calling

I went on these international rotations partially hoping that God would use them to direct me regarding my future work overseas.  Where should I go?  With what organization?  To what people group?

To my disappointment, I didn't find a particular sense of leading from God on these issues as I was traveling.  I struggled with this a bit along the way.  Should I have done these rotations?  Am I simply experiencing some of the hard parts of living cross-culturally (initial language- and culture-learning, minimal relationships with nationals, the adjustment phase again) with few of the rewards of staying in one place longer-term?  Am I missing out on something God wants to be showing me?

As I read On Being a Missionary on the flights back home, the author talked about the issue of calling in missions.  Every child of God has a calling from God, a calling to go and serve others, to love and obey God, to learn to live in healthy relationships with others where we slowly learn to put others' needs above our own, to submit to each other in the Body (Church) and to honor others' gifts and abilities and cover for their weaknesses in love.  But all who go to serve cross-culturally should also have an additional sense of calling to go there, whether a gradual sense building over time or a one-time supernatural experience of calling, which is necessary to sustain them through the difficulties involved.

I do have that sense, I realized, or I have at a number of times in the past.  I don't need to manufacture a new and repeated sense of calling when I don't feel particular direction from God.  The choice simply becomes: will I be obedient to the calling God has already revealed to me to live and work cross-culturally and internationally at some point in my future for a number of years?  This realization was a relief to me.  After all, the larger question of whether I will be obedient to God's will for me is simply the question of the Christian life:  will I allow God to be God and trust that his goodness will lead to His plan for me being the best possible route for my life?  That is a choice I have made many times in the past and can continue to make now, trusting that the details of his calling on my life will become clear as I choose to follow wherever he leads.

from: http://www.flickr.com/photos/35692109@N03/3531523716/

names

I have always enjoyed having a unique name and knowing what it meant (one whom God has promised) and its origin (Hebrew, the story of my birth, etc.).  And part of encountering another culture is learning new names and how to pronounce letter combinations you thought couldn't go together.  :)

In Zambia, I had a different problem:  not smiling at people's names, picked in some cases - I am sure - for how the parents liked the way the word sounded in English even if they didn't know what it meant.  Or they simply name their children Tonga words with interesting meanings.  Here are some I wrote down along the way:

English:  Agrippa, Cleopatra, Only, Obey, Fines, Modern, Favourite, Purity, Precious, Pritness (Prettiness)
Tonga:  Linda (awaited precious one), Trouble, Change-of-sex (as in a girl after a number of boys or a boy after a number of girls), Same-sex (opposite of above)

So even our names carry something of culture in what is appropriate to name your child.  :)

patient stories, 2

Here are some patients I don't want to forget.

A 5-year-old little girl was brought in by her aunt for 15 months of abdominal distension, a cough, and headache.  She was orphaned a year and a half ago when her mother died.  Nothing else really came up on the history, so I took them back to the little room where we do examinations if the patient will lie down or if it requires privacy.  In examining her belly, I found the reason for the abdominal distension: a huge abdominal mass in the right side with a groove between it and her liver, extending to several cm past the umbilicus and down into the pelvis.  My heart just sank as I reviewed my short differential diagnosis for an abdominal mass in a 5-year-old: Wilms' tumor, neuroblastoma, possibly something renal...

I saw them several times over the course of the next few days with various lab results (a normal CBC, negative HIV, normal creatinine and LFTs) and then the ultrasound results: complex, multicystic, intrahepatic lesion.  At that point, my differential failed.  She had already been treated for parasitic disease, so we referred her on to the University Teaching Hospital in Lusaka.  I emphasized with the concerned aunt how important it was that she be taken and seen as soon as possible.  The little girl was by this time sitting comfortably on my lap as her aunt and I talked about the results and possibilities.  Then we prayed together, and I sent them off with the referral letter.

Another was a 41-year-old mother of twins (G12P9).  I saw her for almost two weeks on maternity waiting on the ward for the pregnancy to come to term and then waiting because her twins were breech (twin A) and transverse (twin B) and so wouldn't probably deliver at home on their own.  I used my Tonga phrases for the cardinal obstetrics questions with her every few days on rounds (any vaginal bleeding? any rupture of membranes/leakage of fluid?  is the baby moving well?  any contractions?) and she would smile and respond with the hoped-for answers (no, no, yes, no) for almost two weeks until she finally did go into labor.  Then I actually got to be there to see the breech vaginal delivery (all on her own!) of the first and internal podalic version (turning the second baby using the foot) with breech delivery of the second twin.  I helped with resuscitation, assessed the Apgars, and checked the new-again mom for postpartum hemorrhage since she was high-risk with twins and high parity (number of pregnancies).  She did well, and I was happy to be part of the whole process and see it through to the end!

Another maternity patient I remember was a married 15-year-old G1P0 (first pregnancy); apparently most girls go to high school or get married young, so I saw a number of pregnant 15- and 16-year-olds who were married as well as a few who were not.  I was rounding in the evening and was helping to count for her to learn how to push the baby effectively (something not usually done in Zambia from what I can tell - the counting, not the pushing).  She made a little progress but not much, so I ended up seeing my first Zambian vacuum-assisted delivery (when I couldn't even see the head at all whether she was pushing or not).  It was successful, though, with the nurse pumping the vacuum while the doctor pulled on the head, and we were glad she didn't have to get a C-section.  When I rounded the next day and checked on her and the baby, both were doing really well and she lit up with a smile to see me.  She spoke a little English, so I think she had understood my counting and encouragement the night before and was happy for it.

A final patient was a 6-year-old boy I admitted to men's ward (the cutoff for peds being six years due to high rates of disease/malnutrition in younger kids).  I was worried about nephrotic syndrome (post-strep GN) with complaints of a sore throat two weeks ago, facial and feet swelling, abdominal pain, and headache.  The urinalysis turned out to have only trace protein, though, and the child continued to spike fevers through penicillin and then amoxicillin and looked sick, never smiling at me whenever I came up to check on him.  So we ended up deciding to do a lumbar puncture (spinal tap) to make sure he didn't have meningitis.  I did my first pediatric LP, which was relatively direct (for which I was grateful), and we started him on stronger antibiotics (cefepime, having run out of ceftriaxone for meningitis).  By the time I was leaving, he looked a bit better and gave me a crooked smile.  :)

culture, take 2

On my flights back and in layovers, I started reading a book I have owned for a number of years but never got to read, On Being a Missionary by Thomas Hale.  His chapter on culture shock/stress made me think again about my entry on cultural differences.  I recognize much of his symptoms of culture shock in myself over the past eight weeks particularly: discouragement, critical spirit, self-pity, pessimism, etc.  I know and knew at the time that I was experiencing some stress from the difference in cultures.  It simply costs more emotional energy to do simple things like going to market when you have to say no to several people who want money or a job, ignore some propositions or comments, try to figure out what I'm going to do with the few vegetables available that my stomach won't reject, and then gauge whether the price I'm offered is a fair one or whether I should barter a bit and if so how much to offer and whether the seller speaks English...

Hale goes on to talk about what to do for culture shock.  His steps include recognition, praying for God's grace and enabling, adapting to the nationals except for ethics and faith, making a circle of friends, cultivating an attitude of exploration/adventure, maintaining friendships with other expats, and not taking yourself too seriously.  I was struck as I looked over this list by how little of this I did.  I was much quicker to judge and criticize than to ask God for his enabling to love those around me.  I was much quicker to relate to the simpler relationships with expats than to invite over Zambian friends, even for the little hospitality (tea, games) I could offer.  And this is me, who prides myself on enjoying the challenge of cross-cultural relationships and cultivating a good number of them, including among my closest friends.  Have I been deceiving myself and simply requiring my friends to respond in ways that fall within my expectation or do not require challenge or change for me?

Hale speaks of the way in which Jesus gave up so much to be with and for us, to die in our place, to rise to give us a victory we could never earn but in which we are welcomed lavishly, generously, joyfully, grace-fully to share.  He reminds the reader of how love is shown forth in one giving his life for his friends, and how those of us who serve cross-culturally in an attempt to show Jesus' love for others have a unique chance to give up our lives (our things, our culture, our status, our privileges, even sometimes literally our lives) to demonstrate that love.  How little of that was present in my thoughts and attitudes, although I hope a bit more of it was present in my actions...

So this is my confession.  I have far to go in learning to be like Jesus, who willing and without complaint gave up a place in heaven to be born in a stable, to work as a carpenter, to be rejected and ridiculed, to be humiliated in death and misunderstood in life.  I do not love my neighbor well.  Lord, help me to grow in this, particularly when dealing with the additional stresses of cross-cultural relationships.  Am I willing to be misunderstood, to be rejected, to be unappreciated or ignored?  Am I willing to have my medical judgment questioned, my competence doubted, what little knowledge I have worked to earn ridiculed?  Am I actually willing to follow where Jesus leads and expect nothing in return?

I am reminded of 1 Corinthians 13, the so-called love chapter.  Verses 2-3, 8a: "If I have the gift of prophecy and can fathom all mysteries and all knowledge, and if I have a faith that can move mountains, but have not love, I am nothing. If I give all I possess to the poor and surrender my body to the flames, but have not love, I gain nothing...  Love never fails."  Lord, teach me to love like you do.

Zambia slideshow 5

I am home safely.  I am also starting to lag, so more blogging stories and thoughts later.

blog

Linda's computer also recently died, so I will be on a blogging hiatus (except for borrowing Heidi's right now) for a few days.  I'll try to blog some patient stories when I'm in Livingstone on Wednesday, and I fly out Thursday, Lord willing, to arrive back in Philadelphia Friday.  Yay!  :)

update

Just some details on life here.  I'm on my fourth and final ward starting this week, male ward.  The usual person who covers male ward is off studying right now for an exam, so it is covered by a resident from UPMPC St. Margaret's who is here starting this week.  I will have a day off tomorrow or Wednesday, though, to go to Choma to get my visa renewed for the last week-plus that I'm here. 

In the mean-time, life at the hospital and with friends continues.  Abby, the American nurse here who went to Jefferson, had a group of us girls over for pancakes/crepes on Sunday, which was fun.  Linda and I have been watching a number of movies and reading books in the evenings when we're not on call.  I was happy to get to talk to my family a few times over the past couple weeks (amazing how easy it is to take that possibility for granted in the States!).  That's about it.

culture

I've been thinking about how I don't post about Zambian/Tonga culture like I did about Indian culture.  I think there are two primary reasons for that.  One is that, although it's new in my remembered experience, much of Zambian culture is not surprising to me since I grew up hearing about it from my parents.  So the fact that I curtsy when shaking hands, that one shows respect for the person greeted in shaking hands by placing the other hand below your own outstretched arm slightly distal to the elbow, that women carry the heavy loads and the children, that we eat nsima and relish with our hands, etc. simply don't strike me as novel.

The second reason is the more difficult for me to acknowledge and process.  There are parts of Zambian culture that are difficult for me personally, particularly as a woman.  In many small ways, I am treated differently because I am a woman.  Different things are expected of me.  I think women and men also have similarly different roles and expectations of behavior in parts of India, but those roles/expectations didn't apply to me as a foreigner.  Because of this, they didn't bother me personally so much.  I feel half ashamed of this; should I care more about these different expectations only if they impact on me?  Then again, their impact on me may be greater at least as far as my adjustments to them than on the people who grew up in this culture and so have their own expectations more shaped by it.  But maybe I'd just like to think that so that it makes me feel better that I don't mind the cultural differences as much when they don't affect me.

It comes back to bigger questions about culture, too.  For the most part, I enjoy cultural differences and learning about other cultures.  But I don't think other cultures or my own are above moral judgment.  Just as there are things in my own culture that I wish were different (e.g. materialism, time-focus over people-focus, prizing status and influence over character and inner worth), there are things about other cultures I wish were different.

What is hard is making judgments about another culture from the outside rather than my own from the inside.  Am I simply more sensitive to things that are right and wrong here because they are different?  How can I learn to be more sensitive to what is right and wrong (and not above judgment) in my own culture from being within another?  How can I balance suspending judgment here while learning more about why things are the way they are and trusting that some things are value-neutral and simply different with acknowledging that some things simply should be different here as well as in my own culture?  I don't have any easy answer, certainly not for how I live it here and now or in the future, but I suppose it's good to be asking the questions.

epidemiology

It's been interesting what diseases occur here and don't occur here.  I have seen no coronary artery disease and no lung, breast, or colon cancer, although that may be partly because we lack the imaging or procedural technology to catch the cancers early (CT scanning, mammography, colonoscopy).  However, I have seen multiple women with cervical cancer, something I never saw in the US.  It is on the differential diagnosis for any woman with a watery vaginal discharge, especially if she is HIV-positive.

Pap smears, the common screening tool used in the developed world to detect early pre-cancerous cervical changes, are hard to do on a regular basis here since it requires sending off the obtained scraping to Lusaka for pathology results some three months later.  It requires an infrastructure for following up and treating abnormal results as well, which is hard to put into place.  And it simply isn't part of women's thoughts for health maintenance when they're more likely to be thinking about how to make it through till the next harvest or whether their malnourished fifth child is going to be hospitalized for this episode of diarrhea or fever.  On top of this, immunocompromise (as with HIV, a relatively common infection here) makes cervical cancer progress since its pathophysiology is related to the viral HPV infection, and cervical cancer actually is one of the determining criteria for which stage of immunocompromise an HIV-positive patient is in.

So these musings amounted to the fact that last OT (operating theatre) day we told two women in their fifties that they had stage IIIB cervical cancer (extending to the lower third of the vagina), which has a 40% 5-year survival rate in the best of circumstances with radiation therapy.  These women will most likely not get in at the University Teaching Hospital (UTH) in Lusaka, the only place where these types of services are available in the country, in a timely manner to enable them to get the radiation.  So they're sentenced to living and dying with advanced cervical cancer as it metastasizes through their pelvises, bringing difficulty passing stool and urine as well as pain.  Even the pain of advanced cancer is difficult to treat where we have limited supplies of one opiate, pethidine.  If any place in the world needs the HPV vaccine, which has caused such controversy among some communities in the US, this is certainly one place I would distribute it!

We had an interesting though sad case on rounds a few nights ago.  The patient was being evaluated for lower abdominal pain, hematuria (blood in the urine), and amenorrhea (no periods) for three months.  They did an ultrasound to rule out an ectopic pregnancy and found instead a large renal mass, palpable on re-examination of her abdomen.  Again, there are no resources here to do a nephrectomy (removal of the kidney), and it is unlikely she will get in at UTH soon enough to make a difference in her prognosis...

On a positive note, I had a conversation with the ultrasonographer, a young Zambian man who is pastoring a local church while doing perhaps 200 ultrasounds a month through his job at the hospital and is in further training for ultrasounds.  He mentioned the offers he has received to go to Botswana or elsewhere to earn more money for his job.  His ultrasonography course is through some place in Canada, so that also opens doors.  But "if you want to see change in your country," he said, "you have to be patriotic."  Knowing there are other options available to him, he is choosing to stay here where he is needed and can make a difference.  And make a difference he does since ultrasound and X-rays are our only imaging technologies.  Thank you, God, for people who choose to give up what they could have for the longer-lasting reward of a life lived faithfully and well in service to those in need.  May I remember his example.

communion liturgy

I loved the liturgy used at the communion service and found something with significant overlap online and wanted to share it.   After a period of introspection preceding the service in which I had to acknowledge to myself a number of areas in my life where I was not depending on and submitted to God, I was fully aware of my own unworthiness of the price Jesus paid to be in a relationship with me.  Thus, this communion's invitation to share in God's hospitality at his table was particularly welcome, and the pauses after each short phrase for translation to Tonga made it particularly poignant.

http://oneyearbibleimages.com/lords_supper.jpg

"Come to this sacred table, not because you must, but because you may;
Come to testify not that you are righteous, but that you sincerely love our Jesus Christ, and desire to be his true disciple;
Come not because you are strong, but because you are weak;
Come not because you have any claim on heaven's rewards, but because in your frailty and sin you stand in constant need of heaven's mercy and help;
Come not to express an opinion, but to seek a Presence and pray for a Spirit.
Come not because you are fulfilled, but because in your emptiness you stand in need of God’s grace and assurance.
Come, sisters and brothers, to this table to partake and share.
It is spread for you and me that we may again know that God has come to us, shared our common lot, and invited us to join the people of God’s reign.

And now that the Supper of the Lord is spread before you, lift up your minds and hearts above all selfish fears and cares; let this bread and this wine be to you the witnesses and signs of the grace of our Lord Jesus Christ, the love of God, and the communion of the Holy Spirit. Before the Throne of the Heavenly Father and the Cross of the Redeemer make your humble confession of sin, consecrate your lives to the Christian obedience and service, and pray for strength to do and to bear the holy and blessed will of God.”
- attributed on one website to John Hunter

Zambia slideshow 4

We also went to a wedding coming-together celebration on Saturday afternoon, so this includes some pictures of that to give you a taste of Zambian cultural life as well as one of our modes of transportation (the back of a truck!) in addition to the Easter weekend pictures.

Easter in Zambia

It was certainly a weekend full of festivities here.  Church services Thursday, Friday, and Saturday nights were followed by a 5 a.m. Sunday morning Easter sunrise service, 9 a.m. communion service, and 10:30 a.m. Easter morning service.  The Easter sunrise service was particularly neat since I remember going to these as a child (and being disappointed by an 8 a.m. "sunrise" service in the States that was after sunrise and inside!).  It was neat to be there with mostly women and be reminded of how the women were the first ones to the empty tomb and the first witnesses to the Resurrection.  This is a culture in which women are definitely second to men in priority, and the culture of first-century ancient near east was no different.  So the honoring implicit in the women's primacy in this central event of the Christian story is particularly special.

All the services involved much singing and rejoicing.  There were some culturally specific ways of celebrating that were unique.  The women go to the sunrise service wrapped in sheets (or old mosquito nets!) to commemmorate the linens which had wrapped the body of Jesus that the women found forsaken in the empty tomb.  I forgot mine, but I did manage to remember to borrow a scarf to wear to cover my head so that I would be allowed to participate in the communion service later.  I come from a church tradition often associated with head coverings - Mennonites - and some people in my home church do wear coverings, but I had never worn one before.  It was an interesting experience, thinking of doing something I don't consider necessary to partake in this community's celebration of faith in equal standing.  Then again, I wear skirts every day (something I don't think necessary for women) so as not to offend and to participate in the local community's life as much as possible on the same level...

After the services, we went over to the Thumas for lunch, which included some visiting friends.  We ended up chatting for the afternoon and went home briefly only to join up with Abby and Heidi, two other expat young women, to go for a walk to see the sunset.  So the day which began before sunrise ended with the sunset - altogether, a very satisfactory day.  :)  Pictures to come.

clinical update

Over the course of the week, I finished my first week on maternity which, due to the maternity doctor's absence in Choma getting his car fixed for three days, has included exactly one day of rounds and one day of OB- and gyn-related outpatient visits. But I've done more cervical exams on women in labor (albeit inaccurate ones, according to the nurse-midwife) here over the past few days (three) than in almost two years of clinical rotations in the US. We do also have rounds tomorrow, and hopefully the doctor will be back.  I've been doing some reading and learning relevant OB-related Tonga in the meantime (baby moving? vaginal bleeding?  contractions?  leaking fluid?  nursing well?  milk?).

I also rounded on women's ward again, seeing some patients I knew as well as some new ones, and did my first paracentesis (for fluid in the abdomen) without ultrasound guidance, of course, and attempted several lumbar punctures (or spinal taps - 1/3 successful). For procedural-related things like those, sometimes it's nice not having residents or interns to allow to go first when there is something to be done. But we'll see how I feel about it when I become an intern in a few months! 

I do think that I am gradually gaining something of a team feel as I work here.  The people with whom I work seem more open to me doing things, although I think I've started asking to do more, too.  I feel my judgment on some things is trusted more than previously.  I remember more often to order HIV tests on practically everyone I see.  I can conduct a very basic interview in Tonga as long as the answers consist of yes (ee-ee), no (pay-pay), today (sunu), a little (ashonto), or a lot (meningee).  That's gratifying, too.  We'll see what the next few weeks bring.

Holy Week

I realized last Sunday in Livingstone that it was Palm Sunday when we saw a larger parade of brightly dressed Zambians coming out of the church near Jolly Boys Backpackers carrying palm fronds and singing.  I was sad to miss the day's celebration in the Macha church but began to look forward to seeing how the rest of Holy Week's events are marked in this place.

Last night was Maundy Thursday, the night prior to Jesus' crucifixion on today, Good Friday, a time to remember the Last Supper and all its significance, his suffering in the Garden of Gethsemane, his trials, and his desertion by his disciples.  Linda and I traipsed off a bit late for the service at 1830 to the church after our dinner at the MIAM cafeteria.  Upon arriving, the church was dark and no one visible.  We were about to turn around when Mrs. Spurrier, wife of Dr. Spurrier with whom we work in the hospital, came up from the dark church.  Cheered by each other's company, we decided to wait a bit longer to see if the advertised service would happen.

After about 15-20 minutes, about 10-15 people had assembled, so we entered the sanctuary.  The power was off, so we sang some hymns (including some I knew the tunes and the words in English) by flashlight and candlelight.  Despite the small group in a T-shaped church that usually seats about 800, I've been told, the singing was hearty, lovely, and inspiring.  We then heard a short, bilingual message about Passover and Jesus' institution of the new covenant and fulfillment of the Passover salvation of the Hebrew people in Egypt by becoming our Passover lamb.  As we were preparing for the closing song and prayer, about 20 more people came in.  They joined us for the last part of the service, and then we left.

I've been to a number of Maundy Thursday services, often called Tenebrae (service of shadows), which start out in light and end in darkness (either by the gradual extinguishing of candles or lightbulbs).  This one started in the gathering darkness of late twilight as we walked to the church, proceeded through the companionable sharing of flashlights and candles to read Tonga song words or Bible readings, and ended again in darkness lit by the Milky Way as we walked home.  We'll have another service tonight, tomorrow night, and two on Easter Sunday.

As Linda and I read the events of Thursday night from the account according to Matthew, I was reminded of light and darkness in the story.  The lights of the upper room where Jesus breaks the bread and passes the cup.  The darkness of the garden of Gethsemane.  The lights of approaching torches that allow visualization of the betraying kiss.  The lights on His face as he is silent under accusation on trial first before the Sanhedrin and then Pilate.  The dim light of early morning and fading night fires on Peter's tear-streaked face as he mourns that he has betrayed his Lord thrice before the cock crowed.  The darkness behind the blindfold from which Jesus was mocked and asked to identify those beating and taunting him.  The utter darkness of mid-day on Good Friday as the One who is the Resurrection and the Life breathed his last, crying, "It is finished." 

And I look forward to celebrating the shafts of bright early morning light that lit the empty tomb on Easter Sunday.  But for now, I wait.  I wait in a world in which innocent people suffer, in which the one truly innocent Man was brutally flogged, forsaken, and hung on a cross.  I wait in a world in which we don't live up to our best hopes for ourselves - hopes of courage, faithfulness, sacrifice, a world in which we may even betray our very best Friend.  I wait in a world in which God's call for you, for me, may include walking through pain to achieve his ends; it did for his Son.  I wait.