Mentors in Missions: A Tribute to Henry Farrar

I was about 14 and had decided I would be a physician. My seventh grade science teacher (and my Sunday school teacher) Margaret Beene had told us about her aunt who had a strange, little-understood disease called scleroderma in which the skin, inside and out, hardened to make the affected organs barely functional. In one form fingers could be resorbed from the tips due to the pressure of the skin on the bones, and internal organs such as the digestive tract and heart had major functional problems as their own “skins” hardened. Then Mrs. Beene got the disease, and I was going to find a cure for it: I was going to be a doctor.

We had traveled 50 miles from our small town to Tyler, the closest thing to a city nearby, to attend a service of an evangelistic meeting at the Omen Road Church of Christ. We met some friends, Howard and Betty Waldrip, there and were going to their home for a bit after the service. My parents had split up to assist in finding the Waldrip home, and I had ridden with the ladies. We were sitting in the parking lot about to head for their house when Sister Waldrip turned to me in the back seat:

“What are you going to be when you grow up, Bruce?”

“I’m going to be a doctor,” I answered from the back seat.

“And be a medical missionary like Henry Farrar?” she queried.

I thought, “No way! I’m going to do research and find a cure for Mrs. Beene’s scleroderma.” I had no idea who Henry Farrar was, but I was pretty sure that the kind of research I wanted to do and medical missions didn’t go hand in hand. But a seed had been planted.

A few years later my older sister married a latino evangelist, Victor Rodriguez, and the idea of missions came a little closer to home as they discussed possible work in Spain or Latin America. The seed had been watered just a little, and was ready for the warm sun of the missions youth rally which my dad organized. David Gatewood, already working through forays behind the “iron curtain”, spoke along with Kenny Sinclair who was finishing graduate work toward a long life of service in Malaysia, as well as a young lady whose name now escapes me. On a card that bares David’s name, along with that of Maurice Hall, I pledged a life of medical mission service to Spanish-speaking people. The seed planted with the name of “Henry Farrar” was germinating.

Dr. Farrar continued to appear in my life. First, on arriving at Harding and discovering the library, I read about him in the Christian Chronicle, his establishment of the Nigerian Christian Hospital, and the troubles that institution had during the Biafran war. I heard stories of his making his way through war lines to check on the hospital and serve the people he loved, of slipping an old, invalid passport with an otherwise valid visa inside a new passport that lacked those stamps and signatures and by God’s grace making it work, getting through to do God’s work.

Most recently I’ve been impressed that Dr. Farrar has read and can discuss in detail or is even teaching from every book that I’ve read or been recommended on spiritual growth and development. His mind is still racing to know and to live under the lordship and teaching of Jesus Christ. The arthritis that has bent his tall frame in recent years belies the sharp mind that operates behind eyes keen once again after cataract surgery and under the blooming almond tree of white hair that foretells the wisdom to come from his lips. But his intelligence, sharp as it is and has always been, and his wisdom pale beside this man’s most marked characteristic, his faithfulness, the incredible trust that Henry Farrar has in his God, the Father of us all, and in Jesus Christ, our model as God’s only son, himself a medical missionary, as Henry has always reminded us.

I’m pretty sure Dr. Farrar was present at the first Medical Missions Seminar held by Churches of Christ in the fall of 1968 or the spring of ‘69 at Harding, though his quiet demeanor pales in my memory beside Joe Cannon’s more bombastic faithfulness and charges to physicians on that occasion: “You don’t go to the mission field because you’re worried about your 401K’s and your retirement funds. Why don’t you work until you’re done and then just die and go to heaven?” If it was Joe who said it, Henry Farrar has lived it. The closest to a word of complaint I ever heard from Doctor Farrar was that he was “underworked and overpayed” when he returned to practice in the States. I know nothing of his financial affairs, but he educated several children, one a surgeon, one a doctoral level RN, and one a missionary, and he has continued to give liberally to others who work faithfully in Nigeria and other places. Money never seemed to be a concern of his: the Lord cared for him and for others through him.

At other medical missions seminars that unfolded over the years Henry encouraged successive generations of candidates to just finish medical school and get on the boat, go to the mission field. He seemed to disdain the urging of others to study culture and language, which they said was necessary so that inter-personal ministry on the field could be enhanced. But when my wife and I spent a few weeks at his hospital during my senior year in medical school, staying in what had been his home, I was pleasantly surprised to see an Ibo grammar as one of only two or three books remaining on the bookshelf of the mostly empty house. And he was not just respected in that part of Nigeria where he worked, but truly loved by the people there. He had not ignored language or culture, but his gentle servant spirit, his personal sensitivity, had been the primary catalyst for developing close cross-cultural sensitivity and relationships.

I think Dr. Farrar’s “get with it” advice may have been motivated by the fact that more than 90% of those who said during pre-med years that they were going to do medical mission work ended up in a private practice in the U.S., never doing any long-term work. The acculturation to American private practice and its seemingly intractable pull on mission candidates was probably discouraging to Dr. Farrar, and it remains a challenge to the needs of medical missions around the world. Henry’s practical answer was “just do it”, the sooner the better.

When various circumstances suggested that the Farrar family return to the States for an indefinite period, Dr. Farrar flexibly “reinvented missions”, leading a wave of itinerant service by multitudes of physicians and surgeons, beginning at Nigerian Christian Hospital and expanding to numerous other facilities, a growth that continues today among some perhaps ignorant of its original inspiration. It is probably not an overstatement to say that these methodologies, itinerant surgical missions, owe their practice in Churches of Christ to Henry’s need to be here and be there, a need he has heeded up until the present. Thus he was able to not only continue to meet his own family’s needs and serve in Nigeria, but also to involve many of those who had said they would go, only to find themselves somehow unable or in some way unsuited after finishing their residencies. At least in some sense, a sense that has been a blessing on both sides of the service, the seemingly betrayed intentions of many have been fulfilled through imitation of the latter part of Dr. Farrar’s life, and not uncommonly through his personal invitation.

The influence of Dr. Henry Farrar in medical missions in Churches of Christ would be difficult to overstate. Though he is probably too humble to say the words, what he has done and the Christ-like spirit with which he has done everything cry in the words of the apostle for us to “follow me as I follow Christ”. It is at least fair to say that none of the rest of us might have ever been there had he not gone, so that Sunday school teachers, visiting missionaries, and Bible professors across the nation could invite those of us considering the practice of medicine to be medical missionaries “like Henry Farrar”, and thus like Jesus Christ.

P.S. Dr. Farrar fell Tuesday morning on arriving at his work, suffering a concussion and a fracture of his first cervical vertebra. He has awakened and is lucid and communicating, but is paralyzed from the neck down and is unable to breathe on his own. The family appreciates your prayers.

Any errors in the above stories are mine, as I remember them.

Margaret Beene lived to be 90 years old by the grace of God and the good care of many able physicians, some of whom she surely outlived. She always encouraged my decision to be a medical missionary, to the last years of her life.

Shame: HIV, Death, and the Body of Christ

He glided behind me as he passed the front desk. I didn't have to be there, and he didn't need to stop there, but he seemed to avoid being seen. Somehow I knew he was my last patient of the day. We hadn't met, but as I perused his slim chart, it was evident there were problems. We'll call him Mr. P. The amount of HIV virus in Mr. P's blood had dropped, but not nearly as fast or far as it should have. There were suggestions that he had been on several medications since his infection was discovered, but the documentation was not all there. Then there were his current meds. All of them, nearly a month's worth in most of the bottles, had been last filled seven weeks ago: one bottle was nearly full, another was dosed at half the amount it should have been, and there was only one pill left of one of the meds. "And I don't get paid until Friday," he said from under the bill of his cap. "That's when I can refill it." Three more days. Missing a single dose of your HIV meds each month can increase the risk of resistance developing over the year by 10-15 percentage points. This man, like many of our patients, needed help taking his meds.

He looked to be in his 60's or 70's, but he said he was only 45. As we talked about his disease and what was going on, he wouldn't look at me. On several occasions I asked him to, and he did. Briefly. And then the head was down again, the bill on the cap shading his eyes, hiding his face from my attempt to know him.

"How has this disease affected your life?"

"It's affected me a lot. I'm angry. Angry a lot. I don't know how I got it," the voice spoke from behind the cap.

"Does anyone else know about your disease?"
"My sisters. They know."

"And they've handled that OK?"

"Uuuuh-húh. Oh-Kay. One of them is ok. One of them, she has me drink out of a plastic cup." There was a silence.

"And then . . . she throws it away?"

"Uuuuh-húh," the voice swung up in affirmation.

"But my other sister, she's ok. She feeds me. Lives across the road from me."

His brother-in-law had brought him to the clinic, the husband of the sister "across the road". Without lifting his face Mr. P affirmed that the in-law knew of his disease and that he would sign a release for me to talk with the brother-in-law and sister. I went over a number of things with them, separately, in person with the brother-in-law in Mr. P's presence, and then on the phone with his sister after he'd left. We talked about the CD4 lymphocyte, what that white blood cell normally does, how HIV infects it, then destroys it while diverting the CD4 from its primary mission of protecting us to the role of producing more HIV viruses. We talked about resistance, and the need for adherence to the medication regimen, the need to use a pill box, and possibly for someone to assist him. Then I mentioned to Mr. P's sister his hidden eyes.

"He won't look at me," I began.
"No. He won't look at anybody. Me neither."

"Has he always been this way, or just since he knew he was infected?"

"Just since he's been infected."

Then it hit me! He's ashamed! He's ashamed to be infected with HIV. He's so ashamed that he can't look at anyone. For those who don't know, he's afraid they'll learn, as if by looking into his eyes they would see deep within his brain the "HIV" in red letters, stenciled on the gray matter of his mind. For those who do know, he's ashamed. I was almost overcome with anger and sadness at this man's situation, this man who is now almost Gollum-like, shriveled and be-deviled, his "image-of-God" humanity defaced more than usual because of this disease, the way others deal with him because of the disease, and his fears of what he might receive. Head down he tries to hide in his own dark cave between the bill of his cap and the flaps of his partially zippered jacket. It may be that some of his shame is due to his guilt for how he caught the disease, but that is not my impression. Yes, few know, but of those who do, only two treat him well, treat him . . . normally. And he is overcome with anger, fear, and shame.

This shame, and the fear of it, immobilizes people around the world, keeping them from getting tested in a timely fashion when treatment is most affective and complications are least likely, driving them into caves of despair when they know they are infected, afraid of rejection, loneliness and death, not the stopping of that pumping muscle in their chests, but the death of their spirits through loss of interaction with the rest of us who've been imparted spirits from the One who is Spirit. These fearful ones have not known Him, except through those whom He has created, those He seems to have given life, and now the "living" will, thinks Mr. P, withdraw and leave him absolutely alone, dead. Those who claim to live forget that it is their privilege, their responsibility, at precisely this moment to offer life.

I praised Mr. P's sister and praised God in her presence because she is accepting him, affirming him, loving him, she and her husband. When I see him again I will inquire about shame and if it is confirmed I'll discuss the possible why's of it. If he is guilty, I will offer him the forgiveness that God has given me. "Your sins are forgiven you." "Neither do I condemn you. Go, and cease your life of sin." That is how the Lord dealt with shame. And he has sent us to do the same.

Meanwhile, I am saddened and angered by the way we are, "we" being what too often passes for church, community, and even family in this man's life. That which should be gracious, loving, offering forgiveness, even at the cost of its own life, but rather is too often, especially in this situation, proud, exclusive, condemning: polished, beautifully painted gift boxes full of dead men's bones. "If you were blind, you would not be guilty of sin; but now that you claim you can see, your guilt remains."

Lord, do what is necessary to open eyes, minds and hearts, to impart fear where it needs to be, and courage where it needs to be, so that this disease may be stopped not just in its destruction of bodies, but in its destruction of souls, its defacing of your image in those you made to bear it. Teach the church to be your body, courageous not only in righteous living but also in gracious offering of forgiveness, love and hope, that men and women may know they are loved by you, and can truly live in you.

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.

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.

"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.

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.

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.