Elephants

Last weekend I went to Dedza for the second time, and on Saturday MacPharlen with Dana treated me to day at the wildlife reserve in Liwonde (3 and 1/2 hours South of Lilongwe). They had gone two weeks before and said that they drove around the park for 7 hours, searching and searching for elephants, but the whole day they only spotted one in the distance, barely visible to the naked eye.

This time, luck was on our side. We saw herds of elephants including several small babies (they still must have weighed a couple hundred pounds each, small is a relative term). There was even a scary moment when one large elephant decided we were too close and started charging in our direction after giving us a good loud warning cry with her truck and tusks in the air. MacPharlen manuevered their little Toyota Corolla with stunning dexterity and we left that side of the park to the elephants. The elephants were the unanimous favorite, but we also saw hippos, crocodiles, gazelles, baboons, monkies, warthogs, waterbucks, and many birds including an eagle.

Although elephants are certainly not harmless, hippos (not lions) are responsible for the most human deaths attributed to Africa's large animals. Those seemingly sluggish round shiny bodies weighing up to 3 and 1/2 tons, are actually very swift. Hippos can run up to 40 miles an hour and they are aggresive, a fact which is both impressive and frightening. In the Shiri River, hippos frequently overturn small boats enabling the crocs to feast on who or whatever rode inside. Apparently this senario was so common that small fishing boats were outlawed on the Shiri River. Even so during our drive through the park we saw a couple small boats with fishermen casting their nets on the River. Perhaps for some having fish to sell outweighs the risk of crocodile attacks.

Dante's Inspiration

Tuesday night I went in for my third night shift. Honestly, I was really dreading those 16 hours and the potential unknown horrors they might contain. My previous night shift was so overwhelming that it took me really at least a week to recover. That night there was a point when I just looked around and thought to myself, this is my personal hell and there is no escape. (Mainly because so many women were crying, really crying, in pain and calling out - looking at me pleadingly - but there was no physical way to attend them because of other events going on.) Anyhow, Tuesday night began gently. As I walked through the gates of Bottom all the guardians sat in clusters on the grounds as usual, despite the quickly descending night and dropping temperatures, but unlike usual, one elderly woman danced among them, leading a call and response song. It was a nice beginning. I walked slowly to the labor ward entrance, soaking in the beauty of their voices and finally, reluctantly, closed the door behind me shutting out the singing and steeling myself for the vision around the corner.

Thankfully the ward was fairly quiet and I was happy to see one of my favorite midwives already at work - she is a hard worker who smiles and jokes as she goes, she has taught me a lot, and most importantly, she doesn't yell at the women in labor. There were only four women in the ward, only one needing emergent attention. This woman, pregnant with twins, arrived seconds before I did with her mother, who said she had seized at home. As we started her IV she seized again but she regained consciousness and the babies' hearts sounded good. It was decided that she would have a c-section once her blood pressure stabilized.

And so the night began, most of the time there were only four to six women in the ward and luckily they each took turns with their needs and the timing of their births. There was time to chat and share nsima, time to sit, and enough of us to comfort those calling "A-NURSE-YYYY." Around 3am I went to a c-section to receive the baby and when I returned to the ward, saw that the women with twins had delivered. The twins needed a little resuscitation and did well, but unfortunately the mother was hemorrhaging. The clinical officers went to assist the midwives attending to her, but within just a few minutes two other women began seizing, each pulling away one midwife, and then another woman began crowning, so I went to attend her delivery.

The baby that I caught was pale and floppy. I dried her, cut her cord, and I took her to the resuscitare and began the resuscitation. After about 10 minutes she was breathing and had a heart rate around 100 beats per minute (the minimum that it should be) but she was still pale and floppy. Just then her mother let out another guttural holler, "BWERANI-I-I-I" (come!) and I turned to see the body of a second baby, still encased in its bag-of-waters, emerging bottom first. I left the first twin and delivered the second twin, who looked to be in even worse shape than her sister. When I ruptured the bag a pool of dark and foul smelling fluid formed on the bed, a bad sign meaning that infection was highly likely. I began resuscitating the second little girl but after 20 minutes without any spontaneous respirations, I wrapped her, showed her to her mother, and returned to the first twin who was still struggling.

While I was doing this, yet another woman delivered and the mother of the first set of twins continued bleeding. Finally the hemorrhaging woman was taken to the theatre for a hysterectomy. After that wave passed, another midwife came and attended to the woman whose babies I was trying to help. She dealt with the placenta and gave her medicine to prevent further bleeding while I carried the baby to the nursery. I stayed with the baby for some time. She never improved but just continued hovering in that place between life and death. After a while I left her in the hands of the nursery nurse and returned to the labor ward to find that her mother had also hemorrhaged without anyone noticing. Actually, when I returned the midwife I like so much saw the edge of an ominous puddle peaking out from under her chitengi and said, "Joanne, let's go see your patient and make a diagnosis." We were able to stop her bleeding and she was alright. At that point it was 8:30am, the end of the shift.

Not every day or every birth is a horror story but there are so many. There are so many women and babies who somehow fall through the cracks. Whether prenatally, in the labor ward, or in the days that follow. The shifts are exhausting but they are only really painful when all your efforts are not enough, not even close.

I guess, looking on the bright side, in this kind of environment there is no where to go but up. The potential for positive transformation is boundless and it will be great to be a part of that change. I'm holding onto that thought.

This morning at Bottom I went to the nursery to check on my little girl and found that she had died sometime yesterday. I was also told that the first woman who hemorrhaged continued bleeding after her hysterectomy and was finally transferred to the Intensive Care Unit at Central Hospital. I just now stopped by to visit. She was conscious and her nurses said she is doing well, and so are her babies.

All of YOU

Traveling half way around the world might seem like an attempt to escape life in the form it presents itself to you on your doorstep. During my planning stage of this trip I had a few friends ask if I felt I was running away from something. It is a reasonable question which I also asked myself a couple times as my heart and my head, my fears and longings battled inside. I never came up with anything substantial.

I understand that there is poverty, suffering, injustice, and pockets of the developing world within the borders of the US. I have considered that I might make a greater impact using my skills in a country where I understand the greater context simply because it has been the context for my own life and growth. I have not eliminated the possibility of returning to contribute to positive change in the US in the future, but up to now something has been pushing me (or maybe pulling me) out and away.

Now that I am here, things are as I expected in most ways. This is not to say that things are easy or that I have fully adjusted or that I understand even 10% of what happens here. But rather that I expected what is difficult to be difficult and I expected that I would still find comfort and peace here. That is how it is.

What I did not expect were your reactions. Your support, love, concern, and compassion surpasses anything I have previously experienced. I have known that I am blessed with wonderful people in my life, but usually awareness of that blessing comes in pleasurable sips, not with the force of a waxing tide. Close friends, family, acquaintances, and even strangers have reached out to me personally and to the Malawians whose stories I have shared here. Ironically in some ways I feel closer to many people now that we are separated by thousands of miles of land and water. Perhaps the meaning for my trip really comes from you . . . your generosity provides an opportunity to distribute not only material wealth but also to distribute the love and grace you pour into the world. As I consider all of this, I am shocked to tears and words seem insufficient to express my gratitude. Just know that I am grateful. Truly.

Poverty

Poverty is a clean pair of black plastic shoes – sold for pennies in town – placed carefully side-by-side under a hospital bed; worn until the heels cracked in half then repaired with a neatly stitched row of white Xs.

Lovely

I spent the weekend in Blantyre, or rather in Chigumula which is just outside of Blantyre. I went with Clement, who I have been dating over the past three months, to meet his family (I suppose now that both families know I'm ready to announce this here). Honestly I was a bit nervous to meet his family for a few reasons, (1) culturally it's a big deal, (2) he told me that I would be meeting 20-30 family members during the visit, and (3) I have heard many stories about Malawian parents not wanting their children to partner with foreigners, some even going as far as to cunningly sabotage the relationship.

I feel the need to say a bit about this concept of cultural preservation, which I think at times might be called racism. Dr. Sadik, the former Deputy Secretary General of the UN made a statement at the UN Conference on Women in 1995 that I believe applies to many subjects and I like to reread her words from time to time:

"We must not bend under the weight of spurious arguments invoking culture or traditional values . . . The function of culture and tradition is to provide a framework for human well being. If they are used against us, we will reject them and move on. We will not allow ourselves to be silenced."

Culture is not static; it is the constantly evolving story of a people; it is a collection of wisdom and knowledge acquired over generations. Traditions are the tools, rites, and behaviors used to remind people of what is most important in life. Traditions are used to reinforce values and uphold life. I feel very strongly that all cultures deserve respect, but equally strongly that culture should never fuel arguments/actions that maginalize, disempower, or destroy. Every generation must contribute to the growth of its culture, in this way ensuring its longevity, responsiveness, and relevancece to their context. Every generation must accept what is useful and reject what is not. However, rejection based soley upon difference is rooted in fear and ultimately diminishes what it attempts to preserve.

As a true mutt myself, or swirl (a sweeter term coined by my cousin Joe), I especially detest the common argument that interracial relationships are selfish/wrong because they give no consideration for the poor children destined to be social misfits. Most of us swirls are well-adjusted human beings and, in my perspective, having a multi-racial background is a gift. There is something special about never perfectly matching the crowd; viewing life through multiple lenses may contribute to a deeper sense of empathy and a heightened awareness of the dangers associated with monochromatic perspectives.

Thankfully, Clement's family was lovely and warm even though the weather was a frigid 50 or 60 something.

Blantyre is a short three-hour drive south from Lilongwe but on the express bus it's a painful five hours. I think my 650MK bought me 4 cubic feet of space. Anyway, we arrived stiff but intact early afternoon on Saturday. After walking through the gate we first met and greeted his grandmother, then his mother found us and gave me a big hug, and so it began. There were waves of handshakes, hugs, kisses, and smiles attached to names and descriptions of relationships. (I tried hard and failed to memorize them all; I'm still hoping for a diagramed cheat sheet.) His parents live about 100 yards from his maternal Uncle and between the two households there are almost 20 children. Three of his mother's siblings have died and left children, so now all these cousins are regarded as brothers and sisters and many move fluidly between the houses. Clement himself is the oldest of 8 but I think I only met three of his real siblings, the rest were away at various boarding schools. The weekend was full, and so was I (I think I ate five meals a day). I chatted for hours with his dad, mom, and uncle; went for a long walk with his sister and cousins; slept in a room with his sister and grandmother; took warm bucket baths behind the house; and held chicks, puppies and toddlers. Everything felt good. It felt like acceptance and Clement told me that I passed the test 100%.



Monday morning I took another express bus back to Lilongwe, which brought me home in a mere 6 hours, and this time I had the seat next to the door with a sign reading, "Not for Passenger Use." The seat was better than the one I had on my previous ride even though I ended up sharing a corner of it with Joseph, the guy who opens and closes the door. And, even though I had to jump out at every stop and/or hold my hands in front of my face to ward off the blows of cabbage, carrots, tomatoes, and bottles being thrust in the door by dozens of overeager vendors all clamoring to fit produce and bodies through the single port of access to potential customers. A sense of humor is easier to come by when you're well rested.

A Thank You Note

This is a note from Ven's nephew. I am using the donations that so many of you gave me to pay his school fees so I wanted to pass his thank you on to you in his own words. . .

I greet you in the name of our Lord Jesus Christ. The purpose of this letter to you is that I would like to thank you for the great thing you have done to my life and also to my family. I'm saying all this to you because not all people can manage to do what you have done since nobody can pay fees to somebody whom they have never seen. I therefore ask the Lord to bless you abundantly. I am promising you that I will work extra hard in my education that I may achieve my goal. For now that's all I have.

Yours,
Innocent Chioko

Loss

For all the drama that transpires within the walls of the labor ward there is also lightness. Mornings are always good. I love walking in to the smiles and greetings of the midwives. They welcome me with incredible warmth everyday and everyday renew my desire to be present. I feel I belong when I hear my name, as they pronounce, it nestled in the midst of Chichewa spoken with kindness - even though the context is often lost on me. The labor ward is a world to itself, so many stories, blessings, and tragedies. Birth is never routine.

The day started with the ward half full, I attended two births both uncomplicated and fast. The beds filled, each one holding a laboring woman, rows of pregnant bellies and colorful chitengies stretched on green and black mattresses. I was about to place an IV when one of the midwives who was attending a delivery herself called my attention to a woman laboring on her plastic sheet on the floor. The woman lay on her back under an enormous belly and her bag of waters bulged expectantly between her legs. Quickly I changed gloves and reached her in time to welcome a little girl (her fifth girl) into the world. I dried her, clamped and cut her cord, wrapped her, and placed her next to her mother whose belly had hardly diminished in size. At that point the mother said that she had been told that she might have twins but that the suspicion was never confirmed. So, I reached up gently and felt a foot, at that moment confirming her twin gestation. We slowly moved her to the nearest bed, temporarily displacing the woman lying there, and with the coaching of another midwife I attended the breech delivery. Amazing. Each labor and birth is unique, every birth is raw, often it is beautiful and it is always astonishing. I watched feet and legs descend, followed by belly, shoulders, arms, and head, then I placed the screaming boy (her third boy) on his mother’s belly. Within minutes the mother was off to the shower and soon stood smiling at the door holding arms open to embrace the weight and life that only minutes before she had carried within. I was flying, the first twin delivery and first breech delivery for me all in one, made even more miraculous by the fact that the cord of the first twin had a true knot in it. Very rarely a baby’s swimming movements will tie a knot in its umbilical cord, usually resulting in the death of the baby. But this little girl met the world with open lungs and eyes, very much awake and alive in spite of the ominous knot that followed inches behind.

A few hours later another birth brought me to the opposite end of the emotional spectrum. A nineteen year-old, with her first pregnancy and a very small belly, lay in the bed closest to the nurses’ station. At the time I approached her, she had been laboring for many hours and pushing much longer than usual. At that moment all the other midwives were occupied. I walked up to her, touched her belly, and listened to the fetal heart. My own heart raced as I heard a slow steady beat around 70 (a fetus’ heart beat should be between 110 and 160 beats a minute). The baby’s head was low but not descending further even though the veins on the mother’s neck protruded as she pushed and strained with each contraction. Another nurse called the clinical officer on duty, and with his coaching I extracted the baby by vacuum (the vacuum is a small suction cap that is placed on the baby’s head, the clinician gentle pulls as the mother pushes to expedite the birth). A baby girl was born limp in a wash of meconium but after a little suctioning and stimulation she perked up. A few minutes later I cut the cord and placed her in the warmer besides her mother’s bed while I set out to suture the small tear in the mom’s perineum. When I finished, about thirty minutes later (I’m still slow with suturing), I noticed that the baby was gasping occasionally but still breathing and pink. I showed her to the mother and took her to the nursery. In the time it took me to walk down the hall, the baby became quite pale and the heart rate dropped significantly. I started resuscitation with a bag and mask, oxygen, and chest compressions but the heart rate hovered around 60 and the gasping breaths continued. I asked someone to call the clinical officer and together we continued the same simple resuscitation measures for another 45 minutes. By then the baby was a dusky gray, limp, and the heart rate faint at 40 beats a minute. There was no one else. There was no medication to give. No ventilation machine. No pediatrician to call.

Without any improvement the clinical officer took over while I went to get the mother. I brought her to see her dying child. She went to get her mother and then we stopped the resuscitation, took off the oxygen and handed the gasping child to her mother. The young mother looked more shocked than sad holding her daughter loosely in her arms, shifting her gaze from her baby to her own mother. This first born girl who was pink and wiggling an hour before now lay pale and gasping on her mother’s lap. This is not how it was suppose to be. The clinical officer left. I asked the nursery nurse to ask the mother and grandmother if they had any questions. The mother said she had none. The grandmother, looking sad and angry, said she had none, she said saw us try to help the baby, and she said that perhaps this child was not meant to survive.

I know that no matter what they said or what expressions they wore, the death of this baby girl will beget incredible grief. I know that the loss will exist always, stitched painfully and permanently into their hearts. And, I know that the attempts to rationalize the death are really just attempts to put a more acceptable mask over the face of blatant injustice.

I tearfully said “Pepani” (I’m sorry) and then managed to hold in the sobs only until I reached the vehicle waiting for me outside. If only I had not left the baby alone for that period of time. If only I had started the resuscitation sooner. If only there was someone else present. Maybe the child still had a good chance to live. Maybe I should have continued the resuscitation. I don’t know. I do know that what I did was not enough. I know that baby’s chances had she been born in the US would have been much better. This child might have had a chance for a full life but she died leaving only unfulfilled hopes and grief behind.

Dr Kaponda was home when I arrived; she offered comfort and empathy, telling me the story of the first baby that had died under her watch during her years as a clinician. I will return to the labor ward willingly on Monday. I want to go back. I want to be here, but it breaks my heart to think that I contributed to the death of this child. The vision of grandmother, mother, and daughter will live forever in my mind’s eye.