Wednesday, November 18, 2009

And What About the Barber Shop?

The topic has come up at almost every seminar we've done: "What about the barbershop?" Do barbers, through their scissors clippers and other instruments for cutting hair, pass HIV? For many of us this requires some cultural awareness, if not sensitivity. The folks at our seminars generally have very short hair. Some of them shave their heads to avoid the problem of those little, curly hairs heading back toward their point of origin and causing all sorts of problems. And when folks get their heads shaved, they almost invariably get cuts. "Couldn't this spread HIV?"

Well, surely someone has thought of this, but I've never read anything about it. So in Zambia, in 2005, I went to the barber shop one afternoon in downtown Lusaka for a cultural awareness session. With the head barber's permission, I just sat there and watched two or three men get their hair cut by the same barber. Straight razors were not used, but clippers, electric clippers (there are also similar hand-powered clippers used in the bush) consisting of a row of tiny fixed blades coming to a not-so-sharp point, paired with a set of moving blades crossing over their fixed partners very rapidly. Think of 10-15 (I didn't count them) pairs of tiny, adjacent scissors with one blade moving really fast.

Now, these scissors, the blades on the clippers, are normally not just hanging out there. Usually they are separated from the scalp by a plastic guard which can be from either a fraction of an inch to several inches long such that they only cut hair. But, when the objective is a truly shaved head, then the guard must go. Now the blades are directly on the scalp, and any irregularities in that scalp might find themselves in the teeth. And so they do.

As the barber worked across the scalp, first using the shortest guard, then going over once leisurely without the guard, then carefully and tightly trying to get all remaining stubble off the scalp, I periodically saw the customer flinch, jump, express through total body language not unlike being electrically shocked his very short-lived but very evident pain at being cut. Usually two to three times per hair cut. When the customer was finished, after payment was made, the barber picked up a squirt bottle of purple liquid and sprayed the blades, then wiped them with a towel.

"Could I see your bottle?" I asked as he handed it to me. ("Methylated Spirits" it read, and I'm thinking quickly, going back in history and chemistry, "spirits" are drinking alcohol, ethyl alcohol, and the "methyl" is one carbon with three other hydrogens attached, so "methlyated spirits" would be isopropyl alcohol, what we call "rubbing alcohol", or the alcohol on those little pads that is used to clean the arm before you get a shot.) But is isopropyl alcohol deemed adequate for HIV prevention? No. [It turns out I'm probably wrong, with apologies to my professor of organic chemistry, Dr. England. "Methylated spririts" is denatured alcohol, that kind of drinking alcohol that's sold in shot glasses and fifths but with a little methanol, a highly toxic alcohol, added to it to render the ethanol undrinkable. But that combination is not recommended for killing HIV either.]

So ever since that day I've asked of the public health types who should know, and they've assured me that the barber shop is not a problem. And, we would probably expect more men to be infected than women if the barber shop were a significant source. Except that women also get their hair cut with the same kinds of clippers. In Swaziland we were able to ask the epidemiologist whose work was the first to show that circumcision was protective against catching HIV, leading to the current revival of circumcision (men are lining up for a 50% reduction in risk) in Africa. He assured us that the barber shop was not a significant risk, but he may have been distracted by his enthusiasm over shaving another set of heads. The problem is, I've never heard of a study where the question was truly addressed.

Then this year, in Tanzania, an Infectious Disease doc on the scene admitted that he thought it couldn't be brushed off so easily. It is for this reason that you can't get a shave in a U.S. barber shop anymore. At least not in southern California (I haven't asked here in Alabama). When AIDS hit, the cost of adequate sterilization of straight razors outweighed any possible benefit of continuing the services. And while the multiple tiny blades of the clipper may not inflict as deep a cut as the straight razor could, they can cut. They can cause bleeding. They just might transfer HIV. So they are never used "guard-less" in a U.S. barbershop.

The upshot of all this is that while we know a lot about HIV, and about its transmission from human to human, there are many questions that remain unanswered, not even addressed in any formal sense. And Beth has our personal barber clippers, unused for 20 years of California life, in one of those boxes marked "TO GO". One spouse/one barber/one clippers. And always with a guard.

Saturday, October 10, 2009

HIV Transmission in Africa: What More than Sex?

The work of arresting the spread of the HIV epidemic has centered around changing sex practices: reducing the number of partners, encouraging fidelity between partners, delaying the onset of intercourse, preferrably until marriage, and using barriers such as condoms during sexual relations. There has been much discussion over the utility of some of these as compared to others, but not much disagreement over the fact that sex is what the spread of HIV is all about. The Anglican Canon Gideon Byamugisha from Uganda, mentioned in my last post on condom use, first raised the question for me as to whether there might be other activities equally important as sex for the spread of HIV. He referred in his teaching DVD to a scientific paper showing that about 70% of a small cohort of Rwandan women with HIV had a history of only one sex partner who himself was negative for HIV infection. How did the women get it?

In the summer of 2003, Dr. David Gisselquist, then of Penn State University Medical Center, Hershey, and his colleagues published a review of data collected before 1989 on risk factors for acquiring HIV. Across this multitude of papers they reviewed, some of high risk groups and some of the general population, he came to the conclusion that the most common risk factor, accounting for 48% of the HIV, was exposure to injections or procedures in the health care system, defined as either western or traditional health care. About 25-29% of HIV transmission in women, and 30-35% in men were due to sexual behavior. These papers were published in the International Journal of STD and AIDS in the summer of 2003, generating considerable discussion via letters to the editor and other correspondence.

Gisselquist has subsequently been vilified by many but none have adequately contested his review of the data. He himself notes that the data are far from perfect, that in the early days of the epidemic there was little knowledge to improve the precision of the data collected. He still admits that sex may be the predominant form of passage, but that health care of various sorts is so important that it must be addressed, and studied carefully, not ignored as is being done now. What did not happen, but could have, however, was the careful analysis of the data that was collected (such as Gisselquist has now done) and the subsequent careful design of studies to answer the questions it presents. Why did this not happen?

First, as Gisselquist describes it, the data from the US and Europe were very good, showing that homosexual behavior and intravenous drug use were the predominant causes in the industrialized west, with heterosexual behaviors coming in a distant third. But there was good evidence and consensus that homosexuality and intravenous drug abuse were extremely uncommon in Africa and non-contributors to the HIV epidemic. Thus says Gisselquist, "most infections were assumed [emphasis mine, BS] to derive from either sexual or health care exposures. The 90% estimate for adult HIV from sexual transmission hence rested on the belief [emphasis mine, BS] that health care transmission was very low, despite abundant evidence to the contrary." And what about those women who said they had only had one sex partner ever, and he was negative for HIV? They were and are often dismissed as "unreliable historians"--liars.

Several anecdotes suggest the accuracy of Gisselquist's data-driven conclusions. First, Sam Shewmaker, an African missionary born and raised in Zambia, was travelling with his wife between two African countries by land. It was brought to their attention at the border that their cholera vaccinations had lapsed. In order to bring them into compliance with the regulations of the country they were visiting, the health worker at the site went to a jar full of milky liquid to fish out a needle to use in injecting them. Questions arose in their minds: How long has the needle been there? How long has the liquid been there? Was it properly diluted when prepared? How does the worker know which of the many needles was used last? They were able to persuade the worker to spare them the injection with the promise they'd get another on their return to their own doctor in just a few weeks.

In 1985, Dr. Monte Cox, then a missionary in Kenya and now the Dean of the College of Bible and Religion at Harding University's Searcy, Arkansas, campus, took his two year old son to the pediatrician for immunizations. Dr. Cox and his son were waiting in a room with 11 other parent-child pairs when the doctor came into the room with one syringe full of vaccine and began to work around the room injecting one child after another. Dr. Cox's boy was last. "Are you going to use the same needle to inject all the children?" he asked.

Looking at the speaker, then the needle and back to the speaker, the doctor retorted, "Well! Not your child", then left the room, returning a bit later, presumably with a new needle.

In 2004 while speaking in the village of Ateiku in western Ghana, I apologized for having left a slide of a syringe in the section of the presentation on risks for HIV infection, acknowledging that they did not have the problem of IV drug use in their village. A woman on the front row inquired during the question and answer session, "You are right that we don't have any IV drug use in our village, but if addicts sharing needles could spread HIV, wouldn't it also spread HIV when the mid-wife uses the same instrument to test all the women in her clinic for anemia?" I assured the woman that she must see a new lancet taken from an unopened paper before it is used to check her for anemia.

The data Gisselquist has published have powerful possibilities for reducing stigma in us and in Africans. Nobody knows precisely how a given individual got his or her HIV, especially in Africa, though this should not matter, particularly to Christians. People are in need. Many of us have solutions. Sharing is the right thing to do, no matter how someone got infected. Our work involves sharing these ideas with church leaders so that they can be better informed and transformed to be the life-sharing neighbors, both in prevention and in care, that are needed in villages full of disease, fear and death.

And then there's the barbershop.

Thursday, August 6, 2009

"My Wife is HIV Positive--What Can I Do?"

(Note: this blog contains some fairly explicit material regarding sexuality, HIV, and condom use. Parental guidance is suggested in its use.)

“My wife is HIV positive, and I am not” a participant in our Tanzania seminar offered at 6:30 pm on the opening day. “What can I do?” Our seminar had begun at 9:00 A.M. “African time” (11:00 by the clock), and while we had not put in quite eight hours of work, the group was very tired. I’d been answering questions about HIV for several hours and this question offered a great segue to a discussion on condoms, so I wanted to hold it until the next day.

“That’s a great question,” I offered. The rest of my answer brought down the house: “Don’t have sex tonight and we’ll talk about that first thing tomorrow morning.”

The next morning the group offered three possibilities for the inquirer (whom I learned later was asking a hypothetical question and was not disclosing the status of his wife who was sitting next to him when he asked):
1. Divorce his wife.
2. Stay married and don’t have sex.
3. Stay married and take the risks of sex with an HIV-infected wife.

No one offered a fourth suggestion. After a long discussion of Jesus’ teachings on divorce and Paul’s teachings on sexuality and marriage, everyone agreed that the first suggestion was not legitimate, the second was totally unfeasible and the third was not very desirable either. But no one suggested condom use. Finally, as I continued to entreat the group for a fourth alternative, a very old man who had showed up for the first time on the morning of the second day offered in a subdued but firm voice, “Condoms”. After he confirmed his answer a little bit louder, I turned to the group and asked for their thoughts about his suggestion. It was a hard sell.

The very idea of condom use in any context sometimes quickly heats up the conversation among many Bible-believing church leaders in Africa, though it is always an area we explore in our seminars. “Condoms are the cause of the HIV epidemic,” suggested one participant. Several heads nodded agreement, and then another chimed in, “We didn’t see much HIV until condoms became freely available; then people started dying right and left.” This answer is listed as an incorrect choice on the pre and post test I did not utilize in the Tanzania seminar, but this was the first time it had ever been suggested so explicitly by one of our seminar participants.

Most church leaders simply associate condom use with illicit, extramarital sex, and thus find them sinful in and of themselves. It is often difficult for these church leaders to see that condoms might have a legitimate use, and it is hard for them to see that using a condom doesn’t even make Biblically illicit sex more sinful. So I borrow from Canon Gideon Byamugisha, an Anglican Priest who addresses the issue well. Canon Gideon points out that sex may be licit or illicit, safer or not so safe, two concepts that are not equivalent, (though admittedly not totally independent). Licit sex, sex within marriage, is usually safer than illicit sex, but only if your partner is known to be negative and unexposed to HIV. In a society where 15-25% of the adult population is infected with HIV and there are means of transmission other than sex, assumptions shouldn’t be made. In a case where one’s spouse is infected with HIV, licit sex can still be safer or not so safe.

Similarly, illicit sex, sex outside marriage, is always illicit whether a condom is used or not. Condom use does not make extra-marital sex illicit. It is sinful on its own merits. Though condom use does make illicit sex considerably safer, it is no absolute guarantee of safety. Unless one believes that the only way God can punish people for illicit sex is through the transmission of HIV and other sexually transmitted diseases, and that condom use is thus somehow thwarting God’s punitive will, then condom use should not be seen as wrong, certainly not during licit sex, but really no more so in illicit sex. And innocent children and faithful spouses might be spared. We point out Jesus’ stated objective “not to condemn the world, but to save the world” which suggests that the work we should be doing is the same.

“But aren’t you killing a new baby when you use a condom?” someone asked during the South African seminar. A careful review of the anatomy and physiology of conception and pregnancy reveals that a new being is not formed until after the union of egg and sperm, so preventing that union through condom use is no different than not having sex. In fact, condoms are probably the least likely of all birth control methods to working by interrupting the pregnancy process after the union of sperm and egg.

“But isn’t wasting sperm sinful?” another inquires, and we go back to Genesis 38 to look at Onan’s condemned use of birth control (no, he didn't have a condom, but read the story if you're having trouble remembering the details). Again, a careful review of the text reveals that Onan’s sin lay in the failure to fulfill his social duty to his brother, his unwillingness to be a good family member. If he had never had sex with his sister-in-law he would have been just as guilty under the rules of his society. An older brother in our Tanzania seminar group shares the physiologic fact that one sperm out of millions fertilizes the egg, demonstrating that God is not worried about “wasting” sperm. Some feel the earth is not yet full and that we must still fulfill God’s creation command to “fill it up”, but a reminder of children dying of malnutrition and Paul’s note that those who don’t care for their own are worse than unbelievers convinced many that mankind had probably fulfilled that mandate.

In the end, several of the four planning groups in the Tanzania seminar listed education in condom use as part of their plans for combating HIV. Did they get it? Will they teach it? Or were they just saying that because of my dogged insistence? Condoms will not solve the AIDS crisis, and they are not the primary means we suggest for HIV prevention. They are certainly not the cause of the epidemic, however, and there are instances where condom use would help even licit sex to be safer for committed and faithful married couples. How then did one partner in such couples become infected? More about that next time.

Saturday, August 1, 2009

John: Infected and Affecting Others--for Good

John was not the average participant at our most recent seminar in Nduha, Tanzania, about 1.5 hours south of Mwanza, Tanzania’s second-largest city. (Mwanza lies on the southern shore of Lake Victoria near the borders of Kenya and Uganda with Tanzania.) John had known he was infected with HIV for several years, and had been on anti-retrovirals (ARV’s) for most of that time. According to Kevin Linderman, the missionary who was our primary contact for this seminar, John had frequently made casual public remarks about his medications in contexts that revealed his status, but John had never had the occasion to openly address the problem of HIV before other church leaders. Our seminar provided just such an opportunity.

One of the most powerful events in our five-nation teaching tour in 2005 was a presentation by the female president of the Kenyan Association of Religious Leaders Infected with or Affected by AIDS (KenAReLAA). We shared with John about the positive effect of her talk on the church leaders attending that seminar, and asked if he’d like to address his group. While encouraging him with the thought that his presentation could be equally powerful, I offered him the option of just answering some questions about his feelings about the disease and its effect on his relationships, and we assured him that he should feel under no obligation to speak at all. We left him to think about it overnight.

The next day John told us he was ready to speak. I thought he was just going to answer some questions, but when he got the floor he took off. Though I can’t tell you all (or even most) of what he said (my translators were more interested in listening to John than telling me what he was saying) I can tell you that it was powerfully delivered and captured the attention of our group. Among other things, he addressed the problem of the prejudices of his friends and neighbors. John said he knew many people were wondering what woman he picked this up from. John answered with the testimony of his life.

“When I planted the church in your village,” John asked, indicating one of the participants, “did I pick up a woman there? And when I planted the church in your village,” he asked another, “what woman did I pick up there? And how about your village,” he asked another. “When I planted the church there was I with a woman?” John had planted churches in many villages, and his faithfulness to his wives was as evident as his evangelistic skill. He had come to those villages on behalf of the King of kings, and his life reflected that commitment.

Yes, John had been a polygamist. His first wife had died some years ago (perhaps of HIV-related infections), and he had divorced his third wife after repeated instances of unfaithfulness on her part, perhaps another opportunity for infection. He now lives faithfully with his second wife, who was present in the seminar and who avidly supports the many facets of his ministry. John is now a grandfather, and through his encouragement his children have all been tested and found to be negative for HIV.

I asked John how long he took to reveal his HIV status, which was discovered during hospitalization for a nasty leg infection that wouldn’t get well. He told his immediate family about two months after the diagnosis, then his extended family after a year. He began to tell other church members after about two years. The reason for his delay: fear; fear of rejection. While some of his relationships have suffered since his diagnosis, John’s aggressive defense of his life’s record has stood him well, and the unquestioning support of his family has been an added comfort.

Our seminars attempt to address the stigma of HIV infection in several ways:
1. Recognition that all of us are sinners, whether we have HIV or not.
2. Recognition that those who have sinned in ways other than sexually are just as much sinners, and thus in need of God’s grace as those who have sinned sexually.
3. Recognition that there is good evidence that a great deal of the HIV in Africa, at least early in the epidemic, was acquired through other than sexual means (more about this in a later blog).
4. Recognition that our task on earth as the Body of Jesus Christ (the church) is to invite all sinners back to God for healing, not condemnation. This was Jesus’ work, which he did not only in word, but also in his attitude and social behavior, and which he expects us to continue as his followers.
5. Recognition that those infected with HIV are in great need of care in many ways: socially, physically, mentally, emotionally, and often spiritually and financially, and that the church is the best institution to deal with these needs because it is really the only institution that can deal with all of them.

John’s participation in this seminar added a very special dimension to it. He is a respected leader of the churches in his area and the father of many of them. His ministry has the opportunity to acquire additional power for the Kingdom as his weakness (his HIV infection) becomes a Kingdom strength, a point for connection with his neighbors whose lives are being crushed by their HIV infection, no matter how they acquired it. It is a blessing to know John and to count him a friend and partner in the work we are doing.

Tuesday, July 14, 2009

Aa Malawian Feast of HIV Knowledge

A virtual feast awaited us in Lilongwe, Malawi, in our first week in Africa. The National AIDS Commission had invited all groups doing HIV research in Malawi to present their results at a national conference which occurred on Thursday and Friday, the 2nd and 3rd of July. One member of the Landmark Church group, with which we are enjoying the Malawi portion of this summer’s trip, saw a sign in the center of the city advertising the event. A few days later we drove by the sign, saw that the event would be at the Crossroads Hotel the following day, then headed for the Hotel, learning that the event was sponsored by the National AIDS Commission. On the way home we dropped by the Commission’s offices where we were invited by two different staff members to attend. So we did. It was a very worthwhile investment of two days’ time.

A paper by epidemiologists from the Ministry of Health reported that at the end of 2008, 147,500 patients (about 50% of those needing it) were on treatment at some 211 clinics across the country. Over time progressively more patients have been added to treatment each year, and those patients beginning treatment are increasingly younger and earlier in the progression of their disease. Men have continued to get tested and start treatment in smaller numbers than women, and the men usually have more advanced disease when they come to treatment.

The Malawian Ministry of Health (MOH) and Howard University noted that 100 laboratory technicians had been trained in the last six years to do complex laboratory procedures such as counts of the number of CD4 lymphocytes (the primary target of the HIV virus—basically, the more you have the better) and the “viral load” or the number of HIV viral particles themselves in patients’ blood (the less you have the better). More than 80 additional working technicians had received updates in these procedures. More availability of the CD4 count will spread the ability to track the success of HIV treatment under current Malawian protocols, and access to viral load determinations will apparently prepare Malawi to move to treatment follow-up based on the more precise and sensitive (though also more expensive) use of the viral load for follow-up.

GOAL Malawi reported good results in several senses from having fathers participate in the counseling sessions for pregnant women in which their newly-discovered HIV infection and the medications they would take to reduce risk of transmitting the virus to the baby are discussed. As a result of this special effort to include fathers, the number participating doubled to between 60% and 85% of the number of mothers attending the participating clinics. Male membership in support groups increased by 82.5%. Other desired and possible outcomes that were not documented included reducing emotional and physical abuse by their partners of pregnant women found to be infected with HIV.

Dignitas International and their partners found that provision of HIV care in 16 decentralized sites in one area of the country (as opposed to only 6 in addition to the central hospital in the pre-study period) decreased death and drop-out rates in persons beginning HIV care. Another session found the use of trained community volunteers helpful in enrolling patients on medications, keeping them on medications and ensuring return for clinic appointments.

The Malawi Interfaith AIDS Association found in a national survey that clergy were well-informed regarding the way HIV works to cause disease but most were very opposed to condom use. Thirty-two percent believed that prayer could be an effective treatment for HIV, a fact that seemed to disturb at least some of those present. While I do not think we should ignore the wonderful gift from God of the medications currently available for treating HIV, I wonder why only 32% of church leaders believe that prayer can be an important and efficacious part of an effective treatment regiment.

For a number of good reasons African protocols for treating HIV are generally simpler than those usually used in the USA, including treatment for pregnant women. A group named Sant’ Egidio for the Roman Catholic renewal and discipleship movement of which they are a part reported on their efforts to treat pregnant women with more aggressive protocols, in some ways more like those in the U.S. and western Europe. A part of the Sant’ Egidio protocol was using full anti-retroviral treatment starting early in the pregnancy, while another, quite different from the U.S., included continuing full anti-retroviral treatment of the mother for the first six months of the baby’s life while the mother was breastfeeding. They found that all outcomes were improved, including maternal death, miscarriage, still-birth, pre-term birth, as well as HIV transmission from the mother to the baby. The results were impressive, but not surprising. One member of the audience was encouraged by the outcomes to ask if they were sufficient to seek a change in Malawian policy. A more aggressive protocol for preventing mother-to-child transmission of HIV might yield better results nationwide.

We were impressed with the variety of projects as well as with the rigor of the evaluations. We learned a new technical term with a special meaning in this field--“task shifting”-- which means the delegation of certain medical tasks to personnel with less training than is usually required. We were able to meet many people including the regional representative of the Clinton foundation, an epidemiologist from the CDC, multiple personnel from the Ministry of Health and the National AIDS Commission, and physicians from Baylor Medical School’s project in Malawi and the Sant’ Egidio project. We were encouraged by many to come and join them in the fight they are waging against this disease in Malawi, and we are anxious to return and do so.

Saturday, June 27, 2009

When the Tail Wags the Doc, Does the Lord Care?

“I cried out to the Lord in my distress, and he answered me.”

The first phrases of Psalm 120 took on new and extremely personal meaning for me last Wednesday as we drove out of Albuquerque, New Mexico, toward Oklahoma City, Jonesboro, Arkansas, and eventually Montgomery, Alabama. I was driving the Civic pulling the small, antique (originally “Nationwide” brand) trailer containing the wedding gifts and other possessions our daughter and her husband were unable to carry with them to New York last January, while Charley and Martha Roberts followed behind in the Penske truck containing our things and some for our niece/about to be bride from my wife’s mother’s things.

The road climbs steadily out of Albuquerque for a few miles, and then suddenly begins its descent, turning to the left at the crest as the descent begins, and then sharply back to the right perhaps 1/8th or ¼ mile below. I was caught a little off guard by the crest and turn, which I entered at about 65 miles per hour. The trailer suddenly began to swing left and right behind me in rapidly widening arcs. In a few seconds I knew I was in trouble, shortly later, very serious trouble.

Though I was afraid; I did not panic. I tried to think through the problem. “The trailer is swinging. If I can just pull it straight for a bit, maybe I can track out of the arcs.” Other traffic was giving me wide birth (who wants to try to pass a trailer that might slam into you!), so I cut diagonally across both lanes, and then back across both. But the winding mountain road demanded turns, and if any relief was attained temporarily, it was soon lost. “The trailer is trying to run faster down the mountain than the car. If I can just speed up ahead of the trailer perhaps I can force it to track straight behind me, like an artificial pacemaker capturing a racing heart by forcing it faster.” That may have helped for a moment, but eventually the trailer and gravity caught up on the steep grade, and if you think a widely oscillating trailer is scary at 65 mph, try it at 85!

I was more frightened than I’ve every been. I truly thought I might die. I screamed: “God help me!” and later, “Lord, save me!” The trailer’s machinations were jerking the Civic itself back and forth. Between the sensations of being jerked from behind and the panorama of cris-crossing trailers in the mirrors, I thought of several possible outcomes: being drug off the mountain, the car and trailer rolling over and over down the road, the car and trailer turning on their sides and sliding down the road, or just the trailer turning over and sliding down. I was blessed not to have Charley and Martha’s view as the trailer swung to the left, leaving the right tire open to their view several times, 18 inches off the ground! The trailer was literally skipping down the mountain.

Then it was over. I could attribute the change to nothing I had tried, but the trailer calmed down, the arcs became narrower, then disappeared. I was left with only the pounding of my heart and the sensations that vessels in my head or mid-back might split open with each pulse. I countered the pain by holding my breath and bearing down, opposing the pounding pressure in my arteries as my blood pressure soared and then finally calmed. We pulled off at the next exit and caught our breath, shared our views, then, thanks to God, proceeded more cautiously on.

Martha drove the Civic much of the rest of the way, both that day and the next. Her skills as a marriage and family therapist were greatly appreciated in mediating the seemingly star-struck relationship between driver and trailer, and perhaps her gentle touch at the wheel was better for the trailer. We redistributed some of the weight on the trailer, checked with the expertise of some of you (with special thanks to Dave Borgelt), worked to keep the track very steady with gently initiated turns, and completely repacked the trailer, lowering its center of gravity before turning it over to our children. As we met for the wedding of Beth’s niece in Jonesboro, I especially appreciated the reunions with Betty, Tom, Trudy and David, all of whom have survived to this day life-threatening illnesses or trauma. I think most of the obstacles we encounter on this quest will more likely be of the boring, wear-you-down slowly type. This one was acute and terribly frightening.

“I cried out to the Lord in my distress, and he answered me.” Blessed be the Lord.

Tuesday, June 23, 2009

A Pertinent, If Unexpected, Question

“I need to ask you . . . ,” the question began innocently enough as I recently closed my presentation regarding our proposed work in Africa to our church of 19 years and opened the session for questions. What followed, however, was anything but conventional. Mary, one of our senior sisters, mother of one of our elders, wife of a former elder, a godly woman whose ministry is praying for others, had literally stepped forward from her seat in the second row, taken both of my forearms in her hands, looked me in the eyes, and asked her “question”, “I need to ask you . . . for your forgiveness.”

“When I first heard that you wanted to go to Africa, I was very much against it,” she continued. “I told you so, and even wrote you a letter saying that I was sure that you had been called by God to be with us, and that you shouldn’t leave us because he still wanted you here. But I was wrong. I now understand why you want to go, and you need to go. What you want to do is needed and right, and you should go, and you will have my blessing, support and encouragement.”

Mary had from the beginning opposed our thoughts of moving to Africa, and had, as she confessed, even written us a letter explaining that God had brought us to Redlands, and therefore we must stay in Redlands. I had come across the letter the night before as we sorted through papers, tossing, saving, packing. But now Mary saw things in a different light.

She now understood the danger HIV presents to many African peoples, that we might play a meaningful role in helping some communities escape or recover from the scourges of this disease, that it would be good, perhaps even the will of God Almighty that we would move to Africa to engage this ministry, even as he had brought us to Redlands. So Mary would support us in this ministry, encourage us, pray for us. Would we forgive her for having opposed us?

Mary’s “question” and confession were no doubt more helpful in galvanizing the support of our congregation behind our new efforts than her own opposition had been in encouraging similar reluctance in others. Our answer was, “of course”, and the outpouring of encouragement and well-wishing from so very many of you has been very greatly appreciated as we make these transitions. Leaving has proven much more difficult than we anticipated, and your encouragement has increased our appreciation for you while making our going a little easier. Thank you all, and especially Mary, very, very much.

Friday, May 29, 2009

El Viejito

"I've been telling my friends, 'No sé que voy a hacer sin el viejito.'"

Beginning one HIV ministry necessarily entails closing another. This has been much tougher than I ever thought it would be. Over the last three to four months I have been carefully telling my patients that I probably wouldn't see them again, that I was accepting another position to work on HIV in Africa. With some we have literally "walked through the valley of the shadow of death", while others have been patients for many, many years and done well all along. With others we have struggled to find a medication regimen they could tolerate. Some didn't and joined others who died, and some are surviving spouses whose presence reminds me of the dead. Then came the little homeless man who lives in a field not far from the clinic.

I had seen him in February, and he says he's since made an unexpected visit to his parents in Mexico with transportation supplied by Uncle Sam. He had come back just a day or two before his appointment. Before the visit ended I remembered to ask, "I did tell you I was leaving, didn't I?"

"Yes," he responded. "I've been telling all my friends I don't know what I'm going to do without el viejito." El viejito?! The little old man?! At first I thought he was talking about my dear friend and colleague, Harvey Elder, the senior statesman of our group, and maybe a little shorter than I. Then I realized he was talking about me. We both erupted in laughter. The "ito" suffix is in Spanish a term of endearment. It almost always means that one is greatly appreciated. But, I'm not used to thinking of myself as "the little old man". I realized I had graduated once again.

The other time something like this happened to me was in San Antonio when Beth and I had just moved there for me to start medical school. At first appearance in our new church I was asked to teach the teenage Sunday School class, and after evening services that night we went over to the teen center to meet some of the young people. One of the young ladies, Holly Lee, shook my hand and said, "Good to meet you, Brother Smith. Brother Smith?! That was my grandfather! I had hardly ever heard even my dad called that! The splash of cold reality began to sink in that I was no longer a teenager but rather an adult. I was 21 and Holly Lee had respectfully helped me to see myself as I really was, or at least to begin to.

And so now I'm el viejito. The little old man. Or maybe just "the old man" with a nice spin on it. My patient has affectionately helped me, at the threshold of 60, to see myself as I really am, and given me a good laugh at my resistance to the truth about myself. The steps over this threshold of our lives are often painful as we take leave of a great company of colleagues at work, brothers and sisters in our church and others throughout the region, and, yes, long-term patients too, all carefully, purposefully and graciously included in our fellowship by our Father over the last nineteen years. We trust that He will allow el viejito and his wife to assemble with this pleasant company again some day for a wonderful reunion, along with an equally beneficent (even if sometimes painfully so) set of colleagues, friends, brothers and sisters and patients from the ministry which lies ahead.

Sunday, May 17, 2009

Moving on . . .

After three years of seeking a church to support us in working on HIV in Africa, the Landmark Church of Christ, Montgomery, Alabama, has accepted our proposal, and has asked us to be based in Malawi, in or near the capital city of Lilongwe. We will be moving from Redlands, California, to Montgomery the middle of June. We'll be visiting Malawi briefly this summer, leaving Montgomery June 26 and leaving Malawi July 9. We'll be holding an HIV seminar in Malawi and making preparations for language study and moving, and then will be traveling to Praetoria, the Republic of South Africa, and Mwanza, Tanzania, holding in each of those cities a two day HIV seminar for church leaders. We will close the summer's travel visiting our son and his family in northern Mozambique before returning to Montgomery on August 8. We will move to Malawi after the first of the year and begin language study in Chi-Chewa, an official language of Malawi along with English. Leaving-taking of one sort or another occupies our every minute, and has been harder than I anticipated. But more about that next post. Visit our web site at for more information on our proposal and timeline.