Our God is a Consuming Fire

"All things were created by Him and for Him. He is before all things and by him all things hold together...[and he will] reconcile to himself all things, whether on earth or in heaven, making peace by the blood of his cross." Colossians 1: 16-20


I have to confess that more often than not I feel like God is absent from my world. I come from a solidly Christian tradition and I live in Nashville, so I probably would never verbalize that sentiment to anyone face-to-face for fear of being found out (there is much freedom that comes from the anonymity of a blog post!) In my past I have wrestled with questions of faith repeatedly, and through cognitive deliberation and experiential confirmations I have landed squarely on the position of faith in a loving God who made provision for my sin through the perfect sacrifice that bore the wrath of Love that had to fall on sin. However, I constantly feel as though the biblical passage I most relate to is from Mark 9, "Lord, I believe... but help my unbelief!"

Most recently I have struggled to believe that marriage really IS the sacrament that we are told it is in scriptures. As life gets busier with two kids and two jobs and financial burdens and differing expectations in multiple arenas it has felt as though my wife and I are growing more and more distant rather than closer together. Bitterness has begun to creep in. I feel like I'm ALWAYS giving and never receiving. Why don't I get to pursue MY dreams any more? (of course I always decide to ignore the fact that my wife gives FAR more of herself for our family and our kids than I do!) I thought marriage was going to bring me closer to an understanding of the love and fulfillment and joy that we are supposed to be able to find in God?

I have also struggled to believe in the goodness of God... or the soveriegnty of God. And, really, both. It seems like all I do recently in the hospital is give patients and families bad news. In one week recently I had to tell three patients that their condition was irreversible and that even our modern medicine had nothing to offer them for their conditions. I had to tell several other families whose loved ones were on life support that there was nothing we could do reverse their disease processes. We ended up withdrawing life support on three patients in as many days. I have come to be somewhat immune to suffering and death, but that week I wept in the face of so much suffering.

My best friend lost his sister to a rare cancer when she was in her twenties and his father to a massive heart attack several years later. He called me recently to tell me he was recently diagnosed with cancer himself.

In the past week images of death and destruction from Typhoon Haiyan have inundated us and I wonder where was God for them?

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But God has a way of pursuing his children and he has been pursuing me. In the midst of unbelief and bitterness several separate instances took me to Hebrews 12 recently. Coming out of a chapter listing all of the faithful followers of Christ in ages past who endured all kinds of suffering and trials Hebrews 12 encourages us to follow their examples and run the race set out for us in this life with endurance. How? By "fixing our eyes upon Jesus, the author and perfecter of our faith" who endured everything we will possibly be asked to endure and more by focusing on "the joy set before him", i.e., union with God the Father. Jesus, our savior, conquered sin and evil and has now taken his victorious and rightful seat at the right hand of our Father. As Colossians reminds us, Christ has done the work of reconciling all things to himself... though we still have yet to see the full effects of that reconciliation.

And so the author goes on to encourage us to consider the sufferings we encounter as "discipline" in the way that a parent disciplines a child. Not "punishment", but rather a "building up" or a training exercise. How often have I been bitter or angry at God for the "discipline" he inflicts upon me? And yet have I ever gone the next step and considered that the only parent who does not discipline his or her child is the parent who does not care about how his or her child turns out?

I must daily... even minute by minute... remember the grace that was lavished upon me in my spiritual "adoption" as a child of the King of Glory. The only way to "see to it that no bitter root sprouts up" is to meditate on the wonder of God's grace and love. Meditating on the greater and deeper truths of life put things in their right perspective. The truth is that there is immense suffering and injustice, just as there is a God who is sovereign and full of love and compassion. If I meditate on the suffering and pain and evil, God's love and justice become small in comparison and it becomes impossible to reconcile the existence of all together. If I meditate on the Holiness and Justice and Love and Grace of God then I CAN reconcile the subservient truths of temporary injustice and suffering and evil.

In my personal life in the last two weeks God has already begun doing a minor (or not so minor) miracle in redeeming my marriage. Ever since we started meditating on some of the bedrock scriptures that encourage us to fix our eyes and thoughts on God and his lavish grace upon us through Jesus Christ we have been experiencing a closeness that has been absent for many months. We have confessed some of our burgeoning bitter roots. We had some tears and long, hard conversations... and though NOTHING has changed in our life circumstances we have experienced a very real change in our marriage. I can say that in the past the harder I have tried to change my marriage from sheer willpower I have only made conditions worse. I am certain that the change we have seen in the past weeks has been a supernatural change that has come from God himself. (God, thank you for helping me in my unbelief!)

These are the greatest truths in life and only in light of them will everything else in life make sense: Before the cross of Christ the glory and holiness and justice and love and permanence and pre-eminence of God were things to be feared and desperately avoided because they could only culminate in our obliteration. But once these attributes were "sprinkled by the blood" of Christ who bore the wrath of God in our place, the character traits of God we once could only fear became the aspects of God that welcomed us, his now-adopted children, into a "celebration of thousands of angels in festival gathering" and a fellowship of all of the faithful (yet broken) people who endured and believed before us now made perfect because of the blood of Christ! Ultimate despair became ultimate hope by the power of the spilled blood of the perfect sacrifice.

And in light of those truths the author of Hebrews closes chapter 12 with a reminder that speaks volumes. "Our God is a consuming fire". We can rest assured... even when our doubts come back up and life seems to overwhelm us again... that "all things were made by Him and for Him" (re: colossians 1). The fire of the almighty creator of heaven and earth will, one day, consume and destroy all evil and those who choose to deny the truths of goodness and love for earth's fleeting pleasures (as Esau did in giving up the treasures of God for one meal). Oppressors, doers of injustice, murderers will be consumed and destroyed. But on a positive note, suffering will also be consumed and transformed into pure gold. He will consume and subdue the destructive powers of mother nature. He will consume my friend's cancer. He will consume all of the suffering and loss that my patients and their families have had to endure in recent weeks. He WILL gather all of His creation... men and women, beasts of the fields and birds of the air and all swimming creatures and even the air we breathe and He will make it new IN HIM.


God, be what you are in all of its glory in My life! Consume everything about me, may all that does not fall in line with you be burned away never to return and may all that is good and pure and true in YOU be refined and enabled to grow and blossom into all that You have designed it to be. Amen.

The Light of the World...

A few friends and I have been slowly making our way through Martyn Lloyd-Jones' book "Studies in the Sermon on the Mount". Without a doubt one of the best books I have read in a long time and I highly recommend it. Martyn Lloyd-Jones has a unique ability to dive deep into the text and provide profound exposition in a manner that is refreshingly relevant and conversational. We have come today to the chapter "The Light of the World" and as I sit and reflect I realize that this was just what I needed to read as I enter into the Advent Season.

"You are the light of the world". I have heard this phrase so many times in my life that it has become just another cliche. But MLJ urges the reader to consider the profundity of what Jesus said with this statement. The "you" that Jesus was referring to here were simple working-class commoners. They had no specific talents or knowledge or skills that would set them apart from anybody, and they certainly did not have the positions of power that all people of all ages have felt essential to bringing true and positive change to a culture.

We live in an age in which knowledge is held in the highest regard. Since the Enlightenment when the Greek classics and systems of thought were rediscovered and expounded upon, and particularly in the last two centuries, knowledge and in particular science has dramatically changed our world. Many feel that it is the advancement of knowledge and its effects that will ultimately transform our society into some sort of utopian ideal. And yet we have in no way seen that happening. Certainly in some ways the advancement of knowledge has provided great improvements in health, standards of living, etc.; but are we any better at loving each other? Is peace any more prevalent than it was 2000 years ago or even 50 years ago? While individuals are certainly connected electronically in a way that most of us never would have imagined... the argument could be made that our society as a whole is less connected to deep and lasting relationships than ever before.

As MLJ points out, Jesus certainly was aware of the "amazing flowering of the mind" that had occurred with the likes of Plato, Socrates, and Aristotle only several-hundred years before he stood on this hillside facing a group of fishermen, farmers, and tax collectors and declared them to be, "the light of the world".

A mere passerby might have easily dismissed Jesus as a lunatic upon hearing this. Indeed the thought routinely pops back into my own mind! If these men were anything like me, they were selfish, cowardly, insecure beings who spent much of their time and energy just trying to stay afloat in life, much less bringing light to a world stuck in the darkness of sin! I imagine that the disciples themselves certainly were pessimistic regarding this outlandish claim about them. In fact they may have even forgotten, over time, that Jesus had declared them "light". But as Jesus lived and walked among them his very presence did the impossible act of bringing light and healing and joy into their OWN hidden areas of darkness in their OWN hearts. And history shows us that these ordinary men truly did become great lights that have brought about great transformations in the HEARTS of people throughout history (an area that knowledge and technology has still not been able to penetrate).

How did these first disciples remain faithful followers to the end...even to the point of becoming martyrs? How difficult is it for US to remain faithful even with thousands of years of evidence of the truth of Christ's claims to rely on! The only explanation for the complete transformation of the early disciples was that the power of living and walking with the Light of the World was so completely transformative that they were irreversibly and indefinitely changed at the very core of their being.

Though mankind had lived in darkness for eons before the coming of Christ they did not know it. "The people which sat in darkness saw a great light". It was when the true light of the world came to dwell among us that we realized just how mired we as humans were in darkness. As we begin this advent season may we invite God... the Light of the World... to again walk with us in all of the hidden and unkempt areas in our lives. May we see with more clarity the areas of our lives that still are awash in blackness, and as we proactively spend time basking in the beautiful Light of Christ this advent season may we further be transformed into beings who more accurately reflect that light into the world around us.

Majesty

Last November a good friend of mine and I happened to have a few days off at the same time and decided to head out to Yosemite. Neither of us had ever been there before but had always heard its praises. After landing in San Francisco we momentarily re-thought our backpacking plans when a we saw that a storm front had beat us to the Sierra Nevadas, but instead we decided to just buy some gear for the possibility of snow (leaving the tags on, of course, so we could return the items we didn't use!) and headed to the interior.
Even from miles outside the park excitement welled up within us as the distinctive profiles of El Capitan and Half Dome appeared through alpine passes. Fresh snow drifts were evidence of the previous night's snow storm that, to our great surprise, chased almost every other backpacker out of the park for the week. Indeed, after passing the small crowds at the park entrance and a few day hikers on the first day, we did not see another soul for three days. We spent a the first night camping with a spectacular moonlit Half Dome as a backdrop. On the second night we enjoyed the warmth of a bonfire on the icy shore of Merced Lake where we were blessed with a spectacular sunset.







On the final night we again camped with Half Dome keeping watch over us and on the final morning we ascended Half Dome where we sat and took in brilliance as the cool breath of God Himself gently reminded us that we were privileged guests in the house of the Almighty.




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As we made our way back into Yosemite Village past the now large crowds enjoying the last 70 degree day of the year I was completely spent. My thighs burned under the weight of my pack with each downward step. I was struck by the life lesson that I was being taught: It is easy to be satisfied in this life with the small delights that are easily obtainable. However we must understand that it is when we choose to walk the difficult road, set ourselves to the hard climb, and endure the cold and sometimes bitter nights that we will find unexpected and incomparable joys that only come from the hand of God.

Beautiful Africa

Ever since my last trip to Africa eight years ago I had wanted to one day visiting Ngorongoro Crater, which I had not been able to visit on the previous trip. Throughout this stay in Tanzania I had been looking forward to spending several days on safari to cap off the adventure before heading home. Truly the landscape and wildlife in East Africa are awesome, and Serengeti National Park and Ngorongoro Crater did not disappoint. It is quite spectacular to see the sleek form of a cheetah blended into the surrounding grassland as it rests in the cool of the morning.


There is something soothing and yet terrifying about watching a group of hippos lazily floating in a mirky pond and being reminded that this creature is responsible for more human deaths each year than any other African mammal (except perhaps the Cape Buffalo).



But as incredible as the wildlife is and as beautiful as the a sunset over a grove of acacia trees can be, when my hard drive crashed just before heading back home I found myself worrying more than anything that I may have lost some or all of the most beautiful aspects of Tanzania that I had been able to get on film: its people. We in the West hear only of the conflicts and turmoil in Africa through the media. We read about the civil wars and the corruption and international power struggles and because those are the only things we hear and read about Africa remains in our minds "the heart of darkness" populated by savages and run by power-hungry despots. What we don't read about are the millions of powerless and voiceless people who live a daily struggle to survive and do it with dignity and grace. We don't see the women who juggle several small kids and the responsibility of preparing meals and the crops that need to be tended to and still are able to somehow enjoy the simple moments in life that people with more material distractions would fail to notice altogether.




It is true, however, that a life of constant struggle takes its toll on many. Many faces become wrinkled and weathered far before their time in Africa. There is a fatalistic attitude that affects many in the older generation because they have come to realize that no one seems to be for them in their struggles- often times not even their own leaders. The fact that in only several weeks in the Bugando ICU I saw several people admitted in critical condition from suicide attempts is testimony of the fact that the struggles in life for the average person seem at times insurmountable.



Some adults have been beaten down so much that they seem to have lost the zeal for life. But one need not search far to find where that zeal found a place to dwell: Africa's children. To hear the high-pitched laugh and see the beautiful smiling face of a child playing tag in front of the simple mud hut in which he lives is to learn an invaluable lesson: if you can learn to be content with nothing but the most basic necessities in life there is nothing that can defeat you. There is in the eyes of these children a simple joy... and if one looks deep enough he can catch a glimpse of hope that a generation will rise that will not fall into the fatalistic mindset that seems to come with continual trials, that will break the cycle of corruption in leadership, that will have access to education and resources that will help them figure out their own answers (with the global community's help) as to how to overcome the obstacles that keep their people entrenched in poverty and hostage to disease and famine. These are the beautiful eyes of Africa.

A Woman's Life

Several weeks ago I was standing beside a patient bed in the pediatric ward at Biharamulo Hospital and I happened to glance down at the floor. I had become used to the malodorous fragrances ever present in the hospital by this time. It no longer surprised me to see a patient squat on the floor to defecate during patient rounds. The sight of cockroaches scurrying to find cover under a patient's bag of clothes now seemed commonplace. What caught my attention this day were the bare feet of the mother who was silently sitting on the side of her child's bed as the group of white coats discussed the intricacies of the case in a tongue completely unintelligible to her. I did not know anything about this woman and still I don't claim to understand the complexities of her life, but even without her saying a word her feet revealed much about her and her and her way of life.


She lacked shoes...even the $3 red or blue plastic sandals that are ubiquitous here... most likely because with 4 or 8 or even 10 children to provide for, shoes were a luxury that she could not afford. Without protection from earth and elements her soles had become calloused from long treks over gravel roads and uneven footpaths, often baring the load of not only her own body weight but also the weight of the baby strapped to her back and the bundle of firewood or bag of cassava or bucket of water that she balanced gracefully atop her head. Alternate exposure to dry, dusty paths baked by the intense morning sun and then to a myriad of tiny rivers or pools of muddy water that arise within minutes of the first drops of rain from an afternoon downpour in the rainy season had left her toes and heels dry and cracked. Bruises and scrapes in various stages of healing gave witness to the difficulty of traversing even the most well-known paths in the deep black of shadows of a night with no moon and no street lights...indeed no true street...for hundreds of kilometers. The thick musculature of feet and toes were evidence of the long hours she spent trudging barefoot through muddy fields of rice or maize or potatoes in order to provide food for her family... and hopefully enough extra to make a small profit selling the surplus in the market. She probably was ignorant of the fact that the incessant, though not severe, itching of her feet was due to the tiny hookworms in the soil or the schistosomes in the pool of water where she baths and washes her clothes that penetrated her skin en route to their new living quarters in her gastrointestinal or urinary tracts. Hers were the feet of one who has worked tirelessly, and with little fruit to show for it besides her remaining living children, ever since she completed her government-sponsored primary schooling and realized that she would not be able to attend secondary school (high school) because her family only earned the equivalent of twenty dollars a month and could not afford to pay for further schooling (if in fact she even completed primary school). Her feet had carried the weight of a new infant every year since she had been given in marriage because as a woman in her culture she had no liberty to refuse her husband's advances, and because birth control methods were too expensive or not available and even if she had access to them her husband would likely frown upon them because for him more children meant more respect and higher status.


Her feet were the feet of a woman who understood more fully with each new Land Cruiser that sped by her as she traversed the main road leaving her enveloped in a cloud of red dust, and with each copy of Glamour magazine that somehow made it to her village, that her degree of poverty was unimaginable to many people in more developed countries. And yet they were the feet of a woman who was proud...she walked with head held high... and so refined that in addition to all of her other work she somehow found the time and energy to make sure that her dress and sarong were so meticulously cleaned that when she brought her child to the hospital one would think she had just purchased a fine new wardrobe and would never guess that her day had started in an overcrowded, single roomed, mud-brick house in which she slept on a mat on a dirt floor.




These were the feet of a survivor, of one who has had no choice but to be a survivor because she happened to be born in a poor corner of a poor country on a poor continent where climate and microbiology and economics and a long history of international power struggles have left her and millions like her to bare the brunt of the world's burden of poverty and disease and suffering. I have struggled to try to figure out what is my role...if any...in her story and in the story of a hundred men and women like her that I have passed every day while I have been here in Tanzania. My time here has been rewarding and I feel that it has been valuable if for no other reason than to be reminded that there are a multitude of people who are innately just like me whose entire lives are characterized by struggle and suffering. By no means has everything about my experience here been depressing though. I have had the pleasure of seeing people who are suffering smile and laugh and somehow enjoy simple pleasures that I would have overlooked completely. If I close my eyes the sweet laughter emanating from a group of children in tattered clothes playing with a ball made of wrapped twine in a filthy slum is indistinguishable from the sounds of a similar group in the latest fashions playing in a posh playground in Manhattan. In fact when I open my eyes the sound rings even sweeter. In spite of the pain and the tears that abound there is vibrant life here. Even the clothes people where seem to celebrate life and color. When there is occasion to smile people do so unabashedly and with no self-conscious thought of their crooked tooth or their sun-leathered face...and their smiles are the most beautiful you will ever see!




I feel uncomfortable in this place not only because I don't know the language or the cultural nuances but because it makes me confront difficult questions like is it wrong to take this woman's photograph- even with her permission- with a camera that cost more money than her family will make in three years? I make myself feel better by giving her a copy of the picture. She flashes a radiant smile in response to the gift and I am struck by the fact that her beauty would rival that of most models in Europe or America. What does it say about me that I somehow feel proud of myself for having done my part in making her life a bit better by going out of my way to give her this generous gift? The copy cost me twenty cents.

The Front Lines

Biharamulo district is located in the fertile corridor of Tanzania that lies to the west of Lake Victoria and is home to roughly 400,000 people. It is one of the least developed regions in Tanzania. Agriculture (mostly bananas, coffee, cattle, and goats), fishing, and mining are the main industries in the district but a large portion of the population survives by subsistence farming- though some may be able to make a small profit in a local market if the rains make for a good harvest. For many years Biharamulo district hospital was the only hospital for the entire population. There is one medical doctor employed by the hospital, who also serves as the medical director. Due to the overwhelming patient burden, several years ago the responsibility for health care delivery in the district was split between Biharamulo District Hospital and a hospital in a neighboring district so that now the hospital...and the one medical doctor in the district...is responsible for the health of only approximately 200,000 persons. This ratio is, of course, much higher than the average doctor:patient ratio in Tanzania, which is 1 to 25,000. In the United States there is one doctor for every 400 people.

Five assistant medical officers (AMOs) and a handful of medical clerks are responsible for most of the medical diagnoses and treatment plans in the hospital, which has 130 beds though many times more than one patient may be admitted to the same bed. AMOs receive three years of training after secondary school (high school) to become medical clerks. After working for several years in health dispensaries around the country (treating basic medical illnesses like malaria and pneumonia and referring more difficult patients) they can choose to return for two more years of training at one of the teaching hospitals to become an AMO. At Biharamulo and elsewhere they are responsible for just about everything that has to do with patient care. They make diagnoses, decide on treatment plans, perform procedures such as lumbar punctures or pleurocenteses. They run the HIV specialty clinics and do most of the operations in the hospital including cesarean sections, hysterectomies, appendectomies, and even bowel resections. Although he is often pulled in three directions at once due to his administrative duties, the medical doctor makes "major ward rounds" in each of the wards one day a week, during which he sees each of the patients on a given ward, and will help with difficult patients or some major operations whenever the need arises. Medical officers are in short supply, but the nursing shortage is so severe that a ward of almost 70 patients may be staffed for much of the day by only one "assistant nurse" who has had only one or two years of training after secondary school.

Malaria is by far the leading diagnosis in the hospital, followed by severe anemia which is often secondary to malaria. Malaria is so common and complications so severe that it is a national guideline that any child younger than five years old with a fever should be empirically started on antimalarial medication. Because falciparum malaria is the most prevalent species of the parasite in the region "cerebral malaria" is a common complication of malaria in children here and manifests as neurological complications including strokes and swelling of the brain as a result of red blood cells becoming lodged in the small cerebral vessels. Most children who develop this complication do not survive. Pneumonia is another common diagnosis in patients of all age ranges. Diarrhea is a very common complaint and may be simply viral and self-limiting, bacterial and requiring antibiotics, the result of intestinal worms of various sorts that are ubiquitous here, or all-to-commonly the presenting symptom of HIV infection which has a prevalence of about 10% in the region. There are a significant number of patients with TB in the hospital, but surprisingly there were only 98 documented cases of TB in the entire district last year. Meningitis is very common and usually presents very late. In a matter of two weeks I saw three cases of meningococcal meningitis (a very contagious form of the disease) in children, one case of meningitis that presented in such a severe stage that when I did the lumbar puncture to look at the spinal fluid I had to use a syringe to draw the fluid out (usually it flows like water) because it was frank pus, and another child who had presented with such severe meningitis that I had to tell the AMO who was about to do a lumbar puncture that if he did the procedure the child would die right on the table- the child was unconscious and had one blown pupil and one pinpoint pupil which is a sign of severe brain swelling and doing an LP would cause the brain to herniate into the spinal canal due to the pressure gradient. Traffic accidents are extremely common presenting with all types of injuries including complete quadriplegia. Post-partum hemorrhage, hypertensive emergencies, strokes, diabetes were also seen. All too often we had to just give our best guess at a diagnosis because we did not have the lab capabilities to do the tests that would be needed to confirm or deny our hunches.



I was impressed by the scope of the responsibilities held by the medical staff, and I learned much from not only the medical director but many of the AMOs as well, especially about diseases such as malaria and TB and HIV that I have limited exposure to. However it was apparent that the work load was simply overwhelming. In each of the wards (pediatrics, female, male, and surgical) all of the patients are only seen once a week. On other days only the sickest patients are seen. Unfortunately if a nurse is not trained enough to pick out worrying signs or symptoms, or if a parent is unable to differentiate a soundly sleeping child from a child with a decreased level of consciousness, a very ill person may be missed. A number of times when I walked through the wards just to see if there were any sick patients that had been missed I came across florid meningitis or severe malaria that had been missed. At first my frustration was toward the nurses, or the AMOs, or the parents for waiting so long to bring their children to the hospital...but slowly I began to realize that my frustration ought to be directed towards a system as a whole (not just the Tanzanian health system...a system which we are all a part of in some way) that leaves families so poor that even the money it would take to travel to the hospital would mean that they would go without food for a time, a system that only provides one partially trained nurse to care for 70 people, a system that can pay its overworked doctors only $10 dollars a day, a system that provides only one fully trained medical doctor for 200,000 people.

But somehow in all of the overwhelming workload and disease and mournful cries of mothers who just lost yet another child...there were smiles like this one that greeted me every morning when I entered the pediatric ward...and those smiles gave me hope that maybe things will improve for these people who have waited long enough...

Biharamulo

It is only about 150Km as the crow flies from Mwanza to Biharamulo but the exhausting trip takes about 7 hours if everything goes smoothly, which is never something to be counted on. The trip begins just after sunrise at the shore of Lake Victoria, for the first leg of the journey is a 30 minute ferry ride that saves a 3 hour jaunt around a narrow inlet of the lake that extends south for a significant distance. On a clear, calm morning the ride across the lake is absolutely serene...but the serenity is short lived because if you fail to find your seat in one of the buses packed onto the ferry before the vessel reaches its destination on the eastern shore you are sure to have no option but to take the return trip on the ferry. As the boat approaches the bus engines are already running and almost before the ferry even stops each bus driver has his foot heavy on the accelerator and the steel monsters speed off down the uneven, unpaved, pedestrian-filled road eventually splitting to head off towards their individual destinations. The bus is already full, but the two conductors hang half-way out the open door looking for passengers that may be waiting alongside the road for the Zuberi bus, hoping that it did not break down or miss the ferry because if it did their plans to reach their destination will be canceled and they will have to try again tomorrow. As more passengers are picked up the remaining seats are filled and then the open space in the isle is utilized. Some passengers are in for the long haul all the way to Biharamulo. Some just catch the bus for several kilometers. Most have a small suitcase or duffel in their possession. Some have sacks of cassava they are taking to some town's market. One may have some chickens or a mirror or wheel of a bicycle.

At times the ride is relatively smooth. In fact there is even a several kilometer stretch of paved road at one point. I don't know why that particular stretch is paved, but it is very welcome. Most of the ride is over a washboard road and you will think your retinas may detach if there is no relief soon. The driver does his best to pick out the least traumatic line on the road, and since his vehicle is the largest on the road it does not matter if that line is on the right or the left or in the middle of the highway, everything and everyone else must make way for the king of the road. If you are not used to travel in East Africa you had better receive cardiac clearance from your doctor before taking the trip because even a healthy heart will threaten to stop beating a handful of times as the bus comes frighteningly close to colliding with oncoming vehicles or bicyclists that fail to yield right-of-way (which usually means careening headlong into the tall reeds at the edge of the road because the bus driver usually wants to drive with one set of wheels actually on the smooth "shoulder" which is usually on the "wrong" side of the road). At least a time or two along the way you will pass a broken-down vehicle with three sets of legs protruding from under the engine block and at least five people looking on. Occasionally the most talented drivers may display their superior skills of trail blazing and then take a lunch break while many gather to admire his handiwork.


But for the most part the road is remarkably devoid of other vehicles. There is no in-flight movie but neither the talents of Brad Pitt nor Angelina Jolie have the captivating power of the scenes playing across the dusty windows on either side of the vehicle. The rainy season has turned the countryside into fifty shades of green. Birds ornamented with long flowing tail feathers or bright red breasts bounce between the acacia trees. Further down the road groves of banana trees provide shade for small circles of mud huts with a few children playing on an old termite mound in back. All along the way men pushing large banana stalks on bicycles or women carrying buckets of water on their heads or young men herding their cattle with a bamboo rod fill the road and part like the Red Sea at the sound of the oncoming behemoth.



Twice during the trip the bus stops in fairly large towns. Immediately people selling bananas and sodas and roasted goat strips and pineapples encircle the bus and lift their goods up the the windows to advertise for the passengers. There is just enough time to run out and use the toilet...unless you are a Muzungu and you neither know where the toilet is nor how to understand their directions when you ask, "Where is the toilet?" in Swahili. So you hold it or you somehow find the toilet and return to find the conductor, who fortunately noticed that the only white person on the bus was missing, yelling out to you, "This...express bus!"

By mid-afternoon the bus finally pulls into the town of Biharamulo. You step out and stretch your legs and push past all of the people trying to carry your bags for you as you tell them, "No thank you, I can walk..." and make your way to the hospital where you will spend the next few weeks.