Cuando Cubango, Cave Men, Crusades, Shoulder Shrugs, Confrontations…

 

We began our February trip in Jamba Luiana.  It was the HQ of the rebel forces during the long civil war, in which the people fighting for freedom lost (in contrast to what happened in the US in 1776).  It is a poorly placed city, 30km from the closest river and they are hurting for water.  We drank rain water collected in barrels off of the roofs (contamination-free, but a bit rusty and gritty).  But it is raining.  When I asked the local folks about how the rains have been, they all smiled and said that it hasn’t stopped since the doctor’s arrival in November.  Their corn looks good and in another month will be mature. They are anxious about the rain stopping before the corn’s maturity, as that is what happened last year and they lost their whole crop.  Severe hunger is still a problem here and Brent, our MAF pilot, brought 1,500lb of food to them collected in the churches in Menongue.  So beautiful.

 

The first few days of the trip were remarkable in several ways.  My first patient was a 45y/o man who has new-onset diabetes and has hardly been able to function for three months.  It’s not the diagnosis as much as the setting as there are no glucometers, lab tests, or diabetes meds for this man for hundreds of miles, while in the US these all are available on every corner…  But I carry a glucometer from the US in my boxes and a limited number of test strips which we use sparingly, and his blood glucose was off the charts. I’m carrying almost 600lb of medication and equipment on this trip (thanks to all the packing help from Betsy and Sonja), and we will be able to provide meds for this man, and for so many others (usually about 500 patients), all because of your contributions.  Geraldo (Photo) would not have survived much longer without his diagnosis and diabetes meds, all available to him in this most forgotten corner of the world because of your (unseen) sacrifice.

 

The first morning I saw three teens (one in photo) who had epilepsy cured in the last few months secondary to treatment for neurocysticercosis, an illness caused by pork tapeworms which can form cysts anywhere in the body and, when in the brain, seizures often result. It’s thrilling to see such a cure because it’s a clinical diagnosis (we carry no test to identify this disease) and, not only does epilepsy cause much grief and anxiety for the patient and loved ones, but it also carries a stigma of evil spirits and “possession” because of its false association with the same historically.

 

I also saw a 55y/o man (Photo) who I’d seen here five years ago and diagnosed with Bullous Pemphigoid, an awful disease and likely the “curse” suffered by Job.  It forms blisters all over the body, which then break and yield fragile skin like that of a second-degree burn, which can then become infected.  The blisters and resulting wounds are painful and itch severely, followed by hyperpigmented scarring.  He improved with our treatment five years ago, but when it returned, as it invariably does, he went to other “doctors” and was diagnosed and treated errantly for five years at much cost to him, traveling to various hospitals in Angola, Zambia and Namibia.  He even took a year’s worth of Leprosy meds, which are very difficult to find in Angola, in part because many people with Leprosy do not have meds available to them because they are so often prescribed errantly, as with this man.  He will improve again and will return to us next time it returns.  If we don’t come, how will this man get proper (and pretty simple) care?

 

Serving cross-culturally is tough.  I’m typing at 4a in Licua and it is 90+deg in my room and the mosquitoes are thick, there is no plumbing or electricity and, as I see patients during the day, the flies are relentless and innumerable.  I lose 10-20lb every trip from unattractive food, inevitable bouts with diarrhea and walking everywhere in the heat.  But the people I serve are so much worse off and live in such difficult conditions, most of them sleeping on a grass mat on the ground, scrounging dry wood for cooking on open fires twice daily, carrying water in buckets from wells or rivers, sometimes a mile away, and living daily with virtually no modern conveniences, including eating utensils, toilet paper, towels, etc.  As children in the west, we are encouraged to fantasize about “cave men” and how they might have lived without plastic, steel, paper, etc and this is exactly the culture in which we serve.  It’s funny how we draw conclusions about how all people lived several thousand years ago by what we find preserved in caves.  There were people living in caves then and there are people today living the same way…

 

It’s a different world. There is little understanding and “knowing and being known” fellowship/friendship with those with whom a cross-cultural worker lives and works.  No one here understands a missionary’s joys or (especially) our struggles and the chasm is wide.  Our major issues involve, for example, separation from loved ones and from conversations and activities which are familiar.  We are consistently facing the unfamiliar and uncertain (in the developing world there is far less apparent circumstantial control), and it can be wearing. We also can never communicate with those we serve in our “heart language” about our Father and His Kingdom.  I’ve been on this trip for two weeks and haven’t spoken an English word, and most often I must communicate through a translator from Portuguese to a tribal tongue.  The local people know none of this, and their lives are hard, but they live with those they hold most dear and in surroundings that, to them, are familiar.  These are beautiful, bright, and friendly people, yet we are so different. Who will go to them, serve them, honor them and tell them the Good News of our Father’s affection for them?

 

In a cross-cultural setting (or in any setting), when are transparency and honesty more or less important than maintaining relational and personal dignity?  When is it better to confront, correct, and challenge, and when is it best to hold back, bear graciously, honor different perspectives and “stuff” one’s response/opinion for the sake of the other or the sake of the relationship? As followers of Jesus, how much should we avoid offending people?  There is tension when it comes to following our Father in a world that largely rejects Him. We tend to avoid the difficult middle ground, where the tension is greatest, and we embrace certain phrases or clichés so we don’t have to think through each situation.  Some missionaries think, for example, that we should never offend anyone, because we are “guests” in “their” country.  Others care little about offending the people as we must “always tell the truth”.  I’m convinced that some people historically have been persecuted, and even martyred, in Jesus’ name, not because they were Jesus and people-lovers, but because they were simply jerks.  We are guests and the people deserve our respect, yet we are also advocates for abused and neglected persons in a horribly unjust and corrupt system (operated by our “hosts”) – which necessitates confrontation.  Tension between extremes…

 

I wrote last time about my confrontations with government officials and this week I had some confrontational meetings with the hospital staff in Mavinga re their lack of preparation for my visit.  I have been visiting this municipality of about 30,000 people and no doctor now for five years and I’ve enjoyed working with this team because they have servant hearts for their patients.  But in the last couple years our volume of patient visits has increased to the point where I can’t see everyone, so I have asked them several times, graciously and kindly, to screen the potential consultations and find those with illnesses which they have been unable to resolve.  They have consistently not done this so, after two days this week of turning as many people away as I saw, I called a meeting and essentially confronted them about the many hours of (my) pre-trip preparation and the thousands of dollars spent on each of these visits and that my request for their help has fallen on deaf ears.  I was tactful, respectful but very direct (and “passionate”).

 

They responded by saying that there were so many people wanting to see the doctor and how could they say “no” to them because “even each of us would like a consultation with you”. “Do unto others” is not the best response in every situation!  So I talked about leadership and the need for healthy boundaries in life, in work, in relationships, etc, which involve saying, “no”.  The societal perk to leadership is power and some lead because of the positional power it gives them and some lead to serve, but all leadership involves making tough decisions that never affect all of those led in the same manner, all leadership involves disappointing some people, and all leadership involves disagreement and conflict.  I shared with them that, in the world at large, powerful, charismatic and talented people lead, but Jesus said that, in His Kingdom, sacrificial servants would lead rather than gifted leaders.  Unfortunately this is not what we see in the church…

 

I challenged them that they faced a decision of either disappointing some people or losing my visits, because I would not come here and run ragged doing their work. They responded and said that the people love outsiders and the fact that I am a doctor, and they have no doctor.  I shared that they could have treated many of the people I had seen and that I will not be a celebrity or seen falsely as some kind of savior.  I explained to them the danger of a community seeing an outsider as more valuable than the local team. This happens all too often in the current short-term “missions” fad, when the fascinating, racially different, wealthy outsiders arrive with all their bells and whistles and then exit, leaving the local team, with its minimal resources, looking pretty unattractive.

 

One of my role models was a beautiful man, Bill Hodges, who served as a missionary doc in Haiti for 30+ years and who got to finally see his Father face-to-face a few years ago.  I made many trips to his hospital in the northern part of the country, working for a couple months each time and I would sit at breakfast with him every morning and think of one or two questions to get him talking and listen.  He was a student of history, culture and the Kingdom of God and he loved sharing his thoughts.  One of the conversations I remember well was his description of the crusades that came to his area from the US a couple times/year.  They would bring huge, entertaining teams at great cost, rent the local soccer stadium, draw huge crowds, and the same several hundred people would go forward and “receive Jesus” every time.   Each crusade team went home thinking that they had done much for the kingdom when, in reality, they had done nothing.  What they accomplished was putting on a flashy show with people from another race from the other side of the world, with microphones and music and accented preaching, in a culture that had so little, and providing the most entertaining event of the year.

 

What a beautiful and sad illustration of what so often happens in church activities when we think (and feel) like we are doing something significant and we are, in fact, doing nothing.  Honest evaluation of our service in light of the emphases of Jesus is a must for a Jesus-follower because we are all capable of unknowingly putting forth great effort and bearing no fruit.  Or digging where there is no water…  This is likely what motivated Paul to write the first three verses of 1Cor 13.  No one from these crusades ever asked Bill’s opinions/suggestions on how to best love these people, no one ever offered help to their American brother serving with way too little staff and working way too many hours…  No one ever offered to give their lives and serve the Haitian people full time…  If I’m not discerning and wise, my short term trips to Cuando Cubango can be like these crusades.  The Pharisees that Jesus criticized did good works because of what came back to them in praise, position, increased self-esteem or a more tangible personal reward.  There is such a difference between doing work because it feels worthwhile or it makes the worker feel good about his/her contribution, and doing work because it actually benefits those served… 

 

My role on these trips to southeast Angola must be one which supplements and edifies the local work and augments the confidence of the people in the local team (church and hospital).  If I can’t accomplish this it would be better if I didn’t come.  The ideal missionary is not one who is remembered and honored, but one who causes people to see and honor Jesus, one who serves and builds up those served, and is then forgotten, while Light continues to spread in the darkness through the local people…

 

Shoulder shrugs…  This was only one part of the challenge in Mavinga this week.  The local clinicians “shadow” me during my consults on these trips to learn modern, evidence-based medicine.  This is a priority for me as I mostly travel alone and form relationships with each local team so that the medical knowledge and the manner of my work can be “reproduced” in them (making disciples).  This is a “technician” health system, with very few doctors because all schools, including medical schools, were closed during the war years.  Clinicians are called nurses or doctors, yet most received one year of post 9thgrade “medic” training during the war.  The knowledge base is poor, the equipment is lacking, there is almost no medication and, as with any large group of people, some are beautifully motivated to serve and benefit others while many relish the position of authority and work for personal benefit.

 

On my first day, the director of the hospital, who is about my age, shadowed me and we had some excellent cases and opportunities for instruction.  Solidez has a humble desire to learn and enthusiasm for serving and seeing people improve.  It was a busy day and a delight to work with him… but from there it was uphill.  The second day, the director of nursing, also about my age, was my “shadow”.  He obviously didn’t want to be there and communicated this clearly in various ways. He yawned profusely and loudly a dozen times through the morning, interrupted me constantly in translating, asked no questions, challenged my diagnoses and made ludicrous suggestions, revealing a complete lack of any medical knowledge base.  He was arrogant, loud, a hindrance to the very busy patient flow and obviously not pleased that he was “second fiddle”.  The next morning, I called him into a room and asked him if he had ever been outside of Angola.  He said that he had not and I told him that he had no idea of what he didn’t know and that he had such a beautiful opportunity to learn current, evidence-based medicine through me (someone bringing up to date medical knowledge of the world to his little town in rural Angola) but that he was too arrogant to take advantage of the opportunity.  He was completely and angrily offended and didn’t appreciate my perspective at all. We “had it out” for fifteen minutes and I shared my perspective and listened to his.  When to confront and when to “stuff?  At the end, he shrugged his shoulders like none of what I said mattered.

 

Making disciples in the trenches is about bringing light to darkness, and Jesus said that those in darkness often prefer the darkness and many don’t know the light which they lack.  Demonstrating and sharing the difference between darkness and light is often not easy because none of us appreciate being challenged about our behavior or perspective…  During the hospital meeting mentioned above, I shared with the staff that they had a unique opportunity to learn and most of them were not taking advantage of it (without mentioning my confrontation with the nursing director).

 

With a hallway full of waiting patients, I went to the delivery room to “clean out” a woman’s mildly hemorrhaging uterus secondary to retained placenta for a week after delivering a dead baby.  Nothing was prepared.  The nurses responded with a shoulder shrug.  Then I looked at my watch and realized that our MAF pilot, Brent, would be arriving soon and asked for confirmation that the car I had requested earlier was on its way to the airstrip.  I had been assured that Brent would be picked up.  They never made the arrangements and, when I asked what we could do about it, they said the three functioning cars in the municipality (of 30,000 people) were gone or broken. Another shoulder shrug.  I took off jogging toward the airstrip and passed the house of the army chief and asked if he could pick up our pilot.  He readily agreed.  It was that simple, and when I told the hospital staff, who told me there were no cars available… shoulder shrug.

 

The hospital was out of meds, so the last two days I was interrupted repeatedly to provide meds for people they were seeing in the Emergency Room (they were seeing 100+ patients/day with malaria).  We had seven people needing transferred to urban hospitals for surgeries and only four spots on the plane.  After some messaging back and forth, MAF agreed to come back another day to transport the five who were not urgent.  I was interacting with Florindo in Cavango about a woman dying and what he should do. I was messaging with our eye surgeon, Steve Collins, about a woman needing her eye removed because of five years of inflammation and pain that would not resolve.  So many decisions to be made throughout the day, while seeing 50+ new patients.  I need help. Will anyone come and help? I called a mayor from a local village who I had seen in December and asked how she was doing after I gave treatment to one of the local leaders to deliver to her for a parasitic cyst in her liver.  She said she never received the meds.  I confronted the leader and he said he forgot. Shoulder shrug.  At our morning meeting with the patients about improving physical and spiritual health, the hospital staff was in the back of the large room yucking it up and distracting from the talk I was giving on prevention of malaria, which will kill more people every month in Angola alone than the Coronavirus will kill in the world this year…  I confronted them and asked them (quite politely) to either leave or keep quiet so that interested people could hear the message.  Shoulder shrug.

 

A long Sunday…  “Could you please give the message at our service in the morning?  I’ll send someone to pick you up at 9a sharp.”  I arranged my morning to be ready at 9a.  At 10:15 a man arrived to walk me to the church service which began at about 10:45. I had said the day before that the clinic would begin at 13h, based on the service time, lunch, etc.  I was called on to give my message at about 12:15.  I finished at 12:30 and the service ended a few minutes before 13h.  I rushed home in the 100deg heat, skipped lunch and made it to the clinic about 5min late.  There were people waiting.  One of the church leaders has been doing our vital signs and registering patients and he arrived at about 14h.

 

One young man (Photo) arrived in that first hour with a snake bite, crushing chest pain, soaking wet from sweat and unable to feel his foot on the affected side.  He said he was sitting in the grass and felt a “punch” in his upper, left buttocks and soon thereafter began experiencing these symptoms, never seeing the culprit.  He had what appeared to be four puncture wounds at the site, had no local reaction, but was in severe distress.  We gave him meds for pain and inflammation and hydrated him and watched him gradually improve through the day.  He went home and vomited all night, but the next morning looked like he would survive.

 

Confrontation done poorly… I saw about 35 patients through the afternoon and, at about 5p, Inez, the man registering patients, asked if we could register eight more who had just arrived.  Based on the time and hour before the approaching darkness, I relented and told him that any further arrivals after those eight were to be told to return in the morning. I saw the eight and, as darkness began to make it difficult to see (no electricity here), I saw a ninth and a tenth and I was quite spent.  I walked to the front and saw that Inez was registering more people to be seen.  He had signed up an additional five after adding the original eight.  I angrily exploded at him and asked him what he was doing and that I wouldn’t see nonurgent patients in the dark.  He said these people arrived and he couldn’t turn them away (a familiar phrase this week).  After some poorly chosen words for this man who had volunteered his whole Sunday to take vital signs and register patients, I closed up all the boxes and packed up the ultrasound machine and was walking out the door when a woman was carried in who had passed out moments before and was seven months pregnant.  I unpacked everything, determined over about a half hour that the cause of her syncopal episode was benign, and left for my tent in the dark, a half mile away to set up a generator to charge the ultrasound machine for the next day… and crash.

 

Restoring honor…  The next morning I found Inez and apologized and asked his forgiveness for my childish response.  I thanked him for his selfless service and his desire to serve a few more folks, even when he was tired.  I told him that that my response was all about me and not about him.  He accepted graciously and it was obvious that he was honored by my apology.  This was a reminder for me that an apology replaces the honor that is destroyed by one’s bad behavior.  Inez and I worked well together all that day and we had a meeting at the end of the day which gave me the opportunity to ask the (two) local workers for input on how we could do better next time.  The other beautiful, volunteer nurse, who saw multiple, “simple” malaria cases for me, also accepted my apology for my reaction the previous evening toward Inez. She literally beamed with delight as I apologized and it was clear that her honor was also restored and perhaps her respect for me, as well.  I thanked them both for their selfless service over three days and their beautiful service every day  in this difficult (and so very hot) environment where the sick people are numerous and the pharmacy shelves are mostly empty.

 

On to Nancova and Rivungo today…

 

This is how we make disciples, not as much through study, teaching, church meetings, sermons and conferences, but by slugging it out in the sweaty trenches together, serving, failing, offending, apologizing, resolving conflict and learning together how to love our Father and one another. 

 

“More of Him, less of me…”

 

3 comments

  1. Thank you for taking the time to share your ‘victories and failures’ and your thoughts so honestly. Having lived in South Africa from the mid ’70s to the mid ’90s, and done a little short-term missionary work, your blogs really resonate with me. I totally agree with the need to benefit those we serve rather than ourselves, and it’s not gratifying, but pleasing to our heavenly Father.

    Your (as well as Betsey’s and your co-workers’) faithfulness, and your teachings are truly inspiring. Keep up the good work!

  2. Hard to imagine what it is like to be doing what you do Tim. Thanks for giving us a glimpse. Know that you are not alone in your moments of failure. I have been struggling with burnout and lack of compassion within my cushy American practice. And I still think about a time when I failed to intervene on a patient’s behalf in Sierra Leone amidst a cross cultural dilemma like you speak of, struggling with how far to let a situation go out of aims to respect local personnel.
    Life is messy and compassion is usually inefficient; and the proprietors of compassion are never nearly worthy enough; weakness though has a place on our resume with the Kingdom.

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