Compliance

One of the remarkable things about modern medicine is how good the drugs can be if they are used correctly. All 3 of the individuals below were on their death beds with extremely low CD4 counts. One of our patients (not pictured) had a CD4 count of 2 (as a reference, an HIV patient with a CD4 count of 200 is considered immunocompromised - as in, a count of even 200 is very low). Another was found on the side of the road in a wheelbarrow. For some, their families had essentially abandoned them in the hospital to die. However, thanks to the modern medicine and the grace of God, these and other individuals were able to recover and are healthy today.

Although we do not yet have a cure for HIV, the current drugs used for treating it can be surprisingly effective. During one of my medical school interviews, the interviewer who ran an HIV clinic, said that it was exciting practicing in that field because he saw, "patients who had one foot in the grave seemingly come back to life." Despite the effectiveness of the therapies however, one of the major issues in realizing this effectiveness is the lack of compliance - oftentimes patients will not take their mediations, take wrong dosages, or take pill combinations incorrectly. And a large part of what we do when we visit the patients in their homes, is to make sure that they are taking their medications consistently and correctly - we ask them to show us their medicines, we count their pills, and we "quiz" them on which pills they take every day and how.

In spite of all of these efforts, sometimes the patients will still not comply. Sometimes I can't believe how non-compliant patients can be: there was a woman who after about 2.5 months still did not understood how to take her medicines and was getting more and more unhealthy; in another family, the mother was repeatedly getting drunk on illegal moonshine (changaa) and unable to provide the drugs correctly to her children (We eventually put the eldest son in charge of giving the medicines). In my mind, I wonder if they understand the stakes; their lives are on the line and directly correlated with their taking the medications correctly. HIV ruins lives, families, communities, and nations. Here's a graph I found on wikipedia about the plummeting life expectancy in Africa due to HIV/AIDS, erasing all the gains that had been made in past decades.

The non-compliance of the patients with respect to their physical health reminded me of my own non-compliance regarding my spiritual health. Jesus essentially gives us 2 "prescriptions":

"'Teacher, which is the greatest commandment in the Law?"' Jesus replied: 'Love the Lord your God with all your heart and with all your soul and with all your mind.' This is the first and greatest commandment. And the second is like it: 'Love your neighbor as yourself.' All the Law and the Prophets hang on these two commandments.'" - Matthew 22:36-40 (NIV)

Despite these prescriptions, how many times have I loved myself above God or treated my neighbor lesser than myself. Pretty much all the time. Just like our lives, families, and communities would be better if everyone took their medicines correctly and avoided harmful behavior that spread HIV, those same institutions would be improved if we followed those prescriptions. Just like we have dosing regimens not to constrain them but to help them, we have been given these commandments to not to restrict our freedoms but to improve our lives. But we all see that the world is not the way it should be and that we not been living the way we should be living - and this has been true since the very beginning, starting with Adam. Indeed, we don't fully realize that the stakes in failing to follow God's prescriptions are infinitely higher than failing to follow a doctor's prescriptions around drug therapies.

Theoretically, stopping the spread of HIV could be simple: avoid unprotected sex, don't use dirty needles, and for those already infected, take medications correctly so as to reduce the viral load to low enough levels where it would be unlikely to transmit the disease. Nonetheless, visiting and speaking to patients sometimes offers a glimpse of how difficult it can be to take medications correctly. For example, a patient might find themself feeling better so they might take their medicines less frequently so as to save pills and thus money; a patient might just not have the time/energy after juggling work and home duties to go to the clinics, which are often located far away and inaccessible; sometimes, even if the patients make it to the clinics, they are corrupt or unreliable and don't provide the right medicines to the patients; some patients just don't understand or have the capacity to understand (the woman who was noncompliant for 2.5 months had AIDS dementia). But I am still routinely surprised by the apparently poor decisions of some patients and will never fully understand their behavior as I have not been in their shoes.

But whereas I would not be willing to live the lives of these HIV patients - to contract the disease and to live in Kenya's slums - Jesus voluntarily became a man and became the perfect example for us. Where Adam had failed to be compliant, Jesus was perfect, living the life we should have lived and died the death we should have died. But beyond that, through this obedience and death, we have been saved from ourself.

"Therefore, just as sin entered the world through one man, and death through sin, and in this way death came to all men, because all sinned— for before the law was given, sin was in the world. But sin is not taken into account when there is no law. Nevertheless, death reigned from the time of Adam to the time of Moses, even over those who did not sin by breaking a command, as did Adam, who was a pattern of the one to come.



But the gift is not like the trespass. For if the many died by the trespass of the one man, how much more did God's grace and the gift that came by the grace of the one man, Jesus Christ, overflow to the many! Again, the gift of God is not like the result of the one man's sin: The judgment followed one sin and brought condemnation, but the gift followed many trespasses and brought justification. For if, by the trespass of the one man, death reigned through that one man, how much more will those who receive God's abundant provision of grace and of the gift of righteousness reign in life through the one man, Jesus Christ.


Consequently, just as the result of one trespass was condemnation for all men, so also the result of one act of righteousness was justification that brings life for all men. For just as through the disobedience of the one man the many were made sinners, so also through the obedience of the one man the many will be made righteous.

The law was added so that the trespass might increase. But where sin increased, grace increased all the more, so that, just as sin reigned in death, so also grace might reign through righteousness to bring eternal life through Jesus Christ our Lord" - Romans 5:12-20 (NIV)

The doctor at the hospital I stayed at last week said that the war against HIV as it is currently dealt with now is a hopeless cause - people's behavior is especially difficult to change, especially given different aspects of the culture here (ie: aversion to using condoms, polygamy, wife inheritance). We can keep trying to treat and prevent new infections using traditional methods but we're just putting out fires and not containing the spread - the disease could only be eradicated on a large scale if a vaccine is invented.

If we are non-compliant to the "prescriptions" granted to us by God, then to me, the cross is like the "vaccine" which preempts the inevitability of our non-compliance, addresses our intrinsic inclination to sin, and eradicates death once and for all. In light of the frustrations that our team, doctors, mothers, children, communities and nations face every with dealing with the HIV problem and non-compliance, the new covenant in Jeremiah made so much more sense to me. The compliance issue with HIV offered the backdrop by which I might be offered a glimpse of God's frustration and heartbreaking disappointment at the Israelite peoples' failure to uphold the earlier covenants.

"The time is coming," declares the LORD,

"when I will make a new covenant
with the house of Israel
and with the house of Judah.

It will not be like the covenant
I made with their forefathers
when I took them by the hand
to lead them out of Egypt
because they broke my covenant,
though I was a husband to them,"
declares the LORD.

"This is the covenant I will make with the house of Israel
after that time," declares the LORD.
"I will put my law in their minds
and write it on their hearts.
I will be their God,
and they will be my people.

No longer will a man teach his neighbor,
or a man his brother, saying, 'Know the LORD,'
because they will all know me,
from the least of them to the greatest,"
declares the LORD.
"For I will forgive their wickedness
and will remember their sins no more." - Jeremiah 31:31-34