On the Eve of Christmas

 (from Eric, adapted from our family Christmas newsletter)

Exodus 36:7: The materials were sufficient for them to do all the work. There was more than enough. 

I read this obscure verse this morning. It is describing how the people of Israel gave so much of their personal belongings to make the furnishings of the tabernacle that the craftsmen in charge told them to stop. “There was more than enough.”

Do you hear that provision? It hits my heart like a feast. We’ve known some times like that in 2023. We have seen our medical school flush again with graduates after several years of dryness. We have seen busy schedules align so that we can sign a new 5-year contract with our Burundian partners in good faith of what God will do in the future. We have seen patients healed and funds provided and small steps made towards better care given in the name of Jesus. We have celebrated together with our team what God has done in 10 years here. What have you experienced where it felt like “more than enough”?

But maybe those words sound less like a feast and more like a taunt. Where was the provision last week when we fought hard for a young man with kidney failure, only to have him die suddenly the day after (what we thought was) a successful discharge? Burundians’ crops are flooded this year, heralding a season of exceptional hunger. We didn’t see our daughter for 3 months while she started school in Kenya. Meanwhile, we’re covering extra classes for our boys because we don’t have enough teachers to help us this year. Where have you felt like “there was more than enough” just doesn’t measure up to reality?

Then I think about Christmas. I think about 400 years of biblical silence followed by a nearly unmarked birth in a stable in a small town. In fact, it was the most extravagant, overflowing, lavish gift ever, the epitome of “more than enough”. That was the reality, but in many ways, it didn’t feel like it.

Here on the equator, the sun rises year-round about 6 am. About 15 minutes before that, when it’s still dark, scores of birds wake and sing to greet the day that is not quite here yet.

The sky is dark, but the air is full of song.

It’s beautiful, and it’s every morning for us. It is glory mixed with darkness, but it lets us know that the day is at hand. It’s a good reminder for both the moments where we feel God’s provision as well as the times when it feels so absent.

The night of Jesus’s birth, angels sang God’s glory. The sky was dark. The air was full of song. This seems to be characteristic of God. Often in joy, often in sorrow, but always looking forward to his coming.

We pray grace to you this season to be able to hold on to this promise in both the ebbs and the flows that you experience.

VIPs

 By Alyssa

As one of the most developed hospitals in a small country, we get our share of VIPs, and there is always a tension at to how much time and energy to spend on them versus the rest of the patients. My sense is that this is a challenge in lots of places but especially for mission hospitals in developing countries where the goals of medical excellence, compassionate care for the poor, quality education for trainees, and financial sustainability can sometimes seem impossible to pursue simultaneously. 

Kibuye Hope Hospital's vision is to: 

"Develop a university hospital of excellence where the love of God is manifested to his creatures."

Our mission is:

"To glorify God through quality physical and spiritual care accessible to all and through the training of healthcare professionals and disciples of Jesus Christ."

I'd like to share about a few patients I saw yesterday who aren't particularly prominent by the world's standards but who I hope experienced the love of God at our hospital. I would love for them to walk away from this place after receiving quality healthcare by compassionate healthcare workers with the sense that they are seen and known as Very Important People in the eyes of our Heavenly Father.

1) Mama D (pictured above with one of our nurses, picture taken with permission). This mama is so faithful to care for her little girl through so many heartbreaking challenges over the last few months. She has been in and out of the hospital multiple times and has often stayed for weeks at a time due to complications from probable tetanus. Her mother faithfully keeps every appointment, feeds her and give her meds through an NG tube (and amazingly, the little girl is not losing weight or malnourished), and is attuned to every new symptom that means she needs to bring her back to the hospital. We had the chance to encourage Mama D yesterday that she is doing such a great job in caring for her daughter, and she just beamed. She and her husband display great faith in praying for their daughter and not despairing despite the myriad of challenges their little one faces. 

2) "Isaac" is a 13-year-old boy who came to his follow-up appointment in peds clinic yesterday for cyanotic congenital heart disease. When they checked his oxygen level in triage, they were so concerned that they sent him to the emergency room instead of clinic. But then they came to find me and I explained that his oxygen levels are always that low. Sure enough, Isaac entered my clinic walking and talking normally a few minutes later despite his oxygen saturation of 65%. Isaac is one of the oldest patients I have seen here with cyanotic congenital heart disease (probably Tetralogy of Fallot for the medical folks). He's actually still attending school and can walk short distances around the hill where he lives. It's difficult to decide what medicines to treat him with because the medical literature generally assumes patients with this condition had surgery to repair it as infants. He's currently taking three heart meds and seems to be relatively stable, so we refilled the prescriptions and gave him a follow-up appointment in three months. 

3) "Emmy" is the 7th child in her family and there were complications with her birth. She was resuscitated for a prolonged period of time and that resulted in neurologic complications. Now she is 2-years-old but doesn't walk or talk or even sit up on her own. This is unfortunately a very common story here. Her mom brought her to peds clinic to see if we could help with her development. Emmy smiles and seems aware of her environment but has very little muscle tone. We gave her a referral to a center nearby that provides physical therapy, but there's not a lot else we can do for her. We did explain that she is a beloved child of God, and her mom readily agreed! 

4) Mama A brought her son to the hospital because of a huge tumor in his eye. She heard that there was a center here that could treat this condition, so she traveled from quite far away with her son and his little brother. The boy has now been hospitalized in the malnutrition service for over a month. Unfortunately the cancer (retinoblastoma) was very advanced and already metastatic when they arrived. We have given chemotherapy with the goal of palliative care (to shrink the size of the tumor and decrease his pain), but the boy is still not well enough to eat or drink or talk. He will likely go home tomorrow to continue palliative care. I hope the mother leaves with the sense that she did everything she could for her child and that there is no shame or curse associated with the condition he has. I will miss greeting her and the little brother each day. 

5) "Arthur" is a 4-year-old boy with epilepsy who came to clinic for follow up. Thankfully his seizures are well controlled on treatment. He has only had one seizure in the last year. He has some developmental delay as well, but he is making good progress. His mother is pleased with how he's doing. We refilled the medication and gave him a follow-up appointment for early next year. 

We want to keep growing and improving in the level of care we can provide for all the patients at Kibuye Hope Hospital. And yet as some of these stories show, we can't always provide physical healing for them given the resources available in our setting. But no matter what medicines or treatments are available, we desire that the love of God be manifested to all the patients along with their family members. Our specific pediatric vision includes the phrase "welcoming children, families, staff, and students as Jesus welcomes us." Please pray that this vision will be realized more and more in this beautiful corner of the world.  

Making Virtual a Reality

While a good understanding of anatomy is important for the practice of medicine, it's foundational for the practice of surgery.  Knowing the relationships between structures can be the difference between curing the patient and causing irreparable harm.  Because of its foundational nature, in the U.S. anatomy and physiology is one of the courses taught early in medical school.  Around 90% of U.S. medical schools include cadaver dissection as a part of their curriculum.[1] Even as the pedagogy for medical education is transitioning to a flipped classroom model, the importance of in person time studying cadaveric anatomy is not lost on educators.  In fact, according to anatomy course directors, one of the most common weaknesses in anatomy curriculum was insufficient dissection time, a problem which was only exacerbated by COVID. [1] 

There are many factors that prevent us from maintaining and using an anatomy lab as a part of our medical curriculum here in Burundi.  Both the formaldehyde and refrigeration options for preserving cadavers are very expensive.  Then comes the practicalities of maintaining constant electrical supply or the safe handling and disposing of large quantities of hazardous chemicals.  All this says nothing of the cultural and ethical implications of obtaining cadavers on a regular basis...

So, what are we to do?  

Well, 11% of U.S. medical schools also utilize virtual software to enhance, and in some cases replace, the cadaver dissection portion of their anatomy courses.  In the post COVID era, a full 23% more plan to incorporate Virtual Reality in their anatomy curricula.  [1] While the data is a little old at this point, a 2015 meta-analysis of the educational effectiveness of 3D visualization technologies in teaching anatomy showed that it 1) improved factual knowledge, 2) improved spatial knowledge acquisition, and 3) improved user (aka student) satisfaction as compared to all teaching methods. [2]

Visiting resident Yves Yankunze having some one-on-one teaching time.  We had recently discussed hiatal hernias, so I was pointing out the relationship between the esophagus, vagus nerve, diaphragmatic hiatus and aorta/aortic hiatus.

Since I had the headset and anatomic models ready to go in our (mostly) unused OR 1, I was able to have an impromptu teaching session for the nurse anesthetist students rotating at our hospital.  It was a chance to show them the relationship between the upper airway, the trachea and the esophagus.  A critical understanding for successful and safe intubation of patients. 

When set up in the classroom, other residents are able to follow along with the teaching as I guide the student wearing the headset toward the relevant and important anatomy.

After a few back-and-forth emails, the medical director for The Standford Virtual Heart program graciously provided me with a copy of the software.  So after we finished our chapter on congenital heart defects, our residents had a chance to explore the defects and their associated flow patterns and murmurs in virtual reality.

For now, I'm focusing this virtual experience on our current batch of surgical residents.  Their need for recalling and understanding anatomy is the most pressing.  But the trial run has been well received and quite helpful.  I'm excited about the possibility of significantly expanding our use of VR into the anatomy course taught at Hope Africa University.  

Afterall, it's hard to build a solid house without a solid foundation...

[1] Shin M, Prasad A, Sabo G, Macnow ASR, Sheth NP, Cross MB, Premkumar A. Anatomy education in US Medical Schools: before, during, and beyond COVID-19. BMC Med Educ. 2022 Feb 16;22(1):103. doi: 10.1186/s12909-022-03177-1. PMID: 35172819; PMCID: PMC8851737.

[2] Yammine K, Violato C. A meta-analysis of the educational effectiveness of three-dimensional visualization technologies in teaching anatomy. Anat Sci Educ. 2015 Nov-Dec;8(6):525-38. doi: 10.1002/ase.1510. Epub 2014 Dec 31. PMID: 25557582.

Neonatology part 2

by Jenn Harling

In February I wrote a blog describing what our neonatal unit looked like in our new pediatric building into which we moved at the end of 2021.  I mentioned in that blog that I had attended a neonatal conference a few months prior (Oct 2022).  I had the lovely opportunity to attend that conference again this year.  This is not an ordinary neonatal conference, but rather one to bring together those who care for and treat neonates in Africa. I'll state the obvious in case it's needed - taking care of neonates in LMICs (Low and Middle Income Countries) in Africa is not the same as practicing neonatology in HICs (High Income Countries).  This conference focuses on educating and training as well as sharing up-to-date information regarding neonatal care around the world, and also (and possibly more importantly) innovative ways to treat neonates when all the technology and resources are not available.  

Not only is there a huge opportunity to learn, it's also a place to network and make connections as well aso talk to others who are also trying to find innovative solutions to challenges faced in a low-resource setting. I've met numerous people who are in similar settings and it is so helpful - "oh, do you have this challenge too? this is how we navigate this situation without _____ (insert resource that may not be available in LMICs like blood cultures, electrolytes, intubation, ventilators, IV pumps, arm boards, paging system, caffeine...). 

I have left this conference each year thinking "there is SO much to do at our hospital to improve the care we provide..." but then I looked back and realized we have already started the process!

Below are a few things that changed in our unit after attending last year's conference:

-Trying to keep a cadre of nurses in the unit who do not rotate out.

-Hand hygeine 

-Keeping a particular generalist doctor mostly in the unit when a specialist was not available to round.

-Updated feeding protocol with fortification of breastmilk

-Transfusion protocol to know when to transfuse neonates

-New neonatal ward manual in French being written

-more kangaroo mother care (skin to skin care), with hopes to increase even more this year

-humidification of oxygen

-patient tracking white board

-updated fluids management protocol

-hats for every baby in the unit

This year I hope to expand bubble CPAP and medical air and blenders amongst many other improvement projects. My hope is to write another blog next year to tell you all the things God has allowed us to accomplish! 

There is hand hygeine signage all over the unit now

There is a steady supply / stock of hand sanitizer in the pharmacy now.

Patient tracking board 

One of our nurses washing his hands before touching the baby on the warmer. 

COTW: Postpartum Complication

 by Rachel

Well, we often see strange and bizarre cases at Kibuye, that has not changed!  But it's been awhile since we've posted our old blog standby of Case of the Week.  FAIR WARNING that if you are squeamish about medical things, this might be a post to skip.  But for all the rest of you, I'm curious if you can figure out the problem.  Also, we could use some advice on how to best fix this patient, so contact me after if you have ideas.

This lady came to the maternity service about 4-5 days after a spontaneous vaginal delivery of her 3rd child at a different hospital.  She had no previous medical or surgical history (no previous C-sections).  She was transferred to us with a suspected small bowel obstruction, with some nausea and vomiting, but was passing gas and stool.  Bleeding was minimal.  She had not passed urine for several days.  She had a low grade fever but otherwise vital signs were normal.  Her belly was significantly tender and distended.  Hemoglobin was normal with a very mild leukocytosis.  

Now, this presentation is not terribly uncommon after C/S.  Many women are transferred to us with peritonitis after a C/S done at an outside hospital, and they end up with frank pus in the abdomen and usually a necrotic uterine incision that needs debridement.  This all causes an ileus, not an obstruction.  We see this at least once a month.  But, this lady had not had a C/S.  Also not uncommon is a diagnosis of uterine rupture after vaginal birth, due to trauma or fundal pressure given during second stage of labor.  But, this lady didn't seem to have the classic signs of uterine rupture.  No bleeding, no fluid wave in the belly, and a normal hemoglobin.

On ultrasound, nothing was visible due to a massive amount of gas in the pelvis.  So, we ordered an abdominal X-ray.  And saw this:

I know that it's not a great image (and remember we have no CT scans here) but that's a giant collection of air/gas in her bladder, and in real life we could see a very tiny amount of free air under the diaphragm.  So, we placed a Foley catheter and got out a large amount of gas and around 600cc of cloudy urine.  Strange.  She was started on antibiotics for a UTI and improved significantly within 24 hours of placing the Foley.  We discussed with surgery the need for an ex-lap, but given the patient's significant improvement decided to send her home with the foley for 7 days, and then have it removed at the first hospital.

She came back two weeks later.  After the Foley had been removed, her pain had returned and continued to increase.  She was unable to pass urine, and once we replaced the catheter, cloudy yellow urine came out, but the pain did not improve.  She was taken to the OR, where the surgeons found this:

You can see her urethra with the foley in place.  The small tubes on either side are her ureters.  But the bladder was just a necrotic pile of mush.  Best as we can figure, during her delivery her bladder had ruptured (??), but the uterus remained intact.  Given the late diagnosis, the bladder was not repaired immediately, and perhaps developed an infection, but regardless all bladder tissue died.  She's currently hospitalized with drains and a foley catheter, but there's no awesome urologist to send a case like this to, to create an artificial bladder.  Any ideas? 

We Never Stop Learning

(from Eric)

Roughly thirteen years ago this month, Rachel and Maggie and I visited Burundi for the first time. This was the first trip of our team to Burundi and the one that led to all the others, I guess. We were welcomed generously by the leadership of Hope Africa University. We spent five days in country, mostly in Bujumbura, only visiting Kibuye for a half-day.  We learned about the country and the work of HAU, in particular their medical school which was seeking faculty members like ourselves.

Walking around the main campus of HAU in Bujumbura, I ducked into a classroom, and I looked at the blackboard. Though I didn't speak French and didn't know then (as I do know) what the French acronym "OAP" meant, I caught a few words:

Bleomycin. Cardiopathy. Swan-Ganz catheter.

Why snap this photo? Well, without going into the medical details, I was both astonished and amused that in the middle of Bujumbura, on an old blackboard, students were being taught about relatively obscure treatments and invasive techniques that I was pretty such weren't available anywhere in the country. And years later, I can say that I was right: they're not available and possibly never were.

After years of medical school and residency in the US, and with about a year of African medicine (in Kenya) under my belt at that time, I had learned so much. We were looking forward to working in African medical education, and this blackboard struck me as the epitome of what we were going to better. We weren't going to teach archaic and inapplicable ideas to our students. We could do so much more.

***

Over the years, I have been surprised again and again by things I didn't understand. I remember the day years ago in the NICU at Kibuye when I realized that no one had any idea how to use the scale to weigh the babies. Weight gain in premature babies is truly a vital sign, fundamental to guiding what the doctor should do for the baby. I saw them randomly moving the weights of the balance around, and thought "what have I been doing for the past month?" (Obviously, the NICU has developed by leaps and bounds in the many years since I rounded there.)

Just yesterday, I was working on a small hospital project with some personnel and was again bowled over by my misplaced assumptions. In this case, I thought a certain person would certainly understand some particularly fundamental medical concepts. Nope. So I walked up and met with him for a while, trying to find out exactly where he was at, because it certainly wasn't what I had thought.

Fourteen years after moving to Africa, and I keep getting surprised at what I mis-guess or misunderstand. Each time, I learn a little more, but there is always something else that pulls the rug out from under me. Something else that I didn't understand and therefore I wasn't really engaging the situation correctly.

***

Today, I walked home from the hospital after some late afternoon teaching to our post-graduate interns on bleeding disorders. It had been fun. A new challenge to try and discuss a relatively complicated subject in an effective way, somehow reaching out across the void between me and them to connect.

I thought back to the Swan-Ganz catheter blackboard of 2010. Even now, I don't want to teach like that. I still believe we can do much, much better. But thirteen years later, I would say that sometimes there are reasons to teach things that are beyond the technology available around us. Sometimes students want to know, or maybe it's coming soon. Sometimes I find that a certain point may not be clinically relevant to them, but it can help illustrate a physiology concept in a useful way, so I try to use it to a different end. In other words, I think my approach to this question is more nuanced now.

I'm tempted to look back at my "one-year-in-African-medicine" self in 2010 and think that I didn't know anything then. But that's actually quite unfair. After years of training to become a physician attending, and a year in Kenya, I actually knew a lot. I had learned and learned and had my paradigms upturned and readjusted again and again. 

It's just that I didn't realize how many more times I would keep learning. I didn't know how beyond one mountain there would always be another mountain. How I would just continue to be surprised and made to feel like I was back in month one over and over again.

It would be folly not to take this recollection and flip it forward. I suppose I will continue to be surprised. I wonder what I will know in five years that I understand more incompletely now. I think I can legitimately say that I've learned a lot, about medicine, about a totally different environment, about how to go about effecting needed change. But I'm also learning just how much more I have to learn.

***

PS. on a somewhat related note, Glory Guy's father Bobby has a healthcare business podcast and interviewed me over the summer. Click here for about 15 minutes of us chatting about how experiences here have shaped my lens on healthcare.

Taken Away My Shame

by Rachel 

Every Monday I have OB-GYN clinic at the hospital. It usually runs from 9a-5p and I see sometimes over 40 patients. The pathology is variable, but the type of women that come to see me is also quite variable. Sometimes it’s a little hunched over old widow, wearing no shoes and a dirty wrap, coming to see me for her uterine prolapse. Sometimes it’s a fancy looking woman with well done hair and perfume, accompanied by her husband holding car keys and a giant stack of medical tests, seeking help for infertility. I see farmers and teachers, nurses and business women. They come from Kibuye, Gitega, Bujumbura, and even sometimes Tanzania. Young and old, rich and poor. All seeking the hope of healing in some way or another. That last piece can be hard to remember in the crush of the day, with a long line of patients and a large stack of charts waiting. Trying to get through the day, skipping lunch, going as quickly as I can...but trying to remember the humanity of each person and their own brokenness in some form or fashion. That they need hope. 

One such patient came to see me about nine months ago. She was actually a nurse, a maternity nurse no less, at a different hospital. Her first pregnancy had ended in disaster: she went into labor at term with a healthy baby but her baby's heartbeat had started to look distressed. They performed a C/S for her, but her baby died just after birth. This is sadly not an uncommon scenario, but for it to happen to someone whose profession is to deliver healthy babies...a double blow. There is a falsehood that I probably subscribe to at some level as well, that a better job or more financial resources somehow guarantees a certain outcome in health and in life. This is not always true. 

Well, she was pregnant again, now just 5 months after her first loss. I placed the ultrasound on her belly and we were both surprised to see not one but two heartbeats: twins. This is usually joyful news, but does cause a bit more apprehension for the obstetrician! Her risk of another loss due to miscarriage or fetal death was somewhat higher, so we made plans to follow the pregnancy more closely, having her come back for follow-up visits every 4-6 weeks. And I can say that the rest of the pregnancy was wholly unremarkable. I wasn't even the one to follow her for the most part, my generalist colleagues being fully capable to perform her ultrasounds and follow the babies' growth. Her C/S was scheduled at 37 weeks' gestation. I don't even do very many C/S any more, because there are so many well trained doctors working at Kibuye these days, but that morning I happened to walk into the OR before the day had even started, and she was already on the OR table, prepped and ready to go. So I scrubbed in, said a prayer, and began the surgery. 

First, a girl. I held her up over the drape for the mom to see her and announced, "Bukuru!" The traditional Kirundi name of an older twin. The baby girl screamed her lungs out, and the mom began sobbing. Then, a boy. "Butoyi!" The younger twin. I likewise help him over the drape and the mom sobbed harder. It was, like the pregnancy, an unremarkable C/S. But as I closed up the layers and dressed her incision, a song that we sometimes sing in church came to my mind. "My beautifier, you've taken away my shame, you've taken away my pain. You've made my life so beautiful." And I couldn't help but think about how this pregnancy HAD taken away shame for my patient. Shame of feeling like she had done something wrong, that despite her profession she couldn't save her first baby. Cultural shame of not yet being a mother. These two babies HAD taken away the pain of childlessness and the loss of her first baby. Maybe not completely, as cases like this are intense joy mixed with intense pain, but healing has begun. The loss of her first baby will always linger, but redemption is now happening. Life is being made more beautiful for the loss and the pain and the joy and the new life. And I'm glad that God allowed me to be a part of it.

Shopping

(by Michelle Wendler) 

Here's a glimpse into what shopping in one of the country's largest "malls" looks like.

You first need to navigate a 40 min drive from Kibuye to Gitega. The road is challenging in many ways, from livestock, to pedestrians, and many bikes. And everyone trying to avoid the many potholes and other cars and motorcycles on the road. 

Here are some pictures I've taken of people transporting along the roads:

Once arrived the "on foot" part of the adventure begins. There is no "parking lot" here. You can park along the road or in front of a little roadside shop and walk to the mall. Crossing the streets is always fun, with cars, bikes, pedestrians in a mishmash trying to avoid each other. Many horns honking, people yelling, frantic running when the right moment comes. If you are a white person, you can expect to hear many people yelling "muzungu!!" because it's so rare to see one here. I've actually never seen another muzungu in the market. 

Along the main road is the fabric district with many little shops selling bolts of African fabric and many people sewing using pedal sewing machines. 

Upon entering the mall there are many ground level little booths where people are selling many things, like shoes, beans, rice, metal objects, fabric, etc. Most of the clothing items are not new, but are second hand. The shoes are washed to look pretty good though. And the prices are right. A pair of kids shoes will cost around 20,000 fbu with is around $5. 

Once in a while you might have to dive out of the way of someone transporting fresh meat to the meat shop. Fresh meat is usually a freshly butchered cow skewered on a pole and being carried by two men as blood drips on the ground. 

If you are looking for clothing you climb stars to the second story of a two story building. I've often wondered the journey of each item of clothing. I've seen an item with a Marshalls clearance tag, then a thrift store tag. They ship these clothing items in large bundles tied in twine to Africa from all over the world. The 2nd hand items that couldn't find a home elsewhere are welcome here. Sometimes there are piles on the floor to look through, or neat piles folded on tables. Sometimes you can find shops that actually hang things with homemade hangers. 

Bartering is the name of the game. People will be yelling one price while the shop owner is trying to get a higher. I've found that I always need to go with a local who knows the actual price that things should cost...otherwise I'll pay 10x the correct amount. 

Another thing to get used to how they will try to draw you into their shops. Sometimes they will grab your hand and pull you in. But seeing kids and babies everywhere is something I enjoy. This is a culture that loves family and kids. The little ones will often stare at my because it might be the first time they will have seen a white person. 

The vegetable market is outdoor but covered and is situated along the street. I love the colors in this part of the market. Thankfully I don't have to come all this way to buy our perishable items because we pay a local to come and do a large purchase for our team once a week. Such a gift, especially with gas prices and availability being so problematic. 

Malaria, Mystery and Mitigation

 (from Eric)

One of the obvious differences in practicing medicine in Africa versus the USA is that there are diseases that you have to master here that you wouldn't know how to treat had you not come.  Foremost among these is malaria.  Despite a few locally acquired cases in Florida and Texas this past summer, malaria is basically unheard of in the United States.  At the end of medical school in the US, I had learned some about the disease, but only really on a theoretical level.  I had forgotten most of what I learned, and certainly had no practical experience.

Malaria parasite infecting a red blood cell

But on a worldwide level, this disease is huge.  There were about 250 million cases last year, with over 600,000 deaths, and 95% of them are in Sub-saharan Africa.  Malaria is transmitted by mosquitos that infect the blood, and it can cause lots of different complications in the brain, in the lungs, in the kidneys, in the spleen, etc.

Here in Burundi, for many years, malaria was my number one diagnosis.  As in, more than 50% of my patients were admitted with some severe complication of malaria such as kidney failure, severe anemia, or a deep coma.  Many of them died, but because of good treatments that are available, most of them could live and their recoveries were sometimes quite dramatic (and very gratifying!).  It's a complicated disease, and so it was probably the disease that I spent the most time teaching my medical students about.

Malaria is around all year, but it is also highly seasonal.  I think it was 2017 and 2018 that Burundi declared back-to-back epidemics (with 2019 numbers being quite high but no epidemic officially announced).  The number of cases was more than 80% of the total population.  Most everyone was getting malaria.  Many people got it multiple times in the same season.  Then, starting in 2020, the epidemic rates seemed to be decreasing.

Enter 2023: This year, we have had virtually no malaria.

We are now at the end of the would-be "malaria season" and yet the numbers never rose.  Less than 1% of our tests are positive.  I have no malaria patients on my service, and because of the significant contribution this disease makes to hospital census, for the first time since our team arrived, instead of a steady rise in patients numbers, hospitalizations are actually down.

Kibuye's head lab tech performing malaria microscopy

What happened?  Good question.  There are very effective malaria prevention strategies, including indoor residual spraying and distribution of insecticide treated bed nets.  There is a national malaria program that is hard at work, but as far as I know, they were hard at work even when Burundi was suffering repetitive epidemics.  Médecins Sans Frontières (i.e. "Doctors without Borders") provided a great service to our hospital for a couple years, paying for treatment of all patients hospitalized for severe forms of the disease. But it seems hard to understand how that effort would result in so much prevention.

Christianity refers to an idea called "common grace".  This is a characteristic action of God, who sends rain and sun on everyone, the evil and the good, the just and the unjust (Matthew 5:45).  Across the country, Burundi has experienced common grace in the reduction of malaria this year.  Long may it last.

It strikes me that this situation demonstrates two characteristics of common grace.  First, it is mysterious.  Why did this happen?  Is there a direct cause? Nothing leaps to the eye.  But understanding something is not a prerequisite for being thankful for it.  Second, it is easy to overlook.  Being thankful for the absence of something is not what any of us are good for.  Something amazing has happened to Burundian health this year, yet we are all prone to overlook it because it is something amazing that did not happen.  It gives me pause to think what other grace in my life might be mysterious or invisible enough for me to overlook it.

Water Security at Kibuye

(By Caleb)

In university my studies focused mainly around Water Resources Engineering.  Surprisingly, in my current role here at Kibuye, I do not get to put my degree to use very often, strictly speaking.   However, over this last year, a very generous gift from a friend of the team has enabled us to make a concentrated effort to increase both the quality and quantity of water available at the hospital.  

Despite our best efforts over the last 10 years the hospital continued to experience periodic water outages.  As you can imagine, the lack of water affected the ability of the hospital to function at just about every level.  With the construction of new ferro-cement water tanks, new pipelines, some new controls and a new disinfection system, I hope that our water woes will mostly be behind us!

Planning out the location for these new tanks and a pump house.  There is space for five tanks, but we started with 3.  Each tank can hold 100,000 liters.

Setting out. 

Laying the foundation.

Beginning to lay the reinforcement and starting to construct the small pump house in the background.

With the ground slabs poured, they begin to tie the reinforcement of the walls.

With the reinforcement cages finished, the plastering begins. 

Two tanks complete and curing under hessian coffee sacks.  

Finishing the plastering on the inside. 

A visit from a local inspector.  

After close review, final approval received!  

Tanks complete!  Only awaiting paint after curing.  The hospital's water storage used to be a mere 60,000 liters.  Now with these tanks we have 360,000 liters.    

More curious inspectors checking on the filling process.  

This is our new Ultraviolet disinfection system.  Recent water quality testing showed that we can now drink the water straight from the tap!  

     

Article from Eric at MereOrthodoxy

 Hi everyone.  I recently had an article published at MereOrthodoxy.com on the subject of Lamenting and Rejoicing at the Same Time.  I'm glad for a chance to share it in that venue, and here is the link for any of you that would also like to read it.

(image just a screen shot.  Click the link above to read)

When I'm not treating children...

by Jenn

Before moving to Burundi, I would say I had a black thumb and knew nothing about animals. If I had read a book in the past 10 years, it was likely about the developing fetus, NOT how animals develop.  

Three and a half years after moving here though, I can say that I have become a budding gardener, and have successfully watched the process of chicks hatching.  I phrase the latter that way, because it's truly magnificent how LITTLE I contributed to the process of chicks hatching.  

Maybe not all of you know, but about a year ago, just after arriving back from home assignment, I had a hen house constructed and brought home some cute 3-month old pullets. 

Eight to be excact. But in a few short weeks, we realized that in fact we had one cockrel. 

Two terms I learned at that time : pullet - a young female chicken who will grow into a hen. Cockrel - a young male chicken who will grow into a rooster.  The girls named him Handsome.  

Sadly, he became too lound and so he .... well, let's just say he's not around anymore...

The seven ladies grew like weeds and started producing eggs around 5-6 months of age. Which is pretty typical. Good job ladies. We have been enjoying lovely eggs for the past year. They produce 4-7 eggs/day. 

One day a few months ago, I noticed one hen having some odd behavior. She was not leaving the coop and sat on all of the eggs all of the time. She would leave the coop maybe once to eat, drink, and poop, but otherwise didn't move much. I wondered if she was getting sick, but then a lightbulb went of... she's brooding! 

Another term I learned - brooding - when a hen spends most of her days and nights sitting on the eggs in order that they may hatch. She wanted to be a momma. 

This is great IF you have fertilized eggs and want chicks. I didn't think I had time or bandwith at the time so I tried to break her habits. Note, she does not lay eggs when she's broody, so we weren't getting any from her during this time. I gently took her off the nest multiple times a day and encouraged her to NOT brood, but to no avail.  

Enter Issac. 

A teammate was gifted a rooster one sunny Friday afternoon and he asked if he could "store" his rooster in our coop until....well, let's just say the plan was to have him go to the same place Handsome went...

I said sure, and another lightbulb went off.  CHICKS!

I won't go into details, but suffice it to say all of the ladies produced fertilized eggs for at least 10 days, some for two weeks! 

Another thing I learned - the momma hen actually doesn't produce fertilized eggs. Well, maybe she was fertilized, but she wasn't producing egs... therefore no fertilized eggs.  She was already in broody mode, so her little hen body had stopped producing eggs when she went into "I want to be a momma" mode.  

How do I know they were fertile? Well, I did a lot of reading (because - see first paragraph - I had NO idea what I was doing) and realized you could look in the yolk for a white dot with concentric circles starting to form. So that's what I did.  Here's an example of one of the eggs I cracked 24 hours after Issac's arrival.

You'll see a tiny white dot - the egg is fertilized!

Since the ladies produce tons of eggs, and the momma can't sit on dozens, I marked some with a sharpie and let her continue to sit on those, while collecting and eathing the others that the other ladies were laying. 

Something else I learned, you CAN eat fertilized eggs.  They don't develop unless they are incubated. 

I also read about candeling - an essential step to see if your eggs are developing, or if she is just sitting on eggs that will become rotten. I didn't get a good picture of me doing it, but here's what candeling an egg each step of the way should look like.

Also - clearly I need more experience in this... see later in the story. 

Twenty-one days went by (that's how long... or SHORT it takes for a chick to go from the picture you see above to a fully developed chick that can stand, eat, and drink just after it hatches! God's design is amazing!)

I let the momma incubate her eggs in the coop becuase I really didn't have another place to put her. Not ideal, but it worked. 

The first chick "pipped" (made the first crack in the shell) one morning but when I came back it looked like the other ladies had started to peck at the chick in its egg. Not good - they will attack it and kill it. So I moved the momma, the hatching chick (who I didn't think was going to make it) into a bin and put the bin in our half bathroom with a space heater.  Well, the chick made it! And was named Cookie. Then another one hatched the day after!  They huddled under their momma and they were SO cute. 

The first 5 chicks that hatched did really well and are still growing! Two other chicks hatched but they didn't survive, and three of the eggs didn't develop (hence my need for improving my candling skills.  Despite the brief sadness of the two not surviving, we were thankful for the 5 that made it! 

Once there were no more eggs to sit on, the momma hen was getting quite restless, standing up in the bin and trying to get out.  So we moved them to the back portch.  That lasted for a few days until they all started escaping the enclosure.  

We decided to put the momma back outside where she could eat, drink, poop, scratch, and move about on her own terms. 

And the chicks went back into the bin in the bathroom with the space heater. 

They too started to get a little restless, and so we created a little enclosure inside the chicken run so that they could have their own outside space.  Not pictured, but we created a little slatted door/gate so that they coudl get in and out of this little corner but the bit ladies could not. 

They are super happy outisde! 

They still come in at night and sleep in the bin.  

Amelia, Madelyn, and Mark have LOVED this experience, and I have learned a lot on the way. And let's be honest, I've loved it too! 

Touch base in a few weeks... maybe then we will know if they are cockrels or pullets! (We're hoping for 5 girls!)