Endings

When was the last time you read the last chapter of a book first? Maybe never? For me, it was last week. Having the end in mind frees me, somehow, to observe how the author crafts and weaves the narrative along the way. Before you diagnose me with having broken the eleventh commandment (thou shalt not ruin a suspense-filled-plot(?!?)), I beg you to humor me and read on…

Happy Endings…
Yesterday I received an email from Dr. Louise King in Rwanda informing me that one of my patients and friends, Fulaha, had recently received two prosthetic legs and is now able to walk with crutches. Happy ending! For those of you who weren’t able to keep up with my verbose blog, Fulaha was a young woman and an orphan unable to walk due to a congenital leg malformation. She had been staying at Shyira Hospital for the past nine months after a bilateral AKA (Above the Knee Amputation), sitting in an old wheelchair with two flat tires, making baskets, and waiting for her prostheses. Her name, pronounced “foo-LAW-haw,” means “Joy” or “Joyful” – and that she was! Whenever I approached, she would loudly proclaim “Mar-EEEEEEE-ya!” and throw her arms wide open for a hug.

Only once did I see Fulaha sad. On the day she was scheduled to go to the capital, Kigali, I found her still lying in bed with the sheet pulled over her tear-stained face. Her legs had not been completed on time and her trip was canceled. When I took my leave of Shyira Hospital in rural Rwanda, I departed wondering if my ‘inshuti Fulaha’ (literally: ‘Joyful friend’) would ever walk. A cliff-hanger to be sure…but, like my reading style, you already know the ending.

Fulaha, upon arrival

After her bilateral above-the-knee amputation:
April 2009, after her prosthesis installation surgery:


…Juxtaposed With…
Happy endings make great newsletter-stories, to be sure. I could fill pages about my six months in Africa with stories about the patients that went home well, the lessons I learned, the ways and places I saw God working and moving, the fun and adventures I had, the friends I made, etc., etc. Africa was and is a kind of second home for me. Though I can’t presume to understand even a fraction of the cultural nuances and climate, I look forward (hopefully and prayerfully) to returning after residency.

In medical school they taught us that, when in the position of giving bad news to a patient, it is best to fire a warning shot. Studies have shown that inserting the phrase “I’m afraid I have bad news...” helps most people brace themselves for the ensuing blow. Could this be another form, perhaps, of “reading the last chapter of a book first?” In either case, consider this to be your warning-shot: for every “happy ending” I saw in Africa, ten sad ones soberingly come to mind as well. I would be remiss to gloss over this crude reality.

…Sad Endings
Two weeks after arriving in Rwanda, I got an email from a doctor friend in Cameroon informing me that Mispah, a patient we had cared for together, had died. Despite her recovery from bacterial meningitis. Mispah was so depressed that she couldn’t eat the small amount of food her family could afford for her and consequently I saw her waste away from malnutrition. I brought her food and spoon-fed her. I checked on her ten times a day. I knew her family members by name. You know the ending. Maria, my nineteen-year-old patient in Cameroon who survived meningitis and recovered successfully from half-paralysis returned to the hospital the day after discharge. Unconscious and with a mysterious heart murmur, we helplessly watched her die the next day. I could fill pages about my six months in Cameroon and Rwanda with similar stories about the patients that died, the indescribable suffering, the appearingly hopeless circumstances and politics, the pervading corruption, the seemingly infinite poverty, etc., etc. These are the real-life cliff-hangers, with all their accompanying uncertainty and angst. Some of the bad endings are not in our power to prevent; some of them are, yet we do not. Overall, a sense of powerlessness pervades.

To be continued…
“Bagarira yose ntuzi irizera niri zarumba.” This is a Rwandan saying that can be literally translated as: “Treat every plant well because you do not know which will bear fruit.” My language teacher paraphrased it by saying “You don’t know yet who will be good or bad. God only knows.” Perhaps powerlessness and uncertainty are part of being alive. As much as I would like to read the last chapter of this book now to see how all of this will end, I cannot. However, just because I cannot see the end does not mean that the author Himself cannot. And just because much of this suffering and injustice seems to fly in the face of a loving and just God, doesn’t mean that He has given up on us or that He won’t explain it all in the last chapter. He has the end-goal in mind; He is still crafting and weaving this narrative along.

I’ve quoted Yancey once before, and I will end by quoting him again (from Where is God When it Hurts, Philip Yancey)

“The record of Jesus' life on earth should forever answer the question, "How does God feel about our pain?" In reply, God did not give words for theories on the problem of pain. He gave us himself. A philosophy may explain difficult things, but has no power to change them. The gospel, the story of Jesus' life, promises change…There is one central symbol by which we remember Jesus. Today that image is coated in gold and worn around the necks of athletes and beautiful woman, an example of how we can gloss over the crude reality of history. The cross was, of course, a mode of execution. It would be no more bizarre if we made jewelry in the shape of tiny electric chairs, gas chambers, and hypodermic needles, the preferred modern modes of execution. The cross, the most universal image in the Christian religion, offers proof that God cares about our suffering and pain. He died of it. That symbol stands unique among all the religions of the world. Many of them have gods, but only one has a God who cared enough to become a man and to die...”

" He who did not spare his own Son, but gave him up for us all—how will
he not also, along with him, graciously give us all things?" (Romans 8:31-32)

For more stories and/or pictures, please visit my blog at http://marybuckler139.blogspot, email marybuckler139@gmail.com, or call 414-839-8299. I’d love to hear from you. On June 22nd, 2009, I will enter the next stage of my medical training at my top choice residency program, a five-year combined Family Medicine/Psychiatry residency at the University Hospital & Christ Hospital in Cincinnati, Ohio. Thanks for all of your support and prayers!

An evening at Shyira with the Kings

Imagine you have found your way to the living room of the King’s house in rural Rwanda. It is 7:30 P.M. The sun went down at 6:00 P.M., and after 15 minutes of darkness and flashlights, the electricity came on at 6:15. Dr. Caleb is on the porch chatting with his visitor (though the visit was surprise, having surprise visitors is, actually, a matter of course around here). He is likely needing a signature for some official hospital business. Dr. Louise sits nearby, checking her email at the kitchen table, while two short-termers sit at the school-room table (just adjacent) surfing the web and checking their email. (The King’s have a satallite and therefore the best internet connection on the hill. Graciously, they allow visitors to come and sit in their living room most nights of the week to take advantage of their wireless.)

“Vrrmm! Vrrrmmm!!“ Caleb Jr. runs in with three paper-airplanes and making appropriate airplane noises. “No, mom, I haven’t brushed my teeth yet,” he says. Hannah King, his older sister, sits down beside one of the short-termers, browsing her Facebook account. “Who’s that? How do you know them? What other pictures do you have?” she asks, a better question-asker than most journalists. “Yes, mom, I already brushed my teeth. And flossed.” Dr. Caleb comes in and sits on the couch. The littliest King child, golden-curly-haired Lydia, crawls into his lap for the evening bedtime story.

“I’ve gotten an email from Sara!” Louise exclaims. “She’s wondering what to pack for her trip home next week.” Sara, the oldest King child, is currently a middle-schooler at a boarding school in Kenya. She will soon be coming home for a much anticipated visit. As the three children snuggle up next to their father on the sofa, you wander over to the packed bookcase and browse a few of the titles:

Storey’s Guide to Raising Dairy Goats…
Mountains Beyond Mountains, biography of Paul Farmer…
Pilgrim’s Progress…
Field Guide to the Birds of East Africa…
Looking After a Donkey…
Harrison’s textbook of Internal Medicine…
Biography of Gladys Aylward…
Mere Christianity C.S.Lewis…

Storytime over, Caleb Jr. begins running around in circles with his paper airplanes and a blimp made out of a balloon. Equally as inquisitive as Hannah, he ignores the ’BEDTIME!’ announcement and begins peppering you with questions: “Which do you like better? The blimp or the airplanes?…What’s your favorite mythical creature?…If you had a Greek god for your parent, which one would you choose?…Will you play capture the flag tomorrow? Pleeeeeeeease!?”

Suddenly, the lights fade and the short-termers expel involuntary sighs of disappointment at a last email not quite having finished sending or a Skype-conversation with a sister being cut short. The electricity goes off at 8:30 every night, along with the electricity-powered satellite connection. Laptops are packed up, thank-yous said, fully-charged lanterns gradually illumine in the hands of the King children, and everyone shuffles off to their respective houses, rooms, and beds. A final “Sqawk sqawk!” emerges from the porch-dwelling parrot…

* * *

The above is an example of a typical evening here at Shyira Hospital. Before I arrived, I could hardly imagine what living at a mission hospital in rural Rwanda would look like. One short-termer, arriving a month after me, exclaimed surprisedly, “But where’s the pit latrine?” after he was shown to his personal apartment complete with shower, flush-toilet, and kitchen help. Certainly everyone on “the hill” does not have a flush toilet, but this is one of the many technological advancements (another being the satellite internet connection) that have come to Shyira thanks to Dr.Caleb and his family.

Even without these modern-day luxuries, however, I suspect that most people would be surprised at the comfort and family-atmosphere of Shyira. I myself, having never met the King family before, was hoping to get to spend maybe a few hours a week with them and perhaps to win the trust of their children gradually. Quite to my surprise, from the first day the King family and their children included me in their daily life, from afternoon games to flute lessons to nightly internet and watching movies cuddled on the couch – Thank you, King family, for your seemingly natural and endless hospitality, joy, and love!

Left To Tell...the Truth? (Christmas Eve Reflections)

Last night I attended a Christmas Eve service with my friend Violette, a middle-aged Rwandan woman who teaches trauma-counseling workshops in churches around the country. I have utmost respect, appreciation, trust, and enjoyment of her, and often have said that I wish I could come back to follow her around, listen to her stories, and transcribe them into a book.

A few of you have read the book "Left To Tell," about one of the survivors of the genocide. Last night Violette confided in me that the pastor in the book who hid Immaculee was actually her [Violette's] father, that the woman weren't actually in the bathroom for more than a few hours (they were in another small but slightly larger room), and that there were many other fabricated, novel-esque, and manipulative details included in the book. Her father (who for many years never knew the derogatory content of the book since he only speaks Kinyarwandan) was very hurt when he found out. The examples Violette used were convincing. After parting, I was reflecting on the seemingly-inappropriate nature of this conversation for Christmas Eve, but yet at the same time on how central *truth* is to everything we celebrate. What, afterall, is the truth of all these events and histories? How can reconciliation occur if both sides sincerely (or insincerely) insist on different versions of reality? Regardless of the truth of either one of their accounts, I am amazed at how, despite the webs of lies and deception and manipulations and lack of insight we are entwined in, God still humbled Himself in order to RECONCILE us to himself, us who do not recognize or acknowledge half of the depth of our sin. His appearance of weakness as a baby allows now for His Strength to be made perfect in Our weakness. Grace.

Merry Christmas (Neheri inziza)
~Mary
Solace Ministries
Rwanda

* * *

A relevent excerpt from With What Remains: A Widow’s Quest for Truth in Rwanda, Lesley Belinda

“…Could I trust them? Was their version true? Were they intentionally missing out certain facts, or exaggerating others? Not knowing who to believe was torment…Was there perhaps some cultural element in the interpretation of truth? Coming from a western culture with a heritage of Greek dichotomy, my understanding of truth tends to be relatively clear cut, black and white. But to my understanding the African concept of truth seems much more fluid and relative. Much more important than absolute truth is the maintenance of community and relationship. Fostering harmony and peace --even if it means missing out or embellishing some of the facts --would always be more important than speaking out the full story, if that might cause hurt or offence…But betrayal is much more profound than just a different approach to truth. How hard it is ever to trust again when betrayal has been so deep. Yet this is the current experience of most Rwandans. If those with whom for years you have lived, worked and worshipped then betray you and murder members of your family, how do you ever trust anyone again?” (196).

“Discovering the truth can be shocking, but it can also be freeing. I realized this was part of the message the government in Rwanda was trying to impart to the population in relation to the Gacaca courts. ‘Ukuri kurakira’ proclaimed huge Gacaca posters along the roadside all over the country. ‘Truth heals.’ On the one hand I could endorse that now, having realized its impact in my own life. But on the other hand, when it came to searching for the truth about Charles’ murder, I knew full well that the process necessary to get there can itself be unbearably traumatic. Hundreds of thousands of Rwandans were having to make that choice in these days. Could they face putting themselves through such torment by reawakening the horrors of the genocide months? If discovering the truth could be the guaranteed end result, it might be worth the agony. But when the pathway to search for truth is strewn with lies and silence, intimidation and dead ends, and the reawakening of pain with no resolution, who would choose to follow it? Remarkably many have and still do, and for them the Gacaca courts have revealed details of the deaths of their loved ones, enabling them to unearth their remains and give them a dignified burial. Some kills have confessed to their crimes and there have been remarkable instances of reconciliation….But, for others, truth remains buried with their families…The resilience and courage of the vast numbers of women and children widowed and orphaned by the genocide humbles me to the core…” (132-3).

Kigali genocide memorial

A week ago, Natalie and I found our way to the Kigali genocide memorial. Free to the public, it includes outside mass graves containing over 250,000 bodies, an indoor exhibit detailing to history of the 1994 genocide in Rwanda, a memorial to children killed, and an exhibit describing a few of the other well-known genocides. Despite the many books, stories, and accounts I have read and listened to regarding the events of 1994, I still cried my way through the tri-lingual exhibit.

There have been many books written on genocide. There have been many memorials built, many classes taught, and many “never again” resolutions made. This entry is in no way comprehensive. Rather, it is a scattering of quotes and/or historical points I jotted down as I cried my way through the exhibit…

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Igiti kigororwa kikirigito
Un arbe ne peut etre redresse que lorsqu’il est jeune.
A tree can only be straightened when it is young
-traditional proverb
(I saw this saying posted on signs around the city and had been told it was referred to HIV prevention education. Seeing it prominently displayed in the exhibit and knowing that the youth played a prominent role in the slaughters made me ponder another possible application.)

Ukijije ubuzima bw’umwe aba akijije isi yose.
Qui sauve une seule vie sauve le monde entire.
He who saves a single life saves the world entire.
-Talmud

Igihe bavugaga ngo ‘ntibizasubira’ nyuma ya jenoside yakorewe abayabudi, bashakaga kuvuga ko bireba abantu bamwe gusa abandi bikabirengagiza.
Quand on disait “plus jamais” après l”holocauste, cela concenait a certaines personnes et pas d’autres?
When they said ‘Never again’ after the Holocauste was it meant for some people and not for others?”
-Apollon Kabatici

Ntabumuntu Buzabaho budatanga imbabazi ata mbabazi zizatangwa hatabayeho ubutabera ariko na none ubutabera ntibuzashoboka ubumuntu butariho.
Il n’aura pas d’humanite sans pardon. It n’y aura pas de pardon sans
justice. Main la justice sera impossible sans humanite.
There will be no humanity without forgiveness, there will be no forgiveness without
justice. But justice will be impossible without humanity.
-Yolande Mukagasu.

I yo uza kwimenya nianje uk ntagengwa feres iyani.
Sit u me connaissais et sit u te connaissais vraiment, tu ne m’aurais pas tue.
If you knew me and you really knew yourself, you would not have killed me.
-Felicien Ntagengwa

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-26,338 kilometres squares, 8 million people killed.
-300,000 orphans, 85,000 of which are heads of households.
-500,000 women rape victims (many now HIV positive)

-“There was no ethnic war. There was a civil war. But the genocide happened, and it was something different.” (a significant comment in that some politicians and/or history textbooks have chosen to refer to the events of 1994 as a “war” instead of a genocide. From my readings and research, the correct term is actually “genocide.”)

-Other genocides (not a comprehensive list):
Armenians 1915-1918 15 million (75% of their population
the Hereros 1904-1904 65,000 Herero people killed (80% of their population)
10,000 Nama killed (50%)
the Holocauste 1939-1945 6,000,000 Jews killed, 10,000,000 people forced labor
Cambodia 1975-1979 2,000,000 Cambodian Vietnamese, Buddhist monks, Chinese, Trais, Cham,
Muslims, the Kola (30% of the population), 95% of Buddhist temples
the Balkans 1992-1999 ethnic Muslims and Croatians
Bosnia 2,200,000 displaced persons. 200,000 Bosnian Muslims killed,
10,000 Kosovar Albanians, 1000s of Croations

Pictures were not allowed inside.
Here are some of the mass graves surrounding the memorial

Natalie looking at one of the mass graves with an open-view-window.
Notice the sign: "Please do not step on the mass graves."

Goodbye, Shyira!

Things I will miss most about Shyira:
-waking up to fresh Rwandan mountain air from our porch every morning
-sleeping in my mosquito net/tent (yes, it was a little romantic somehow)
-Rwandan hymns flitting through the air at random times throughout the day
-teaching “Medical English” to the hospital staff (they are SO motivated to learn English, it’s quite humbling)
-practicing my (poor) French (Excusemoi pour ma Francais trais faible!)
-Carina, the Kings, the Kohls, and the close ex-pat community
-Clementine, our cook and friend, and our constant game of charades to communicate. The day I left, she gave me a sweet present: a handwoven tapestry that said (in English, which she doesn’t speak): “We wirr be together in Heoven.” (In Rwanda they frequently confuse their “L”s with their “R”s, which made it even MORE special.)
-Walking forty-five minutes to the nearest market on market days
-Fresh fruit everyday, an infinite supply of mini-bananas, and the smell of fresh-baked-bread three times weekly
-the children

Things I (so far) have not missed:
-rounding on patients who still hadn’t gotten the medication I ordered on them three days before
-asking the lab about lab results that were supposed to have been finished days earlier
-struggling to communicate with the nurses about life-or-death patient issues
-unreliable internet connection (although it was freeing)
-“The man with the key has gone.” Self-explanatory, I think? (Also supposedly the name of a book about Africa (Ian Clarke - author). I will be buying it promptly upon my return home.)

Some Rwandan History

For those of you who aren’t aware, fourteen years ago in 1984 Rwanda underwent a massive scale genocide. While American television was discussing the OJ Simpson scandel, Monica Lewinski, etc., 800,000 Rwandans (in particular the Tutsis, one of the three ethnic groups in Rwanda) were slaughtered over a mere one hundred days. What some people are not aware of, also, is that both before and after the genocide, there were various other fightings and killings, from both sides of course. Many people I have talked to have listed parents, spouses, children, and friends killed at various times. Because the majority population in the region of Shyira is Hutu, many of them have had family members killed in the years after 1984.

Since coming here, I have discovered that now in Rwanda, people rarely if ever say the names “Hutu” or “Tutsi” out loud. They say “Rwandan.” On the day of my arrivalI was advised that, if I must refer to the two main ethnic groups, it is best to say “the majority group” or “the minority group.” Otherwise when I talk people will hear only a foreign language (English) with these two very loaded words occasionally thrown in, and they can start to think I am saying something derogative. It is better to not give the wrong impression. Indeed, since arriving here I have felt like I talked more about the genocide at home before I came then I have here in Rwanda. Once, in the middle of a conversation, a nurse replied in answer to a question from me, almost in passing: “Well you know we had a genocide here, and after that…” blah blah blah. I was a bit shocked (and relieved) to hear someone say the word.

I’ve been told that this seeming-silence is not a year-around-mandate. Every April (April 1984 was the beginning of the “100 days of terror,” during which 10,000 people were killed everyday), the country goes into “100 days of mourning.” The “events” of 1984 are supposed to be a fairly open discussion topic in schools and in public, for the purpose of mourning for those who died and, hopefully, prevention of any sort of recurrence. Unfortunately I will not be in the country this coming April. I wish I could be.

"Why should I help this one person?...I can't believe I just said that." ~from Blood diamond (the movie

"My donkey stepped on someone and I have to check on them!" With that, Dr.Louise raced out of the patient consultation room, leaving me with the patient, nurse, and Dr. R, one of the better English-speaking doctors here at Shyira Hospital. "Does this happen often?" I asked, hoping to break the silence. "No," replied Dr. R unconcernedly, "most people wouldn't do that. It's just because Dr. Louise is, well, how do I say…Dr. Louise is nice." "Ahh, I see" I said, smiling to myself. Though I still knew nothing about the statistics of donkey-induced injuries in rural Rwanda, the answer I got was just as interesting.

Drs. Caleb and Louise King value individuals. An HIV-positive boy used to return repeatedly to the malnutrition center after continual relapses. The Kings got to know him, took him home, and now he is part of the King family and thriving. A few years ago, they got a phone-call from a woman desperate to get rid of an unwanted child; now "Moses" is 6 years old, included in every King family activity, and on the verge of adoption by their cook. Many short-term visitors (like myself) come for one, two, or three month sojourns at Shyira Hospital; they are issued a standing invitation to dinner most-nights and are welcomed into almost every family event or game. And one morning a man is stepped on by a donkey; within the hour, he is personally attended to by the donkey's "Umuzungu" (white man) owner. What do all these anecdotes have in common? Drs. Caleb and Louise King value individuals.

This dialogue touches on a larger public health issue – in a world with limited resources and multiple problems, how do we choose what to spend our limited money on and what to not spend money on? In my medical school ethics class, public health was often used to discuss the opposition between advocating for the anonymous masses vs. the pleading individual. Of course, the so-called "anonymous masses" are made up of pleading individuals in desperate need. But if one person has limited resources, say $1000 - should they spend it on vaccinations for 100 children to prevent deadly childhood infections? Or should they spend it on keeping one premature baby with a heart defect alive in the ICU for 2 weeks, after which point chances are high that he would die anyway?

Certainly there is no simply or easy answer to this question. Many people focus on the suffering premie but seem unable to comprehend the delayed ramifications of non-vaccinated children. Other people advocate passionately for public health policies while appearing cold to such individual cases. I hope, were we able to analyze the hearts and motives of people belonging to both groups, that they would both be motivated by compassion, desire to relieve suffering, etc. Personally, I tend to lean more toward the "public health" mindset (the greatest good for the greatest number so to speak). I am frustrated when my fellow pro-lifers focus only on the "unborn" without acknowledging the suffering homeless living under the bridges, the malnourished in Africa, or even (dare-I-include?) the recalcitrant alcoholic that few doctors or people enjoy treating. Certainly we must 'choose our battles.' But how much of our "battle-choosing" is based on prejudices and biases we can't even begin to fathom? (As a side-note, this was certainly that the case in Rwanda - because the colonial powers preferred the nose and face shape of the Tutsis, they began planting the seeds that eventually led to genocide.)

All that being said, I have had various patients both at home and during these few months in Africa that I found myself caring more about and, therefore, going the "extra mile" for. As a surgeon may be drawn to a traumatic injury requiring sutures, I found myself drawn to a malnourished women with depression, a new-onset schizophrenia, a woman with post-partum depression, etc. Does the fact that I find myself naturally caring more about them make them more valuable? Certainly not. Several of my pediatrician friends tell me that they enjoy pediatrics more than adult medicine because, while most adults seemed to have problems of their own making (smoking, alcoholism, obesity, etc), children are rarely culpable in their diseases. Superficially this seems reasonable - I have certainly beat my head against many walls for all of the times I saw adult patients return again and again to the hospital for problems of behavior. Certainly the unborn baby is more innocent of all the things that most annoy and offend us about the alcoholic - it has not drained societies resources, it has not spent time in prison from some alcohol-encourage crime or in the hospital from the fifteenth episode of D.T.s. Yes, an unborn baby is more attractive and even more innocent. But is the unborn baby somehow intrinsically more valuable then the adult alcoholic?

I do not think the value of a human being comes from his or her skills, abilities, expenses, or even whether it does good or evil. I believe our value comes from how God sees us, and since He wants all of us as His sons and daughters and friends, He sees us all as infinitely valuable. But of course God also does not have the issue of limited resources that we tend to have. Even if I see every person as being equally and infinitely valuable, how do I choose to help some and not others?

And on a macroscopic level, what motivates health policy— Quality of life? Expense? The "Greatest good for the greatest people?" Value? Or perhaps it more practical than philosophical – limited resources? Immediate gratification? Acute care issues? Supply & demand (i.e. the people with the most money give to their personal interests and not to others)? Is that so wrong? Is that, afterall, any different than my having certain patients I am more drawn to than others, or the Kings taking special care for certain patients that would never be feasible for everyone?

There are no easy answers to any of these things. It is encouraging to me, however, that missionaries and medical workers in Africa are able to somehow balance the two. I hope personally that I can be, as much as possible, an advocate for those who are unable to advocate for themselves. I want to value the individual and not be afraid to go above and beyond for individuals, while still advocating and focusing on the needs and suffering of the multitudes. Jeremiah, a Hebrew writer, prophet, and poet wrote a beautiful description several thousand years ago, connecting knowing God with helping the oppressed.

He defended the cause of the poor and needy, and so all went well.
Is that not what it means to know me?" declares the LORD. (Jeremiah 22:16)