New Chaplains and New Chapels

 (from Eric)

When our team returned from the Serge conference last month, we found a new face leading morning chapels at the hospital.  Last year, after decades of faithful service, Pastor Pascal Nyawenda retired from his role as a Kibuye Hospital chaplain.  Now, Pastor Mélance has arrived to fill that void, joining Pastor Silas and Madame Pascaline on the chaplain service dedicated to spiritual care at the hospital.  It has been a joy to see the enthusiasm and energy that a new person has added to the team's work.  We see them praying with inpatients and outpatients, and if you take the time to ask them, they will enthusiastically share stories of healing, repentance, conversion, consolation and faithful presence.

Pastor Mélance, Pastor Silas, and Madame Pascaline

One of the things that I love about our chaplains is that they embrace not only the spiritual care of patients and their family members here at Kibuye, but also the employees and the numerous students that pass through the hospital at different stages of training.

Ever since the beginning of the Covid-19 pandemic, it has been a challenge to decide how to handle the long-standing practice of daily times of morning prayer/singing/devotions from 7:30 to 8:00 each morning.  After trying a number of different models, the hospital leadership restarted this practice a couple months ago.  The response from students and staff has been encouraging with an enthusiastic participation.

The chaplains' response to this was to reflect on how best to use this reinstated time to engage well those that are involved.  They are planning a number of different activities, but one of them is to dedicate one week per month to a thematic message.  The idea is, instead of a different speaker and theme each day, there will be one speaker on a chosen theme who will give four different messages from Monday to Thursday, and then Friday will be dedicated to Q&A.

I had the honor of being the inaugural speaker for a theme week, the chaplains asking me to speak on "Walking with Those who Suffer".  On Monday, I spoke on suffering according to the Bible.  On Tuesday, I spoke on the significance of a God who has suffered and died.  On Wednesday, we talked about consoling the sufferer, and on Thursday, we talked about Finding Hope.  Even this week, it seems that these messages have changed the tenor of some of our conversations about our work in ways that I think are positive and authentic.

I wasn't sure what to expect in the Friday Q&A.  I appreciated what the chaplains were doing by leaving that time for more interactions, but I wasn't sure how people would respond.  After an initial long silence, the questions started to come and had no difficulty filling the time.  They asked about God's redemption of evil and the presence of temptations in their lives.  They asked why prayer matters if God is sovereign.  They asked about the difficulties of caring for the whole person when the work is voluminous and overwhelming, as well as the proper way to talk about the offer of eternal hope with someone who has just receiving hope-shattering news.  In other words, they didn't pull any punches!

Pray for these chaplains in the months to come and for the patients and staff and students that they will impact.

Teaching Bioethics

(from Eric)

For the last 3 sessions of the Christian Philosophy of Medicine course, I had our students break into groups of 3 or 4 and present the following cases.  Very interesting discussions ensued.  Just for those who are curious, here were the 8 cases presented, 7 of which are more or less based on true stories we have experienced in the last few years (the exception is the Ebola case)


1. A man comes to you, admitting to having visited a prostitute last week.  This week, the prostitute texted him, saying that she is HIV+.  He wants an HIV test.  It is negative, but you explain that it takes weeks to months to convert an HIV test.  He is married, and does not want to tell his wife, because he regrets his actions, but knows that his marriage will be over if he tells her.

2. A patient is hospitalized on the service where you are the doctor.  1 day later, he is confirmed to have Ebola.  Your service has 3 nurses, 1 man and 2 women, all married, and one woman has 3 children.  None of them want to treat the patient, being afraid of contracting Ebola.  The hospital has decided that only 1 nurse will treat the patient, to limit exposure, and it is for you to decide who.

3. A 70 year old lady presents in a coma, and is put on a mechanical ventilator.  The next day, CT of the brain shows massive cerebral hemorrhage.  Recovery is impossible.  She is a widow with 2 sons that are present.  One wants her to remain on the ventilator, in whatever circumstance, which could be months.  The other wants to withdraw care of the ventilator, given that she will never survive without it.

(This is the most "American" of the cases, and as I have seen before, most Africans consider withdrawing care a form of euthanasia, a terminology distinction which I discourage, since I don't think it helps them to discuss the issue with others.  It always highlights to me the difference in thinking about such a case and experiencing such a case.)

4. A 75 year old man presents with epigastric pain and severe anemia.  He is transfused and endoscopy shows an unresectable gastric cancer.  Before rounds the next day, the patient’s son comes and asks you if it is cancer and if it is treatable.  You explain what was found, and he asks you not to tell the patient, because it would cause him to despair.

5. You are the medical director at a hospital where there is one unit of O-neg blood left, and none at your referring blood supply hospital.  You have a 5 year old girl with severe malaria in respiratory distress with a hemoglobin of 2.5.  At the same time you have a postpartum lady with a hemorrhage, now controlled, mother of 5 children young children, who has a hemoglobin of 3 and a blood pressure of 70/30.

(This is one of the most common scenarios.  In fact, right after the discussion, someone came to interrupt the class to tell me we had a patient in an eerily similar situation.  However, I'm not sure there's a real good way to talk about it.)

6. A mother of 8 is hospitalized for a C-section for baby #9 at the same time that baby #8, age 15 months, weight 3.5 kg is hospitalized for severe acute malnutrition due to family food shortage and poverty.  The mother agrees to a tubal ligation, but the father refuses.  The mother asks you to do it and not tell the father.

(This generated the liveliest discussion, which was a lot of fun.  I had to cut it short.)

7. A 30 year old woman comes with severe anemia and respiratory distress after a femur fracture.  She needs blood and surgery to survive.  Your hospital has a policy of paying a deposit before surgery due to a high rate of repayment.  The patient cannot pay.  What to do?  The following week, the medical committee is meeting, of which you are the president.  Your hospital has not been able to pay salaries for the last 2 months.  Do you try and change the pre-payment policy?

(Also common and relevant, but pretty painful to talk about.)

8. A 40 year old mother of 3 children has HIV and is on ARVs (antiretroviral therapy).  She started the ARVs 18 months ago, and has been getting slowly better, despite a hospitalization for dysentery.  At this visit, she says that she visited a prophet on the border of Tanzania last week, who prayed for her healing from HIV.  She believes that she is now healed, and has stopped her ARVs.  She does not want to be retested, because she already knows by faith that she is healed.

(This one was harder to discuss than I anticipated, and maybe could be given more time and depth the next time around.)

Haunted

Yesterday, around noon, we admitted a man in his 50's with known severe heart disease. Apparently, he had been somewhat stable until a couple weeks ago, when he stopped with 4 heart medications. Why? Probably financial, given that even inexpensive medications require time and money to travel to the pharmacy to get refills. Also, many people only marginally believe in "western" medicine, and gravitate often to their traditional healers. And given our lack of ability to help in some situations, it can be easy to sympathize with their skepticism.

At any rate, here he was, sucking air even with our most aggressive form of giving him oxygen. His blood pressure was low and his heart rate was fast in an irregular rhythm called atrial fibrillation. We don't have much to do in this situation, except to restart his prior meds at a bit more aggressive level, paying special attention to try and not lower his blood pressure further. I sent him to our little ICU because (for once) they had room available, even though it had been decided that he wouldn't be intubated if his breathing should ultimately fail.

He died at 3am last night. Even though I was on call, I didn't find out until this morning, which was a bit surprising, but overall fine, since I wouldn't have done anything differently.

He was one of a hundred cases that haunt me. The memory of it will play around the edges of my mind, while I go about my work, laughing with the interns, building a block tower with Maggie, watching the birds, deciding on a course of action for the next patient. Just a bit of a whisper:

Could I have done more? Maybe if I had stayed at his bedside all night instead of in my own bed, I could have bought him some more time. Wouldn't that have been worth it? I should be working harder. Tenwek is all these people have for options. Maybe it would have helped. Maybe if I worked harder...

I think about it when a workday seems kind of light, and I get home at a good hour. I think about it when I discuss a new patient over the phone with an intern and decide that I don't need to walk up to the hospital to see the patient for myself. When one of my colleagues works harder and longer than I do.

Some of this is some kind of warped fear that I need to earn God's approval by trying harder. Some of it is knowing that I have been given much, and much is expected of me. 350 years ago, speaking of medicine, Thomas Sydenham wrote: "He must one day render to the supreme Judge an account of the lives of those sick men who have been entrusted to his care." I wonder what this means.

In the end, there is always more work to do, and we have to make decisions about our own limits. And truth be told, I'm pretty comfortable with where those limits have fallen for me. I'm pretty comfortable, but not one hundred percent. Our lives of full of a lot of great joy, and we thank our all-gifting God for it. Nevertheless, a small whisper continues to haunt. Maybe this discomfort is necessary to keep us diligent. I'll seek some conclusion, but it may just be one of the burdens intrinsic to what we do here.

The Problem of Good and Evil

I'm on call again this weekend. It's not been too bad as things go around here, but the numerous tragedies are ever-present. A two-year old had meningitis and subsequent problems draining the fluid around the brain. We had a neurosurgeon visitor at the time, and were able to place a drain, but things are tough to keep sterile here, and he ended up with a worse infection. He hasn't spoken in days, and it's only a prayer that maybe, somehow, he might again. A three-year old has a brain filled with strokes, and we're supplying oxygen and not much else of benefit, but this is what the family wants. I'm not expecting anything to get better, and so I guess I'm waiting on something to get worse. Trust me, the list goes on and on.

Sadness is the predominant image. Tragedy. But it's more than that. There is evil in the sadness, some sense that things could have been otherwise. Should have been otherwise. I don't have the strength to stare at it all day, every day. But it's there whenever I open my eyes.

Philosophers and theologians have, for years, debated the “problem of evil.” The reasoning goes something like this: How can God be all-powerful and all-good, and yet there is evil in the world? If you accept the contradiction and hope for some resolution, then you can (a) reject that God is good and/or omnipotent, (b) reject the reality of evil, or (c, seemingly the most popular option) reject that God is there at all. Actually, there are other options out there, and I would assert that some of the proffered Christian answers out there hold some decent water. However, they may or may not satisfy the intellect, but they will rarely satisfy the heart, when you're staring at a mom and her sick child.

And yet recently, I can't shake the feeling that there is a missing piece to the discussion. As I write this, little Maggie, growing every day, is repeatedly crawling up on top of her dad, just for the fun of it. A cool wind blows on a sunny day. A friend is only too glad to help. In fact, though we see our fair share of wailing in the hospital, if you could walk through it, you may notice that the predominant sound is laughter and friendly conversations, not just from the families whose loved one is getting better, but from the others as well. And not just because we can't bear to look at the sadness for too long (though I certainly vouch for that phenomenon). Rather, there is the simple fact of all the goodness around us all the time. Shattered and mixed up, like one would expect in our fallen world, but emphatically there nonetheless.

What do we make of this? Mostly we ignore it, but one could say it creates the philosophic “problem of good”, whose reasoning goes something like this: If God is not there or not good, then where in the world did all of this goodness come from? And thus, the suggested answers to the “problem of evil” may be creating another equally-challenging question. The presence of good is certainly subjective, but no less subjective or real than the presence of evil.

I'm not suggesting ignoring the evil or the sadness. Jump into the middle, in the moments where we have the strength, and take it on. But celebrate the small and forgotten graces. Celebrate the large, overarching blessings that are too big to keep track of most of the time. Celebrate the strong and holy goodness of God.

Here and There and Everywhere

“Here and there in the world, and now and then in ourselves, is a New Creation.” - Paul Tillich

“It's a new day. Everything will change. We will never be the same.” - David Crowder

Year by year, I grow more to love that Christianity expresses the paradoxes that are the reality of our lives. These are the impressive truths of our faith. That mankind is cruel and magnificent. That life is incredibly simple and hopelessly complex. That the world is dying all around, yet being renewed day by day.

It may be part of the nature of things here that this last observation is exemplified. Many are the days when, at my utmost optimism without abandoning realism, I can only say with Paul Tillich that goodness and newness are peeking through “here and there”. It does take a certain set of eyes to see even that much, but I believe that agreement with this can be found more or less empirically. It's a humble acknowledgment, and beautiful in its honesty and humility.

And yet the promises of Jesus loom large. They would be embarrassing if they weren't so utterly lovely. “I am making all things new,” he says. All things? Not just “here and there” and “now and then”? The deep joy this fosters rings true, but it also forces me to reckon with the worst tragedies. I won't rehash the details here, but you know the stories. You are making this new? Here?

And so we live in expectation. Maybe even paradox. But if the story of the bible – it's depiction of God's character, it's worldview, it's overarching redemptive story – is to be believed, then it may be true. Maybe even this can be reconciled.

Think of Abraham. God delivers an embarrassingly large promise. Leave your home. Go to the place I will show you. Your descendents will be like the stars in the sky. Abraham goes. And he dies in a foreign land with one promised son, his only inheritance a cave to bury his wife, for which he was charged an extortionate fee.

Did the promises fail? No. And yet, though Abraham looked forward to their fulfillment, he didn't see it. But we have. We have seen it come to pass, and it is marvelous in our eyes. All peoples are blessed. His descendents are without number.

And thus was the New Creation always present, everywhere, but peeking through to our eyes, only now and then.

Hope requires faith, but it need not be unfounded. For if it was true of the promises to Abraham, then maybe it is true now, in some way that can be looked forward to, but not yet seen, for now only popping up now and then, through some brief rent in the curtain.

Then, one day...

So, may our eyes be blessed, that we might see the New Creation, here and there, now and then. And may our hearts be blessed with faith that we might believe, through these small glimpses, in an ever-present reality of Jesus our Savior making all things new.

My Second Call Weekend

Given the interest that resulted from sharing my first call weekend, I've been meaning to share the sequel, but busyness that will be the blog fodder of the near future has prohibited me, and now I sit on the brink of my third weekend. But before it is lost...

First, the result and then a couple thoughts. My second weekend on call was still quite tough, and though better than before, 3 kids died in my 48-hour shift. My ability to walk through this tragedy was to me the evidence that God is indeed teaching me something, even as I am confounded at the beauty and the brokenness all around me. I didn't have to pull anyone in from home for reinforcements this time, slept a decent amount both nights, and even finished daily rounds at a decent time on Sunday (Saturday didn't really fit my idea of "decent").

Thoughts: First, know that all the feedback from all of you was so much appreciated. Knowing that so many people care, sympathize with my difficulties, and are even personally challenged by it - it all makes a huge difference and was very encouraging.

Second, regarding God's mysterious goodness and how it is often veiled to us, Chuck Jacob has talked about "Extraordinary Grace in Ordinary Life". Abraham, father of faith. Did anyone have God working so much in his life? He dies in an alien land with one son, and only enough property to bury his family. Was God working? Yes. Could Abraham see it? No. Was it because he wasn't looking? No. I look forward to the day that we can praise our Maker for his love seen in all his mysteries revealed.

Lastly, two quotes from Frederick Buechner (from "Wishful Thinking"):

-On Prayer: "What about when the boy is not healed? When, listened to or not listened to, the prayer goes unanswered? Who knows? Just keep praying, Jesus says. Remember the sleepy friend, the crooked judge. Even if the boy dies, keep on beating a path to God's door, because the one thing you can be sure of is that down the path you beat with even your most half-cocked and halting prayer the God you call upon will finally come, and even if he does not bring you the answer you want, he will bring you himself. And maybe at the secret heart of all our prayers that is what we are really praying for."

-"Who knows whether their acquaintance with grief will open their hearts also to the grieving of others or whether it will turn their hearts to stone? But for the sake of the one who bore it before they did, we are to honor them for the sanctity of their burden. For his sake, we are called to see their terrible beauty."

I did write a song, because as Carlan says, I "process life through music". My fear is that the song won't stand up to the subject matter, but since I busied the limited Kenyan bandwidth to upload it, I may as well share it.

What I've Been Looking For

(if the player doesn't work, try clicking here)

she is six years old, and she just breathed her last

with my hand upon her chest, and my words hung in the air

like a fog condensing to a drop that falls

and shatters like a piece of broken glass

maybe I should press on

maybe at the end, you'll show me your face

and maybe that's what I've been looking for all along

she breaks into my feverish dream and sparks a crystal voice

she says she thinks she'll understand in just a little while

a little while and all the lines connect

the ground is the air is the ground we walk upon

maybe I should face another day

maybe now it's one day closer to when you show your face

and maybe that's what I've been looking for all along

and even as our tears are fresh

she's looking at your face

and seeing all the reasons why

and all the beauty those solutions display

so just maybe she's rejoicing now

and maybe I will, at the end, when you show your face

and maybe that I've been looking for all along

My First Call Weekend

This past weekend, I was on call for the Pediatric wards, which means that myself and the intern on call had to see all 60 or so of the children on the wards and in the NICU each day, and cover any neonatal resuscitations after delivery. A couple of weeks ago, this seemed incredibly daunting, but at the end of last week, I was feeling up to the task.

I had it all planned out. The intern would see the Peds ward patients, while I came in early to start seeing the NICU babies. I would leave the NICU at 9am (to leave the ladies alone during the 8th day of Christmas) and go and see the floor patients with the intern, have some chai, and head back to finish NICU. All in all, I should be done by noon.

It went well for about 10 minutes. I got to the NICU, and the overnight nurse wanted to draw my attention to some "sick" babies. One was a preemie in obvious respiratory distress despite our most aggressive assistance. The other was a full-term baby brought in from home for severe jaundice, leading to a brain problem called kernicterus (which, in this case, was due to mom not getting that little Rhogam shot that some pregnant ladies need based on their blood type). The baby was getting light therapy and I thought that was all we had to offer. The nurse asked about "exchange transfusion". We do that here? (And by "we", I guess I meant "me")

The next several hours, I had to consult a total of 7 of my colleagues, despite my ardent desire that my efforts would enable them to have a well-deserved weekend off. During this time, the other baby died. I finally made it to the general ward, where I learned that my tardiness was not minded, given that they had been busy trying to save a little girl, whom we had been treating for HIV and TB. She also had just died. So, it was lunchtime, no work was done, a bunch of my colleagues had helped out from home, and two kids had died.

For the sake of at least facade of brevity, I won't tell the whole saga. Five children died during my 48 hour watch. Each time I watched one die, I would pray for God to receive his small child, and each time it got harder and harder to trust in the subtle, yet powerful, albeit mysterious, goodness of God.

It doesn't break my faith, but it creates a tension inside me, one that is greatly complicated by my feelings of helplessness, despite many years of my life, gone into training that is seemingly not nearly enough for the need around me. This tension makes me want to run, but I don't deny its presence. And I would assert that I have the Psalmists and a chunk of biblical prophets who would back me up.

God, how can you let this happen?

God, I can't do this.

God, I still believe that you're good. Please, please, show me.

There's so much death. How can I just keep going?

Rachel wraps her arms around me, and softly says that God's strength is made perfect in my weakness. Later, Alyssa empathizes with the simple retelling of her own first call weekend, and reiterates that I can always call her at home. And late Sunday night, we gather in the Cropsey's living room and listen to an old sermon from Knox, where Chuck preaches a characteristically somber sermon on joy from Habakkuk, asserting that we must decide whether we will view God in terms of what we see in the world, or view the world in terms of what we see in God.

This is only one part of life here, as our lighthearted exploits into pet squashes, milking moms, and dead geckos surely show. But it is significant. It is expected. It is incredibly hard. And by God's grace, I pray it be fruitful.

"Give me an undivided heart, that I may fear your name."

Responsibility and Compassion

Yesterday, a chronic low back pain patient sits across from me. "My back has been killing me for the last few days, since I ran out of my meds."

He is one of the few who has the privilege of having a primary doctor, this area of IHS being severely understaffed. "When is your next appointment with your regular doctor?" I ask.

"Oh, I missed my last appointment, and they were going to set another one up for me, and I haven't heard back from them. That was in September." September? That's almost two months ago.

I pause for a moment and try to sort out the right thing to say. I've heard lines like this so many times in the past month. There's a bunch of thoughts and emotions spinning around in my head, and I'm not sure which direction to go.

"Look, I know the system can be difficult, and I know sometimes you might have limited communication resources, but this is your health and therefore your responsibility. If you don't hear back from them, call them. And then call them again. You've had two months. I know it would be nice if everything would be done for you, but it is and will always ultimately be your responsibility."

He nods graciously and doesn't seem overly put off by my miniature rant. I pray for the ability to be merciful as I walk out the door to work on his paperwork.

There's another chart waiting for me at my desk area. "Dr. McLaughlin, this is a patient you had instructed to follow-up today, and he didn't show." He is a new diagnosis of diabetes, and terribly symptomatic from it. There's a form for me to fill out, as to whether I called him or sent him a letter, and what follow up he needs. What does he need? He needs to show up for his appointment! If he doesn't care enough about his own health, why should I? The words of Cain spring to my mind, "Am I my brother's keeper?"

Important aside: Domestically and abroad, the question of how aid work can stifle initiative and responsibility is an important one. I haven't decided whether my actions or my words were inappropriate, in and of themselves. But that's not the point at present. The point is this:

I tell this to Rachel over a dinner of a precious jar of curry we imported from Phoenix, wanting her to agree that I'm in the right. "Hmm, that doesn't sound very compassionate," she says softly. She also reminds me that this is likely to be all the more potent in Africa, where we have been told (i.e. warned) that losing your temper or speaking in anger is the greatest of cultural sins, and is the quickest way to sever ties with Africans.

Paul says "speak the truth in love." I'd like to think that being right is enough, but it's not.

Bob Lynn is fond of pointing out that the Good Samaritan parable was in response to the question "Who is my neighbor?", and Jesus gives the answer that we are to extended neighborliness wherever it is needed. Am I my brother's keeper? Maybe not by any natural right, but as a Christian, I make others my neighbors, and accept the responsibility that comes with that.

I am grateful that I have a month more to work on this, prior to heading to Kenya. Could this be the reason why God brought us here? I won't presume to say, but we're here, and "as long as it is called Today, let none of you be hardened by the deceitfulness of sin."

I found this the other day:

“Oh God of Abraham, please give us humble hearts. Oh God of Isaac, please give us thankful hearts. Oh God of Jacob, please give us faith. Let us see Jesus.”

Shot Through

A while back, our Knox pastor Chuck Jacob made a comment to the effect that, if you were hoping to avoid getting your hands dirty in the problems of life, then you probably have the wrong religion. In other words, that's what we do.

This was remarkable to me, because as a physician, sometimes I would be overcome with all the brokenness around me. Broken homes, broken bodies, broken minds, broken relationships. I just wanted to spend some time with someone who was whole. And though there is something to be said for the idea of a retreat, by and large, I wouldn't begrudge anyone the observation that "You're a doctor. What did you expect?"

And then, stunned at my own amazing connection, I realized that Jesus had made it thousands of years ago, and in fact I've heard it innumberable times. "Those who are well have no need of a physician, but those who are sick." (Matt 9:12)

Shot Through

The world is shot through with holes
Riddled with bullets, haggard and old
It seemed to be fresh, the breezes new
But you put your nose down to the ground and find that it’s not true

I set out to heal what I thought was a leak
Loosened the dirt, my feet in a creek
Downstream a rapid that weathers me down
Shooting me through with current that threatens to drown

And it’s always been this way, whether I would let it be seen

And if you would bring light
You must dive into the darkness
before you find the tinder you can strike to break the night
And if you’d bring a balm
You must dress the wound
and bring your fingers to the skin

where you can pour the ointment on
For it is the sick
It is the broken that need a physician

It’s still hard to believe
That such a change can spread so quickly through the trees
From afar, the leaves are whole and new
But autumn knows that really they have been shot through

Never looking in, and never looking close would cause me to believe
That everything is void of scars, but never looking hard
Would let me think that all is whole
All the while the sun is shining in where all the gaps are

They’re not as they once were, tremble when breezes stir

And if you would bring love,

then come and wrap arms around the terrified
Who’ve caused the crimes you never have dreamed of
For you and I have been loved like this

Atheists, Priests, and Dependency in Africa

I don't think that I'll try to provide a direct answer to the questions from Paul Theroux, as posted below. Instead just a couple stories and thoughts that seem to bear upon the issue. The most significant is an amazing article sent to me by the good James Paternoster from The Times, by Matthew Parris, entitled "As an Atheist, I Truly Believe Africa Needs God." I recommend it in it's entirety. It's subtitle reads: "Missionaries, not aid money, are the solution to Africa's biggest problem - the crushing passivity of the people's mindset." He then goes on to make claims that even I, as a Christian, might not be so bold as to make. The main supposition is that Africa needs a new worldview, one that encourages initiative and ingenuity, and does not bow to thuggish pseudo-dictators. He (almost reluctantly) admits that he finds this change taking place in the areas where missionaries have been the most active within Africa. Of course, this falls into the category of "faith in God as a means to an end", which is a camp in which I cannot put myself, but nonetheless, it gives me great optimism about our goal of Word and Deed.

The second story that has seemed relevant to me is that of Abbe Pierre, a French priest that Paul Brand (long-time leprosy doctor/hand surgeon/missionary in India) met years ago. His story is that he started a mission to help the homeless of Paris, and found the greatest effect in having the homeless serve someone more needy than themselves. This apparently turned out to be enormously successful, to the end that they were in the danger of not having enough need to serve. This, in turn, brought Abbe Pierre to Dr. Brand in India, and he found in Indian pariah lepers someone for the homeless of France to serve. He expressed his great concern to Dr. Brand that a lack of service would turn their focus inward and thus be their own destruction. Service as simply a means to your own fulfillment is fraught with difficulty, but I do agree with basic ideas here, and thus remember that turning a blind eye or a hard heart to the suffering in the world is just as likely to be our own end as theirs.

Paradigms - Part II: Henri Nouwen Book Titles

As the ideas discussed in the prior posting swirl around in my head and heart, a phrase climbs slowly out of the fog, giving itself an extra prominence: The Wounded Healer.

The Wounded Healer is a book written by Catholic priest and contemplative writer Henri Nouwen in 1972. Nouwen was a fascinating man, and the book a worthwhile read, though the title itself has more bearing on the present discussion than does the content of the book. The phrase, of course, makes me think of Jesus, and Nouwen uses it to describe us as we imitate Christ. It does not at all remind me of the medical institution’s image of its own practitioners. There, the two pervading images are, either the healer who needs to be whole himself/herself before extending help to others, or the healer whose personal condition has no bearing on his/her healing work.

How is Christ a “wounded healer”, and in what sense are supposed to imitate this? I can think of two ways. First, Christ’s wounds are substitutionary, as Isaiah wrote centuries before Christ, “The punishment that brought us peace was upon him, and by his wounds we are healed (53:5).” Because he was wounded, we no longer have to be. I can envision a few glorious human examples where one might imitate this (such as the end of A Tale of Two Cities), but overall this provides little in the way of guidance for my own medical practice.

But there is a second and more subtle way that Christ may model the “wounded healer”. The unknown writer of the letter to the Hebrews writes that part of the reason Christ is the greatest “high priest” (able to mediate perfectly between God the Father and mankind) is because he “has been tempted in every way, just as we are – yet was without sin. Let us then approach the throne of grace with confidence, so that we may receive mercy and find grace to help us in our time of need (5:15).” Did these temptations “wound” Christ? I do not know. But what is evident is that the personal story of Christ (both its ebb and flow) enables his healing of others, instead of detracting or even distracting from it. There is potential here for an appropriate guide for us to model. But how?

I do recommend Ellen's comment from the first post for more food for thought.

Paradigms - Part I: Medical Care for Friends

We were asked the other night how we felt about being the medical provider for our friends. This is hardly a theoretical question, as Rachel has agreed to provide obstetrical care for a good friend of ours. The institution of medicine does not provide a definitive stance on this, but it does provide a thought framework that lends itself to a certain position: We are uncomfortable with it, because though it may be enjoyable and rewarding as long as everything is straightforward, the possible threat to our personal relationship that is created by a possible bad outcome is a risk most are not willing to take. You are caring for a friend, and they are diagnosed with late-stage cancer. Will you ever be able to forgive yourself for not finding it sooner (even if there is nothing to forgive)? What will become of your friendship and the relationships you hold in common?

We recognize that we had better make peace with this. If my appendix ruptures in a couple years, Jason Fader will become intimate with my colon, and will have to deal with the responsibility of operating on me. If little Elise Cropsey gets malaria, it will likely be my treatment plan that will recuperate her. This is part and parcel to a desire to work in an area where there are minimal other medical providers.

The medical paradigm that creates these (and other) levels of discomfort with treating friends seems to be this: You are the patient. You are coming for help. I am the doctor. To best help, I need to be disconnected, and thus objective. I should not be bringing my personal story into yours, because this is about you, not me. And from this comes a separation between your patients and your friends, for friendship requires a give and take, an intermixing of personal stories. I think that our pastor at Knox was correct is stating this is likely an outgrowth of medicine’s modernistic bent.

And so I question this: Is it really possible to separate yourself personally from the patients you treat? If so, does this really provide objectivity? Does objectivity lead to healing? (If a person can be treated as a scientific physical specimen, then perhaps.) Is this a paradigm that will make a drop of sense in Africa? Is this consistent with Christianity?

More to come, but I would appreciate any thoughts from those who may read this.

Medicine and the 4 Levels of Happiness

Several years ago, I heard John Patrick speak at a conference, and he talked about the 4 levels of happiness. The first and lowest level is animal happiness, that is, our hungers, thirst, physical drives. The next level is discipline happiness, or the happiness that comes from applying yourself and acheiving that goal, such as in athletics or academics. The third level is that of needing to be needed, which can result in altruism. The highest level is that which comes from knowing and loving God (and, I would say, being known by and being loved by God). It's a very Neoplatonic idea, in the sense that we strive to aim for the higher levels, while de-prioritizing but still enjoying the lower levels.

At first blush, I didn't see much more than an interesting thought exercise in this, but later my friend James (of the Lyntelnosters) gave me pause to think how the work of medicine fits into this. I think two things can be gleaned:

1. Medicine is fundamental: This is the gravity of what we do. When physical and mental health deteriorate, the ability to pursue any of the happiness mentioned above is seriously challenged. This is the reason people will drain all their resources to pursue a cure; because what good are all these resources if I'm not alive or functional to pursue any other happiness?

2. Medicine is foundational: To me, this is the other side of the coin. What we do gives people the lowest level of happiness mentioned above, but that's it. Whether anything higher is achieved is up to them. Yes, physicians can help people to pursue higher happiness, but at that point, most people would say they have gone beyong the limits of medicine and into some other service more common to friendships than doctor-patient relationships.

So, in this light, medicine becomes humility and honor. It reminds me of a scene from Lewis' Narnia: "'You come of the Lord Adam and the Lady Eve,' said Aslan. 'And that is both honour enough to erect the head of the poorest beggar, and shame enough to bow the shoulders of the greatest emperor in earth.'" Those of you who didn't think this was going to come around to CS Lewis ought to have known better.

Faith in Medicine: Thoughts from Dr. Chang

The miniseries at Knox Presbyterian goes on, and last week, the venerable Dr. Robert Chang, hospitalist extraordinnaire, gave a rockin' talk on what he's learned from his work at the hospital. And he did so on a minimal night's sleep, having just come back from a Honduran hospital early in the a.m. He's in internal medicine, and likes these long, sleepless runs.

There were a lot of great points that he made, but I'll focus on one. There's an old testament story (2 Sam 12) that I've heard for many years. King David, after committing adultery with the wife of one of his soldiers and getting her pregnant, he indirectly murders the husband and marries the woman himself. Through the prophet Nathan, David learns that God is going to punish his actions by the baby dying. That such a renowned hero of the Bible as David was guilty of such heinous actions, and that God took the life of the innocent, are both parts of the story that deserve long conversations not to be found here.

Here's the focal point: David hears this, and fasts and prays and lays prostrate on the ground for days and days, imploring God to change his mind. He was so desparate that, when the infant did die, his men were afraid to tell him this news, not knowing what he might do. But he senses their hesitation, and they tell him the truth. He gets up, bathes, changes clothes, goes and worships in the temple, and then eats. They ask him how he could act like this. He answered, "While the child was still alive, I fasted and wept. I thought, 'Who knows? The LORD may be gracious to me and let the child live.' But now that he is dead, why should I fast? Can I bring him back again? I will go to him, but he will not return to me."

Here is a solemn model for the physician. Ardent striving to save, ardent sacrifice on behalf of the sick and dying that we love. And then, peaceful recognition of the limits of our efforts. Acceptance, and the ability to move on and continue to live as God desires. We sense this tension in which we live. Robert, thanks for using this illustration to acknowledge the tension and instruct in the midst of it.

Learning from Jesus the Healer

Our church is doing this awesome miniseries of classes on “Faith in Medicine”. Seeing as though this website is to be a forum for all things Faith, Medicine, and Africa (and the intersections of these themes), this may not be the last posting from the aforementioned miniseries. It’s part of a broader goal the church has of trying to help people discover how to serve God in the work they do.

The first week was Dr. Steve Telian (of dubious Lyntelnoster fame) speaking on what we can learn from the healings of Jesus as well as the worldview from which he seems to have been healing. Here are a couple of my favorite take home points:

1. Healing through medicine is a good gift of God against the destructive effects of sin in this world, regardless of the motivation of the practitioner. It is not only those with a wrong motivation who often presume on God’s grace to accomplish healing through medicine.

2. Health is a gift of God, since He is keeping and preserving (in addition to healing) everything in nature. Thus, it is fitting that we praise God for our health, since the hand of God is not less active here than in health restored after sickness.

3. Sometimes glorious redeeming work comes through suffering. This is a mystery and a difficult thing to find appropriate application for in medicine, but it is certainly in line with Jesus’ teaching. It is plausible because of the fact that we are never at a position to know the whole story and all the ramifications of a given suffering.

Maybe these paraphrases won’t communicate the same as stand-alone ideas, but food for thought…

"Word and Deed"?

A good friends asks me, "Are you first a missionary and second a doctor, or is it the other way around?" In other words, "Is proselytizing (a.k.a. evangelizing) or medicine your primary goal?" This is a good question, and one that many ask, and likely even more want to ask but don't know how. But the most truthful answer requires a different question.

We believe foremost that the message of Jesus is good news. OK, so what is this news that's so good? Namely, that Jesus' life, death, and resurrection has accomplished a way to new life. Our old life (i.e. without the good news of Jesus) has been full of sin. Jesus offers forgiveness and His Spirit to overcome sin. We had lies. He offers truth. We had hatred. He offers love. We had selfishness and inwardness. Jesus offers a way of serving Him by serving others. We perpetrated injustice. Jesus bring true justice. We had death. Jesus brings new life.

For many years, Christians have chosen between the categories of Word and Deed. One group chose to spread the message of Jesus, and the other to do the works he commanded. But these are inseparable. The Gospel (which simply means "good news") is to be in Word and Deed. The good news is that Jesus is your salvation for all of time and that His kingdom is bringing you medical care here and now. Word without Deed would be an incomplete Gospel. Deed without Word would also.

This idea endows everyday medical care with eternal significance and makes it not just a means to a more "spiritual" end. And it causes the message of Jesus to be rightly endowed with transformative power here and now. This truth is central to our mission.