A prayer to the God of my life...

The backyard of a local church compound

Psalm 23:1-6
The Lord is my shepherd; I shall not want. He makes me to lie down in green pastures; He leads me beside the still waters. He restores my soul; He leads me in the paths of righteousness for His name's sake. Yea, though I walk through the valley of the shadow of death, I will fear no evil; for You are with me; Your rod and Your staff, they comfort me. You prepare a table before me in the presence of my enemies; You anoint my head with oil; my cup runs over. Surely goodness and mercy shall follow me all the days of my life; and I will dwell in the house of the Lord forever.

Psalm 42
1-2 As the deer pants for the water brooks, so pants my soul for You, O God. My soul thirsts for God, for the living God. When shall I come and appear before God?
5-8 Why are you cast down, O my soul? And why are you disquieted within me? Hope in God, for I shall yet praise Him for the help of His countenance. O my God, my soul is cast down within me; therefore I will remember You from the land of the Jordan, and from the heights of Hermon, from the Hill Mizar. Deep calls unto deep at the noise of Your waterfalls; all Your waves and billows have gone over me. The Lord will command His lovingkindness in the daytime, and in the night His song shall be with me - a prayer to the God of my life.

Psalm 27
1 The Lord is my light and my salvation; whom shall I fear? The Lord is the strength of my life; of whom shall I be afraid?
4 One thing I have desired of the Lord, that will I seek: that I may dwell in the house of the Lord all the days of my life, to behold the beauty of the Lord, and to inquire in His temple.

Serenity

I captured this photo on an idyllic afternoon last week. It's hard to discern the features unless you zoom in but if you do, you may see in the centre a little boy pushing a huge tyre (as big as himself!) with a stick. It's one of the favourite games the kids here play.

At any rate, last weekend almost broke me, mentally speaking. I was so tired that I slept from 9pm last night till noon today - 15 hours of bliss. Let me give you a taste of what confronted me over the past week:

Paediatric ward:
In bed 1, we've an 11-day-old female who presented with 48 hours of seizures. She had a home birth and the mother had not received any antenatal care prior to delivery. Diagnostic dilemma: febrile convulsion vs cerebral malaria vs meningitis vs neonatal tetanus. Malaria smear was negative but we had otherwise no way of proving any of the other possibilities so we ended up covering with ampicillin, gentamicin, aciclovir and metronidazole as well as phenobarbital and diazepam (no neuromuscular blockers, paraldehyde or chlorpromazine). At any rate, over the course of her admission, neonatal tetanus became more and more likely as her seizures were tetany-like and were provoked by touch. Pray for us as we'll be deciding in the next few days if treatment should be withdrawn depending on what we think her neurological outcomes could be (which is going to be a challenge since no one can besides God can foretell that with certainty).

In bed 2, we've a two-year-old boy with gross generalised oedema (swelling) and 16 hours of anuria (no urine output). The anuria was later found to be secondary to urinary retention as he had one of the worst cases of penile and scrotal oedema that we've seen and he required a suprapubic tap to relieve the post-renal obstruction. We've finally got the ability to test electrolytes (hallelujah!) but the machine was playing up; our first specimen gave a potassium of 14.2mmol/L (!!!) and the second was so high it could not be recorded. The troubling thing about this was that both samples were arterial in source since none of us could get venous access due to the oedema. However, it's doubtful he would have lasted this long with such severe hyperkalaemia.

In bed 3, we've a one-year-old boy with the same presentation but less severe.

In bed 5, we've a fourteen-year-old boy with worsening dyspnoea and chest pain as well as abdominal pain and distension. Found to be febrile and on examination to have massive hepatosplenomegaly as well as cervical and inguinal lymphadenopathy and CBC showed severe anaemia (Hb 4.9) and thrombocytopenia (Plt 21). Treated for presumptive malaria and transfused one unit but the Hb post transfusion actually dropped to 4.8g/dL and there was bilirubin and urobilinogen +++ in his urinalysis, indicating an ongoing haemolytic process. CXR did not show any obvious cardiomegaly, effusions or consolidation, his WCC was normal, LFTs were only mildly off and both ESR and triglycerides were elevated. At this point, our differentials were leukemia/lymphoma, autoimmune haemolytic anaemia, autoimmune lymphoproliferative syndrome +/- Evans syndrome, haemophagocytic lymphohistiocytosis and macrophage activation syndrome. We started prednisolone on Saturday night but unfortunately, he developed worsening respiratory distress overnight and passed away this morning.

We had a total of five premature infants last week, four born at 31 weeks! Sadly, two died.
- The first died on the night of admission: I wasn't on call that night but the little two-day-old boy (~35 weeks' gestation born at home a/w possible meconium-stained liquor) had been tachypnoeic since birth and apparently had frank haemoptysis/haematemesis before passing on. We still can't figure it out but one hypothesis is the nasal cannulae causing epistaxis which bubs normally swallow and then cough out and another possibility is meconium aspiration syndrome but his respiratory distress seemed more severe than expected if that was the case.
- The second died on Sunday morning; the one-week-old boy had been noted on Friday and Saturday nights to have reflux associated with apnoeas and bradycardia. This was a particularly vexing case for me since the sequence of events was that at 5am, the mother notified the night nurse on duty that he seemed to be in a bit of strife; by the time the nurse arrived, there wasn't any cardiac output but I was only called about it 18 minutes later! By which time, it was way too late. Argh...so frustrating, especially since his twin later developed the same problem that afternoon but we got there within a couple of minutes and basically brought him back, thank God. The poor mum, a 15-year-old primip, was crying into my lap for an hour and a half.

Obstetrics ward
In bed 1, we have a HIV-positive mother who is two weeks post elective C-section (four previous scars) with acute right hemiparesis and facial droop as well as mild dysarthria and confusion. She had only one documented fever, was normotensive without any signs of pre-eclampsia, and had a normal ECG but was surprisingly neutropenic (0.8). Was it a stroke? Cerebral toxoplasmosis/TB? Some autoimmune disease? CNS lymphoma? She was asymptomatic and well besides these neurological deficits so it's a bit of a mystery. We covered with cotrimoxazole and sent her back to the local antiretroviral treatment centre to hopefully be recommenced on HAART.

In bed 2, we had a 20-year-old primip who delivered twin girls; one a stillbirth (foetal death in utero at time of presentation) and the other one of the prettiest babies I've ever set eyes upon. Both mum and baby had malaria and received adequate treatment but the mother was persistently anaemic (with Hb levels < 5.0g/dL!) despite four units, which is a lot in our context (most patients get only one unit even with Hb levels as low as 1.9g/dL). She was later found to also be Hep C positive and had massive splenomegaly; no retained tissue on ultrasound examination. DDx: FDIU-related coagulopathy, hyperreactive malarial splenomegaly (aka tropical splenomegaly syndrome), Hep C-related cirrhosis and some form of autoimmune haemolytic anaemia. None of it was ever proved or disproved but my money's on the first two.

On Friday evening, a two-year-old boy arrived in status epilepticus, later found to be secondary to cerebral malaria. On Saturday morning, we had another primip who proceeded to C-section for foetal distress followed by a VBAC with unproven pelvis (first child was delivered via C-section for breech presentation) that eventually required a vacuum. That evening, a lady arrived near-collapse a day post septic miscarriage at 10 weeks' gestation. And in the early hours of Sunday morning was the death of the second premmie.

Amidst all this madness, we were also taking care of one of our nurses who had the misfortune to be in a hit-and-run pedestrian vs motorcycle accident the week before. He almost certainly had a base of skull fracture (bleeding from both ears and nose as well as left sided LMN facial nerve palsy) but thankfully has gradually recovered with conservative management (the only option available to us considering there isn't a CT scanner or neurosurgical service in this country) and is now fully oriented to TPP with mild persisting dizziness and no further headaches.

God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And wisdom to know the difference.
- Reinhold Niebuhr, 1943

Amen and amen, brother.

Faithfulness

Hymn by Brooke Fraser
If to distant lands I scatter
If I sail to farthest seas
Will You find and firm and gather
Till I only dwell in Thee

If I flee from greenest pastures
Would You leave to look for me
Forfeit glory to come after
Till I only dwell in Thee

If my heart has one ambition
If my soul one goal to seek
This my solitary vision
Till I only dwell in Thee
That I only dwell in Thee
Till I only dwell in Thee

- From the album Albertine -
http://www.youtube.com/watch?v=jRW8WV5cFaU

No matter where, no matter how, He will neither leave us nor forsake us. May this be our prayer for the world in which we find ourselves today. May we remember our brothers and sisters suffering in Syria, Egypt and countless other countries (Making sense of the Middle East). May we know His love is stronger than death and may this truth be lived out in our every word and action.

This is a faithful saying: For if we died with Him, we shall also live with Him. If we endure, we shall also reign with Him. If we deny Him, He also will deny us. If we are faithless, He remains faithful; He cannot deny Himself. 2 Timothy 2:11-13

Home is where the heart is

The three resident cats

Psalm 137:1, 4-6 By the rivers of Babylon, there we sat down, yea, we wept when we remembered Zion...How shall we sing the Lord's song in a foreign land? If I forget you, O Jerusalem, let my right hand forget her skill! If I do not remember you, let my tongue cling to the roof of my mouth - if I do not exalt Jerusalem above my chief joy.

Being in South Sudan now for two months (three if I included the brief time I was here in March/April), I'm naturally homesick. Frankly, I get homesick quite easily (like the time in internship when I was attached to a rural clinic about two hours out of Melbourne, I would drive home every weekend I wasn't on call). This takes it to an entirely new level.

No family. No friends. No car. No Chinese food. Just to get basic amenities like soap or groceries means a trip into town, which involves catching a boda (motorcycle) and negotiating the dirt roads that turn into slippery mud in the rainy season. No international ATM machines so you better hope you brought enough cash prior to arrival. No 000/911/999 number to call in case of any emergencies; e.g. if in need of an appendicectomy, your options would be to either submit yourself to the local health service or going down the very complex (not to mention expensive if uninsured) route of organising a medical evacuation. No postal service so what you packed in your luggage is what you'll live with for the next few months or, at any rate, until your next flight out to neighbouring Kampala, Nairobi or back home.

Truth be told, it isn't all bad. I gained a new family in the other missionaries here in the compound (some of whom have been here for over a decade and have lived through the war together with the longsuffering Sudanese). I've the chance to make new friends in the people I meet everyday, be it as a doctor, kawaja (foreigner) or otherwise. I'm young and healthy - I can walk where required. I've three prepared meals a day (we have communal meals here in the compound) and I can cook (although procuring ingredients can be tricky; I'm currently lamenting my lack of foresight in bringing essentials such as oyster sauce!).

It's taught me that 'home' is a fluid concept. I guess I first learned this when I migrated from Malaysia to Australia as a teenager back in 2003. It took me almost eight years to get over my homesickness then, and I still consider Malaysia my first home. Home is such an integral component of one's identity, so much so I firmly believe that it could cause a crisis when there's an inability to shift or to reconcile a dissonance between what was and what is. Will there ever be a time when I can say that such a place is no longer home? I don't think so. It will always be a part of my heart and soul, but I believe that these can expand to include other people and other places. It has to as a matter of necessity, even if only to survive the emotional trauma.

Psalm 122:1, 6-9 I was glad when they said to me, "Let us go into the house of the Lord."...Pray for the peace of Jersualem: "May they prosper who love you. Peace be within your walls, prosperity within your palaces." For the sake of my brethren and companions, I will now say, "Peace be within you." Because of the house of the Lord our God I will seek your good.

For the sake of my family and friends both in Malaysia and Australia, I will always seek the good of these countries and uphold them in my prayers. Who knows whether this place would eventually take on a similar role one day? All I know is our final home will never change, and I choose to find comfort in that irrevocable reality.

Pressure

This week has been one of the busiest weeks of my life! At the end of Wednesday, the other doctor (a recently-employed Ugandan-trained South Sudanese PGY2 - who has done 200 Caesarean sections during her internship!!) and I looked at each other and mumbled that if the rest of the year was like that day, we would totally break down in exhaustion. Well, ironically enough, Thursday was worse than Wednesday and Friday was even more terrible! I heard yesterday was très horrible too, hopefully things have settled down by today.

We had another bub who died on Friday. She was born via vaccum-assisted vaginal delivery two days prior. Her mother had a previous C-section but did report one successful VBAC (vaginal birth after C-section). In retrospect, I thought it would have been reasonable to take her to theatre for repeat C-section; she had prolonged rupture of membranes (over 24 hours) and there were multiple decelerations on monitoring as well as a persistent anterior cervical lip on examination. Anyway, that didn't eventuate and it mightn't have changed the outcome either (hard to predict since we had no way of telling how long the foetal distress had been present). We try to avoid C-sections if at all possible since contraception's unheard of here and it'd be disastrous for a woman with two or more scars to deliver at home.

Anyway, on delivery, there were large amounts of meconium in the liquor as well as in the baby's airway, she had low Apgar scores and took quite a bit of resuscitation. She seemed to do well over the next few hours and was even weaned off oxygen. Right around midnight, I was called back to the ward since she started developing respiratory distress and became febrile despite already being treated with IV ampicillin and gentamicin. The next 36 hours was chaotic as we battled with temps over 41 degrees, seizures presumably due to the high fever, and ongoing laboured breathing even with oxygen and CPAP support. Poor baby, it was all too much for her and she just gave up after around midday. The first hint I got of it (since I was on clinic duty) was when I saw the large group of people congregated around her bed, all of them standing stock still and solemnly listening to someone inside the room speaking. It was quite touching as they then sang a song (a requiem, if you like) before leaving with the body, the women weeping as they did so.

Could we have done anything differently? I honestly don't know. Meconium aspiration syndrome +/- peripartum foetal asphyxia +/- ?occult subgaleal/intracranial bleed (no way of excluding it but no pupillary or limb movement asymmetry) = ultimately futile efforts. Of course, it's no reason to stop trying; in the end, God is the decider of our fates. Because, really, we all die one day. The question is when, where and how. Will we be ready when the time comes? Am I prepared to meet my Maker? At times, I can confidently say 'yes, Jesus, take me home'! However, I've to confess that my heart has also sought greener pastures that inevitably turn out to be gateways into the wilderness instead.

Jeremiah 2:13 "For My people have committed two evils: they have forsaken Me, the fountain of living waters, and hewn themselves cisterns - broken cisterns that can hold no water."

P.S. Regarding the pic, we had an unexpected appendicectomy a few weeks ago. A German missionary from another NGO developed appendicitis (in first trimester pregnancy, no less!) and we had the opportunity to host a visiting general surgeon for the procedure.

Complexity

The pic is a preop X-ray of a little boy's left foot (yes, left - I had unwittingly flipped the film over when I took the photo). He presented two weeks after accidentally kicking a fence while playing football (such a dangerous sport!), a week after his mother had found and removed a wooden splinter sticking out of his great toe just adjacent to the toenail, and a few days after he developed three sinus tracts over the dorsum of his foot that subsequently discharged frank pus. As you can (hopefully) clearly see, there is a transverse fracture running through the epiphysis of his proximal phalanx. What was worse was that when we took him to theatre for washout and debridement, it was an open fracture; the proximal edge of the toenail had lifted off, revealing the bony structures underneath. The little box at the corner of the pic shows the epiphysis of the proximal phalanx on the left and the entire distal phalanx on the right (looks rather similar to a tooth, right?); these bone fragments were found to be completely detached from the neighbouring soft tissue once the nail was removed. At any rate, he's probably headed for a partial amputation, poor kid.

Two days ago, we had two deaths, both boys under the age of five years. The first was dead on arrival; he had been admitted at our facility for over two weeks back in June with developmental delay, stunted growth, pectus carinatum (pigeon chest), and an incidental finding of malaria, which was treated but never really made a complete recovery. At any rate, he represented with respiratory distress, was seen at another clinic that morning and got referred to us. However, due to it being Saturday, he was left sitting outside the clinic (which is closed on weekends) for around half an hour before I was notified of his presence and by the time he was brought to the ward, had already passed on, presumably from a primary respiratory arrest.

And neither's even the complex case I wanted to discuss. The second boy, aged 2 years and 8 months, has got to be one of the most complicated cases I've encountered in my brief career and, in my humble opinion, would have warranted ICU admission posthaste as well as a postmortem back home (but unfortunately, such resources are unavailable here). He presented in a pre-terminal state - obtunded with minimal response to external stimuli, bradypnoeic (RR 8/min) with a Kussmaul's respiratory pattern, as well as generalised oedema. In fact, he was so puffy that none of us could obtain intravenous access and we had to rapidly make the decision to insert an intraosseous line. On the (correct) hunch that hypoglycaemia could have contributed to his moribund state, we gave a bolus of 50% dextrose with immediate improvement in his respiratory effort.

Over the course of the afternoon, more history was elicited; the oedema was first noticed a MONTH prior to presentation, which in turn was preceded by (non-bloody) diarrhoea, some oral as well as buttock sores and possibly a sore throat. On the other hand, his respiratory distress was an acute event, having only started that morning after breakfast. A CXR and quick ultrasound scan did not reveal any drastic effusions (pericardial, pleural or otherwise), consolidation, cardiomegaly, cardiac valvular pathology, hepatic/splenic lesions or ascites. We don't have biochemistry so we were unable to exclude renal or hepatic impairment but his urine output was borderline adequate and there was no obvious hepatosplenomegaly, jaundice or coagulopathy; urinalysis did reveal a mild degree of haematuria and proteinuria with white cell casts seen on microscopy. No paediatric sized blood pressure cuff either so his BP remains unknown.

At this stage, my top differentials were glomerulonephritis of some form (likely post-streptococcal) +/- malaria (smear proven two weeks ago with likely suboptimal treatment elsewhere). As you could probably tell, that wasn't the end of the story. As a matter of fact, it only got curioser and curioser (as Alice would put it). He then developed seemingly refractory hypoglycaemia; it was persistently low despite numerous boluses of dextrose. Was it due to leakage of the dextrose solution from the intraosseous line? A false reading since the samples were capillary in source and there was gross oedema giving a dilutional effect? Or something occult like central adrenal insufficiency? Not having any hydrocortisone, we trialled a stat dose of dexamethasone. Either way, despite our throwing everything we have at him, it was a case of too little, too late. Spontaneous respirations ceased eight hours later; throughout the whole admission, he had been (almost malignantly) tachycardic with laboured breathing and a decreased conscious state.

If it had in fact been GN, why was his respiratory distress so acute one month after the precipitating cause? If it was malaria causing severe hypoglycaemia, why was the smear at our lab negative when it should have shown at least some degree of parasitaemia? If it was APO secondary to some other cause (cardiac, hepatic or otherwise), why was it not shown on CXR? Why did the hypoglycaemia not respond to treatment? Could it have been HUS secondary to enterohaemorrhagic E.coli; if so, why was bloody diarrhoea absent? There were just so many points that didn't add up and it's left us confounded. Worse still, it's left his family with one less member. His mother wasn't even present to say goodbye as she was at home with a newborn. At least, he died surrounded by his father, grandmother and a cohort of aunts and uncles.

It reminded me of how finite our knowledge is, how limited our skills and talents are, how powerless we are in the face of death. The good news, thankfully, is that through the love of God incarnated in the body of Christ, we can transcend this mortality and know that this is not the end.

1 Corinthians 1:20-25 Where is the wise? Where is the scribe? Where is the disputer of this age? Has not God made foolish the wisdom of this world? For since, in the wisdom of God, the world through wisdom did not know God, it pleased God through the foolishness of the message preached to save those who believe. For Jews request a sign, and Greeks seek after wisdom; but we preach Christ crucified, to the Jews a stumbling block and to the Greeks foolishness, but to those who are called, both Jews and Greeks, Christ the power of God and the wisdom of God. Because the foolishness of God is wiser than men, and the weakness of God is stronger than men.

Let the little children come

This picture is of a precious little girl who can be seen most days running around the hospital compound as her mother is one of our cleaners. She is such a cutie! And very bright too. She now associates me with my iPad mini, which I carry everywhere with me (since it contains most of my medical references such as UpToDate) and always asks to see the photos on it and has already learned to swipe to get to the next pic! Mind you, this is on the background of most people here having never seen a computer or a camera.

Kids can be found in abundance here. In fact, I recently met a patient who was surprisingly distraught over the revelation that she was 17 weeks pregnant. She kept repeating, 'No, I'm not pregnant. I cannot be pregnant!' in spite of my showing her on ultrasound that there was clearly a baby in her womb and his or her heart was beating along at a happy pace. With further probing, it appeared that she was so upset because she was currently breastfeeding her second child (a nine-month-old girl who, incidentally, I later found out was an inpatient in our ward suffering from malaria) who was also conceived while she was breastfeeding her first one! So much for lactation as a form (really, the only version here) of contraception.

But Jesus said, "Let the little children come to Me, and do not forbid them; for of such is the kingdom of heaven." (Matthew 19:14). Expanding in Mark 10:15 that "whoever does not receive the kingdom of God as a little child will by no means enter it" and in Luke 9:48 that "whoever receives this little child in My name receives Me, and whoever receives Me receives Him who sent Me. For he who is least among you all will be great."

It has often puzzled me what He meant by "receiving the kingdom of God as a little child". Did He mean in innocent wonder? Open acceptance? Trusting credulity? All of these and more? I haven't been a child for a while now (although my parents still treat me as one!) and I don't have one of my own so feel free to leave any thoughts or comments on this point. For now, I guess I will have to study these little ones and attempt to discern the difference between childlike and childish faith :)

P.S. To my amazement, I discovered that the little girl's hair was NOT held up with any hair tie or band; apparently, the hair fibres of the Africans here are stiff enough that when braided, will hold together of their own volition! Pretty crazy, hey?

The socioeconomics of health (or the lack of it)

View from the front of the hospital

My nose is running (leaking?) like a tap. Probably an after-effect of almost 25 hours of work yesterday; got woken up at 4.30am to attend to an increasingly tachycardic pre-eclamptic primigravida lady post vacuum-assisted vaginal delivery. She turned out to have postpartum haemorrhage (with an acute drop in haemoglobin level from 113 to 53 in less than 12 hours) requiring manual evacuation of clots under sedation. And didn't get to bed until 5.30am the NEXT morning. "You have got to be kidding me" was my apt reply when informed by the nurse on duty at 10.30pm that the heavily pregnant mother of one of our long-stay patients (a malnourished pre-school boy) had gone into labour. I've been awake for much longer before but haven't needed to be "switched on" (seeing patients and having to navigate the intricacies of their management) nearly that entire time.

Anyway, that brings me to another of our long-stay patients, also incidentally a malnourished boy who's just under 3 years old. He's been with us for 2.5 weeks (which is very very long by the standards of a mid-level rural African hospital where the average turnaround time is just a couple of days). Poor kid's severely wasted and we've been trying to get his weight up to little avail despite successfully treating his malaria and diarrhoea (secondary to ascariasis, which I previously didn't know existed). We think it's most likely attributable to his HIV-positive status. We've been trying for over two weeks now to get him to the local public hospital's antiretroviral treatment centre (the only clinic in town with UN-funded HIV meds), which has to be one of the most trying endeavours I've ever embarked on.

First time, his mum 'forgot' the referral letter we had given her. Second time, she said that the centre had told her that there were no meds available. Third time, we sent our own VCT counsellor (voluntary counselling and testing for HIV prevention) to go along WITH her to firstly, act as an advocate on the patient's behalf and secondly, because we were suspicious that the mother had never actually reached the centre. You see, due to the stigma associated with the disease, most patients are (understandably) very reluctant to be seen anywhere near that centre. It doesn't help that it's located prominently right smack in the centre of the hospital compound with the sign "ART Centre" (antiretroviral treatment) written in large letters; not very subtle, indeed. Anyway, they were sent back to us the third time without any mention of further management for the kid's HIV, whether his CD4 count or viral load were tested and when and how ART should be commenced, etc etc. Just some desultory notes (which were basically copied from our own notes) about his intercurrent infections and starting cotrimoxazole (which we've already done). Gah! Felt like screaming at them.

And against all this was the backdrop of the mum's insistence on being discharged home in spite of the kid weighing less than on admission (hovering betwen 6.4kg and 6.8kg from 7.3kg for a 2 years and 7 month old boy on a maximal therapeutic feeding regime)! So so frustrating. Upon further questioning, the socioeconomic factors behind that bizarre request were elucidated. Firstly, she was concerned over how to pay for the boy's admission as she, being his full-time carer, was obviously out of work (just as a fyi, we never force our patients to pay and there have been many a patient who has defaulted). Secondly, she was worried about her husband and what he was up to; he had been MIA the whole time, which is pretty unusual as I've seen most African dads showing up every now and then to check on their family. Thirdly (and this I found most strange) she wanted to go buy soap and her boy's favourite food items since he didn't like what we offered (and I don't blame him - it consists mainly of beans and rice BUT it's probably more than what he would have gotten at home; when I suggested that she could leave the boy on the ward during the daytime to get the food, she actually confessed that she didn't have the money for the purchases so I thought this a moot point and just another excuse to leave).

Anyway, tomorrow's our fourth attempt at trying to procure these ridiculously elusive drugs. God willing, we will be able to start him on the meds he needs and that would prove to be the solution (since we've already exhausted all other options). The harrowing likelihood (and what's most depressing) is that the boy is going to return to his baseline state and possibly die in the next few weeks or months as soon as he goes home unless his social situation dramatically improves.

Why fight so hard for what seems to be doomed for defeat?
James 2:14-18 What does it profit, my brethren, if someone says he has faith but does not have works? Can faith save him? If a brother or sister is naked and destitute of daily food, and one of you says to them, "Depart in peace, be warmed and filled," but you do not give them the things which are needed for the body, what does it profit? Thus also faith by itself, if it does not have works, is dead. But someone will say, "You have faith, and I have works." Show me your faith without your works, and I will show you my faith by my works.

As the Apostle James so poignantly puts it. This passage has been one of my life's driving forces over the past few years. A Christian who does not lift a finger to help his or her brethren is no Christian. When would the church wake up and realise that there is so much need outside her doors? That God put us on this earth not just to eat, drink and be merry, but to use what we have been given for the greater good and for the glory of His name?

11-Aug-2013 Update:
Bah! The public hospital straight out refused to give him the meds without his attending a supposedly obligatory three-session education course which takes place only once a week, i.e. we've to wait a further three weeks to start him on ARV meds! This is despite our giving the hospital's medical director a call, who promised to give us what aid he could but then backtracked and gave in to the clinical officer (not even a doctor for crying out loud!), who persists in being obstinate over a stupid protocol! Dear God, give us patience...

Did you know?

Did you know that:

• South Sudan has the highest maternal mortality rate in the world?
  The UN quotes a 1 in 7 chance of a South Sudanese woman dying during her lifetime from pregnancy-related causes (2,054 per 100,000 live births).
• It also has one of the highest under-five mortality rates in the world?
  According to the World Bank & WHO, 1 in 8 South Sudanese children do not live to reach their fifth birthday (121 per 1,000 live births).
• The average life expectancy in South Sudan is only 62 years?
• Nearly 1 in 3 South Sudanese kiddos are malnourished?
• Merely 25% of the South Sudanese have access to any form of health care?
• The poverty rate in South Sudan is over 50%?
• Less than a third of South Sudanese are literate?
• South Sudan was the epicentre of Africa's longest running civil war (over the greater part of the 50 years between 1955 and 2005)? Cost: 1.5 million deaths (population: 9 million).
• South Sudan is the youngest nation on this planet as of 9 July 2011? It celebrated its second independence day just three weeks ago!

Sources:
United Nations Development Programme: Millennium Development Goal 5
United Nations Development Programme: About South Sudan
World Health Organization: Under Five Mortality
The World Bank: Under-Five Mortality Rate
Save the Children: South Sudan
BBC - Sudan Country Profile

Why did I ask? Because all these stats, these numbers that seem so overwhelming initially, means that the work we do at my hospital here is not for naught. The photo is of the foundation that is being laid for our new special care nursery as well as an expanded labour/delivery suite. Improving the health of South Sudanese women and children is our daily bread (and butter - not that we get that here!). So I'd urge you to prayerfully consider giving towards this service; all the missionary staff here (including yours truly) work free of charge so rest assured that the money isn't going to fund our imaginary Lamborghini sports cars or Hermès Birkin handbags :)

Operating Funds Goal: $238,217 ($19,850/month) - $33,249 raised so far
Capital Funds Goal: $105,844 - $37,225 raised so far

Find out more here: Bet Eman - His House of Hope Hospital for Women & Children
Donate here: Harvesters Reaching The Nations

Waiting in the dark of the night

Well, it's 11.18pm and I'm sitting on my bed safely under the cover of my mosquitto netting (double layer for the win! The one provided with the room was full of holes). Waiting for a primigravida to progress to the second stage of labour and hopefully deliver her baby uneventfully in the next few hours (wishful thinking?).

At any rate, this is my second or third night on call solo and it's been pelting rain the entire evening, which means slippery mud, clothes that won't dry and fewer patients than usual (which makes perfect sense when one considers that there are no tarmac roads and the primary form of transportation here is either by foot or by boda [motorcycle]. Only 'kawaja's' [the Juba Arabic term for white men] and the wealthy South Sudanese own cars - or more appropriately for this environment, four-wheel drives). Hats off to the long-term missionary docs here; I can't imagine doing this - being constantly on call without a break - for years! Just a few months will soon wear me out without the help of God's Spirit.

It calls to mind this particular verse from the Bible:
Jeremiah 12:5 "If you have run with the footmen, and they have wearied you, then how can you contend with horses? And if in the land of peace, in which you trusted, they wearied you, then how will you do in the flooding of the Jordan?"

I've often pondered on this passage and wondered what it means in my life and how it can be so pertinent in situations like these. Ever since I started medical school, and now even more that I've graduated and have entered the work force, my default modus operandi seems to be one borned out of tiredness (it's became a joke in my family that whenever they ask how I am, I reply, 'Tired!'). No, I'm not anaemic (had my haemoglobin level recently checked when I donated blood and besides, I always feel rested so long as I get my beauty sleep). It's quite easily explained due to a combination of bad sleeping habits (sleeping past midnight even when I used to start work before 7am back home) and a multitude of activities always running in the background (severely trying my multitasking skills). Sometimes, I think it's a good thing I'm single because I think the degree of my fatigue would be at least doubled if I had a family of my own.

It also underscores the importance of keeping a consistent quiet time and of being disciplined in seeking rest in God and God alone. As Jesus once said,
Matthew 11:28-30 "Come to Me, all you who labour and are heavy laden, and I will give you rest. Take My yoke upon you and learn from Me, for I am gentle and lowly in heart, and you will find rest for your souls. For My yoke is easy and My burden is light."

Of all the promises He's made, it definitely ranks as one of my favourites. And it's one that I have to remind myself over and over to practise, rather than trying to find escapism in trivialities such as the latest TV series, a good storybook or even the higher pursuit of time spent with loved ones. It is in Christ that our souls will find repose. As St Augustine aptly puts it all the way back in the 4th century AD, "Thou hast made us for thyself, O Lord, and our hearts are restless until they find their rest in thee." (Confessions).