COTW: Tuberculeus Adenitis, PEPFAR and Education

 (from Eric)

Over the weekend, some of us were talking about the recent lack of medical blogs.  This is largely driven by the fact that, when you've done something daily for several years, you start to think "what is there to talk about?  It's just everyday normal stuff."  Not only is our daily work not-normal for the majority of this blog readership, but we in the daily grind need fresh ways to "see" what is around us, particularly when it proclaims goodness and hope, though the white noise of the everyday threatens to drown it out.

So, in that spirit, our first Case of the Week (COTW) in the last 11 months.  =)

My first morning back on Internal Medicine last week, my students guided me to the bedside of a new patient.  A young man in his early thirties, he had swelling on both sides of his neck that was quite painful, in addition to multiple weeks of fever and poor appetite.  Just before coming to the hospital, he had gone to a local nurse-run health center, which had tested him for HIV, which was positive.

The students wanted to know if I knew what was causing this neck swelling.  Yes.  Yes, I do.

Note the swelling on the side of the neck and the skin breakdown where it had been oozing.

Painful swelling of the lymph nodes on either side of the neck muscles in an untreated HIV+ patient with a couple weeks of fever and poor appetite in Burundi is about 99% certain to be Tuberculosis.  In fact, he even had the classic matted appearance and evidence of past oozing fistulizations which are typical of TB. We put him on TB medications (which are free) and contacted our HIV nurses to come and get him into the system to start ARVs in the next couple weeks (which will be free).  He slowly started to feel stronger and we let him go home yesterday, but he'll return in a week to start HIV medications.

***

For me, this guy is about as simple as my cases get, but I peel back the veneer of a To-Do list checkbox and find a number of things to celebrate:

1. THE PATIENT: This young man is probably going to do great.  Yet without a proper diagnosis and the medications for his problems,  he would likely die, from his TB alone, even more so from HIV.  His TB is curable.  With proper treatment, he can live a long and healthy life with his HIV.  It is a changed life, and I got to be a part of it.

2. PEPFAR: I don't think that most Americans are aware that the US has spearheaded the largest global health effort against a single disease (until Covid) via PEPFAR, which is the US President's Emergency Plan for AIDS Relief.  It was started in 2003 by George W. Bush, and has continued since then.  This fund has provided care in over 50 countries and is estimated to have saved over 20 million lives, largely in Sub-Saharan Africa.  The US is not extraordinary in regards to foreign aid compared to other rich countries, but PEPFAR is a great example of something America has done that has truly changed millions of lives.  

15 years ago, medicines for HIV would likely have been unavailable for this young man.  Around 10 years ago, it was found that, if someone is well treated with ARVs for their HIV, their ability to spread it to someone else drops dramatically, which has caused policy makers to try to get everyone with HIV on treatment, since it was prevention as well as treatment.  Now, though considerable challenges exist in implementation, the difference feels palpable to me.  Yes, this guy came in with previously undiagnosed HIV, but these cases feel increasingly uncommon.  This is a very good thing.

3. EDUCATION: I don't know the mental image of the above story that automatically comes to you.  But if it didn't include the white coats of at least 15 trainees or various stripes (medical, nursing, allied health), then it wasn't accurate.  All of this was an opportunity for these growing professionals to see a problem that they should be able to correctly diagnose and manage the next time.  HAU currently has hundreds and hundreds of graduates that trained at Kibuye that are now working all over the country and the region, and this was another small moment to help them to do that future work better.

A role I thought I'd never have and a bit of gardening

(by Jenn Harling)

"Chef de Service, Pédiatrie" - that's my current role at the hospital - head of Pediatrics.

REWIND to one year ago, during our "vision trip" the summer of 2019.  This is how I imagined it would play out:

• September 2019 - We would go back to the States to deliver Mark (our third child) and I would have learned enough during our vision trip at Kibuye to be able to round on my own when we came back in January 2020.  Just enough to scratch the surface of the vast amount of information there is to learn regarding pediatrics at Kibuye, but enough to take care of patients and be in a position to continue learning under Alyssa and Logan. 
• End of 2019 - Alyssa (head of Peds at Kibuye...well, the only Pediatrician at Kibuye) leaves Kibuye to return to the States for home assignment (furlough) for an anticipated 5 months.  Logan Banks would take over the role of head of pediatrics while Alyssa was gone.  
• January 2020 - I would return to Kibuye in January, Logan would be head of Peds until Alyssa returned in April and during this time I'd be gleaning information and wisdom from the docs who are used to this stuff, who go to the department meetings, who fix problems, who run the pediatric specialty clinic, who know how the hospital works, how the feeding program works, etc etc etc... 

Enter.... need I even say it? 

Alyssa was stranded in the States and the Banks left for home assignment in April.  

I was named head of Peds in April. 

This is how I saw myself at that moment in time: Dr. Jenn Harling, who had never taken a tropical medical course.  Who had just finished the chapter in a tropical medicine textbook about malaria because she had so much to learn and people were asking questions expecting the expert, the specialist to know the answers. Who at that point didn't know all the names of the nurses on Peds.  Who never expected this responsibility, this title. 

Do you know what I've learned? None of those qualifications or un-qualifications matter in the kingdom of God.  God will accomplish His will despite my readiness or my unreadiness, despite my breadth of knowledge or lack thereof, despite my not-so-great medical French and essentially non-existent Kirundi, and despite my imperfections.  

"Moses said to the Lord, “Pardon your servant, Lord. I have never been eloquent, neither in the past nor since you have spoken to your servant. I am slow of speech and tongue.” The Lord said to him, “Who gave human beings their mouths? Who makes them deaf or mute? Who gives them sight or makes them blind? Is it not I, the Lord?"

Exodus 4:10-11

These past six months have been such an amazing time of growth, learning, and stretching for me. And a whoooole lot of being humbled.  I can't count the number of times I've said "I'm not sure, I'll need to look that up" or more frequently "I'm not sure, I'll have to talk to Dr. Alyssa and get back to you."  God knew Alyssa wouldn't come back in April. He knew Logan would be leaving in April.  And it just so happened that He placed a pediatrician to be at Kibuye when otherwise there wouldn't be.  He is sovereign and so so good. 

_________________________________

Since Michael and I job share, I work Mondays and Tuesdays and some weekends, and he works Wednesday through Friday and some weekends.  That means I'm home a good amount and while I'm not taking care of the children, I'm tending to household things, working on lectures, etc.... and sometimes find time to do some gardening ◡̈  Turns out I love it!

Here are a few pictures of some things we've tried since being here!  

Our first two tomatoes 

Carrots, pole beans, bush beans, tomatoes, broccoli, parsley, hot peppers, lenga lenga, celery, Swiss chard. 

We ended up with baby carrots. The girls loved snacking on them! 

Brussels sprouts plants

Baaaaaaaby brussels sprouts

Baaaaaaaby broccoli

Lettuce! 

While gardening has become a hobby, as we discussed during our family worship time this week, it is God who makes the seed grow.  It is He who made the soil and causes the sun to shine.  My part and privilege is to serve Him diligently, in all my weaknesses, and He will make His kingdom grow.

He told them another parable: “The kingdom of heaven is like a mustard seed, which a man took and planted in his field. Though it is the smallest of all seeds, yet when it grows, it is the largest of garden plants and becomes a tree, so that the birds come and perch in its branches.” - Matthew 13:31,32

Book of the Month: Factfulness

by Rachel

It's actually probably been years, but we used to have a blog feature entitled "Book of the Month."  There are a number of books our team has read which have informed our views and thoughts.  You're welcome to check them out here.

So, a few months ago I was reading Melinda Gates's new book, The Moment of Lift.  Excellent book, by the way (even though it's not the focus of this post).  I loved getting to read about the amazing work the Gates Foundation is doing to promote the development and empowering of women around the world.  Each chapter focuses on a different aspect of difficulties that women face, and people/organizations around the world working to ensure that each woman is seen as a life that is valuable; in fact, a life that has equal value to those around her.  Apparently, when the Gateses were forming their organization, they leaned heavily on the advice and wisdom of a man named Hans Rosling, a medical doctor and professor of international health.  He too had written a book....so off I went to check it out.

Hans Rosling was a Swedish doctor who spent years working in Mozambique and the Congo.  He then moved into more public health roles and investigated a number of disease outbreaks (including the 2014 West Africa ebola epidemic).  He passed away in 2017, and the book Factfulness was his last work.  Dr. Rosling's premise is basically that the world is a much better place than we think it is.

He uses a number of actual statistics from the world--infant mortality, life expectancy, kids attending school, average household income, even number of endangered species--to demonstrate that while most people interviewed will guess that things are getting worse, statistics show the opposite: that things have actually been improving over the past several generations.  Not only does he use statistics to demonstrate this, but the book is divided into 10 chapters of WHY he thinks we view the world the way we do.

As an American, coming from one of the most affluent countries in the world, who has now moved to Burundi, one of the most impoverished countries in the world, reading the book was actually surprisingly eye opening.  I tend to think of the world as either the "American" camp or the "Burundian" camp, while in reality there are so many more middle countries than either extremely rich or extremely poor.  You can't put Burundi in the same category as South Africa, or Egypt, or Thailand, or India.  Life expectancy and income are much higher for the average citizen of one of those countries than Burundi or Malawi, for example.  Rosling demonstrates that many of us use an "us and them" mentality when we look at the world, instead of recognizing that there are many different levels of poverty and development, and that the difference between a salary of $1/day and $4/day can have exponential benefits for the individual and society.

One of the lines Rosling uses towards the end of the book is this: The world can be bad, but getting better at the same time.  He's not asking us to pretend that everything everywhere is ok.  It's clearly not, and there are many many problems to overcome and injustices to surmount.  But, we can also celebrate the work and developments that have occurred over the last 100 years, even 10 years, as well.  That knowledge can give us hope that our efforts and the efforts of so many are not in vain.

As an addendum, I'm including some of his data graphics below.  The book is full of them, and it's a book that's fun and easy to read.  You can also compare your knowledge of the world to various Nobel laureates, billionaires, scientists, and chimpanzees...and see how you stack up. ;)

Global Missions Conference Africa 2019

(by Eric)

As some of this readership knows, Rachel and I met each other in Louisville, Kentucky in 2003 at an annual event called the Global Missions Health Conference.  We have been back to that conference a half dozen times since then, including a bit of a capstone last year, when the we (the couple who met there) moderated a panel on "Marriage and Missions".

Halfway around the world, a sister event was established in Nairobi, Kenya, about 7 years ago.  This GMHC (rebranded this year to GMC-Africa) had a few partners from the West (or "Global North", i.e. the USA and Europe), but is truly an African run and led event, where Christians, especially in health professions, gather together to share about the question: "How do we pursue the mission of God in his world?"

For several years here at Kibuye, we have offered a small sponsorship of senior medical students at Hope Africa University to attend this conference.  Sometimes we've had as many as a dozen of them take the long bus ride to Nairobi, and their report has always been excellent.  However, early September being a bit of a difficult time for our teammates to travel (e.g. end of summer, start of school), it's been a challenge to get there ourselves to participate.  

This year, I was pleased to get to travel with our Burundian Medical Director at Kibuye, Dr. Gilbert, to GMC-Africa.  The two of us had a great time together, and I got to see a few old friends from Kenya (in addition to some HAU graduates now studying in Kenya).  The sessions were truly encouraging, especially regarding the quality of the African leaders and speakers.

So, what is an African-led missions conference like?  Generally, two things stuck out to me.

1.  Wholistic Mission Comes Much More Naturally to Africans

As someone who has thought a lot and presented multiple times on the wholistic nature of the Gospel and the Mission of Christianity, I have often received responses from my fellow Westerners like "Wow, I've never really thought about this before."  The presenters at this conference took the question for granted.

"Wholistic mission is looking at the total needs of the total person because the total man is broken."
"We say 'Complete the Task".  But we have not asked 'What is the completed task?'"

This guy, Rev. Dr. Dennis Tongoi kept me scribbling notes the whole time, thinking "that's what I've wanted to say!"

I'm so glad that our African brothers and sisters have resisted the false dichotomy of word and deed.  Another presenter asked "If you had to choose to only read your Bible (without praying) or only pray  (without reading the Bible) for 2 years, which would you choose?"  Answer:  "I hope you think that is a ridiculous question.  May the day come when we react the same way to the idea of 'Should we be doing word ministry or deed ministry?'"

2.  Call to the Global South

As the below table from the Pew Forum shows, the global distribution of the world's Christians has shifted dramatically in the last century (see also this article from the Washington Post).  The "Global South" is the term used to refer to Africa, Asia, and Latin America.  Note from the last column that most of the World's Christians live in the Global South today, a percentage that is only expected to increase in coming decades.

Given this reality, the question that (rightly, I think) preoccupied the African audience of this conference was "What are we going to do about it?"  The prevailing sentiment was that it's time for Africa (and yes, Shakira was quoted) to step up and lead, and not wait for other countries to get on with the work of Christianity in the world.  There was a definite willingness to continue to partner with brothers and sisters (like me) from the Global North, but they emphatically wanted to see this task as their task as much, if not more so, than a task belonging to another culture.

And from what this conference displayed of the leadership potential of that Global South, I was encouraged to hear it.

Zigama Mama

Zigama Mama logo, designed by Carlan

by Rachel

I've always been interested in the idea of public health.  People have likened the idea of medicine in the developing world (or elsewhere) to pulling drowning people of of a raging river.  Public health is going upstream to figure out why so many people are falling into the river in the first place.  Of course, if all your time is spent saving the drowning, it's pretty hard to find the time to pull yourself away to take a walk upstream.  Important and necessary, but challenging to prioritize none the less.

After six years here, Eric and I decided to take that walk.  Ever since the first months here at Kibuye, I have been noticing a huge amount of uterine rupture (UR) cases.  They are very rare in the US, but we have about 20 cases per year here (Side note for the medical folks: I looked at cases of UR from 2015-2017 and found 55, which is over 1% of our deliveries. !!??  Only about 50% of there are on uteri with previous scar.  So we have a huge amount of UR on unscarred uteri, which is pretty rare in the medical literature.  Harder to prevent for sure...).  A big risk factor for UR is labor after a previous Cesarean section.  Everyone in the health community "knows" this, but given broken systems and difficulty in education, many women who are at risk for UR continue to labor at home, in their villages, way after their due dates, instead of receiving a scheduled C-section or coming in to the hospital to deliver under surveillance.  Some show up with three previous C-sections, in labor, and don't even know their due date.  If only we could find a way to get these ladies to come in sooner, to decide if a C-section is the best decision, and to choose a date for that C-section, maybe we could prevent some of these cases of UR.  At the very least, we can decrease complication rates of infection, hemorrhage, fetal distress, etc, which are all higher in women with emergent vs scheduled C-sections.

Enter, Zigama Mama.  This is technically Kirundi for "protect the mother."  Our Burundian friends say that's not exactly the way they would say it...but we decided to use the phrase anyway given its catchy nature! :)  Our hospital is the referral site for 17 health centers in our district.  Any woman needing a C/S or increased surveillance would get sent from them to us, which also explains why our C/S rate is about 30% of our deliveries each year (instead of the national average of 6%).  The idea of Zigama Mama was to look at all of our C/S data from the health centers for one year, then do a training session for the nurses at the health centers.  The intervention is simple:  every woman with a previous C/S, even one, gets identified by the nurses, written into a register, and then she gets a "coupon" for a free ultrasound at Kibuye.  While ultrasounds are recommended in pregnancy, they are cash pay ($5) and most women can't afford them.  So, the free ultrasound is the incentive to come to Kibuye, where I can confirm their due date and decide if a C/S is indicated or not.  If yes, I schedule it.  If no, I encourage the women to come to the hospital (not the health center) for monitoring as soon as labor starts.  That's it.  We'll look over the next year to see if our rates of emergent C/S and UR decrease.

Training on Postpartum Hemorrhage, using resources from Laerdal Global Health

We had the initial training session last week.  Honestly, I wasn't sure how it was going to go.  Eric made up a schedule that involved a start time of 8:30.  At 8:30 on Thursday morning, only one person (out of the possible 35) was there.  However, people trickled in over the next hour and in the end, 16/17 health centers were represented!  We presented the rationale for the program, the nuts and bolts, and then had several hours to do some training for the nurses on post-partum hemorrhage and neonatal resuscitation, as well as share a meal together in the canteen.  It was great to see our Burundian doctors coming in to help out with the hands-on training programs.

We divided up into groups to practice techniques on a uterine model for treating PPH

Dr Ladislas, one of the Burundian docs on my service, also did a great job leading one of the groups

On Monday morning, I actually already had four ladies show up with their Zigama Mama coupons!  I'm excited to see how this intervention can have a positive impact on the health of women in our district.  There remain so many barriers to access to care, but hopefully, little by little, we can chip away at them.

The Zigama Mama ultrasound coupon

Dry Season (music video)

by Logan

During last year's dry season I had a crazy idea: what if I took a time-lapse video of my walk across the field to the hospital?  If I took a photo every day, just one step further, perhaps it would tell the story of dry season.  You could watch the field grow more and more yellow and dusty as the season progressed, and then at the end, watch the return of green grass.

It actually worked out pretty well, and I was pleased with the result, except that it was completely silent.  I asked our musician teammate, Eric McLaughlin, if he had written any songs that would go well with the theme of dry season.  He recommended a song called Banga Hill, that he had written during their very first dry season in Burundi.  It talks about our need for God's grace to "rain" into our lives, washing away our sins and quenching all our thirsts.

Enjoy!




For I will pour out water on the thirsty land, and streams on the dry ground; I will pour out My Spirit on your offspring, and My blessing on your descendants. 
-Isaiah 44:3

Blessed are those who hunger and thirst for righteousness, for they shall be satisfied.
-Matthew 5:6

Now on the last day, the great day of the feast, Jesus stood and cried out, saying, "If anyone is thirsty, let him come to Me and drink.”
-John 7:37

Jesus answered and said to her, "Everyone who drinks of this water will thirst again; but whoever drinks of the water that I will give him shall never thirst; but the water that I will give him will become in him a well of water springing up to eternal life.”
-John 4:13-14

More of Eric's music can be found here.

Paternalism

by Rachel

“We want autonomy for ourselves and safety for those we love.”  —Atul Gawande

 I’ve had a lot of bad outcomes lately.  I guess things tend to run in spurts…bad things come in threes, or multiple patients come in with the same diagnosis after months of not seeing that diagnosis at all.  Lately, I’ve been thinking about multiparity, or really, grand-multiparity.  For the non medical folks, “parity” refers to the number of times a woman has given birth.  When that number reaches 5, she falls into the category of “grand.”  When I was doing my training in residency, it often seemed that the first pregnancy was “the worst."  Meaning, if you were going to get a complication, it would more often happen with the first one.  Walking in to Labor and Delivery and seeing a whole unit full of “nullips” (first time delivery) meant a long day and/or night of unknowns while we watched and managed and hoped that a C-section wouldn’t be necessary.  A unit full of women who were on their second or third deliveries was much more upbeat, fast paced, certain.  Of course, it wasn’t very common to have a unit full of women on their 5th, 6th, or 7th deliveries.

Burundi is very fertile country, in more ways than one!  The average woman will have 6 babies in her lifetime.  My clinic is flooded with women who can’t conceive, so it stands to reason that for every one of those women, there’s another on her 10th pregnancy.  And, soberingly, a woman stands around a 1:30 chance of dying due to a pregnancy complication during her lifetime (UNICEF statistics from 2010).  It also stands to reason that the MORE pregnancies you have, the more risk you expose yourself to.  I had an attending who liked to say that getting pregnant was the most dangerous thing a woman could do with her life.  OK, I think that’s a bit extreme.  But oftentimes, especially in the US with a well developed medical system, we forget about the potential risks of pregnancy and childbirth, especially because the risks seem so minimum in comparison to what you get out of the deal.  Even with all my training and knowledge of the complications of pregnancy, Eric and I decided to go through the process three times! (And let me tell you, I do NOT take the fact that we had three uncomplicated deliveries and three healthy kids for granted).

So, back to my bad outcomes.  I had two maternal deaths in March with almost identical stories, women who should have had a straightforward delivery.  Two previously healthy women, both on their 7th pregnancies, both with 6 living children, who presented to another hospital after prolonged labor.  Both had a ruptured uterus (where the uterus basically tears open because it’s been working so hard to get the baby out) and a dead baby.  Both received surgery to attempt repair, which failed, and were transferred to me for “better management”.  Both arrived in shock.  Both received hysterectomies to try and stop the bleeding.  Both died within 12 hours of arrival due to coagulopathy.  

I felt very powerless in the process.  I felt like my best efforts were not good enough.  And I felt regret for a system that tries but isn’t good enough to save these women and ensure their children grow up with a mother.  And finally…I felt myself wishing these ladies had just stopped having babies.  If only they had decided 5, or even 6, was the perfect number of children.  If only.

These are not the first two women who have died after similar circumstances.  In fact, after doing some research I found that it’s shockingly common in the developing world to develop a ruptured uterus because of long labors or limited access to care.  And experiences like this color my opinions and decision making.  If it can happen to those two women, why not others?  

So I keep advocating for better care, and better birth control.  I perform a C-section for a woman…it’s actually her 5th, and she has two living children.  The surgery is a mess and takes forever, due to layers upon layers of scar tissue.  At the end I tell her that we should tie her tubes because this is getting too dangerous for her.  She refuses.  Multiple times.  I take one tube, and then the other, in my gloved fingers and think about how easy it would be to tie her tubes right now, even without her knowing.  Even without her consent.  Surely, she doesn’t have enough knowledge or experience to know how dangerous another pregnancy could be for her.  I could probably be saving her life if I tied those tubes.  Or at least, saving her from terrible complications in the hands of the next, possibly unexperienced doctor who tries to perform another C-section on her in the future.  I am the one who spent years and sweat and tears and money to receive my medical training, to be able to advise and treat…my knowledge base is far superior to her own.  

And then I think about why I am here in Burundi.  About how much I care for these women, all of whom have suffered so much at the hands of family, husbands, an incompetent medical system, life.  About how they are all fighters, and how I want what’s best for them, to empower them.  And I realize that taking away one of the only choices she has, to make a decision for her, is exactly what I’m fighting against.  And I slip the uterus back into her pelvis and close up the layers, and hope that she never gets pregnant again….but if she does, I hope, I hope, I hope that she lives through it.

I don’t know.  I doubt myself.  But I know that change does not come by taking away autonomy.  I want these women to be safe, yes.  But there are other ways to bring safety.  If only…

Lesson Learned from African Roads

(from Eric)

Stephanie wrote a while back about their misadventure on Burundian roads, but after our past weekend, it seems that there is (perhaps unfortunately) more to share.

Our family is heading back to the US for a spell in about six weeks.  As Rachel and I thought about it, we weren't at all sure that our kids had even gotten in a car since early January.  Such realizations can give one a bit of cabin fever, so we thought we'd have a family weekend down on a beach resort on Lake Tanganyika.

The drive down was three hours, one of which was on Route Nationale 16.  Here is a picture:

Lesson 1:  Even though something carries a national highway designation (and there isn't a level above this, though many roads are nicer) you cannot make assumptions.  

And a GPS on your phone is invaluable, but there should be limits to the extent you trust a road that you have not yet seen.  But we arrived safe and sound, and were treated the following morning to one of the loveliest rainbows we have ever seen.  

Lesson 2:  African beauty is all around us.  Getting out can help us to see that, and we need to see it.

The kids wanted to do nothing else but swim.  We splashed and floated and played.  We applied sunscreen liberally and then reapplied in an hour.  And we promptly got burned.

Lesson 3:  White missionaries in equatorial Africa are among the pastiest white people you will meet.  

It's a little difficult to explain exactly why this is the case, but it is undoubtedly true.  Maybe it's that we take the perfect weather for granted too often, or the cultural norms that cover most of your body most of the time.  I don't know.  But the combination of pasty whiteness with the intense equatorial sun means that there is nothing that you can do to sufficiently protect yourself.

Two mornings later, and we're ready to head back to Kibuye.  Despite being in the full swing of rainy season, our time at the beach was rain-less.  Until we got in the car.  Right around the time we hit RN 16 in all of its unpaved, rutted glory, the rain starts falling.  We made a game of it.  Whenever a particularly hairy section was coming up, we would tell the kids that we could do this only by "grunt power".  Everyone in the car would then grunt loudly until we cleared the present obstacle.

About two miles from the end of the bad road (and about 1 hour from Kibuye), we came face to face with an obstacle that no amount of grunting was going to help.  A river was running across the road.  It was solid water for about 30m across, and we had no idea how deep.  The river was swift.  We stopped at the edge and studied it for a while.  A couple guys with bicycles waded through the downpour.  At least where they stepped, it came up to knee deep, and threatened to knock them over.

I forgot to take a picture.  Luckily, on returning to Kibuye, I found a picture of it on google images.  Here is RN 16 at the moment of our encounter:

Lesson 4:  Hold your travel plans loosely and prioritize safety.

After considering our options for about 20 minutes, we decided that this wasn't going to work, and proceeded to travel back on wet, bad (and increasingly dark) roads for the next 4 hours in order to get to the capital city, where our very gracious friends the Guillebauds put us all up for the night at the last minute's notice.  Yes, we wanted to get back, and yes, we needed to get into work the following morning.  But sometimes things happened.  

On the flip side, our trip back down the mountain did get us another stunning view (during a brief pause in the rains, see Lesson 2 above).  The hills of Burundi followed by the largest lake in Africa, followed by the Congolese mountains.

So, this morning, after more than doubling our trip the day prior, we drove another three hours back to Kibuye, where we were delighted to be home.  Six weeks until we get in a car again?  Definitely doesn't sound too long.

Lesson 5:  The quickest way to solve your African wanderlust/cabin fever problem is just to go somewhere.  Anywhere, really.

***

As a final aside, whenever Rachel and I travel, we are struck anew at the difficulties people undergo to seek care at Kibuye.  Burundi is a small country (about the size of Massachusetts), so to say that every week we get patients from every province in the country, that doesn't seem like too big of a deal.  But it is not a uniformly accessible country.  The areas that we were slogging through were the provinces and communes that usually elicit a "well, that is a bit far" response from me when I think about my patients.

Lesson 6:  Good roads are not just a matter of convenience.  They save lives.  Take a moment and thank God for the roads that you have.

Beautiful Burundi

(from Eric, with help from everyone)

Burundi, like anywhere else, is a mixture of brokenness and beauty, of glory and shadow.  And this blog has told its share of tragedies.  Today, however, we'd like to honor the goodness and the wonder that is around us in Burundi, country of a thousand hills, country that reflects the glory of its Maker.

So here's a feast of photos that we've collected over the years.  There are two focal points here.  The first is the beautiful green landscape.  The second is the beautiful people of Burundi.  Over the years that we have been here, the people of Burundi have been examples to us of joy, love, enduring forgiveness, hard work, undying hope, intelligence, and great kindness.  We have seen faith and self-sacrifice that we pray that God will enable us to emulate.

Voilà!  Beautiful Burundi: