story is Abraham. “Take your son, your only son, whom you love, Isaac, and go to the land of Moriah and offer him there as a burnt offering” (Gen 22:2). In this story, we see the faith and trust of Abraham, but we must also see the love of the Father for us. As Abraham struggled, so struggled our heavenly Father. We watch The Passion of Christ and we are appropriately moved by Christ’s suffering on our behalf, but can we possibly conceive of the suffering the Father underwent in sending His Son, His only Son, whom He loves, to die in our stead, to bear His wrath? The Father loves us perfectly, just as Christ and the Holy Spirit love us. And He encourages us to come to Him and ask for good things. And He gives us good things. There are times when His gifts do not appear to be good. Trials test our metal, but they are a source of growth and maturity (James 1:2-4). Illnesses and suffering comes to all, but the Father is watching over us and using the suffering for good. Let us come to the Father as to One who loves us deeply, trusting that whatever He brings our way will be proved to be good.

14 February 2011

Earlier in the week Gabriel Amat came to me asking me to type up a list. That is not an uncommon occurrence. All the Dinkas want to learn how to work on computers, just as they all want to learn to drive, but unfortunately they do not have many opportunities. I have put an old laptop in a room where some are learning and I hope to get a typing tutor from the US for their use, but there are just not enough to go round. So I typed the form. It was another ECS (Episcopal Church of Sudan) form. This one was entitled “Decision making committee.” I was surprised but also somewhat honored to find my name on the list.

Gabriel came to me today asking if I had typed the list. I pulled it up on the computer, went over it with him, made a few corrections, and then we printed up some copies. “Now that we have the list for the ‘Decision making committee’ I need to ask you a question.” In the uprising January 2010, the soldiers had been fairly indiscriminant in their destruction. They were like the Huns. Not only had they broken into the ECS church and taken a large number of benches (pews), but they burned several tukuls, 12 mattresses, several beds, and took all the church’s livestock, which amounted to 13 goats and 25 chickens. They also occupied the bishop’s manse and set up their tents all over the church property. At one point Gabriel tried to return to the church and several soldiers were taking him away to either beat or possibly shoot him when some other soldiers intervened. They knew he was a pastor and interceded for him. It was weeks before the church services started in that building again and they are still much smaller than before the uprising. But later, saner heads prevailed. The friendship of the SPLA with the church may be more official than actual, but there are some fine men in leadership of the SPLA and they have helped restore the relationship. One of the leaders met with Gabriel and asked him what the church lost. Gabriel gave him the list above and that general went to Salva Kiir, the President of South Sudan. According to Billy White, a friend of mine who knows many people in the Government of South Sudan (GoSS), Salva Kiir is a believer. That may be true, or he may just be a wise politician, but Salva Kiir had someone make an estimate of the losses and gave the church 5000 NSP. Gabriel had come to me with that bundle before Christmas and I put it in our safe for a time. He has now put it in KCB (Kenya Commercial Bank) in Rumbek.

His dilemma was what to do with the money. First I asked if Salva Kiir or the general had specified how they should spend the money. They had not. Bishop Isaac suggested that they buy 12 beds and mattresses. He also suggested that they build a guest house. Gabriel favored building an office. We talked for a while about the needs for the church. There are several meetings that occur every week, but there is never a time when there are multiple conflicting meetings, so the office did not make much sense to me. Besides, they have no power and no internet, so it would not have the function that our office has. I asked him how often people came to stay at the church. In Dhiaukuei the ECS has a training center where the leaders can stay for weeks as they are taught. I figured if that was the purpose, the guest house made sense, but it did not if it was only for celebrations. Gabriel felt that the latter was the real reason. The bishop had not spoken of any training center in Akot. So I suggested that they keep the money in the bank and let it draw interest. Gabriel looked at me for a bit and then smiled. “Mak Maker!” It was as if I had come up with a solution to the Middle East conflict.

When Israel escaped from Egypt, the people had to overcome their slavish mentality. Four hundred years of being dominated by Egypt had not prepared them to become a new nation. We see their fear and foolishness repetitively throughout Exodus and the remainder of the Pentateuch. Likewise perpetual war has not prepared the Dinkas for delayed gratification. During the more recent war (Anyanya II), food not eaten was likely to be stolen or burned by their enemies. But the Dinkas are coming around. Gabriel was happy to delay, to keep the money in the bank, to wait until there is a clear need. Many people want to minister holistically to this culture, and I think they are showing signs that they may be ready.

15 February 2011

I combined two of my least favorite activities today and had a good day. There was a time when I really enjoyed making the trip to Rumbek. That time is over. The road is so bad and the town holds almost nothing that interests me other than a few decent restaurants, so I avoid trips if possible. And I have never liked meetings. I went over to attend the monthly meeting of the health care providers with the Ministry of Health, but for the second straight month, that did not meet. However, there was another meeting I needed to attend, with the World Food Program (WFP), so I went there. My direct connection to the WFP was to attempt to help with school lunches. We have several primary schools in Akot, but orphans are generally excluded. Let me explain. There is a system among the Dinkas to deal with orphans. If the parents die, extended family members take over the care. But they are generally not treated as well. They get less food, less clothes, and almost never go to school. So some of the long term and faithful supporters of the work here in Akot have given money to educate these children. Two schools are going: Living Water and Abundant Life. 516 children were enrolled in these two schools last year and the number is expected to climb to 750 this next year (like so many schools, both add a level each year). Not all of these are orphans, but the majority are. Besides providing a building and teachers, these supporters have paid for lunch for these children. We put in a grant last year with the WFP, but we were too late to be considered. But I had two other reasons for going. One was to try to get some help for the hospital and our patients. The other was to meet Kefa Ojwando, a health care provider with Life in Abundance. Kefa is Kenyan and has been in Rumbek about a year providing general health care. Mustard Seed International (MSI) is seeking to partner with Life in Abundance.

In many ways, this was a typical Dinka meeting. Abraham Maper and I arrived at the meeting right on time (from 2 hours away), but that was 40 minutes before the meeting commenced. When it finally began, the lady leading the discussion spoke quietly and used a great many TLA’s (three letter acronyms) without identifying them. I asked about one of them and someone else about others until they finally got the message and posted a poster identifying the TLA’s. I cannot say that the rest of the meeting was efficient, but they made it clear what we needed to do and say to filed an application that they would fund, which is what we needed. It took us 8 hours to accomplish what could have been done in 2-3, but I got to know Kefa during the meeting. I also met Anteneh, an Ethiopian, who is serving Life in Abundance as their accountant. Both men were articulate, interesting, dedicated Christians. I look forward to getting to know them better. And I feel fairly confident that we will be able to get some food for the schools and for our pregnant women. We might even be able to get some food for our inpatients.

The strange but maybe good thing is that I was appointed sector lead. Instead of each potential partner applying separately to WFP, we are grouped by sectors. I was elected lead for the health care sector. I have no illusions of honor. I know that Dr. Geoffrey is the better known to the group, but he works with Malteser who may be leaving Sudan in the next few months. Everyone else also had an excuse. But I think a couple of advantages may be hidden in responsibility. I think it will be harder for them to not choose the sector leader as a partner. And I think I can probably get them to pay for a position here to give out the food, generate reports, and keep the group in line. And that could be a great thing.

16 January 2011

I had another humbling experience today. Unfortunately, at least in my case, humbling experiences do not result in true humility. If they did, I would be one of the rarest of all creatures, a truly humble man. I was in the midst of clinic today when I heard Makur’s wife wailing. Makur is one of our most faithful workers here. He is a shuffler. He never seems to get excited. He never seems to push himself too hard, but he is steady: the tortoise, not the hare. His tukul is just outside the compound and his wife just delivered about two weeks ago. I was afraid that she had found her baby dead, though SIDS (sudden infant death syndrome) usually occurs at night. I heard the stampede of worried folk, so I kept working and figured I would hear soon enough. I was right. Within another 5 minutes the story made it back to our room. One child had been rolling a car tire, but it got away from him and fell on Makur’s next to youngest child and broke his leg, his R femur. The femur is a large bone, probably the longest in the body, and quite strong. I was hoping they were wrong, but I held out little hope, and that vanished as soon as I laid eyes on him. His right upper leg was 3 inches shorter than the left and there was an exquisitely painful bulge in the upper part of that leg. After a few minutes consultation among themselves, they decided to take the child back out because of an ironic truth: though man has been setting bones as long as children have been climbing trees, doctors in the US do not. Bone setting falls into the exclusive domain of the orthopedic surgeon. The options for the child were to be transported over miserably rough roads to Mapuordit or to go to the local bone setter.

I first became aware of this phenomenon about a year ago. Pothe told me his nephew had fallen out of a tree and broken his femur. I told him that was a major problem. In addition to the severe pain, there is substantial loss of blood, so he needed to bring the boy in right away and we would transport him. The next day Pothe informed me that it was okay, that the bone setter had set it and all was well. I have subsequently come to know Pothe’s nephew well. It is likely that the broken leg of that boy is slightly longer than the other (another irony, but when broken, the bone is spurred into growth, so a bone set end to end tends to be a bit too long), but I notice no significant problems with that youth.

Based on that limited experience, I was ready for the idea of the local bone setter, but then Jacob wanted to take some Lidocaine to inject at the break. I threw out a different plan. Why not bring the child and the bone setter here, let me inject the femoral triangle with Bupivacaine and give some ketamine and make it easier on the child and the bone setter. I instilled the Bupivacaine into the femoral triangle, just lateral (to the side) of the femoral artery. That is the area of the femoral nerve. The child did quiet down substantially after that. Ketamine can be used intramuscularly (IM), but I have used it primarily IV (intravenously). I tried several times to start the IV without success. The room was dark, the child was held in a strange position, etc. I had some legitimate excuses, though they did not lessen my humiliation. When I gave up and started to give it IM, the vial was missing. But the child was quiet and the bone setter ready to do his work. He put his left hand on the site of the break and the right hand on the knee. He wiggled and pulled and pushed. Within five minutes the bone was set. Could I have done it? I do not know. He then kept his grip on the knee while lifting the leg slightly so that Jacob (our trauma man) could wrap the leg with a roll of spongy gauze. He wrapped that relatively tightly. Then he cut some cardboard (I am not lying) into 4 x 4” squares and placed two of them around the leg. He then switched places with Jacob and wrapped again with another packet of the spongy gauze, this time considerable tighter and then cut the gauze down the middle 18 inches or so and used that as a tie. The child was sound asleep by that time.

I hope that the people of Akot will never again go to the witch doctors for treatment for maladies such as a peritonsillar cellulitis. The outcomes have been horrible. I hope one day they will quit injecting themselves with dirty needles and quit having someone open abscesses using unclean methods. But I hope one day to learn from the local bone setter and be able to set fractures the way that man did today.

17 January 2010

In America, we often say, “I have the flu.” Typically we do not mean, “I have influenza.” What we mean is, “I’ve got the crud,” or “I have a little illness.” In Sudan, when people have fever, they say, “I have malaria.” In America if someone comes the doctor in January with fever, chills, aches and says, “I have the flu,” the doctor may conclude he does have influenza. Likewise, during the rainy season in Sudan, someone telling me he has malaria if often right, but that is less likely to be true the farther we get from the rainy season, just as “the flu” is less likely to be influenza the farther you get from that year’s epidemic. John Deng is a health care provider in Sudan, a former employee of our hospital, and a friend. His wife came to me saying that John had malaria and was too sick to walk to the hospital, so would I come and get him. We did. Rose and I took his wife, headed towards Makur-agaar to as close as we could drive and then walked in to see John. He was sick. His temperature was 39.5C (103F). There is a bit of the dramatis persona in each of us, particularly when we are ill. At one point, I was afraid I would have to carry him to the car, but eventually he walked leaning alternately on Rose and his wife. I did carry him into the hospital from the car (and rejoiced that I did not have to try that for a quarter of a mile). On his exam, he had fairly dramatic tenderness in the right lower quadrant (RLQ), but he had no vomiting or diarrhea. His spleen could not be felt, and it usually can be in malaria, but that is certainly not universal. We gave him some IV fluids, reduced his fever, and started him on anti-malarials (ACT-Artemisia combination therapy). The next day he was better, but not dramatically and the RLQ findings were more prominent. The next day he started with massive bloody diarrhea and we started Flagyl and Chloramphenicol. From that point on he improved rapidly and I took him home today. He was still weak, but he had no fever, his appetite was returning, his stools were normal.

I think he had Typhoid fever. There is a problem with that diagnosis here in Sudan. The test is what we call a titer. It is a reaction that occurs in a time and temperature related manner. Typically, it is not a yes or no, but a number generated. But that number is based on a curve generated at 27C (71 F), whereas all labs, at least during the day in Sudan, run the test at 35-40C (95-104F). Therefore practically everyone in Sudan has Typhoid fever if you go to the labs in Rumbek. The malaria rapid diagnostic tests (RDT) are much more selective. I question their sensitivity, but when they are positive, we are certain that they have it. Unfortunately, we have run out of our RDT’s.

18 January 2011
I was faced today with the simple and the complex. I do not what it is about Sudan that tends to breed infectious complications. We do not have basic simple hygiene, and maybe that is the whole issue. I had a simple abrasion on my elbow, and true to my usual careful self, I neglected it. A few days later it was warm and puffy, but I had some Neosporin ointment and the infection has almost completely resolved. I saw a man today who could have used some Neosporin a week ago. I was asked to see him in the treatment room. His right hand was significantly swollen, but there were three areas where it was warm and somewhat tense: the medial (inner) aspect of the thumb, and the tips of the index and middle fingers. There was a bit of swelling in the more proximal (towards the palm) part of those fingers and in the web between the thumb and index fingers, but it was not tense and there was almost no pain. I asked him what happened. “I was cultivating.” He showed how he was gripping the instrument (somewhere between a hoe and shovel) through those fingers as he worked. He had worked up some blisters on his fingers. A week ago he needed some Neosporin and the whole thing would have resolved. Today I opened three fingers and he was put on two oral antibiotics, and I was tempted to put him in the hospital. Could he have died or become crippled from simple blisters? Looking at that hand, I think it is entirely possible.

The second patient was brought to me by Justin Machar. She is a woman I saw a year ago. She came in with an area of swelling on her forehead. It felt fluctuant and I drained it, but it was all blood. Then I found some other areas and I told her I thought she had cancer and that these were metastases. When she came to me this time, she was said to have tuberculosis osteomyelitis: TB of the bone. She was quite cachetic (wasted). And she had numerous areas of swelling: 5 on the skull, one on the L clavicle (collar bone), one on the R humerus (upper arm). Those were the ones that were obvious. She was not able to walk, suggesting that there were some more of these areas of swelling on the vertebrae or other weight bearing areas. We looked at her chart from Rumbek, where she received the diagnosis. They had indeed looked for TB, but all their smears were negative. Moreover, the family reported that during the month she took anti-TB drugs, she got significantly worse. It is true that in a severe, disseminated infection that the start of effectual medication will often make you sicker, but that tends to last for 4-5 days. Typically, at least in TB of the lungs, where we have the most data, two weeks of an effective regiment will stop the person from coughing up more of the organisms and clear clinical improvement is seen.

I am very uncertain about this patient. She has lost so much weight that I think if she had a breast cancer it would be obvious: there is no tissue to hide it. And breast cancer is the most common cancer to metastasize to the bone in women. But if this was TB osteomyelitis, it should grow and spread contiguously (connectedly) rather than in islands. There is an entity called miliary TB, but without proper treatment, it is fatal within the month. We are looking for TB, but we are not continuing her antituberculosis drugs until we prove she has it. We are helping her with pain. If this is cancer, the woman will die in the not too distant future, but we will not abandon her.

Cancer and heart disease are the most common causes of death in the US, but not in Sudan. In Sudan, the most common causes are still eminently treatable. Many are simple like the man above who with good hygiene or a trip to Walgreen’s would never have needed us. Many of the deaths are from diseases preventable by vaccination. We do not have to be brilliant to make an impact in Sudan. One of these days, Sudan may catch up. Malaria and dysentery may be controlled; Neosporin may be available for anyone who needs it. Doctors may be vying for patients one day. But we are a long way from that today. For now, there are things we cannot do. What do we do? We will be content to limit our scope and try to impact the most people in the most cost effective as well as compassionate manner possible. We are impacting the lives of many, and we seek to help the rest in other ways, if possible.

19 January 2011

Yesterday afternoon, Helena Ajak fetched me from my tent. “Martha Ayen” and she gave the sign for labor (heels of the hands together, pushing downward at the groin). I do not get called very often for deliveries because we have competent TBA’s and good nurses backing them up, so I quickly followed Helena. Our delivery suite is not state of the art, though about half the time we are able to persuade the women to labor on the exam table rather than on the floor. Ayen was on the table. There were a lot of women around her with long faces. The inclusion of fathers in the delivery process has not gained a lot of traction in Sudan. There is a belief among some Dinkas that if a woman is struggling in labor, it is because the father of her child is not her husband, and if she calls out the name of the father, the pain will be less intense, so some of the men want to be “around” in case true confessions are made, but in the suite or tukul where the actual delivery occurs, Dinka men stay clear. When I examined the woman, the reason why I was called was clear. The introitus, the opening to the birth canal, was too small for the head. I needed to cut an episiotomy. That is a cut to the side that does two things: extends the opening and directs tearing away from the anus. In the US, probably the majority of vaginal deliveries have an episiotomy done as a matter of course, but that is not true in Sudan.

When I first came, probably in one of the first discussions I had with the nurses, I was told that episiotomies were not done. About 6 months ago there was a young girl (she conceived after her second period) who could not make any progress and so I did what I believe was the first episiotomy ever done in Akot. The delivery was not rapid, but it was uneventful and both the mother and child did well. About a score of times I was asked if the tear had gone into the anus and I was happy to be able to tell them that it had not.

This delivery proceeded in a similar manner. The cut did not make it easy; it did make it possible. The end result was a healthy baby and a not too unhappy mother. She did not enjoy the suturing afterwards, but her sister, who was practically glued to my ear, apparently did. I also think she spread the good news about the sparing of the anus. The next day, some of the women were praising God for the safe delivery of this child.

The remarkable thing about this event was that Helena Ajak, a hospital employee who is also a relative, called me and the mother and others in the room did not need to be convinced to allow this procedure. A year ago it was unthinkable. Six months ago prolonged persuasion was needed. But now it is a viable option for those needing it, particularly the young girls.

Traditions die hard. Many should be preserved, but those that are harmful need to be exposed and cleared away. The fact that these women had heard of the other episiotomy and were ready to put aside their traditions for the sake of this woman was encouraging to me. I do not expect episiotomies to become routine (indeed, it is not usually needed in Sudan), but at least I think there is less likelihood of young girls dying because the irresistible force (labor) has come against the immovable object. There other traditions that I have sought to address that also need to be laid aside. Maybe we will start seeing that soon. I am encouraged.

20 January 2011

A year ago, shortly after my return from the US, I was confronted by a delegation of Dinkas, headed by Mayek, my friend (and many on the staff say, my son). They were requesting a raise. That was a major step forward. There was a time when they felt the need for a raise and so made threats against the hospital, so to handle the situation diplomatically was good. It reflected several things. First, they had matured. Second, their trust in us was higher. Third, they felt a loyalty to the hospital. They wanted more money, but they could see the benefit that the hospital had on the community and they wanted that to continue. A week ago, following devotions, Gideon asked if I would meet with the staff and scheduled that meeting for today. I may be getting old, but I am not brain dead, so I figured out what the meeting was about, though I did, in monydit fashion, forget to ask Bill Deans about the raise.

Gideon Mabok, the true monydit and outspoken leader of the staff, said some nice things about the hospital and me and told a story that might, with a good imagination, have some bearing on the question at hand and then asked if I had anything to tell them. He did not ask me for a raise, nor had the question been alluded to even once. I have too much of my father in me to simply address the unspoken question. I thanked them for their nice words and said, “I am a bit surprised. A year ago you got a raise after a long time without one. I thought that you might be asking for a raise in this meeting as well, but I guess I was wrong.” There was laughter and assurances that I was not wrong. The raise is clearly needed. Food in Rumbek has gone up at least 15%. They are not hoping to afford season tickets to the Braves’ games; they need to put food on the table. I am not saying that all their money is invested wisely; I am saying that we are really giving them a COLA, a cost of living adjustment, rather than a true raise.

“He has told you, O man, what is good, and what does the Lord require of you, but to do justice and to love kindness and to walk humbly with your God” (Micah 6:8). A quick perusal of Isaiah and Micah (and most the other prophets) makes it clear that God is concerned about justice. I think a significant part of justice is fair wages. Actually, no one from the US would look at the salaries we give and think them fair. Our top workers get a day what a worker at McDonalds gets an hour. But we pay on time and a decent salary compared to the average worker in the community. I know there are many who would love to get on with the hospital. So if we are going to ask God to provide for our needs, I think we need to be fair with our workers. And say what you will, there are few things that make a worker smile more than a raise.

21 January 2011

Devotions today were very encouraging. First of all, there had been a drift, a casualness in the starting time so that when devotions were scheduled to start, no one was there but the kawajas, the Americans and Kenyans. So yesterday I addressed the issue. Now I have noticed that there is a slight change in the length of the sunlight. For Americans who are experiencing the dramatic shortening of daylight hours, what we have is hardly worth mentioning. But a few months ago, 6:30 was fairly light. Now, following the winter solstice, the rising of the sun is delayed to 6:45 or even closer to 7. It is hardly worth shifting the clock: we still have more than enough daylight, so there is no reason to save it, but I think it is an explanation for the shift in time of arrival for people who generally do not have working clocks or watches, many of whom have a fairly lengthy footing for their daily commute. Still, I felt like some tightening needed to occur, so I told them that devotions started at 8:30 and I expected them to be on time, and that if things continued as they were, I would be forced to dock their pay. So at 8:30 this morning, we did not have full attendance, but we were much closer than before. I was asked to speak and I talked about Judas. My Scripture references were Romans 6:16, 7:21-25, and Luke 15:16-20, but my story comes from Matthew. I tried to think about what was going on in the mind of Judas as he stole from the purse and thought he was clever. We talked about how he must have been received by the Council when he came to them. They had given up any hope of arresting Jesus during the Passover because the crowds were so attracted to Him, so when Judas came to them with his plan, they must have been ecstatic and treated him as a king, as a noble man who was working for the a great cause. And they paid him handsomely. I also talked about Jesus’ warning to him, how that must have given pause when he found out that Jesus knew about his treachery, but he would not take the warning. Finally we talked about the height of his treachery that he betrayed Jesus with a kiss: the sign of affection employed to betray. But then, from Judas perspective, the shift comes. Suddenly he sees the designs of the Council. He may have witnessed the mockery of a trial or been sickened in the beating and disrespect shown to Jesus. He goes back to the Council, disturbed and filled with remorse. I think he expected the Council to make him feel good about himself again. I think he hoped they would reassure him. When he complained of betraying an innocent man, he hoped they would tell him that he did the right thing, but they do not. These who probably appeared to be his friends at one point say to him in his hour of need, “What is that to us? See to it yourself.” They are encouraging him to commit suicide, which he does.

At the moment of temptation, sin always appears to be our friend. He puts his arm around us and tells us that we deserve the pleasure before us, but he is no friend. Romans 6:16 tells us he is trying to enslave us. Instead we need to resist him and remember who it is who truly loves us. But when we do sin, we also need to be like the Prodigal Son, coming to our senses and trusting the heart of our Father.

22 January 2011

Yesterday I admitted an 18 month old girl to the clinic. She had a high fever (39C) and a tender abdomen, but nothing else of significance. Her spleen was not enlarged, leading me away from malaria as a diagnosis. Besides, I have not seen a convincing case of malaria in a couple of weeks, so I was leaning towards Typhoid fever, a diagnosis we have been making frequently lately. She did not respond rapidly to the Amoxicillin (at her size, I was a bit reluctant to start Chloramphenicol). I thought we could get by with oral meds. However, when her fever did not break, the nurses added ACT (Artemisia combination therapy) to cover for malaria. She had a decent night and on rounds she was afebrile and looked pretty good, but as I left for the clinic, Samuel said something happened. The child started a strange cry and then “turned completely white.” When she did not improve after 45 minutes, Samuel came to the clinic to get me. The child was crying like one in distress. She was anything but white, being a Dinka, but her nail beds and conjunctiva were very pale. Moreover her lungs were clear, yet she breathing very deeply and rapidly and her heart was beating fast. Her abdomen still showed a slightly large liver (2-3 cm below the ribs or costal margin as we say), but the rest of the abdomen was soft. Her spleen was still not felt. But she was afraid, and so were we. Malaria lowers the blood counts by rupturing blood cells, but as they explode, they are cleared by the spleen. Thus the spleen is frequency enlarged (splenomegaly) in malaria. Blood is an irritant, so if she was bleeding into the gut, I think her abdomen may have been hard, showing signs of problems, but it was not there. And there are just so many places where you can bleed so much that you get into this kind of acute distress. A small amount of bleeding into the brain will cause distress, but it would not be enough to lower the blood counts so rapidly. I started thinking that maybe the problem was more chronic. The parents said she had been sick for a month. We decided this could possibly be acute leukemia. If so, she was in the wrong place. In America, acute leukemia at that age carries a good prognosis. Over 90% of them are cured (i.e. no sign of relapse 10 years after the disease is treated). But that would not be true here. Acute leukemia is a death sentence in Sudan. Because of her distress, we decided to take her to Mapuordit. They can give blood. If she has leukemia, a transfusion would only be a temporizing measure, but we thought it was the best we had to offer. Samuel took her. I finished the patients in the clinic and then went to pick up Chadrach Chol’s aunt who reportedly had a convulsion (I was not quite sure after the history). Samuel pulled up about the same time as me. “How did the little girl do?”

“She died just outside Agaan. I took her and her parents to their home.”

There are times when it is frustrating to be here. A simple blood count (including platelets) would have told us if it was likely that this child had leukemia. A blood bank could have extended her life. A good referral center and the odds are that she does through some misery, but with an ultimately good outcome. Instead she is dead. But there are many every day who live because we are here. When someone like this child dies, we have to remind ourselves of that truth and stay focused on what we can do.

23 January 2011

When I was in my fellowship in Pediatric Pulmonology, one of the other fellows (James) asked an ethicist for help. He was facing a difficult dilemma. He was caring for a cystic fibrosis patient in his early twenties who was going into respiratory failure. James did not want to put him on the ventilator; the man wanted to be ventilated. The ethicist said something I regard as profound: we have no obligation to administer futile or ineffective therapy. James thought he was off the hook, but the man defined ineffective therapy as that which does not do what it is supposed to do. It does not necessarily look at the end result. James’ goal, of course, in ventilating this patient would be to keep him alive and hope that he came off the ventilator. He thought it futile to ventilate because the odds were heavily against the man getting off the ventilator. But if they could ventilate the patient, James could not refuse the request on the grounds that it was ineffective therapy.

I am often asked to do ineffective therapy. In my first month here, a man was carried in after being hit by a motorbike. I figured the guy was knocked around pretty well, but there was no evidence of a break or internal injuries, so we gave him analgesics (pain meds) and watched him. One of the local chiefs came in to see him and suggested that we give him a shot of penicillin. I facetiously asked if he did not think the man’s pain sufficient already without causing more pain without benefit. Subsequently I have seen how often Dinkas desire an injection. One of the mildly retarded ladies here with epilepsy was on the ward because she could not care for herself. She complained bitterly and often that we were neglecting her because we only gave her medicines at night. She always wanted an injection, preferably one on each side to balance the effect.

Today Malith came to me with what looked like and sounded like a primary (first time) H. simplex infection (cold sore). He had blisters on his gum and soft palate on the left side of his mouth. He wanted me to give him some Gentamicin. I refused. It is ineffective. Herpes simplex is viral, and though there are therapies available, we do not have them. Gentamicin would have no effect and I felt no obligation to prescribe it. Through Angelo I told him to be careful with his family. He needed to not kiss them or share their food until all the vesicles (blisters) had healed. That conversation took place near the pharmacy, an unfortunate location. Several of Malith’s buddies heard the advice and were being sympathetic, Dinka style. Isaac Meen was coming up to the group and they asked him if he wanted to kiss Malith. Isaac said, “Certainly, but I will go to the back of the line. When I have seen you all kiss him, then I will.” We all laughed.

Public display of affection (PDA as it was called when I was in high school) is different in Sudan. Though I made the warning to Malith, about the only kissing I have seen in Sudan has been between a mother and her infant. On the other hand, it is very common for men to walk along holding hands. It is my very strong opinion that they do it because they the whole idea of homosexuality does not even register. Affection for another man is a David and Jonathan kind of deal. At least I hope that is true, for I have found myself walking in the market of Akot or Rumbek holding the hand of a friend.

24 January 2011

In my residency, there was a rule that all orders for drips such insulin or aminophyline that were written by a first year resident had to be co-signed by an upper level resident. It was because the drips were dangerous, and as I used to tell my children when I was teaching them math, decimal point errors kill patients. I remember being an upper level resident and writing for insulin and getting the intern to check my orders. He picked up a decimal point error in time to prevent any problems. It was a good lesson to me. We never cease to be able to err, and we always need backup.

I admitted a 20 year old man from the cattle camp a few days ago. He was clearly sick, coming doubled over and complaining that he had not been able to urinate for 2 days. He also said that he was having some “pus” out of his penis at the end of urination. I actually thought this was a severe case of urethritis. In other words, I thought he had a rip roaring case of clap. I have had many Dinkas about their sexual promiscuity, and I was just trying to get this guy to own up to reality, but he refused. He kept insisting that he had not had relations with any one in over 2 years. I put him in the hospital to get some IV fluids and a urinary catheter, but it turns out that he had been vomiting and was dehydrated. With fluids, he voided and his abdominal spasticity abated, but he remained very tender in the abdomen, particularly the right lower quadrant (RLQ). Day 1 he had significant spasticity on the entire right side. The last two days, the pain has been more localized to the RLQ, but now there is more of a mass effect and his bowel sounds are virtually absent. He is drinking fluids and has not need IV fluids for 2 days, but he continues to vomit (twice yesterday). I am suspicious that he had appendicitis, that the appendix has ruptured and he has a localized abscess, but I am getting mixed signals, so we will watch him for now. Clearly, however, my initial thoughts were way off base and I am glad that the nurses picked up when I fumbled.

“For the body is not one member, but many. If the foot says, ‘Because I am not a hand, I am not part of the body,’ it is not for this reason any the less a part of the body. And if the ear says, ‘Because I am not an eye, I am not a part of the body,’ it is not for this reason any the less a part of the body. If the whole body were an eye, where would the hearing be? If the whole body were hearing, where would the sense of smell be? But now God has placed the member, each one of them, in the body just as He desired” (I Cor 12:14-18). I am very thankful for the body of Christ around me, doing their work and covering my deficiencies.

25 January 2011

My tent often feels like a coffee house. During free hours, I often resort to my enclave, but friends often drop by to talk about various things. Dinkas are not Americans. They do not come rapidly to the point. What generally happens is that a man comes to my tent and stands at the flap, waiting for me to bid him enter. Some women have come to my tent. I think maybe one time a woman entered when some other men were in the tent, but they would never enter alone. I think they would rather be stung by a scorpion than enter my quarters alone. But men come in regularly. We greet each other, usually three or four of the usual Dinka phrases, and then we make small talk. No one seems to care about the Braves here, so we have to go to other subjects, but they are just as trivial. Often then we sit and look at each other for a few minutes before I say something profound like, “What can I help you with today?” One time I went to Rumbek with a kawaja and several Dinka friends. We went to Safari Style to try to exchange money, so I walked in, asked the man running the place (Lynn was out) who told me he had no Sudanese pounds to exchange. We exchanged pleasantries and left. The Dinkas were amazed at how quickly it all occurred. I think secretly they were also shocked at my rudeness of coming so directly to the point, but they would never say that to me.

Gabriel Amat, a frequent visitor, came by today and invited me to a party, or really more of an assembly. Abraham Laat Ding had returned home. I am unsure of all the details, but I suspect Abraham was one of the “Lost Boys of Sudan,” though I know he did not leave from Kokuma, the large refugee camp in northern Kenya. I do know that 10 years ago he and several others went to Israel. And his story is touching. Martha Yar is one of the elderly matrons and leaders of the ECS (Episcopal Church of Sudan) in the area. Ten years ago she led prayers (a church service) for Abraham as he prepared to leave his family, pursuing a great opportunity. Then on Christmas Day just past, she came to the family and invited them to come to the ECS church in Akot to celebrate Christmas. That is not unusual. Akot is the center of the Christmas celebration for the Lakes State. But it is also not easy. Ding Polic, the father, lives 5 to 10 kilometers from Akot. Martha may have hopped on the back of a motorbike (side-saddle, of course) or jumped on a bicycle, but there is a good chance she walked there and back. And of course the family faced the prospect of walking that distance in the evening and then coming back on foot in the middle of the night. But they accepted the invitation and came with Martha Yar. When they got to the church, there sat Abraham Laat Ding. And like the father in the Prodigal Son parable (Luke 18), Ding Polic had killed the somewhat fattened bull and had a celebration for the return of his son. Though as far as I know, none of them had ever met me, they invited me to be a part of the ceremony and to share a word. Of course, Gabriel did not mention that part until we were leaving, so I told I story I recently told in devotions, but it is a favorite of mine. We arrived around 5:30. The original invitation was for 2, so I was afraid we were causing a great delay in the proceedings. How slow I am to catch on. There is a church next to the home of Ding Polic, so I was hustled to a seat in the circle with some ECS dignitaries such as Amat and Martha, but then we sat there for over an hour while the main party was by the home. As the pastors and archdeacons conversed in Dinka, I had plenty of time for contemplation and observation. About 40 yards to my left was a well. It did not have a hand pump, but there was constant activity as the girls lowered jericans on ropes, retrieved them, and continued the process until they had filled their own jerican to carry home. It occurred to me that Dinka girls almost never have time for play. They are always busy drawing water, fetching water, grinding grain, heating water, stirring pots, cleaning pots, caring for babies, but they are always together and they seem to enjoy life. My contemplations were interrupted by another observation. About the same distance away, and about 20 feet from the well, ostensibly behind some bushes, but the bushes blocked no one’s view, were two cattle camp men bathing. They were stark naked, but the only one who seemed to notice was me. Very noticeably, the young girls at the well treated the bath with complete indifference. They were neither shocked nor aroused nor curious; they were oblivious. Many young girls arrived, yet not once did I notice giggling or furtive glances; they continued on as though the men were not there.

About 2 hours after our arrival, I was asked to give the devotion. The Scripture reading was Romans 12:17-20. The story comes from I Samuel 25. David, though fleeing from Saul, has his men in the bush. Nabal (meaning fool) has his shepherds out in the bush with their flocks. David and his men, though unbidden, do him a great service and protect them so that their sheep flourish. They are not harassed by wild beasts or marauders, so they multiply and Nabal has a great year. At the time of shearing, David sends his men to share in some of the bounty of the harvest, but Nabal is arrogant. “Who is David? And who is this son of Jesse? There are many servants today who are each breaking away from his master. Shall I take my bread and my water and my meat that I have slaughtered for my shearers and give it to men whose origin I do not know?” (I Sam 25:10-11). David’s servants reported back and David was enraged. “Each of you, gird on his sword.” David made an oath to kill every man in Nabal’s house. But though a fool, Nabal had a wise wife named Abigail. One of the servants came to her and told her how David had treated them in the wilderness and how Nabal treated his request. She rose immediately, made gifts of food for David and his men, and then went to David herself. When she came to him, she fell at his feet, declaring, “On me alone, my lord, be the blame.” She pleaded with David not to take revenge on Nabal. “And when the Lord does for my lord according to the good He has spoken concerning you and approves you as ruler over Israel, this will not cause grief or a troubled heart to my lord” (I Sam 25:30-31). David turns back, but when Abigail tells Nabal what has happened “his heart died within him” (I Sam 25:37) and he died 10 days later. Then David took Abigail to be his wife.

There are three lessons in this story. First, we must not take our own revenge. God is our defender. He will put things right. Second, we should be like Abigail. When we see our brother headed into sin, let us seek to turn him away. It took great courage and humility for Abigail to go to David, but she spared him great grief. Third, we should be like David, receiving the warning and turning away. We who have experienced grace should be quick to repent when confronted with our own sin. We err continually, but if we receive the counsel of our brothers, we may be spared much greater pain by repenting right away. These are good lessons for us all.

26 January 2011

As we were finishing rounds today, I was told that another patient had been admitted. It was a 2 yo girl. Her history was diarrhea and vomiting, so my initial thought was enteritis, but I always listen to the chest when there are gut problems. Pneumonia often presents with fever and vomiting. This child had diffuse wheezes and crackles throughout her chest, so I was glad that I followed my usual approach. I used some inhalers and a face mask. In the US we have Aerochambers with masks to use, but I have found that we get a fair number of masks for ambu bags or nebulizers, and they work well with the inhalers. And sure enough, she cleared up well with that treatment. But the physiology of the chest causing abdominal problems and the efficacy of inhalers through face masks is not what made me want to talk about this child.

I was more taken by her name: Panda Rakchok. Panda means home. Using the bit of Dinka logic that I have acquired during my time here, I assume that means that the family had recently moved into a new tukul about the time of her birth. (I checked that with the family and confirmed my suspicions). Rakchok is her father’s name. All the children he has will have as their second name Rakchok. “Rak” means Lulu tree. “Chok” means foot. Rakchok then means at the foot of the Lulu tree. Rakchok’s mother gave birth to him at the foot of the Lulu tree. She was probably going to find the mid-wife. She may have even been coming to the clinic to attempt to give birth with some trained medical workers on hand. Typically, if they are safely ensconced in their home, they will give birth in the tukul, not under a tree. But the real reason the name caught my eye is it is the name of my journal. I heard the name Rakchok months ago and had its meaning explained to me. I chose it for the name of my journal because I live in a tent under a Lulu tree, and that is where I compose or “give birth” to my journal every day. In a very real way, I am Rakchok. So I was very glad to meet someone with my name. I was also glad to find that I was spelling it correctly. Dinkas pronounce “C” as “Ch,” so I was unsure if the correct spelling would be Rakcok or Rakchok. I was glad to find that it is the latter, as I have been spelling it in that fashion for a long time.

27 January 2011

Martha Ayen, the mother who delivered with the help of an episiotomy, returned today. She is healing well, the absorbable sutures have been absorbed and are no longer irritating her, but she brought in her child: Marial Warkuei. Marial is a bull I know well: black with white sides. But Warkuei was an unusual name. I knew that it came from his father. Often Dinkas have three names, such as Joseph Mayek Biljok. First is the “Christian name.” In our heritage, we used to say Christian name to refer to the given name. But among the Dinkas, the Christian name is the one given when the adult is baptized. It is mainly used for kawajas. That was brought home to me one time talking with John Pothe. He called his wife Debora, but then when I was around her with him not present, she was called Rebecca. I asked him about that one day and he said, “Her name is Rebecca; I just keep forgetting it.” So I think he calls her Yar and does not worry about her “Christian name.” The second name is the given Dinka name, such as Rakchok if you are born under a Lulu tree or Mayek if you are sickly and your parents do not expect you to live. The third name comes from your father. Mayek’s father was Biljok; Mayek’s son is Akot Mayek. Warkuei also comes from the cattle camp, but it means to change the rope by which the bull or cow is tied at night. At the cattle camp, every night the cows are tied to a particular stake using the same rope. The keepers know their cows and their ropes and do not often make a mistake, but on occasion the rope has to be changed. Warkuei. In this family, all the children preceding Warkuei had died, so changing the rope was a metaphor for changing the outcome in Warkuei’s life. Unfortunately, it did not work. Warkuei died at 6 years of age. So Martha Ayen was “engaged” to marry Warkuei even though he had been dead for many years and she never knew him. Indeed, she really knows nothing about her “husband.” However, there was a family member who did live. He is the one who approached Martha Ayen about marriage. He is the one who built the tukul in which she lives. He is the one who buys food and clothing for her and her children. He is the one who sleeps with her in those brief intervals between the weaning of one child and the conception of the next. He is the one that Martha knows and presumably loves, yet each of them would say that Martha’s husband in Warkuei.

There are many strange sexual practices within the Dinka culture, but I think the Dinkas are closer to the Biblical norms in this area than we are. “When brothers live together and one of them dies and has no son, the wife of the deceased shall not be married outside of the family to a strange man. Her husband’s brother shall go in to her and take her himself as a wife and perform the duty of a husband’s brother to her” (Deut 25:5). Admittedly some only seem to perform the duty of assisting in the conception, a not particularly onerous task, but in Martha Ayen’s case, the brother is doing the duties of a husband to her and is preserving his brother’s name.

28 January 2011

Yesterday afternoon as I walked through the market I saw a family we had discharged from the hospital. The patients were twins with diarrhea and vomiting. We treated them for enteritis, suspecting Salmonella typhus (Typhoid fever) because they had significant fever along with their gut problems, but the second one had a large spleen, so we treated them for malaria as well. Their names are Ngor and Chan. Ngor is the name of the first born twin, at least if he is male. Cien is the usual name of the second born male twin, but the doctor delivering them was from Northern Bahr el Ghazal where the second born is called Chan and he persuaded the mother in that direction. Their second night in the hospital, I was coming in from some travel and checked on them. The mother was trying to nurse both children and was weeping out of her concern that her sons would die. That is a sight to move a heart of concrete. I reassured her that night and from that point on the children improved, and my attachment grew, so seeing them in the market several hours after discharge concerned me. They live in Atiaba, about 8-10 kilometers away, easy footing for most Dinkas, but a bit more difficult with sick twin babies. I told her to wait and walked back to the compound to get a car and drive them. Abraham Maper accompanied me. The trip was easy and they were grateful. But as I was leaving, one of the policemen flagged me down and asked me to come and talk with them when I returned, supporting the theory that no good deed goes unpunished.

The police official and Chief Sawat requested that I transport them to Aluakluak to investigate some cows that had turned up there. Cattle rustling may have ceased being a hanging offense in the US, but it is still high on the list of offenses in Sudan. And Chief Sawat is a friend and a powerful man in Akot, so I agreed to take them. Plus I wanted to support a peaceful resolution of the difficulty rather than a counter-raid. The agreed upon time was 8AM. So this morning I arrive at the police station (our rendezvous point) at precisely 8AM. Understanding that I was doing them a favor, Chief Sawat arrived by 8:40 and we left shortly after with two policemen in the car: one in the middle between Sawat and me and one in the bed of the pickup. The placement of the first policeman was unfortunate. There are several members of my family who are quite at home with guns. My gunnery skills are on par with Mr. Wardle in The Pickwick Papers (Dickens—if you have not read it, I recommend it), but I have some idea of gun etiquette. It is my opinion that the closer to the center of my face the gun is pointed, the more uncouth the marksman. Using that standard, my passenger was in gross breach of manners. Though I do not know much about guns, I used to jog on the Battery in Charleston, so I have seen my share of plugged cannons, so I was a bit reassured by the cement-like substance in the end of the barrel. Still the road is very rough and a gun pointed in my direction still gets my attention. I redirected the barrel several times, but he did not seem to get the hint.

We arrived in Aluakluak shortly after 9AM. Realizing the importance of the driver for Sawat, the meeting started before 10. We sat under a rhab tree. I was not familiar with this variety. It had a relatively smooth tan bark with dark green moderate size leaves, but what got my attention was the fruit. They were about the size of a fig, with 75% green and some turning red. I was given several to try, and it is tasty. I was allowed to sit in during the conference. My Dinka still is lacking, but I gathered from the conversation that 14 cows were found by people from Aluakluak and the chief from there (I was not introduced to him) and Sawat were negotiating the return. By the best of my understanding, the cows were found along the Bahr el Naam (the river between Akot and Rumbek and the opposite direction from Aluakluak), and that makes sense, because several major cattle camps from our area are located there. The cattle were described, the identification verified, and the issue was settled to everyone’s satisfaction. We then moved about 150 yards from where we were, sat down for another 15 minutes or so, and then we left. I have no clue what the second sitting was about, for virtually no conversation took place, probably because I was between the two chiefs, neither of whom speak English, but I am sure it served a necessary function. We drove back, with the passenger arrangements identical to the drive down. I dropped them off at the police station and went to clinic.

29 January 2011

The other day in clinic I was in a foul mood. There are some things that Dinkas do that are aggravating. I tell them to breathe and they look at me with condescension as if to say, “I am breathing just fine.” I finish up with a patient and they come up with 4 new things that they need to discuss. I go to feel their abdomen and they move my hand to the point of pain rather than letting me get there in an orderly fashion. I ask them a question and they laugh at my funny way of talking and proceed to tell me what they want me to know, refusing to answer the question I need answered. In addition, several people were asking for my help with various non-medical problems, and though the books were stacking up, people would pop in and speak, usually to Isaac my translator, so we could not reduce the back log. But generally I laugh at those things. They are part of being in Sudan. That day, however, all those peculiarities “got on my last nerve” as a friend of mine use to say. And I realized that Sudan is getting to me a bit. Many mission organizations limit your stretches in Sudan to 2-3 months at a time, but I have been in for over 4 months and have a month and a half to go before I take a break.

But then I started thinking about the Sudanese. Though they are a bit more used to the climate, it still has to wear on them. When I am hot, they are hot. When I am cool, they are shivering. I have a fan, a nice tent, and ready access to shower any time I desire. Hardly anyone in South Sudan can make that claim. I do get asked to help people a lot, but that is because I have an arabia (car) at my disposal most of the time. I make no exaggeration when I day that 99% of the people of South Sudan would trade places with me without a second thought. So then I asked myself, if irritability is a sign that I need some time away from Sudan, what about them? If four months is too long for me, how about 60 years for some of them? If I want to excuse myself because it has been a stressful time, how about those who grew up knowing nothing but war? The questions are rhetorical. I am not considering spending a year here with no break. But if I get in a bad mood from the stress, how much of their warring and fractions can be traced to environmental stresses?

Today on rounds Rebecca, a young woman I know, was in the hospital. The first day I met her, she called me monydit (old man) so I called her tiendit (old woman) and that is how we have addressed each other since. But she was not in a mood to joke this morning. She was in the advanced stages of pregnancy, but she was not in labor. She was in the hospital because she had been beaten up by a man, a friend of mine. She was fine and the baby was fine, but I was dismayed by the news. How could this man I know, respect, and love have hit this woman, a pregnant woman at that? I realize that women can needle a man in just the right way. Show me the married man who has not felt the desire to strike. But for him to actually hit her, a woman who is not his wife, especially when she is pregnant, seems inexcusable. How much of this kind of thing arises from the years of stress and uncertainty that has characterized the lives of all South Sudanese? I am not excusing my friend, but I am seeking to understand him. I still want to see Dinkas quit squabbling. I still find it inexcusable for a man to hit a woman, but let me at least consider their background before I condemn them. Maybe I can learn a thing or two from my bad mood. Maybe it will teach me not to be too quick to condemn. “Who are you to judge the servant of another? To his own master he stands or falls, and he will stand, for the Lord is able to make him stand” (Romans 14:4).

30 January 2011

I enjoy being invited to churches where I have never been before. Today I went to the Malual Baptist Church. Like so many of the Baptist Churches in the area, it meets under a Lulu tree. The pastor is Moses Ater. He had sent word through a friend that they would like for me to come. Unlike almost any church I have attended here, when I arrived at the time appointed, the church was already gathered and had started singing. Justin has gotten some of his Dinka friends to write up some of the Dinka praise songs (or are they hymns?) and has typed them up, so I was ready to join in with four different songs, but the ones we had were not sung while we were there. We will have the opportunity. There is one I already know (sort of) and the Dinkas love to see me seeing it. I am sure I slaughter the language unmercifully, but they are forgiving.

My sermon texts today were Joshua 1:5-9 and Hebrews 12:1-2. My story came from Matthew 27 and was about courage. I defined courage as the ability to do the right thing irrespective of the consequences. I compared Jesus before the Council and Pilate to Pilate himself. Jesus had every reason to be afraid. The Jewish religious leaders conspired for His death; the leaders of the Roman government wanted to please their subjects. There was no possibility Jesus would get a fair trial, but He stood mutely as false testimonies and accusations were hurled in His direction. Pilate, on the other hand, had nothing to fear. He was the highest authority in the land and the power and prestige of the Roman government stood behind him. But Pilate shows his cowardice, while Jesus personifies courage. Why? Pilate was more concerned about pleasing men than God. His perspective was completely earth bound. He gave no thought to anything beyond the immediate. He had also sinned gravely, slaughtering Galileans and mocking the Jewish religion by mixing their blood with the blood of the animals they were sacrificing (Luke 13:1). I suspect that Pilate, having so insulted the Jewish religion, was anxious to improve his relations with the chief priests, and so did not want to stand up to them. He was afraid to do what he knew was right. Therefore he tried to out maneuver them by offering Jesus versus Barabbas for freedom. However, when the people chose Barabbas, he found himself more vulnerable. So instead of doing the right thing, he brings out a basin and washes his hands of the matter, as though such symbolism means anything. In contrast, Jesus’ courage came from His trust in His Father. He had wrestled with the Father, stating most clearly that He did not want to go forward, but that He would if the Father still thought it the best thing. “Yet not My will, but Your will be done” (Luke 22:42). The battle was won there. He had no sin to weigh Him down. And He had an eternal perspective. “For the joy set before Him, [Jesus] endured the cross, despising the shame” (Heb 12:2). For the joy of heaven, Jesus could quietly endure the false accusations, the torture, the humiliation, the beatings, death. Courage ultimately comes from trusting God and looking for “the city which has foundations, whose architect and builder is God” (Heb 11:10). We will need plenty of courage in the days ahead as we seek to aid in the forging of a new nation.

31 January 2011 The mahogany trees here in South Sudan are beautiful, particularly at this time of year. There are many simply magnificent trees, but none greater than our mahogany that gives us our waiting room. This month they have renewed their wardrobe. It is hard to call them deciduous because they are never really without leaves, but now they have this fresh bright green foliage that is striking. I remember last year at this time being chagrined when my Rak, my lulu tree, dropped all its leaves and I thought I would spend the remainder of the dry season without shade, but even without rain, the fresh new leaves came out and provided shade (and fruit) long before the rains came.

Renewal, revitalizing is always special, but I was struck by an unusual one today. Despite years of seeking equalization, the double standard of behavior is alive and well in America. The quarterback who gets the cheerleader pregnant is a stud; she is a slut. But the double standard is almost comically benign compared to its counterpart in Sudan. Part of it may be the great disparity between the numbers of eligible men and women. Because the war had decimated the men, there use to be 9 women of marrying age for every man. I think those numbers are much less disparate at this point, but philandering among men is almost expected, whereas it is not tolerated at all when the wife is the philanderer.

Today I was helping Abraham Mangar and he was giving me more details on his story. I recently met his wife. When I met her, I was under the impression that they were newlyweds. She had some symptoms that suggested some unchaste behavior and I treated her accordingly, but today I got more of the story. She and Abraham were married about 3 years ago and they have an 18 month old son named Laat (meaning he was born on Sunday). Theirs was not a high society match. Her dowry was only 10 cows, but Abraham’s family had not paid up the dowry. Therefore her family took her back waiting for the payment (not a good idea, but very typically Dinka). While she was at home, she ran off with another man and lived with him for some period. I do not know the details from there, except that she came back to Abraham, acknowledged her sin and asked for forgiveness. Abraham wanted her treated for the STD she got from her fling, but he received her back. Abraham has a big smile, maybe a bit too big for his face, and it dominated his face when he said, “And I am very happy.” She seems shy and a bit reserved, and very happy to be back with Abraham.

I was reminded of Hosea, buying back Gomer (Hosea 3), his harlot wife who left him with three children to pursue other lovers. And of course, Hosea’s life is a metaphor, a picture of God’s love for us despite both our unworthiness and unfaithfulness. I was glad to see this renewal of the Abraham’s marriage and to be reminded again of the love God has for us. And I am encouraged to see real forgiveness despite the pain among the Dinkas. But really, when we think about it, how can any of us withhold forgiveness when we have been forgiven so much?

1 December 2010

“Sola Scriptoria.” One of the cries of the Reformation dealt with the issue of authority. The Bible is our final authority in faith and practice. I remember as a young Christian being offended by this. “The Holy Spirit is our final authority,” I shouted to myself. But the problem with that approach is us. The Holy Spirit guides me through various means, all of them subject to my interpretation. I have felt as though God spoke directly with me at times, but how much of that was really God and how much was my emotions? The one means of communication from God I am least likely to have created out of my own desires or be able to alter to my convenience is the Bible. We do argue over the implications of passages in our lives, but at least we acknowledge we have a higher authority in our lives than how I feel about things or what seems right to me. Paul understood authority. I believe that is why he starts his letters stating his office: “Paul, a bond-servant of Christ Jesus, called as an apostle” (Romans 1:1). He spoke not as a brilliant theologian, but as the messenger from God. His words had weight because they ultimately were God’s words.

We are dealing with some issues of authority here in Akot. There are a couple of works here than have been semi-autonomous in the past and we are trying to decide how united they should become and how they should be governed. And we are wrestling with missiology question of the 21^st century: should it all be turned over to the indigenous leadership? There seems to be a tide swelling, a consensus among mission groups that everything should be turned over, but many of the problems that Sudan has suffered since Britain pulled out in 1955 were because the country was turned over to indigenous leaders who were ill-prepared (at least in the South) and did not have the welfare of their fellow citizens at heart (clearly the North). The track record among missions turning over does not appear to be much better. I was thinking about this with respect to the Constitution of the United States of America. It is the presence of a higher authority that keeps democracy from anarchy. Why has the fragile experiment with democracy worked fairly well in the US and been such a dismal failure in so many other countries? Without a higher authority, democracy reverts, as one wag put it, “to two wolves and a sheep voting on what is for dinner.”

I believe it is safe to say that everyone involved in the work in Akot wants to see it continue after we are gone, whatever takes us away. There is a hope and dream for the Sudanese to assume the leadership positions, just as there is the same hope and dream for such a transition in other 3^rd world countries. But the issue is much like parenting: how much authority do you turn over and when. When is my child ready to make his own decisions? That varies with the child. There are no hard and fast rules and no one gets it right all the time. Some things have come up here to suggest that we may have been moving too quickly in our delegation of authority. Pulling the reins back is always harder than slowly letting them out, but now we face that task. Please pray for us.

2 December 2010

There are trivial things we heard in med school that for inexplicable reasons stick with us. The tsetse fly was one of those. Tsetse flies carry African Sleeping Sickness. I am sure I learned that somewhere in infectious disease or pathology, though why that stayed with me when so many more important facts failed to register is beyond me. I never expected to use that knowledge or even have an encounter with a tsetse fly, and until this year, that expectation was realized. For the past six weeks or so, we have had a swarm of tsetse flies, though today outstripped the others by a long shot. The tsetse fly looks like a large horsefly. They are aggressive and they sting through clothing. Actually, they do not sting; they bite. To bite, they have to settle on you for a bit, burrow through the clothing, and then attack. The bite is like a horsefly bite: more annoying than really painful. Still it is not pleasant to be intently examining a patient and have one of the creatures bite you unexpectedly.

It was antenatal day, so we were down in the optometry room. Our normal quota for tsetse flies is about 3-4 daily. Today we had a bumper crop, but if they were expecting this to be their Pearl Harbor Day (coming soon), they were sadly mistaken. First of all, we had Isaac Meen. He was the first Dinka I ever saw catch the flies. I have killed scores, but mostly I find them on the window screen or resting on some other surface and I dispose of them with whatever is at hand: my hat, my hands, a book, etc. Isaac catches them and then folds them in half (almost like a fetal position), then twists off their head. He then drops the severed parts on the ground, presumably as a warning to other tsetse flies, though they are slow to realize their peril. I killed a lot of them myself, possibly double figures, but mainly in the window sills. I did catch one in full flight, slammed it to the ground, and then stomped it. But as I watched the Dinkas, I realized that there was some artistry at work. In A River Runs Through It, Reverend Maclean says that if he had his way, no one who did not know how to appropriately cast a fly and did not appreciate that trout should ever be allowed to disgrace that fish by catching one. I think that is how the Dinkas feel about me with the tsetse flies. Their technique, as I observed today, is to stay very still, acting as though they are unaware that the tsetse fly has entered their air space. When it lights, there is a swift sweep of the hand from behind the fly. Once in their hands, they are not disposed to rapid and humane execution like those of us from the west. I watched one woman who was nursing a child in one arm and giving a medical history for another child casually snatch one. She then folded the fly as Isaac had shown, pulled off the wings, and set it on the ground. I was unsure whether this form of barbarism was like the mafia breaking the thumbs of the uncooperative, but it did not slow the onslaught. I saw 8 year olds casually snatch a few, but the one who impressed me the most was a tiendit (old woman). She was dressed in a full length orange dress and seemed fascinated by the show in our clinic (most Dinkas are). I do not know about any color preferences of tsetse flies, but within a ten minute span she calmly and methodically caught and disposed of five of the disease carriers. She seemed to prefer the guillotine method of capitis dismemberment. By the time the clinic ended, there were forty or so carcasses littering the floors and sills of the optometry room. Maybe this Pickett’s charge will so deplete the forces that there will be a turn in the war, but I am not very hopeful.

3 December 2010

What is the value of a life? This is a disturbingly practical question. In medicine, many have tried to look at this question from a dollars and cents perspective. Medicine is said to be cost-effective if we are enabling someone to continue a productive life so that they contribute to the welfare and affluence of society. As a Pediatric Pulmonologist, I was never willing to buy into that argument because a large percentage of the children I cared for might never become “productive citizens.” As a Christian, I see life as having immense value, both now and eternally. Indeed, soul of a man, viewed from an eternal perspective, is of infinite worth, far more than the trinkets of modern living that we call the American Dream. But it is far easier to speak in those terms abstractly than let them have their practical implication.

I have argued in the past that of all the promises of the Great Society made by President LB Johnson, the only one realized is improved health and longevity. Poverty and crime have not been eliminated. Indeed, many would argue that our focus on those issues has resulted in their growth, not elimination. Schools are more equal, but public education is of far lower quality, compared to the rest of the world, than it was in 1964. But overall health and longevity have increased. Medicine cannot take all the bows for that increase, though we have contributed significantly. But the costs have been substantial. Despite the fact that the GNP has quadrupled since LBJ’s time, medicine is taking a significantly higher percentage of the GNP than ever before. Is it worth it? I think it is. Both of my parents are alive and relatively healthy even though I have reached what was the average life expectancy during Jane Austen’s time. People resent having to pay for medicine, figuring that essential things should be free, allowing us to use our money to buy a bigger house, fancier car, fantastic vacations. But now the distress in our economy is forcing us to reconsider this issue. Philosophically, am I willing to drive an older car, live in a smaller house, watch that Braves’ game on TV rather than in person so that the tests and medicines needed will be available to me when the time comes? It is a tough question.

The question is just as tough in Africa, but the resources are much scantier. Is the life and soul of a man in America of more value than in Sudan? I hope all Christians would say no, but that has practical implications. We average 500 patients/week at Akot Medical Mission (AMM): more during the malaria season and less when that ends. During malaria season we average about 10 in-patients a day, and about 1/3 of those would be at moderate to high risk of death without our intervention (these are rough estimates from the top of my head, but I think they are valid). It is impossible to estimate how many of the out-patients would have advanced to a life-threatening form of the illness without our intervention, but I think that is likely to be in the 10-20% range. If those numbers are anywhere close to being accurate, then this hospital spends about $30-70 for each life it saves. Compare that to coronary artery bypass graph (CABG) procedures which cost around $50,000 and yet have not been able to demonstrate improved longevity. At the same time, at AMM we have our devotions daily and interact with the local churches continually. I know that times are tough and that no one has as much spare change as graced their pockets a few years ago, but what is the value of a life and a soul? We will seek to continue to maximize our effectiveness while minimizing our costs. We would love for you to partner with us in this endeavor.

4 December 2010

We had an admission to the hospital this week that spoke to the tragedy and courage of the Dinkas. A pretty young woman early in the third trimester of her second pregnancy came to us in pain. She is the wife of a soldier, living in the barracks. Her husband was away on some maneuvers and a soldier came in to her living area and attempted to rape her. She resisted and screamed, so the captain of their unit came in, ran off the other soldier, and then he attempted to rape her. Again she resisted, so the captain drug her by her arms a hundred yards or so, resulting in significant pain in her abdomen. That is why she sought help.

As she told her story, I became indignant. “Could you identify these men? We should go to the commander and tell him what has happened to you and get him to protect you and punish those men.” The woman became very quiet. She said that she could not identify the men. I thought that was a bit strange, but she talked on to Isaac Meen, my translator. After hearing the story, Isaac concluded, “The men were justified.”

“No one is ever justified in raping a woman, not even her husband,” I retorted, my western sensibilities on edge.

Then I heard the rest of the story. The woman’s husband had sex with the captain’s wife. Because of that indiscretion, the captain felt justified. He would not be the cuckold to anyone. But instead of facing the soldier or confronting his wife, the captain decided that this woman should pay. When she fought off his sexual advances, the man was roused more to anger than libido and sought to hurt her. I believe his intention was to kill the baby. Fortunately he did not succeed.

The woman would not identify her assailants because she wanted to protect her husband. I was reminded of the movie Rob Roy. An Englishman, expert in sword fighting, rapes Rob Roy’s wife trying to provoke Rob Roy to retaliate so that he could kill him. But the wife sees through the scheme and never tells her husband about the rape. She even lies with her husband that night so that if there is conception, she will not know if it is her husband or her assailant. That is the courage I saw in this woman. When her husband came to the hospital to visit her, I was angry. I told him that he needed to make things right with the captain and make sure his wife was safe before I would send her home. After a few days, she said she would go to live with her mother in Rumbek, away from her husband and her assailants. I thought that was the best plan.

“I, the Lord your God, am a jealous God, visiting the iniquity of the fathers on the children on the third and fourth generation of those who hate Me” (Ex 20:5). But here in Sudan, it seems that it is often the wives that bear the sins of their husbands. Yet even in this sordid tale, we also see courage and hope. There are many changes I would like to see in the Dinka culture, but I admire their courage.

5 December 2010 I spoke on my two favorite parables this week. My favorite parable is The Prodigal Son. In Friday devotions, I told about the Prodigal coming to his senses and seeing his desperate state and remembering the character of his father and coming back in repentance. Today at church I told of the indebted slave, which I think has become my second favorite parable. As you will recall, Peter asks Jesus how many times he should forgive his brother, “‘Up to seven times?’ Jesus said to him, ‘I do not say to you up to seven times, but up to seventy times seven’” (Matt 18:21-22) and then He tells this parable. The Scripture readings were Romans 12:19 (Vengeance is Mine; I will repay) and Luke 17:1-5, regarding stumbling blocks and unforgiveness (a combination we do not usually group, but should). The parable itself is about the servant who owed the king 10,000 Talents. To understand the parable, we need some knowledge of the economics of the time. A man worked a 12 hour day for a denarius. If he worked 6 days/week for a little over 15 years, he would have earned a Talent. Of course to possess a Talent, he would have to not spend anything during that time. This servant owed the king 10,000 Talents. The king determines to sell the man and his family into slavery to get a small portion of the debt he is owed, but the man pleads, “Have patience with me and I will repay you everything.” The king is moved with compassion and forgives the whole debt. The slave is rejoicing but then he sees a man who owes him 100 denarii. I think that debt amount is chosen wisely. One hundred days wages is a significant debt, about 1/3 of the yearly salary. It is not an easy debt to just write off. The scene that has just been rehearsed before the king is reenacted, but this time our slave is the offended party. The words are the same, but the slave forgets completely about the grace just shown him and throws his fellow slave in prison. Others, friends of the imprisoned slave, observe what has occurred, get upset, and report it to the king. Then the king becomes indignant. He brings the slave back in, reinstates the debt and sends him to be beaten until he pays the debt in full. The applications were that we are called to imitate Christ. We love because He first loved us (I John 4). We forgive because he has forgiven us. Second, He calls us to forgive real debt. Trivial offenses, particularly when they are unintentional, are easy to forgive. The 100 denarii debt only looks small when we compare it to the debt we owe to God.

I spoke on this because of issues in my life. Dinkas have a real problem with forgiveness. I think revenge is the cancer of Sudan. But there are some issues in my life and the lives of some friends that brought this to mind. Ironically, I think Christians tend to be particularly hard on, particularly unforgiving toward other Christians. Our bumpers may declare, “Not perfect, but forgiven,” but too often we hold our brothers to a standard of perfection. How can we do it? Because the debt we are trying to forgive is not trivial. What Jesus calls us to do is remember what we have been forgiven. If we can do that, forgiving our brothers even for big things becomes…, well not easy, but doable.

6 December 2010

“Be strong and courageous” (Joshua 1:6). I have mentioned many times about my admiration for the courage of the Dinkas. Even things that I think are foolish, such as the cutting of the forehead or pulling the front lower teeth, take a significant amount of bravery. I am glad I was not asked to do them, particularly as a young adolescent. But then we see this extreme fear, a cowardice if you will, existing alongside the other. Today I had a woman referred to me from Gideon. He book said she was 20, but she seemed to have a lot of experiences in life for that tender amount of years. I then found out she had five children, so I concluded it was the book, not her face, that was lying. The history was that this woman had swelling in her R axilla for a month. In her examination, her breasts were normal, though atrophied after nursing five children. But she had a huge area of induration (thickened skin, hardened underneath) about 10 x 10 cm, a large area (2 x 2 cm) where it was “pointing,” and several spots where the pus had broken through. Actually I was later informed that she or people in her family had cut those areas themselves. I thought it was a straight-forward case. I injected her twice to numb up the area. As I injected in one spot, pus came out of one of the previous eruptions. I prepared my instruments, gloved and was ready to prep the area (clean it with Betadine) when she freaked. I am sure the injections were not pleasant. I am equally sure that, despite the injections, there would be significant pain when I explored the large areas of the abscess. But I was also convinced that the results of doing nothing would be far worse.

She got up and departed. Several family members tried to persuade her to have the procedure. Several staff members also tried, but all to no avail. She could face the horrible pain of having an abscess cut into without any anesthetic. She could face more sleepless nights where the throbbing in her chest and breast made sleep a rare commodity. But the unknown, even when explained, was too much.

“Now faith is the assurance of things hoped for, the conviction of things not seen. For by it the men of old gained approval…And without faith, it is impossible to please Him, for he who comes to God must believe that He is and He is a rewarder of those who seek Him” (Heb 11:1-2, 6). There are many ways to view faith, but ultimately it is handing to God all our hopes and fears for the most important issues in life. We often feel as vulnerable as this poor Dinka woman felt, but God calls us to lie on the table and trust His skills. Fortunately, His hands never falter.

7 December 2010

To convulse is to be caught up in a tumultuous event. Earthquakes cause convulsive changes, both during the shake and in the aftermath. We have adopted the word for medicine to describe what happens during an epileptic event, and we get proprietary in the use of the word. So when someone comes to me saying that they are the patient they brought has had a convulsion, certain visions crowd my thoughts. But I have found over the years that some people use convulsion in the non-proprietary sense. It happened to me relatively early in my medical career in the US, so I have always been somewhat careful to demand a description of the event labeled “Convulsion” before I would accept it. That skepticism has served me well in Sudan.

Today I had a 4 year old boy whose mother brought him to us saying he had fever, headache, and convulsions. We are at the tail-end of a severe malaria season and we have had lots central nervous system (CNS—brain) involvement, so my mind was spinning. But then she told me that the convulsion was 7 days ago and I started becoming skeptical. I asked why she did not bring him sooner. She had good reasons. She had recently had surgery herself. She lives about 20 kilometers and she was waiting for the child to recover enough so that he could walk instead of being carried. By the time I saw him, the child looked fairly good. He was not running fever and he was alert. I pressed mother more about the seizure. She described some shaking, but it appeared to be more shivering than convulsing. She said he stopped breathing. I asked how long. She told me an hour. Now admittedly if your child quits breathing, 45 seconds may seem like an hour, but I was confident the child had not been apneic for an hour. That is not compatible with life if there is no one and nothing doing the breathing for you.

It is very possible that this child had a febrile (fever-induced) convulsion. Though they scare parents and medical personnel to death, febrile convulsions are common and benign, occurring in about 2% of children. In general, febrile convulsions do not need treatment. But I was confident that the child did not have CNS malaria. If not treated promptly, CNS malaria is usually fatal. Could there be spontaneous recovery? It is possible, but highly unlikely.

I did treat this child for malaria, but I did not admit him. The reality is that the peak of the child’s illness was past. I can sympathize with the mother’s logic, but by waiting until he recovered, the mother made it impossible for us to really help the child. If he had CNS malaria or any other equally serious disease, he probably would have died as she waited a time when she could bring him. “There is an appointed time for everything. And there is a time for every event under heaven” (Ecc 3:1). Praise God that child did not die. We can take no credit.

8 December 2010

It is nice being needed and wanted, but there is a burden associated with that as well. Over the last year, the reputation in the region for our hospital has grown. I would be lying if I said that was not gratifying. But there are consequences. People may be coming from many miles away, but they still mainly travel on foot, no matter what the ailment.

We had a 13 year old girl today from Bar-Parkeny. We are getting a lot of patients from that area. She said that she had hard stools and swelling of the anus for 3 months. Now we have tons of patients with constipation and hemorrhoids, though usually not that young. And if they have traveled that far with a relatively mild complaint, it is usually in a group: the mother has three sick children and since they are making the trip, she will get seen as well for this lesser ailment. But this little girl had traveled with her brother to get checked out “at the big hospital” in Akot. She did indeed have some hard stool in the lower abdomen, but in the buttocks she had a large swelling. Indeed, it looked like a large pimple with the head extending 2 inches above the normal tissue. It was a bit strange, but the area around it was fairly normal, not the thickened areas you usually associate with an abscess. One glance and you understood why she was there. As I looked at it, I was impressed that the family did not seek the help of the local witch doctor. It was one of those things anyone could drain, at least partially. But the family chose for this child to walk 30 kilometers with her brother even though the abscess rubbed her and caused pain every step because they wanted her to be handled correctly. Perhaps they had heard of others getting worse diseases, such as AIDS, by instrumentation by witch doctors using unsterile needles or scalpels. Perhaps it was a matter of faith. An unfortunate number of patients do go to these pagan healers, but often when I am warning patients not to get the witch doctor to stick a needle into an abdominal mass, the parents respond that they are Christian and would never seek the witch doctor’s help. I like thinking that was the motivation of this family as well.

The point was tense, so I figured it was “pus under pressure.” Therefore to numb the area, I instilled Lidocaine and aspirated pus. Melissa did the initial incision after the Lidocaine was given time to work and the pus erupted, spraying out about 18 inches. But then as we probed to make sure we had released all the pockets, Melissa found her position difficult and handed me the hemostat. I found several pockets tracking downward before we had completely evacuated the wound. We placed a wick and bandaged the area. They had some relatives in the area, so the brother and sister went there for the next two days until they could be re-examined and dismissed.

I remember in medical school hearing of a woman who rode on horseback for three days to get to a doctor, had a fifty pound ovarian tumor removed (benign) and then rode back. I thought at the time that you could not find people that tough and that desperate for a doctor today. But that desperation is here. I am just glad to have the privilege of helping people who want and need help so utterly.

9 December 2010

“The last enemy that will be abolished is death” (I Cor 15:26). I was just reading in Kimberly Smith’s book, A Passage through Darkness about her horror at losing Elisabeth to meningococcemia as she struggled in labor. I can relate. It is strange, but because we have some tools with which to battle against disease, death seems harsher, more the result of personal failure. Yesterday on rounds I was told that the young woman who had the severe CNS malaria and was flown to Juba died shortly after her arrival there after I had worked to convince the family that she might possibly live. I was also told about Debora, the young girl who contracted HIV from a penicillin injection with an unclean needle. She died within a few days of getting to Rumbek.

We had a young child admitted about 10 days ago with respiratory distress. On rounds the next day, I noted that the breath sounds in the right lower lobe (RLL) were accentuated compared to the left. That is a stage of consolidation (literally turning solid, but in the lungs it means becoming filled in the airspaces) that happens in a lobar pneumonia. I had everyone listen to the area and explained the physiology. We changed the child from oral to IV antibiotics. The next day, much to my gratification, the breath sounds in the RLL were diminished and there were crackles, the usual progression of consolidation. Again I had everyone listen and again I waxed eloquent. I felt like Sir William Osler, the greatest physician of all times in my opinion. A day or so later and the child was still spiking fevers, so the nurses added ACT. I had no problem assuming that malaria could be the underlying process that led to pneumonia. We continued the IV Penicillin and Gentamicin.

Last night I heard the wailing. I hoped it was a woman in labor, but I did not really think that was the case. I went through our census in my mind, thinking who would be the likely one to die. There was the old man with a stroke who remained unresponsive, but the wailing seemed too bitter for that. I went through a few more possibilities. This morning Elijah told me it was the child with pneumonia. He suspects the child had HIV. I think he may be right. I would like to test the mother, but Francis had already taken the child and family home for burial. In the US, it is also discouraging when a patient dies, but then we wash our hands of the process and others take over. Not so in Sudan. There is a strong need to have the burial quickly (usually that day) at the home site. We do use our cars as ambulances here, but just as often we use them as a hearse. It is a morbid duty, but one that we have taken on because it is a time when the Dinkas are so needy. I am proud that our nurses do not even need to be prompted to do this. We have great nurses who have a real heart for the people and the task at hand.

But I feel deflated. We lost another battle. If we had oxygen, we would have started that last night and this child may have pulled through. If we had… It always feels that way when there is a death. We are doing a good work here. I know there are many who would have died except for our interventions. I know that many will never die spiritually because they are hearing the truth of the gospel and are either responding or are “working out their salvation with fear and trembling” (Phil 2:12). “O Death, where is your victory? O Death, where is your sting?” (I Cor 15:55). Paul speaks there with the perspective of heaven, but I do not feel that at this point. I feel the sting anew. I cannot wait until death, the final enemy, dies.

10 December 2010 I combined several of my least favorite activities into a relatively pleasant day. First was the trip to Rumbek. It is not just that the roads are horrible; I dislike Rumbek. I love Akot. In Akot I am known and greeted frequently. That is happening more in Rumbek, but still a large percentage of the time when someone from Rumbek speaks to me, they are asking for money, and that almost never happens to me in Akot. Do not get me wrong: people approach me for money frequently in Akot, but with specific requests (help me pay for my school fees, lend me money to pay for a wedding or grass for the roof). Second was the Ministry of Health meeting. I have never like committees. One old pastor dubbed church committees as, “A group of the unwilling elected by the unfit to do the unnecessary.” The third was chasing down an elusive person for a signature.

We left early this morning. Typically we leave for Rumbek after devotions, but today we depart at 7:15 because the Ministry of Health meeting was at 10. This was the first of these meetings I have attended. Indeed, I chose the day so that I could get to this meeting. We stopped first to see our Across friends in Adol who were also coming, though in a separate car. The bridge over the Par Naam was still out of commission, but the GOSS (government of South Sudan) built a temporary ramp over a culvert as a substitute, so we lost the excitement of driving across a slanting and unstable bridge. We also stopped at some friends’ house on the outskirts of Rumbek. So we arrived in Rumbek about 9:40. Banking went well, for Rumbek. I was able to walk straight up to the teller and hand him a check. It took half an hour for the check to be processed and to get the money we needed for purchases, payroll, etc, but that was relatively prompt. During our wait, I was informed that the location for our meeting was changed two different times. I arrived 10 minutes late, giving me about 30 minutes before the meeting actually began. I felt that was fairly prompt for Sudan. We introduced ourselves. Being Southern, I am a bit self-conscious of my accent anyway, but in this group I might as well have been speaking Martian, so different did I sound from the rest. The majority of the conference was about the push for eradication of polio in South Sudan. That touches me in several places. First, I remember the Salk (injection) and Sabin (oral) vaccines. I remember standing in the lines at our elementary school, adults and children alike, to receive the Sabin vaccine. One Italian lady was scolding the rest of the group because some of the designated vaccinators were wasting their vaccines rather than making the arduous journeys from village to village and seeking to vaccinate all the children under 5 for 10 NSP/day (about $3.50). I asked about vaccinating everyone. During the Sabin vaccination push, the goal had been to vaccinate 70% of the people, which they felt would then result in virtual complete immunization of the “herd.” I went out with Pothe one day to immunize and all the adults wanted to be immunized as well. There was no one I saw who was resistant to being immunized. That position is reserved for the pseudo-sophisticated in the west. My question was acknowledged but never answered. I presume it was an issue of vaccine supply, but we will never know. We were left to appeal to the patriotism and Christian duty of the vaccinators. We will see. Some other issues were discussed such as abuse of mosquito nets. I asked about Kala-azar. I have seen a number of patients with huge, hard spleens. That prompted another discussion with no conclusion, but then Andrew Marial after the meeting said that it could be chronic malaria and he had seen them respond dramatically to Chloroquine. That was not much help, as Chloroquine has been outlawed, reportedly because of the resistance of malaria to it. Maybe we will learn some more next month.

I walked to the village and met Rose. We actually had two vehicles in Rumbek: the pickup to get drums of fuel, and the LandCruiser to carry the remainder of the supplies and fuel, but they were both away. I had arranged with Peter that we would meet for lunch at one, but if I was late, they were to go without me. Rose and I walked down to the assigned place, but no kawajas. The plane from Loki did not arrive until 1:20, so I, who again was 10 minutes late, was again 30 minutes early. We did eat at the Darfurian diner. Peter was giving a sad farewell to the Omar and Josef.

Justin and Peter had exchanged the money and Rose had ordered most of the food. Justin had gotten the fuel. As we were waiting for the last orders to arrive, we met Leno, a businessman from Akot and a member of the SDA church Rose’s husband Paul pastors. We arranged to have Leno lead us to Chief Dut’s tukul. Around 3 we split ways again, with Rose and me going to see Dut in the pickup with the fuel and everyone else going to Akot in the LandCruiser.

I had only seen Chief Dut once in a year. He came to Akot the day Salva Kiir, the current president of South Sudan, visited us, and I spent a few minutes with Dut then. Other than that, he had been avoiding Akot because there were some of the SPLA soldiers who still were likely to take a pot shot at him. Sawat, his half brother, had also kept away from Akot for the same reason, but now he had returned. Dut told me he planned to return to Akot soon himself. He had a document from the government giving us possession of the land and buildings indefinitely and promising to use police and military to protect us, should the need arise. It had multiple signatures, including the Governor of the Lakes State, but was still missing one, the commissioner of East Rumbek County (our county). I thought the document valuable as it was and I also thought I would be able to get the commissioner to sign it soon (much sooner than Dut, as he had made no progress in a year). We talked for a while, including issues about Dut’s health. I drank a soda, gathered Rose, and left.

When we got back to the Par Naam, they had closed the ramp and would not let me cross over it with the barrels of fuel. I adamantly refused to remove the fuel for several reasons. First of all, just getting the barrels out and then back into the truck would be tough. Second, I saw no good way to transport those barrels over the bridge. I saw no hand trucks around. Third, if I left the barrels and came back, the fuel would be gone. And we would be in the same dilemma as before the trip, except that we would also be out 2000 NSP. So we pulled over. Rose has shown resourcefulness in similar dilemmas in the past and she did not fail me. Once we had been going to UNICEF when pulled by a policeman. He obviously wanted a bribe and we “don’t cotton” to such notions. Mayek and others started yelling at him and the man became frustrated. Rose spoke to him gently. By that stage he had given up hope for a bribe and just wanted to exit with some dignity, and he had focused on Mayek as the target of his anger. Rose told him that Mayek was a drunkard we had picked up and to not listen to him. Mollified, the man let us go with a warning (though we were still not sure what the warning was about). This time Rose told the soldiers that we were from the Akot Hospital, that we were out of fuel and therefore could not pump the water or have electricity without those drums of fuel. The man became empathetic, but said he had been threatened if he did not control traffic. We needed a note from the commissioner (the same one) to let us cross. About that time Leno came up again. Rose explained the situation to him and he rode his motorbike over to Thon-Aduel to get the note for us. Meanwhile one man crossed over the barricade to the ramp (which consisted of a 3” log on the ground) and the police chased him. Then a man from the government came with a caravan of cars crossing the ramp and the police, feeling the accumulative shame of depriving a hospital and the blatant hypocrisy of letting the others cross, waved for us to cross as well, which we did with no problems. We got in after dark. I planned to take Rose home, but she had some things in the hospital, so I stopped there, switched cars and drove her to Malual. As I was riding back to the hospital, Leno drove to his tukul beeping the horn. It had been a fun day.

11 December 2010

On our trip back from Rumbek, I asked Rose about Mary Abyea. I knew Mary was Paul’s niece, but I was unsure how long they had kept her or the circumstances around her coming. It is not at all unusual for a young child, particularly a niece, to be shared. Pothe’s wife Rebecca has a niece Mary Yar Bol who lives with them, helps with the chores, cares for the children, and, of course, receives her room and board. But those arrangements are usually based on needs. Rebecca needed help, so Mary Yar came. I did not think that was the case with Mary Abyea, and I was right. Mary’s father died before she was born; in fact he died before her conception. The Dinkas follow what I consider the more Biblical way: when a man dies, his brother is to take his wife and raise up children for him in the dead brother’s name (Deut 25:5-6). Of course, the commandment states that the brother shall “take her to himself as a wife.” Mary Abyea’s mother is Paul’s sister. But this brother to her dead husband slept with her, but performed none of the other duties of a husband for her. She has been left on her own to provide for the children. So Paul and Rose took Mary in three years ago to provide for her, particularly schooling. The problem now is that Mary is becoming a woman. I have gotten to know Mary a bit since the time she was admitted to our hospital with malaria. She seems to be a very sweet girl, but in no way anywhere close to being ready for matrimony. Yet Rose is concerned that once she goes through menarche (the start of menstrual cycles), that same father will enter the picture and want to get her married off so that he can get cows for her. I asked Rose if there was any way to keep that very private information quiet until Mary was more emotionally prepared. Rose thought that was unlikely, but that they would tell the man she was in school and to leave her alone. That might delay things a bit, but not too far.

I was thinking about Mary’s story as I drove towards Thon-Aduel. I was going to bring Gabriel Matur’s father-in-law back for some mysterious illness. I passed a party of six women, some with their babies in their goat skin carriers, so I picked them. Dinkas are generally happy people, particularly when they get a ride, but these broke into a cappela tunes as they entered the LandCruiser. It was as though I had picked up Take Six. They rode three or four kilometers and then got out before Atiaba. There was a great celebration. The menarche had visited the man’s daughter. The celebration was essentially announcing that this daughter was of age and he would be receiving the offers of the suitors. And I thought of Mary again. I hope she will keep private mattes private. The celebrations will be much more heartfelt if she can wait a few more years.

12 December 2010

Today I preached at the Episcopal Church of Sudan (ECS) in Akot. It is actually called the Cathedral of Akot because years before there was a beautiful church building here that was destroyed in Anyanya 1 (the first war of northern aggression against the south). There was a gathering of most of the leaders of the community. I would like to think it was to hear me speak, but in reality it was because Gabriel Amat had asked them to come to prepare for the Christmas season. Because it was the end of the time when Peter and Melissa would be here, because we are nearing the end of the year and because the end of the association with northern Sudan, I thought it appropriate to speak on end times (besides, that is where I am in my study through Matthew). The Scripture readings were I Thess 4:13-18, Romans 8:19, and Matthew 24:32-51. We are told to understand the signs, the seasons, but we are not given “insider information.” There are wars and rumors of wars. Tribulation continues everywhere. And the gospel has been preached throughout the whole world. Could Christ return soon? Yes He could. He tells us His return “is near, at the door” (Matt 24:33). But He told that to His disciples. He does not give us specific information because it is good for us to be ready. He is not lying, but He has a different perspective. “With the Lord one day is like a thousand years and a thousand years is like one day” (II Peter 3:8). So what do we do? The most appropriate response to the knowledge that the Lord’s return is eminent is to remain faithful. Jesus followed His information with a parable about the faithful and unfaithful servant placed in charge (Matt 24:45-51). Second, we need God’s perspective on what is most important. Here in Sudan, we think that government officials are the most important. But God says that the work of the kingdom is the most vital. The little things we are doing here in this hospital to advance the kingdom have more weight than the big negotiations in Khartoum and Juba. Third, we need to remember who we are in Christ. We are the main actors in the drama of God’s redemptive work. All of creation holds its breath in anticipation of the day when the sons of God will be revealed (Romans 8:19). And we must warn those who do not understand this. A day will come, and it may be very near, when the trumpet sounds and the Great Day of the Lord is ushered in. Amen.

13 December 2010

Today I ran into another interesting dilemma in the life of the Dinkas. Helena Ding, one of our cleaners, came to me with several complaints that started shortly after she weaned her last child and therefore started meeting with her husband again. After the history and examination, I was convinced she had a sexually transmitted disease (STD). I asked her what she thought. She thought it very likely. She said that frequently her husband would stay in Akot for weeks instead of coming to her, but she could not ask him what he was doing or why he was neglecting her because of their culture.

I first met Helena Ding about a year ago. She was a former worker here in the hospital, and she was applying for work again. The nurses said that she was a good worker, but they were upset with her because she suddenly quit without warning or notice, so they were reluctant to hire her again. Helena came with her husband who took responsibility for Helena’s abrupt departure. There was a time when he wanted a second wife, but Helena would not cooperate. The custom of the Dinkas is for the first wife to go to the family of the woman the husband wants to marry and plead for him. She talks about what a good husband the man is, how he provides food and seldom beats her. If the family is convinced and the husband has sufficient cows, the deal goes forward. If the man comes himself, the family becomes suspicious and the suit is unlikely to be successful. Helena’s husband looked at the arrangement as a favor to Helena because the second wife would share many of the responsibilities of the home (gathering water, making fire, cooking, etc), but Helena did not want a second wife. He could not convince her to go, so he made her quit work without notice.

Now she is absolutely convinced that there is at least one other woman, but her culture forbids her confronting her husband about her. For many months now I have adopted a policy of not treating women for STD without the husband except in rare situations (say the husband is a soldier and is stationed away for several months) because often the husband refuses to be treated. If the wife tries to withhold relations until he is treated, there is a good chance he will beat her. The husband usually has no difficulty getting the other wives treated, so I am not as strict the other way. But this time it would be a bit tricky. The husband needs to identify and bring the woman (? women), and that is ticklish. If he refuses and continues to meet with her, our treatment will be for naught or worse, as we might select out for resistant strains. Trying to be sensitive to the culture, I suggested to Helena that she agree to a second wife if he will confine he sexual proclivity to the two (or three) legitimate partners. I am not a big fan of polygamy, but I believe it is better for Helena if he has a second wife openly rather than constantly meeting with other women. At least this way, all the members of the sexual triangle can be treated simultaneously and, we hope, the STD can be eradicated.

14 December 2010

“Go, swift messengers, to a nation tall and smooth, to a people feared far and wide, a powerful and oppressive nation whose land the rivers divide” (Is 18:2). This is one of the favorite quotes of Ann Rao, one of the main supporters of Akot Medical Mission (AMM). I think she is right when she says that is describing the Nilots, those people who trace their origin to the Nile River basin, and that would include the Dinkas. But though the skin is smooth (not hairy), it is far from disease free. It was not long ago that I spoke of the problem the dry skin among the Dinkas brought on by the overuse of soap (among other things). Today we had a variety of skin diseases among the patients seen today. During rounds we had an 8 yo girl admitted with malaria. She responded well to the ACT (Artemisia combination therapy), but we noticed a lesion on her scalp. It was a little larger than a silver dollar, was higher overall than the surrounding skin and had a raised border, and many broken hairs so that it appeared about half as hairy as the surrounding areas. As this was my next to last rounds with Melissa Kuei, I was picking on her, and she correctly identified the problem as tinea capitis, or a fungal infection of the scalp. Unfortunately, tinea capitis does not respond to topical treatment such as Clotrimazole, and we are out of Griseofulvin, the treatment of choice, but we hope to get some more in soon. Then when we were in the clinic, a woman complained of a rash on her neck. This, too, was a single lesion. It was also raised with a questionable raised border. It was in a hairless area. There were no other lesions like it anywhere. I also thought this lesion was fungal, but this time I prescribed Clotrimazole because it should work on the neck. Then I had a man come in with skin that was very shiny and itchy, particularly on his hands, but also on patchy over all his body. He had lost his book (read medical records, a common failing among the Dinkas), but he claims to have seen me before and that I prescribed some white medicine he put on his body and left for 4 hours before washing off. He says that helped a great deal, but it has started coming back. The man was describing scabies. Scabies is a mite infection. The mites burrow into the skin and cause an intense inflammatory/allergic reaction. Fortunately the webs of the fingers looked less involved, leading me to think (hope) that our therapy for scabies worked and now our problem is some residual eczema. I had him decrease his use of soap, use oils after bathing with water, and gave him some Betamethasone ointment to use twice daily. Last was a young girl with crusty sores on the scalp, ear, and trunk. It had been there about 10 days and was spreading. Melissa did not need my help diagnosing impetigo, a common malady in both the US and Sudan (and I presume worldwide).

15 December 2010

This was a day of firsts and lasts, of steps towards completion and new beginnings. It was the last day for Peter and Melissa Morrison, a young couple I met at the Louisville medical mission’s conference last November who have been with us for 6 months. I have been impressed how quickly the Dinkas took to them and vice versa. I have never liked goodbyes and I am not getting any fonder of them. Mathiang and Kuei, you will be missed. But I am pleased that even in our low condition AMM is contributing to the global effort. Peter grew up on the mission field and worked with Samaritan’s Purse in Sudan for a couple of years, so this was not a first for him (nor his most challenging assignment). Still, he has broadened his scope by working as a hospital administrator and also being involved in community development. Melissa made great strides towards becoming a functional nurse practitioner. If nothing else, God used their time here to cement their calling to serve Him in missions, preferably in Africa. I had a first in removing a sliver from the eye. A 10 year old boy was climbing down from a tree in distress (he was in trouble) when some branches fell on him and one struck him in the eye. He had a ¼ inch sliver embedded in the sclera of his right eye, southwest of the iris. I irrigated his eye with Lidocaine several times over a 15 minute period and then snared the “speck” out of my brother’s eye (Matt 7:3) using some hemostats. He was a bit fidgety and could not keep his eye still, but during one of the attempts, the hemostats caught hold of the end of the splinter and it was removed.

I took some major steps towards completing a task that has been mine since I got here. Mustard Seed International (MSI) president Bill Deans asked me to stay on top of Chief Dut regarding obtaining signatures for a longer lasting agreement for our time here. All but one signature was on the document last January, but the unrest in Akot has prevented Dut from being around, so the document has remained in neutral. But today I got it to the person who needs to sign it. I least I hope I did. This part of the quest started 5 days ago when I saw Dut in Rumbek. He had the documents and put his signature on them, and transferred the burden for the last remaining one to me. A couple of things made it a good time to try and obtain closure. First, Mayek approached me about driving some of the staff to Bar-Parkeny to get a goat for the hospital dining. Then Angelo Manyiel asked for help in getting a letter to the Commissioner of Rumbek East County, his cousin and the man I needed to see. Finally, Elijah told me today that we were almost out of IV Quinine, which was distressing as we continue to see malaria involving the brain in our patients admitted to the hospital. So I agreed to try to kill four birds with one LandCruiser.

As little as I looked forward to this trip, it turned out to be one of my most successful ones. We, of course, loaded up the pickup as we came through the market. I was in a foul mood, convinced that I was being “sent on a fool’s errand again.” But my mood brightened a bit as we bounced along I-40 towards Thon-Aduel. We let out and picked up a few passengers along the way, but made decent time and arrived in Thon-Aduel before 5 PM. We did not attempt to go by the Commissioner’s office at that hour. That would have been the height of foolishness and shown that I had learned nothing in my time in Sudan. But Daniel and Angelo knew the home of the Commissioner and we stopped there. He was not there. He and his two subordinates were in Rumbek for another emergency meeting. (All tongue in cheek aside, let me say that the people of South Sudan have the highest regard for the upcoming referendum and have set for themselves a rigorous schedule of steps to be accomplished so that there is no last minute delay). But the man, Abraham Maluk, giving me this information, was the 3^rd subordinate and he took the task to heart. I may be deceived, but I felt that by handing those documents to Abraham, I was assuring that they got into the hands of the Commissioner. I also gave him Angelo’s letter.

We then drove on to Bar-Parkeny. Daniel directed me to the place of the auction, but my mother never raised such a fool. If I drove our pickup there and the Akot workers emerged, we would pay 1.5X as much for our goat. I parked in the market and split ways with my party. Daniel joined me part of the way and we got into some conversations with the local Dinkas. They were amused at my language skills, small as they are and they invited me to play some volleyball. I never need too vigorous of a persuasion. Graciously I was selected to play in the first round and I found myself on a good team. I made some good shots: several set ups and a few spikes. Our team won the first five games and then they split us up. Unfortunately that was the height of my achievements on the court that day, but I relished the experience. I also enjoyed the comradery of guys who enjoyed competing against a kawaja.

We bought the goat. It was small and overpriced, but I was told that Christmas was the reason, not my presence, for I kept away from the auction site as much as possible. We loaded up and headed back. We drove into Adol to the Across compound and were able to obtain some IV Quinine. Overall, despite my misgivings, it ranks as one of the more successful trips in my recollection.

Sudan Mission Trip

Thursday, July 14, 2011

A meningitis post by Dr. Clarke

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What we took to Sudan