True Religion?

The Mass readings these weeks have been from the book of James, who has a lot to say about what it means to live our Christian faith.  One of the things that is inescapable in Shisong is the degree to which religion (not only Catholicism) permeates the culture, and the fervency and apparent joy with which it is observed.  One of the visitors that I have spent time with in Shisong doubted the faith of many of the people here.  This individual felt that much of the fervency and enthusiasm expressed in the Catholic community was based on the culture and behavioral expectations rather than true love of Christ or belief in God.  In her country, the cultural aspects of faith have largely disappeared, but she feels that those that practice their Catholicism are sincere because those without faith simply don’t bother.

Being here for 5 months certainly does not make me an expert on anything, and I am not inclined to judge the faith of individuals or a community in any case.  However, it could be interesting to share a few observations.  I think that nominal faith and participating in a faith community for social reasons exists everywhere and in every faith and philosophy.  Even in countries where there is severe persecution it is possible that people seek martyrdom for the wrong reasons, although you might suspect that there is less “acting” in a community where the faith costs much.  In Shisong, the Catholic community is served by Capuchins (Franciscan friars), as well as diocesan priests from Kumbo.  I have heard teaching at high levels to general audiences (homilies and instructional settings) on Christian living, the differences between superstition and sacramentals, the tension between one’s Christian faith and the traditional practices of one’s community or position, Christian sexual morality, and care for the poor.  The Mass attendance for the hospital weekday Masses on Wednesdays and Fridays is high; for some it is certainly that they are attending to say they have attended because they work in a Catholic hospital.   However, the level of participation within the Mass is high and I think it would be unreasonable to suspect the motives of most of the people.  In any case, it is much easier for people to be exposed to Christ and to come to a true knowledge of Him in this setting than in a secular setting where Christianity is routinely disparaged, misrepresented, or absent.  A tailor I have worked with does not work on Sundays and leaves early on Saturdays to go to Bible study (and yes, she is Catholic).  Some of the nurses in the operating room belong to various men’s groups that study the faith together as well as serve the community; these activities take a great deal of time – more than activities in America usually expect.  Obviously the sisters dedicate significant time to prayer, study, and service, feeding not only their own faith but also the faith of others.

On the downside, one of the most disturbing stories I have heard came out of Central Africa on the BBC.  The BBC has no love for Christianity and may well have been trying to present “Christians” in the worst possible light.  There have been stories of extreme generosity and Christian heroism from the CAR as well.  However, in this story, people identified by the BBC as “Christians” were participating in clearly un-Christian behavior.  All Christians choose wrongly sometimes, but only rarely is the wrong behavior intentionally identified with our Christianity.  I do not know if the men in the news story identified themselves as Christians, or if to the BBC reporter, any non-Muslim could be identified as a Christian.  These men were seeking revenge against a Muslim man for atrocities committed against Christians by other Muslims (not this man).  Not only did they desire revenge, but they identified it as an obligation.  Additionally, they were described as wearing amulets which would protect them from harm.  In no aspect of the story did God or Christ have anything to do with their behavior or their motivations.  It is possible that these people had had some exposure to Christianity, but clearly their behavior in this story was not related to their Christian lives.  It would be better if the BBC would simply describe “ethnic violence” rather than to portray this as a religious war.  There are true Christians suffering in the CAR, and probably there are people of traditional religions suffering in the CAR, and there are a few Muslims remaining who are suffering in the CAR, and many refugees from the CAR in other places.  Please pray for all of them; I see little of this in the American news, although if you are praying for Syria you can just add the CAR.

The press has a tendency to present Catholicism as ridiculous.  If I learned about the Church and her doings from the New York Times I certainly might think that the Catholic Church is ridiculous.  It is important not to learn about Christianity from the mainstream press, which has its own agendae (primarily selling advertising, but there are others).  There is much rich and beautiful writing to help us understand the life Christ offers and the grace found through the Church.  In much of Africa, books and the internet are not readily available, so people learn about and celebrate Christianity in many other ways, including cultural practices and beauty.  It is not easy, or necessary, to judge.

From Today’s Liturgy:
I will recount all your wonders, I will rejoice in you and be glad, and sing psalms to your name, O Most High.  Ps 9:2-3

Cardiac Center vs. the Hospital

Although sometimes this sounds like political infighting, yesterday it referred to a sporting event.  The men of the Cardiac Center took on the men of the Hospital in volleyball and football (soccer), while the women challenged in a handball match.  I had not been asked to play, but on my arrival to watch was informed (begged) that I should go and change since the women’s team for the Cardiac Center did not have enough players.  I agreed to this, since I thought that we were playing volleyball!  I ended up on a handball team – a sport that I had never even heard of, much less played before.  These women were serious, and somehow the Cardiac Center won despite having me on their team (we also had to adopt a couple of hospital staff to make the team complete).  It turns out that handball is quite popular in Africa as well as in eastern countries.  Fortunately, there is a Wikipedia article about it so that after I was finished playing I could find out what I was supposed to be doing.  Actually, the game is not so complicated, but there are rules and it would probably be good to know them ahead of time.  You know, like whether you can run with the ball or not.  You (and Sr. Jethro) will be relieved to know that I suffered no serious injuries.  The men split their games, with the Hospital taking the volleyball tournament (wearing yellow) and the Cardiac Center winning the football game (in white).  As far as I can tell, a good time was had by all.

Clinical Judgment

In the beginning of medical school, we learned the scientific and humanistic foundations of medical practice.  It isn’t far into medical school, however, before students are introduced to “clinical judgment.”  I think of this as the decision-making process used to decide on a course of action based on the information available, which is always incomplete.  Even within well-studied conditions, it is not possible to know with certainty to which population of patients the person in front of you belongs, and even if the diagnosis is certain, the response to treatment might not be.  Add to this the necessary cost-analysis and the inherent conflicts of interest, and the practice of medicine can suddenly become quite challenging.  Usually within one’s own practice, a physician becomes accustomed to the various considerations that are required, so that only the rare patient is enough out of the ordinary to require extensive additional concern.  In the US, it is likely that your patient is actually in a population that has been studied, that any relevant guidelines apply to him or her, and that if you are wrong you will have an opportunity to follow through with another decision.

Although western physicians have contributed greatly to the care of the poor in developing countries through mission teams and individual efforts, I have always found this judgment issue to be quite challenging in a new location and culture.  It is difficult on a short-term basis to know what options the patient has available, what the risks are in that patient for the procedure or treatment that you want to give (given the differences in equipment, sterilization, and so forth), and how complications will be addressed.  Here in Shisong, we have the opportunity to provide, in many ways, “first-world” medical care to cardiac patients on a long-term basis; yet the judgment issues remain challenging and the uncertainty, while not paralyzing, is disconcerting at best.  In western countries, rheumatic heart disease is not defeated but it is rare, and to see severe rheumatic disease in a very young person is nearly unheard of.  [This is the point at which the issue of prevention is usually raised.  Everyone who treats advanced rheumatic disease in developing countries is aware that the problem should be preventable.  How to prevent it in this cultural setting is less obvious, and in the meantime it does not seem appropriate to refuse to treat the patients in whom the disease has not been prevented.]
 

Dr. Mve Mvondo and I have written an article for submission to a journal which addresses the issue of repair vs. replacement of diseased mitral valves in sub-Saharan Africa.  Although the article addresses primarily the treatment of mitral valve regurgitation, several of the concerns are general.  I outline a few of them here for your understanding (for my non-medical readers, some of these are not unique to Africa and apply to the decision-making process in our own lives in the US, especially if you have faced a rare disease or a treatment not covered by insurance).  Most of the patients who present for surgery are young (between 10 and 30).  Patients who are young who require valve replacement almost always receive a mechanical valve, because their durability is much better than current tissue valves.  There are several issues associated with living with a mechanical valve, but the most important one is the need for anticoagulation.  Lifelong anticoagulation is necessary to prevent strokes and to maintain valve function.  In the US, this is a burden because of the need for on-going monitoring as well as the risk for bleeding.  Athletes and people with high-risk jobs occasionally refuse this treatment rather than change their lifestyle.  Although there are modern valves which might require less anticoagulation, it is not yet certain that it is safe to forego anticoagulation in most circumstances.  Here in Cameroon, there are numerous additional considerations to subjecting a patient to lifelong coagulation.  First is the understanding of the patient that this is a necessary commitment.  It is not uncommon for a patient to stop their medication because they decided that it was unnecessary.  Another consideration is cost; neither the medication nor the monitoring is free, and most patients do not have insurance or much money.   The need for many patients to travel long distances to get their medication and monitoring also impedes successful therapy for many people.  Even where there are roads, most people do not own cars, and travel is also not free or easy.  Pregnancy is an important issue for many of these patients.  It is possible for many women to safely bear children, but it requires intensive prenatal care, careful drug management, and hospital delivery because of the risk of bleeding as well as the underlying poor cardiac function present in many of these young women.  This is a culture in which bearing several children is desired and expected.  Recommending against this is difficult, and in many cases impractical, so even if a patient agrees with all of the recommendations it is unwise to assume that she will follow through.

The alternative, then, in the case of mitral valve disease, is valve repair.  Although this is not meant to be an extensive discussion on mitral valve therapy, I will point out two important issues.  The best methods of valve repair in the setting of inflammatory disease, especially mitral stenosis, are controversial, and in western countries this is not routinely attempted.  Secondly, a failed valve repair here is even more of a problem than in the west.  Many patients will not return for follow-up, most patients cannot afford a second operation, and the risk of repeat chest surgery in this setting is significant given the limitations and costs of blood products, monitoring, and advanced supportive therapies.

An additional consideration here that is somewhat different than my practice in the US is the advanced stage of disease at which most patients present.  There are evidence—based guidelines in Europe and in the US recommending the stage at which the benefit of surgery will outweigh the risk.  Even if the risk of surgery is slightly higher in this setting (and I am not sure that it is), most patients present well past the recommended time of surgery.  Even if they come for consultation early in their disease, they wait a long time for surgery due to fear, lack of support, and financial considerations.  And of course, the options that Americans and Europeans have of heart transplant or artificial hearts are not available at all without travelling abroad.

One final area that looms large, that I have mentioned above, is cost.  In the US, cost is something of a general issue, and we do not often consider it as a deciding factor in the treatment of individual patients.  At the cardiac center, we can overcome the cost issue for the in-patient care of many patients.  However, this does not make the issue go away.  Some patients have co-morbidities or suspicion of co-morbidities, and additional evaluation could be beneficial.  We do not have a CT scanner in Shisong (although hopefully that is coming), so if a patient has a problem best evaluated by CT scan, they must travel several hours and pay for the CT scan, and bring the results back to us.  There is other testing and treatments for which patients must travel and pay additional fees, and we must decide whether to proceed without the tests or not.  In the US, there is always a point at which further testing is not cost-effective, but that moving target is even more difficult here.  From an anesthesia standpoint, deciding to proceed now versus advocating waiting until different drugs or supplies are available is not something that often applies in my practice in Rochester.

In the US, we often over-test, over-treat, still fail to have optimal outcomes, and assume that someone else will pay for all of it.  Here, the answer is frequently, “you can’t have that,” and we are still left to make decisions with the information that we have based on our discussions with the patients and hope to honor their trust and dignity.  I am confident that we always act with good will and that the personal conflicts of interest are minimized.  The rest remains difficult.


From today’s liturgy: “They ate and had their fill, and what they craved the Lord gave them; they were not disappointed in what they craved.” (Cf. Ps 78:29-30)

Ending the week with Jesus

So we had a busy (and successful) week with our local team.  The patients are doing well and one has left the ICU.  Unfortunately, they are young patients who required valve replacement for rheumatic heart disease.  Many thanks to the generous sponsors who make it possible to help these young, otherwise healthy people. 

On Monday, the operating theatre staff finally had our Christmas party.  It had been delayed for various reasons.  Each staff member drew a name from a dish of a coworker to pray for during the Christmas season and to give a gift at the party.  Of course, there were speeches before the gifts were presented and food afterwards.  I presented my gift first, so I do not think anyone had started taking pictures yet.  Here is Mr. Benoit receiving his gift from Mr. Ralph:

 

One of the things I try to do is to attend evening prayer with the sisters (I will write about the community that I spend time with in another post soon), so today we finished in time for me to attend.  As usual, I forgot that it was Friday and that there would be Exposition and Holy Hour, and tonight was a special treat.

Some of the readers of this blog know that one of the central aspects of our Catholic faith is the Eucharist.  We believe that when Jesus said “This is my body” that he meant this and not something else, that he has the power to make it happen, and that the priest at the consecration during Mass makes present the sacrifice of Christ and the body of Christ under the appearance of bread.  This means that later, the body of Christ remains and if reserved in the tabernacle that His sacramental presence is ongoing; it is then appropriate to adore Him in this form.  Usually the host is placed in a monstrance and placed in a prominent location.  This, then, is what was available to me this evening to end my week.  (Well, almost end, anyway.  There are still patients in the ICU.)  Sister Mary Charles, who was assigned to organize the prayer times this week, began with several minutes of reflective praise songs.  Although the community is very small (especially since people are away), there are multi-part harmonies and drums.  A reflective and focused (recollected) atmosphere reigns and it is easy to be aware of the presence of God and the love of the sisters, even with the children of the orphanage in the next room.  Evening prayer consists, of course, of “Evening Prayer” from the Divine Office or Liturgy of the Hours, and also the Angelus, the De Profundis (Psalm 130), a prayer for the sainthood cause of Sr. Maria Huber, the foundress of the TSSF, and sometimes some other prayers.  The holy hour generally concludes with Night Prayer (from the Liturgy of the Hours).

From Evening Prayer:

We ask you to remember tonight those who are in great difficulty:

give new heart to those who have lost their faith in man and in God, to those who seek the truth but cannot find it.