Dr. Clarke's Journal

1 October 2011 

Malaria is like baseball: things tend to happen in streaks.  In baseball, the season is long, but it can be divided up into mini-streaks.  A team like the Atlanta Braves goes through streaks when they seem invincible, and then times when they cannot put a game away.  Malaria in Akot usually starts about 3 weeks after the rains come and continues until about a month after they end, and correlates with the mosquito population.  But it is not a uniform disease during that period.  First of all, it tends to be patchy.  One week all our hospitalized patients seem to come from Makur-Agaar; next week Mayom is supplying all the ill ones.  Also the characteristics of the disease tend to run in cycles.  Headache and fever tends to be almost universal, though we have had streaks where we had several very sick patients without fever from presentation to discharge.  We will have weeks when everyone has severe vomiting and diarrhea.  Recently we had a streak where everyone was coming in hypotensive (low blood pressure) though they were not having severe vomiting or diarrhea.

            This past week, a large number of our patients had significant respiratory problems: asthma, pneumonia, marked difficulty breathing.  In several of them, the fever and usual symptoms of malaria subsided quickly with the anti-malarials, but their breathing problems kept them in the hospital.  This was true for those under 3 months and for adults.  In malaria, there is clearly documented lung edema and inflammation.  Because of that, it makes sense that malaria should be a trigger for asthma, and we do see the episodic cases of asthma all malaria season, but this is different.  We had more malaria patients in the hospital on inhalers than who were vomiting.  And we have had weeks like that every year I have been here (my third malaria season, but enough to see a pattern).  According to all the sources I can find, we have Plasmodium falciparum as our only culprit causing malaria.  I am sure there are sub-strains of the various forms, but I still have not heard a good explanation for the streaky characteristics of malaria patients.  Of course, I have also not had a good explanation for the streakiness of the Braves.  

2 October 2011 

It was an interesting Sunday.  I had planned to be in the cattle camp this weekend, but those plans changed.   I decided to go to the ECS (Episcopal Church of Sudan) church and some friends from Hope and Resurrection Secondary School wanted a ride as well, so Dr. Rossi and I picked them up.  The service was actually fairly short, so we returned to the hospital for some tea before carrying them back.  Elijah needed to use the recently rejuvenated LandCruiser, so we our tea lasted a bit longer than anticipated, so we were around 2 pm returning from Atiaba.  As we were munching another round of red beans and rice, Abraham Chol came with a request.  They wanted us to go to Abil gong for a service.

“When?”

“Now.”

“Mithioga? (now?)”  

“Mithioga.  And Bishop Isaac said you are the main speaker.”

I have been in South Sudan too long to fall for this again, but I did.  They were being truthful about me being the speaker.  That was okay.  I had prepared something for this morning just in case I got called.  What I fell for the immediacy.  I did not drop what I was doing, but I did hustle out fairly quickly.  We got in the old pickup and headed out.  Instead of going to Abil gong, Abraham had me turn in to the church.  About that point, I started realizing I had been had again.  I saw many of the youth milling in the school yard (the ECS church of Akot is directly behind Akot Primary School, off the main road).  We pulled into the manse and greeted one another for ¾ hour before loading the truck and heading to Abil gong.  Bishop Isaac and his wife Rebecca were sitting up front with me.  I am uncertain the number shoehorned into the bed, but I am sure it was more than 20.  Off we went, singing and enjoying ourselves on a 1-2 kilometer journey.  When we arrived in Abil gong, the process became clearer.  Under a Rak (Lulu tree) there were a number of Y-shaped limbs driven into the ground supporting 8-10 foot logs (about 5 inches in diameter) 30 inches off the ground.  We were coming to a church opening/dedication. 

Abil gong is a small military camp.  We have a number of barracks a stone’s throw (actually about 4-5) from the hospital, but I think this encampment was established during one of the Agaar-Atuot clashes earlier in the year.  I had driven past when it was very active and fairly crowded with the soldier’s make shift housing.  Their housing always reminds me of the three little pigs, for they are primarily constructed of sticks and straw.  Later it looked like a ghost town, but now there are some of the tukuls reoccupied.

When we arrived, the youth started dancing and singing.  I truly enjoy their performances, but my enjoyment was tempered because the young lady with a good voice and great smile that usually leads them was out.  That went on for about half an hour, and then it was the jump-dancing in the circle.  It was fun to watch, particularly because one man seemed to have a 36-40 inch vertical jump bare footed.  They encouraged me to jump.  Not after that. 

About an hour or so after arriving in Abil gong, there were some encouraging movements suggesting the start of the program.  Bishop Isaac whispered something to me about “3 minutes,” but by this time I was quite aware that we were on African standard time (it is going to happen when it happens).  The meeting was interesting because there was translation going on for virtually the entire service, but English only when I spoke.  Half of the soldiers spoke no Dinka, so the translations were from Dinka to Arabic.  I found myself following the Dinka fairly well (I think the presence of a translator slowed down their speech) initially, but then they sped up and lost me.  There were about 5 speakers before me talking about the soldiers having a lot of bad dreams and other concerns that prompted the church construction. 

I read from Matt 6:31-33 and 13:44-46 and told a story about the Gibeonites (Joshua 9).  I like the story.  The people of Gibeon tricked Joshua into making a covenant with them with a wily deception and they were content to spend their lives as slaves to Israel rather than receive death, physical and eternal.  They are the antithesis of the health/wealth gospel.  But as I was telling this story, the obvious hit me: many of their ancestors had been taken as slaves.  There is something inappropriate for a kawaja to be standing before a group of blacks commending those who chose to be slaves.  I still say the story is good.  It has a message that is important for us to hear: our calling, our salvation is about knowing Christ, not having lesser needs met.  It is what Paul understood.  Gabriel Amat, who interpreted for me, said he liked the story, but I am not sure.  I do not think I will trot that horse out again in Africa.

3 October 2011 

I really had no excuse for my short fuse today.  I have just returned from some time out of South Sudan and I will be heading for America this month, so I should be refreshed.  Moreover, we had a huge rain this morning, so we were very slow.  Francis was heading back to Kenya in the routine swap, so Dr. Rossi and I rounded independently of Elijah, freeing him to start IV’s, administer medication, discharge patients.  After that, I treated half of Rose’s family and let them watch a movie in my tent.  All of that was pleasant.  I do get angry over the casualness of their attitude towards rain.  It is like a snow storm in the south.  It is as though everything is put on hold, so why should they explain strolling in 4 hours late.  It was raining.  I decided I would not fight it.  Instead, I got out The Return of the King and had some tea.  I am completing the Lord of the Rings series for about my fourth time (my children have me beat by a mile).  I had read for a while and sought to ignore all that was going on around me when Rose said gently, “There are some patients they need you to see.”

“I am reading.  I may go see them when I feel like it.”  I did feel like it about 10 minutes later, and I was embarrassed by my rudeness, particularly to Rose who had done nothing to deserve it. 

            When I did go, my curtness went with me.  I was snippy with Dr. Rossi.  The volume of patients was down, and those we saw were quite ill.  We admitted several.  Again I was struck with the lack of any apparent protective immunity from malaria in children.  Patients admitted to the hospital one month before with malaria were back and just as ill.  By the time we got somewhat from under the pile, it was after 3 pm and we had not eaten lunch, so I took it upon me to stop us.  As I was walking to lunch, someone from behind said, respectfully, “Dr. Clarke, I need to talk with you.” I did not turn around.  “I do not want to talk with you.”  And I walked on.  He came back around 5 pm and I did hear what he had to say. 

            Later I was pulling up some ground nuts.  Gabriel Amat and I have put in about half an acre of ground nuts and we have been waiting for the rain so that we can extract them from the ground.  We had a great rain, so I decided to experience ground nut harvesting.  I had been working about an hour when to young men walked up.  “Why are you doing it that way?  Do you not know the proper way to do it?”

“I do not need your advice and I do not want to hear your criticism.  Why don’t you just go away?”  They did not.  In fact, they stayed and helped harvest for about half an hour, persisting for a few minutes after I was called away. 

            “Love is patient; love is kind and is not jealous…does not act unbecomingly; it does not seek its own, is not provoked” (I Cor 13:4-5).  Praise God there is grace.  

4 October 2011 

Constance, my daughter is soon to be wed.  Many have jokingly asked me how many cows I will get for her.  I say 400.  In truth, that is a reasonable figure.  She is tall, beautiful, extremely smart, highly educated, white, a woman of intense faith, all of which are desirable in a Dinka wife.  I think Oli, my future son-in-law appreciates the tremendous sacrifice I am making in not holding him to that dowry.  Of course, the fact that he is from the UK where they lag behind in such matrimonial niceties and understands the difficulty I would have transporting those cows to Sudan may temper his appreciation. 

            I have written of the dilemma dowries put on young men.  A man at the height of hormonal influence finds little hope of coming up with the dowry needed to wed his beloved.  It is not an adequate excuse, but it is a component of the rampant infidelity in South Sudan.  But what about the young woman?  All people want to be fussed over.  There is a sense of pride that women here have that they were worth 50 or 100 or 200 cows.  But what happens to them when they are in love with a man who has no capacity to pay the dowry.  Elizabeth Yar is a young woman at Hope and Resurrection Secondary School.  She is educated, smart, graceful, beautiful (as beautiful as my daughter?  Of course not, but she is beautiful).  She is also the daughter of one of the leading chiefs in our area.  In some joking conversation (typical of Dinka jokes), we asked her how many cows her father would demand.  “At least 150.”  She was not joining in the joke or being conceited.  If anything, she was probably being modest.  I could tell from her voice and mannerisms a kind of resignation there.  In truth, she has no say so in the matter.  How would Constance feel towards me if I denied Oli or postponed the wedding until he could come up with the requisite cows?  How would she feel if I allowed Oli to marry her with only 200 cows, but later threatened to take her and children away if Oli could not come up with the balance of the dowry in the time frame I wanted?  Those are not theoretical concerns.  They arise every day in the lives of the Dinkas.

            There is gratification in being the subject of a bidding war.  Any woman who says she would not enjoy it is lying.  But talking to Elizabeth, I was sad for her.  The gratification quickly passes.  How can a woman not feel betrayed by her father when she is joined to a man not because he loves her, not because he seems the best for her, but simply because he and his family could come up with the highest number of cows?  The cost of the dowry system takes its toll on both the young men and women.  I hope it will be put aside in the near future, but that will take a miracle.  Even if it comes, it will probably be far too late for Elizabeth. 

5 October 2011 

Our nurses have been here a lot longer than I have.  This month, Samuel will have been here for 5 years.  Francis is just behind him and Elijah a year later.  They have learned things that I have not, particularly about guarding oneself from continual onslaught of requests.  Today was not a particularly busy day, but the patients seemed to continue to trickle in.  Every time I would think I was done, another 1-3 patients would show up, with malaria being the predominant illness.  I was finally finished and walking to my tent when a father intercepted me and directed me to his little girl.  I struggled to get an interview, but got some vague symptoms of fever, abdominal pain, and then clearly that she had not stooled in five days.  Her exam was remarkable for clear chest, no spleen, and large, hard stool mass in the L lower quadrant of the abdomen.  We deal with constipation all the time, but this child was more severe than is typical, particularly with a child.  She was completely blocked off.  I knew that laxatives would take too long and would probably cause as much distress as the enema I thought necessary, but I was afraid of how the parents would react.  Through gestures I suggested that an enema was required and, to my surprise, they readily agreed.  All the enemas we have are for adults, but they are only about 100 ml and I felt that was about what she needed.  So on the sidewalk in front of our ward, with all the patients watching, she lay across her daddy’s lap and I administered.  She was very good, though she resisted a bit when she started getting full.  I was able to get almost the whole enema into her, but when I did and pulled out, she erupted, much to the enjoyment of the observers.  I was flying back and everyone, including the parents, was whooping.  The girl was far too relieved to be embarrassed by anything.  

6 October 2011  

In the midst of our malaria epidemic threatening to take down all comers, a car pulled up and 120 men jumped out carrying one girl.  She was a student at Hope and Resurrection Secondary School.  She came to the school that morning looking well, but after a bit, she became unresponsive, rigid, and started making a sound that was a blend of a wail and a moan.  The boys, really closer to five than 120, carried in the board like body and conflicting reports soon followed.  I heard that she had 8 convulsions that morning.  I finished the patient I for whom I was already caring and fought my way through her valiant guards until I could get close enough to see and examine the patient.  She was an adolescent, probably around 15.  If she had any fever, it was mild.  Her pulse was normal despite the cries.  Her chest was clear, her heart normal, and her spleen was not enlarged.  About that time, Paul Mayol informed me that the bidding for the girl had started last night.  It was not clear whether her objection was due to the particular man or just her age, but it was clear that she and her father did not see eye to eye on subject.  About that time Mary Agum guided the wheelchair into the room, but her rigidity returned and her male escorts toted her to the wards. 

            We see a fair amount of hysteria.  Hysteria comes from hysterus meaning uterus, though feigning illness occurs in both sexes.  When I came to Africa, my thoughts were that malingerers would no longer be a consideration, but I was very wrong.  One of the reasons for malingering is as a silent protest.  A husband ignoring his wife may find that she develops more illnesses.  Children respond to neglect more often with misbehavior, but sometimes we see hysteria in children.  This girl was sending a very clear message to her parents: I do not want to marry.  I want to stay in school.  Indeed, I heard from one of her teachers that she said to her father, “If you are going to sell me away, at least to the aparak (young man) with 74 cows instead of the monydit (old man) with 110.”  How can a father push his little girl into such a marriage?  The father appears to be a gentleman, and he seems very concerned about his daughter.  Indeed, everyone was concerned about the daughter.  Many of her classmates and teachers came to the hospital, as did both rival factions and her family.  But can they really hear her protest.  I do not think that they can.  It is a different culture.  I believe it is changing, but too slowly to help this girl. 

7 October 2011 

We had another meningococcal vaccination today.  During our first few rounds, we were concentrating on the schools in the area.  We immunized the secondary school and all the primary schools in Akot and Atiaba except for Mayom Primary School.  The reason for the omission was that the school was not in session.  It was not an unseasonably scheduled break.  There was fighting between the Nyuei and the Pangar.  Mayom is primarily settled by the Pangar and was abandoned to a large extent during that stage, but now they are back in session.  Do they extend their school year in compensation for those days they were out?  I do not think so. 

            Mayom Primary School is a beautiful structure.  It has just been completed.  My friend Isaac Makur is an instructor in Primary 8 at the school and somehow heard of a grant through Save the Children Sweden (I think) for constructing schools.  He applied and his proposal was approved.  When I say it is a beautiful school, we, of course, recall that beauty is a relative thing.  It is the nicest, prettiest school in our area, though in fact the construction is quite simple.  It is a variation on the warehouse theme.  There are two buildings, each with four classrooms built end-to-end and covered with a metal roof. The walls are painted yellow; the roof is rust color. 

            We did not arrange the immunizations before hand, and rounds took a long time because of the number of patients, so we drove up around 11:30.  I stopped the car and we searched for teachers.  They enthusiastically agreed for us to do the immunizations then.  I pulled the LandCruiser around to a big mahogany and the teachers were to send the recipients by classes.  I did not turn out to be quite as orderly as I had hoped, but we did immunize over 200. 

As we were about to leave, we were told that the Primary 8 class had not been immunized because they were having an exam, but we could go into the classroom and immunize there.  That was an interesting experience.  First of all was the classroom.  These would be among the nicest classrooms in the Lakes State, but the room is really basic.  It did have floors, but of bare concrete.  The walls were bare brick with a cement dry wall.  There were spaces for windows but no glass.  The roof was the bare metal with nothing else.  There was no electricity or water.  The seating consisted of short benches, narrow benches, probably 1.5 times as wide as typical American desks and 2/3’s as long.  The next thing I noticed was the students.  There were two or three students in each desk.  They were orderly, but, of course, they were taking an exam.  The exam was not handed out.  It was written on the board and the students copied the questions and supplied the answers.  It was probably health or biology.  The questions had strong sexual overtones (The origin of sperm is in the 1) ovaries and penis, 2) spermatic cord, 3) testes), but there was no giggling and I perceived no embarrassment.  Another thing that struck me again about the students was fear that the immunizations invoked in the students, particularly the males.  No one likes shots, but meningitis is not a theoretical concern in South Sudan.  I would be willing to bet that everyone of them knew someone who died of meningitis in the 2007 epidemic, yet a high percentage of the boys (and these “boys” were primarily 16-20 age range) were not willing to be injected until a couple of brave ones could honestly say that the injection did not hurt, even though many of them had received the 6-8 cuts across the forehead as induction into manhood (something I could never survive).  Finally, I noted that despite the very visceral interruption of immunizations invading the classroom, the students kept to the task of taking their test.  It was an interesting diversion for me. 

8 October 2011 

As an intern, I had a young lady, maybe 14, with advanced stages of a non-Hodgkin’s Lymphoma.  Her prognosis was dismal, but the attending on Hem-Onc wavered and would not clarify her status with respect to resuscitation.  I was on call the night she went into cardiac arrest multiple times, the fourth attempt at resuscitation being unsuccessful as the dawn broke.  That morning I had a new patient, another 14 year old girl admitted to the same room.  She had cystic fibrosis and was considered end stage.  She was admitted to make some attempts at pain control before she was sent home to die.  She had a tension pneumothorax (rupture of the lung with air inside the chest collapsing the lung) and died that afternoon.  I wept as I have wept few times since for the death of a patient.  A fellow intern had another Hem-Onc patient who was very ill.  They started to move him into that room, but he refused.  “Don’t send me to that room; I’m not ready to be beamed up.”

            We had an 8 year old girl with severe malaria, the half-sister of Daniel Ayuik.  She was on IV Quinine, her fever was down, her chest was clear, her abdomen soft, but she looked bad.  She died in the afternoon.  A couple of hours later another 8 year old girl was admitted with cerebral malaria to the same bed.  She was also hemorrhaging in her kidneys.  In addition to the IV Quinine, we started Dexamethasone.  On rounds yesterday I commented on the severity of her illness.  Elijah commented on her being in a bad bed, bringing to mind my intern experience.  When we made rounds this morning, there was another patient in that bed.  I had heard nothing and was confused.  Then Elijah spoke of a child that died this morning, pointing to a different empty bed.  I thought it was déjà vu.  But then Elijah told me the child that died had been brought in during devotions comatose and died as they started the Quinine infusion.  The 8 year old with cerebral malaria was on the mattress by the bed.  She is far from well, but she is speaking and eating.  She is weak and confused, but dramatically better.  And she is out of that bed. 

9 October 2011 

            Mayom Mading Agau is, I believe, one of the “Lost Boys.”  I know that he is South Sudanese, a Dinka-Agaar, living in Australia.  His mother lives here.  Mayom is the oldest living child.  The first and third born died, but he has five living siblings, though the last fathered by a kinsman redeemer.  Mayom has been away from Sudan for about 14 years, around the time that his father died.  That means his mother, Debora Ding, has survived the last decade and a half as a widow with her oldest living child far away.  As I have said far too many times already, life in South Sudan is tough on widows, so it is far from surprising that Mayom has taken tangible steps to help his mother.  The church he attends with his Australian family put forth the money to buy a pair of oxen and a plow for them to pull.  It also made sense that Mayom wanted me to tell him more about his mother after she has been having weakness in the L leg for 2 months. 

            Mayom’s mother lives in Mayom.  It is entirely possible that Mayom got his name from the village, but Mayom is a common Dinka name.  Mayom is a handsome bull that is roan colored (red-brown) with a white face and I know many Mayom’s.  When I say she lives in Mayom, it is taking into account the flexibility of boundaries.  When it suits them, Dinkas change the name of villages in shorter spaces than Americans change the name of subdivisions.  Yet if it is their purpose to give an account that sounds closer than it is, someone living light years away may be said to be in the same village.  Fortunately his brother-in-law, who lives in Akot and is named Chol Duk, correctly foretold that there was no way to drive to her home, and it is a long way for footing, so he drove me on his motorcycle.  Motorcycles (sometimes called piki-piki) are one of the most common modes of transportation in South Sudan.  In the US, I am not a big fan of motorcycles because of their nemesis, the car.  The majority of severe motorcycle wrecks involve cars, with the automobile driver at fault and the motorcycle driver dead.  That is far less a concern in South Sudan, and I have ridden on the back of motorcycles several times, but this was my longest excursion to date.  It is near the end of the rainy season, so grasses and crops are nearing their greatest height.  I used to think the pier, the grasses that lined the roads and obscure our vision were useful in making the thatched roofs.  It is not.  Nor do the cattle, sheep, or goats seem to like it.  In fact, it has no known useful purpose.  Pier grows to about 6 feet, bends over the road, and is loaded with quill-like seeds that penetrate clothing and irritate everyone.  The paths we traversed were narrow, so the grass formed a low canopy through which we sped, spearing us with its seed.  Chol, appropriately, kept sounding his horn so that any pedestrians or cyclists would hear and avoid us.  It was fun, though, particularly because of the reaction of the locals in seeing the kawaja on the back of the motorcycle.  Most of the people know me, or at least know of me.  I am the lone kawaja, and they tend to wave at me anytime I come by, but I enjoyed their surprised expressions seeing me on the back of the motorcycle. 

            I was impressed with the home of Debora Ding.  Kenyans use the term shamba.  It means the farm around ones home.  Her home was neat and her shamba productive.  The sorghum was 12 feet high and the grain was maturing quickly.  Her pumpkins and okra were flourishing.  She had a rack of simsim drying that looked like many of the dried flowers that decorate American homes.  Until recently, her shamba was poor, but having an ox plow has made it possible for her to keep a prosperous shamba.  Debora is a small woman.  I calculate her age to be around 50, though she could pass for her 30’s.  She greeted me warmly, as though we had known each other for years instead of me being a strange kawaja descending on her.  She and Chol also prepared some of their sorghum/sugar cane for me to chew as I listened in on her conversation with her son.  I also could not help but be struck by the similarities of my conversations with my mother.  They were speaking about common acquaintances and occurrences within the community.  I am sure that they, like me, have a desire to say something profound, something that conveys the intensity of their missing one another, but we fall into what is comfortable.  Like Paul Simon in Slip Sliding Away, our intentions are noble, but the words will not come.  It is true for all of us.  And yet in that conversation, the underlying message was received.  I watched Debora’s face.  She heard it. 

            I believe Debora has sciatica.  She attributes the onset of the pain to a wedding she attended where she was jumping like one of the young girls.  As a kawaja looking on the dance, it is easy for me to miss the subtleties.  In many ways, the dance looks more like warm-ups for basketball.  But there are ways in which the head is maintained, the position of the feet, the rhythm of the body that determine that this is dancing, whereas my imitation of it is mere jumping.  It is vigorous, whether with rhythm or not.  Debora almost undoubtedly forgot her age and joined in fully.  Her exam showed that she was not truly weak on the left side, as you might find with acute polio.  Instead, she was in pain with pressure over the sciatic nerve.  I could push her toes up with no pain (pain would suggest a clot in her calf), but if I pulled the toes down, she had pain all the way to her hip.  The good news is that sciatica tends to be benign.  It is inflammation of the nerve and should respond to medication.  I put her on Diclofenac every night. 

            Theirs is a strange family.  Debora has given up her son, the person she could most reasonably look to for provisions, so that he can know things, experience things that will always be foreign to her.  He studies in Australia to learn things to help South Sudan, but being there will make it hard for him to return.  If he does, he will never live in South Sudan as he does now in Australia.  They are separated by thousands of miles, yet more by cultures.  And yet they are truly united as well.  And I, a foreign interloper, am welcomed into their circle. 

10 October 2011 

            The first case of cerebral malaria I saw was in my first three months here in Akot.  The child had been sick for 8 days, had made several visits to the witch doctor, and then finally came to us.  She died within hours of coming.  She probably had an abscess in her brain before dying, because her eyes were deviated towards the left.  She was the only case of cerebral malaria I recognized that year. 

            Currently we have seven cases of cerebral (brain) malaria in children on the wards.  Most of them presented within. One has been there 6 days and started speaking again 3 days ago.  A second child is now eating and speaking 2 days after coming to the hospital.  The other three came two nights ago, and two came in last night.  Those five were unresponsive, though two have awakened.  All are on IV Quinine and Dexamethasone.  All have shown improvement.  One of them also had nephritis complicating her course.  Three of them have asthma/pneumonia as well as the cerebral involvement.  Thus far, none have died.  They have all become ill rapidly, usually within 48 hours of the onset of fever. 

            Malaria is a tough disease.  We are seeing treatment failures on ACT, up to now the standard of therapy.  We are seeing frequent relapses in patients who appeared to respond, but are sick within the week.  And we see frequent re-infections, with patients who apparently had a good response to therapy showing up a month later just as sick with all the signs of malaria.  Now we have all these patients with cerebral malaria who are dreadfully ill and require Quinine for the entire course of therapy.  We feel blessed that most of our patients continue to improve and go home intact.  But there is no question we have been challenged this year. 

11 October 2011 

            I have another child who has malaria and an unusual presentation.  She had been sick for three days at presentation, was quite febrile and looked very ill.  About half the patients with malaria have big spleens and about half of those are relatively big (3 cm or larger), and the spleen are usually tender (to feel a spleen at all implies it is 2-3 times normal size and therefore almost always somewhat sensitive), but this child’s spleen was 6 cm and exquisitely tender.  She had been vomiting anything mother tried to feed her, so we went to IV Quinine even without signs of cerebral involvement.  But now she has been here two days, continues with high fevers, continues to vomit everything given by mouth.  Her liver is less tender than before, but the spleen has not improved; it may be worse than at presentation. 

            Doxycycline is used primarily for prophylaxis.  I take it every night during the rainy season, and so far I have not contracted malaria.  But as our ACT and Quinine supplies have dwindled, I have started using Fansidar followed by Doxycycline.   The combination appears to be effective.  Generally Doxycycline is not used in patients under 8 because of some risk of darkening their teeth, but that risk is low with a short course of therapy and dark teeth are preferable to death.  Since Doxycycline is water soluble, I mixed some in water and gave it to our patient rectally.  I am going to do the same with ACT.  Necessity is forcing some strange births these days.

12 October 2011 

            Rose told me once of an Adventist conference she attended in Juba.  There were some kawaja women instructing the Sudanese women about the Bible, raising children, keeping home, etc.  It was a holistic ministry, so they wanted to say something about exercise and fitness.  The woman charged with this area of instruction told the Sudanese that she tried to exercise some every day.  She described walking down some stairs and circling the courtyard several times briskly.  Rose noted for the teacher that Sudanese women walk much farther than that every day, usually with a heavy burden upon their heads.  The kawaja thought for a second and then said, “You know Rose, you are absolutely correct and that ends our discussion on exercise.”  And to her credit, she ended the discussion. 

            I have always enjoyed exercise and therefore it was never a burden.  I have done various types of exercise over the years.  Probably the most fitness-inducing was swimming.  Without question, my most enjoyable was tennis.  Here I jump rope, a standby that I have done at various times throughout.  The last week or so, I have been doing the Sudanese exercise routine.  I have been pulling ground nuts or bringing them in from the field to be separated from the plants.  It is not nearly as intense as jumping rope, but it takes a long time and is strenuous.  I have pulled up about 2/3’s of the field, though I have had several different people helping along the way.  I cannot pull any more until it rains again, as now the ground is so hard that the top of the plant comes off and the nuts remain interred.  So today I started bringing in the sheaves.  Dr. Rossi helped me.  I made several discoveries.  I do not think these will be written up in any agricultural texts, for I fear that my errors were neither new nor unique.  First of all, I realized that the pulled plants probably need to be gathered shortly after leaving the soil.  My goal had been to complete the pulling and then move to the gathering portion of the harvest, leaving the separation for later.  The shelling, pounding, crushing were going to be pleasures I deferred.  But a week in the sun and rain of Sudan invited various crawlers to gather.  I use gloves.  I want to experience some of the work Dinkas routinely perform, but there are limits.  Many of the rows of excavated ground nuts had become the home of ants.  Often I was pulling off my gloves, beating them together, and swatting the invaders off my arms and legs.  Rossi killed the one scorpion we saw.  The other problem was that so many of the nuts had come off themselves and sought renewed interment.  About every third bundle, I was scraping up large numbers of the abandoned legumes.  My plan was to take the ground nuts into the porch of the men’s ward and separate them later, but as Rossi and I came by with the second load, the in-patients gathered under the Lulu tree motioned for us to bring them there.  They would separate them for us.  We managed to haul about 1/3 of the excavated nuts, and we were both ready to quit.  I did a few pushups, as my exercise always ends with that routine, but I was in agreement with the kawaja woman: Dinkas do not need my instructions in exercise. 

13 October 2011 

            Physicians see themselves as healers.  That is why we go into medicine.  Oh, I know that there are plenty of “perks” along the way, but the vast majority of doctors I know find much of their satisfaction in medicine in seeing patients improve under their direction.  When our interventions fail, we feel like failures, and it is hard on all doctors to deal with that feeling.  Consequently, we enjoy being around patients we have helped and do not enjoy being with those we who remind us of our fallibility. 

            Michael Macar is a 35 year old teacher with severe glaucoma.  When the eye team from Tenwek hospital came to Akot in Mar 2010, Michael had already lost all vision in his right eye and was rapidly losing vision in the left eye.  Despite normal rules saying you do not operate on such a person without the possibility of proper follow-up, the desperateness of Michael’s situation forced Dr. John Cropley’s hand and he did a procedure to lower the pressure in Michael’s eye and so preserve what vision remained.  The mornings after eye surgery are generally a joyous occasion.  The majority of the procedures are cataracts and so people who came blind woke up seeing.  That was not true for Michael.  Dr. Cropley never thought it would be.  And in fact, there is a good possibility that the surgery has been successful, because Michael’s vision is stable.  But despite the clear description of what could be expected, Michael remains disappointed in the outcome. 

            Michael’s plight has not been pleasant.   As his vision declined, his teaching position was given to another.  Thus in a world where survival of the fittest is the norm, Michael had to bear with one of the chief disabilities and lose his main source of income.  Though I was not involved in the surgery, Michael has looked to our hospital and me in particular to provide for his needs.  He also is protesting to the Ministry of Education about his firing, as the only reason for it was his blindness.  And he has looked to me to help him in the process.  He gave me the letter to type for him for its various recipients.  He practically demanded that I give him and his brother space in the vehicle the next trip to Rumbek, which we accomplished today.  We went in the pickup so that we could buy more fuel, but that also meant that three people were up front and the rest were in the pickup bed.  Because of his blindness, Michael was one of the three.  Dr. Rossi was the other.  Michael was in the middle.  On the way home, the warmth and strain of the day finished him off and he dozed.  Actually he wracked.  Because of the gears in the middle of the floorboard, Michael’s legs were aimed somewhat to the right and they stretched more that way as he dozed.  Suddenly I felt this great weight upon my right shoulder.  His head and shoulder were draped over mine.  The road to Rumbek has resumed its horrible condition after a brief period of “traversability.”  Therefore half the time I drive on the shoulder of the road, often at a 30 degree slant.  I thought that might be useful in dealing with Michael, but I was mistaken.  Several times we woke Michael, but only briefly. 

            He did get a letter from the Ministry of Education chastising those in Yirol for their shabby treatment of Michael.  The letter implied that he was entitled to the salary denied him during those months and suggested that he might be able to regain his employment, though he had to take the letter and go to Yirol himself.

            We arrived in Akot in the evening.  We were exhausted from the rough travel and long day in Rumbek and still needed to unload the provisions and fuel, including two 200 liter drums.  Upon completing that task, Michael asked me if I would take them out to Makur-Agaar.  I hate the road to Makur-Agaar.  Once the rains begin, it becomes treacherous and stays that way until a month or so into the dry season.  It is a difficult passage in the middle of the day; it is a minefield at night.  So when Michael asked, I gave a non-committal answer.  “I don’t know, Michael.  Let me think about that.”  However, all that went through my mind was Matt 25.  I could hear Jesus saying, “I was blind and in need of assistance and you ignored Me.”  I reluctantly consented. 

            We have not had rain for over a week and ground is again becoming rock-like, but the road to Makur-Agaar retains many treacherous spots.  And there are turns that are blind in the evening hours.  A couple of times I felt the back wheels spinning, but we continued our forward progress out the swamp.  Once I hit a stump with the passenger side front tire, but all seemed well.  Then on a sandy stretch, the vehicle was much more difficult to steer than usual.  I let go of the steering wheel for a second and we dove to the left.  I stopped.  The driver side front tire was flat.  I cursed a blue streak.  Fortunately we had a spare and all the components of the jack. 

            I like LandCruisers, both the “high box” and the pickups, but I hate changing tires on them.  I am used to scissor jacks that fit into a prescribed place on the frame.  There is nothing like that on the LandCruisers.  In the failing light, I reached under and found a joint in the frame where the hydraulic jack could go.  The road was a bit sandy, but firm.  I told Michael and his brother to go ahead.  We were practically in Makur-Agaar and it would take me twenty minutes or more to change the tire, so there was no reason for them to wait.  “We will not leave you alone.”

            The car was in gear and the parking brake set.  I got out the spare from the truck bed, raised the jack until it was firmly under the frame and loosened the lug nuts.  Twice the tire tool was stuck on the lug nuts, but Michael’s brother coaxed it off.  As I was raising the jack, the mosquitoes rang the dinner bell.  Michael’s brother took off his shirt and fanned me, keeping off the mosquitoes as I worked.  I got the car up high enough to take off the wheel, I thought, and then did another 20 turns to be sure, but when we removed the flat, the spare would not go on.  I turned it another 20 times and finally we did get the spare on and the lug nuts as tight as possible in midair.  As I started lowering the jack, it slipped out from under the joint.  All kinds of thoughts went through my head.  I had reached under once to reattach the extender.  Had it fallen then, my arm could have been crushed.  Had the car fallen with the wheel off, I do not know how we could have gotten it back up.  Michael and his brother had no idea how blessed we were in the timing of that slip.  I drove them a bit further and dropped them off.  Michael asked again about going to Yirol, but he was content for me to give him money for the matatu there. 

            In reading the Good Samaritan (Luke 10), it occurs to me that the priest and Levite were not vicious in their refusal to help.  It was just that the helping was inconvenient.  It usually is.  But it is helping in inconvenient times that glorifies Christ.  In truth, it is a privilege to know and help Michael Macar.  

14 October 2011 

            I am not into meetings.  I find that the majority of times, meetings are done to check boxes, not to accomplish anything of importance.  So I was not anxious to be a part of the Ministry of Health meetings here in the Lakes State.  I feel that the meetings here are as bureaucratic as any I have attended in the US, but I have been surprised at the appreciation we have been shown when we do attend, which turns out to be about every other month.  I usually have either Rose or Mary Agum with me, and that makes the meetings more enjoyable.

            The October meeting was notable for several things.  The meeting combines government and NGO’s who are discussing various issues related to health care and some important ones were discussed this week.  First of all, I had heard that things were bad with respect to malaria, but I heard the true scope of the problem.  One of the main issues is that the government has encouraged the NGO’s to trust them in their supply of medications.  We get a lot of our medication from MEDS (Ministry for Essential Drugs and Supplies), but we have gotten all our ACT (Artemisin Combination Therapy, the standard treatment for malaria) from the GoSS (government of South Sudan).  Now we find that we cannot get any more ACT.  ACT is expensive relative to most of the drugs we use, so we were glad to get the help from GoSS, but their lack of reliability puts us in a difficult situation.  I thought we were in bad shape, but we are better than most hospitals in the Lakes State.  Second, we were given some rare insight into South Sudanese governmental actions.  It had previously been reported that government drugs were making it into the market place.  That report has yet to be adequately addressed, but at least the sitting chairman (not the Director General) is keeping the issue alive.  Mary Agum tells me that some men, possibly including those who were in the room, had been diverting medications and selling them to vendors and sending only about half the stock to the health centers.  I cannot verify her assertion, but there seemed to be some men dodging the spotlight.  I also heard about some of the shenanigans in Juba.  I do not know if the medications we need are there, but that was implied.  Is this just the problems of starting a new government or is it evidence that South Sudan has already joined the club of corruption that dominates Sub-Saharan Africa?  Third, we were accused of neglect.  In our relationship with Malteser, we often hospitalize patients with TB or AIDS awaiting their transport to Rumbek, but one of the participants accused us of allowing a patient to wait an excessive period.  I explained our situation and our understanding of how things were supposed to be handled.  The chairman sided with us, but I was surprised to be called on the carpet in that manner.  Fourth, I did make a suggestion that many took to heart.  We have used a combination of Fansidar and Doxycycline effectively as we ran out of ACT.  Others were planning on using that approach until the supplies of ACT resumed.  Fifth, the meeting does provide a forum for making good contacts.  I have gotten to know Dr. Ezzu in Yirol, a good and dedicated doctor running the best hospital in the Lakes State.  And I met Madeline who is running a nursing school for Sudanese.  I hope to have some more contact with her, both sending students to us and us possibly enrolling some of our people there.  I am still not a meeting buff, but I am glad to be a significant part of this meeting and will come as often as possible.

15 October 2011 

            I was the one who raised it with Peter Malual.  We were talking together and I mentioned I would like to go back to cattle camp with him.  Through a series of issues, coming from each side, we have put it off until the last weekend before I head back to America.  We were going to go yesterday, but the rains came and Peter said that the camp was moving and that the people of Paloc had requested that we make the journey there because they have so many sick people and essentially no health care provider.  That reduced my commitment to a day rather than a weekend for which I was glad.  But the night and this morning had steady rains and I figured we were scratched again.  The road to Paloc is always tough; with the new rains it would be treacherous.  I was out pulling the remnants of our ground nuts when Peter came up.  He assisted for a bit and said we should go, maintaining that the road from Karic to Paloc was in good condition.   I gathered the medicines and some IV fluids in case that was needed and we headed out.  In the market we picked up two of our staff, their bikes, and several others traveling to Karic.  We got to the turnoff and found instead a trench filled with soft mud.  Undaunted, Peter said we should go through Adol.  That seemed like a great idea for the first third of the trip.  The road was overgrown with the grasses so that visibility was limited and I was forced to sound my horn regularly to warn approaching travelers, whether by foot, bike, motorbike.  After a bit, though, there were abundant challenges.  Indeed, I believe it would make a tremendous video game.  The grasses and curves hide your view.  The roughness of the terrain makes driving fast a bad idea, but the softness of the mud make maintaining a good momentum imperative.  We were bounced and showered and stabbed by the grasses as we plunged forward.  I think it would make a tremendous video game.  The people in the back were whooping.  In truth it was about as much fun as I have ever had driving, but there is always the pressure that you can get the whole group stuck, ruining everyone’s day. 

            We arrived in Paloc about noon.  We soon settled on the all but abandoned primary health clinic (PHC) and the people started coming.  Eventually the TBA (traditional birth attendant, a midwife with minimal training) came and unlocked the door.  She locked the door and left, and we had to call her back.  We settled outside, however, because of the heat.  Peter Malual gave a devotion to those assembled and we began in earnest.  For most of the day, I saw patients and Dr. Rossi manned the pharmacy.  There was a desk in the room that I used for an examination table and we found some medicine bags, something I had forgotten to pack.  Like Akot, the people in Paloc have been suffering with severe malaria.  Unlike Akot, there is not much they can do.  As I took the histories, I was continually hearing of people who had been sick for 10 days, 2 weeks, 3 weeks.  Normally I am skeptical, thinking that if they had been as sick as they described for that long, they would have come to us, but where can they go.  I struggled to get to Paloc with a four-wheel drive vehicle.  Acute malaria does not equip you for an arduous hike.  All I could do was sympathize with them in their illness.  Three of the patients were very ill needing IV fluids.  Fortunately I had packed canulae and fluids, but the issue of hanging them remained.  We used packing straps looped over the rafter’s and ran in the fluids as we saw more patients.  One of the three was a child with severe malaria and vomiting who needed IV Quinine.  She and a woman with an abortion (miscarriage) and early shock were later transported back to Akot.  We saw around 60 patients and had to leave at 5:30 to try and have some light for the trip home.  One of the most memorable of the patients was not one of the sickest.  As I was taking the history from one patient, I felt someone stroking my arm.  John Kaman is a 2 ½ year old little boy who had malaria.  I smiled at him and it seemed to encourage him and he stroked my arm with both hands and laid his head on the arm.  Dinkas are fascinated by the hair of kawajas.  When it came John’s turn to be examined, I noticed that his right foot was somewhat disfigured, probably an intrauterine accident.  He was not limited by it.  Indeed, with his eyes he conveyed utter trust.  I usually examine young children in their mother’s lap, but we had no chairs for the mothers, so for the little ones, I put them in my lap.  John lay their quietly as I examined him.  When I lifted him back up, I kissed his head.  The surrounding audience gave an appreciative laugh. 

            Paloc is very much like John.  Except when I have gotten stuck, I have enjoyed my visits to Paloc and would like to do it more regularly, but I hate that road and I do not foresee a time when travel to Paloc will be easy.  So people will continue to die in Paloc of treatable diseases and at best we will help a little.  They would have us come back every week.  Indeed, they want us there full time.  The needs of South Sudan are so great.  “The harvest is plentiful, but the workers are few” (Matt 9:37). 

16 October 2011 

I love the Dinkas and I am tempted to keep this story “under wraps,” but I think it is important, a kind of full disclosure.  I was watching a marginal Tom Cruise movie when Dr. Rossi called me from outside the tent.  “The volume is up too loud.”  It probably was, but not very much. 

“What do you want?”

“I want to show you something.”  I waited, expecting him to enter, but after a minute or so, it dawned on me that I needed to join him outside.  He led me to the latrine and shined his light in. 

            Earlier in the day, Samuel Maker had told me about leaving the computer out when he left the men’s ward (really our guest house at present) and not finding it when he returned.  Dr. Rossi usually keeps the computers locked in his room since two of the four came up missing in a short period.  He had stressed the importance of either returning the computers to him or putting them in my tent, but not to leave them out. 

            The computers, a generous donation from Richmond, VA, had caused tremendous dispute to which I inadvertently added.  I wanted the computers so that people who had a desire but no access to computers could gain some experience.  But I wanted someone in charge, for I considered the gift handsome indeed.  I thought a double blessing could be had by giving the computers to Akot Christian Ministries (ACM), our sister organization, who could charge a nominal fee, keep the computers safe and in order, and make a bit of money to assist their ministry.  I thought it a “win-win situation” (Seven Habits of Successful People).  But instead of pleasing, I infuriated many of the young men on our staff who thought the computers should be free for them.  We tried to bring about some understanding, but the young men thought I had sold them out.  On top of that, there was some controversy in the Dinka community about the selection of Gordon Mayom and Isaac Bol as the head and ex-o.  The computers were locked away, but I am constantly lending my keys out, so the computers were an easy hit for so many people.  When the first two came up missing, Isaac Bol went to Samuel Mathiang, who I think correctly deduced that what the thief intended was for us to go to the police, launch an amateurish investigation, incriminate and embarrass Isaac Bol and ACM.  So we did not move. 

            It was hard to contain my fury when I saw that bright Macintosh computer floating in a sea of refuge.  I started thinking of ways we could possibly retrieve it, but in truth it was hopeless. 

            I have been working my way through the stories of Elijah and Elisha (I and II Kings) for several weeks now, taking the stories in order of appearance.  The story for today came from II Kings 9, where Elisha anoints Jehu to be the next king of Israel and he is to exact revenge on the house of Ahab and Jezebel.  I read from Rom 12:19.  After the story, I told of finding the computer in the latrine.  I told them that I knew what they were trying to do and it would not work.  Akot Medical Mission (AMM) is committed to ACM, Gordon Mayom, Isaac Bol and we would not be persuaded of their guilt or incompetence in the matter.  Second, the used computers I had planned to bring back with me to Akot would find other uses.  And I assured them that even if they were somehow able to elude me, they would never elude God.  Though it might come slowly, as it did for Ahab and Jezebel, it would surely come.  It was not a fun devotion, but it was needed. 

17 October 2011  Bill Deans warned me.  “Don’t push it.  Go on out to Nairobi a couple of days early if you need to.”  I am coming to the US, but the uncertain leg was getting to Nairobi.  I tried to “hop” a flight with AIM or MAF, but that was unsuccessful.  So last week I sent an email to Evelyne who usually handles our travel arrangements, but I found out that I had used an old email account that was no longer working.  So I resent it, but it arrived at the weekend.  Through some more missed communication I was late confirming the ticket request and the ALS flight I had been counting on was full.  I was furious, mainly at myself.  Now everything would be thrown off.  I went out to collect the remainder of our uprooted ground nuts, as I was unfit for anything but manual work. 

            But Bill, instead of rubbing in about my stupidity, set to work in arranging alternatives.   One of Bill’s strengths is that he makes and keeps good contacts within various organizations.  I have a few, but nothing like his.  As I completed the gathering of the groundnuts, I called Bill again and he told me there were some decent possibilities of getting me out, but I needed to call back in a couple more hours.

            This morning the Samaritan’s Purse (SP) DC3 landed on the Akot strip and I was in the air for Juba before 7 am.  SP is providing food for Nubians displaced by Khartoum’s aggression against its own citizens (they seem to be fairly non-discriminating in their bombing).  The Nubians are displaced to the Unity State, our neighbors to the north.  The pilots were heading back to Juba to continue their Berlin airlift like rescue, so they diverted to pick me up. Not only was I going to get out, but I did not have to travel to Rumbek.  I even got to sit in the jump seat and enjoy the pilot’s eye view.  On the ground I assisted the loading of some nonfood items (NFI), such as blankets and pots.  As we were landing, the pilots asked how I was getting to Nairobi.  I told them I was supposed to catch a ride on a Caravan.  It turns out that John McNeeley, a fellow South Carolinian who had stayed a few days with us in Akot was the pilot.  So from Juba to Nairobi I was seated in the co-pilot’s chair.  Shortly after I would normally be taking off from Rumbek I was through customs in Nairobi.  Now all I needed to do is get from Wilson Airport to Jomo Kenyatta Airport, a relatively short trip.  Moreover, Bill had arranged for Patrick to pick me up.  The only problem was that I did not have a phone or Patrick’s number.  I was in no hurry, so I sat down figuring Patrick would show up soon.  I was sitting at a table when a Kenyan spoke to me.  He said he thought he knew me, but I could not place his face.  After a bit it turned out that he was a friend of Patrick’s and had driven Rose and me to the US Embassy last month.  He had Patrick’s number and called him for me.  I am not sitting in the airport, feet away from where I will depart on my journey home.  Twenty eight hours ago, the chances of me being here seemed nonexistent.  Now I am here.  “God moves in a mysterious way His wonders to perform” (William Cowper). 

18 October 2011 

I am sitting in DFW (Dallas-Fort Worth), awaiting the last leg of my journey home.  If we are coming from Akot, I believe we compete with anyone as far as time in passage is concerned.  When I arrive at my final destination, Lord willing, I will have been in transit for 48 hours, but it has been pleasant.  As mentioned above, by all rights I should have been abandoned, left behind because I had not made sure the connection with ALS had been made, yet I had more pleasant flying than ALS ever provides without driving to Rumbek.   My flights have been uneventful and I slept fairly well on the overnight leg.  The highlight of my journey was spending 2 hours in Heathrow with my daughter Constance and her fiancé Oliver (Oli).  But even other encounters were good.  I met an Australian couple and heard all about their travels, including their aborted attempt at flying in a balloon over the Kenyan plains.  I met an Ugandan who now is a US citizen in Washington, but had been back to visit family.  Like the Lost Boys from Sudan, he has ambivalent feelings about Africa, with strong affections drawing him, but he also feels disgust with the corruption and backwardness of his homeland.  As I talked with Vincent, I was convinced again that sending our citizens out of East Africa is not the way to help South Sudan develop, for so few are willing to return to South Sudan after living in the first world.  Even customs was not too painful, though I did have to have my shoes examined because of my sheep.  I am thankful to be here and excited about what God is planning to do to equip our hospital for the work He has for us to do.   

21 November 2011  I am sitting in Hartsfield International Airport awaiting the start of my return trip.  I obviously did not continue my journal during my time in the US.  I thought about it, but I feel that it is my African, particularly South Sudanese connection that gives the journal any distinctiveness.  My trip home had multiple purposes, but foremost was the desire to get out the word about Akot Medical Mission for the purpose of increasing our support.  As I am convinced that the work we are doing is good work, indeed, God’s work, I do not apologize for that goal.  Mustard Seed International (MSI) is a small missions program.  We are the only medical ministry MSI has.  We are the only mission work in Africa for MSI.  I appreciate the faithfulness of groups such as Samaritan’s Purse and World Medical Missions, but the reality is their budgets are much more secure. 

            There was a point where my trip home was almost cancelled.  We did not have the number of engagements, interactions to make the journey appear worthwhile.  Bill Deans and I actually discussed cancelling the trip, but we decided to move forward, trusting that God would open doors for us and continue to provide for our needs.  I believe we can praise Him for faithfulness in that arena.  Indeed, there was a time on my “vacation” when I was wondering if I was going to have any time off.  Shortly after arrival in the US, I headed down to Charleston, SC for the MSI banquet.  I have family in the “low country” of SC and I was able to visit my mother and later my sister.  I had the privilege of speaking at my sister’s church in Walterboro, SC, a small but historic town that would approximate the size of Rumbek, the capital of the Lakes State.  There was the possibility of a trip to Florida, though that did not materialize, but the next week Bob Claytor and I headed up to our nation’s capital.  That was the start of the great excursion.  Over approximately four weeks, Bob and I logged over 5000 miles.  In Washington we spoke with representatives of the South Sudan embassy (they were proud to have achieved embassy status as the world’s newest nation) and the two senators from SC.  I must confess that I am glad God has not called me into that arena.  We were received politely, of course, but I feel that we accomplished little, though you can never be sure.  Following that trip, I had my first Sunday at my home church, Norris Hills Presbyterian Church.  It is a blessing to have a congregation that prays for and supports you while in the field, and it was good to be home with them.  The next week marked our greatest travel time.  We headed up to Cincinnati where we met with a small but strategic group.  I have only been to Cincinnati a few times, but I have always thought it was a great city, a true slice of Americana.  I felt that even more in this trip.  Cincinnati has a working class feel, a city that does not take itself too seriously, but does understand its own worth.  The group was very responsive and encouraging.  From there, we headed east over the Appalachians to Richmond, VA.  As a southerner, I have always had a place in my heart for Richmond, but I did not realize what a beautiful city it is.  I have always maintained that, next to Williamsburg, VA, Charleston, SC is the most historic city in America because of both its age and its relative lack of growth.  I realize that Boston, NY, Philadelphia, Baltimore were equally or more prominent in the colonial period, but they have grown so that they have lost any of the flavor of history.  Richmond, however, gives Charleston a run for that title.  The downtown seems to have kept all its antebellum charm.  I was particularly looking forward to Richmond because we have two churches in the Richmond area that make mission trips to Akot, so I feel I have many friends there.  I feel that more strongly now.  We had five meetings in 3 days, each of which was encouraging.  We started with a more traditional church gathering at St. James Episcopal in the heart of Richmond, but then our friend Elizabeth got creative, so we met with a small group at Christ Episcopal Church, a gathering at a neighborhood swim and tennis club, and then two classes at the University of Richmond.  Each gathering had its unique flavor; each was encouraging.  The next week was in Louisville, KY.  Those who are not geographically challenged may wonder why we did not arrange our trips to consolidate our travel.  I wondered the same thing, but the reality was the dates were not that flexible.  Northern Kentucky is one of the most beautiful areas of the country in my opinion.  Travelling along I64 we passed great pastures of beautiful horse farms.  Southeast Christian Church in Louisville sponsors the Global Missions Health Conference (GMHC) every year.  This was my second time to attend.  I was impressed again with the quality of the program.  I got some significant help medically, confirming some things I had already thought and enlightening me in others.  We made some good contacts, but I realized there what was dawning on me before: the primary purpose of my trip home may have been to seek funds for our hospital, but a second purpose was to encourage others who are considering medical missions.  That was particularly evident at the GMHC.  I know that many of those who visited our booth were “window shopping,” but I truly felt that I was able to encourage many young medical professionals in practical ways.  I am also hoping that some of them may end up in Akot.  Our final journey was to Toccoa, GA, a small town where Bob taught and preached for many years.  Again, the flavor was unique, but the interest real. 

            How successful was our journey?  Was it worthwhile for me to come to the US?  Personally it was great.  I needed to reconnect with family.  I enjoyed the opportunities to talk about the work we are doing.  I gained a lot of weight from eating innumerable great meals (I am confident I will get it off back in Akot).  The dollar amount raised by this visit is unclear, but I remain confident that God will use these contacts and whatever other means He chooses to continue His work.  I am glad for my time, but I am ready to be heading back to Akot. 

26 November 2011 

Continuing my airport tales, I am sitting in Heathrow Airport, starting the next to last leg of my journey back to Akot.  I had a lovely layover in London.  My eldest child, only daughter Constance married Oliver Smith (Oli) yesterday.  She is a remarkable girl.  I know that all fathers think that about their girls, as is only right, but I believe I have as much cause for celebrating her as any father might have.  She is a lovely, brilliant, committed girl.  She has just completed her Masters of Philosophy at the University College of London.  Simultaneously she worked with the alternative culture in Camden Town to reach that portion of our culture that many (including myself) tend to write off as hopeless.  Her husband is in the same ministry.  Indeed, Oli has been in some kind of ministry to the unreached in London for many years, initially with London City Ministries and more recently with World Harvest (the same as Constance).  The wedding itself was so much like them, a stark mixture of the avant-garde and traditional.  It was held in St. Michael’s Episcopal Church, a downtown church built only 100 years ago, but in the gothic style of the more stately cathedrals.  The church was beautiful, though as the rector Philip pointed out, there had been great neglect at some point, so it is stately and magnificent, but rough, again adding to the appropriateness of the setting.  Constance was elegant in her traditional, almost medieval wedding gown, modified from the dress her mother wore, but she testified to the alternative culture with her blue-based black hair and multiple piercings.  Oli was completely Camden with a non-traditional but handsome jacket created along the lines of a confederate general’s coat.  The colors for the wedding were black, gray, and red.  Each of the bride’s maids wore black dresses that they already owned, carried red flowers, and wore a red necklace.  Completely out of the loop, I wore a gray sports coat and the McIntosh plaid tie.  Clarke Jr. wore his military formal uniform.  It was an eclectic but truly wonderful affair.  Philip was the perfect rector for the ceremony, not only because of his support of the ministry of World Harvest, but because he was the perfect bridge of the cultures, as traditional a rector as one could wish, yet with a heart for the alternative culture surrounding them.  The entire event felt utterly outside both the American culture of my birth and majority of my life and the Dinka culture that has become my home, and yet it also felt surprisingly comfortable and appropriate.  It does make one think about heaven.  Imagine the diversity of backgrounds and cultures that will be spanned as we gather before the throne of God and sing His praises. 

            I had been to London 30 years before, though I had never been to Camden Town.  Several people told me that at that time, there was no reason why I would have come up that way.  I did have a day with Clarke, Jr. seeing the magnificent sights of London.  Again I was struck by the contrast.  I am sure all Americans seeing the House of Parliament, Westminster Abbey, Buckingham Palace, St. Paul’s Cathedral are as overwhelmed as I at the sense of history that predates all our country.  As we walked down the Strand, Clarke and I were amazed by the various buildings that would have been national land marks in the US because of their elegance, age, and history, yet they seemed to just blend in to the ambience.  Soon I will arrive in South Sudan where our hospital is one of the few structures with even aspirations of lasting more than a decade.  It is a diverse world. 

            I have had an eventful journey to this point just from Camden Town to the BA plane.  I have enormous luggage, mainly bringing back things for the hospital or individuals in Akot.  The hostel in Camden Town where I stayed had an extra baggage room, but it was full, so I had to leave my luggage at Constance’s flat.  That meant I needed to arrive about 6 am and get those pieces plus what I had for current living and needed to haul those to the tube.  The porter there was helpful with directions, but as I pulled my great pieces behind me to get on to the escalator, they jammed as I set foot on the moving steps, threatening to permanently divide either my body or me from my luggage.  In a Laurel and Hardy type moment, I was running against the flow of the steps to retrieve my luggage.  “One before you” shouted the porter in his most helpful manner.  The one exchange was accomplished with less drama and I arrived at Heathrow with no more issues, but I had arrived at what I thought was A10 of Terminal 5 in plenty of time, but then I noticed that the sign said escalator to A10 and as I came there, they were making the final boarding call for my flight.  But here I am, ignoring the safety instructions for the flight as I enter this leg of my journey, thankful for my time in London and ready to return to my world in South Sudan.  

28 November 2011 

Continuing the airport narratives, I am sitting in Loki (Lokichogio), I think the northern most airport in Kenya and the site of the origin of the UN food drops into South Sudan during the war.  I am told Loki was very busy in those days.  Since I have been stopping here (and I do most visits into and out of South Sudan), it is quiet.  There are a few planes for Doctors without Borders (Medecins Sans Frontiers) in addition to our ALS plane, and a couple of UN planes off the runway.  There is another plane from AIM, but no others.  Loki is usually hot, almost as hot as South Sudan, but today it is pleasant with a slight breeze.  Our ALS flight was fairly full, but I think the majority of the passengers were for Loki, so Elijah and I will probably be among the very few going on to Rumbek.  Maybe some of the passengers will be diverting to Juba, though there are direct flights from Nairobi to Juba.  AIM has a base here in Loki, primarily for flights into Sudan and South Sudan, though also into Uganda and other areas of their ministry.

            Being in Loki confirms I truly am on the way back.  In London, the wedding and enjoying the city dominated my thoughts.  There were some things to do in Nairobi (buy some adaptors and a multi-plug power source, go to church, make some acquaintances at Mayfield Guesthouse) but now by being in Loki I am actually and irrevocably back.  It is a conflicting emotion.  I love the work in South Sudan.  The good is frequently evident.  Patients live who would have died had we not been there.  Pastors look to me for guidance and instruction.  I feel needed.  But I have always hated good-byes and it is also hard to think I will not see my family for a year, maybe more.  I met my son-in-law on this journey home and then gave my daughter into his hand for marriage; by the time I return, they will feel as though they have always been married.  My son will be nearing completion of his Army obligation by the time I return.  My parents continue in good health, but their age makes every good bye feel as though it could be my last with them.  My siblings and their children have changed in ways that initially are imperceptible, but that are actually important and profound.  I sense but do not grasp their significance.  I already feel distant and removed from those I love, and it sinks in as I sit here.  For the last six weeks, when I was not speaking at banquets and gatherings in an attempt to raise funds for our hospital, I was catching up and getting re-acquainted with those whom I love, and the same process will occur the next time I venture across the pond.  That is the way of life.  Hebrews 11 describes us as pilgrims, as those without a city, searching for a permanent place that we will inhabit in heaven.  I think of the missionaries of the 19^th century who packed their belongings in caskets, anticipating that they would never again see their loved ones and I know that my journey is nothing compared to theirs, but it is still something.  I put down on my visa applications that I live in the USA, but in reality I spend much more of my life now in South Sudan.  I would not have it any other way, but there is some sadness just the same. 

            Within two hours I will be back in Rumbek.  Samuel is coming out.  Elijah and I will take the car, get whatever staples were required by the hospital, and we will be back at it.  Seeing patients, ordering medications, speaking at devotion, cooking oatmeal will be reestablished as my daily routine and for that I rejoice.  By Christmas, my time in the US and London will feel like a remote occurrence, an aberration from our routine.  While at home, I found it difficult to remember my Dinka words; soon they will roll off without thought.  It is a strange sensation and a unique blessing to be a man of two countries.  I do not regret it, but it does feel strange as I sit here in Loki. 

29 November 2011 

My welcome started in Rumbek.  That is not really true.  I met Elijah in Nairobi and was warmly welcomed by him.  On the flight I did get a strong feeling of moving against the tide.  Though our plane to Loki was full, there were only 4 people coming to Rumbek, though the flight out was full.  Most people are heading out of South Sudan for Christmas.  That is too bad.  I love the way Dinkas celebrate Christmas.  There is little in the way of gift exchange, as the people are very poor, but there is a great feeling of celebrating the Lord’s incarnation.  When Elijah and I arrived at the Rumbek airport, Samuel was there.  He, and almost everyone else, commented on how much weight I had gained.  With Samuel, it was good natured teasing and we started speculating on what would happen to me if I ever moved back to the US for good.  Almost every Dinka I met had something to say about my weight as well, but it was complimentary.  In a land of starvation, bulking up is a good thing.  Perhaps that explains the appeal of Reuben’s paintings in the 18^th century. 

Getting through customs is holds unique challenges in South Sudan.  First of all, the price of entry has increased from 84 to 160 pounds.  In truth, that is not such a dramatic increase, as the exchange rate in the last 2 years has increased from 2.5 to 3.9 pounds/dollar.  But we had planned for the former, so it was good that Samuel had some pounds to give us to get through.  I am sure that if I paid in US currency, my “exchange rate” would not have been so favorable.  Second, you have to watch the customs officer.  If you have multiple bags (and who does not when coming into South Sudan), he will get you to unzip your bag, check through it for a while, then finish and get you to unzip the other.  If you do not watch him, he will snitch something out of the first bag.  Elijah, being wise to this maneuver, helped me get through without the loss of valuables. 

We drove into town and parked in our usual location.  The first person I saw was Rose Paul, with Paul Mayol (her husband) immediately behind.  Rose is one of those warm people who make you feel that she has been counting the hours since your last meeting.  Isaac Marial (our Dinka accountant and administrator) and Isaac Bol (local pastor) were also there and made me feel much missed and very welcomed.  Suddenly I was back.  The melancholy of Loki passed quickly and my emotional focus switched from those I had left behind to those I was rejoining.   

            The weather is perfect.  Dinkas talk about it being cold, and this is probably the coldest month of the year, but it feels like one of the most desirable days of Spring or Fall: a very warm April or October day with low humidity and temperatures are in the 80’s during the day and probably reaching the low 60’s at night.  There is a light breeze.  The day may be cold for those with no body fat, but as I have been addressing that issue well during my stay in America, I love it, though the nights do get chilly with scant covers. 

            Upon arriving at the hospital, a series of warm greetings was supplanted by a number of requests for me to see patients.  I did not mind for myself, but I felt badly for Dr. Rossi.  I have been the “new kid on the block” many times.  I remember well starting at UAB and later at Duke when my expertise was established to some degree, but the housestaff (residents) and patients treated me as though I knew nothing.  As far as they were concerned, I had to recertify, passing their exams.  I feel blessed having Dr. Rossi here and I believe we have greatly benefitted from his presence, but he still is treated as the second doctor.  He handles it much more graciously than I ever did, but I do try to avoid situations where the sensation of being challenged arises.  The numbers in our hospital are down, but the level of acuity (the severity of illness) is high.  We have a 13 year old who was stabbed by a spear (not a typical ER scenario in America) with a resulting pneumothorax (air between the chest wall and lung), an young woman whose child died in the womb (we think from malaria, though the family suspects that someone cursed her), and a woman with a benign brain tumor complicated by cerebral malaria.  There is a significant likelihood that any or all of these might have been transferred to a more advance level of care, such as a teaching hospital.  I made a few suggestions, but did not dramatically alter the course in any of them. 

            It feels good to be back in Akot.  I feel certain that I am where God would have me to be.  The needs are palpable and we are often able to meet them.  That is a great privilege as well as responsibility.  I feel blessed.

30 November 2011  aaa

I have mentioned John Malith before in my journals.  He is a great man from Akot.  He is a sophisticated, educated man who now is spurring the ECS (Episcopal Church of Sudan) to address the issue of HIV/AIDS in the community.  I had spoken once before in a conference in Akot on the subject.  He wrote me that there was another conference to be held, but I received it in the other world, when I was in the US.  I did not remember that it was actually being held or that I would be back in time to attend, but last night Gabriel Amat and Adhanom (an Eritrean who has come to South Sudan via World Gospel Missions) told me about the conference and asked me to come.  I finished rounds this morning and completed the referrals for the day (it is clear that the malaria season is winding down) and then headed over to the Akot Cathedral (the name has been retained from past glories; it is a simple church).  Rossi and Mary Agum went with me.  We slipped into the back of a service that was ongoing, but were fairly quickly waved up front.  About 10 minutes later, I was given the floor to say whatever I felt needed to be addressed, so I spoke about three topics.   First was the Safe Circle.  I told them that whatever the size of their circle (polygamy is the norm in South Sudan), as long as no one in the circle has HIV and no one ventures outside, there is no risk for contraction, but as soon as anyone breaches the circle, the risks go up in proportion to the HIV in the community.  Previously the HIV incidence has been low, so going outside the circle brought problems, but most could be treated.  Now HIV is sharply rising, and so is the risk of venturing outside the circle.  I also told them that if they had previously been unfaithful but had not contracted HIV, they should thank God and stay within.  Second, I again addressed with them their potentially deadly traditions.  Mothers who instructed their girls to not have sex with their husbands when they were pregnant (fear of miscarriage), nursing (fear of diarrhea), and then take a 6 month break before resuming sex.  Such traditions promote promiscuity and are against clear Biblical teaching (I Cor 7:3-5).  Third, I emphasized the role of condoms as a birth control method.  What those Dinka mothers were trying to do for their girls was to space out their pregnancies, but in fact what they were doing was bringing in STD’s (sexually transmitted diseases).  I am convinced that the strategy of pushing condoms to control the transmission of HIV/AIDS has backfired, at least in South Sudan.  Condoms are virtually never used, because they are associated in the minds of the people with prostitution and lack of trust.  But in fact, condoms would address the concerns of those mothers without sending the husbands out to meet their sexual desires in any fashion they chose.  The talk was little different than the one I gave three months ago, but the reception was very different.  Virtually everyone received the message well.  Will change come?  Not over night, but I am hopeful.