Word and Deed

"Don't worry," says Elysé

2025-10-08T14:56:00.001-04:00

(from Eric)

Sunday morning, I woke with worries I didn't think that I had.

In that liminal space where you're not quite asleep, but you still have no control over what you're thinking about, my mind raced. It was probably five in the morning. It was still dark outside but the birds were loud enough to shake up some part of my subconscious. I was fretting. I was worrying about the medical school three years from now. I was worrying about our water supply in the next day. It was like a parade of anxiety.

Strangely, I hadn't gone to bed worried, or even thinking, about any of those things. I didn't think I was actually that stressed about any of them. However, they say that, if you want to know what you worship, notice where your mind goes when you have nothing to distract it. Or maybe where your mind goes when you're just awake to notice what you're powerless to stop thinking about.

Somewhere in my stupor thoughts, I realized it was Sunday morning, and I tried to tell myself that this was the dumbest moment of the week to worry about anything. But, to no avail. The mental catastrophizing continued.

Through the fog, I remembered Jesus' words from Matthew 6 about not worrying about tomorrow. "Why wouldn't I worry? It could be really bad." Then a mental response: "The only reason to not worry is that God your Father is actually sovereign."

I drifted off, and woke later, wishing I had slept better, and got ready for church.

***

After the songs, the welcoming of visitors, and the offering which always encourages us to dance, we sit down in our plastic lawn chairs to listen to the sermon. This week it will be given by Elysé.

I met Elysé years ago when he was a local teenager playing different instruments in the church worship band. He seemed invariably cheerful, and would sometimes lead a prayer. I remember him preaching for the first time. He went away from some additional studies, but was soon back, and would often come out on Sunday afternoons and play ultimate frisbee with us.

Last year, I was taking care of an older man on our Internal Medicine service, and he wasn't doing well. I learned that this was Elysé's dad just a couple days before he passed away. Elysé has always struck me as kind and also joyful, and he found a way to show these qualities even in the grief of his father's passing and the fears that can bring about. I was delighted and thankful to see him hired by the hospital the following month as a secretary. These days, when I come in for morning prayer, he's often playing the guitar, and when I go into the Admin wing, he smiles and greets me, most often in English.

***

So, Elysé stands up and says that he is going to speak today in English, because we have several visitors that don't speak French. He says that today, he wants to tell us all: Don't worry. He reads out of Matthew 6 where Jesus says don't worry about what you will eat, because you are more valuable than sparrows, and don't worry about what you will wear, because you are more valuable than flowers.

Verily, verily, I say to you that I've never really worried much about food or clothing in my life. I've always had them, but Elysé might have had good reason to worry when his father passed away. He mentioned that time of his life, and then he quoted Psalm 68:5 in English from memory: "A father to the fatherless, a defender of widows, is God is his holy dwelling." "Don't worry," says Elysé with a smile, "because if you have Jesus, you have everything."

***

I think you can imagine how these words were a balm to my heart, and not just the words, but hearing them from Elysé. I spend my years teaching and studying, and Elysé, maybe 25 years old ("still single and searching" he introduced himself), stands up and says the simple words in the simple way that I need to hear.

What do I worry about? It's not food and clothing, like Matthew 6 talks about, or even basic financial security, like any rural Burundian family would worry about when their father passes away before they have a job. What do I worry about? Meaning, I guess. Having my life "count" and "making an impact for something that really matters". That's certainly something that moth and rust can destroy. That's certainly something that I also need to lay down and commit into the hands of a loving Father.

But maybe it's not "meaning" or "impact". Maybe it's just worry. Maybe I just worry about the next thing. If I had food insecurity, I'd worry about that, but that being shorn up, I move on to the next thing. I worry about whatever the leading edge happens to be. Truth be told, I've been giving incredibly meaningful work in my life, and the opportunity to have a great impact. But it (like everything) is limited, so my worry lies wherever the uncertainty happens to be.

"Don't worry," says Elysé. "If you have Jesus, you have everything. God is a father to the fatherless and a defender of widows. Don't worry."

***

Final thought: My early morning worries were truly incongruous and surprising. Could it be that they were given to me in order that I might truly listen to the words of the sermon? Could it be that my 5 a.m., uncontrolled, heart fretting was actually a grace to me?

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

2025-04-03T04:12:00.002-04:00

(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

New Serge Video: A Day in the Life

2025-01-20T06:09:00.002-05:00

Here is a new video from our organization Serge: Grace at the Fray featuring different work being done by them in four different countries, including Burundi.

An Aerial Tour of Kibuye

2025-01-02T13:24:00.000-05:00

(by Michelle Wendler)

We are so thankful for all the support we have received over these 10+ years of ministry here at Kibuye. When the team arrived there were only a few hospital buildings and a handful of houses for the staff. But as you can see, much has changed! We hope you enjoy this aerial tour of our hospital and community here at Kibuye.

A Wedding and a Funeral

2024-11-19T10:12:00.000-05:00

(from Eric)

Saturday, Rachel and I were in the city to attend the wedding of Dr. Jean de Dieu. Jean de Dieu was once our medical student at Kibuye. He graduated about five years ago, and shortly after, he got a job working as a generalist doctor at Kibuye, mostly on the maternity service. We have seen him grow in his ability to take care of patients and lead in many different hospital areas. He does so calmly and wisely, being the kind of doctor that we would both want to work with and also be treated by.

Jean de Dieu and Guillaine: the happy couple

So it was a joy to go to his wedding. We had received the invitation and knew where the church was because of some other weddings a few years ago. We got there in the pouring rain, only to find it empty. We called a friend who informed us that the church of the same name is now in a different part of town, but he would meet us at a known landmark and direct us. So we drove through the rain of Bujumbura, finding our friend and letting him guide us (a bit late) to the ceremony.

The power was out, but the church was well lit with natural light. Honestly, we couldn't hear much because of the rain on the metal roof sheeting, but we could see a joyful couple become one, so I guess that's all that mattered. Right at the moment of the processional, the power came back on. The timing was perfect in my opinion, since they had planned an awesome dancing-exit/conga-line, and the blasting music served the effect very well indeed.

The elegant reception

It was joyful. Joyful for Dr. Jean de Dieu, and that joy spilled over, even to me. Later, at the reception in another part of town, we saw former students that we hadn't seen in years, church friends that we met when we first came to Burundi, as well as numerous current hospital staff who had found a way to the wedding despite a nationwide fuel shortage.

***

But we had to leave before the very end of the reception. We needed to get back to our hotel. We had a funeral to attend.

I met James Paternoster my first year of medical school where he was working with the Christian medical student group via Intervarsity. He was then the same age that I am now. In James, I found a wise and extremely well-read friend. In his family, Rachel and I found a warm and welcoming home.

James grew up in Nigeria and Niger, and when we decided to move to Africa with the Cropseys and Faders, James formed part of the three-headed think tank we referred to as the Lyntelnoster. After less than a year in Kenya, we found ourselves organizing a mini-retreat and we needed a speaker. James agreed to come out and visit, and I'm so glad I got to be in Africa with him.

James on the far left leading our retreat

This past January, James was diagnosed with a glioblastoma in his brain, and after 10 months of very faithfully walking that road, he passed away. I was honored to record a short eulogy and send it for the memorial service, of which Rachel and I now needed to get back to the hotel for the livestream.

We got to see friends on camera, friends singing in praise of God, friends sharing about James and what he taught them. James' eldest son Abraham (and possibly Kibuye's most legendary intern ever) spoke well of his dad.

It was sad and sorrowful, and...joyful. As the homily said: The opposite of joy is not sorrow, but hopelessness. And James' memorial service was definitely not hopeless.

A good friend shared at the service these words from James just before he passed away: "Joy is deep. The fear comes and goes, and when it comes, it's hard. But joy is deeper and it remains."

***

The juxtaposition of the wedding and the funeral was striking, but not as weird as one might think. James' wife Barb talked about how much "James loved a good funeral", because of how it could be a reflection on a life well-lived, and a good marriage is part of such a life. The joy of the wedding was different than the joy of the funeral. One was happy and the other sorrowful. Strange that we can still somehow know the thing we call joy in the midst of both of them. Humankind is not usually so discerning, but somehow we figured this one out.

James' second son Paul led the congregation is a catechism reading:

Q: What is your only comfort in life AND death? (you can guess where I added the emphasis)

A: That I am not my own, but belong with body and soul, both in life AND in death, to my faithful Savior Jesus Christ

Saturday gave us a chance to reflect on both life and death, and to remember that our comfort in both is one and the same.

A Kids Perspective of Kibuye

2024-08-13T15:47:00.000-04:00

by Michelle Wendler

We hope you enjoy this glimpse into what it's like for a kid living on our team here at Kibuye. Some highlights are: watching locals eat termites, and hiking to the top of Kibuye rock.

Here's another little clip of Gabrielle and Isaiah discovering a little creature here called the Bagworm Moth Caterpillar.

This Life

2024-07-01T01:54:00.002-04:00

(from Eric)

This life is not an experience I have procured by planning. It is a gift.

This life --

with its interpersonal conflicts,

unexpected medical problems,

pizza nights at Kibuye,

the writings of CS Lewis,

needs to learn how to communicate with teenagers,

Rachel's steady love,

the popping sounds of sheet metal roofing expanding in the sun,

eucalyptus branches in the wind,

a poor country not prospering the way we wish it would,

laughter at the stories of Wayside School,

watching grown-up movies with our kids,

birdsong a bit louder than distant church music --

This life is not an experience I have planned and executed.

It is a gift unfolding.

Tree vs House

2024-06-14T07:11:00.000-04:00

By Jason Fader

Recently I moved a table onto our front porch for a place to do computer work, since the view of the green grass, tight hedges, and various fruiting trees was simply gorgeous. I love landscaping here at Kibuye - in fact there are fewer things I enjoy more than listening to a John Piper sermon while mowing the lawn or trimming hedges. And these few months towards the end of the rainy season here in Burundi provide ample opportunities for these activities.

Recently I also noticed two trees near our house that were dying, and one was leaning somewhat precariously over our neighbor, Alyssa’s, house. My brother Caleb called some local loggers to come cut down these trees before they caused significant damage by falling.

During the felling process, ropes are used for pulling the tree in the desired direction. Normally this works well, but on the occasion of felling these trees near our house, one of the ropes broke, which caused the enormous tree to fall directly towards our house. Thankfully there was a robust avocado tree in its path, and the tree fell in the Y of the avocado tree, resulting in half of the tree precariously perching over our house! After much mental maneuvering, we decided the best plan was to pull the half-felled tree through the Y in the avocado tree until it wasn’t suspended over the house and then chop it up from there.

So we chained the tree trunk to our 2 Landcruisers in parallel and put them in 4-low, and then we created all kinds of carnage to the perfect lawn as the tires dug in and spun and the trunk plowed right through a row of pretty hedges – but thankfully, the plan worked, and the house is still standing.

Due to the misfallen tree, 3 others were damaged and so we had to take down a total of 5, which certainly detracts from the scenic view that I had loved gazing at from the front porch. I have recently become interested in grafting avocado and mango trees so, not to worry, I have about 250 avocado and mango trees to choose from to replace these that have come down.

Maybe there is a lesson in all of this which I can mull over while mowing the lawn: it is wise to deal with felling the dead trees before working on the hedges and grass, not the other way around. The same seems to be true for landscaping – start with the trees, then bushes, then the flowers, then plant the grass. I.e. get the big things in life figured out first, and the small things should come after. Broad brush strokes, then the touch up. Matthew 6:6 – “Seek first the kingdom of God and his righteousness and all these things will be added to you.”

Crix!!

2024-05-23T05:03:00.004-04:00

by Craig

In September 2023, we bought a machine to make our own bricks for construction projects at the hospital. This machine makes bricks by compressing soil mixed with cement, and the combination of compression and cement makes them resistant to damage from weather. These blocks have a special shape which allows them to interlock with all their neighbors above, below, and side to side. This means when building a wall, we don’t need to use any mortar to bind the bricks to each other like we do with the traditional bricks. These bricks go by different names, Interlocking Stabilized Soil Blocks (ISSBs), Compressed Earth Blocks (CEBs), but we have just been calling them Crix (a stylized portmanteau for "Craig’s Bricks"). It's an honor (but not my idea) to have my name integrated, but it’s not because I deserve any credit for them, I am just the person who is most excited about them.

Our press, when it was still shiny and new, and some of the first Crix it produced

side by side comparison

stock of traditional bricks (top) and Crix (bottom)

There are a few good reasons why I am so excited about Crix, and why you should be too! They save on time, labor, fuel, firewood, sand, and cement; and all of those things lead to saving money. They also look really smart…in my opinion.

These Crix walls look nice, right?!
I know, I know, it looks like the Crix on the right have been mortared in place. But truly, they have been dry-stacked, and we just filled in the chamfer with a tiny bit of mortar to make it look a little nicer.

Traditional, local made bricks in Burundi have served us well for many years, but there are some inherent characteristics that can be improved upon. Those bricks are stabilized by heating them with a large fire, which consumes a lot of firewood – a precious commodity in Burundi. They also are far from uniform in shape, which requires a lot of mortar to make up for the inconsistencies. I measured a typical section of wall and estimated that only 52% of the wall was made of bricks, the other 48% was mortar! Another challenge is that these bricks are made in various locations around Kibuye and need to be transported here. This increases the cost, and is dependent on the availability of diesel, which can not be taken for granted here. Whereas, Crix don't require any firewood, they are uniform, use almost no mortar, and are made right here on site.

But, just because Crix offer an improvement on all of those challenges that are baked into the local bricks, doesn’t mean they are a slam dunk solution. Bringing in a new technology like this can really upset the order that we have worked for a long time to establish. Even though it seems much easier and faster to build with Crix, it is completely different from what the masons are used to doing, so it takes a lot of adjustment for them to get comfortable and fast at laying the Crix. We also didn’t really know if the community or the hospital administration would like Crix, they have a different value system than an American engineer. And, we needed to invest quite a bit of time and money into buying the equipment and learning how to use it well, before we could start to save any time or money in the construction process. Regardless, there will still be some applications where traditional bricks are more appropriate...but now we have options.

So, after buying the machine, we started slow and small in our brick production. We played around with our soil mixture and moisture content, the force required for compression, and the rhythm of many people working together to use the machine safely. We only produced 20-50 bricks per day in those first days. But steadily we improved our production to grow to roughly 200 per day! We also started using the Crix for small, low-risk structures to see how they would perform, how the masons would use them, and how others would like the look of them.

Two days worth of production in the early days

Our very first structure being built... a chicken coop

A privacy wall (left) and some small cookhouses (top and right)

We learned a lot along the way, and eventually found success in our small production and construction. And, everyone involved seemed to like the Crix! So, we started to ramp up the production in order to do bigger projects.

First, we agreed to pay our workers per brick produced instead of per day of work, which took our daily production from 200 to over 400. But, it became hard to sift our soil fast enough to keep up with the brickmakers, so we built a rotary sifter to speed up that part of the process. We also realized that it was difficult and slow for the masons to cut the Crix, when laying them. So to help with this, we built a slicer to add on to our brick press, which slices the bricks before they have hardened, as they are being ejected from the press.

Compressing a Crix

Approximately 400 Crix made in one day

Top: Dirt being shoveled into the rotary sifter
Bottom: Turning the crank on the end where the rocks are removed

Nicely sifted dirt piling up

Brick slicer in action

After making these improvements we were able to build some larger projects with great success, including a 150-meter perimeter wall around hospital staff housing, and a new kitchen/dining area for the hospital.

150-meter wall made of roughly 9,000 Crix

New hospital kitchen and patient dining area under construction

This technology has proven itself to make a positive impact in the construction practices at Kibuye. But, if we zoom out and look at all of Burundi, then it is just a drop in the bucket. That’s why we recently took the opportunity to help facilitate a workshop in Bujumbura focused on this technology. I took seven of our workers who have been involved in making Crix to teach others what we have been learning over the past 8 months. It was awesome to see our guys – many of whom have not finished high school – teaching a group of architects, engineers, and professors about how to make and use Crix!!

Our workers (in yellow shirts) attending the workshop

they were featured in the presentation

participants sifting soil

answering participants questions

everyone was excited by the first brick

All the participants and facilitators of the workshop

A Tale of Four Patients: An Exercise in Opening Our Eyes

2024-05-17T11:51:00.000-04:00

(from Eric)

I can't honestly say that I enjoyed the whole of A Tale of Two Cities, but I thought the ending was fantastic. Sydney Carton is a lawyer and a scoundrel (or "ne'er-do-well" or "blackguard" or pick you colorful Dickensian description). He is talented but shameful, and he knows it. Yet, he bares an uncanny resemblance to a good man who has been unjustly sentenced to death. He chooses to switch places with him for the sake of the good man's liberation, and as he goes to the end of his life, he utters the immortal words:

"It is a far better thing that I do, than I have ever done; it is a far, far better rest that I go to than I have ever known."

Without devaluing Carton's sacrifice, I have often thought of the way that his whole life was imbued with new meaning when his actions redeem the life of one man. Why is this important to me? Because my attempts to be a healer in rural Africa are a mixed bag of outcomes. Yes, some people are healed, but so many people continue to suffer and die, and on a day to day basis, this can easily crowd out the amazing victories. And they are amazing; make so mistake. They are of inestimable value. They are transformed lives, each of which is enough to imbue meaning to the entire existence of an otherwise scoundrel.

But we won't feel this, unless we proclaim it.

So, in the spirit of "far better things that I do", here are four simple but glorious stories from recent Kibuye life:

1. Tiny baby. Big Milestone

Last week, on the hospital employee WhatsApp group, this picture circulated with numerous celebratory responses and emojis of dancing women.

This little baby was born at less than 1000g (about 2 pounds), and went home at about double that weight and in good shape. If you've ever had the chance to follow a very small preemie, you know that it is a patient process. Feed, sleep, feed, weigh, feed some more. Small unremarkable days that form a steady trend towards a transformed life. This photo was from a return visit, demonstrating that the baby is continuing to grow well at home.

The story of the Kibuye NICU is a long one, and we don't always see these little ones survive. But this one did. And all of Kibuye is rejoicing.

2. Kidney disease gone

About six months ago, the internal medicine service hospitalized a young mother. She was swollen from head to toe. Her kidneys didn't filter well, and they were leaking protein at such a rapid rate that she looked like a terrible care of malnutrition no matter what she ate. We could easily figure out the problem, but our medicines weren't helping very much. She needed a biopsy and a pathologist and all sorts of treatment that we knew she wasn't going to get. But we put her on a bunch of water pills to take the swelling down, and hoped that it would at least make her life a little better for the time being.

A couple weeks later, she went to refill those water pills at a distant pharmacy, and the pharmacy gave her diabetic medicines by mistake. Not being diabetic, this sent her into a hypoglycemic coma that nearly killed her. Her family rushed her back to Kibuye, where we fixed her sugar problem, put her back on the right pills, and gave our government colleagues the necessary feedback about the error in the private pharmacy so they could investigate. The situation continued to be desperate.

Six weeks ago, she came to see me in clinic, and I hardly recognized her. Gone was the puffy face and the malnourished air. She smiled at me. I double checked the name on her file. Not only was the problem better, but this was despite being off her medicines for a week. We confirmed that her kidneys were now functioning totally normally. I told her to come back six weeks later to see if this was sustained. Last week, she showed up in good health with normal testing. We sent her home with no treatment, and we thanked God together.

3. Full continence

One of the possible, but rather difficult, repairs of congenital problems that our surgeons tackle here is anal/rectal malformations, i.e. babies born with no way to pass stool. This becomes an emergency after birth, and a provisional solution is made by creating a colostomy in the newborn.

Later on, when the baby is a bit bigger, there is a more complicated procedure to basically create what wasn't there at birth, i.e. a functioning outlet for stool. Given the intricate nature of this surgery, the difficulty with anesthetizing little babies, and their ongoing nutritional challenges, it's not hard to imagine why these are difficult patients. But one of the greatest challenges is a fully functioning sphincter so that the child will grow up without fecal incontinence.

Two weeks ago, just such a follow up kid showed up. Doing well. Growing. Full continence.

He wasn't too happy to see the doctor but mom was ecstatic

4. Redemption after Loss

We do a lot C-sections. Last Thursday was yet another C-section. But this one had a known backstory. A couple years ago, this mom had carried her baby nearly to term only to lose the pregnancy. She came to Kibuye where it was found that she had a bunch of big fibroids in her uterus and she was scheduled for surgery to remove them.

She did well for her surgery, and afterwards got pregnant again. This baby went all the way to term and the couple's first baby was delivered healthy this past week (6-pound girl!). The health baby was carried to the side warmer where another doctor was diligently training a new nurse about how to resuscitate newborns and care for them well after delivery.

***

May you also have grace today to see the goodness of your life and work.

Awaiting Provision

2024-05-11T05:57:00.001-04:00

by Rachel

Several months ago, I shared a message at family worship from 1 Kings about the prophet Elijah. I've been working my way through a Bible study entitled "Elijah: Faith and Fire" by Priscilla Shirer, and one of the chapters felt particularly meaningful to me, so I thought I'd share it with our team (and now with all of you). In 1 Kings 17, Elijah shows up to the Israelite king, Ahab, and shares a word from the Lord that due to Ahab's wickedness and Israel's rebellion, God is sending a drought on the land. He leaves the palace and ends up going into hiding for three years. God hides Elijah in a small ravine with a brook...and how does Elijah get food? "The ravens brought him bread and meat in the morning, and bread and meat in the evening."

So here at Kibuye we don't have ravens, but we have the African pied crow, which must certainly be a close cousin. These are not anyone's favorite birds. They look angry/evil (with beady eyes), they make a lot of noise, and they steal things and cause a nuisance. We have amassed some stories of them over the years in their devious behaviors...stealing eggs and produce from our market baskets, killing small animals (even pet chicks), and even one year swiping Easter eggs from our Easter egg hunt (and somehow managing to open them and eat the candy inside). I gather that ravens are much the same. These are not the kind of birds or animals that seems generous in any way. Bring food? Absolutely not--they are much more likely to eat it for themselves! And in addition, they are found on the list of "unclean" creatures that God forbids the Israelites to eat in His law. And yet this unimaginable event is how God chooses to provide for Elijah, for years. When the brook dries up and Elijah has to go elsewhere, God sends him out of Israel to a pagan land (the homeland of Queen Jezebel, actually, who is trying to kill him) and has him go to an impoverished widow to ask for food, of which she has almost none. A foreigner, bottom of society, vulnerable, starving woman. Another unimaginable provision.

Shirer points to Ephesians 3 at this point. "Now to him who is able to do exceedingly abundantly above all that we ask or think, according to the power that works in us, to Him be the glory in the church by Christ Jesus..." She writes in her study, "God can craft solutions and remedies for me beyond my ability to reason...your loving Father has categories of answers, solutions, and options for you and your life that you don't even know exist...have you fully trusted him to do what he wants to do, the way he wants to do it?"

There's a lot of application here for us in Burundi. We're wrapping up another wonderful school year at KHA, but we're awaiting the provision of another teacher or intern for next year. It seems to us that providing another teacher would be a great way for God to meet our needs! But is that how he will work? Will he send someone now, or later, or never (or maybe he'll send YOU!)? There are so many lives being changed at the hospital, but we pray for more staff and better outcomes. Will God provide miraculous healing, lower patient numbers, send extra staff? Or will He use this season to help us lean into him more? I need to remember to trust him to work in the way he wants to work. I need to remember that he has solutions that I can't imagine. I need to remember that he will always provide for us, in his perfect way.

Don't you want to teach these adorable kids?

This baby was born prematurely at less than 2 pounds, but is doing well and just went home (topping the scales at over 5 lbs!)

International Women's Day 2024

2024-03-20T07:14:00.001-04:00

(by Julie)

March 8th is International Women’s Day. It comes and goes every year without much fanfare in America. But we have found that it holds a certain importance in many African countries. Not the least of which is Burundi.

We as a missionary community have been involved with the local womens' celebrations for several years now. Every year a fabric is chosen and as many women as are able use it to make a dress or skirt. It’s always so much fun to see the creativity in all the beautiful dresses!

At the end of the day, women who work at the hospital join together for a Fanta and a few words. Someone from each department of the hospital says a few words of appreciation for what the women bring to the workforce and to Burundian families.

I shared a short message based on Psalm 45. I encouraged the women that the “King is enthralled with your beauty.” (Psalm 45:11 NIV) In fact, before that in verse 10 it says,

“Listen, daughters, and pay careful attention:

Forget your people and your father’s house.

11 Let the king be enthralled by your beauty;

honor him for he is your lord.”

Meaning what? Forget your label, your title, your role, or whatever you're comparing to others. Forget what lies may have been spoken over you or about you concerning your worth. Let, allow the Lord to tell you who you are. Because what he is telling you is “You are beautiful. You are a perfect creation. You are my daughter.” We honor the Lord when we let him give us our worth. He is enthralled, captivated by your beauty and who you are.

We had fun reading the psalm together and delighting in how God delights in his daughters as princesses. Verse 13 says “her gown is interwoven with gold.” Well, the chosen fabric this year has what looks like gold thread woven into the design! So I encouraged them to remember, every time they put on this dress, that the King is enthralled with their beauty. If we forget what the world or the enemy tells us, we will be able to let the king be enthralled with our beauty.

It was a great day with lots of smiles and lots of pictures! Thank you for your prayers for Kibuye, and for the women in particular to be respected and honored by the men around them.

Wounded Healers All

2024-02-24T04:32:00.006-05:00

(from Eric)

Nadia was admitted to my service last night. Two months ago, she delivered twins. One of them is doing well, but the other has had trouble and is admitted to our NICU. So she's been living at Kibuye taking care of her babies.

Apparently, last night, she went to get some dinner and had difficult breathing all of a sudden. She stumbled into the Emergency Room where her oxygen levels were super low and she was breathing way too fast. Her blood pressure and heart rate were also quite high. She was admitted to internal medicine where we did all the available tests that might help her, concluding finally that her heart is bad and her lungs have suddenly filled with fluid.

We're doing what we can, but I fear for her. I fear that we won't be able to pull her out of this, and that her twin babies will lose their mother, who seemed perfectly well twenty-four hours ago. Despite maximal oxygen therapy, she still has low oxygen levels and is breathing quite fast. Our team is gathered around her bed.

***

Also admitted to our service is Pastor Elie. Elie was a chaplain at Kibuye for decades. He's retired now, but has massively out-of-control diabetes. Despite all our effort, he has lost tons of weight, and he gets admitted for a few days during most months of the year. His disease is super challenging, but he's survived a lot longer than most people around here with a similar problem because of ready access to the hospital.

As soon as he feels better, he's usually wandering around the hospital talking with old friends. In fact, this morning, we passed by his room and he wasn't there.

***

Gathered around Nadia's bed, we have made all our medical decisions. She is still not doing well. Her mom has the healthy twin bundled up on her back. I'm wanting to pray for her. My Kirundi prayers are quite halting, but since Nadia is conscious, it seems like praying in Kirundi might encourage her.

Suddenly Pastor Elie walks up. He knows that we came by his room when he was out chatting. We answer his questions, and then I ask him if he would be willing to lead us in a Kirundi prayer for Nadia.

He answers without hesitation. "This is my job." He places his hand on her shoulder and begins to pray. From his words, I can tell that he is aware of her situation and that her other baby is already admitted in the hospital. Apparently, Elie's visits to the hospital help him keep his ear to the ground.

It's a beautiful picture. One obviously ill patient leading us all to pray for the healing of another. We do not help each other to healing only from some kind of disease-free platform of security. We are wounded healers, just like our Savior.

***

And then there's me. My body is more or less intact, but my heart is struggling. I'm leading my team of students and nurses, teaching them the best way to take care of these patients, but knowing that we won't succeed in a good number of cases. We're praying for healing and compassion and understanding, and even as we pray, I'm struggling to believe for these things. I wish my heart could be content with the situations in which I find myself, content to just be faithful in the daily work in front of me, but it's hard. My heart doesn't react the way I wish it would.

In the television series The Chosen, the producers gave James the Lesser (or "little James"), one of the disciples, a physical disability, and then Jesus sends him out to heal. He struggles to understand why he is not healed, and how he could be a vessel for healing when he is himself broken. The scene is extra-biblical, but the themes discussed are not. Jesus speaks of God being glorified from James praising Him even though is not healed, precisely because he knows that there will be healing in the end.

Healing for Nadia and Elie. Healing for my own heart and all of us striving to bring life and wholeness in the midst of our own brokenness. Wounded healers all.

***

48 hours later update: "Nadia" has actually done much better than I was expecting. In a way that we don't often see here (without super intensive care), she has been pulled back from the brink and is breathing much better (though still on a lot of oxygen). Sometimes I'm hesitant to hope in such situations, since we're not out of danger, but I'm grateful for how it's going and pray it will continue.

***

7 days later update: "Nadia" discharged home today. Her baby was also discharged, so they will actually go home. Just taking some pills. So thankful!

The Very First....

2024-02-05T02:51:00.000-05:00

(By Caleb)

Training is a cornerstone of what our team does here at Kibuye. Most of our team is involved in training surgeons, doctors, and nurses, but on the construction team we also have an apprenticeship program where masons, carpenters, iron workers, and welders can be trained by those already in the 'guild'.

When the first members of our team arrived in 2013 my brother ran the construction crew when he was not in the operating room. He strongly encouraged this apprenticeship program and to this day the construction leadership team still reminds me, "But Doctor Fader said we must always be teaching..."

Each year now for most of the last 10 years we've had a cadre of apprentices in various trades enter the year-long program. In order to enter the program, one must show good work ethic, a willingness to learn, and must be able to provide one goat for the induction ceremony/feast at the end of the year. The goat sacrificed represents the life-long dues required by the guild. Most of the time these apprentices are chosen from among our hard-working laborers. Hence a goat represents about 2 months' salary for them: no small sacrifice!

In November we celebrated the induction of 10 new members into their respective guilds. Since there were 10 of them it was decided that instead of 10 goats we should just get one very large cow. Each of these 10 graduates were allowed to bring their extended families to witness the event. There were speeches, pictures, laughs, and lots of beef shared around. Each graduate was presented with tools of the trade by their primary teacher such as a trowel, level, measuring tape, etc. As expected, it was a lovely team-building experience.

Our foreman, Sadiki, welcoming everyone. Graduates are seated in the front row.

Cooked bananas, french fries, and lots of beef.

However, this year was extra special. For the first time in these last ten years we had our first female graduate. Her name is Savella and not only did she finish this year-long apprenticeship in a field absolutely dominated by men, but she was anonymously voted by the whole mason's guild as one of the top two graduates!! As our foreman was announcing the results of the vote he opened with, "Now please hold on to your hearts...." Everyone is very proud of Savella and we are so pleased to have her as a part of our construction crew.

Savella receiving the tools of her new trade!

Skillfully adding the finishing touches...

Threads of Years Long Gone: Ministers, Babies, and Reasons for Reconsidering Hope

2024-01-21T04:58:00.004-05:00

(from Eric)

On Friday, the hospital inaugurated a new district health office. In addition to being a church hospital and a teaching hospital, Kibuye is the referral hospital for Kibuye Health District, a geographic area of over 200,000 people. Anyone sick in that area goes to one of 18 health centers in the district which refer necessary cases to the hospital. Of course, we also get cases from all over the country and neighboring countries because of specialized care here, but we are the primary hospital for this catchment area, and this health district is administered and supplied by the district health office.

Their office was insufficient and helping them build a better office just outside the hospital wall also liberated some valuable real estate within the hospital that the old office was taking up. So we partnered with them to build a new office building. The building is lovely, and governmental dignitaries were invited to cut the ribbon.

The guest of honor was Burundi's Minister of Health. Newly appointed to the presidential cabinet in the last few months, this was her first visit to Kibuye. Burundi's amazing traditional drummers pounded and danced out a welcoming rhythm as the Minister's vehicle arrived, and we formed a receiving line, of which I was about number eleven.

Burundi's Traditional Drummers with the new district health office

As the Minister proceeded down the line, I shook her hand and said "Welcome to Kibuye." Over the thrum of drums behind us, she said "I know you. I met you in Banga when you were learning Kirundi. You had babies with you."

A journalist caught the moment where the Minister tells us she remembers us

I couldn't believe it, to say the least. Banga? Banga is where our team spent three months in 2013 when we first arrived, fresh from French language school but wanting to get a small smart on Kirundi language study before moving to the hospital.

Future Kibuye kids at Banga.

It wasn't the easiest three months. In fact, the "green soup" that we ate every night for dinner has become a bit of team lore. The electricity and water were usually out, and thus staying healthy was quite a challenge. I remember one night walking outside to see the adjacent hillside aflame (apparently a "controlled" burn for farmers) and wondering where the fire would spread.

During meals, the nuns who ran the guesthouse and restaurant, in order to help out high-chair-less parents (and to amuse themselves), would take Toby (who was about 5 months old) around and greet the other patrons. Apparently one of those patrons was the future Minister of Health, who came to Banga for a malaria training event.

Mama Lea - Toby's favorite nun

Now the Minister is at Kibuye, cutting a ribbon and remembering our team fondly. The ceremony began, and the governor of our province gave some opening remarks. Bishop Deo did a wonderful job discussing the work of the Free Methodist Church's institutions at Kibuye and their involvement in health care, including some upcoming plans. Then the minister took the podium and gave a very favorable speech. She again mentioned to everyone meeting our team in 2013 and remarked on our love for their country. She said that she would like to take a tour of the hospital afterwards, and spend close to an hour being guided deftly by Dr. Gilbert our medical director. All in all, a very successful visit.

***

The collision of past and present filled me with gratitude. It was the gratitude of someone who had been living on the back side of a tapestry, where all the threads are knotted and seemingly disorganized as they do their best to get from here to there. Then, for just a moment, you're allowed to catch a glimpse of the other side of the tapestry, where a beautiful, complex image has been created by those same threads.

You see that there were a couple stitches way over there, and then the thread disappeared for so long that you thought it was gone, and then it resurfaces in just the right place. And that makes you reconsider the other threads. It gives you hope for the other long-invisible strands. Or maybe this one over here has always bothered you, and you wish it would be gone. But maybe it actually plays a role in a bigger picture. It's been a source of tension, but maybe it's like the musical tension of a passing note to a beautiful chord. Who knows?

No thread makes a tapestry. Rather it's all the threads together. It's the whole of all our lives and days and interactions, woven together by One whose perspective is so much bigger than ours that it's like how the heavens are higher than the earth. It's incredibly hopeful, and also incredibly humbling.

Is that what Banga was for? Probably not, or rather maybe one thing among many. Who knows? The point is that there are these moments where you see a bigger story and though you may not have much more of an idea of what's going on than you did before, you now have a reason to hope that there actually is a bigger story. And that changes everything with regards to how you look at the beautiful and the problematic that surround you even now.

Is that what the Minister's visit to Banga and now to Kibuye was for? Maybe a bit, but she is not just a character in our story any more than we are just characters in hers. Surely God has many plans for her life in so many other domains. And so we see that the big Kibuye tapestry is itself a piece within the tapestry of Burundi, within the tapestry of His kingdom throughout His creation.

It's too complex. It makes our heads swirl. No one could weave together such a complicated web of billions of people's lives into a single beautiful work of art. But if someone could... If someone is, then that One is most worthy of praise.

(On a more personal level, here's a song I wrote a while back on a similar theme: The Weaving of My Days, also on Spotify and other streaming sites)

I Bless the Rains Down in Africa

2024-01-17T06:59:00.002-05:00

by Rachel

If anyone knows anything about Africa, usually they can at least hum the above line from Toto. It's a great song. Most of my life I thought the line was "I MISS the rains down in Africa," which I think fits with the longing of the song, but anyway. I've been thinking about that song a lot lately as Burundi has had a pretty epic rainy season this year.

Now that we've been living here for 10 years, the dry and rainy seasons (instead of a classic summer/winter pattern seen in northern climates) have become second nature to us. The rains usually stop in mid to late May, bring in the annual dry season. Upsides of this would be massive amounts of solar energy for our powerpac, easy drying of clothes on the line, and reliably dry days and nights for outdoor activities. Downsides would be massive amounts of red dust everywhere! By September the rains usually return, maybe 3-4 times per week until May (with a one month pause in Dec/Jan). Obviously if you are a subsistence farmer, these seasons are quite important for the growing of various crops. In fact, if the rains are late (like a year ago), harvest comes late as well meaning that hunger and malnutrition increase until the harvest arrives.

This year, the rains were a welcome return by the first week of September. We love the sound of rain on our metal roof, and all the dust washing away. The profusion of green leaves, grass, etc is pretty amazing in this lush climate. However, what was NOT normal this year was the volume of rain. The rains came hard and fast and constant...in fact, there have been weeks where I don't think we saw the sun at all. There is an aid website called Relief Web that publishes data on things like food security and humanitarian crises. You can see the table below from the end of December featuring above average rainfall projected through February. While not as severe as some parts of Kenya, rainfall has been 50-70% more than average this year.

We drove a Burundian friend to Gitega last month and asked him about the community and their thoughts on the rainfall. He replied that when people see this volume of rain, they worry about famine. Below are some pictures that Eric and I took on a recent walk around Kibuye. Notice the brown stalks of corn, dead from flooding, and even the flooded rice patties in the valley. Rain has also caused some significant erosion behind the hospital as part of the hillside washed away.

Flooding fields and dead corn plants

Erosion behind the hospital

Flooded rice fields

I love rain. I think it brings green and life and beauty. But if I was a subsistence farmer living in Burundi, and if my crops died I had no other way to feed my family, I would be worried right now. Could you pray for our friends and neighbors, that God would provide the right amount of rain for crops to grow? That they would have enough food to feed their families, even miraculously so? It's quite possible that numbers will swell in our malnutrition program this spring as well. You all contributed over $75,000 to that fund in the month of December, which is amazing! If you'd still like to give, here is the link.

Burundi looked good in this report from November, with only a few regions being "stressed." This might change in the next report. Also, as you can see much of the region is in crisis, sometimes due to war in addition to natural factors.

On the Eve of Christmas

2023-12-23T03:48:00.001-05:00

(from Eric, adapted from our family Christmas newsletter)

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

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

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

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

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

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

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

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

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

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

VIPs

2023-11-30T08:35:00.001-05:00

By Alyssa

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

Kibuye Hope Hospital's vision is to:

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

Our mission is:

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

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

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

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

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

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

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

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

Making Virtual a Reality

2023-11-22T09:52:00.001-05:00

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

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

So, what are we to do?

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

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

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

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

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

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

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

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

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

Neonatology part 2

2023-10-29T14:44:00.000-04:00

by Jenn Harling

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

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

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

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

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

-Hand hygeine

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

-Updated feeding protocol with fortification of breastmilk

-Transfusion protocol to know when to transfuse neonates

-New neonatal ward manual in French being written

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

-humidification of oxygen

-patient tracking white board

-updated fluids management protocol

-hats for every baby in the unit

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

There is hand hygeine signage all over the unit now

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

Patient tracking board

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

COTW: Postpartum Complication

2023-10-04T05:31:00.001-04:00

by Rachel

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

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

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

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

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

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

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

We Never Stop Learning

2023-09-29T12:04:00.005-04:00

(from Eric)

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

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

Bleomycin. Cardiopathy. Swan-Ganz catheter.

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

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

***

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

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

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

***

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

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

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

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

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

***

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

Taken Away My Shame

2023-09-24T05:07:00.002-04:00

by Rachel

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

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

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

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

Shopping

2023-08-21T06:33:00.010-04:00

(by Michelle Wendler)

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

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

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

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

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

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

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

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

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

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

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

Malaria, Mystery and Mitigation

2023-08-15T11:38:00.003-04:00

(from Eric)

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

Malaria parasite infecting a red blood cell

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

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

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

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

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

Kibuye's head lab tech performing malaria microscopy

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

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

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