The Patience-Producing Publishing Process


by Carlan

Our team has been blessed with the opportunity to share some of our reflections, observations, and developments with others. Some of us have recorded music (Michelle still gets royalty checks from time to time). Some of us have published whole books (Eric’s book). Many of us have participated in the process of scientific-medical research and journal publication. All of us have posted on this blog and everyone in the whole world has shared something on social media.*

As a physician I have been fielding lots of questions from friends about different preventative measures, vaccines, medications, and treatments for COVID-19 over the past year, a year in which I have been getting more personal experience with the process of publishing research studies. I wanted to share some observations from my own heart as well as elucidate a bit more of why the process is so slow. I hope that the reader will thus understand why controversies over specific treatments or the impacts of preventative measures continue.

Publishing in a peer-reviewed journal starts with a question. It could be a very general question like, “how do I treat malaria if we run out of our usual medication?” or a very specific question like, “is it safe to perform a lumbar puncture on an AIDS patient with a CD4 count <200 in the setting of behavioral changes?” Then you look for evidence published by others that can answer your question. In the case of the first question, the Burundian Ministry of Health has a whole treatment protocol dedicated to malaria and it includes first- and second-line treatment regimens. In the case of the second question, there are related guidelines from many institutional and professional bodies which don’t specifically address the behavior changes as well as some peripheral data from journals about the eventual diagnosis in such patients with those behavior changes.

Occasionally, you pose a question that is not yet directly addressed in the published evidence AND is amenable to you studying it. This happened with one of my students in 2018. We wanted to know if the surface area of a Burundian’s hand was really about 1% of their total body surface area. You see, we use the surface of the patient’s hand to estimate how extensive a burn is, especially when it is large and irregular in coverage (like a splash burn from a pot of boiling beans). There were some studies in other populations that showed it was variable, but almost no one had ever looked at Africans.

So in 2018 and 2019 we traced the hands of hundreds of patients and collected data about their age, gender, height, and weight that would allow us to estimate their total body surface area (TBSA). We plugged in the formulae and compared the measured surface of their hands with 1% of their TBSA. Lo and behold, it was significantly different. Now I felt an ethical obligation to share this finding with the broader community. You see, overestimating the extent of a burn might lead the clinician to give too much fluid in resuscitation. Especially in kids and especially in settings where malnutrition is a consideration, overly aggressive rehydration can lead to swelling of the brain and fluid on the lungs…neither of which is benign.

So my colleague and I (he had graduated med school in the meantime) wrote up our results as a paper. We triple-checked all the figures. I spent hours reading formatting guides for various journals. We looked at similar types of articles to get a sense for how verbose or succinct we needed to be. I had Randy Bond look over the draft of the paper and made corrections based on his feedback.
These med students solve other challenges to writing in Kibuye.

When everyone had signed off, I went through the somewhat convoluted process of breaking the paper into its constituent parts and submitting them separately so that the online submission tool could build them back together as a PDF. Then I waited for a bit over a month. Two out of three reviewers had asked for “major” corrections, so I redid all the figures, added another table of data, and resubmitted. Then I waited for a bit over a month. The rebuilt PDF was formatted incorrectly. So I broke it back into its constituent parts and resubmitted everything. Then I waited.

That is where I am today, waiting for a decision from the journal editors as to whether or not my revisions pass muster and to know if they have a spot to publish our findings. What started as a question and some data in 2018 is still unpublished in early 2021. I need also to say that ours was not a complex study. The data set was relatively small (~350 patients). The math was pretty straightforward (multiplication, averages, Student’s t-test). In all, it took about 3 pages to report everything.

We might get accepted by this journal. We might have to start the process over at a different journal. (You are not allowed to submit to multiple journals simultaneously, so rejection results in lengthy delays.) Yet I find in this process that God is teaching me some valuable lessonslessons that I should have learned by now but that show His incredibly patient love towards me. 

First, to be hurried is to be harried. A friend of mine told me recently that he doesnt read newspaper websites anymore because they are too slow. He gets his news exclusively from Twitter. I understand that instinct, to want to be on the cutting edge, to hear in real time what is happening in the world. But at some fundamental level, God did not design me (or you, I would contend) to be au courant of everything all the time. Eternal omniscience is distinctive to God. When I submit to that, I feel more relaxed and at peace.
One of my favorite musicians/authors.

Second, God wants us to be subject to process. Think of it, God invented time. He Himself was not subject to process. There is no necessary order of operations or steps 1, 2, and 3 for God. As He is He thinks and He does. The theological term for this is Godsimplicity and I cant stop thinking about it. There is no space or delay between Gods character, Person, will, and action. This makes it all the more remarkable that Jesus came down as a baby and grew in wisdom, in stature, and in favor with God and men (Luke 2:52). Furthermore, God established some processes. A sabbath takes 24 hrs because it is a day. You cant hustle a sabbath. A gestation takes 9 months. You dont want to accelerate a pregnancy. From digestion to development, from germination to glorification, life requires process.

So as I hit refresh once again to see if that paper has been accepted for publication, I call to mind Gods gift of process. As I sit typing in California instead of treating and training in Kibuye, I remember that God has chosen a slower pace for my sanctification than I thought best. And as you navigate your social media feeds and the rancorous debates about the science of vaccines, masks, school reopenings, and repurposed pharmaceuticals, I hope you are able to appreciate a little more why good answers in a complex world come slowly.

The greatest encouragement to publish our data.
*I realize that there are some folks alive who have not actually posted on social media…it just feels like all eight billion people are using some form of it these days.


The Hardest Thing

 by Jess Cropsey

Our life in Kibuye is pretty comfortable. We have a nice house with appliances, indoor plumbing, and tile floors, all luxuries that most Burundians don’t have. We (now) have relatively reliable power, water, and internet. So when people ask me, “What’s the hardest thing about living in Burundi?”, my answer has always been pretty immediate — being away from family. Yes, for sure there are a host of other challenges including cultural and language barriers, limited resources, and conflict. But the hardest for me has always been missing out on time with family and sharing special events like birthdays, holidays, and family vacation. We’ve had nieces and nephews that we never got to hold as babies. While I appreciate how travel and communication are much easier than they once were, that separation has always felt like the biggest sacrifice, only now the scope has widened.

Last weekend, 3 Kibuye families dropped off their kids at Rift Valley Academy (RVA) in Kenya, a boarding school for missionary kids. The Watts were the first brave souls from our team to embark on this venture. Faders and Sunds sent their oldest girls there last year. This year, it was our turn too. For 4 years, I have watched these parents grieve sending their kids away and navigate parenting from afar. I’ve listened to their pain and watched them weep. I don’t know why it surprised me how incredibly hard it was to leave our daughter Elise (8th grade) last Friday. 

Of course it didn’t help that we faltered on our final decision multiple times in the days leading up to travel due to a rapidly changing situation with new information from the school about online options, rising covid numbers in Burundi & Kenya, land borders closing in Burundi, changing test requirements for travel, and increased mandated quarantine times, all of which made us second guess this decision.

And yet as our family considered the situation, we remained convinced this was the right choice for Elise. In her 7 academic years in Burundi, she’s had an age mate twice for less than a total of 1-½ years and both were boys. Over the last few years, one after the other of the older kids she was grouped with have gone away to RVA. She’s longing for friendship with others her age in her heart language and we can’t provide that for her here in Kibuye. She needs discipleship, social interaction, extra-curricular opportunities, and a larger community.

Elise with new classmates

RVA is an amazing place with staff who are dedicated to loving and serving students and their families in a wholistic way. Yet as a parent, it feels like such a big loss to send her out of the nest 5 years earlier than most people have to. The cost feels immense and I’m so jealous that other people are going to be the ones to hug her when she’s sad, to make her birthday cake, to help her with a problem, to answer her questions about homework, to make special memories with her, etc. 

Elise's dorm parents who, I hear from many people, are amazing!

Elise's dorm, complete with a really nice yard and beautiful view of the valley

Getting settled in her new room

I know the time always comes when parents relinquish those roles, but it just feels too soon right now. And while I know in my head that RVA is a good place for her, my heart is broken and so very sad. I now really understand the feelings that my teammates have shared over the years.

Getting some final snuggles in during orientation

Lord willing, tomorrow I’ll be getting my 4th covid test in 12 days (technically 5 since one guy decided to give me both throat & nose tests in the same sitting) and after a negative result the following day, will be released from a 7-day quarantine at a hotel in the capital city. I’m looking forward to seeing John and the boys again but I know that grief will linger as I walk by Elise’s empty (and now always clean!) bedroom, set 4 plates on the table for meals instead of 5, or realize that I don’t need to order as much produce each week or do as much laundry. 

Please pray for Matea (11th), Anna (10th), Micah (9th), and Elise (8th) as they transition to a new year at RVA (and the Sund kids too). While Micah & Elise are the new ones this year, even returning students have adjustments to make as school is so different with masks and social distancing. Pray that they would grow academically, socially, spiritually, and emotionally. And don’t forget to pray for their parents too.

(left to right) Anna, Matea, Piper, Elise, Ella, & Micah, 
all current or former Kibuye Kids now attending RVA


Still Learning

by Rachel

As for many people this year, we've had to be quite flexible to figure out a way forward with school in the Covid era.  We are very thankful that we've had the capacity to continue with in-classroom schooling!  And as most of you know, our teachers arrived, safe and sound, in early December so since Christmas Break we've been "back to normal" around here.  One thing that we've done in previous years that we've been able to continue this year is one of the kids' favorites, Learning Experience Day.  Once a month we take a break from regular school in order to focus on one specific subject, learning through nature walks, videos, games, and projects.  In past years we've explored everything from construction and solar panels to chickens and germs.  I thought I'd give everyone a brief recap of our themes from this year so far.  Enjoy...we sure did!

September: Owls and Raptors.  A throwback to a similar day from 2017, we were able to observe both a barn owl and several local hawks, in addition to learning about bird beak adaptations, dissect owl pellets, and sew cute baby owls from socks!

can you spot the hawk?

owl pellets

Bird "beaks"

October: Rocks.  While unable to actually tour our local quarry due to safety restrictions, we hiked to an overlook to observe heavy machinery mining and making gravel for the road.  We also had fun categorizing and observing rocks and minerals, and wrapped up by creating artwork and stories from rocks.

the quarry is behind us in this picture...dust from the gravel creation
A little mascot we picked up on our rock walk

Some story/rock art

November: Cows (and Cheese/Dairy): We spent some time learning about cows, dairy farms, and properties of milk before trying our hand at cheese making! (moderately successful, at least) In the afternoon, we got a tour of our friend Fidele's farm across the street from the hospital, where the kids got to see pigs, guinea fowl, chickens, and cows.  A worker even showed them how the cows get milked.

cow getting milked

January: Kingdom Fungi: With the arrival of new teachers, we didn't know we were also getting mushroom experts!  Steve and Mary took us on a mushroom hunt where we found a TON of different varieties growing around Kibuye.  We learned about fungus, yeasts, and molds (plenty of that in our wet and warm environment here), did some science experiments and observations, and made some spore print artwork.

look at the variety of specimens collected!!

spore prints

mushroom art!