Lots of news from Dr. Clarke

16 December 2011 

There are no child labor laws in South Sudan.  Dinkas love their children, but they also view them as more of a commodity, much as farmers use to view their children in America 100 years ago.  Children do require some maintenance, but the work they do more than compensates for the food they take in and the living quarters that they receive.  Children also frequently move between families, based upon the needs of the time.  A young mother may get a niece around 9-13 to assist in household chores.  It is usually a good relationship builder.  The children appear to me to enjoy the close relationships with extended family, and working is a normal part of all Dinka children’s lives.  But I have a story from today about a boy laborer that did not turn out well. 

            The problem is complex, as many in South Sudan are.  Part of the issue is polygamy.  The main culprit in the story was married, but he decided he was tired of his first wife and married a second, a common story.  Often the Dinka husband maintains relationships with several wives at the same time, but in other situations, it is more like serial monogamy: he has relations with one wife until he marries again and the first wife is put out to pasture, whether she feels ready for that move or not.  Usually the husband continues to provide for all his wives, even those out to pasture, but the culprit essentially decided he was done with his wife.  He neglected her.  The wife went to her brother-in-law who was much more sympathetic.  He started providing for the woman clothes, food, shelter, etc.  There is no evidence that he was garnering any sexual favors in return.  He simply was trying to help his sister-in-law.  The culprit’s new father-in-law, father of the new wife, needed some extra help around the house.  I do not know the tasks he had in mind, but he wanted an older boy to help him.  The first wife had many children, including an adolescent boy.  So the husband took the oldest son from his first wife and gave him to his father-in-law to do the needed work.  But the first wife still had a significant need of older boy and so objected.  The brother heard about the disagreement and sided with the sister-in-law.  After all, the husband had abandoned his wife, so all that she had were her children and this brother-in-law to help her.  Instead of discussion and possible compromise, the husband got mad and started beating the first the brother for siding with his wife and then his wife for daring to oppose him, using a large stick.  And the ultimate adding insult to injury, he, the assaulter, has now taken the case to the courts. 

17 December 2011 

The story does not end there.  The wife was struck on the head with a stick, opening a gash on the scalp that needed suturing.  It was obvious that it was several hours old.  Not only had the bleeding stopped, but when I injected the Lidocaine, very little bleeding resulted.  Normally the scalp bleeds profusely because the skin is relatively taunt compared to other parts of the body.  Thus when the scalp is parted, whether by sharp or blunt trauma, the vessels have difficulty collapsing upon themselves.  In addition, there is a lot of blood flow to the area.  The laceration was relatively clean.  I did have to shave an area around the laceration, but I do not try to be too fancy in the scalp.  On the face, I use small sutures, preferably nylon, and fairly close together, but on the scalp, a little scar will not matter, so I use silk and few sutures.  We did give her a tetanus injection, the first of her life. 

            The Good Samaritan brother-in-law’s case was more complicated.  He had been to the witch doctor for bone setting.  When he came in he was in obvious pain.  He was wearing one of the local casts: some cardboard cut to fit, some netting with Popsicle sticks in it, and torn bits of cloth wrapped around the whole.  As crude as it sounds, I have seen it used effectively many times, but not in this case.  Part of the reason, I believe, was that the bonesetter failed to recognize half the trauma.  I made him take his shirt off.  He was okay in the chest and shoulder, but his elbow was severely swollen.  When I pressed on the epicondyles, the bony structures on each side of the elbow, he was in severe pain.  I would have liked to have him turn his palm up and down, but he was in so much pain from the forearm that it would not help me decide on the elbow.  When I removed the bonesetter’s cast, I noticed two punctures.  The bonesetter did that, supposedly to help him set the bone correctly.  In reality he changed a closed fracture (skin intact) to a semi-open one (there was no bone sticking out, but there was the potential for infection to enter, setting up a bone infection (osteomyelitis).  The site did feel unstable and there was a great deal of swelling, so I decide against a complete cast and settle for a gutter splint.  I got some plaster sheets, folded them to the length needed, wet them and then fitted them to the arm.  I put this on the underside of the arm from mid-hand to about 5 inches above the elbow, keeping the thumb up and the elbow at 90 degrees.  It was interesting to watch the patient.  He was in pain as we began and more as I was rubbing the plaster, shaping it to his arm, but then as it started to harden and give some support, he started to smile and was obviously in less pain.  After the gutter splint hardened, we wrapped the splint in gauze.  I then took a bit more of the plaster and fitted it to his hand and wrist to stabilize the cast, yet leaving the top open for swelling.  Because of the punctures inflicted by our bonesetter, we gave him his first tetanus shot and started him on Keflex, attempting to nip the osteomyelitis bug in the bud.  We will see him again in 1 week.  He still faces a court case for helping a woman in distress, but I hope we can relieve some of his pain and prevent something more disastrous from occurring.

18 December 2011 

Mary Agum and I had exchanged a couple of barbs already today before a woman came in complaining of amenorrhea for 2 years.  In Jan 2010 she weaned her last born, but her menstrual cycles had not resumed.  She had five children already, but that is a small number in Dinka land.  She wanted more.  My estimated age was that she was in her early 30’s.  I asked about the spacing between her other children to see if she had difficulty conceiving before.  The answer was no.  There was the usual 2-3 year spacing between the children.  I asked Mary to ask her if she was continuing to meet with her husband.  Mary balked.  “She is not having her menses, so why does it matter?”

“Just ask.”  It is strange to me that a people characterized by such promiscuity before marriage show such little interest in sexual relations with their spouses after marriage.  I thought it likely that this woman could be waiting on the resumption of menstruation before she started meeting with her husband.  That was not the case, however.  She and her husband had continued to have relations. 

            Mary examined the patient, but she wanted me to feel the abdomen.  Her spleen was enlarged (though she did not give much of a history for malaria), she had a bit of fullness in the right lower quadrant (around the appendix), and I thought her uterus was enlarged.  I did an ultrasound and there was a gravid (pregnant) uterus.  The heart was beating fine and then he did a somersault as we were watching. 

            I do not have a good explanation for her prolonged amenorrhea.  My best guess would be total body depletion, though she did not appear to be significantly anemic.  The woman was not as excited as I anticipated.  I guess for two years she kept thinking she must be pregnant with nothing to show over time.  “When will I deliver?”  My guess was that she was 2-3 months pregnant, so I estimated she would deliver in 6-7 months.  I presume when she starts showing she will be more excited.  But it was fun to diagnose pregnancy in that manner and it is rare but always enjoyable to get one over on Mary Agum. 

19 December 2011 

One of the drugs I always hated to use in America was Prednisone.  I used it a fair amount, but I always hated it.  It is associated with huge side effects, particularly when used for prolonged periods of time, and there were some rare but disastrous side effects that could occur with even a short course of treatment.  There is aseptic necrosis of the femoral head, the problem that ended Bo Jackson’s career.  And there is an even rarer but more disastrous one.  If someone with an undiagnosed lymphoma receives steroids, oral or IV (but not inhaled or topical), it can induce a remission.  That sounds good, but the problem is that the remission will not last and when the lymphoma returns, it will be relapsed and much more difficult to treat. 

            The man I described recently (14 Dec) with the huge, hard spleen probably has lymphoma.  If it is Hodgkin’s Disease, which it could be, his chances of cure in the US are high, but we will never find out.  There is virtually no chance he could make it to Kenya to receive chemotherapy, much less the US.  But just because we cannot cure him does not mean we give up on him.  We will seek to do all within our power to make his life more comfortable.  Initially he was dehydrated, but we gave him fluids and that probably saved his life, at least for the time being.  He has probably 15-20 pounds of spleen lying on the splenic flexure of his colon; it is not surprising, therefore, that he is very constipated.  We started him on Ducolax and gave him an enema.  He feels much better and has some appetite.  Then I started thinking about that phobia of mine.  What if we give him high dose steroids and induce remission?  I am sure it will not last, but if we can get him a few good months, it will be worthwhile.  We started them yesterday and the spleen is somewhat smaller today, though certainly nothing dramatic.  He does feel much better and he appreciates our efforts, even though he knows they will fall short of our ultimate goal of curing him.

            We are called to be about kingdom work: transferring our indebtedness to God into works for people.  All of our work will have limited success.  If this hospital surpasses all our dreams, it will still be imperfect, not be worthy of heaven.  God calls us to serve Him, even though He knows our service will be imperfect, and He receives our work graciously.  “Well done, good and faithful slave.  You were faithful with a few things; I will put you in charge of many things; enter into the joy of your Master” (Matt 25:21).  I am glad my efforts will be received graciously.  I am encouraged by His grace to strive all the more to glorify Him.  And the Dinka people receive our best, though imperfect, with great appreciation as well. 

20 December 2011 

This was bigger than Christmas.  Today in Atiaba, Hope and Resurrection Secondary School (HRS) graduated its first class. I do not know when the dream started.  The school opened for classes in Mar 2008.  South Sudan follows the East African system for nomenclature: Senior form 1, Senior form 2, etc.  They enrolled 63 students in Senior form 1.  Twenty-three students completed Senior form 3.  Sixteen graduated today.  I believe 3 or 4 may be able to graduate later.  Of those original 63, 4 were girls.  Four girls graduated today.  That is a monumental achievement in South Sudan.  Several months ago I told the story of Debora Nyanawut.  She is the leader of those girls.  There were plenty of tough times for them.  There was a time when they feared that the boys from the cattle camp would rape them and take them for their wives.  Things got much easier for them when the school provided a tent with room for two cots on which four girls slept.  They actually had time to study and they were not in fear of unwanted advances.  And each of their parents agreed to put off marriage for the girls until they completed their education.  The high attrition can be attributed to many factors.  Though Hope for Humanity supplied the majority of the funds for the school, there were still school fees the students had to raise, and many found that impossible.  There were many times of instability in those four years, and some dropped out or transferred out of a justified fear for their lives.  Debora’s brother Nelson had to leave for some time, but came back to Atiaba when Rumbek Secondary School closed.  Others found the academics too challenging and gave up or repeated grades. 

             The ceremonies were scheduled to begin at 10 am, but Cleous, the deputy head master, said it was Sudanese time, so I did not feel bad about finishing rounds prior to departing.  Also, Chief Sawat and Balang, the payam administrator, sent word early in the morning that they wanted to ride up with us.  Between gathering up those from the hospital who wanted to ride and waiting for Sawat (Balang was fairly prompt), we were closer to 10:30 when we left Akot.  I was not in a panic.  When we drove in to the school, we were the first car and there were maybe two dozen people there.  I was not surprised.  At about 11:15 there was some movement to suggest that we might begin.  I was asked to sit up front.  That did not surprise me.  I was speaking and I am a kawaja.  I sat beside Sawat.  I was disappointed at the crowd.  There were probably 70 chairs around and less than half were filled.  I expressed my disappointment to Rose who assured me that there would be no empty chairs by the time the program really got into gear.  She was right.  We had talks from the various faculty members and some representatives of the PTA.  Chief Sawat talked about how he helped make sure the school as in Atiaba rather than Dhiaukuei.  In the midst of these talks, another LandCruiser roared in and everything came to a complete halt.  The guests of honor had arrived: the director general of education for the Lakes State, MP Daniel Gumwel, and a few other notables.  I would have been perfectly happy to give up my seat, but I found myself instead in the midst of their party.  Indeed, there was some shuffling of chairs and I found myself in the very middle of the head table next to the guest of honor.  I knew that any minute someone would approach me about giving up my chair and make me go lower in front of everyone (Luke 14:7-11), but fortunately that did not occur.  My other fear was that I would fall asleep in front of everyone, but that did not occur either. 

            I was in the latter half of the speakers, though the last two speeches were from our invited dignitaries.  I read a letter from a student of Christ’s Church, the home church of Jennifer and Darryl Ernst, the co-founders of HRS and then one from the Ernst’s.  The letters, particularly the latter, were received well.  In my address, I compared the students to our founding fathers.  I told them that they would transform their society and gave them examples of how things would change by the time they were parents seeing their children graduate.  When I finished, one of the town’s people in the now overcrowded general admission section started up a song.  Mary Agum motioned that he was singing for me.  I do not know, but I took it as a compliment.  The MP and the director general of education gave their talks, and then two students were appointed to speak.  Angellina conveyed her thanks to Hope for Humanity, the Ernst’s, the teachers, her parents.  The male speaker was Marial Akec.  I enjoyed his message, but I was really moved when as an act of tribute and respect, he knelt before the teachers, thanking them for giving of themselves to insure they had a quality education. 

The diplomas were handed out.  The director general of education was to actually give the diploma to each student.  All the dignitaries, including me, stood, shook hands with and congratulated each student.  Then the students all knelt down before the dignitaries.  Then it was over, except for the eating and pictures and celebrating.  Some traditional dances put on by the students from the three lower classes were part of the celebration.  The first class of HRS had graduated, and they were with the first class of graduates in the new nation of South Sudan.  The celebration had been intense and appropriate.  It was a great day.             

 

21 December 2011 

After the graduation, the girls who were living on the school grounds needed help moving home.  Debora Nynawut, Maria Adut, and Mary Agam lived in adjacent villages (Agam lives in Karic; Nyanawut and Adut live in Adol).  Think about this.  Here are three girls in their late teens who have been living away from home for 9 months plus their families who were at the graduation ceremony.  And they are taking their beds.  In America, we are talking moderate size U-Haul.  We loaded it all in the LandCruiser with no difficulty.  In fact, Gabriel Makol, an uncle of Nynawut and a good friend of mine, also needed for us to take his bicycle that was not working, and Nynawut’s father Mayom did not want to share the front seat, so everyone else had to be in the back and we still did it without problems.  Actually, several of the family members had ridden either their bicycles or motorbikes to the graduation, so there were only 6 in the back.  Still, they were transporting all that they had back home and it was easy.

            We dropped Agam off at her home in Karic.  That took out 1 bed and mattress, a table, and a chest.  Adol and Karic are almost joined, so we easily proceeded to Adol and unloaded the remainder of the furnishings at Nynawut’s father’s tukul.  All that was left was Maria and her small suitcase, which we dropped off at a tukul that was fairly close.  Maria is to complete a marriage to John Malok, the half-brother of Nyanawut. 

            Nynawut is interested in medicine.  She graduated high in her class and has significant drive, so I think she has the ability to move forward.  I had suggested to her earlier that she consider coming to the hospital and working, following me in the clinic, working with the nurses, etc, so that she can get a feel for what medicine is really like and if she really wants to pursue it.  We sat in a circle: Maria, Nynawut, the father, Gabriel Makol (uncle), John Malok (brother and future husband), and me.  I asked the girls about how the final session of the national exams went, but Maria said, “I think you need to tell them your plans for Nynawut.”  Wisely, this had been their plans all along, but I had been oblivious.  I started to speak through the girls and they directed with their eyes to John Malok, who is an excellent English speaker and much the more appropriate for me to use.  “Nynawut has expressed an interest in medicine.  I believe she has the mind to be able to pursue it well.  But I think it would be wise for her to move to the hospital.  We could give her a tent and board.  Her salary would be small, but she could work with me or Dr. Rossi or the nurses, plus with others like Rose to get a feel for how a hospital is run.  The advantages to her would be that she could be sure she wanted to pursue medicine, decide if being a doctor or nurse is what she wants, and get some practical experience that will aid her later.”  I said the whole spiel to John who then translated it for his father and uncle.  They discussed the plan between the three of them; neither girl made a comment.  In the end they decided they would hold an extended family gathering to further consider this move, and I was instructed when to return to make this presentation again.  It sounds intense, but there was plenty of goodwill in the mix. 

            I had promised Charles Chol (Gabriel Amat’s brother) and a few of his friends that I would stop by the school on my way back to Akot and pick them.  But the process had taken longer than expected and the designated riders were gone.  However, Angellina Lella was moving her bed to Elizabeth Yar’s home where they would continue to be roommates for the present.  It was close by, so I grabbed one end of the bed and we walked there.  By the time I returned, the male dancers were piling into the car to ride back to Akot.  I have had the car packed with women as part of a wedding.  They always sing, often about God.  The men sang as well, with much greater volume, though nice blending, but their songs, as much as I could understand, were about women and cows, two of their favorite subjects.  It was sundown when I dropped them in the market of Akot. 

           

22 December 2011 

Leno Marial is a randit, a big man in the Akot community.  He is an entrepreneur.  He is a farmer, a trader, a business man.  Little goes on in the Akot community or the western part of the Lakes State without Leno knowing about it and often contributing.  He is a Christian, very actively involved in the Malual SDA church, the one pastored by Paul Mayol.  He is also big.  If he were younger, I would try to recruit him to play tight end for Clemson.  Leno came to the hospital last week wanting to host a celebration for my return.  I have just come back from that celebration. 

            Like all gatherings in South Sudan, there was a bit of drama.  Leno came by the hospital to instruct us to be there at 3 pm, and to request that Rose could get off early and come to his place at noon.  I gave my permission, but at about 3 Rose was still in the hospital, just setting off.  Rose is the big woman in Akot, though for her, that means more work than honor.  There is hardly a wedding celebration, a funeral, a holiday feast, or any other gathering in Akot that does not have Rose directing the affair.  I am sure it gets old at times, but she does seem to enjoy it, and she would not think about missing this one.  With Rose’s departure at 3, I decided 5 was a better time to leave.  I had just completed some tasks and was heading for the truck when Mary Agum called out to me that she had been sent by Leno to bring me.  I was also to pick Isaac Marial and Balang in the market.  Balang is the payam administrator and one of AMM’s best friends in the area.  He knows what is happening in the community and he makes sure that AMM is treated appropriately.  He also maintains a good relationship with the SPLA commander in the area, so he is the perfect one for us to turn to when we have problems with the soldiers.  I was glad to hear that he was coming and was glad to give him a ride.  As we started out, Mary got into the back, but Rossi and I forced her to sit upfront.  She was anticipating what was going to happen.  When we picked Balang, about 15 other riders joined us.  It was not a question of rudeness or a show of force, but Balang sat in the front seat.  He knew he belonged there.  John Terakuc is the assistant payam administrator.  He was among the many getting into the truck, but he went straight to the back.  No one was surprised to see Balang in the front or Mary in the back.  That is the way it works in Dinka land and the only ones it bothers are westerners.  Dinkas have a high regard for rank and protocol.  When Mary got into the back, she was observing that tradition.  Had I strongly objected, they would have given way.  It still bothers me, but much less than before. 

            Our group constituted about half the male population at the feast.  The bulk of the police force was there.  They had gathered early and were conducting their daily affairs at Leno’s.  There was Leno’s family.  They have had many illnesses in their family requiring hospitalization, so I know them well.  They all look like their daddy, and I suspect Clemson would do well to recruit them.  There were the women, primarily Leno’s wife (who is 2-3 inches taller than me), Rose and Mary Agum.  Rossi, Isaac Marial, and I sat with Balang and Terakuc.  Balang started talking about the meeting taking place between Salva Kiir and the US, UK, and Norwegian representatives who had an interest in helping South Sudan.  He was well informed, and his English is fairly good.  He and Terakuc started telling me about the rebel forces from Sudan who seek to foment unrest.  He also seemed to understand the assurances that the US was seeking to get from Salva Kiir with respect to transparency of operations.

            Supper was served with the same quintet, but like at all good meals, the conversation died as we attacked the food.  Afterwards we gathered in a large circle.  I think there were about 50 men in that circle.  Leno spoke first, then the highest ranking policeman, then Balang.  All were expressing their appreciation for the work of the hospital, for not leaving during times of unrest, for helping in the community.  It was nice.  I like to think my motivation comes from on high, but it does feel good to be appreciated. 

23 December 2011 

At 9:30 today I received an invitation to a celebration for the students finishing the year at Abundant Life School.  If Hope and Resurrection Secondary (HRS) is my first school, Abundant Life and Living Waters Primary Schools are tied for second place in my heart.  I know all the teachers and many of the students at both schools.  The schools are supported through Akot Christian Ministries, and several friends of mine play pivotal roles in that organization.  In the invitation, the starting time given was 8 am, 1.5 hours before I received the invitation.  This is another example among hundreds where the Dinkas set ridiculously early times for beginning with no thought that anyone would take them as having meaning.  According to the invitation, the ceremony was to start at 8 and end at 2 pm.  When I did arrive at 4, the ceremony was in progress, but all indications were that it had just started.  I tried to sit towards the back and again was moved forward.  I was again among the dignitaries, though this time in the second row.  (Maybe if I had come at 8 am I would have been in the first row).  Samuel Mathiang was speaking and congratulating the students.  He had something nice to say about the hospital once I arrived.  So did Gabriel Maper, the next speaker, and I was instructed to stand and wave to the crowd who generously gave applause. 

            Then we got down to business.  They were handing out the certificates of completion, starting at Primary form 1 and continuing through form 4, the highest level currently offered at Abundant Life School.  I am not one of these Pollyanna-types who always wants to make everyone feel good about themselves.  I think competition is healthy.  I have participated on and coached losing teams and whatever tears come are quickly forgotten if the parents do not make too big of a deal about it.  But I was disturbed by the proceedings.  The top student in the class was announced and given appropriate recognition.  The same thing occurred for the second.  “Fine,” I thought, “they both worked hard and deserve some praise and it might motivate the other students to strive for that position.”  But that was not the end.  They had each student come forward to receive his certificate in his order class rank.  There was significant applause for the first 2-3 students, polite clapping for the remainder of the top 10, and then applause was forbidden for the rest.  They announced how many students were in the class, how many passed and how many failed before they started naming the students, but the failing students were still expected to come up front and obtain their certificate.  There was hooting for the student that finished last in his class.  Then they went to the next grade up until they came to the Primary form 4 students.  Out of twenty-five students, only 12 passed and there were 3 who sounded to be in limbo (I suppose they had work to complete before they would pass).  There were no girls in the first 10 slots and only 1 who passed.  Several of the girls that I know and like were in either the limbo or failing group.  I felt humiliated for them.  Many of the students were fighting tears.  Ironically, at the graduation for HRS, where class rank really means something and where the students were mature enough to handle this type of pressure, the graduates were announced in alphabetical order and no information was given as to who the top students were. 

            The Dinka society is tough.  If Dinkas were wimps, they probably would be extinct.  But I hope by this time next year, this public humiliation of young students ceases.  I will refuse to come again unless it changes. 

24 December 2011 

I was riding back from Atiaba when I picked up my friend Mayek Biljok and his roommate.  They were finishing their national exams: only one more left.  So they were headed back to Akot.  They needed to stop at Helena Ding’s house.  Helena is a good friend of Rose and she has become my friend as well.  She used to work at the hospital and will again if there is an opening.  Mayek and his friend had been staying at Helena’s house.  The friend is Helena’s nephew.  Mayek’s bike was broken, so he was looking for a place close to Atiaba to stay for the last month of the year and asked his friend.  The friend asked Helena and she said yes to both of them.  She gave them a tukul to share between them, a large bed (probably like mine, which is a ¾ double).  She also cooked for them and gave them heated water with which to bathe (she had to pump and fetch the water and then heat it).  And she charged them nothing.  As we were gathering their things, she served up cuin (ugali) made from dura (sorghum) and an okra and ground nut paste.  I thought she was serving up something for me and I started to object.  I did share some of the boys and it was good.  After the boys finished, the children ate the remains. 

            Helena and her family do well by Dinka standards, though measured objectively there is probably no one in America living on less than her.  She does have a bicycle, but no car.  Her tukuls are clean and dry and their land fertile, but she is not looking for a job to get out of the house; she could really use the $60-70/month we would pay her.  Yet her generosity puts me to shame.  The Dinkas are funny people.  They have lots of problems, but they are generous, and that is a great trait. 

25 December 2011 

Christmas celebration actually begins Christmas eve.  But for the last two years, the start of the Christmas celebration has been Gabriel Amat coming to me to find lighting for the church.  The midnight services we love in the US are valued here, but there are no lights to flip on.  We have some sockets that we wire together and string up in the church for that one night.  The power comes from the generator that we supply.  Being the expert electrician that I am not, we struggled with this simple procedure, but in the end succeeded.  Dr. Rossi and I were told that the ECS service would begin at 11 pm.  I had planned to go to the Baptist Center as well, for I heard they were meeting earlier in the evening, but later we were informed of the truth: they were gathering early, just as at the ECS, but the service really started after midnight.  We arrived at the ECS Cathedral of Akot (it bears that name because it was at one time a fine structure, though the Khartoum government burned it during the war) about 10:20 and everything was in full swing.  There were about 300 people outside the church, joining the ceremony through the windows because the inside could accommodate no more (and remember, these are Dinkas who crowd well).  One of the young boys led Dr. Rossi and me around to the side entrance and made some signals.  Soon women gave up their chairs for us (I hate it, but it is true) and he and I were led to the front dais.  All the ECS churches in the area had come with multiple representatives and each one had a time of leading chants (“Renderem” [youth of youths], “Remde Nhialic” [youth of God], etc to which you shout back “Yo”), songs, and prayer.  Each leader was seeking to prove himself the more charismatic.  Everyone was in high spirits.  Then there was a sermon to the congregation.  Gabriel Amat said it was from Matt 2:1-10, so I presume it was about the wise men, though in truth I had no clue.  It was already several hours past my bedtime and I was less attentive than usual.  About quarter to midnight, the leaders started consulting their watches.  They concluded we had 10 minutes to go, but Peter Mangar corrected them.  They looked at me and I agreed with Peter, though I really did not understand why precision in timing, usually utterly absent from the equation, was suddenly so important.  So right at midnight according to my watch the celebration began.  It was like being in a rock concert.  Everyone was dancing and singing, flashing their torches, and celebrating because Christ had been born.  The song lasted 15 minutes, but it was followed by another equally rousing song.  The joy was palpable.  After 45 minutes or so, they cleared the room, but invited all who desired to return for communion.  I really enjoy communion.  My church in Asheville celebrated every week, but I have never celebrated communion in Africa.  Tired as I was, I did not consider leaving.  Using broken glucose biscuits and some orange drink, the tie between the incarnation (Emmanuel, God with us in the flesh) and the propitiation (Redeemer, the One who paid our debt) was established for all.  Without Christmas, there can be no Easter; without Easter, Christmas is not a cause for celebration.  Bishop Isaac deposited the broken biscuits into our cupped hands and then one of the church ladies brought around the shot glasses of remembrance.  In typical Dinka fashion, those glasses were then washed on the spot and reused until all had been served.  I love having communion at Christmas.  I came away with a greater appreciation of the Dinka celebration of this holy day. 

26 December 2011 

On yet another trip to Atiaba, I had dropped the students off and was planning on a rapid return, but Marcelina, one of the teachers from Uganda, invited me to share lunch with them.  I do not like being a burden or taking food from those less fortunate, but I find that the people, instead of understanding my motives, feel insulted if I decline food.  Besides, the teachers are not really lacking.  Their lives are fairly comparable to ours.  It turns out that the cook for the staff has been on maternity leave.  Unlike Dinkas, the Ugandan men will cook, which is good, as there are about 8 men and only one woman on staff.  Noah made the beans and rice today.  It was excellent with very different flavor from our usual fare, making it doubly enjoyable. 

            Shortly after getting back on the road, I was flagged down by some women.  I assumed they wanted to go to Akot and I stopped.  “Lortio?” (Where are you going?”)

“Matagar” (Another name for Thon-Aduel, as is Madria).  It lies in the opposite direction to the one I was taking. 

“En alor Akot” (I am going to Akot).

Victoria became their spokesman.  “But we are going to Rumbek and there are no more matatus.  If you give us a ride to Matagar, we can catch a matatu from there.”

“En alor Akot.” 

“Dictor, you cannot leave us here.  Give us a ride to Karic.”  I am not very good at resisting the pleas of women and children.  Karic is only 7 kilometers away (Thon-Aduel another 2-3 kilometers).  I agreed to take them.  If I was handing out money, I could not have made them happier.  Instantly the truck was packed.  I knew the truth about what Victoria was saying.  Burdened with children and goods, many could never make the trip in time to have any hope of getting to Rumbek, and those who could make it would have been exhausted, whereas for me it was but a short trip.  As we got to Karic, I started to pull off.  “Dictor, why not to Matagar?”  I did not even try to argue.  I just wheeled back onto the road and took them to the great mahogany tree that serves as the town square and bus terminal in Thon-Aduel.  I pulled in and turned off the car.  There was no way the exchange would be rapid, though the people did hustle.  Of course, now I had an empty truck heading back to Akot.  Dinkas, more than nature, abhor a vacuum.  I was quickly full again, including several members of Poth’s family, friends I am always glad to help.  As I was driving away, I saw the people who rode with me running to catch a matatu.  They would be in Rumbek in an hour.  I am a sucker, but many times here I do not regret it.  “Tis the season.”

27 December 2011 

Several weeks ago I had talked with Nynawut about coming to work in the hospital, I had no idea of how much personal involvement I would have.  Today was the day for returning to face the family council and seek to persuade them that what I proposed for Nynawut was both safe and profitable for her.  Early in the day, however, I had a fortuitous conversation.  Gordon Mayom is back from Uganda.  He, Rose, Paul, and I sat down to discuss the school situation.  I have been concerned because of some things I have heard and what I witnessed recently, so I wanted to share my concerns with these leaders.  I mentioned that, with the graduation of Hope and Resurrection Secondary School (HRS), there would be a number of men and women who needed jobs and were more qualified than our current teachers, so they could have some leverage with which to motivate the current teachers to strive for excellence.  Rose mentioned that they were holding a position for a woman who would be the deputy head master of Living Waters Primary School.  Mary Agam came to mind.  Mary Agam is one of the four women graduates of HRS.  Maria and Angellina were completing marriages.  If Nynawut’s position was considered a go, then Mary Agam was the only one of the four with no direction.   She had expressed some interest in pursuing agriculture, but I thought it likely that she would take a definite position over a theoretical one.  I mentioned her to the group and they were excited.  She was the perfect candidate. 

            In the afternoon as I was heading towards the meeting, Gabriel Makol came up.  Gabriel is my close friend and he is the uncle to Nynawut.  He was coming to remind me, though I had remembered.  It was nice having his company as we went.  I was expecting something out of Dances with Wolves, with solemn ceremony and some traditional act, even if it was not a peace pipe.  Instead, we drove up to an empty tukul, or at least we thought it was at first.  Nynawut was inside and joined us a few minutes later.  I told her about Mary Agam.  She thought I was referring to Mary Agum, but when it was clarified, she thought it was a great idea.  They had been roommates for four years.  This would make things better.  We talked for a few minutes then drove into the market of Adol to round up everyone.  I stayed a bit in the fog as to what was happening.  Gabriel brought me to a place where I had some water, then soda, then tea in rapid succession.  Nelson Ding, Nynawut’s brother, came up.  Then Wun Nynawut (father of Nynawut) came up and we wandered over to a Lulu tree.  Nynawut told her father about the plans for Mary Agam (assuming Mary would be interested).  He was pleased.  I understood his concerns: I have a daughter.  But in the Dinka culture, a girl as old as Nynawut who was unattached was at risk of abduction.  Having the two of them together on the hospital compound made things much better for everyone.  The council itself had been almost entirely the same as last time.  John Malok and Maria were not there, but Nelson Ding and John Ater, a cousin, were.  The father did request that I transport them to Akot and back for the first week, which seemed a fairly reasonable request.  The last piece was to ask Mary Agam about the position.  She was thrilled.  Things appear to be shaping up. 

28 December 2011  A patient came in today with swelling over his lower abdomen and penis for a month from being hit by a basketball.  It is amazing the stories we derive to fool ourselves.  I knew full well that was not the case and asked directly about penile discharge and sexual partners.  Initially he denied any sexual contacts, but then he admitted to one in July.  His symptoms suggested gonorrhea (GC, the clap).  His exam showed no real swelling, but pain around the urethra.  GC is one of the few STD’s (sexually transmitted diseases) that causes more symptoms in the male.  But it is more dangerous for the female because of the risk for PID (pelvic inflammatory disease) that can cause scarring of the fallopian tubes, leading to sterility or ectopic (outside the uterus) pregnancies.  Therefore I told him we would treat him, but he needed to tell the girl that she has a serious infection that needs treatment. 

“But she is in Rumbek.”

“You will never travel to Rumbek again?”

“I cannot tell her.”

“You can have relations with her (politer version), but you can’t tell her that she has an infection that could make her unable to have children.”  I was mad and stormed out of the room to get the Ceftriaxone. 

Eventually it came out that he met with a prostitute in Rumbek.  Because of the high risk in that group we tested him for HIV.  Fortunately he was negative.  I told him that had the hooker been from Juba, the odds would be that he was infected, and that the odds of him contracting HIV in Rumbek are increasing every month.  He was worried sick as he waited for the test results.   I think we made an impression on him. I hope he will share it with others.  Sometimes a good scare is more valuable that exquisite logic.

29 December 2011 

Schizophrenia is a sad and bizarre affliction.  All illnesses of the brain are troubling, not only to the general public, but also to the medical profession.  Mental retardation is hard, particularly when the children grow up and can become dangerous because they have the mind of a two year old and the body of an adult.  Epilepsy scares everyone.  I always thought it was amusing that we always instruct parents to stay calm, whereas if you ever witness a seizure in an ER, the entire staff goes into an absolute panic, running and yelling and grabbing supplies as though if we do not control this seizure in the next 30 secs, horrible consequences will follow.  But schizophrenia, in many ways, is worse.  Often it seems to afflict those who are bright, usually manifesting itself in the late teens or early twenties.  The afflicted seem often to be so earnest in their speech, but what they say is so off the wall that the listener struggles against laughter.  And the problem is much worse for people who live in South Sudan. 

            We have a lady in our village named Ayen who is so afflicted.  She is also blind or close to it.  Rose remembers her in her lucid days; that was before my time.  She comes around regularly, seeking assistance from us.  Her current dilemma is that though she has not been meeting with any man, she has conceived two white girls within her womb and she wants us to take pictures so that she can send them to the governor and to Salva Kiir, thus curing her of her affliction.  When she comes, she is generally loud and appears to be angry, though she is generally not mad at me.  Even if she is, if I go and put my hand on her face and stand beside her, she will usually quiet down.  Today we gave her 10 pounds so that she could ride to Thon-Aduel and see the commissioner to start the process of identifying the miracle children and getting the word to Salva Kiir.  Most weeks we give her some sugar and powdered milk for tea.  We have some Chlorpromazine that might help her, but she has no family to administer the medications or even persuade her to come to the hospital for admittance for treatment.  But she does have Rose, to whom she looks for everything. 

            Doctors are known as healers.  I love hearing about someone who was sick and I helped; I hate it when I am confronted with medical problems I cannot help.  I would like to help this woman, but I do not think it will happen.  Still, I think we have the obligation to be compassionate towards her, to put up with her bizarre behavior, even to tolerate her unjustified abuse.  After all, God has put up with much more offensive behavior from me for a long time without losing His patience with me.  

30 December 2011

Psychiatrists tell us that depression is from chemical imbalances within the brain, altering our mood, disturbing our sleep, robbing our energy.  Though I am convinced that the alterations of serotonin and other hormones play a critical role, I believe situations also play a major part. 

            We were rounding today on an 8 year old boy with malaria.  He had completed his course of ACT and appeared to be improved.  His fever was down and he was no longer vomiting, but he was lethargic, lying around in bed all day, and he had no appetite.  He did not appear to be anemic.  I discharged him, thinking that he would do better in his own home, eating his own food.  We had moved on a couple of beds when Mary Agum mentioned that this child’s father was one of the two men killed last month by the Atuot.  Then it all made sense.  Malaria is a tough illness and many do feel lethargic for days or even weeks afterwards, becoming an orphan in South Sudan is even harder, more depressing.  

            Today in clinic, we saw Rebecca (see 11 Dec note) again.  She was vastly improved, both from a respiratory and a mood point of view.  I asked her if she continued to harbor any suicidal thoughts.  She thought for a minute.  “It is hard having a child like mine.”  Her eldest child appears to have full blown schizophrenia.  He wanders about, getting into mischief.  He is strong and potentially dangerous. 

            In the US, such tragedies are rare.  Two men getting shot down on a motorbike would make national news.  It is not rare in South Sudan.  A child with schizophrenia still weighs down a mother’s heart, but at least there are some decent medications and some in-patient facilities.  I still believe serotonin is a major ingredient in depression, but the tragedies of life make up part of the recipe, at least here in South Sudan.

31 December 2011 

I mentioned a few months ago the death of John Makur Akec, one of our most steady and faithful workers.  His wife approached me today asking a favor: she needed her tonpiny (ground nuts, peanuts) moved to the Akot Primary School.  The request made little sense to me, but I feel I should help his family as much as I can.  I asked how many and she said twelve bags, so I figured this was more than just providing some lunch for her children. 

            Akot Primary School was built about 40 years ago.  Forty years is a long time in South Sudan, and the buildings show the effects of the harsh climate.  Several have fallen down.  Moreover, when school is out (as it is now) the buildings are occupied by squatters, usually members of the SPLA, because there are no decent buildings in South Sudan that remain unoccupied for long.  How these things are negotiated is beyond me, but it had clearly been arranged that Makur’s wife could store her tonpiny there.  We loaded the tonpiny at tukul neighboring hers.  There were about 5 large bags and about the same number of moderate size bags.  The bags are huge, but tonpiny are fairly light so they can be moved around well despite their bulk.  We filled the pickup bed and drove over to the school.  The distance was nothing.  We started unloading the groundnuts.  The room to the left contained a hammock, a bed on the floor, and 3 large bags of groundnuts, so we put our bag beside the others.  Wrong.  That room was for living; the closet to the side was for the tonpiny.  It already contained bags shoulder high with just a small space to walk in.  I was initially signaled to a seat and I had a broken conversation, with my Dinka the closest to a bilingual speaker in the group.  But I realized that one young man and several women, some quite old were struggling to put the bags up.  I helped from below for a few minutes, but it was obvious that the major need was on high.  We hoisted and stacked bags about twice the height they had been.  In the end, we not only got Makur’s groundnuts into the storage, but also the other three bags.  All the bags were off the floor and the door would close.  Success.  How they would identify whose bag belonged to whom I could not fathom, but I was confident that they could.  And Makur’s widow had one less thing to worry about for the coming year.

1 January 2012

          Whereas the Christmas celebration for the region is always held in Akot, the New Year’s celebration varies.  Two years ago it was to be held in Akot, but the fighting between the cattle camp and SPLA broke out and the town was deserted.  Last year we were in Thon-Aduel.  This year the celebration was in Paloc.  Paloc is sort of like Dodge City: it is a trace of civilization on the frontier.  It is the one place where I have spent time in the cattle camp, and so I am told by those in the know that I have never really been to the cattle camp, because the community dampens the freedoms of the cattle keepers.  On the other hand, Paloc is much more isolated than most of the communities I know.  They often go months with no medical care unless the patient ventures over the rough journey to Akot.  Fortunately a new road has been cut from Karic to Paloc.  I had gone up the road a little bit, mainly to see what it was like, and I was curious to see the whole length, so I volunteered to take some of the ECS (Episcopal Church of Sudan) people there.  I had been in Karic the day before and found many already waiting for a ride to Karic, so I had little doubt that my truck would be full and that I would be asked to make more than one trip.  I was aiming for an 8 am departure time and we left Akot at 8:40, which was nothing short of miraculous.  We left behind at least as many as we took, and Jacob Majak was asking if I also planned to take the youth.  I told them all I would not be making another trip from Akot.  When we made the turn from the main road to the road to Paloc in Karic, people started swarming towards us as if our “money was coming unstole” (Brother Where Art Thou).  I committed at that point to a return trip because we had no room for any of them.  The road to Paloc is far from complete, but as it is, it is a great improvement over what we had.  From Karic to Paloc is about 20 kilometers.  It was quite an undertaking.  They cut a 30 foot wide path through brush and tree country.  The first 5-8 kilometers are very nice by South Sudanese standards, meaning it was like a decently maintained dirt road in the US.  I was in 4-5^th speed for all that portion.   The rest has not really been graded, so much of the time I was driving on the old road to Paloc.  Still, there were no horrible spots.  Of course this is the dry season, so we will not get the real challenge test for several months, but I feel at minimum Paloc will be much more accessible now than in the past.  Because of my promise to return, I unloaded the passengers and started back.  Two guys came with me.  Gabriel Mading was with me for his English skills, which is much better than my Dinka.  But I felt that the trip was straight forward and that we could use every slot to bring more to Paloc, but I was unable to convey that to Gabriel or the other passenger who had no positive function in the process.  I have learned not to demand my way unless it is truly necessary, so I let it slide.  As I anticipated, every slot and much more were needed, but my passengers had to be returned, so some who would have been helped were not. 

            I had made the decision not to spend the night in Paloc.  Generally speaking, when the option is mine, I choose my own bed.  Still, I expected that I would be involved in some of the festivities.  It was not to be.  When we arrived with the second load, there was a brief gathering in the church and a few songs sung.  Then we retired to some shade.  A Dinka lady brought some water in a pot, and I assumed it was for washing hands, so I scooped some and was letting my hands dry when another lady came with a basin.  Joseph Meen Kuotwel signaled to me that it was for washing my feet.  I declined.  I wear shoes.  My feet are not too dirty.  Besides, I have ugly toe nails.  What I did not realize is that the woman was going to wash my feet.  I felt like Peter (John 13:8).  She went ahead, however, and washed the feet of my companions.  I have heard of “foot-washing Baptists” all my life, but I had never witnessed it. She washed the feet and sandals for each man.  They obviously did not find it as remarkable as I did.  Then the pastor served everyone with orange juice, the remarkable thing of that being it was a man, not a woman.  We changed trees, going to the Abyei tree that had been the church before Samaritan’s Purse rebuilt the church burned by Khartoum.  In reality, we just sat there.  I had brought a papaya and it was cut and divided among as many as could share in it.  But mainly we sat.  Fortunately I had brought my Kindle, so I discretely retrieved it from the truck and started reading it.  It is not as though I can really do anything without notice anyway, but the Kindle did attract a lot of attention.  The only other entertainment was when the cattle keepers drove their cattle around us, singing to us about the wonders of the particular bull they were driving.  After a couple of hours, they brought food for the traveling companions and me.  I presume they brought some for the rest later, but we left shortly after the food was consumed.  Everyone sought a promise that I would return tomorrow.  I did not make it.  We shall see.  Two trips to Paloc in one weekend feels like enough.  

2 January 2012 

Yesterday Gabriel Amat asked, “Who will preach tomorrow?”  I quickly volunteered.  First of all, I knew he was looking to me to volunteer.  Second, I do love having the opportunity to expound on God’s word to His people.  And third, it gave me more of an excuse not to go back to Paloc.  I do like the town of Paloc and I am glad that the road is so much better that we can make the trip more easily, but it is still not an easy trip.  Even if I did make the trip, I could only bring back a handful, so I decided that my traveling to Paloc had temporarily come to an end.

            I feel that there are certain days that dictate their message.  Christmas is all about Emmanuel, God with us.  The day virtually demands that we consider the amazing humility of God, taking on flesh and dwelling among us.  I believe that New Years demands introspection: a time of reflecting on the year behind and looking forward to the year ahead.  Thus New Years becomes a division, an island if you will, between the year past and the year to come.  And that reminds me of the Great Day of the Lord, the Judgment Day.  It, too, will be the day of division.  The current era will end; the new will be ushered in.  The old world and Jerusalem will be consumed; the New Jerusalem will come in all her glory.  And there will be the division of the sheep and the goats.  So we read from Matthew 7:21-23 and 25:19-21.  Here again is division.  Everyone will hear one or the other.  Those who are in Christ will hear, “Well done, good and faithful slave; enter the joy of your Master,” whereas the rest will hear, “I never knew you.  Depart from Me you who practice lawlessness.”  How can we be certain?  We are to evaluate ourselves.  We are to “work out your salvation with fear and trembling” (Phil 2:12) and “make certain His calling and choosing you” (II Peter 1:10). 

            In II Timothy, Paul calls his protégé to evaluate himself with respect to his salvation.  I believe the two most critical issues to discern are if we have love and forgiveness.  There are many other things that should be true of Christians, but none more central than these two.  I told the congregation that one of the areas the Dinkas fail most is in forgiveness.  Revenge is not compatible with forgiveness.  And if there is no forgiveness, we will not be forgiven.  And if that characterizes our life, we will hear the dreadful words, “Depart from Me you who practice lawlessness.”  But if our lives are characterized by love and forgiveness, we can be reassured.   That is the way God wants us to live. 

3 January 2012  Today was crazy.  This is another staff holiday, so it looked like a disaster as the patients kept piling in.  I had talked with the students from Atiaba, particularly Nynawut and Mary Agam, about coming to get them and bring them to the hospital, but with the staff holiday and all, it was unclear what to do, and I had barely missed a vital connection two days earlier.  So I was very pleasantly surprised to see Nynawut, Mary Agam, and Michael at the clinic, ready to work.  They had decided I was confused and hopped a matatu to come to us.  It was a good thing, because it was a full day and we needed all the help we could get.  It was a good day for students who think they want to go into medicine, for there were many finding on the exams and interesting things for them to witness.  We had finally seen all the patients, given all the drugs, sewed up the lacerations, drained the abscesses and were sitting down for a late lunch when Roberto walked up.  Roberto is a fascinating Italian man who has been working in South Sudan since the start of Anyanya II (the second war of northern Sudan aggression, starting in 1983).  He was in Juba to celebrate the signing of the Comprehensive Peace Agreement on 9 Jan 2005.  He and a group of Italians were coming up from Kapoeta and wanted to break up the trip with us.  I invited them without counting the number.  With their two guarded escorts, there were 16.  A couple of them did take our offer to sleep on the ward, but most erected their pup tents and then settled in to the routine.  Shortly after the arrival of the Italians, it was time for me to take the students home.  Mayom, the father of Nynawut, is an appropriately concerned father and asked that the girls come home every evening for the first week, so I was fulfilling my agreed upon obligation .  When I reached Mayom’s tukul, I asked him about letting the girls spend tomorrow night at the hospital.  I would pick them in the morning and return them the next night.  After some discussion, this idea was nixed.  For the week, I would pick them in the morning and deliver them in evening.  It was a bit of a disappointment but understandable.  So I hopped into the pickup to leave, but when I attempted to start the car, nothing.  Not the first sound.  I lifted the hood and quickly discerned why.  Half the (-) battery cable was lying there.  The rest, along with the terminal, was gone.  Apparently the terminal had slipped off the post and bounced around.  It was also evident that the cable itself was corroded, for the end left was rusted.  A quick survey convinced me that I could do nothing with the truck and that it was safe, so I left it.  Nynawut arranged for Mary and me to hop a puota-puota to Thon-Aduel and from there to Akot.  I have ridden on the back of a motorcycle before.  There were three of us in Kenya, but the roads in Kenya are not nearly as rough as in Sudan.  Mary was in the middle riding side-saddle and I was behind her, my left hand on her arm and my right holding on to the tiny bar behind the seat.  She grabbed my leg and we were off.  I have been to Adol, Thon-Aduel, and Karic many times, but everyone looked at me as though I had just landed from a different planet.  I think it safe to say that kawajas do not often ride third on a puota-puota.  We stopped at a shop owned by a friend (Moses, brother to Nynawut).  While I was there, a policeman came up to me to ask if I was associated with another group.  There were four people, two men and two women, that I took to be Dinkas.  The soldier was upset because one of the women kissed a man in public.  The fact that the man was her husband did not matter.  They did not want to encourage that kind of thing in public.  Dinkas are an interesting society.  The motorbike driver, John Makur, is the brother of friends and so went to arrange for a puota-puota to Akot, but that did not work out, so he volunteered to drive us himself.  Riding on that puota-puota was like entering a deeper level of Dinka society.  Everyone waved at me and we stopped several times to explain what happened to the truck.  We took Mary to Karic and then John drove me back to Akot.  I bought him some fuel, so he was decently compensated, but I appreciated the spirit in which he put himself out for my sake. 

4 January 2012  

When I got back to the hospital, I asked Elijah if we had another battery cable somewhere.  He did not know of one, but he informed me of another problem.  The LandCruiser was on empty and the pump was not working.  This quickly became issue number one, because we needed that pump to fuel our one currently working vehicle and to keep our generator working (and thus have water).  I am not a particularly gifted mechanic, but the problem was obvious.  The black hose connecting the pump to the remainder of the hose was split.  But the crack stopped about 2/3’s of the way down, so I sawed off the bad and reconnected the hose.  Simple but critical.  I filled the LandCruiser.  Just as I was finishing, Roberto the Italian informed me that dinner was ready.  Our guests turned the table and served us a great meal with cream of mushroom soup, salad, fish, a far cry from our usual fare. We heard some stories from Roberto about his many adventures in South Sudan.  We talked about their homes, most of which were from northern Italy.  Dr. Rossi added some things about his years of living in Rome. 

            It was a perfect ending to a quirky but good day.  We did not invite the Italians in looking for a meal, but we were more than amply rewarded for our hospitality.  I think there is a parable there.  God calls us to do the right thing, including showing hospitality.  We do it because it pleases Him, but then He turns it into a blessing for us.  Maybe the next group will be Greeks. 

5 January 2012 

The celebration was ongoing at the BTC (Baptist Training Center), but Rose was not pleased.  She had decided to sit this one out.  She was going to be the guest, not the main organizer, but things were falling apart.  First of all, they did not have the cooking utensils needed and she had come to the hospital to procure some more.  Second, there was no firewood and she needed me to go get some for them.  So I drove her to the BTC, unloaded the utensils (and her bicycle), got Malith and went out to gather the firewood.   This is the season when the Dinkas start all the brush fires to burn the grasses.  One good thing that emerges from those fires is that the trees get scorched and dry out, leaving plenty of wood that burns easily.  We went to one such place and gathered sufficient wood for a week or two and headed back.  But Rose was still not pleased and decided that she needed some more utensils from her home and she needed to change from her guest apparel to her cooking outfit.  So I drove her.  Upon arrival, I noticed a woman holding her hand in a characteristic fashion.  She had been stung by the scorpion.  It had happened moments before and she was in significant pain.  I invited her to go to the hospital with me and get injected.  My plan was to drop off Rose and then take this lady to the hospital for a Lidocaine injection.  As we made our way to Akot, several boys ran after the truck.  I like giving the boys a ride, but they have gotten to the place they try to hop on while the vehicle is moving, so I have been forced to curtail the activity.  I was not listening to the boy attempting to run alongside us, but Rose did.  “Mamadier thaban” (My mother is sick).  We turned around and picked her.  We drove up to the tukul.  There was a crowd gathered to witness the festivities.  The woman was sort of grunt/moaning, but she had no fever and did not appear to be truly ill.  We manhandled her into the seat of the pickup.  We could get no history from anyone.   She had been well until that day.  The husband was in the market.  There had been no fever, no vomiting, no cough.  Now our plans changed.  We would drive to the market and pick the husband.  Rose would go on to the BTC using “number 11’s” (footing), and I would take the two ladies to the hospital.  The exam on the sick mother was unremarkable, but we admitted her for observation.  The lady with the scorpion sting was treated and was happily sent back to Malual. 

            Christmas and New Years is the chief holiday season of the year, both in America and in South Sudan.   It is a time of intense emotions.  There are more suicides during that period than any other.  Dinkas feel it as well.  I believe this mother (of 6) felt neglected and needed some attention from her husband.  Indeed, when he joined us, her groanings diminished.  She may have malaria or some other illness that we have not seen yet, but this seems classical for hysteria. The intense season brings out the best and worst in us all. 

6 January 2012 

In balance and contrast to the woman above, we have so many who do delay coming even in the face of significant symptoms.  In medicine, it is always nicer, cleaner, more rewarding when we can explain all the patient’s symptoms in terms of one disease process.  This more frequently occurs in the younger patients, but our population, overall, is young.  In South Sudan, many delay their coming to the clinic for various reasons: the distance seems prohibitive, they sought traditional remedies (i.e. the witch doctor), they have no one to watch the children, fear of kawajas or the unknown, their husband or father forbids them.  Today we had a nice young couple come.  Usually when I see a couple come in together, I get ready to treat for STD’s (sexually transmitted diseases).  We have a close to inviolable policy of only treating for STD’s when all parties are present, for we find that despite their oaths to the contrary, the remainder of the family circle never gets treated, so even the treatable STD’s are not eliminated.  But that was not what was happening.  The husband was just concerned about his wife and accompanied her to the clinic.  She had been ill for about 6 weeks with abdominal pain and poor appetite and then had gotten much more ill for about 5 days with fever and headache.  She was a particular challenge, because she spoke only Arabic, and Rose was in with Dr. Rossi. 

            It was not a regular day.  The staff was off for the holidays, but the patients did not recognize the break.  That made things more difficult for this couple, because they had never been to our hospital.  There was no one to register the patients, so they bring their books to me, but this couple did not know the ropes.  Rose was not on duty, but was forced into action by the patient numbers, and Rose is always willing to help.  She noticed that the couple had not given us their book and started looking out for them a bit.  When we had a lot of soldiers and their wives in the area, I learned some extremely rudimentary Arabic, but I had forgotten the simple commands to breathe and to question about pain.  But the patient was trying to be as cooperative as possible and we got through the exam fairly well.  Her chest and heart were fine, but she had a large, tender spleen about 3 cm below the left ribs and a round, tender, hard 3 cm mass in the right lower abdomen (in the area of the appendix). 

            Putting her history and physical together, I could not come up with one diagnosis, but it fit nicely into two.   The large tender spleen went together with acute worsening of symptoms to suggest recent onset malaria.  We have been out of ACT (artemisin combination therapy) for a while, but we have been using Fansidar followed by Doxycycline with good success for some time.  Indeed, my observations are far from controlled, but we have seen a lot of treatment failures and relapses with ACT, but I have not seen that with the Fansidar/Doxycycline combination.  I had mentioned our experience at the Ministry of Health meeting in Oct and in the December meeting, several groups were using it out of desperation because of the shortage of anti-malarials in the Lakes State.  The large, hard, tender mass in the right lower abdomen together with the six weeks of abdominal pain strongly suggests an amoebic cyst.  So I also put her on Flagyl.  I will see her back in a week to see how she has responded. 

7 January 2011 

One of the problems with holidays in a hospital is that illness does not take a vacation.  When I was on staff in American hospitals, holidays were divided.  If I worked Christmas, I got New Years off.  But as we do it here, the staff get days off with no days that they have to cover, and the balance falls upon us.  So again we have a load of patients and no one to help us, and the next holiday will be the same unless we make some alterations, which I am planning on doing. 

            I was busy seeing the patients in the out-patient area when Dr. Rossi called.  “There is a man shot in the leg on the wards and you need to come.”  There has been some more unrest in our area.  The supposed disarmament has been shown to be a farce.  Those in Akot say that they have been disarmed, but the ones in Aluakluak have not.  However, some Dinka Agaar from this area stole cattle and killed two guards from the Dinka Atuot recently, so the disarmament appears to have fallen equally short on both sides of this traditional tribal disagreement.  The man who was shot today may have been done in retaliation, but in fact the man was a Darfurian.  Reportedly, he was driving through and gun men shouted for his to stop.  When he tried to drive on, they shot him twice in the legs.  One of the shots appears to have done little damage, but the other went through his femur.  We say, “Dry as a bone,” but in fact bones are very vascular.  A femur fracture in an adult usually bleeds two units of blood into the muscle.  This man had lost a lot more than that.  He was shot two hours before arriving at our hospital, but there was more blood on the floor than in the bloodiest delivery I have attended.  He also had at least two liters of blood in his thigh.  I was trying to keep my cool as I scurried about trying to set up an IV.  He was in the darkest corner of our ward, lying on the floor.  He was a big man, well over 200 pounds.  We lifted him onto a gurney and I got a bulb from another socket to try to find a vein.  The man was in terrible pain and was thrashing about.  I put on the tourniquet and saw nothing.  I needed a central line set up, but we do not have any.  I thought I could see the “anesthesiologist’s vein,” running over the wrist below the thumb, and it looked like the catheter should be in, but there was no blood return.  I went more proximal to the antecubital fossa (where most blood drawing takes place), but again I was unsuccessful.  By this time, the man had ceased fighting me and started gasping.  He died moments later.  If I had gotten a line in him, it would have put off the inevitable, but it would not have saved his life.  We needed central lines, a blood bank, an operating theatre, and maybe the outcome would have been different. 

            After his death, I went back to the clinic where the patients had continued to accumulate in my absence.  For the next 4-5 hours, I was working through the patients who seemed to double each time I finished one.  By mid-afternoon, it had slowed down to a slow trickle and I ate some lunch.  That was when I noticed that no one was in the ward.  An open ward is typically not a big deal in Dinka land.  Privacy with regard to dressing or having your disease discussed is not a luxury most expect.  But having a dead body on the ward was beyond Dinka tolerance.  Part of it is understandable.  A dead body in the hospital in the US makes everyone anxious until it is taken, even though it is closed away from view, so one lying on one of the beds in the open ward is a bit much.  I also it has to do with their regard for the body.  It is like the Greeks’ concern.  Think of the Iliad, when Achilles defiled the body of Hector.  The ward is again somewhat crowded, but not one soul was in the hospital while the corpse lay there.  As the afternoon was wearing on and we were getting no instruction from the police, Elijah and I decided to ride in and stir the pot a bit.  As Elijah had predicted, they felt that they had done what they needed to do and the body was our concern.  They gave us the option of driving to Rumbek.  I respectfully declined.  We went to the payam administrator, Balang.  Balang has a much sense as anyone I have met in the South Sudan government and he is a friend of our hospital, so I was glad to have him direct us.  But he was trying to contact the county commissioner, who ultimately had jurisdiction, so we returned to the hospital to await word.  We decided to move the body to the generator room.  That removed it from the ward.  Elijah even got the people laughing by telling them that he was taking the body off the compound to leave it for the hyenas.  Within an hour, the police did come and instruct us to take the body to Thon-Aduel.  Elijah volunteered to go, as I was admitting a child with malaria and convulsion and was struggling to start the IV.  He started out in the pickup, but before leaving Akot, there were some disturbing sounds emanating from the R front wheel, so he stopped and walked back to the hospital and got the LandCruiser.  Then he drove the LandCruiser with the soldiers and the body to Thon-Aduel, but there the commissioner, instead of thanking Elijah for his help, commanded him to either take the body to Rumbek or return it to Akot.  In the end, the body spent the night and part of the next day in the generator room.

8 January 2012 

Because of the sound emanating from the R front tire, I cancelled the trip to Rumbek.  I needed to take the pickup because we were low in fuel.  But Samuel Maker, one of the teachers at Abundant Life School, is also working with us, maintaining the vehicles.  He looked under the car, found a rock wedged into a bad place, pulled it out and the horrible sound went away.  He pronounced the vehicle fit to travel and we were in business again.  I quickly gathered up the troops and we were on the road again.  Rose had considered not going because of the celebration at Living Waters School, but she had pressing business and so went ahead.  We arrived at 11:10.  I went straight in, found that the money had made it to the account, and then stood in line for 2 hours.  But shortly after 1 o’clock, I was headed back to the market and the baby (our money pouch) was full.  I parked in the usual slot, but no one was there.  I may be one of three people in all South Sudan who does not carry a phone, but I get so sick of not having network that it is not worth it to me.  Anyway, I had an idea that I knew where they might be.  We never exchange money at the bank; their exchange rate is far lower than what we find in the market.  But that does put a burden on us to find the best exchange.  However, between Isaac Marial and Rose, we usually can find as good a rate as is available.  We exchanged the money, had lunch with some friends, and then separated to get the purchasing done.  My duty was to get the diesel fuel and some parts for Lazarus, the old truck resurrected by Samuel Maker.  Virtually the only place for parts in Rumbek is owned by some Ugandans.  They are honest and reasonable.  I came by last week and asked them for the parts.  We are replacing some gear wheels that form the interaction between the drive shaft to the left rear wheel.  They had one, but we need two (the parts are identical).  So I left Jacob to supervise the filling of the drums and I went to the parts store.  They had forgotten about me, but they were sure they could find the other part.  About 1.5 hours later, they were still convinced they would find the part, but I told them I would have to get it next week.  I did get a number to call to remind them.  I walked back and settled the account for the fuel.  The Somalis there, Mohammed and Adam, were grateful for our patronage and gave us a small discount.  I drove back to the Bright Shoppe and we loaded the truck and left.  Of course, as usual, there were far more who wanted to ride than there were places for them, but we sorted it out and accommodated most of them.  We arrived back in Akot after sunset.  Instead of going to unload the truck, we drove directly to Malual to drop off Rose.  The celebration for Living Waters School was still in progress.  Paul met us and ushered us over.  I was able to gather some information about the day.  It went well and the turnout was more than anticipated.  All were pleased.  Afterwards Abraham Mangar asked me to deliver his wife and small child to their tukul in Mayom.  That is a tough declination.  Try it.  “I am so bushed that I cannot drive an extra fifteen minutes to save your wife from walking and carrying her small child in the dark for an hour.”  I did not try.  And we had others who also benefitted from the journey.  I pulled up into Peter Makoi’s tukul (hers was a short walk from there) and all the children greeted me as though I was a returning hero.  I was glad I had not declined.  The day ended well, and we accomplished most of the tasks.  It is hard to ask for better than that. 

9 January 2012 

Jacob Majak handed me an invitation to the Mayom Primary School celebration this morning.  I was less than thrilled.  To say I was not a party animal in my youth is to cut the line pretty thin.  One year, when I was in medical school, my father made a small speech at our New Year’s dinner.  “We had a good year.  We made some money.  Clarke had a date…”  But my affinity for parties, especially those that keep me out late at night, has dropped considerably.  This was the fourth celebration in five days.  I had contrived to miss the Akot Primary School celebration while dealing with the dead body.  Isaac Marial had stayed up to 5 am dancing that night.  Mayom would probably try to outdo Akot.  There were some requests during the day for the loan of a generator, etc, but since we had still not unloaded the pickup, we could not accommodate them.  Finally we finished clinic and unloaded the truck.  I was resting when Rose called me to go to the school.  Gordon Mayom and Mary Agum accompanied us, and we picked Chief Sawat and Balang, the payam administrator, in the village and proceeded to the school.  I had envisioned how big a role I might play and had brought my Kindle along.  We arrived after the first class had been announced.  I tried to sit in the back, but I was ushered to the front between Sawat and Balang.  As in the other celebrations, the students were called in order of their class rank.  The top 10 were applauded and shook hands with the dignitaries, including me, and the rest were called and applauded as a group.  The lowest still got hooted.  After the second class, I started reading The Pickwick Papers (Dickens) after the first 10.  That is probably why I was oblivious to what happened.  The guys from the cattle camp arrived a bit early.  They were doing their running, strutting, chanting ritual which was a bit out of place, but of little consequence really.  But some of those finishing primary 7 and 8 decided that this intrusion was an affront to their dignity.  I heard a scuffle.  Then I heard a gunshot and everyone was running.  Not knowing whether to run towards or away, I kept my seat.  About 10 minutes later, everyone was returning to their seats.  I asked Balang what had happened.  He confirmed that the shot was a policeman firing into the air to separate the combatants.  Things appeared to be calming down nicely and everyone had just about returned to their seats when a newer, rawer commotion took place.  To the best of my reckoning, the cattle camp guys had recruited allies and were ready for a knock out in round two.  Suddenly everyone was ready to depart.  A few of the teachers I know were going up to the boys and stopping them.  I was impressed.  Most were fleeing.  So did we, though it was an orderly retreat.  I arrived home with time enough to exercise.  I know many people were gravely disappointed at the premature termination of the festivities; I was just not one of them. 

10 January 2012  We admitted a woman with AIDS some days ago.  Whether she had been previously diagnosed or not was not clear, but I was convinced she was positive for HIV before the test came back.  Her child had already died of diarrhea and wasting, and she was severely wasted herself.  She came in with diarrhea and prostration, a common complaint among those with AIDS.  She had crackles in her chest suggestive of PCP (Pneumocystis carinii pneumonia) and she had a large mass in the left upper quadrant of her abdomen, but it was ill defined.  We put her in the hospital, confirmed the diagnosis, and started her on Septrim.  The next day, her breathing was improved, her cough was less, but her liver was 3 cm below her right ribs and very tender.  Because she has AIDS, having multiple infectious diseases is not difficult to envision, and even though she was spiking no fever, I suspected an amoebic abscess.  We started her on Flagyl, but the combination of Septrim and Flagyl proved too much and she became very nauseated, so we stopped Flagyl.  Finally on rounds yesterday the liver was slightly larger, but less tender, but the mass in the left upper quadrant was more clearly defined.  It was a huge spleen.  The large liver and spleen, the nausea and diarrhea made more sense.  She had malaria. 

            Since AIDS and malaria are both common in Africa, there are significant data stores concerning the two.  Unlike so many infectious diseases, malaria does not usually cause significantly more problems for AIDS patients.  This woman’s severe wasting made her more vulnerable, but she did not have fevers and she showed no signs of brain involvement.  We started her on IV Quinine and the results were good.  The nausea quickly subsided, which is notable because Quinine itself can cause nausea.  The liver and spleen were smaller.  She even ate something yesterday and slept last night.  I think she will respond well.  Her ultimate prognosis is bad, but her immediate is good.  I believe we can help her.  I think she will recover from the malaria. 

11 January 2012 

Hope and Resurrection Secondary School (HRSS) graduated 19 this year.  The initial enrollment was 63, and the dropout rate was even worse than the numbers suggest because I know of at least 2 of the 19 who transferred into the class later on.  There are many explanations for the failure to graduate for such a large number.  Some have been held back.  Many had to skip a year because of family obligations.  One of the four girls initially enrolled got pregnant (she was already married) delaying her education.  Probably the majority did not have the support of family to complete their education.  The point is that achieving a high school education in South Sudan is difficult.  

            These last few days, I have felt more like a job placement specialist than a doctor.  Before she graduated, I spoke to Deborah Nyanawut about working in the hospital.  She has an interest in medicine and I believe has the aptitude.  She in turn spoke to Michael Marial, another one of the top graduates at HRSS who also is interested in medicine, and we are trying to find a slot for him.  I matched up Mary Agam, another graduate, with Paul Mayol Kuot, the director of Living Waters and Abundant Life Primary Schools because they were looking for an educated woman to be the deputy head master of one of the schools.  I also am trying to help Abraham Maker Ding apply for a teaching position at the school.  I am trying to help Nelson Ding Mayom get some help to pursue his dream of engineering, and I hope Joseph Mayek Biljok will be able to go to nursing school in Rumbek.  My reason for cataloging this is to point out two things: 1) a milestone in education is really just a stepping stone in life, and 2) no one makes it on their own.  I greatly appreciate the work that Jennifer and Darryl Ernst, the founders of HRSS, have done in reaching this milestone, but others are needed to help worthy students find their way.  University education in East Africa is a bargain compared to the US, but still far beyond the capacity of most South Sudanese.  Regarding #2, I was glad to hear that there will be a movie about Jackie Robinson and that Branch Richey, the owner of the Brooklyn Dodgers who signed Robinson and took the heat, will get some recognition.  The students at HRSS are brave and industrious, but they need Branch Richey’s to open the door for them if they are going to help South Sudan the way we hope.  And from what I can see, the students seem very greatly appreciated what the Ernst did and will feel the same for any help they get in the future. 

12 January 2012 

As mentioned above, we have some students just graduated from secondary school working in our hospital.  I have always fancied myself a teacher and enjoyed that role during my decade in academic medicine.  Therefore I find myself too often waxing eloquently at the students as we make rounds. 

            We had two patients recently admitted that speak volumes to our limitations.  The first was a woman in her second pregnancy with symptoms of malaria.  We admitted her to the hospital, started her on ACT (artemisin combination therapy) and put her on bed rest.  The second was a three year old sick for two days with high fevers.  He came to us in the afternoon.  He was prostrate, febrile, with a spleen 4 cm below the left ribs and liver 6 cm below the right ribs.  The diagnosis of malaria was obvious and we sent him to the hospital for IV Quinine.  Despite our appropriate therapy delivered as timely as possible, the outcomes were not good.  The woman went on to “complete the abortion.”  She bled for a couple of days before passing what was almost unmistakably the dead child.  And the 3 year old died three hours after receiving the IV Quinine and fluids. 

            Medicine is a humbling art.  There are patients for whom we are late in making the diagnosis and may miss appropriate treatment who nonetheless recover well.  And there are those who we treat correctly who die despite our interventions.  The motto of Tenwek hospital is, “We treat; Jesus heals.”  It is an appropriate motto.  And this is a good lesson for those considering medicine to learn at this point.  We are fallible and limited, but if we humbly approach our calling, God will use us to do much good. 

13 January 2012 

There is an Andy Griffin episode where Barney dabbles in real estate and has three or four homes lined up to sell, but one fails and all the deals collapse.  I felt like that episode was happening today.  Deborah Nyanawut has expressed an interest in medicine and I want her to work in our hospital.  She very much wants the same.  I feel that Deborah and China Paul (a rising senior form 3 [junior] student) are the two young people in this area with the most potential to help their country and I want to see her succeed.  Then things just seemed to come together.  Mary Agam, her best friend, could live with her a take a job at Living Waters School.  Michael Marial, her brother Nelson’s best friend, has also been coming to the hospital to participate in this opportunity to see what medicine is like, learn important skills, gain valuable knowledge.  We had a good week, though I had to pick them every morning and return them every evening.  Mayom, the father, set that condition and we accepted.  But it cannot persist in that manner. 

            This evening Mayom and Nelson met to discuss Deborah.  They decided against letting her come work and live in Akot.  The given reason was insecurity: Akot is near the edge of the Agaar and Atuot territories.  Though both are Dinka sub-tribes, they fight one another regularly.  Killings happen fairly commonly, but it has always been men killing men.  If a woman is shot, it is virtually always domestic, so Deborah is an unlikely target.  I pointed out that we treat both Agaar and Atuot in our hospital, so we are unlikely to be a target.  I also assured them that I would still be trying to work for Deborah’s best interests, but that I really felt it was in her best interest at this time to work for our hospital.  Our discussion ended there.

14 January 2012 

The day started like an episode from A Series of Unfortunate Events.  I realized a couple of things as I got up.  First my keys were not to be found.  Then I remembered giving them to Rose and do not remember collecting them again, so I presumed that they were with her.  Second, I noticed the lights out on the kitchen wing, meaning no power in that direction.  It is Saturday, the day to wash clothes.  I decided to go and get the clothes soaking, but then I discovered that the nurses had locked the kitchen door, meaning no coffee and no soaking of the clothes.  I recovered my cool and returned to my tent for my devotion, which worked out fine.  As daylight appeared, I decided to soak my clothes even without soap until I could borrow one of the nurses’ keys, but I also tried the back door.  It was open and Rose left some powdered soap for the cleaners, so I swiped a bit to get the soaking going properly and then started boiling water for coffee and oatmeal.  When I finished the washing, Charles Chol met me, asking for my assistance with transport of mudbricks, and shortly after that, John Terakuc asked me to help transport some bags of tuomping (peanuts).   I also agreed to that, but only later.  I tried to start the pickup, but the battery was dead.  I tried jumping it without success, so I took the battery from the LandCruiser, started the pickup, then put the dead battery back in.  Charles’ bricks were just outside the hospital.  I parked the truck and left Charles to load while we made rounds.  After rounds, Charles was almost done.  I tried again to start the truck.  There was a minimal sound and then nothing, so it was the battery switch again.  Samuel Maker pointed out that the driver’s side rear tire was low, so I kept an eye on it as we made our way to Charles’ home site.  As we made our way into the market, Isaac Niak (Tomorrow) pointed to the passenger side rear tire.  It had a tear and was rapidly going flat.  I had this vague hope of reaching the home site and unloading the bricks before changing the tire, but it was not to be.  So in the market, quite to the delight of all who were there, I had to change the tire.  I considered unloading the bricks, but decided against it.  We have a hydraulic jack.  As we got nearly to the height needed, the circular piece of metal holding the twist in place broke off.  Fortunately we were on sand and could scoop out enough to put the new tire on.  The spare was also slightly low, but succeeded in making it to Charles’ home.  We unloaded the bricks and headed back, but the pickup was out of commission for the day because of the tires.  That also got me out of some of the tasks promised.  But even better news awaited.  Nelson Deng Mayom was there to inform me that they had discussed the matter more after I left and decided to let Nyanawut try living in the hospital for a month.  They did need for me to return to Adol for confirmation, which I did gladly.  So, like with the children, The Series of Unfortunate Events ended well.  A good ending makes the rest more tolerable.

15 January 2012 

The “Leaving exam” is a big deal in South Sudan.  There is no assumption of continuing on.   There is a much sharper decline in students progressing from primary to secondary school in South Sudan than there is America going from high school to university.   That is particularly true of girls who have reached potential marrying age, so the father is putting off collecting his cows if he allows his daughter to go forward.  But even to be allowed to continue your education, you must do well on the leaving exam.  The case of China Paul illustrates the importance.  Because of the unrest of January 2010, Makur-Agaar school was late in opening.  China was supposed to be in Primary Eight that year, but rather than sit out the year, his parents took him to Hope and Resurrection Secondary School (HRSS) asking that he be allowed to enter.  Cleous, the deputy head master, quizzed China and discovered that China was an exceptionally bright student, so he was allowed to start at HRSS.  He has been the top of his class (by far) for two years, but they still insist that he sit for the leaving exam.  Because of a technical glitch, he was not included in the students from Mayom Primary (the only school in our area currently with Primary Eight), so he is in Rumbek now preparing to take the exam. Last year, Isaac Makur approached me about taking the students from Mayom to Bar-Aliep.  Here is another curiosity.  Because there is no mail in South Sudan and because there are relatively few students taking the leaving exam, it is held in only a few places.   And, of course, it is up to the students and the school to get the students to the place for the exam.  Bar-Aliep is near Bar-Parkeny, about 20-25 kilometers from Akot.  Dinkas can make that walk.  Indeed, as the lost boys illustrated, Dinkas can walk amazing distances when pressed.  But they would prefer an alternative, just as we would.  The cost of taking all the students and their gear by matatu is prohibitive.  So last year I agreed to take them, but I made no promise of returning them.  But the students stayed in Bar-Aliep and the teachers campaigned for them with me until I consented.  By this year, the tradition is established.  I did not even complain when John Abec, the current head master of Mayom Primary, approached with the request for transport.  And I knew when I agreed that I was also agreeing to pick them in Bar-Aliep on Friday. 

            We had 36 students finish Primary Eight this year.  Again that speaks of the small percentage of potential students finishing even primary school.  We have five primary schools currently functioning in the Akot area: Makur-Agaar, Akot, Mayom, Living Water, and Abundant Life.  Each of them enrolled around 100 students in Primary One this year.  Assuming a fairly constant birth rate (a fair assumption), there should be in the neighborhood of 500 students taking the leaving exam this year, but there are only 36.  There is a curious coincidence in the numbers.  When I started Clemson University, there were 500 students enrolled in premed.  We had 35 students go on to med school from my class, the largest Clemson had up to that point.  So the difference between those who should be taking the leaving exam and those who actually are is similar to the decline from freshmen declaring they are premed to those actually going to med school.  That does put it in perspective.  One encouraging trend was that of the 36, it looked to me that girls constituted about half.  But where are the others?  Many never enrolled, particularly the orphans.  The children taken into a home once the father dies end up on the short end of everything.  Many of those are now being served by Living Waters and Abundant Life schools.  Others fail or dropout because of lack of family support, needs around the house, marriage (for girls), enrollment in the military.  When I got them to Bar-Aliep, they had to scrounge for accommodations, including food.  But they were there.  Their exams will last five days. 

            I continue to say that South Sudan desperately needs help in three areas: medicine, development, and education.  I am proud of these 36 students, just as I was very proud of the 19 students who graduated from HRSS.  We are making a dent, but the educational needs of those remaining are astounding.  I am privileged to be able to help in small ways, but we have a long way to go.

16 January 2012 

Meningitis was a fairly common diagnosis when I was a resident.  Immunizations have changed that in America, but those same immunizations are not available for the Dinkas.  A 5 month old child was brought in with fever and poor feeding.  I took a look at the child and thought meningitis, because his fontanel was full.  However, the more I looked, the less convinced I became.  The child looked too good.  He did have fever, but he made eye contact and followed my keys into his lap.  I decided to admit him and do a lumbar puncture (LP-spinal tap) later.  Working with students slows down the process (though making it more enjoyable), so though we were not swamped with patients, we were mid-afternoon before breaking for lunch.  After lunch we examined the child again.  This time the fontanel was less full, but the child was a bit more irritable.  I decided to go ahead with the planned LP.  I have done many over the years and a few here.  One thing I always understood was that the holder for a LP was of critical importance.  I got Mary Agum to hold, though she had never held before.  The child was still squirming a great deal and there was a small amount of blood initially, but then it was cloudy.  Indeed, it had been a long time since I had seen spinal fluid that cloudy.  I did not really need to count the cells, but I have a counting chamber and I wanted to make sure that I would see the cells on the chamber, since all my previous LP’s here had been yielded no cells.  I took Deborah and Michael to my tent to look at the fluid under the microscope.  I pulled out the scope.  Deborah said, “Microscope?”  She could name all the parts, and she had used one at secondary school, but it was clear that they had rehearsed the names of the components of the microscope much more often than they had used one.  I got the counting chamber in focus and let them both look.  The cells were too numerous to count. 

            I thought the case was interesting for a couple of reasons.  First, I misjudged it clinically.  The child looked good, almost too good for meningitis, and yet his spinal fluid was horrible.  Second, though I think our US schools have gone too technical in many instances, it would be nice for South Sudanese students to have enough microscopes that their experience matched their interest and knowledge.  Third, it may be that meningitis is on the rise again with the return of the dry season.  We will have to watch this carefully.

17 January 2012 

I got a notification 2 days ago that the UN World Food Program (WFP) was having a meeting regarding proposals for their support.  Last year I attended a meeting inadvertently and was elected to chair our section, then put in grants that were accepted, but then some shipments of food destined for our area were captured by the SPLA, so the WFP cancelled our programs.  But I see the value for our community if we can participate in their programs, so I decided to go again.  I took Deborah Awut and Mary Agam with me, primarily because I thought they would have little to do with me gone and secondarily because they needed to see this.  I believe I am fairly typical among doctors in hating bureaucratic meetings, but they are part of medicine, so Awut needs to see that upfront.  Mary will be with Living Waters School and I thought there might be some discussion on school meal programs (there was a minimal amount) and she could represent the school. 

            The presentation consisted of them reading word for word some published material out of Juba.  Typical of such meetings, there were tons of TLA’s (three letter acronyms) that were finally identified near the end of the meeting.  I, however, do not enjoy sitting in fog, so I would ask what each particular TLA meant.  Interestingly, when the presenters quit reading and started answering questions, you realized that they actually had a fair grasp of what they were presenting, but they were following the prescribed script. 

            It dawned on me during the presentation that this might be a good way to get some decent money for Michael and Deborah.  We are paying them a minimal amount, because I feel we are mainly training them, though we get some tangible benefits from them.  My analogy is residency, where there is a small salary, but the reason you are there is to be trained.  But their parents are expecting more.  To put off work and marriage all the way through secondary school should yield some more tangible results when they do start work, but I cannot justify the expense.  But if they can basically head up the WFP programs for Akot, we could get some more money for them and WFP could get some good follow-up data, which is lacking for the most part.  I also found that, despite the ridiculous format, there were a lot of practical things said that should make writing the grant much easier.  Suddenly I was not so down on bureaucrats. 

18 January 2012 

I retrieved the team from Rumbek today.  There are always many who desire to go to Rumbek when I go, but I only brought along Gordon Mayom.  It was a nice day.  We enjoyed seeing good friends we had not seen in some time, and they were enthusiastic about being in South Sudan.  Gordon and I did everything we could to make their arrival as easy as possible.  Despite the rough roads, all arrived in Akot with undampened enthusiasm.  Gordon helped unload the vehicle and assisted others in getting settled and then headed home.  Shortly after his departure, someone from Adol came to inform us that Gordon’s brother had died. 

            The death of his brother was not a shock.  He was chronically ill and we knew the death was imminent.  But there is nothing like death to throw a pall over a good time.  The word reached Gordon soon and he returned.  Now he needed help.  He told me he needed to go to Thon-Aduel.  My anticipation was that Gordon was going there to be part of the grieving and burial, so I got Judy to ride with me so that I would not travel that road back alone at night.  When we arrived at Thon-Aduel, however, instead of Gordon getting out and leaving us, a big discussion ensued and the next thing I realized, they were putting the body in the car.  I jumped out to help with some practical issues (getting the seats to stay up on one side, pulling in the body [which I did too quickly]).  We returned in silence until we were in Akot.  Then a major discussion followed regarding the site of the burial.  The brother had expressed a desire to be buried at his uncle’s home, but the father overrode this and dictated that the brother be buried at Gordon’s home.  It was black outside and we had to feel our way over the rough roads to Gordon’s home, including a fairly long stretch in reverse, but we eventually arrived.  There were a few wailings and women casting themselves on the ground, but I thought my night was over.  But the family discussed the matter some more and decided that it was more appropriate to bury the body that night instead of waiting for the next day.  Gordon asked to borrow some of the tools from the hospital.  We traveled back, let Judy off, gathered the picks and shovels and returned.  I asked Gordon about the practical issue of digging in the hard ground.  I had discovered long before that the ground during the dry season is stone-like, but that water soaked into it makes the digging possible.  “It is against our culture.”  I was distressed by this.  I was tired.  I was ready for bed and I figured Gordon felt the same way, but before him and his family was the task of picking and shoveling through stone the grave of their brother.  It was a horrible prospect, but I am sure that they completed the task.  He would have it no other way. 

19 January 2012 

I am one of those people who feels the need to wax eloquent on occasions.  Having young students around me who are holding on to everything I say aggravates the tendency.  So rounds last longer as I go through explanations about meningitis and cerebral malaria, assessing burns, helping patients when they have a disease we cannot cure.  Today we had finished clinic, but some others came looking for medical care.  I was walking out to see one when someone else interrupted my flow to say their patient was in the hospital.  The child I could see looked healthy enough, so we decided to check the other one first.  I spoke to Deborah about triage.  “It is important to be able to decide who is the sicker when you are faced with a lot of patients.”  We went into the ward and found a monydit with a history of fever, some chest pain and joint aches for 5 days.  He seemed fine on exam and did not have a spleen, but I suspected he did have malaria and treated him accordingly.  We then went back to the child who had swelling in his perineum (the area between the anus and scrotum).  It was not the most convincing abscess I have seen, but I was sure enough to open it.  We gave the child some Ketamine and Promethazine, so we did not have to fight him.  There was about 3 ml of pus.  I explored the abscess cavity and put in a wick.  We admitted him to the hospital because the family lives far away and he was not going to wake up for a couple hours and we were close to evening.  As we finished, Deborah commented, “It is interesting that one who did not look sick ended up the sicker of the two.”  It is what I get for waxing eloquent. 

20 January 2012 

Today was the day to return for the students in Bar-Aliep.  They did their work.  They put in 5 days of exams and I had virtually promised to pick them again.  But I am usually putting things together to cover all my obligations.  This morning Jacob Majak asked me if I would go to his sister’s house and be part of the funeral for her step-son.  The child came in with malaria and died quickly this week.  The burial had taken place, but they were holding the funeral this afternoon.  I told Jacob I would attend, meaning I would address the family.  After completing things in the clinic, I gathered Nyanawut and John Abec (the headmaster of Mayom Primary) and we started off.  Actually, we had to go by the Baptist Center and get the pickup, and there was a bit of shuffling to decide who would take what, but it did not last long.  We reached Mith-Agok at close to the appointed time, parked the truck and Nyanawut and I started walking.  We came to the first tukul and Nyanawut explained our journey.  They said it was very far and implied that the kawaja could not “foot it” all the way there.  It was a bit ironic.  Typically what happens to me is a Dinka tells me something is close by when in reality it is five kilometers through bush away, but this time we may have been a half a kilometer away at most, yet they were convinced we (really I) could not make it.  Well, we did make it without difficulty.  We did get another confirmation along the way that we were on the right path, but it was not really any form of a challenge in getting there.  When we arrived, the men were gathered together under the Lulu tree.  The women were in the tukul, but they quickly gathered around.  Nyanawut was asked to pray and she also served as my translator.  The father said some things first and then I was asked to speak.  As in every culture, the women are supposed to be the ones more demonstrative in their emotions, and that is particularly true among the Dinkas, but this father was the more emotional.  He shared with us the difficulty he had.  On the same day this son died, he had been riding his motorbike and was giving a co-worker (lady) a lift.  Apparently she did something wrong and fell off the bike and was instantly killed.  So this father was really wrestling with the goodness of God.  I told of the covenant God established with Abraham and his descendants and how that applies to Christians, and I told them of the assurance that we, too, are participants in Christ’s resurrection.  I told them that it is appropriate for Christians to take from these two pillars of our understanding the assurance that the children of believers who die young are in heaven.  I made a brief comment about the Great Day of the Lord when our bodies will be reunited with our souls and we will be in fellowship with all believers and with God Himself.  Afterwards, one of the uncles there asked if they believed in Mangrol (their tribal god), Allah, or Jesus.  I felt as though I had planted someone in the audience.  I mentioned that in Mangrol and Muslim and in every other religion, man sought to reach up to God, but in Christianity God reaches down to man.  We discussed this for 20 minutes and at the end, they declared that their hope and allegiance were with Christ.  They were so appreciative of our time with them.  What a privilege.

21 January 2012 

After the funeral we continued on.  Those who had hitched a ride from Akot had waited and we were off.  Next stop was Adol.  Deborah needed to deliver some medications to her father and to ask permission to spend the weekend in Akot because the team was visiting.  Also, Maria needed for us to inform John Malok, her fiancé that she would be staying in Akot for a time.  I had this fear that we would be running around looking for everyone, but in fact when we drove into the market, Malok was there and Mayom, Deborah’s father, was not far away, so we accomplished it all in one stop.  Then we were on to Bar-Aliep.  The road from Thon-Aduel to Bar-Parkeny and then Bar-Aliep was cut this year, but it is already in bad shape.  Still it is somewhat better than the road from Karic, so we rode over to Thon-Aduel, then turned south.  When we reached Bar-Aliep, the students were waiting.  They had finished their exams hours earlier, but they were not angry for the delay; they were grateful for the ride.  They piled in.  John Abec, the headmaster of Mayom Primary School, had the right to sit in the front, but elected to have one of the students sit up there with Deborah and me and he stood in the back with the students.  We chose to return via the Karic route as it would put us a few kilometers closer to Akot when we emerged.  All went well until we were about half way between Karic and Atiaba.  All of a sudden the rear started fishtailing.  I thought I had hit some loose sand, but it felt like I had hit a patch of ice (an impossibility in South Sudan).  I decided to look at the tires.  The passenger side rear tire was flat.  Then I remembered about the jack.  I broke it a few days earlier and forgot to put the good one in the car.  No use hoping to find one somehow deposited into the vehicle.  I locked up the car and we started walking (it was about 10 kilometers from Akot).  Deborah left her phone in the truck and I went back to get it.  We were 200 yards away from the truck when a LandCruiser came along.  We flagged them down and persuaded them to assist us with their jack (it is called a spinner here).  When we got close to the height needed, the spinner popped a few times.  I told them to stop.  We got the wheel off and had to dig a depression so that we could put the spare on, but it worked out well.  We made it to Mayom Primary School at around 8 pm.  Athiei Nhialic piir (the blessing of God on our lives). 

22 January 2012 

I was preparing for church when I was informed that Gideon Mabok’s son had been killed the night before.  Several things flashed through my mind simultaneously.  The first, I am glad to say, was concern for Gideon.  As frequent as traumatic deaths seem to happen in this country, they still leave the loved ones shocked and dismayed.  Second, I wondered how this would affect the hospital.  It was unlikely Gideon would be back for a week if not longer.  Third, I expected to get asked to take him to the burial site, near Thon-Aduel.  Indeed, the messenger asked me if I when I was going to take Gideon.  Fourth, I knew that we would be traveling in a car over rough roads with no spare and no jack, just to put a bit more suspense in the driving.  I told the messenger I would wait at least until I was asked.  I went on to church with Billy White (Mabor), my monydit kawaja friend.  While we were in church, someone brought news of the murder and the preacher asked me from the pulpit whether I would be taking Gideon to Thon-Aduel.  After the service, Gabriel Amat asked me if I was going to take Gideon.  “If he asked me, I probably will.”  Amat also wanted a favor.  If I was going all that way to drop off Gideon, couldn’t I extend my travels to Dhiaukuei and pick up Helena Ding, his wife?  Helena is one of my favorite people in the area.  He had me.  I ate some lunch and started out.  There were, of course, the usual additions for the trip so the truck was fairly loaded by the time we rolled out.  One of Gideon’s sons was with us and told me that they had not informed Gideon that his son was dead, but rather just wounded.  We had many to pick up before heading out, so we were full by the time we left.  When we got to Karic, we stopped at another of Gideon’s sons (he has 5 wives, so he has multiple sons) and I believe it was there that Gideon was informed about the death.  The son from Karic then led us from Thon-Aduel to Malou, the place of the burial.  There were some tight squeezes along the way, but nothing remarkable and we arrived in the bush at a large collection of men and women.  As with Gordon’s brother, the hole was penetrating rock hard soil without the use of water.  In previous burials I have attended, the hole has been somewhat triangular and there is a tunnel going out from the main hole into which they place the body, but this hole was rectangular and looked like an American hole.  Gabriel and I stayed long enough to drink a bottle of water and then we moved on.  We went through Bar-Parkeny, but then headed west towards Dhiaukuei.  We had gone just outside the market when some women flagged us down.  They were related to Gabriel’s sister Ayen and wanted a lift to Dhiaukuei.  It made me wonder how often cars did travel this path that was slightly larger than a footpath.  I know this: when we said they could go, they were packed and in the pickup bed in less than 5 minutes.  Dinkas do travel light, but I think they knew I would be coming along. 

            We arrived at Dhiaukuei at the end of a week-long conference on the family.  I knew many of the people there, and both Amat and I were treated as dignitaries.  We had to sit up front and were served another meal (I was not particularly hungry at the time).  Bishop Isaac was trying to get me to promise we would build a clinic there.  I told him that it did seem like a good place to do some outreach clinics or help keep some health care workers on top of their game, but I was careful not to insinuate more.  By the time we headed back, we were even more crowded than with Gideon’s crowd, including Martha and Emmanuel.  That seemed right.  The first time I ever came to Dhiaukuei, they rode with us.  Emmanuel is a tall man and a preacher with a great reputation, though his health limits his effectiveness at present.  They are also one of the older couples who speak decent English.  I really enjoy both of them.  We picked Mary Agam in Karic and then headed back to Akot.  We encountered no difficulties.  I went ahead to drop Martha and Emmanuel at their tukul because Emmanuel is quite old and not able to move around easily.  The adventure closed with Gabriel Amat, Helena Ding, Mary Agam, Emmanuel, Martha and I sipping some overly sweet orange drink and receiving the blessing Martha invoked upon us for our help. 

23 January 2012 

I was returning from yet another adventure when a man approached me with his wife.  She had vomiting and bloody diarrhea for 2 days since delivering her fourth child.  I was about to take her to the exam room, but she was having difficulty standing up, so I took her straight to the wards.  While there, she resumed her vomiting and then staggered away to the latrine.  I knew she needed fluids without examining her, but when I did, I found a pulse of 160 and BP 84/62.  I felt like she was in shock already, so I stopped my exam and started an IV of Ringer’s Lactate.  I got an 18g in her arm and hung a half liter bottle.  I listened to the chest and heart, which were remarkable only for tachycardia (fast heart rate), but her abdomen was tense and tender, particularly on the right.  By the time I finished my exam, the first half liter was almost in and I hung the second.  I diagnosed her as an endometritis with secondary peritonitis and shock.  Samuel Ireri came in about that time and I handed her care over to him, instructing him to give at least two liters and more as necessary.  We also started her on IV Gentamicin and Metronidazole. 

            Shock is not an esoteric disease, but it is still a killer.  I do not like being overly dramatic, but a few more hours and this lady, and later her baby, would probably have died.  When the blood volume gets too low, vital organs are not perfused and death (first of that organ, but later of the person) ensues.  It did not take a brilliant diagnostician to figure out what was wrong and the underlying causes, but it did take someone with competent medical training being here.  The woman has done very well.  The fluids revived her remarkably.  The diarrhea stopped the first day and the vomiting slowed markedly.  By the third day she was able to eat and drink on her own.  She was also producing milk so her child did not starve.  Are we making a difference here?  You bet we are. 

24 January 2012 

I am reading through Primary Surgery, a free download I heard about at the Louisville conference.  We had a father bring in his three year old son with swelling under the mandible (jawbone) and across under the soft tissues of the mouth.  I had another case like some I have had before, though I did not know the name.  It is Ludwig’s angina.  The patient was not in respiratory distress, which is a good thing, because we have nothing to help the patient who goes into respiratory failure.  He was having significant problems swallowing.  He had a 3 x 10 cm area of swelling and induration (feeling hard, wood-like) and what I took to be fluctuance, though my incision and drainage yielded no pus.  I left a drain in and started him on IV Ceftriaxone.  He did not have a great first night.  He was still having fever and pain to interfere with his sleep, though he was able to swallow some.  By the next day, the swelling was significantly decreased and he looked better.  By this afternoon he was active and starting to eat.  He was clearly on the mend.  In Primary Surgery, the author says that if there is no respiratory distress, we can watch for 24 hours and give the antibiotics a chance to work.  That may have been the wiser course in this child, though he tolerated the surgery well. 

            It is always encouraging to have the chance to apply what we read.  The authors of Primary Surgery seem to have come to South Sudan, for they describe so many things that we do see.  I think I will remember Ludwig’s angina well the next time one rolls into our clinic.  And even with this child, a little scar in the neck is not too bad of an exchange recovery. 

25 January 2012 

The team from America left today.  I drove them to Rumbek.  I knew most of the team from previous trips and the two new members were a great blessing to me and to the people of Akot.  The time together was cordial, fun, rewarding, refreshing.  I could truly say that though getting back to normality in our hospital will be good, we will all miss this team. 

            There is a kind of undeclared war between “short term missions” and “full time mission work.”  Short term missions are a relatively new phenomenon and probably account for over half the mission spending in “mission minded churches.”  There is some good rationale for that.  Short term missions tend to involve members of the local congregation.  Also many of the full time mission workers started in short term mission groups.  But there is also some just criticism of the short term mission movement.  Many churches send use “mission trips” as a thinly disguised youth retreat.  In order to get members of the church to support the retreat, a service project of some kind is tacked on to a trip to the mountains or Disney World.  There is nothing wrong with youth retreats.  When I was in college I worked with the youth in my church and with Young Life and I found retreats fun and potentially a good time to get more into depth with the students.  But I do think it is hard to justify the title mission trip to a weeklong excursion with a day of speaking to people on the beach about Christ tacked on.  So if any meaningful discussion about short term missions is to take place, there must be some discrimination.  I believe the short term mission teams that have come to our compound could be examples for the movement.  First of all, though there is an adventure in coming to South Sudan, it is not Disney World or the beach.  Coming here involves identifying with the people to some degree: putting up with roach-infested latrines, eating rice and beans, walking a lot, having no air conditioning.  Those who come do so because they have an identity with the people and desire to show the love of Christ in visceral ways.  It is not a mission trip if the side trip is the main motivator.  Second, a consistency of involvement shows a real commitment.  If the goal is to visit all the world, then it is a vacation.  Many of those who come to us pray for our mission in specific ways regularly because they are invested in the people here.  Many contribute to the on-going work.  It is not hard to admire the people here.  They have endured much and yet continue to have an optimism about life.  There are many others around the world as needy and towards whom it is easy to feel love.  But just as “God bless all the people in the world” is not a great prayer, visiting people in 30 countries for 1-2 weeks is not a particularly effective means of showing Christ’s love.  Paul, our best example of missionary activity in the Bible, did go to many places, but he maintained continuing relationships with the various churches he planted.  He usually invested long initial visits (often terminated not because the scheduled time was up, but because persecution drove him onward) and then returned to the churches or sent some of his close associates to keep the connection.  It is right and good to ask whether our goal is self-fulfillment or showing the love of Christ.  And he prayed long and detailed about the needs of the churches he planted.  “For God, whom I serve in my spirit in the preaching of His Son, is my witness how unceasingly I make mention of you, always in my prayers making request…” (Rom 1:9-10).  It is good when the trip is edifying, gratifying, but the goal should be to demonstrate Christ’s love through word and deed.  One of the reasons why this team is effective is because many on the team maintain a continual contact and concern for the people here.  Third, I do think it is fair to compare how much giving occurs for the ongoing work as compared to the mission trip.  That can be unfair.  I trip to South Sudan costs an individual around $3000 in air fare alone (and at times much more), so it is hard to pay for, much less match that contribution, but again, a large expenditure in a place away from home for 1-2 weeks and then nothing again sounds more like a vacation than a commitment.  Many of the members of our teams continue to pray and give to our work or work going on in the area. 

            I am proud of the mission groups who come to us.  I think of them as partners in ministry.  They refresh me when they come and I miss them when they go.  If all short term mission groups were like those coming to Akot, there would be much less grounds for criticism.  

26 January 2012 

We admitted a pregnant lady three days ago with abdominal pain and fever.  We diagnosed her as a threatened abortion and malaria.  We put her on bed rest and ACT and she seemed to be responding well.  When I got back from our journeys yesterday and Debora the TBA (traditional birth attendant) called me to examine the patient.  This mother is about 3 months along.  Yesterday she had some pain and the next thing she anyone knew, the umbilical cord was dangling between her legs.  In the US at term, a prolapsed cord is an emergency.  The doctor who finds it reaches up to the cervix and pushes on the head of the infant to keep it from engaging fully into the uterus while the C-section is arranged.  But even in the US, a prolapsed cord in a four month pregnancy is fatal unless the obstetrician can put the cord back into the amniotic sac and get it to stay.  I was surprised how big the cord is at that stage of the gestation.  The baby is still quite small, probably 2-3 oz, but the cord is half the normal size.  I had been involved in several things around, so when I heard about the problem, the cord had been out for several hours and I knew the baby was dead.  When I examined mother, the cervix was dilated.  I figured all we would need was a bit of a push, a good contraction or two and the remnants of the baby would be expelled.  Mother could agree that the baby was dead, but she wanted to proceed immediately to the oxytocin to try to get it done.  I understood her concern, but I thought it would be better for all involved to wait and run the oxytocin during the day.  The mother and TBA were all for going then, however, so I went to ask the nurses about it.  Elijah was adamant.  There was no emergency, and oxytocin can be a risky drug.  We should wait until the morning.  I had to agree with him.  Oxytocin is not a very risky drug when monitored, but night time is a time for errors.  In the end, Samuel gave a small dose of Oxytocin once and when nothing happened, started the drip the next day.  She delivered the dead child that evening. 

            Most rules have a fairly decent foundation.  When we ignore those rules, we take unnecessary risks.  That happens frequently in OB, one of the most emotional fields of medicine.  I remember well the internal medicine resident’s wife who was allowed to push far past the two hour limit and ended up with a flaccid uterus, an emergency hysterectomy, and on the ventilator in ARDS.  I appreciated Elijah’s wisdom. 

27 January 2012  

After the team from America left, Rose Paul and Gordon Mayom teamed up against me.  Rose had delayed her vacation until the team left, but now she needed to get to Bor, Paul’s home.  She had not seen her in-laws in years (I think from before they were married).  They had never seen any of their five grandchildren and they had been begging Rose to bring them to Bor.  There was also blind Joseph who needed to go home for a time to see if his parents would try to help him get married; Abyei who had been raised the last four years by Paul and Rose, but who now was of an age to get married and bring in cows, so they wanted her at home.  There were the two Danny’s and Kuot who had not seen their parents in years and needed to get home to them.  Each person would cost her 250 pounds there and back, bringing her one way total to 2750 pounds.  Then Gordon needed to return to Kampala for studies.  His classes had already started, but he had delayed to be with the team.  Now he needed to hustle down there.   He also need for his father to get to Juba.  That was another 500 pounds.  Two of my closest friends in Akot were making the request.  I parried with them for a bit, knowing in the end I would give in.  I did. 

            Though I had landed in Juba a couple of times, I have only been in the city once, before the independence, so I was also curious to see how it had changed.  I had also heard that the road from Aluakluak to Yirol had been redone and was in decent shape, something I wanted to see before the rains undid it all.  The drive was not too bad.  The road to Yirol was as advertised and that portion of the journey took 1 hour, less than half the time of previous trips.  I also again saw the bald eagles of that region.  I saw a total of three on this trip.  They Dinkas call them Kuei because of the black body and white face (Kuei is a heifer with those characteristics).  The white extends down to their shoulders and chest, so they are a bit different than the symbol of our country, but they are magnificent birds.  From Yirol to Juba there are two major challenges.  First are the spotty challenges.  From Akot to Rumbek, the road goes from bad to worse.  You never are tempted to get any real speed going because severe hazards are just ahead.  But from Yirol to Juba, the road acts well behaved for miles and miles and suddenly throws at you an axle-bender of a pot hole stretching across the entire road, so you slam on brakes and control your skid through them.  The second thing is the dust.  When you get behind one of the big trucks (and there are many), so you blind.  And they do not help you at all.  If you can see ahead, well and good, but there are times when you have to try to get even with the truck to be able to see.  They were the greatest hazard. 

            On the way down, we stopped at a restaurant run by Ugandans.  We had fresh fish from the Nile, rice and chapatti.  It was outstanding.  We were 75% of the way there and our spirits were up.  We reached the outskirts of Juba and a soldier pulled us over.  He was going to make us unpack everything, but as the 15 of us piled out of the car, he changed his mind and we ventured forward. 

            Juba has changed a lot in the 10 months since my last visit.  Paved roads stretch out to the boundaries of the city, though there are still plenty of horrible roads.  The city is bustling, particularly with young people.  There are loads of cars and far more motorcycles.  The traffic reminds me of Nairobi, except that we drive on the right-hand side of the road and Kenyan drivers are a bit more experienced.  If there are any traffic rules, they only apply to kawajas.  And I hit rush hour traffic.  That may not be a fair way to assess the size of a city, but I suspect Juba is in the neighborhood of half a million people.  It truly has become a city.  Shortly after passing a few critical junctions, Gordon got out.  He was arranging a bus ticket to Kampala to join his second semester of law school.  He would sleep nearby and board the bus first thing in the morning and start classes on Monday.  Rose took over as navigator and we arrived at Paul’s brother’s home without incident.  We took a short rest and were served water and then soda.  Then Rose’s thoughts turn back to the hospital.  “We only have enough beans for five days.  We need to go to the market and get some here.” 

            The Juba market is a wonderful thing to behold.  It is far more extensive than anything I have beheld in South Sudan.  It has a great variety from which to choose and people from all over South Sudan and East Africa have booths there.  In the produce area, there is a lot of competition.  Instead of having separate stalls, the vendors have their area marked by their plastic sheet.  In Rumbek, the beans are all bagged.  To see what they look like, Rose sticks her finger through the sacking and pulls out a few to inspect.  Not in Juba.  Everyone is trying to show how good their produce is, so it is out there for you to see and handle.  We arrived late.  Someone had warned us the market closes by 5, but that was not true.  Rose checked out the beans of a couple of vendors and selected one.  She asked the price for a 50 kg bag.  “220 pounds.”

“Make it 200.”  Bobby Keith says he wants to bring Rose to the US to negotiate his next car purchase.  I think he is wise.  The woman wisely accepted. 

As she went to fill the bags, I watched them close down the market.  Everyone was folding their plastic sheets and putting their produce back in its original bag.  Then the tiendits, the older ladies, probably widows.  They had coarse burlap sacks and brooms made from brush.  They swept the ground where the produce (beans and lentil) and spilled, gathered in a pile, put it on the burlap and sifted out the dust and debris.  They deposited the remaining beans in their other sack, and moved to the next place.  It reminded me of Ruth and the poor gathering the barley behind the harvesters.  They came back with the sacks.  Rose challenged the weight, but they assured her it was right.  I picked it up and it felt like 50 kg.  We hired a transporter.  He loaded the two bags plus some other smaller items into a rickety wheelbarrow and carried them to Paul’s brother’s house for 10 pounds. 

            The dusk was falling rapidly and I had still not seen the Nile.  It is actually the White Nile River that flows by Juba.  It becomes the Nile River when the Blue Nile River joins it at Khartoum.  It is one of the most famous rivers in the world and I had seen it from the air, but never up close and I did not want to miss the opportunity again.  Isaac Mayen and I wound our way down to the river.  The river’s edge was bustling with activity, though most people were leaving.  Along the shore were innumerable barges, loaded and ready to flow north to Khartoum.  The river is wide, about like the Ohio.  There is a steady current northward (the Nile is the only major river in the world that flows north), but it was not swift.  I felt the water.  It was cool and refreshing.  Isaac and I worked our way out onto one of the barges.  I took a good look around.  There are crocodiles in the Nile, but they are lacking in the social graces and therefore tend to be away from people.  I dove in and swam against the current about 15 yards and then came back.  It was as though I had thrown a rock through a store window.  When I stopped swimming, I heard shouts from all sides.  I was back out of the river within 30 seconds.  But I had succeeded.  I was refreshed and I swam in the Nile, a fitting end to the day. 

28 January 2012 

Actually that was not the end of the day.  When we returned to the group, we had a parting of the ways.  Isaac and I were to go with the men; Rose and the women were to stay at Paul’s brother’s home.  First we had supper.  China and Danny, Paul’s nephew, joined the men at a nice restaurant where I had roasted lamb.  I also had some “fuul and jibna” (beans with cheese).  It was topped off with orange juice, though the juice was so diluted and the sugar content so high that it was several sips before I recognized it.  Despite the juice, it was a great meal.

            We then drove to our night quarters.  Kuot, my guide and Rose’s nephew directed as we snaked over rocky ravines that only in the most charitable sense could be called roads through a labyrinth into a corner I never knew existed.  Dinkas have an innate sense of direction that I do not share, but even Isaac was confused.  We both concluded that if our guides left us, we would wander aimlessly the remainder of our lives.  However, we wound up in a nice home with a flush toilet and shower.  Having refreshed myself in the river, I initially declined the shower.  But I had not counted on the increased temperature and humidity of Juba.  About an hour after lying in smothering heat, I got up and showered, got back into bed wet and slept well the remainder of the night.  Kuot rejoined us and arranged coffee and mendazi for my breakfast, whereas my hosts, including Isaac, opted for the hot milk and sugar (what I jokingly call SDA tea).  Kuot led us out to buy fuel for our return trip and got us back to the main road before leaving us. 

            The main tribe around Juba is the Mendari.     If there is a difference between them and the Dinkas, it is too subtle for me.  They are tall, dark, smooth, dress in bright colors, and love cattle.  Isaac told me that they were not as fractious.  It gives me some hope for the Dinkas.  Having a now practically empty car, we gave many people lifts to various destinations, though there were still more asking.  I trusted Isaac’s intuition on the matter and it worked out well.  By early afternoon, the great adventure was over.  I was again reddened by the clay dust, but none the worse for the wear.  Rose and Gordon were also well on their way to their separate destinations, and I was glad to have had the opportunity to help them.  

29 January 2012 

I had not made any plans for church, so when Judy informed me she needed to go to Gordon’s church afterwards for choir practice, I decided I would probably go there as well.  I made quick rounds with Samuel, having been gone the last two days, but the hospital is quiet at present, so rounds were short.  I was walking back from rounds when Gabriel Amat and Michael Marial came walking towards me.  “You are preaching today.”  It was news to me.  I had been the ECS church last week with Billy White, but nothing was said to me about preaching this week.  At one time there had been a schedule for me to preach the first Sunday in every month (I guess that is a compliment, at least over every 5^th Sunday), but the schedule never worked out.  I had prepared something for Gordon’s church and I decided to give the same one.  At that point, I was ready to go, but Gabriel and Michael wanted to take tea first.  During tea, we had a discussion about hand pumps and what was needed to get the community involved in keeping them running.  When Amat left for church, with the Scripture readings I had given him, Judy wanted me to drive so we could go from the ECS to Gordon’s church in Malual.  We picked up a few people headed for church and then made our entrance.  As soon as I sat down, Amat and Martha Yar motioned for me to join them.  As we walked along, Martha said, “You are late.”  I started to protest my innocence, but I just apologized. 

            The readings today were Matt 5:20 and II Cor 5:17.  The first, from the Sermon on the Mount, says that our righteousness must exceed that of the scribes and Pharisees.  The second tells us that if any man is in Christ, he is a new creation.  Old things have passed away and new things have come.  I told the story of the Prodigal Son, but putting emphasis on the setting.  Jesus is addressing the scribes and Pharisees who are furious with Him because of His association with tax-gathers and prostitutes.  I put forth to the people that there are three states in the parable: the Prodigal son in his foolishness, the Prodigal Son after coming to his senses, and the self-righteousness of the elder brother.  The Prodigal Son is my favorite of all the parables.  The reception of the father for the return of the foolish and rebellious son chokes me every time I tell it.  It is so unexpected.  The father should sic the dogs on him or at least turn his back on this ungracious offspring when he sees the Prodigal top the hill, but instead he runs and embraces him.  The son does make his heart felt protest of unworthiness, and the father receives it as he plans the party.  It is the perfect picture of grace. 

            But the major point of the parable is a warning, and it comes from the elder brother.  He thinks his righteousness is sufficient.  The Prodigal has shown his stupidity.  All those following after the Prodigal should heed the warning and come to their senses.   All those who have come to their senses should rejoice in the grace of God and should extend that grace to others in the form of love and forgiveness.  However, to those who think they have no need of grace, who think they stand in their own goodness, the parable is disheartening.  The father comes to the elder son and pleads with him, but he will not extend grace for he does not believe he needs grace himself.  There is little hope for such a man.  There are three states in the parable: two are bad and one is miraculously good.  Those who are in the good state will extend grace to others; those too absorbed in seeking their own pleasure or too good to need grace do not extend grace and will not receive it.  May we take the lesson to heart. 

30 January 2012 

Dr. Rossi called me to see a patient.  It was a 30 year old man with swelling of the R arm for 1 day.  His R arm was twice the size of his left, particularly from the middle of the upper arm downward.  The skin was hard, almost like wood.  He had a guinea worm abscess before and it was possible that this was again, but it seemed to originate in the biceps muscle.  I have just finished reading Primary Surgery on pyomyositis.  They take a very aggressive approach, and for good reason.  A severe abscess can destroy a muscle, rendering that arm useless or much less useful.  The infection can go into the bone, resulting in osteomyelitis, which is both more dangerous and requires longer therapy.  Or it can go into the joint, resulting in a septic joint that may be rapidly destroyed and never able to move again.  The risk of the procedure is virtually nil.  So I said, “We needed to drain it immediately.”  Mary Agum reacted.  “It has only been 24 hours.”  I told her it was my opinion that it needed to be drained.  I injected the Lidocaine and aspirated.  No pus.  I still wanted to incise and drain, but the man refused, so I stopped. 

            I am afraid the outcome for this man may not be good.  It is possible that he will return tomorrow before too much damage has been done, but delay is not his friend.  Yet I did not push him on the issue.  He did not want my opinion.  I have learned over the years to present what I think should be done and leave it unless I am convinced that it is a life-threatening decision.  Mary reacted in ignorance, yet her reaction probably swayed this man away from the procedure.  It is amazing how often people will side with the one who has no or little training over the one with more knowledge and experience.  Possibly it was because she is Dinka.  I think it is because she said what he wanted to hear.  I hope we do not regret this decision years from now. 

31 January 2012 

We still see plenty of abscesses, but I am trying to write about other things.  However, today we had a funny case.  A 12 yo boy came to us with the complaint of fever, headache, and swelling at the anus.  In my experience, hemorrhoids are rare in this age, so I suspected an abscess.  I got Deborah to examine him.  He was wearing typical cattle camp clothes: a long shirt or a short dress, however you choose to call it, and nothing underneath.  Now Deborah is a very sweet and modest girl, but she is also very funny.  When Deborah told him to sit on the table, he started pulling down his garb.  “Hey, why are you doing that?  You are trying to hide your testicles and I will see them anyway.”  The boy was horrified.  I do find that ironic, as the odds are 3 years ago he was walking around naked for anyone to see.  Moreover, he shows no signs of puberty (Dinkas are thin and therefore tend to mature later), so nothing has changed, but Deborah’s joke did not sit well with him. 

            He had swelling along the left side of the perineum.  The perineum is the space between the anus and scrotum in a man (vulva in a woman).  The swelling had been there 10 days.  A round of Flagyl was tried by James Bol without success.  There was fluctuance towards the anal end.  It needed drainage.  I recognized he would not be cooperative, so I gave some Ketamine, about 3 mg/kg.  Instead of knocking him out as usual, he was vocally hallucinating.  “The doctor is trying to kill me.”  I injected some Lidocaine where I needed to cut, and that seemed to confirm his opinion of me, though Deborah and Rebecca tried to calm him down. I gave him another mg/kg of Ketamine and added some Promethazine, which put him into light sleep, but when I walked back into the room, he aroused himself.  I was a bit nervous about using any more Ketamine, so we held him down and did the procedure.  We found a fair amount of pus and several areas that looked to be on the way.  I placed a wick and we bandaged him.  By this time, he was overwhelming the Ketamine.  He was crying from the pain, but what seemed to disturb him more was being exposed to Deborah.  I cannot claim to have been very empathetic.