I went to visit Cromwell again yesterday and he's much the same. The doctor told him that all the tests came back normal so far, and that they would do an x-ray (I'm not sure of what). He's still just lying in bed with the glucose drip and aspirin, nothing else, and I'm not sure that anyone has told him that it may take quite a while to recover. He asked me if I was going to run this morning (usually we run Tuesdays), I said of course not, and he smiled a small smile and said that he thought he'd be better by next week. Although he's holding it together, he seems pretty down and the thought occurred to me that it might be nice to flood him with get well cards. If any of you are interested, send cards to me at:
Joanne Jorissen
KCN - Research Center
P/Bag 1
Lilongwe, Malawi
AFRICA
Just write his name on the back so it won't confuse the postoffice or the people sorting mail at the College.
Tuesday, May 31, 2005
Monday, May 30, 2005
Highs and Lows
I had a wonderful weekend, the ALSO group treated me to a divine 24 hours of R&R at the 
lake – sun, good conversation, lots of laughter, swimming, good food, and snorkeling among beautiful fish (there are more than 280 species of fish there). The lake is amazing. It appears so vast that at first glance you might think you’ve arrived at the Ocean; it even has its own gentle waves that lap softly at white sand beaches. This was my first real get-away here in Malawi away and I ate it up. It is only an hour’s drive from Lilongwe, but without a car it has seemed inaccessible. I’m going to have to find a way to get there via minibuses and plan occasional camping excursions, now that I know what I’ve been missing, I don’t want to go on missing it.
Sunday we packed up early so the group could make their flight out of Malawi at 1pm. Some of them will come back in October for another follow-up course and I’m already eager for their return. In such a short time I grew accustomed to the presence of these midwives and physicians around Bottom, I looked forward to their smiles, hugs, and words of encouragement/advice. Just knowing they were around made the difficult experiences a bit easier to bear. They have left the hospital in much better shape than they found it but it will seem emptier without them.
This weekend was great, mostly fun and restful and but it ended on a sad note . . .
Saturday, as we were driving out of Lilongwe I received a call from Cromwell’s brother (Cromwell is my friend who runs with me a couple times a week) saying that Cromwell had collapsed and was in the hospital. He didn’t have any additional information at the time. So, when I returned to Lilongwe on Sunday, I made my way to the hospital around noon and found him asleep in bed with a glucose drip running. The minutes before he opened his eyes were surreal, finding him in that environment, knowing something was wrong but not having any idea of what it could be. I just watched him as he slept and he looked to be the very same healthy and fit friend who meets me at the gate at 5am for our runs. Nothing seemed ominous in the room itself, only one IV running slowly, no tubes or monitors or bandages, no hospital personnel, and yet at the same time two days had passed since he collapsed and he was still in the hospital. The best case and worst case scenarios sprinted through my head, but the minute he opened his eyes and began talking it became clear. The left side of his mouth remained fixed while the right side moved full of words and expression. Initially I hoped it was just Bell’s Palsy but then he said he couldn’t move his left hand or left leg either. He had had a stroke.
Thursday he had called to tell me he would be visiting his brother Friday and wouldn’t make our usual run. He said Thursday was a normal day, he even played soccer for about an hour with a group of kids. But, around 4am that night, he tried to get up and just collapsed because his leg wasn’t working. His brother immediately brought him to the hospital where they gave him aspirin and started a glucose drip. He said they did some tests for his heart and might have drawn blood (I was unclear about that from his story) but they have yet to give him the results for anything.
Why does a 29 year old have a stroke?! And, why is he still waiting in a hospital bed three days after the incident without any sort of assessment, knowledge, or care plan? He said a few times that he would be all right (another example of the staunch optimism of Malawians) and I certainly hope so, but I cannot imagine that he’ll be back to playing soccer anytime soon. I feel so sad. He is my friend. One minute he’s playing soccer and the next he’s a hemiplegic. He’s so young and was so active, and, not that tragedy ever notices but, he’s such a good person. I am learning an unfortunate lesson that is being repeated again and again, which is that all Malawians have had at least one major tragedy in their lives, whether on not it is visible in their outward appearance, you can be sure the story is there.
lake – sun, good conversation, lots of laughter, swimming, good food, and snorkeling among beautiful fish (there are more than 280 species of fish there). The lake is amazing. It appears so vast that at first glance you might think you’ve arrived at the Ocean; it even has its own gentle waves that lap softly at white sand beaches. This was my first real get-away here in Malawi away and I ate it up. It is only an hour’s drive from Lilongwe, but without a car it has seemed inaccessible. I’m going to have to find a way to get there via minibuses and plan occasional camping excursions, now that I know what I’ve been missing, I don’t want to go on missing it.Sunday we packed up early so the group could make their flight out of Malawi at 1pm. Some of them will come back in October for another follow-up course and I’m already eager for their return. In such a short time I grew accustomed to the presence of these midwives and physicians around Bottom, I looked forward to their smiles, hugs, and words of encouragement/advice. Just knowing they were around made the difficult experiences a bit easier to bear. They have left the hospital in much better shape than they found it but it will seem emptier without them.
This weekend was great, mostly fun and restful and but it ended on a sad note . . .
Saturday, as we were driving out of Lilongwe I received a call from Cromwell’s brother (Cromwell is my friend who runs with me a couple times a week) saying that Cromwell had collapsed and was in the hospital. He didn’t have any additional information at the time. So, when I returned to Lilongwe on Sunday, I made my way to the hospital around noon and found him asleep in bed with a glucose drip running. The minutes before he opened his eyes were surreal, finding him in that environment, knowing something was wrong but not having any idea of what it could be. I just watched him as he slept and he looked to be the very same healthy and fit friend who meets me at the gate at 5am for our runs. Nothing seemed ominous in the room itself, only one IV running slowly, no tubes or monitors or bandages, no hospital personnel, and yet at the same time two days had passed since he collapsed and he was still in the hospital. The best case and worst case scenarios sprinted through my head, but the minute he opened his eyes and began talking it became clear. The left side of his mouth remained fixed while the right side moved full of words and expression. Initially I hoped it was just Bell’s Palsy but then he said he couldn’t move his left hand or left leg either. He had had a stroke.
Thursday he had called to tell me he would be visiting his brother Friday and wouldn’t make our usual run. He said Thursday was a normal day, he even played soccer for about an hour with a group of kids. But, around 4am that night, he tried to get up and just collapsed because his leg wasn’t working. His brother immediately brought him to the hospital where they gave him aspirin and started a glucose drip. He said they did some tests for his heart and might have drawn blood (I was unclear about that from his story) but they have yet to give him the results for anything.
Why does a 29 year old have a stroke?! And, why is he still waiting in a hospital bed three days after the incident without any sort of assessment, knowledge, or care plan? He said a few times that he would be all right (another example of the staunch optimism of Malawians) and I certainly hope so, but I cannot imagine that he’ll be back to playing soccer anytime soon. I feel so sad. He is my friend. One minute he’s playing soccer and the next he’s a hemiplegic. He’s so young and was so active, and, not that tragedy ever notices but, he’s such a good person. I am learning an unfortunate lesson that is being repeated again and again, which is that all Malawians have had at least one major tragedy in their lives, whether on not it is visible in their outward appearance, you can be sure the story is there.
Friday, May 27, 2005
Thirteen Babies
I just completed my five days of orientation in Labor and Delivery. Orientation is not quite the right term for this period, basically a nurse took two minutes to show me around the room, pointing out where meds are kept, gloves, suture, IV, etc. and then turned me loose. There is no practice of assigning particular women to a particular nurse. Everything is done on a first come first serve basis or, more accurately, on a whoever-is-walking-by basis. Someone is moaning or calling for help, go there, a head is crowning, glove up and run to make the catch. At the moment, this place represents the antithesis of true midwifery. True midwifery being . . . staying with a woman throughout her labor, offering constant support, encouraging movement, protecting privacy, and in general working in partnership with the women. But, there is hope for change.
The scene: there are eight beds on one side of the labor room (the low risk area) and six on the other side (the high risk area). The beds are simple metal frames high off the ground (too high to get up and down without the use of a step ladder, but still not high enough to protect the backs of those catching the babies) with bare mattresses. Among the items a woman is required to bring to L&D is a plastic sheet (they look just like large black garbage bags and aren't much bigger than that, they don't cover the entire mattress). Once a woman is in active labor, she enters L&D carrying all of her things and is told to find a bed. Finding an empty, and hopefully clean mattress, she spreads out the plastic sheet, puts a chitenge on top, undresses, climbs on to the bed, and covers herself with another chitenge. Those of you who have either experienced a birth or seen one, know how messy it can be and you can imagine that often times the chitenges are soaked not far into the process, leaving the poor woman lying in a cold puddle - the plastic sheet doing nothing to protect the larger mattress on which it rests. The mattress is cleaned and dried only after the delivery and an hour observation period. It is really hard to keep the women warm and dry since there are no sheets or blankets and only a few cleaning rags. Most women are so eager for their shower/bucket bath, which of course is cold but is a better alternative to lying on those mattresses. The women get up, bathe, wash their chitenges, and go to the low risk postpartum room for 24 hours. I'm still not exactly sure how that works since there are fewer beds in that room than in L&D. A lucky few get beds or mattresses on the floor and the rest . . .?
Over the past two weeks the visiting Scottish midwives and OBGYNs did a fabulous job of putting a new face on L&D. They scrubbed from ceiling to floor, painted the walls, cleaned the curtains, had new cupboards made for materials, and donated a bunch of useful stuff like shower curtains to use instead of the plastic - which can easily changed and washed - and sheets. So it's looking much better. Hopefully the improvements will last, and the curtains, sheets, and other items will not walk out too soon. One of my Malawian friends suggested writing, "Stolen from Bottom Hospital," on all the sheets. I laughed, but apparently it's already being done at many institutions and it's still not a strong enough deterrent for theft. Theft is such a complicated issue. Everyone is poor. Who is stealing? employees? patients? guardians? Is it just poverty? A sense of entitlement? Are people earning money by selling stolen items? I have been told that so many people and organizations have donated things over time but the items never stay long, slowly and inevitably they all disappear. I recently heard an interesting theory, "Poverty and wealth both have an equal ability to corrupt." I have many jumbled thoughts about development work, poverty, and charity but perhaps I should come back to them later, on to the births . . .
I caught 13 babies in five days (3, 3, 4, 1, and 2), 8 boys and 5 girls. I was a bit nervous the first day, since almost a year had passed since the last birth I had attended, but it all came back. Everyone left the labor ward in their mother's arms within an hour or two of their birth, even though I did have to resuscitate one little boy who was born blue and floppy. This time I managed to find a bag and mask quickly, warded off all those who wanted to suction, and he was breathing, crying, sucking, and kicking within minutes. I suppose (I hope) each time will be a little easier and that soon, even with the surge of adrenaline, I will be calm, gentle, precise.
I feel good about the care I provided this week, sure it could have been better - especially if I spoke Chichewa - but I did my best, and the moms seemed happy and the babies healthy. On my first day, one of the laboring women was rattling away in Chichewa to me and when I called a nurse over to find out what she was saying, the nurse told me that she just wanted to talk to me as a distraction. I asked if she wanted someone else to be with her since I couldn't understand and she pointed at me and said "Ayi, awa" (No, her). That was nice and she continued talking to me in Chichewa.
All in all it was a good week. Exhausting but good. I am being forced to learn my limits, and recognize when I really physically can't give any more before I've had a break. I've helped convince a few people to change their practices (i.e. no suctioning, less episiotomies, and starting with a lower dose of miso for inductions (they are using 100-200mcg of miso in one dose for induction?!)). And, of course I'm learning a ton too; so many lessons are packed into each day.
This week did also have its tragedies. Friday morning I came in to find one of the visiting OBGYNs resuscitating a baby. The mother had a long difficult labor, an infection, and was delivered by an emergency c-section. The baby had been left for sometime before he was found by the OB who started the resuscitation. In the end, after 50 minutes with a heartbeat but no respiratory efforts (and no other life sustaining options available), the OB stopped the resus and we stayed with the baby until it died.
This morning one of the interns came by the college, where I'm planted doing emails, to return a book and told me that last night they had a maternal death. Apparently the woman had seized at home and was taken to a few traditional healers before being brought to the hospital. On L&D she was given Hydralazine to lower her blood pressure and MgSO4 to prevent more seizures, she was then left alone for about 10 minutes and when people returned to check on her they found that she had died. She may have died from her eclampsia but she may have died from the medication (MgSO4 causes respiratory depression at high doses), no one will ever know.
Bottom Hospital?!
The scene: there are eight beds on one side of the labor room (the low risk area) and six on the other side (the high risk area). The beds are simple metal frames high off the ground (too high to get up and down without the use of a step ladder, but still not high enough to protect the backs of those catching the babies) with bare mattresses. Among the items a woman is required to bring to L&D is a plastic sheet (they look just like large black garbage bags and aren't much bigger than that, they don't cover the entire mattress). Once a woman is in active labor, she enters L&D carrying all of her things and is told to find a bed. Finding an empty, and hopefully clean mattress, she spreads out the plastic sheet, puts a chitenge on top, undresses, climbs on to the bed, and covers herself with another chitenge. Those of you who have either experienced a birth or seen one, know how messy it can be and you can imagine that often times the chitenges are soaked not far into the process, leaving the poor woman lying in a cold puddle - the plastic sheet doing nothing to protect the larger mattress on which it rests. The mattress is cleaned and dried only after the delivery and an hour observation period. It is really hard to keep the women warm and dry since there are no sheets or blankets and only a few cleaning rags. Most women are so eager for their shower/bucket bath, which of course is cold but is a better alternative to lying on those mattresses. The women get up, bathe, wash their chitenges, and go to the low risk postpartum room for 24 hours. I'm still not exactly sure how that works since there are fewer beds in that room than in L&D. A lucky few get beds or mattresses on the floor and the rest . . .?
Over the past two weeks the visiting Scottish midwives and OBGYNs did a fabulous job of putting a new face on L&D. They scrubbed from ceiling to floor, painted the walls, cleaned the curtains, had new cupboards made for materials, and donated a bunch of useful stuff like shower curtains to use instead of the plastic - which can easily changed and washed - and sheets. So it's looking much better. Hopefully the improvements will last, and the curtains, sheets, and other items will not walk out too soon. One of my Malawian friends suggested writing, "Stolen from Bottom Hospital," on all the sheets. I laughed, but apparently it's already being done at many institutions and it's still not a strong enough deterrent for theft. Theft is such a complicated issue. Everyone is poor. Who is stealing? employees? patients? guardians? Is it just poverty? A sense of entitlement? Are people earning money by selling stolen items? I have been told that so many people and organizations have donated things over time but the items never stay long, slowly and inevitably they all disappear. I recently heard an interesting theory, "Poverty and wealth both have an equal ability to corrupt." I have many jumbled thoughts about development work, poverty, and charity but perhaps I should come back to them later, on to the births . . .
I caught 13 babies in five days (3, 3, 4, 1, and 2), 8 boys and 5 girls. I was a bit nervous the first day, since almost a year had passed since the last birth I had attended, but it all came back. Everyone left the labor ward in their mother's arms within an hour or two of their birth, even though I did have to resuscitate one little boy who was born blue and floppy. This time I managed to find a bag and mask quickly, warded off all those who wanted to suction, and he was breathing, crying, sucking, and kicking within minutes. I suppose (I hope) each time will be a little easier and that soon, even with the surge of adrenaline, I will be calm, gentle, precise.
I feel good about the care I provided this week, sure it could have been better - especially if I spoke Chichewa - but I did my best, and the moms seemed happy and the babies healthy. On my first day, one of the laboring women was rattling away in Chichewa to me and when I called a nurse over to find out what she was saying, the nurse told me that she just wanted to talk to me as a distraction. I asked if she wanted someone else to be with her since I couldn't understand and she pointed at me and said "Ayi, awa" (No, her). That was nice and she continued talking to me in Chichewa.
All in all it was a good week. Exhausting but good. I am being forced to learn my limits, and recognize when I really physically can't give any more before I've had a break. I've helped convince a few people to change their practices (i.e. no suctioning, less episiotomies, and starting with a lower dose of miso for inductions (they are using 100-200mcg of miso in one dose for induction?!)). And, of course I'm learning a ton too; so many lessons are packed into each day.
This week did also have its tragedies. Friday morning I came in to find one of the visiting OBGYNs resuscitating a baby. The mother had a long difficult labor, an infection, and was delivered by an emergency c-section. The baby had been left for sometime before he was found by the OB who started the resuscitation. In the end, after 50 minutes with a heartbeat but no respiratory efforts (and no other life sustaining options available), the OB stopped the resus and we stayed with the baby until it died.
This morning one of the interns came by the college, where I'm planted doing emails, to return a book and told me that last night they had a maternal death. Apparently the woman had seized at home and was taken to a few traditional healers before being brought to the hospital. On L&D she was given Hydralazine to lower her blood pressure and MgSO4 to prevent more seizures, she was then left alone for about 10 minutes and when people returned to check on her they found that she had died. She may have died from her eclampsia but she may have died from the medication (MgSO4 causes respiratory depression at high doses), no one will ever know.
Bottom Hospital?!
Thursday, May 19, 2005
The Bright Side
A group came to Lilongwe from Scotland this week to teach a 2-day course on Advanced Life Saving Skills in Obstetrics (ALSO) to a group of nurses, midwives, physicians, and clinical officers here. Of the nine instructors, 7 were midwives. It was a great course for multiple reasons (1) the information was great, very complete, evidence-based, and supporting interventions only when absolutely necessary; (2) there was a lot of practice with dummies and hands-on activities; (3) all levels of providers participated, it was a nice leveling experience; (4) the instructors were all volunteering their time and are still here for another week just cleaning and painting the labor ward. They're trying to recruit people here to teach the course elsewhere in Malawi and they said they would like me to be an instructor after I have a bit more experience (maybe only 6 months). So that is an exciting possibility.
This morning when I walked in, I was told that a mom was about to have a vacuum delivery so I went to watch. When I got there the baby was out, gasping and the clinical officer was calmly standing over it just waiting for a suction. He asked me how I was and I said, "fine, how's the baby?" and he said "not so good." He had just completed the same ALSO course with me where we were taught not to suction, because it does more harm than good (it can damage the baby's throat and mouth in addition to causing a vasovagal response which will drop the BP and heart rate further) and just to start resuscitation and yet there he was standing over this baby who was looking back at him wide-eyed and shocked. I gently reminded him about what we learned but then an OB who had not taken the course came and instructed him to take the baby to the nursery for suctioning and so he started off, picking up the baby by the ankles (another no-no since it can damage the baby's spinal cord and injure the neck). The Scottish midwives saw the scene from across the room where they were cleaning and one came over and gave me a hug, bringing tears to the surface I didn't even know were there. Coming to the hospital is like plunging into ice cold water first thing in the morning, painful at first, but once you're in, you adjust, smile, and begin.
I want to add another thought here about Dr. Meguid. I have been seeing him more and more around the hospital and he also took the course this week. I am so glad he's here. He's constantly reminding me to smile, checking in to see if I'm okay, and reassuring me that change is happening and that it will happen. He makes me believe that it is possible to turn this place around. He told me that he's been working in different places in Africa and that the reason he has chosen clinical as opposed to policy work is because, "At least you can make a difference to one person, even if they forget you the minute they leave, you still made a difference." I agree.
On that note, I checked-in with the 21-year-old today and she was smiling. She motioned from her waist up, showed me her wounds and said, "bwino bwino" (very good). Talk about looking on the bright side.
This morning when I walked in, I was told that a mom was about to have a vacuum delivery so I went to watch. When I got there the baby was out, gasping and the clinical officer was calmly standing over it just waiting for a suction. He asked me how I was and I said, "fine, how's the baby?" and he said "not so good." He had just completed the same ALSO course with me where we were taught not to suction, because it does more harm than good (it can damage the baby's throat and mouth in addition to causing a vasovagal response which will drop the BP and heart rate further) and just to start resuscitation and yet there he was standing over this baby who was looking back at him wide-eyed and shocked. I gently reminded him about what we learned but then an OB who had not taken the course came and instructed him to take the baby to the nursery for suctioning and so he started off, picking up the baby by the ankles (another no-no since it can damage the baby's spinal cord and injure the neck). The Scottish midwives saw the scene from across the room where they were cleaning and one came over and gave me a hug, bringing tears to the surface I didn't even know were there. Coming to the hospital is like plunging into ice cold water first thing in the morning, painful at first, but once you're in, you adjust, smile, and begin.
I want to add another thought here about Dr. Meguid. I have been seeing him more and more around the hospital and he also took the course this week. I am so glad he's here. He's constantly reminding me to smile, checking in to see if I'm okay, and reassuring me that change is happening and that it will happen. He makes me believe that it is possible to turn this place around. He told me that he's been working in different places in Africa and that the reason he has chosen clinical as opposed to policy work is because, "At least you can make a difference to one person, even if they forget you the minute they leave, you still made a difference." I agree.
On that note, I checked-in with the 21-year-old today and she was smiling. She motioned from her waist up, showed me her wounds and said, "bwino bwino" (very good). Talk about looking on the bright side.
To Be A Mother
Last week I began my orientation in the postnatal ward. This ward consists of two large rooms with about 20 patients each, two medium sized rooms of 6 each and two small rooms with 3 patients each. Once again, all cared for by a single nurse and two nurse assistants (a.k.a. auxiliary nurses). The women here are mostly post-cesearian patients but these rooms also house women with preeclampsia and eclampsia, symphasis pubis dyastisis, women with intrauterine fetal demises (IUFD) awaiting delivery (laying on mattresses aside women nursing their healthy newborns).
Today I saw a woman who delivered premature triplets at home. They were all alive when she arrived at the hospital but when I went to see them they were already wrapped and set aside in a corner of the nursery. The nurse said, “They were so cold already and they didn’t stay long.” No one had told the mother yet, the guardians had been told but not the mother (apparently culturally the guardians are supposed to tell the mother).
Then, I saw a 19-year-old who began laboring in Mozambique but who made her way from home to health center, once she or her birth attendant realized the labor was not progressing normally. The health center transferred her to a larger health center, which then transferred her to Bottom. When she arrived at Bottom, three days into her labor, her uterus had ruptured and her baby had died. She survived but her life cost her her uterus and a blood transfusion.
I saw two eclamptic patients. One of whom, when I asked for her clinic booklet, did not have a single blood pressure recorded for any of her prenatal visits. (Preeclampsia is an awful, poorly understood, systemic disease of pregnancy characterized by high blood pressures. A woman with preeclampsia can seize at any time, but women with elevated blood pressures are usually monitored carefully and given medications to prevent seizures, or delivered early. The only cure is delivery. Once a woman seizes it is said that she has eclampsia. Eclampsia is fairly rare in the developed world. One Scottish OBGYN recently told me that in his 9 years of practice he had never seen eclampsia.)
In the last hour of my day I saw a preeclamptic pregnant woman at 30 weeks gestation seize in the hall. Around the same time, the doctor determined that another woman, complaining of abdominal pain, was approaching septic shock and needed to be prepared for a stat uterine evacuation.
This of all really happened, and more. One day. Eight hours. Unbelievable.
There is so much going on, so much to take in, so much to feel. Some of it is only witnessed but some reaches deep inside. At certain moments I can feel a force moving through me, changing the rhythm of my heartbeat, pressing on my chest, electrifying the tips of my fingers, creating a wide empty space in my belly as an experience is permanently and viscerally recorded. Wherever I choose to be in the world, the stories in Malawi will continue unfolding with their drama, passion, and loss. I could be in so many places, but now I want to be here. Even in the most tragic moments there is solace in the experience of sharing the pain and in the hope that just as pain can compress and diminish life, if met with love, it can expand life. That is the hope.
Last week I met a girl 21 years old, who had had three pregnancies, three deliveries, and no surviving children. Her most recent pregnancy ended with a term IUFD and she was delivered via c-section. After waiting a week in the hospital for her incision to heal, she was discharged home but soon returned with a raging infection (peritonitis and a necrotic uterus) and had a hysterectomy. I met her while she was in the ward recovering from her hysterectomy. She is a beautiful girl but her young body takes the form of an old woman when she walks - bending forward, moving slowly, each step cautious and tender. And yet, even though everything about her communicates the depth of her loss, she almost always smiles at me when I enter the ward – warm and genuine. Over the past week, I always looked for her when I came and I watched her wounds, they are healing well. One large untidy line - thick here then thin, puckering at points - stretches down from her navel and a smaller perpendicular scar marks the right side of her abdomen. There is nothing subtle in her story or in its transcription on her small body.
I was with her today when the clinical officer discovered that somehow - in the process of her illness, and healing, and illness and healing - she had developed a fistula between her urethra and her vagina. He found a hole where it shouldn’t be, but there it is, and now urine constantly runs down her legs. They can and will surgically repair the fistula, but she must wait three months before her body will be ready for the operation. Three months after losing her third baby. Three months after losing her uterus. She will wait three months smelling of urine for yet another surgery. As he explained the problem to her, tears began to silently spill from the corner of her eyes. He said she could go back to the room, to her bed, and then she could go home. Just come back in three months.
I followed her back to her bed. In the middle of the noisy room filled with mothers and guardians, visiting husbands, crying babies, nursing babies, she collapsed on her bed in a small heap and began sobbing, “Amayi, amayi, amayi.” I rubbed her back and her head. And, when I realized she was crying “Mother mother mother . . .” the tears I was holding, broke free. We are so much the same in our expressions of pure emotions. We all call for the same person when life ravishes us, the only person whose love can offer comfort in moments of utter devastation - our mothers. I also realized with a bit of tragic irony that here in Malawi where women are raised to be mothers, this small woman had tried so hard to be just that and it broke both her body and her heart. I cried. And, I prayed. I prayed that she did have a loving mother and a loving husband, that she would again find hope and strength. I stayed with her until she fell asleep.
Only once she was still and her breathing deep and regular, did I notice a small wizened woman standing near the bed. She smiled a kind sorrowful smile and said, placing her hands over her heart and nodding at the sleeping girl, “Mwana anga,” my child.
Today I saw a woman who delivered premature triplets at home. They were all alive when she arrived at the hospital but when I went to see them they were already wrapped and set aside in a corner of the nursery. The nurse said, “They were so cold already and they didn’t stay long.” No one had told the mother yet, the guardians had been told but not the mother (apparently culturally the guardians are supposed to tell the mother).
Then, I saw a 19-year-old who began laboring in Mozambique but who made her way from home to health center, once she or her birth attendant realized the labor was not progressing normally. The health center transferred her to a larger health center, which then transferred her to Bottom. When she arrived at Bottom, three days into her labor, her uterus had ruptured and her baby had died. She survived but her life cost her her uterus and a blood transfusion.
I saw two eclamptic patients. One of whom, when I asked for her clinic booklet, did not have a single blood pressure recorded for any of her prenatal visits. (Preeclampsia is an awful, poorly understood, systemic disease of pregnancy characterized by high blood pressures. A woman with preeclampsia can seize at any time, but women with elevated blood pressures are usually monitored carefully and given medications to prevent seizures, or delivered early. The only cure is delivery. Once a woman seizes it is said that she has eclampsia. Eclampsia is fairly rare in the developed world. One Scottish OBGYN recently told me that in his 9 years of practice he had never seen eclampsia.)
In the last hour of my day I saw a preeclamptic pregnant woman at 30 weeks gestation seize in the hall. Around the same time, the doctor determined that another woman, complaining of abdominal pain, was approaching septic shock and needed to be prepared for a stat uterine evacuation.
This of all really happened, and more. One day. Eight hours. Unbelievable.
There is so much going on, so much to take in, so much to feel. Some of it is only witnessed but some reaches deep inside. At certain moments I can feel a force moving through me, changing the rhythm of my heartbeat, pressing on my chest, electrifying the tips of my fingers, creating a wide empty space in my belly as an experience is permanently and viscerally recorded. Wherever I choose to be in the world, the stories in Malawi will continue unfolding with their drama, passion, and loss. I could be in so many places, but now I want to be here. Even in the most tragic moments there is solace in the experience of sharing the pain and in the hope that just as pain can compress and diminish life, if met with love, it can expand life. That is the hope.
Last week I met a girl 21 years old, who had had three pregnancies, three deliveries, and no surviving children. Her most recent pregnancy ended with a term IUFD and she was delivered via c-section. After waiting a week in the hospital for her incision to heal, she was discharged home but soon returned with a raging infection (peritonitis and a necrotic uterus) and had a hysterectomy. I met her while she was in the ward recovering from her hysterectomy. She is a beautiful girl but her young body takes the form of an old woman when she walks - bending forward, moving slowly, each step cautious and tender. And yet, even though everything about her communicates the depth of her loss, she almost always smiles at me when I enter the ward – warm and genuine. Over the past week, I always looked for her when I came and I watched her wounds, they are healing well. One large untidy line - thick here then thin, puckering at points - stretches down from her navel and a smaller perpendicular scar marks the right side of her abdomen. There is nothing subtle in her story or in its transcription on her small body.
I was with her today when the clinical officer discovered that somehow - in the process of her illness, and healing, and illness and healing - she had developed a fistula between her urethra and her vagina. He found a hole where it shouldn’t be, but there it is, and now urine constantly runs down her legs. They can and will surgically repair the fistula, but she must wait three months before her body will be ready for the operation. Three months after losing her third baby. Three months after losing her uterus. She will wait three months smelling of urine for yet another surgery. As he explained the problem to her, tears began to silently spill from the corner of her eyes. He said she could go back to the room, to her bed, and then she could go home. Just come back in three months.
I followed her back to her bed. In the middle of the noisy room filled with mothers and guardians, visiting husbands, crying babies, nursing babies, she collapsed on her bed in a small heap and began sobbing, “Amayi, amayi, amayi.” I rubbed her back and her head. And, when I realized she was crying “Mother mother mother . . .” the tears I was holding, broke free. We are so much the same in our expressions of pure emotions. We all call for the same person when life ravishes us, the only person whose love can offer comfort in moments of utter devastation - our mothers. I also realized with a bit of tragic irony that here in Malawi where women are raised to be mothers, this small woman had tried so hard to be just that and it broke both her body and her heart. I cried. And, I prayed. I prayed that she did have a loving mother and a loving husband, that she would again find hope and strength. I stayed with her until she fell asleep.
Only once she was still and her breathing deep and regular, did I notice a small wizened woman standing near the bed. She smiled a kind sorrowful smile and said, placing her hands over her heart and nodding at the sleeping girl, “Mwana anga,” my child.
Monday, May 09, 2005
One Family
There is a girl who works in the office here. She serves tea and food to employees, does some cleaning and small secretarial tasks. She's 23. She's one of those people who always looks elegant, small and thin with perfect posture. She is quiet, friendly, and always smiling. Last week her sister died. Her mother had six children, but now all but two have died. Each sibling left a few more grandchildren in their mother's care, and now their household includes the grandmother, her 23 year old daughter, and eight grandchildren ranging in age from 7 to 20. The grandmother was the only one of her siblings to get an education, so she has always been the one to give financial support, never the one to receive it. Several of the grandchildren have finished high school but cannot continue on to college because of a lack of money. The 23 year old wants also to go to school but must work to pay school fees for the younger children ($30/term). I gave her some money today and told her I would help pay the school fees, I told her the money was from my friends and family. I just wanted to let you know that you have helped this family. Thank you.
Friday, May 06, 2005
The Little Things
This morning as I stepped out of the car on to the grounds of Bottom Hospital, a woman wearing a bright green chitingi and carrying a red plastic tub of water on her head, smiled and said, "Muli Bwanji, Joanna?" (How are you?). On Monday, my first day in the nursery, the nurse introduced me to the fifteen-or-so mothers in the nursery as they sat on the floor breastfeeding or expressing their milk into small plastic cups. The woman who greeted me remembered my name from that quick single introduction. Her greeting and beautiful white smile made my day.
The nursery at Bottom, like all the other wards is its own adventure. Only the sick babies stay here, the rest stay with their mothers and/or guardians and then are quickly discharged home. The nurse who works in the nursery is responsible for maybe 25 babies in the main room, another 5-10 in an isolation room, and then 5-10 in the kangaroo care room. [Mothers of very premature babies are taught to carry their babies skin to skin between their breasts until they gain significant weight. This process only begins in the hospital and should continue at home, babies are discharged as soon as they demonstrate a steady weight gain - many are discharged home weighing less than 2,000gms.]
The first task after the night nurse hands over the ward is "damp dusting," which involves wiping down all the babies' mattresses and then rewrapping each with a clean sheet. [I love that on my list of clinical experiences, which I will turn into the Nurses and Midwives Council at the end of orientation, the nurse actually wrote "damp dusting."] It's slightly tedious but in the process you also see and touch every baby, which is a good thing since vital signs are only taken once a shift. Today during damp dusting we found a little one under the heat lamp, lying with two others, who had probably died one or two hours before. I rewrapped him and the nurse showed me where to put him while we waited for the mother.
After damp dusting, the mothers come in carrying clean chitingis and plastic medicine cups to tend to their babies. The women fill the room, a few in chairs most on the floor. Many of the babies have problems nursing, so the mothers express their milk by hand into the plastic medicine cups and then slowly pour the milk into the little ones' mouths. It's a tender beautiful scene. Not all of the mothers come at once and of course there is always one or two who are left screaming while their friends feast. So today I picked up a sweet loud little girl not realizing at first that her mother was there breastfeeding her twin . . . These are the little moments that fill my heart - feeling the trust of the mother, watching me, smiling, as she breastfed one twin while the other fell asleep in my arms; then sitting on the floor with this mother, both of us laughing softly as we failed to wake the little beauty for the meal she wanted and needed so badly.
I wish I knew more about caring for sick and premature babies. Yana and Dzung, I wish you were next to me at these moments to give me a little guidance. The mothers and guardians do most of the work, I'm just there holding babies, making sure they're warm and dry, telling the nurse who did or didn't get a meal. Hopefully in time I'll learn more.
The nursery at Bottom, like all the other wards is its own adventure. Only the sick babies stay here, the rest stay with their mothers and/or guardians and then are quickly discharged home. The nurse who works in the nursery is responsible for maybe 25 babies in the main room, another 5-10 in an isolation room, and then 5-10 in the kangaroo care room. [Mothers of very premature babies are taught to carry their babies skin to skin between their breasts until they gain significant weight. This process only begins in the hospital and should continue at home, babies are discharged as soon as they demonstrate a steady weight gain - many are discharged home weighing less than 2,000gms.]
The first task after the night nurse hands over the ward is "damp dusting," which involves wiping down all the babies' mattresses and then rewrapping each with a clean sheet. [I love that on my list of clinical experiences, which I will turn into the Nurses and Midwives Council at the end of orientation, the nurse actually wrote "damp dusting."] It's slightly tedious but in the process you also see and touch every baby, which is a good thing since vital signs are only taken once a shift. Today during damp dusting we found a little one under the heat lamp, lying with two others, who had probably died one or two hours before. I rewrapped him and the nurse showed me where to put him while we waited for the mother.
After damp dusting, the mothers come in carrying clean chitingis and plastic medicine cups to tend to their babies. The women fill the room, a few in chairs most on the floor. Many of the babies have problems nursing, so the mothers express their milk by hand into the plastic medicine cups and then slowly pour the milk into the little ones' mouths. It's a tender beautiful scene. Not all of the mothers come at once and of course there is always one or two who are left screaming while their friends feast. So today I picked up a sweet loud little girl not realizing at first that her mother was there breastfeeding her twin . . . These are the little moments that fill my heart - feeling the trust of the mother, watching me, smiling, as she breastfed one twin while the other fell asleep in my arms; then sitting on the floor with this mother, both of us laughing softly as we failed to wake the little beauty for the meal she wanted and needed so badly.
I wish I knew more about caring for sick and premature babies. Yana and Dzung, I wish you were next to me at these moments to give me a little guidance. The mothers and guardians do most of the work, I'm just there holding babies, making sure they're warm and dry, telling the nurse who did or didn't get a meal. Hopefully in time I'll learn more.
Wednesday, May 04, 2005
A Happy Note
I realize that the last two entries have been less than cheery so I think I need to fill you in on some parts of life outside Bottom. Life is good.
I feel very content here. Of course I miss friends and family from home, but this place is really growing on me and in me. All the sights, and smells, and sounds, and foods that were at first foreign are becoming familiar and comforting. I am really loving my nsmia and am becoming pretty good at eating with my hands. I can hum along with all the popular songs. And, I know a lot of the city - unfortunately you do really need a car to get around this place. My Chichewa is not great but I'm still trying. (I speak so much English now. I realize that the women in the hospital don't speak any English so I'm thinking that I'll hire a tutor again.)
As for my social life. . . I am still running with the expats every Wednesday (and usually feel like I'm dying during the run) and sometimes I run with them on Mondays.
There is a bigger group that runs on Mondays, they call it the hash. Apparently there are hash races all over the world. Anyway, it involves searching for a trail that is set earlier in the day by "the hare" and then afterwards everyone just hangs out for a while drinking and talking. The expats I have met are all really nice and I have received a lot of invitations to different activities and outings but so far the running is all I have done. I'm enjoying my evenings at home with the Kaponda family and I have a few Malawian friends that I spend time with on the weekends. I even met a neighbor who runs so I've been waking at 5am to run with Cromwell a couple times a week. It is pitch black at that time here, since the days are getting shorter and we're entering "winter," but there are few cars on the road so you're not inhaling exhaust with each deep breath.
The Kapondas are wonderful and I still feel great being in their home. Yankho, Dr. Kaponda's daughter, just left this past weekend for Chicago to begin her undergrad there. So, that was a big event. It was nice to be a part of her send off, seeing her nervousness and her excitement made me feel like we were trading places on the planet. Chimwemwe, a niece to the Kapondas, and I go for walks a couple times a week. Janet, their cook, makes me practice my Chichewa daily, with great patience, I should add. And, Tonto, their son, makes sure my weekends are not entirely spent within the walls of the house - last night we went out with a couple of his friends to play pool and eat pizza.
So all this to say, I am living well. People are taking good care of me. And Malawi, which was once a small unknown spot on the map, now has its place in my heart.
I feel very content here. Of course I miss friends and family from home, but this place is really growing on me and in me. All the sights, and smells, and sounds, and foods that were at first foreign are becoming familiar and comforting. I am really loving my nsmia and am becoming pretty good at eating with my hands. I can hum along with all the popular songs. And, I know a lot of the city - unfortunately you do really need a car to get around this place. My Chichewa is not great but I'm still trying. (I speak so much English now. I realize that the women in the hospital don't speak any English so I'm thinking that I'll hire a tutor again.)
As for my social life. . . I am still running with the expats every Wednesday (and usually feel like I'm dying during the run) and sometimes I run with them on Mondays.
There is a bigger group that runs on Mondays, they call it the hash. Apparently there are hash races all over the world. Anyway, it involves searching for a trail that is set earlier in the day by "the hare" and then afterwards everyone just hangs out for a while drinking and talking. The expats I have met are all really nice and I have received a lot of invitations to different activities and outings but so far the running is all I have done. I'm enjoying my evenings at home with the Kaponda family and I have a few Malawian friends that I spend time with on the weekends. I even met a neighbor who runs so I've been waking at 5am to run with Cromwell a couple times a week. It is pitch black at that time here, since the days are getting shorter and we're entering "winter," but there are few cars on the road so you're not inhaling exhaust with each deep breath.The Kapondas are wonderful and I still feel great being in their home. Yankho, Dr. Kaponda's daughter, just left this past weekend for Chicago to begin her undergrad there. So, that was a big event. It was nice to be a part of her send off, seeing her nervousness and her excitement made me feel like we were trading places on the planet. Chimwemwe, a niece to the Kapondas, and I go for walks a couple times a week. Janet, their cook, makes me practice my Chichewa daily, with great patience, I should add. And, Tonto, their son, makes sure my weekends are not entirely spent within the walls of the house - last night we went out with a couple of his friends to play pool and eat pizza.
So all this to say, I am living well. People are taking good care of me. And Malawi, which was once a small unknown spot on the map, now has its place in my heart.
Tuesday, May 03, 2005
The Graveyard Is Too Small
I participated in a training last week entitled Saving Newborn Lives (SNL) along with the new midwifery faculty at the College and this was the name of the course organizer. He asked me over lunch if my name had any meaning when I said no, he asked another student to translate his name for me, "Manda Yachepa," she said, "the graveyard is too small." They both laughed and told me that this is a very typical Malawian name. I didn't catch his brother's name but he said it is something like, "All our days are tearful." Of course I have met others named Blessings, Sunshine, Memory (yes in English), Tontoso (consolation), and Yankho (answer) - most Malawian names have meaning - but many of the names are quite tragic. This of course reflects in part the high neonatal mortality rate here. The student correctly guessed, by his name alone, that Manda Yachepa's family had experienced the death of many babies before he survived and so began giving their children these names, expecting that they would also die.
This past week I had my first glimpse of what this high mortality rate looks like. As you walk from outside into the labor ward you first pass through a small room with a big metal sink and mops and a small metal rack with four shelves. On the shelves are small bundles, colorful chitingis (the cloth that women wrap around their skirts) with women's names written on tape and stuck on the outside. The first time I passed by, the thought occurred to me that these small colorful bundles might be babies, but I quickly banished the thought when I read "package of so-and-so" written on the tape. I learned later that they are indeed babies and Friday when I walked into the labor ward, I counted seven. Seven bundles of various sizes, which once held life and expectations - life known to the mother by her growing belly, by the twisting and kicking and sleep disturbing movements she had been feeling for months - and now here they are inert on a shelf.
Friday I also attended my first delivery here, assisted by a wonderful Malawian midwife. I came into the ward when the young (maybe 18) first time mother was pushing and a small patch of hair was already visible. Both she and the baby were doing well. Of course since I just was coming from the SNL class, I asked about a bag and mask. People began to search but none was located. The baby's head crowned and was born easily. (I successfully warded off the threat of an episiotomy from an obstetrician who wandered through and made the suggestion to the midwife, and the mother's perineum had no tear! a small success.) Then we waited for the baby to restitute (the baby's head usually turns to the side after it is born to realign with shoulders - part of what it has to do to negotiate the pelvis) but nothing happened. Finally the midwife used her hands to birth the shoulders, arms, and body (the baby's shoulders had never turned), and she lay a blue flacid baby boy on the mother's abdomen. The search for the bag and mask resumed at a more rushed pace but the seconds passed like hours, I kept pleading to do mouth to mouth and the midwife kept saying no.
Finally a bag was located but it didn't work. I took the mouth piece off, covered the baby's mouth and nose and started to try to resuscitate the little one. (I was so nervous I'm not sure I did anything at all.) In the meantime people began searching for string to tie off the cord, so we could cut it and take the baby to the nursery down the hall (no string in the delivery pack). Finally string was found, the cord was cut, and we rushed down the hall. By the time we got to the nursery the baby was pinking up, the heart rate was good, but there was still no cry. The midwife continued the resuscitation - with a proper bag and mask - until it seemed that the baby was stabilizing in its own rhythm of breaths and heart beats, and that was it. Still no cry and the baby's posture was looking ominous to me. I could feel the tears welling in my eyes and I just wanted to stay there with the baby but the midwives walked me out and told me that there was a good chance that the baby would recover. I came back three hours and brought the mom to see her little one - she still hadn't seen him. When we got to the nursery he was screaming and I helped her try to breastfeed. At this point there is no way to tell if the baby sustained any permanent damage that will result in developmental problems but I certainly pray that he will recover fully. He is a beautiful baby. Monday he was discharged home from the nursery.
The experience really shook me up. Of course these things do happen and they are never pleasant but the lack of resources and time delay just made it so much worse. The midwives in my class were all very reassuring and encouraging, no one saw it to be as traumatic as I did but they understood my reaction, since it was my first time to witness and participate in such an event. That was just one story. There are so many already. All I can say is that it really is a miracle that so many do survive.
The SNL training in and of itself was good, but a lot of it was review since I'm fresh from school. I think the most interesting tidbit I learned is that the janitors who work in labor and delivery are also trained in SNL because they are often the ones who end up delivering the babies. Just think about that. Really?!!
Today all the nurses at the hospital are on strike (a skeleton staff is working to assist with emergencies) so I have the day to sit and email and journal. There are two issues (1) there are no supplies at the hospital, not even gloves to do surgeries (2) DFID - the British governmental agency that does development work - recently approved funds to increase the salaries of nurses and physicians here but the vast majority of those monies has been given to people holding administrative positions (e.g. Ministry of Health). What has been allocated to the nurses and doctors is being taxed so heavily that they really are not seeing much of a raise. Nurses currently earn something like $140/mo. Hopefully there is room to maneuver. At least the President has a reputation of no nonsense and no corruption, we'll see what happens. These issues are so huge and yet so basic, where do you even start?
This past week I had my first glimpse of what this high mortality rate looks like. As you walk from outside into the labor ward you first pass through a small room with a big metal sink and mops and a small metal rack with four shelves. On the shelves are small bundles, colorful chitingis (the cloth that women wrap around their skirts) with women's names written on tape and stuck on the outside. The first time I passed by, the thought occurred to me that these small colorful bundles might be babies, but I quickly banished the thought when I read "package of so-and-so" written on the tape. I learned later that they are indeed babies and Friday when I walked into the labor ward, I counted seven. Seven bundles of various sizes, which once held life and expectations - life known to the mother by her growing belly, by the twisting and kicking and sleep disturbing movements she had been feeling for months - and now here they are inert on a shelf.
Friday I also attended my first delivery here, assisted by a wonderful Malawian midwife. I came into the ward when the young (maybe 18) first time mother was pushing and a small patch of hair was already visible. Both she and the baby were doing well. Of course since I just was coming from the SNL class, I asked about a bag and mask. People began to search but none was located. The baby's head crowned and was born easily. (I successfully warded off the threat of an episiotomy from an obstetrician who wandered through and made the suggestion to the midwife, and the mother's perineum had no tear! a small success.) Then we waited for the baby to restitute (the baby's head usually turns to the side after it is born to realign with shoulders - part of what it has to do to negotiate the pelvis) but nothing happened. Finally the midwife used her hands to birth the shoulders, arms, and body (the baby's shoulders had never turned), and she lay a blue flacid baby boy on the mother's abdomen. The search for the bag and mask resumed at a more rushed pace but the seconds passed like hours, I kept pleading to do mouth to mouth and the midwife kept saying no.
Finally a bag was located but it didn't work. I took the mouth piece off, covered the baby's mouth and nose and started to try to resuscitate the little one. (I was so nervous I'm not sure I did anything at all.) In the meantime people began searching for string to tie off the cord, so we could cut it and take the baby to the nursery down the hall (no string in the delivery pack). Finally string was found, the cord was cut, and we rushed down the hall. By the time we got to the nursery the baby was pinking up, the heart rate was good, but there was still no cry. The midwife continued the resuscitation - with a proper bag and mask - until it seemed that the baby was stabilizing in its own rhythm of breaths and heart beats, and that was it. Still no cry and the baby's posture was looking ominous to me. I could feel the tears welling in my eyes and I just wanted to stay there with the baby but the midwives walked me out and told me that there was a good chance that the baby would recover. I came back three hours and brought the mom to see her little one - she still hadn't seen him. When we got to the nursery he was screaming and I helped her try to breastfeed. At this point there is no way to tell if the baby sustained any permanent damage that will result in developmental problems but I certainly pray that he will recover fully. He is a beautiful baby. Monday he was discharged home from the nursery.
The experience really shook me up. Of course these things do happen and they are never pleasant but the lack of resources and time delay just made it so much worse. The midwives in my class were all very reassuring and encouraging, no one saw it to be as traumatic as I did but they understood my reaction, since it was my first time to witness and participate in such an event. That was just one story. There are so many already. All I can say is that it really is a miracle that so many do survive.
The SNL training in and of itself was good, but a lot of it was review since I'm fresh from school. I think the most interesting tidbit I learned is that the janitors who work in labor and delivery are also trained in SNL because they are often the ones who end up delivering the babies. Just think about that. Really?!!
Today all the nurses at the hospital are on strike (a skeleton staff is working to assist with emergencies) so I have the day to sit and email and journal. There are two issues (1) there are no supplies at the hospital, not even gloves to do surgeries (2) DFID - the British governmental agency that does development work - recently approved funds to increase the salaries of nurses and physicians here but the vast majority of those monies has been given to people holding administrative positions (e.g. Ministry of Health). What has been allocated to the nurses and doctors is being taxed so heavily that they really are not seeing much of a raise. Nurses currently earn something like $140/mo. Hopefully there is room to maneuver. At least the President has a reputation of no nonsense and no corruption, we'll see what happens. These issues are so huge and yet so basic, where do you even start?
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