Our return to Cavango… I am awake early in the dark by a warm fire after a full couple days.  Betsy and I drove about 12hr, through many police road stops (all were kind and respectful) to have our temperature checked and to wash our hands (!), in a country with virtually no CoVid deaths. We arrived exhausted, with no further delays, only a broken mirror and window and some smashed groceries.  We arrived after dark to the main dirt road running through the village and it was lined with waving, laughing people yelling “Welcome back!”.  Then I stopped at the clinic and most of the barefoot people left their 20+ open cooking fires around the clinic (it’s mid-winter here with temps in the 40s at night) and applauded as they walked toward me standing at my car at the clinic entrance. They stood around for several minutes, all 50 or so adults, offering a warm greeting of welcome.  I drove the last mile home through the trees pretty emotional.

 

We left in June, telling everyone here that we wanted to return, but that we would only return with assurance of support from the government, but also, and especially, the church denomination which owns the mission, in order to minimize the risk of investing here and having the government close it down for no reason (which has been threatened many times).  The denomination responded enthusiastically and assured whatever support we needed to further invest in the rural people we serve.  So their welcome was not a given a month ago, and pretty special considering all the unknowns when we left.

 

Then into the clinic in the morning.  I began the day with a meeting with our staff, a group of about 20 workers, who work a week, off a week, so they can maintain their fields on their week “off”, which is the source of all their food.  Life is as simple as it gets here, as there are no stores or imported goods. Everyone showed up, those working and those off.  I told of our time away and of our many meetings, and how we are returning with more of a sense that our Father wants to use Cavango to truly impact this region, through the clinic, a quality school, agriculture, outreach into other regions with the Good News of Jesus’ grace and hope for every rural Angolan. We are open to anyone from anywhere in the world who would want to serve here…

 

This was followed by several lengthy and touching speeches, both in their own language and in Portuguese.  Several talked about all of the guesswork and gossip over the past month, and the “certainty” that we wouldn’t return.  They expressed surprise and gratitude that they were again sitting in the same room with me.  They said it had been 51 days (they counted), and that they couldn’t do anything all day yesterday when they heard we were returning (no phones or cell coverage out here), until they saw our lights come over the hill, in the darkness, 20km away, when they began gathering on the village road to welcome us (likely about 40 minutes in the cold, as the last valley and hill of “road” is quite a crawl).  Such emotion expressed by this stoic people was beyond heart-warming and appreciated… We met for 90 minutes and then began to see patients.

 

What an emotional rollercoaster, from the warmest greeting to the harsh reality faced by these beautiful, rural people.  I saw about 45 inpatients and, perhaps twenty new patients.  People waited all day and I heard no complaints or whining. Many had been camping on the cold ground around open fires for up to two weeks for their five-minute consultation.  Many had treatable illnesses and many had waited so long before coming that complete resolution was unlikely.  Perhaps five cases just that first day of new-onset TB in cachectic, malnourished adults. A child of three arrived with difficulty breathing for two weeks, having severe pneumonia in both  lungs and breathing 90 breaths/minute.  We treated him aggressively with oxygen, antibiotics and IV fluids, but he succumbed to his illness in the evening.  His father then began the 5hr walk home, carrying his precious son’s body.

 

The realities of this place are grabbing me as I sit very near a fire again in the early morning darkness and cold (about 55d inside).  What crazy beauty was demonstrated by these people in welcoming us back and how many people ever get to be on the receiving end of such affection?  And, then, to be confronted with the dregs of the human condition, the forgotten and neglected, dressed in rags, always wearing a pleasant smile, and suffering so… as the rest of the world is otherwise preoccupied.  A few doctors and some education would prevent so much pain and premature loss and disability.  Our mortality as human beings is secure, but to live our few years on this earth so forgotten and painful?

 

The next week… A 20y/o girl arrived after about three days of pain in her pelvis, believing she was pregnant. She and her husband were sharp and from a city about three hours away by motor bike.  Ultrasound revealed an ectopic pregnancy, or viable pregnancy growing in the fallopian tube, outside the uterus.  These can be deadly, as the doomed pregnancy outgrows the small tube and erodes through the walls, causing potentially fatal bleeding in the mother.  Definitive treatment is surgery to remove the pregnancy, but surgery is a flight and a long way away.  Another treatment is to give a chemotherapeutic agent that will kill the developing embryo, incapable of surviving pregnancy, and save the mother’s life.  The risk with giving the medication and waiting is that if she would begin to bleed during the week of treatment, we might not get her to a surgical center on time. One of the many tough decisions in a low-resource setting.  We must always be cognizant of whether we are spending our resources in the best way possible, thus we operate in an arena of far greater risk than the developed world. We gave her the medication and the embryo disappeared in a week and this young woman, who will go on to perhaps have many children, went home, likely never really appreciating that she had been healed of an otherwise incurable and fatal disease.  The Wind…

 

A 30y/o woman arrived simply not feeling well for several months and arrived after traveling by foot for two days.  When people here visit our clinic, it is never for a minor complaint, and this must always be considered, as the average cost of their consultation and treatment is more than a week’s wage (about$10US).  Her exam was unremarkable so I did an ultrasound screen of her vital organs and her spleen was full of multiple small granulomas (tumors) revealing disseminated TB. She will likely recover over eight months of treatment, but would otherwise have died.  We are averaging 2-3 new cases of TB/day and the numbers are more than we can manage.  The ultrasound machine uncovers many cases and is of huge benefit in the diagnosis of occult (otherwise hidden) TB.  The Wind…

 

A 23y/o man arrived agitated and unconscious with difficulty breathing, after visiting many health posts over almost a year. He was carried into the clinic after riding on a motorbike for several hours, strapped between two men to hold him up.  He had lost the movement of his left side after onset of a severe headache several days ago.  His blood pressure was 240/140, malaria test negative, and ultrasound revealed heart failure and inflammation of his kidneys.  The blood pressure likely caused his heart failure and perhaps a hemorrhage in his brain and this severe blood pressure elevation was likely caused by his kidney damage, cause unknown.  We transported him, via our beautiful MAF colleagues, to our skilled surgeons in Lubango to see if surgery might be necessary to relieve the pressure in his brain. No diagnosis at government “health posts” for over a year of his blood pressure elevation, for which treatment would have prevented his likely fatal condition(s).

 

A 26y/o man arrived after several days of severe abdominal pain and vomiting.  Exam and ultrasound revealed appendicitis for which, of course, surgery is the definitive cure.  We could try to treat with antibiotics and, since we couldn’t get a flight for at least 24hr, we began.  He didn’t worsen over that time period and the difficult decision re resources faced me again.  We continued with antibiotics and he improved daily, going home, symptom-free, after a week. To treat such a patient in a nonsurgical facility involves risk, for if his appendix would have perforated, he likely wouldn’t have survived.

 

The day the above young man went home, a nine-year old girl arrived who had begun vomiting with severe pain and had no intake for three days, preceded by a week of fever. This is a classic presentation of typhoid fever and she looked ill.  Because she arrived in the evening, we had no option but to wait and reexamine the next morning.  We put her bowel at rest and began antibiotics.  The next morning we tried a few liquids orally before calling MAF for transport.  Her exam revealed signs that she needed surgery, but a minority of these cases survive without.  The tough decision to call MAF or wait 24hr, which would delay surgery for 48hr, during which time she could die, if the disease progressed.  I decided to wait and the next day she was the same.  Another decision.  Today.  I chose to wait again. As I write it is Saturday and I am hoping she survives until the morning, which will call for another decision. Another man arrived with the same condition yesterday…

 

We drained 5-8 liters of liquid from the abdomens of five women with cirrhosis (liver failure) from taking “traditional medicine” (herbs, roots, and who-knows-what-else) administered via enema or soup by well-meaning shamans in their villages in a region where there is no evidence-based medicine apart from our clinic, which is more than a day’s walk for most..  All will likely die from a long and painful course of liver failure, for which we can only offer palliative care.  We typically have 3-4 people dying similarly in our hospital on any given day. Most are otherwise young and quite healthy, having sought care for minor and benign conditions.  Many are women who wanted help with fertility after perhaps 3-4 months of not becoming pregnant.  Every time someone, adult or child, enters the consultation room with a grossly distended abdomen, my heart breaks for them.  Was it their fault that they went to the only help accessible?  Yet they will die slowly and horribly, nonetheless.

 

But all will be loved, cared for and introduced to the One who has life eternal for them. The Wind…

 

With the plane unavailable for 24hr (written permission is needed from the federal government for every flight), a woman arrived after three days of labor and in shock.  We put her in the ambulance and sent her several hours to the closest city for a cesarean.  She did not receive the surgery and died.  My first year here, in an attempt to work with the government health system, we sent 10 similar patients to government hospitals and nine died, never receiving the necessary surgery. This is why our relationship with MAF and CEML in Lubango is so vital, as the system here is grossly inadequate for critical patients. Then the government had the audacity to contact us to pick up and transport the body home…  We are here to serve, in whatever menial manner, so we sent the ambulance, at significant cost, to assist this family in their loss.

 

A boy of five years arrived in severe heart failure resulting from Rheumatic Heart Disease which developed from untreated strep throat. His severe difficulty breathing abated during the night secondary to medication, but he needs valve replacement surgery, which is not available here, and we may be able to give him a few years with medical treatment, reducing the stress on his weakened heart.

 

This week we diagnosed nine new cases of TB, including a 57y/o woman who arrived paralyzed from the waist down for three weeks from spinal TB.  Several had begun treatment in a city during the last two years, but stopped somewhere during the 8-month course because the government continues to run out of meds and sends the people home.  All partially treated are at risk for developing resistant TB because not all of the illness is killed and mutations in the mycobacteria give it the ability to survive treatment with the common four-med therapy.  Our TB facilities are inadequate to handle all of the newcomers, as all of our TB patients stay with us for the first two months of treatment to make sure they take their meds correctly, hear the Good News of Jesus’ grace and care for them and fully understand that they must complete the full course of treatment.

 

Quite a day…  Thursday is usually our lightest day.  This past Thursday we began by sending four patients via MAF to Lubango who needed surgery.  This is always a frantic morning, getting all the documents together to satisfy our “police state” and cramming them all (each patient and a helper) into our “ambulance” for the hour drive to the airstrip, and at 9a I was already looking forward to a lunch break!  Then the flood gates opened.  We had 30+ patients arrive, and 12 almost dead (literally) from various illnesses.

 

A man of 63 arrived with severe pneumonia and an oxygen level of 67% (normal > 93%).  Two babies arrived in comas, having no intake for 48 and 72hr respectively, one with malaria and one with gastroenteritis.  We couldn’t get an IV in either because of their severe dehydration, and we put in an intraosseous line (IV in a bone) in each (photo) for hydration and meds.  By the end of the day, each had awakened and had begun nursing.  A man was cutting down a tree with a machete and hit his calf, severing his calf muscles almost completely and slicing an artery.  He arrived quite a bloody mess, almost comatose and in severe shock. Over an hour, we stopped the bleeding and went on to repair the muscles.  The next day, he had no swelling and the wound looked great.  He will have some extended time without weight-bearing, but will recover.  The Wind…

 

An elderly woman arrived in a coma.  The young girl above arrived with peritonitis from typhoid fever. A woman arrived with acute, severe facial and other burns, with difficulty breathing.  A woman arrived with so much liquid in her abdomen she couldn’t breathe, which we easily drained (>10L).  Two men arrived having not urinated for more than 48hr because of prostate enlargement, which we remedied with a catheter into their bladders, relieving their kidneys of severe obstruction, visualized as hydronephrosis on ultrasound.  Two more children arrived in coma from malaria and were awake the next day.  A child and adult arrived in severe heart failure and both were improved the next day, sitting up and eating.  One man arrived with severe TB and couldn’t breathe, perhaps not immediately life-threatening, but severe.  Mix in a couple fractures, a couple abscesses, some minor cases of malaria, several cases of advanced cancer, an assortment of others and it was quite a day.  More Wind…

 

The next day (yesterday), I sat in my car at the end of the day, outside my house, after seeing them all improved and out of the woods, and marveled at what a privilege it is to be here and play a small role in each of these lives.  Our work is radically imperfect and under-resourced, and our Father sure could have found someone more talented and with more faith, more patience, more enthusiasm, more fortitude, more grace, a better disposition… But here I sit.  It sure isn’t easy, but it is good… for so many…

 

Each survivor will return to their simple lives and will have more opportunities to meet their wonderfully caring Father (the Wind).  Each patient and family receives caring attention for their pain and are introduced to Jesus and His tangible love for them, in such a unique way, like each of those He physically touched while He walked some other rural roads 2000 years ago.

 

Each of you who support this work play a significant role, as significant as my role, in saving these lives and introducing them to Jesus, because I can’t be here without the team which sends me through financial contributions…

 

Every life is a garden… there is no such thing as a garden without cultivated, purposeful, miraculous beauty and there is no such thing as a garden without a persistent battle against weeds, insects, storms and other destructive forces.

 

Years ago, I appreciated reading the description of the garden in “The Shack”, called a “fractal” – “something considered simple and orderly that is actually composed of repeated patterns”, explained by the character representing the Holy Spirit.  She tells the main character, Mack, that the garden which Mack describes as “the mess,” is his very soul. “This mess is you!  Together, you and I, we have been working with a purpose in your heart. And it is wild and beautiful and perfectly in process. To you it seems like a mess, but to me, I see a perfect pattern emerging and growing alive – a living fractal.”

 

My trust rests in my Father’s intervention all these lives in Cavango, and His ability to use all the (messy) circumstances here, both pleasant and unpleasant, for His eternal purposes.  The Wind…