is it possible

this was the billboard i passed on the way to town today.

i'm not sure. 


today i got mad at the many things that are broken around here and the lack of fixing. i was driving home from clinic, on some back, barely paved road with a slow*** tanker truck in front of me.  it was spewing black diesel smoke from one side and pouring what i hope was water, from it's tank which had stenciled in small letters H2O.  it was like the little engine that couldn't.  the thing could barely get up the small hills.  i really wanted to get away from it- for all the obvious reasons especially that who knows what was really in that tank.  the thing wouldn't let me pass- every time i tried he moved over into the middle of the road.  now i usually have road zen here- it's not worth getting mad- but today i was mad.  swearing out loud mad.  thankfully i was driving alone. 


then i came to a place where i knew they were doing some road work but it was in a dead stand still. like, put your car in park, stand still.  in typical fashion all the cars behind me began pouring onto the other side of the road and forming another lane going in the same direction.  this infuriates me, because of course it creates a bottle neck and we're stuck longer.  when we finally move a little i see that they'd begun to do more road work and had some how created a  lot of mud and the road was now two levels that an ordinary car couldn't go between, but several had tried and were stuck laterally - as in across both lanes stuck.  as had a matatu and that stinking H2O truck.  of course there is no signage and no police helping to direct traffic.  instead there are several road workers in hard hats pointing and commenting to each other about which car would make it out of the mud first. 

i began to reflect on why i was so annoyed and i realized it was about much more than the leaking, broken down old truck and the bad road work.  it's being constantly faced with the broken systems all around me.

today at clinic i saw a woman for the second time.  the first time is saw her she came in for her regular visit and thought she had malaria which i tested her for but she didn't have.  i happened to also take the time to look through her chart and saw that she'd been sent for a work up over the summer for dysfunctional uterine bleeding, lots of it, enough so that her hemoglobin was 4 (less than half normal).  when i asked about what had happened, in typical fashion, she wasn't sure- she may have had surgery, she did have some lab tests done, and maybe a biopsy.  no follow up had happened.  i rechecked her blood, put her on iron supplements and told her to go get her records, her results, all of it from the hospital.  i gave her my phone number and wrote a note to the doctor who was 'treating' her with the questions we needed answered. 


today she showed up looking pale again, and with her results.  a cervical biopsy had been taken, it showed severe dysplasia- it was from 4 months ago.  no one had followed up- not the person who had ordered it- nor the pathologist reading it.  i know this situation can and does happen in the states- but somehow it seems almost the norm here.  as i'm discussing with her the need for treatment and that likely it will be more aggressive given her HIV status, i realize that i can't fall back on the promises i'm used to giving.  i can't promise that she will have very little post operative pain- i can't promise that this is a routine surgery that will go perfectly smoothly with very little chance of a bad outcome.  i don't think either are true! this is a country where women die in childbirth while in a hospital from lack of blood or sutures!  a place where you pay first and if you don't have money you lose.  a place where the drug you need may not be available- or where there might not be enough nurses to get your pain medicine.  i sat there trying to explain why it was so necessary for her to go back to the gynecologist and get treatment but i just kept thinking about trust.  how can she trust this system to not fail her?  how can she trust a doctor to cut her belly open if the same doctor didn't even follow up on the tests ordered in the summer?  how can she be sure she'll not have intense pain, or that she'll even survive the surgery?  it made me sad and mad and feel quiet helpless.

after that i saw a man about 60 years old who had been on ARVs for over 2 years.  i looked as his CD4 count it was 30.  we put people on ARV's when there count drops below 350, he'd been put on ARVs when his was 25, but over two years ago.  it was now only 30.  i couldn't find any work up about why this was and what we were going to do about it.

while i was talking to him about adherence, the woman who had the baby with the seizures stopped over to give me an update.  i'd given her money last week and she'd taken him to get a work up with a CT scan of his head and an EEG, but was told she was supposed have come on a monday not a thursday and sent away.  he'd had another seizure that night (although not sick) and she'd had to bring him to a small local hospital where they treated him for guess what..... malaria as usual- and then IV antibiotics because they needed to 'treat his infection' (although they couldn't tell what or why or even if he was infected) before any scans or further work up could be done.  so all the money for the work up was now spent on probably a lot of unnecessary medical 'care'.

so driving home i passed the sign again. "is it possible?"  it stood there looming over me- asking an ambiguous but hard question.  and after my day, i wrestled with my answer.   is it possible?  i don't know, but i have to believe yes.  something is possible on some level.  some things must be possible- over time things are possible.  and then a matatu sped by and i remembered all the wise old sayings that i pass numerous times each day written on their rear windows.  they are expressions of hope- reminders of our place in the universe, phrases of encouragement and i'm beginning to see why they are so prevalent.  i'm not the only one in the country wondering 'is it possible?'  so it's good to read - 'God is able', and maybe tomorrow i'll see my new favorite, 'with God, it's possible'.

silenced by it

silenced by it.

i was very conscious about my decision to not do pediatrics.  sick children break me.  but at Reach Out clinic, we see kids sometimes.  today i saw a boy who is 12 with AIDS and TB, coming for fever, cough, diarrhea, and vomiting.  he was diagnosed last year with HIV, his cd4 count was 11.  he's now on ARV (anti-retroviral meds), he's on TB treatment, but he has difficulty with adherence.  he is neglected at home.  his mother is also sick, and they are poor.  he walked 3km to clinic alone. sick and alone. 

as i talked with him i kept my hand on his back- his thin and wraspy back that rattled when he breathed or spoke.  i lifted his shirt to listen to his chest.  he was covered in the same rash that covered his face.  he also had shingles lesions crusted over all along the lower right side of his back, his body was old- old and sick. i moved the stethascope around to all the regions of his lungs, and his heart, my hair was loose and hung long over my face- thankfully- because i cried.  i stayed there hidden in my hair listening to his distended abdomen, holding his clubbed fingers.  somehow he symbolized everything that is wrong with the world- everything broken- a sick child born sick.  a sick child with a sick mother, a father who'd abandoned them, two dead grandmothers, two dead uncles and no one to just pick him up and hold him.

i so wanted to.  i wanted to take him on my lap and tell him he is loved.  that he is valuable.  i wanted to feed him a big meal and put his many pills in a neat pill box and make sure he took them.  i wanted to give him hot chocolate and tuck him in a bed at night under a mosquito net and help him to feel safe- to have hope- to see a future other than what he lives.


was that all i cried about under that shield of my hair? or was it for the woman who lives at someones house and does work for them so they will pay her sons school fee's- who has no income for herself- except the beans she is fed twice a day.  she hates beans- but is thankful that her son is learning- thankful that she is still here and able to work after 8 years on ARVs- after coming back from nearly dead.


or was it the woman with high-grade cervical dysplasia who didn't have enough money to get to the hospital for further evaluation and treatment.  i explained the importance, the necessity of going and she understood- but it would cost about a day's wage and she doesn't work.  i have a car, i drive by her neighborhood three times a week going into town- she has a need- she needs a ride.  we tried to figure out a time, a place, a way for me to pick her up and take her- but her english wasn't good and my luganda even worse.  she had a need, she didn't ask, but i could give her bus money, which i did- the price of a latte.
'thank you', she kept saying, 'thank you for helping me to live.'


or was it the skin and bones baby who tried to smile in the arms of his weeping mother.   the 4 months old boy- who is starving before her eyes- who eats and eats but is unable to gain weight.  this child who has been to two 'health centers' and turned away with out a diagnosis or treatment.  this broken child brought in by his broken mother- begging for an HIV test- because why else would her baby be dying?


i didn't mean to cry.  i didn't want to, i really didn't want anyone to know that under my curtain of hair- i broke.  but i did. 


i'm the only muzungu at Reach Out- well except for a kid from germany who volunteers in the lab. no one understands what i'm doing here.  they keep asking why we left the USA- why we moved to uganda.  they ask with concern about our children- are they in a good school?
i explain yes- they are. i explain that we came because we feel we are supposed to be here- because there is a need and we happen to have a desire and the ability to help meet the need- like a puzzle piece.  it's not a huge sacrifice because we fit- because this is where we want to be.  our great gladness, the worlds great need- they meet- for us, they meet here.


it's not that i think i can fix any of it really.  and it's not so much that i will run away.  but the need can scream so loud sometimes that it hurts.  the disparity, the discrepancy, the random injustice of who is born where.  someone born with a silver spoon, someone born with a sexually transmitted disease. someone working all day for food and her sons school fees, someone else able to send her kids to private international school and never have to eat beans because she doesn't like them either.  someone with an infant unable to thrive and no good access to care, someone else able to fly back to the US if we were sick in an instant.  someone unable to pay the bus fare to get treated for her possible cancer, someone else with 4 wheel drive complaining about an outdated tape deck.   i see my excess everywhere.  but i will try, and i will give, and i will remember, and i will impress upon my children as best i can- how fortunate we are- and to whom much is given, much is required. 

i drove quietly to the boys school biting my lip- so i wouldn't cry again.  it was pretty and each parent around me inquired genuinely about their little persons day.  such focus on each detail of the story, a kiss for each little bump, an ooh and ahhh over each letter formed or picture drawn.  i didn't just hug the boys when i got them- i clung to them. 



and i was silenced by it. 

owning the slippers

i love to travel, but i hate airports.  they stress me out.  people seem annoyed- things are delayed (like my flight yesterday) the food isn't good and it's expensive, and there is elevator music. but with a coffee, a biscotti and an assigned seat-  i can sit and write-alone.  ahhh.

yesterday i woke up early and sat out on my porch watching the sun light up one side of this super tall water oak in the woods behind my house.  it's the same every day- that light- on that spot.  and i thought, 'i will miss that when i'm gone'.  that is where my head is- it's on 'going'.  so i wasn't very excited for my airport trip that morning to head up to my family reunion in grand rapids.

i love my family- all of them- really.  this was an extended family reunion- some of my cousins and all of my aunts and uncles from my mom's side of the family- but many more people that i barely know or haven't even met- my cousins cousins.  and, given the pace of life these days, what needs to get done in the next few weeks- i almost didn't go.  i was dreading flying, packing, being away another weekend, losing that time to "do" stuff- to "get done".  but mike was great.  he gently reminded me that people are way more important than getting "stuff done".  that relationships matter most. that you don't get another chance to see people all together like this.  he is right, so off i went.

and i am so glad.   it was a day of reconnecting with really good people who i haven't seen in years but know me- people who've prayed for me- prayed through the seasons of my life.  people who know the value and importance of family and of relationships.  people who've had brokenness, people who are going through hard times right now.  people just like me, and just like you, because we all know broken and we all know hard.  but what do we do with it?  our brokenness?  other peoples hard times?

on friday, at work, i had one of those days where the system gets in the way of the people.  that really gets to me because there are so many times when we do things in medicine because the patient said the 'right words' even when we know it's unlikely to be  the medical entity that classically goes with those words.  but then sometimes- you know what the right thing to do is- you know this guy needs serious IV pain control to be able to sit still for the radiation to his bone metastasis- which will then bring him relief- you know he's failed it as an outpatient - but the system balks at his admission diagnosis- at the hassle of how to categorize him.  and this gets to me.  the right thing to do is get him comfortable enough that we can radiate him and help his pain - even if it means an admission.

i know soon in uganda i will have many struggles between systems and people's needs.  very different struggles.  the medicine is too expensive, the person is too sick to come into clinic, there is no MRI machine.  and like my friday situation- you do what you can- you think outside the box- and you always give the treatment you administer by ear, "words of comfort".  (another gem from cutting for stone- abraham verghese)

and that is what we do with our own brokenness- ours and our families- you ask- you listen- you give words of comfort- even when it might be easier not to.  because it is right.  because we are made of the same stuff.  because we want that when we are in the hard times.

today i was back at the Gerald Ford International Airport in grand rapids michigan.  sometimes in the airport you can look around at other peoples lives and wonder.  you can easily and quickly make assumptions about them- what might be easy- what might be hard about their life.  you can even try it on your imagination- what if i'd made 'that' choice or what if i wore 'those' kind of clothes.  usually from my eyes- somehow most peoples lives in the airport seem simpler- easier and i romanticize them because of this.  i'm looking at this tan guy, wearing a polo shirt with his wife and baby- they look like they're going on vacation- they don't seem stressed out by their lives- by there one, young healthy child.  i see the guitarist from a popular band who i'd sat with the day before when i accidentally got first class with a frequent flyer ticket- he seems to breeze around- no luggage- first class- no kids- no major ties.  i see some business guys - calling home- telling someone about the convention- kind of bland- it's a job- can't wait to get home.  i see a dad with his daughter.  she's about 12, carrying two crimp haired dolls and a bedazzled backpack,  she's asking where her brother is- she's reminding me of zoe, she's smiling- she has downs syndrome.

nothing is easy.  it's just life.  tan and polo-ed, rich rocker, business guy, dad of a child with a chromosomal anomaly, girl with her dolls and pack.  all beautiful and all broken.  just like me.  just like zoe.  just life.  the secret is knowing your life- owning your life- not wanting to be the rocker- or the business guy.  we are who we are.  what we do with it, or don't do with it- that is what further shapes us.

"The key to your happiness is to own your slippers, own who you are, own how you look, own your family, own the talents you have, and own the ones you don't. If you keep saying your slippers aren't yours, then you'll die searching, you'll die bitter, always feeling you were promised more. Not only our actions, but also our omissions, become our destiny."
abraham verghese - cutting for stone.

now i'm home.  on the porch but it's evening.  the light comes from the other side now - from the west.  and instead of lighting the bark- it lights the leaves- all of them- each of them.