Legacy and Multiplication: Meeting Dr. Clarisse again after a long time

 (from Eric)

This weekend, I was taking a walk around our housing area with Toby. Standing near where the Harlings live, I saw a Burundian family that I didn't recognize. As I got closer, the dad greeted me in good English with a smile. While wondering who he was, I saw the mom come up behind him, holding an infant in her arms:

"Dr. Eric. It's been a long time. Do you remember me?"

My mind struggled for a moment to put together the different threads when you see a familiar face in an unexpected context. Then the lights came on.

"Dr. Clarisse?"

She smiled.

"Wow. It has been a long time. I thought you were far away."

"Yes, but we are visiting a few months in Burundi, and we wanted to visit Kibuye, because we haven't been here since I was a medical student. It's amazing the work that you have done. It's so transformed. You should be very proud."

"Thank you, Dr. Clarisse. You graduated when? Almost ten years ago?" She nods. "And then you started PAACS surgical training at Galmi Hospital in Niger. You have finished now?" She nods again.

I had heard that Dr. Clarisse had graduated as a general surgeon this past year, and that she and her husband, with a desire to continue to testify to the love of Jesus in a Muslim context, had signed up to be missionaries with SIM and were moving to the north of Togo.

"Dr. Clarisse, I heard that you were moving to Togo now that you are done?"

Her husband nods with a smile. Clarisse says "Yes. You know, for so many in my class, our time at Kibuye with you was so influential in terms of understanding mission, and helping us think differently about medicine."

"Well doctor, I can't tell you how encouraging it is to see you. It encourages us, after so many years, to see how Kibuye has helped people like you to develop a vision of serving the Lord as a doctor."

***

Click here for a great story from Dr. Clarisse via MedSend.

Click here to support Dr. Clarisse and Audace in Togo via SIM-USA.

Dr. Clarisse (center) and classmates at the end of their Kibuye time in 2014

Dr. Clarisse and Audace with their family

Hip hip hooray for medical education

(by Ted John)

A few months ago, I wrote a post on medical education and my experience organizing a 2-week dental course for the medical students, which you can read more about here. It was the first time teaching such a course at our hospital and the first time for me to coordinate/organize a course. Since we don’t have any dentists on site, teaching was done exclusively through audio/video recordings and live video conferencing.

Fast forward a few months, and I have now finished coordinating a new course on orthopedics and trauma. Here’s a table to give you an idea of how they were similar and different, at a glance.

	Dental	Ortho/Trauma
Number of students enrolled	46	52
Duration of course	2 weeks	5 weeks
Number of instructors	3	6
Number of (different) lectures	9	29
% of lectures taught in English (PPT slides in French)	78%	26%
Method of instruction	tele-education	in-person (some distance learning)

Of course, there are a number of other differences. For example, the scope of the ortho/trauma course was broader, but more related to general surgery (at least as it pertains to trauma). Thus, while it would be ideal for orthopedic surgeons to teach the more strictly ortho topics, we did the best with what we had in terms of available expertise. In what other context could you imagine an ortho/trauma course taught by a motley of 4 general surgeons, an ER doctor, and a visiting orthopedic surgeon? 😄

Lecturing in our newly renovated classroom

Another big difference was that not all students were present for the in-person instruction at Kibuye. At any given point in time during the course, there were 8-16 students doing clinical rotations off-site in Bujumbura. As a result, it required more effort and coordination to ensure that these students could have timely access to recorded lectures and corresponding slides. The usual routine was that as soon as an instructor finished giving their lecture, they would send me their recorded audio file, which I would then upload to Dropbox (along with their slides). Then there’s the logistics of administering quizzes and exams in two locations simultaneously, getting scanned copies of the completed off-site quizzes, and grading and reporting all students’ results in a timely manner. Doing this in the US with high-speed internet and ubiquitous Wi-Fi would be challenging in and of itself, so accomplishing this in our context is nothing short of incredible.

Medical students taking one of their weekly quizzes

Here’s a condensed list of the content we covered:

• ATLS/Burns
• Trauma of the spine and chest
• Trauma/fractures of the upper extremities (shoulder, humerus, elbow, forearm/wrist, hand)
• Trauma/fractures of the lower extremities (hips, femur, knee, ankle)
• Musculoskeletal infections and tumors
• Differences in the pediatric population (plus congenital abnormalities)

Skeleton models of bones and joints were available for students throughout the course 

Much of the content goes well beyond the expertise of a typical general surgeon, so we are thankful for a French textbook that we used as the foundation for our instruction. In reading through this book and preparing slides, I’m certain that each instructor learned something in the process, whether deepening their own medical/surgical knowledge or perhaps learning additional French words for specific terms. For instance, I learned that the commonly used English abbreviation ORIF (open reduction, internal fixation) does not translate exactly into French as with other terms and is probably closest to réduction sanglante avec contention interne (which is literally “bloody reduction with internal compression/immobilization”). One can only wonder if this is actually what is colloquially used in France. In this sense, it felt like I was earning continuing medical education (CME) credits.

We’re also thankful for Joel Post, an orthopedic surgeon who visited for 2 weeks during the middle of the course. We intentionally planned the course to correspond with when he was around so that we and the students could benefit from his expertise. With Dr. Post’s fellowship training in orthopedic oncology as well as traumatology, he was the perfect person to give the lectures on osseous tumors and ankle fractures (which I view as generally more complex both in terms of injury patterns and management). As I sat in the back of the room listening to him, with stories of patients from his own current clinical practice, I couldn’t help but think, “Wow, this is so interesting. I wish Joel could teach all the ortho lectures!”

My family with Joel just before his return to the US

Overall, though, I’m quite pleased with how the course turned out, and I think the students learned a lot. As with the dental course, I recognized the top performing students, but this time with little bags of calcium supplements (tums) for fun. I even trialed an electronic post-course survey through google forms to solicit feedback, the template for which others can continue using in future courses going forward. In response to the question of what was the best part of the course, a good number of students said “everything”. Yet, I know there’s room for improvement, and will take to heart the students’ suggestions for the next time this course is taught again in a couple years. For now, I can redirect my attention elsewhere, perhaps in helping with the start of a surgery residency training program in the coming months. Tibia continued...

Group photo with the Kibuye cohort of students at the end of the course

A Tale of Tele-Education: Mouth Matters

(by Ted John)

A big part of our ministry in Burundi is medical education, a topic which has been previously written about and most recently here. A couple years ago, there was a major change in re-structuring the medical school curriculum such that med students would do nearly all of their clinical rotations at our hospital (whereas it was only about a third of their clinical time with us in previous years). Awesome! This continuity and increased face time had many positive implications, including more opportunities for building relationships at a deeper level and for medical education and discipleship. 

Not surprisingly, this transition also came with some added responsibilities, including the organization and teaching of more coursework, much of which was previously taught elsewhere by others. Thus, there has been increased time and effort putting together resources, creating PowerPoint presentations, and organizing courses to fulfill the med school curricular requirements (especially if it’s the first time a course is being taught at Kibuye).

It makes sense that the pediatric course would be taught by pediatricians, and we are thankful that the knowledge and expertise was contained within teammates on site. It’s no small task to organize a 75-hour pediatric course! But what about the courses for which we don’t have the specialties represented here at Kibuye? For example, Cardiology, Psychiatry, ENT, PM&R, Dentistry, Ortho, and the list goes on. Well, nowadays with modern technology, it’s possible to do this creatively in the truest sense of tele-education and distance learning using a combination of audio and/or video recordings and live video conferencing, often in both English and French.

I am certain each course has its own story behind it, but I will share a little about my personal experience of how I (a general surgeon) ended up organizing a 2-week, 15-hour dental course (“cours de stomatologie” in French), implemented and completed in December 2021.

Med student courses are usually taught in the hospital chapel

Back in August 2021, not long after I returned to Kibuye, I remember having a conversation with one of our teammates about how the dental course had been postponed due to the challenge of finding instructors. Then I thought about my dentist friends in the U.S., many of whom I had befriended when I was a med student at the University of Michigan (which also has an excellent dental school!). So, I contacted some of these friends (big thanks to Amy, Dave, and Ben), who all expressed interest in being part of the development of this course.

What went into putting this course together? In a nutshell, these were the major steps that occurred during the subsequent 3 months (in mostly chronological order):

•         Determine educational content based on provided learning objectives and context
•         Organize the material into 1-hour lecture blocks
•         Divide work amongst presenters
•         Create PowerPoint presentations
•         Translate English slides into French, if applicable
•         Pre-record each presentation as a video, in French if possible
•         Write quiz/test questions for each lecture (and translate into French)
•         Coordinate selected lectures over live video conferencing (Zoom) over different time zones
•         Proctor, grade, and submit results of quizzes and final exam

Dr. Ben Kang giving a lecture on inflammatory diseases of dentistry over live video conferencing (Zoom)

Things didn’t always go according to plan due to unforeseen circumstances, and an element of flexibility was required. For example, on the first day of the course, we had planned for a live Zoom lecture, but earlier that same day, lightning struck the hospital and damaged the Wi-Fi equipment. As a result, I had to re-arrange the schedule and show a pre-recorded lecture instead. It also happened that there was a concurrent anesthesia course, so the schedule had to be adjusted a couple times such that there was no overlap.

Dr. Dave Chiu giving a lecture on the temporo-mandibular joint

In the end, the content was delivered, even if not in the originally planned order, and all the students passed the course successfully (which I’ll take as a surrogate measure that some learning has taken place!). I even recognized the top performing students with a new toothbrush each.

I also gained some cultural insights about teeth and dental care in Burundi. For example, have you ever thought about what people in other countries and cultures do with their baby teeth? Most Burundians apparently throw it under their legs (described to me in the manner of hiking a football) and say the phrase, “nyamanza tora iryinyo ryawe unsubize ryanje ryiza,” which rougly translates as “a small bird will take your tooth and give you another (permanent tooth) that’s better.”

While I was glad when the course was over, it was definitely meaningful and worthwhile to be able to be part of teaching and equipping these future medical doctors with basic dentistry knowledge. Since it was the first time teaching this course, there was more upfront time and energy invested in content creation. But in future years, we should be able to use the same didactic content, and focus our attention instead on how to make the course better.

Group photo with all 46 students at the end of the course

What’s next? Well, there's actually a 45-hour "synthesis" course already underway, which is being coordinated by Eric and taught by many of our teammates. After that, I'll be coordinating a new 45-hour trauma / orthopedic course, currently being prepared for a tentative start date in mid-February. It’ll be a bigger undertaking than the dental course, but thankfully we have a French textbook as a reference and 5 surgeons involved (one of whom is an orthopedic surgeon who will be visiting Burundi at that time).

Looking back at my own med school days, I can say that I took the courses and the quality of education for granted. Funny how God is using my role as an educator now to give me a new perspective and deeper appreciation for anyone and everyone involved in medical education.

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.

Post-Graduate Interns: A Major Highlight

(from Eric)

One of the perennially funny things about blogging is how you can look back and notice how you've missed something major.  Such is the case for our post-graduate internship program.

A reform in medical school curriculum back in 2011 set the roadmap for graduates from Burundi to follow medical school with a one-year post-graduating "rotating" internship (meaning that they rotate through several different specialties during this year).  This is what is done in other countries in our region, and what several of us help to supervise when we lived in Kenya.

The program hasn't yet begun on a national level, but many doctors will go somewhere in the country for something similar but less formal, called in French a "stage professionnel".  Many of our graduates have expressed interest in more training after graduation, and we have been eager for several years to take young doctors through a more formal and intensive "stage professionnel", following the model of the internships to come.

After several years in planning, we started this program on May 1, 2019.  We took eight doctors, and later expanded to twelve.  They spend 3 months each on Internal Medicine, Surgery, Pediatrics, and OB-GYN.  They take lots of call, and they see patients in clinic.  They have weekly lectures and reading assignments, and they have been a big part of a weekly doctors' bible study.  Because of their dedication, they have, in many ways, been the heartbeat of the hospital these last several months, and we are so thankful both for them, and for who they are becoming.

Several of the "stage professionnels" with "Papa Banks", their fearless leader

Last night, we all had a dinner ceremony together to celebrate the end of this program for the first five doctors.  Since these five all went to medical school at HAU, we have known them since their very early clinical rotations as a student.  We got to see them progress steadily towards graduation.  Now, we have seen them grow tremendously this year into true colleagues.  It is a delight to think of them going out to truly bless the population of Burundi with their intelligence, their hard work, their practical capacity, and their love for Christ and the people of Burundi.

Congratulations to Dr. Cesarine Nishimwe, Dr. Emmy Prince Ndengeyingoma, Dr. Moïse Niyuhire, Dr. Christian Niyoyitungira, and Dr. Olivier Hakizimana.  Thank you for trusting in a new program and for blazing a trail that many can now follow.  May God bless you and guide you in the days to come.

Some pictures from last night's fête:

Five finishing doctors with their certificates

Eric and Dr. Gilbert (Kibuye's medical director) congratulating Dr. Prince

All but one of the current post-graduate interns

Video messages from those who couldn't be present

Cutting Madame Cynthia's awesome cake

Now we look forward to another year.  We have 6 doctors that are roughly halfway through the curriculum, and another six who began on May 1.

Thesis Whirlwind

by Logan

Whew! In some ways it feels like I can finally come up for air. The specialist doctors at Kibuye have just finished a ridiculously busy time, supervising research, editing papers, and judging the thesis defenses for over 40 medical students in about a month’s time. 

Carlan Wendler, Alliance Niyukuri, George Watts, Greg Sund, and Logan Banks chat in between students' theses

Why this sudden sense of urgency?

Burundi recently changed the way that they authorize doctors to practice medicine in Burundi. In the old system, as soon as a medical student defended their thesis (a final research project that is the final step before finishing medical school) they could apply for a license and start practicing as a physician. There was no pressure to finish before a certain deadline, so the work that this thesis project represents could be spread throughout the year. This also means that the work for the specialist doctors that act as “directors” of the students could be spread out as well. If someone was directing 4 or 5 students, they could do perhaps one a month so that the work wouldn’t be overwhelming.  

But a few months ago, the government said they would only authorize these new physicians once per year. This meant that a large group of medical students were suddenly desperate to finish their final research projects before the end of the year. 

What is it like to direct a thesis project?

The student comes to a specialist and asks them if they would be their director. Depending on their workload, availability, and other factors, the doctor agrees. The director helps the student come up with a research idea, review the research process, edit the paper (several times actually — which is more like a book, with an average length of around 60 pages), and help the student get ready to present the research and answer questions about it in an oral “defense.” This represents several weeks to months of work for the student, and several days to weeks of work for the director. 

When the student is ready to defend their thesis, the director recruits two other specialists to sit on the “jury” with them, and after a 15 minute oral presentation by the student, each person has a chance to make comments about the study and to ask questions to the student. 

Jason Fader, Alliance Niyukuri, and Ted John sit on a jury

The whole process from start to finish takes over an hour. Then the grade is given, and the student immediately takes the “Serment de Genève”, the French equivalent to the Hippocratic Oath.  

Just some of the 41 medical students as they take their "Oath" after successfully defending their theses.

This process was then repeated over 40 times between December 6th and January 11th. 

Greg Sund, Rachel McLaughlin, and Logan Banks celebrate with the new doctor Abel Nzoto after he successfully defended his thesis.

As you can imagine, this was an incredibly busy time for all the doctors at Kibuye. There are 10 specialists doctors currently at Kibuye. 41 students x 3 doctors per jury = roughly 123 times that a combination of 3 doctors sat on a jury. Some days there were 5 theses in the same day. That is nearly 8 hours of defenses. Sometimes one doctor would sit on 3 juries in the same day, reading and critiquing research in French for 5 hours. During this month-long period, one doctor actually sat on 26 juries, 9 of which as the director. 

This also meant that all the other doctors at Kibuye (the Burundian generalists and interns in the Stage Professionnel program) all had to pitch in to help the hospital services continue to run smoothly during this time. There were days that I was supposed to be rounding on Pediatrics that I could hardly make it over to the ward. I am so thankful (and I know all of us are) to the other doctors on our services that helped keep things going during this hectic time. Carlan even organized a “Thank You” dessert for our Burundian colleagues.

"Thank you! Thank you! Dear Colleagues!"

We are so thankful for the help from all the doctors at Kibuye. We are so thankful for all of these new doctors that just finished their theses. These 41 new doctors represent so much more than the work that went into the past month. They represent years of hard work -- on their part, and on the part of all the professors that taught them (whether in the classroom or on the wards) how to care for their patients in a compassionate, Christ-like way. 

Forty-one new doctors to help care for patients in Burundi (and beyond). What an answer to prayer!  That makes all this craziness worth it. 

But for the moment at least, I know that we are all ready for a nice long break from any more theses.  

Teaching and Learning

(By Alyssa)

Sad to say goodbye to this great group of peds interns who have been working with me for the past 2 months. They have certainly made my job easier as they have worked hard, studied diligently, and cared for patients compassionately. And I was especially proud of them today as they rose to the challenge of teaching nutrition to our malnutrition service. Fifty to seventy patients continue to come to the hospital twice per week for our outpatient malnutrition program. These children suffer from hair loss, swelling, apathy, skin changes, and other evidence of both acute and chronic malnutrition. And in this country with extreme poverty and a falling economy due to the political situation, it’s hard to know how to teach the mothers about foods that are both nutritious and affordable. Most of the medical students grew up in the city in more affluent families, so it can sometimes be difficult for them to relate to our rural, impoverished patient population. But they related admirably today. They had previously researched what foods were available in the community and for what price and then they asked questions while they taught the mothers about the foods included in a balanced diet. Protein is the hardest food for these patients to find as was confirmed today. Only two or three mothers raised their hand when asked if they could buy eggs for their children (eggs cost 10 cents each) and few had access to milk. But many could buy the tiny salted fish that come from Lake Tanganyika, so that was helpful to discover. Peanuts are also readily available. The mothers asked questions as well such as whether to add salt during or after cooking or what kind of oil to use. It was great to see them engaged and responsive to the presentation. I do hope for more for these precious patients - more food, more education, more growth, more opportunities - but I’m thankful today for the hope for the future reflected in the medical students as they taught, learned, and cared thoughtfully in a challenging situation. 

We’re not the best people for this job…

(by Carlan)

…our students are.

As we say “au revoir” to another group of bright, talented med students it strikes me again how true that statement really is. To watch how natural they are with patients, how easily the adopt the role of educator and advocate, how quickly they laugh and make everyone around them laugh fills me with a profound gratitude for what God is doing here and that we, a ragtag group of knuckle-headed missionaries, get to be a part of it.

One of my attendings in residency liked to say, “If a picture is worth a thousand words, a video is worth a thousand and one words” (to discourage the use of movie clips in grand rounds presentations). Though I would never contest the wisdom of such a seasoned medical educator, I humbly submit to you the following film, prayerfully intended to convey in sound and image what we are hoping to be in word and deed.

Please click here if you can't see the embedded video above or just want to see the bigger, higher definition version.

Testimonies from our Medical Students

(by Eric)

Some things are easy to write about.  And some things are just as (or even more) important, but hard to write about, so they feature less in the blog.

One of the core items of our work here is the education and discipling of Burundian medical students (some are also from other countries in the region: Rwanda, Congo...).  It's a primary reason we're here.  As Carlan put it, "We're not the best people for this job.  Our students are."  Burundi has one of the lowest doctor/population ratios in the world, and these students form part of the remedy for a country with no to minimal access to quality health care.  So, we educate them.  Day in and day out, we are surrounded by uncomfortably large crowds of students.  They are bright and talented, and they are learning.  They will be a tremendous blessing wherever they are.

But what will they do?  What will guide them?  Will a good education be a ticket to a land with less need, or a way to simply increase personal prosperity, or will it be a calling, a gift of God for his purposes and not their own?

And this is discipleship.  Less tangible.  Harder to measure.  Like many less-tangible and hard-to-measure things, it is among the most important things of life.  We lead bible studies.  We teach classes.  And more than anything, we live side-by-side with them, and in our brokenness, God's grace shines through.

Currently, we are coming to the end of a 4-month stint with 34 medical students.  I will try to share a couple testimonies from them.  It is fitting for an American to write about this, just before Thanksgiving, since we are very thankful for these students, for their testimonies, for their growth, and for the opportunity that we have to be part of their lives.

Last Thursday, at our most recent bible study, 4 students volunteered to share testimonies.  Normally, these are incredible stories about the students' lives growing up, losing parents in wartime, being put in jail, unexpected deaths of siblings.  But this time their testimonies were about their time here at Kibuye. Here is a summary:

One young lady spoke of how she had neglected the church for several years, being sure that God was with her when she did good deeds.  But she was haunted by never doing enough, and every year she would promise God that next year, she would do better.  She said that here at Kibuye, for the first time, she knows that Jesus loves her, not because of what she does, but because of his love.  And this is transforming her.  She said that here she saw a miracle:  humble specialist doctors.  (This is a theme we have encountered.)  Doctors who care more for their patients, doctors who pray with them, who lead worship for the staff to sing.

Another lady spoke of how her time with the student outreach group has transformed her.  I love these stories.  The students from the city are often quite shocked by the poverty here, and form a Christian outreach group, to pray for their patients in the evenings, share with them, and collect money to buy them food or maybe medicines.  This is independent of us missionaries, which is probably the best kind of testimony.  =)  She spoke of how nervous she was going out to talk with these patients, but how the patients put her at ease, and with time she has grown in her capacity to pray and share with them, more than she would have imagined.

The next day, after the final lecture that I gave in the Christian Philosophy of Medicine course (this one on facing suffering), another student asked to talk to me.  She said that, prior to coming to Kibuye, she saw medicine as a job.  She wanted to do the right thing for her patients, to avoid her supervising doc pointing out her misdeeds.  But now, for the first time, she thinks she loves her patients, and she wants to treat them because she has found a new care for them inside her.  She said she now sees medicine as a calling, and is trying to figure out what God is calling her to do.  She wanted to know about missionaries.

After arriving here, she kept asking her friends what these Americans were doing here.  They gave such answers as "Maybe they are just adventurous tourists" or "Maybe they've always wanted to live in Africa" or my favorite "Americans do all sorts of weird stuff!  Who knows!?"  But she said, those answers didn't pan out.  We had our little kids with us (another common theme), and she couldn't even imagine bringing her little kids up to the country from the capital.  She recognized that we were here to try and follow God, to serve Burundi and to see him glorified here.  She wanted to know how we decided that was what God was calling us to do.  So we spent an hour talking about how much potential she has to glorify God in her country, about keeping our eyes fixed on Jesus, and about exploring possibilities with her church to join together and maybe send out some doctors to serve.

These words are joy and life to us.  We know that we live out these things so misshapenly, with so little grace, and often so much frustration.  And yet we believe ardently that here, seeking God and his will, we can all together find the source of life and of joy.  And so to find our students recognizing this same true source, is a great encouragement.