Applause, 19, Walkers, Dirty Hands, Sheetch…

 

Betsy and I returned to Cavango after our three-week interruption to South Africa for treatment of my heart issue (which is doing well) and we drove up to our simple hospital at dusk (after a rough ten-hour drive) to greet the workers.  There were already 50-60 cooking fires scattered around the clinic (pretty normal scene), each with a family or two sitting near and preparing for their simple dinner.  Over about a minute, as we slowly approached on the dirt and parked, these simple, rural folks stood in unison and applauded.  150-200 people in rags, splints and bandages, previously sitting on the cold, hard ground (40s at night) around their small fires in the dimming light… standing, grinning and applauding as we exited our car!  Our nurse director told me later that he had told them of my illness and they were applauding both because I was better and because we had returned (the rumor among them was that my heart issue would cause me to permanently return to the US and no longer work in Cavango).  How can words ever express what I felt as I encountered this reception by people I admire, people I’ve so grown to love, and people who, without exception, live such difficult lives?  We are not here for such a reception, and we certainly would never have expected something so profound and spontaneous, but I hope I never forget that moment, especially on the tougher days…  We know why we are here and we daily sense our Father’s pleasure, but I have sometimes wondered if those we serve perceive real benefit to our presence and effort…

 

 

Every one of you who support this work please picture this setting and receive the pleasure and gratitude expressed by these people.  We are only the hands and each of you are a part of a beautiful body of people who care for the rural underserved in Angola as we do, and who enable what we do with your sacrificial financial contributions (you are exceptions to those in the church referred to below).  That applause was for the totality of our work, impossible without our self-sacrificing team who enable every treatment we render.  Please know today the pleasure of your Father, the gratitude of these people and the blessing you are to the hands that you send to touch these remarkable people!!!  Estamos juntos! (Portuguese – google it :-))

 

 

Over two days last week I saw four seriously ill 19-year-old young women.  The first was beautiful, tall, educated, quite healthy, spoke flawless Portuguese and came to us from a city several hours away.  She had been feverish for several days and tested positive for malaria, but also complained of severe pain in her left leg and arm and, when questioned further about this pain, confessed that all she could remember was that she had been bitten by a small street dog on her thigh about a month prior (dates are always questionable in this culture where time passage is rarely accounted for and time is measured by the location of the sun).  It was small and she dismissed it.  The bite was a small puncture wound which had healed nicely, with no evidence of infection.  When I asked about the dog, they said it was known to them, but that it had disappeared after the bite and had not been seen since.  The family couldn’t recall this dog previously disappearing in a similar manner.  I explained to the family after praying together that we would begin treatment for the malaria and observe her in the hospital, leaving my concern for rabies unspoken.

 

 

By the next day, the girl was highly agitated, the fever gone, and she was complaining of severe pain everywhere (can happen in malaria with fever).  Her mother was quite sharp and obviously concerned about her daughter’s “cerebral malaria” and said that she had never behaved like this before.  I took this distraught mom aside and broke to her the news that her beautiful daughter had rabies, that she would soon die and that there was no treatment anywhere in the world for this disease, once it manifested symptoms.  She asked about the vaccine and I sadly told her that at this point it had no value and I didn’t want her spending a lot of money needlessly (about $30US – a lot of money for these folks).  She tearfully and bravely accepted the news and thanked me for my honesty and care, admitting that the bite may have been two months prior (the typical incubation period for rabies).  The next morning found the girl highly agitated at any sound or movement, writhing on the floor and unintelligibly and constantly screaming.  She had been in this state since the previous evening (despite receiving a strongly sedating anti-psychotic medication that we stock for such cases) and the mother was obviously exhausted in her state of sleeplessness and profound grief.  She asked if she could take the girl home to die and the girl’s father bravely and tearfully tied his beautiful, inconsolable daughter to his back on a motor bike with his son behind the girl, trying to wrestle her still.  She died in her mother’s arms on a path about an hour from the hospital at a river crossing.

 

 

I’ve now seen (too) many cases of rabies, and each one provokes many emotions, including sadness, helplessness (an awful feeling for a doctor), and anger.  This disease should kill no one.  I drove from Cavango for 12hr three years ago (my first case there) to get a vaccine from the Angola government (only place in the country where it is available) for a woman with a minor bite from a rabid dog the previous day.  We found the vaccine in a larger city and brought back enough to give her the complete series over 28 days.  She died of rabies two months later.  Since then, we smuggle all of our known-good-quality rabies vaccines in from Namibia and have given the vaccine to about 30 people bitten by a rapid dog – without one fatality.  The vaccinated woman’s death was because the vaccine was not kept cold and became ineffective. This is quite a problem in a country where no one has consistent electricity and few are educated in the science of vaccines and the necessity of maintaining a “cold chain”.  An example of the lack of knowledge: The director of the vaccine department of a large health post (where we obtain for our clinic the standard vaccines from the government) told me once that they were out of a certain requested vaccine, but that I could substitute another (different vaccine), because they were the same thing!  We have rabies come through our region about twice/year and each time we see at our hospital about 5-6 people with bites, some in time for us to vaccinate, thus preventing the disease, and some we helplessly watch die, over 2-3 horrific days, from this incurable (but completely preventable) disease.

 

 

I try to take advantage of teachable moments, so the next morning at our daily gathering of all of our patients and their families, I taught them (over 100 people) and our nurses about rabies.  The discussion was animated and highly interactive and lasted for over an hour.  They had all witnessed the girl’s awful demise and no one forgets such a tragic spectacle.  They were quite interested and I was able to give them the basics of the disease (and the need for early, post-exposure vaccination) and instruct all of them to gather their communities together upon their return and share the information with everyone.  I believe that most of them likely will do so, based on the intensity of our discussion.  Few knew of the vaccine’s reliability because all of the people they knew who had been vaccinated had died (Angola vaccines).

 

 

This is one of our huge challenges here, because when people think of “modern medicine”, they associate us with other health posts that stock a few pills/injections and are staffed by caring people with little education.  To these rural folks, a pill is a pill and a shot is a shot (all the same and shot is always better).  They know nothing of specific treatments for specific illnesses (neither do many treating nurses) or that each medication is chemically different than the others (they all look the same).  They put all health posts in the same boat because we all have “the” pills and shots.  An example of treatment at gov’t health posts: I recently saw a 22-year-old man with an obvious STD who was treated by a doctor at a hospital with a basic antibiotic that doesn’t treat STDs.  He was treated for a urinary infection (because of the always contaminated urine specimen) that men almost never acquire, and will likely now be sterile for the rest of his life.  This was completely preventable with a correct (and easy) diagnosis and treatment.  I won’t touch the morality of his disease because virtually all men here will have one of this large group of diseases at one point in their lives because they don’t live by our Father’s recommendation of monogamy – which quite effectively prevents this group of diseases that has historically killed millions, and rendered many more men and women infertile.

 

 

Another of the 19-year-old women presented with a “swollen” and painful abdomen that she’d had for over a month, after she had delivered twins two months prior, both of which died at birth.  Her abdomen was distended and felt like a rock, unlike any abdomen I’ve examined (in 30+yrs).  It was different than the firm abdomen of peritonitis and this girl had been eating, drinking and pooping (medical term), ruling out this diagnosis.  Thankfully, I have an ultrasound machine which clarified this girl’s strange condition.  She had about an inch-thick layer of pus covering her entire abdomen, which I suspect occurred after she had a post-partum uterine infection that ruptured through her uterine wall and leaked into the muscular space of her abdomen (her uterus had an abnormal appearance, as well).  We prayed together and drained more than a liter of pus from this space and sent her to Lubango urgently via Marijn, our passionate Jesus/people-loving pilot with MAF for surgical treatment of her uterus by our wonderful servant-colleague, Rebecca (OB/GYN).

 

 

With any basic health care, this woman would be the smiling (and tired) mother of three-month-old twins, as most immediate delivery deaths (millions world-wide) are preventable with simple warming, drying, positioning, agitation, and basic airway management.  She wouldn’t have suffered infection in a clean hospital (she delivered at home on a dirt floor because of lack of access to a hospital delivery) and, in the (very) rare case that she did acquire an infection in a hospital, it would have been treated early and uneventfully, her uterus would not have ruptured, and she would be able to have more kids (unlikely at this point).  I’m grateful, however, that our Father used us to spare her life, so that she might have further opportunity to know Him.

 

 

The third 19-year-old woman presented with acute-onset (several days) of profound agitation, fever and “talking nonsense” according to her family.  Her diagnosis was pretty straightforward as her malaria test was negative (we see many cases of cerebral malaria with a similar presentation) and her neck was board-like stiff.  We prayed together and began aggressive treatment for meningitis and, within a few days, her fever resolved and she was walking, eating and drinking, though she was still confused at times and agitated during the night.  The family knows that she may have a long recovery but they are grateful for her progress.  This disease is also preventable by vaccine (at her age the likely culprit is meningococcal meningitis) and, in any country with decent access to health care, disturbing “acute” symptoms like hers would be addressed in hours rather than days.  Earlier treatment for meningitis (infection of the brain and spinal cord) is key to prevention of permanent nerve or brain damage.

 

 

The Wind…  The last of our 19-year-old women who came in during these couple of days was tall, weighed 35kg (<80lb), had been coughing for six months, had stopped having periods, had profound difficulty breathing especially supine (simply couldn’t lie down), and had an oxygen saturation level of 85%.  With ultrasound, we were able to determine that she had fluid around her heart (why she couldn’t tolerate the supine position) and that she was three months pregnant.  Auscultating her lungs with a stethoscope revealed marked inflammation in the upper lobe of her left lung, caused by tuberculosis. We prayed together and immediately began treatment for her TB, began anti-inflammatory medicine for the fluid around her heart, and started her on vitamins for her and for her baby (which appeared healthy).  Within just a few days, she had gained a kilogram, was coughing less, was sleeping at night (lying down), had less fluid around her heart, and greeted me one morning with a huge smile (she was literally too sick to smile when she arrived).  She will likely do well and, Wind willing, the world will greet another of our Father’s miraculous creations in just a few months.

 

 

Readers of this blog and supporters of our work know that these cases are, sadly, a small sample of what we see every day at our remote hospital (why I returned) and what set these women apart was simply their ages arriving in close proximity with each other, which made me take notice.  All had preventable and/or easily treated illnesses with access to decent evidence-based medical care, common in disproportionately wealthy North America and Europe, the main areas in the world with historical cultural deference to our Father’s guidelines and principles until greed, earthly success and comfort replaced our Father as the culture’s (and church’s) principle motivations.  How many “Christians” do you know who would turn down a million dollars because of Jesus’ warning about money?   Would you?  The loss of this deference to our Father’s pleasure (and Jesus’ words) is becoming more and more apparent as discontentment rules in global areas of prosperity far more than in the impoverished parts of the world.  Jesus advised us against the pursuit of that which money can buy because He knew how it would distract us from our relationship with Him, stealing the joy and contentment which can be found only in Him.  He also knows how sorry so many Americans will be when they realize that most of the resources HE gave to them to steward (to participate/partner with their Father in helping, serving others) was spent on themselves…

 

 

The church in the above mentioned prosperous parts of the world, claims with animated words and songs that it loves Jesus more than that which money can buy, but our lives speak otherwise.  The world (and the church) desperately need today more “walkers” and less “talkers”.   We follow pretty, animated public personas whose personal lives we are unable to evaluate (whether they walk the talk when off the stage, at home, unobserved) and we don’t hold in esteem and follow the man/woman that lives what they say.  In our church culture, the outgoing, entertaining and polished “talker” leads us and the sacrificial “walker” is irrelevant because he/she isn’t pretty, a good orator, highly skilled or famous.  Pretty images and rhetoric receive a lot more attention today than dirty hands.

 

 

As in Jesus’ day, today we have theologians with clean hands, soft feet, and hearts cold to their suffering global neighbor; fat on the law, full of trite answers, and deaf to the calling of the Spirit to follow the Wind to the hard and lonely places, where live the broken, the wounded, the hungry, the smelly, the dirty, the hurting… the least…

 

 

It happens every so often…  I pray with each person, recognizing the beauty and limitations of the care I offer, calling on my Father to have mercy on the patient, and to grant him/her healing and/or peace/intimacy with Him during their trial…  So many people are healed, but sometimes something unnaturally special transpires.  Last week, as I prayed for/with a woman about 30-years-old and from a city several hours away, she broke down and began weeping.  I asked her what was happening and she smiled at me through her tears and shook her head.  I was touched…  The Wind…

 

 

We also sometimes see things that are difficult to naturally explain.  A fifty-five-year-old woman arrived one afternoon last week suffering full-blown generalized seizures while we transferred her from her husband’s motorbike to an exam room.  She’d had these convulsions for almost 14 hours with barely a break, beginning when she was working in her field.  She was deeply comatose and had a recurrent seizure every few minutes as I checked a glucose, did a quick exam which revealed nothing obvious as to a cause, did a negative malaria test and confirmed that she had no sign of meningitis or a stroke (more common causes of a similar presentation).  We gave her some IV fluid and an IV medication (diazepam) to stop her seizures (a medication we purchase at a public, outdoor market in the city, without any regulatory controls) and her seizures promptly stopped.  We prayed with her and her family and hydrated her during the night and began treatment for a parasitic disease that can cause seizures (which needs days to begin to affect a cure, if that was the unlikely cause).  The next day she walked into the exam room to see me and denied any complaints.  She had eaten breakfast, slept well through the night, waking several times to walk out to the hospital yard to urinate, and said she felt fine, with no recollection of the events of the previous day.  She is staying at the hospital for a week (I left for the US) and, barring the unforeseen, will return home soon.  With many years of experience in treating people with seizures, I can’t explain it…  Thank you, Wind!

 

 

We also have a man in his 60s who arrived urinating only droplets for several weeks.  His bladder was hugely distended because of a large prostate and ultrasound revealed significant damage to both of his kidneys.  We put in a urinary catheter and emptied his bladder, but he also complained that his greatly swollen left eye was causing him intolerable pain (more than his bladder) and that he had lost vision about a month previously (when the swelling and pain began).  He’d had a severely swollen, painful and blind eye for a month before getting a motorbike ride of several hours to our hospital!  Lack of access to trusted care…  Ultrasound revealed marked swelling behind his protruding eye, but repeated attempts at draining his posterior orbit with a large-bore needle (which he tolerated stoically) failed to alleviate the inflammation.  After about a week of little response to antibiotics, I had to remove his eye to attempt to afford him some relief.  He tolerated the procedure well but continued to have intense pain for several days, which left me without further treatment options.  We prayed for him again, and he walked in the next day smiling and joking, saying he had slept pain-free for the first time in almost two months.  We have not because we ask not, but the Wind will do, what the Wind will do, how the Wind will do it, when the Wind will do it…

 

 

I left Cavango soon after hearing of our son Luke’s cancer diagnosis and need for urgent surgery (successfully performed yesterday while I was traveling), knowing it would take many days for me to arrive back in the US (I arrived without incident yesterday afternoon).  On my second day of driving (10hr on day one and 14hr on day two) I stopped at a gas station and, as the attendant (raised in Angola speaking Portuguese and studied in Namibia speaking English) was filling my car, he asked (in English) where I was going and why.  The typical pattern for conversation in Angola is that, after a kind greeting, one person will share how they are doing and what’s going on in his/her life (for example where a traveler is going and why) and the second will then do the same.  They hold to this pattern religiously, and all conversations begin thusly, whether with friends or strangers.  I’ve come to appreciate the formality and the relational benefits.  I told him where I was going and why, and he, quite compassionately, exclaimed, “Oh sheetch!” (how the English “word” shit would be pronounced in Portuguese 🙂   The combination of languages, his genuine compassion, and his entirely appropriate use of an expletive caught me pleasantly off guard!

 

 

In response to his diagnosis, Luke wrote from Mozambique (before he left for the US) a powerful blog post found here, which will challenge and encourage you.  Please take a look!  His posts are mercifully much shorter than mine…

 

 

2 comments

  1. Tim, your work always inspires me and challenges me! I always end your writings asking the Lord to lead me in a path to serve. I truly believe that even with my mother on Hospice & my father fragile, there is something that the Lord wants me to get involved in. I am seeking and searching as we speak. The few paragraphs you wrote about the money is truly where my heart is resting. I feel that being a good steward of what God has blessed us with, is of the utmost importance. I would appreciate your prayers as I speak to mentors and organizations that could open doors for me. I am also praying for Luke. What an amazing blog he wrote!! He truly has the eternal perspective that God wants us to have. But to be in that place at such a young age……you and Betsy done good!! Besides the fact that Luke is such a sweetheart 🙂

  2. Thanks Tim, you challenge me a lot once again. I’m embarrassed to say that my actions are still mostly the same even though I have been challenged before. However my heart has been moving in steps, because each time I’m challenged I realize I surrender more of myself. Please continue to call this stuff out, because there are hardly any voices here in our first world culture which have the perspective that you have. I’m glad to hear that Luke is doing well. Ally and I enjoyed his recent blog post.

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