Sunday, August 31, 2014

Red Wrath of Ebola


In the depths of poverty, in the heat and the sweat of Western Africa, is the world of red.  Unique red dirt exposed by two great turners of the soil—the African termite raising great mounds of the crimson stuff, and people, clearing the rain forest to show the red clay previously hidden by lush and full vegetation.  The green stands ready to take it back over in an instant when untended. Formed of the clay, “road” is a seasonal term.  That which carries a vehicle in the dry season, swallows it in times of rain.  Houses of people, formed from the red clay into bricks, lose some of their deep color in the drying process as the sun shines mercilessly.   The hands of the farmer are red, constantly moving and forming this soil to make room for the crops.  Using the hand hoe is like spooning the ocean as she bends at the middle to reach dirt, a baby tied on her back.   Clothing is streaked and stained with the soil, mixing earth with the daring colors adopted in this part of the world.  Wearing something white is more like bringing out a canvas than a choice of fashion, for it is only a matter of time for the West African paintbrush to bring that permanent mark from the world of red.

A new red stain has come to this world.  As if years of civil war, anarchy, and misrule were not enough to satisfy whatever demons delight in the separating of the blood from the body of the black man, a people who fear cruel leaders now find an even greater wrath: Ebola.  At first it was a mystery as the patients passed blood in their feverish fits and then died.  But many and assorted doctors from other lands have come in plastic suits and rubber gloves, to diagnose this disease, label the outbreak and collect data.  What has worked in the past they have implemented in hospitals and tents:  intake, isolation, support.  In former days, this demon has been content to destroy a few villages in a quick but containable horror.  Now it has found its way across families and cities and even borders.  Fear and ignorance have been its friend, as patients hide from help, fearing isolation, and useless bush treatments cause even more damage.  One cannot help but notice an adaptation--patterns that have been effective over thousands of years--the isolated village, fear of others, independent beliefs and superstitions.  The village that has been for the people a place in this world, not only of survival in the midst of old-world disease, but a fertile thriving of family, culture, art, and even science and medicine. 

The doctor is the foreigner to the scene.  Yet that doctor or nurse was born and raised in West Africa, speaks an unwritten tribal language with his heart and not just his mouth. He nonetheless carries with him the foreign, the unusual, the new approach, saying: “no, we do not want to go back to the village, not like this.  We will use the modern tools to fight this disease, and deliver our people.”  The doctors from the West come as well, assistants to these noble men and women of Africa—all bravely risking their lives as the plague rages on. 

The West Africans have changed, dramatically so in fact.  They have laid down their guns, have stopped spilling each others' blood.  They have courageously used the ballot following no longer the empty promises of the bloodthirsty.  And in this outbreak, they have largely followed the request of their leaders to stop meeting, suspend schools, change their greetings which are so important to them.  They have followed the instructions of the world's designated smart people.  And yet, the blood still flows.

What will happen next in this great drama? There was another epidemic virus ravaging Africa, more in the East:  HIV.  It took many years for changes to take place to bring medications and resources already in use in developed countries to the continent.  A few visionaries worked diligently to bring to reality what most people thought impossible or at least impractical:  effective HIV treatments in Africa.  Having the treatments available not only saved lives, it vastly improved the ability to educate people and impact populations.  Those who knew there was a treatment were now willing to discuss the problem, get tested, and listen to the education needed to interrupt the spread. 

In the case of Ebola, there are medications and vaccines available, though they need further testing.  The development funding came in part from the US military, which planned to protect its soldiers from the disease.  Will visionaries be able to coordinate with the military, the Centers for Disease Control (CDC), the World Health Organization (WHO), the companies with patents, the doctors on the ground, the researchers, and others, to make treatments available?  Or will there be only nods of “supportive care” when it comes to Africans, who have nearly no access to supportive care in the sense the term is used in the West, which includes blood products and an ICU.

The whole world is nervous, affected, ready to act.  Money is offered.  What is needed is creativity.  Obviously, with a disease that has broken the boundaries of our experience, we need new approaches that break the boundaries of tradition to bring it under control.  Not forsaking what has worked in the past, not lightening up on containment, education, supportive care.  But creatively seeking cure.  Finding out which weapons work best in this kind of battle.  What sanitation systems are needed.  How the family and village support systems can be a help instead of a hindrance.  How an ICU and a blood bank can be built and, more importantly, supported, in such a setting.  How money from outside can be channeled usefully into the already existing research Universities and other structures in West Africa.

God's wrath is red, like the West African soil.  And yet so is the life-giving blood He put into every one of us.  Perhaps in His Providence, God has allowed this time that people whose blood is red might come to help their brothers and sisters in the world of red.

Sunday, August 10, 2014

How to Get Doctors to Small Towns?


The State of Missouri, using what has remained in State governance all of these years, the licensing of doctors, to make a very unusual ruling: allowing doctors without any residency training whatsoever to practice medicine (see article). This with the goal of providing medical care in rural areas.

This decision is short sighted and fraught with difficulties. It will serve to degrade quality and standards in the health care field. And yet it does illustrate the difficulty that the rural areas have in obtaining adequate health professionals in this country. And indirectly the failure of the medical education system to ensure the supply of doctors to rural America. This despite millions of dollars of loan repayments, various pilot projects, general guilt-tripping of students to goad them into primary care specialties, etc. Some fundamental changes must occur to reverse this trend and it is the responsibility of those in medical education and their f
und sources to ensure that this happens.

“Begin with the end in mind,” as Stephen Covey would say. What do we need to see? Doctors in rural areas need to be different than primary care in the city, where a multitude of specialists line up to compete for every possible disorder, especially every possible procedure. In fact, different rural areas need different things from their doctors: some may have a well-established OB practice and need primary care doc who can work in the ER. Some have ER docs and need some people who can do OB and ICU. Many need docs who can do psychiatry, since there is very little mental health support in much of rural America.

The current training system does not produce what the rural communities need. Residency has become more and more focused on producing sub-specialists. Primary care residencies such as Family Practice and Internal Medicine have become so heavy with top-down direction, that there is very little room for the innovation necessary to address the needs we are talking about. Endless streams of directions come from the central planners such as the Institute of Medicine, and the ACGME, ensuring that any possible change is nearly impossible.

In desperation, the State of Missouri has decided: this field in which training is done is too restrictive, and we are punching a hole in a fence. Maybe at least we will get some doctors out to our rural patients by doing this. I disagree with the specific decision, but I can certainly see the reasons for it. And if the organizations such as the IOM, ACGME, Medicare (holding the purse strings and thus basically guiding a lot of this), the American Board of Medical Examiners, and the specialty organizations tie the hands of the trainees and the trainers, then the states and the doctors and whoever can, will have to also help break down some of these fences, though hopefully in more strategic locations.

Some examples of things to try:
1. Pick out more procedures for the primary care to do that strategically expands the capability of the medical care provided in the rural setting: colonoscopy and echocardiogram interpretation are low hanging fruit, that could be incorporated into primary care training.
2. Form more residencies in rural medicine. Perhaps tailored to the specific community in need, and at the community level. In the age of the internet, a resident could train in the community he or she is to work in, with needed supplements of education and experience in larger centers and through teleconference.
3. Fusion of specialities: why make a “family practice” doctor and an “OB” doctor? Why not credential someone in those areas or subsections of areas that they need to do their job in their town? Board certification is a way of ensuring quality, but when it becomes impractical and stands in the way of patient care, it may be time to replace the process or the particular board, or both.

Friday, July 18, 2014

Darkness and Stumbling



“Those who walk during the day do not stumble because they see the light of this world. But those who walk at night stumble, because the light is not in them.” -Jesus (John 11)

The disciples were afraid of being killed, worried that Jesus would be jailed or killed, if they went back close to Jerusalem to visit Lazarus and his family. Jesus told them that the day has 12 hours, and one should walk during those hours, not at night. Once again, Jesus is pointing to another reality. A picture of something else. He speaks of light and not stumbling, and that makes sense to them and to us. A reasonable proverb. If you walk during the day, you do not trip; a very important thing in a time before electric lights and steel toed boots. But Jesus means that that there is a reality like the light. And there is a stumbling that is apart from hitting your toe on a rock.

What is this reality? The disciples are afraid of stumbling. They know there is darkness in Judea. But Jesus, as he has explained repeatedly, is in fact the light of the world. Where he goes there is no darkness. So it matters not whether there is war, or peace, or danger, or risk, or disease, or even death. All of those things are immediately tamed because they are like stumbling in the dark: when there is light, there is no stumbling.

In verse 16, Thomas finally gives in and says “let us go and die with him.” That is the best most of us can do in following Christ: resign ourselves to defeat, to death, to failure. We play the sad martyr and bring ourselves (with some self-righteousness thank you) to a giving up of security and success. But Jesus himself does not ask us to go this way. It is our insistence on holding to this world and closing our ears to Jesus' words that makes us joyless followers. Jesus himself says:
“Lazarus sleeps” - giving hope that he will rise again. A better picture for us of the reality that Jesus can see but we cannot. Jesus sees Lazarus, and all of us, rising again. We, never having seen anyone ever rise again, do not get that picture when the word “death” is mentioned.
“I am glad for your sakes I was not there, that you might believe.” Not that Jesus is a sadist but that Jesus, again, sees the end of things: a risen Lazarus, a woken Lazarus. A joy after the sorrow. A baby born after the pain. Faith birthed. The church begun.

Sunday, June 15, 2014

Poem Space

A poem says
My language is not enough
I need more room
Let me dance my words
Even if I knock over a planter
Or some heirloom

Saturday, May 17, 2014

Darings



Now, against the sacrilegious and impious darings of reason, we assert both that God knows all things before they come to pass, and that we do by our free will whatsoever we know and feel to be done by us only because we will it.

                                                                                     -Augustine (City of God)

Friday, March 28, 2014

Listening?

If God speaks not to us, then we are imagining him and all our time and energy thinking about God and praying to God and donating to God and discussing God is a fantasy and a self-invention.  At best a soothing distraction, at worst playing with razor blades.

Saturday, March 15, 2014

The Time of Death




Howard Miller Postema 625-406 49 Inch Large Wall Clock

The question from the nurses:
“what was the time of death?”
I have been asked that enough times
That I do now sometimes look at the clock
Before I am asked.
I think about that moment
When it happened
When the final breath left
And the heart quit beating
Must be written somewhere
And everywhere
Such an important time it must be
The time of death

But the “time of death”
is a misnomer
It cannot be
for it is the end of time
At least for one
How can there be a time 
For the end of time?
When you are out of string 
There is no string
You can’t say:  “be sure to tie a string around your finger,
when you run out of string. 
Then you will remember to buy string.”
But then the analogy breaks down.
As all do, it is death we are talking about
Speech is gone
Thought is gone
Theories are gone
Life is gone
The person is gone

But still I am called
To pronounce the “time of death”
As if I the doctor
Have a magic key
To an invisible box
Wherein this life will hide
As long as I give it a time