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.

Baby Tally

So I survived the night shift last week, all 15.5 hours! And, by the end of it I had, with my hands, caught 8 babies (6 boys and 2 girls). Nights are definitely busier. There was a point when all 14 beds in the labor room were occupied and two women were laboring on top of their chitengis on the floor. I'm planning another night shift next week. Of course the nurses are appreciative of me just being at Bottom, since they are so understaffed, but I felt I really earned some good points working a night with them. One of the clinical officers recently told me, "I've been watching you and you are the kind of person who can really survive here." Then a nurse added, "Yeah, and she even worked a night." I felt my head swell : ).

Yesterday at Bottom was my day for big babies. The first one (a boy) I caught weighed 10.7lbs. Really! The delivery happened so quickly that the head didn't even have time to mold (usually as the baby's head moves through the pelvis the skull bones ride over one another to allow it to pass through more easily, giving some little ones temporarily a funny shaped head). As it crowned it seemed as though the head of a five year old was being born. Thankfully the baby was born easily and the mother's perineum did not even have a tiny tear, incredible. (This was the mother's fourth delivery.) When I told the mother her baby's weight, she said, "A gift." A couple hours later I caught a girl weighing 9.24lbs also healthy. She was the second child of a very small young woman.

To date I have caught 34 live babies here in Malawi.

Fire in Dedza

8:00 Friday night in Dedza, Dana's husband, Macfarlen, received a call from a friend of his who said that there had been a road accident, that the vehicles were on fire with people burning inside. Macfarlen is not a medical professional (he's an electrical engineer) but he lives nearby and he has a truck. In a world without EMS, without quick responders, and few ambulances, the lives of people involved in MVAs often depend on local good samaritans and those who happen to be passing by.

We hurriedly piled into the truck and drove the 10 minutes to the scene but by the time we arrived, the flames engulfing the three vehicles had already devoured everything carried and were now hungrily licking at metal and rubber. A large solemn crowd encircled the wreckage at a safe radius, passing around fragmented versions of the collision in shocked voices. Macfarlen's friend had come across the scene on a motorcycle just minutes after it had occurred, the fire just beginning to build and screams of trapped people close but unreachable. He called the hospital, the police, and the local law enforcement but when those responses were unsatisfactory he called Macfarlen. We didn't learn much that night other than the fact that several people were rescued including one man who had been pinned under a truck and had his leg hacked off with a hoe in order to attempt to preserve his life. Four vehicles were involved in the wreck, a two ton open bed truck that was carrying people. A three ton truck loaded with potatoes and tobacco, with a couple people perched on top, a pickup, and a sedan. Only the sedan, which was pushed to the opposite side of the road escaped the fire. Recognizing that there was no longer anything to be done, we climbed back into the truck and drove home. In front of the truck, just millimeters above the horizon hovered the most amazingly beautiful and enormous full moon. The vision was somehow both comforting and confusing. The night illuminated by the serene timeless beauty of the full moon juxtaposed with the horrifically tragic end of so many human lives. I imagined our individual lives as short flashes of light over the planet filled with incredible motion and emotion . . . searching for meaning, loving, living, struggling, surviving . . . but why this type of end?

The next day Macfarlen met the man who had driven the pickup and we all got his story. Apparently the large truck was loading potatoes but was parked in the road facing oncoming traffic with its lights on (the night was already thick) and the other side of the road was blocked by minibuses loading passengers. The driver in the sedan saw the impasse and slammed on his breaks, as did the pickup which followed, unfortunately, the open bed truck was unable to stop in time and slammed into the others pushing the sedan across the road and the three remaining vehicles into the ditch. The fire began instantaneously and the driver of the pickup was only able to extract his wife and child from his truck. By the time they were safe all he could do was watch and listen to the screams of those trapped under the burning wreckage.

Certainly accidents happen everywhere. Fatalities from motor vehicle accidents are common everywhere there are motor vehicles, but once again I am reminded of the differences between poverty and wealth. In addition to the obvious difference of the absent 24*7 EMS response, there was an unknown number of people who died in this wreck. Open bed trucks are a common means of transportation here and no one will know how many people died or even the identities of the dead. These people will simply never return home sparking mysteries partially solved over time only by probabilities. Lives in the developing world so often are not counted, they are estimated in, imperfect but easy to work with, round figures. I imagine if this happened in the States, the names and perhaps pictures of the dead would appear in the paper along with interviews with family members and pieces of their personal histories. The fact that these people entered and left the world perhaps without any official recognition does not mean they were loved any less, or that their deaths were any less tragic, but just that their individual beauty and worth is more difficult to convey. I believe that those of us who live in the developed world should be grateful for what we have but never complacent, we must resist the tempting illusion that round figures are merely figures.

Apart from the tragedy, the weekend in Dedza was wonderful. Dana and Macfarlen have a really sweet cozy little home located at the base of Dedza mountain. They own a few hectars of land and have planted gardens with vegetables, flowers, and trees. From their plot the view is spectacular - the pine covered mountain (which is quikcly becoming deforested), other houses nestled in the trees, and more moutains pink and tan in the distance. It was cold but we made a fire every night, we ate well, spent hours and hours talking, visited some near rock paintings that are over 2000 years old (unfortunately they being defaced), and just had fun. Dana took lots of pictures which I will have to post as soon as I get them from her.

20% Chances

Life is settling into distinguishable patterns of color and experience. Landing in a new environment is something like sitting in a snow globe, with no fixed landscape, that someone just shook vigorously. Everything seems to whirl around, you're just taking in a wash of vivid color and sensations, and every day is filled with the unexpected. It's sometimes difficult to know what is stable and what is just part of the transition. Of course the adventures continue, but now there is a least a stable backdrop against which they are occurring.

My three weekly shifts in the hospital continue to exhaust and surprise me, but I am more frequently seeing beyond what initially seemed to be pure chaos. I am able to enjoy moments of beauty, notice what functions, and envision positive changes. I want to share a little analogy that Dr Tarek Meguid recently told me. He said that if a patient has a condition that needs surgery but the surgery has only a 20% chance of success, you absolutely must counsel the patient about the risks so that they understand they only have a 20% chance. But, if they agree to the surgery and you agree to perform it, you (the physician) must believe 100% that that patient is among the 20%. If you don't believe that, wholeheartedly, there is no point of doing the procedure. So you take that philosophy and apply it to life. . . In relation to whatever you are doing, even if the chance you will succeed is small, you must absolutely believe that you will succeed or you should not be there at all. What a wonderful gift to have a boss with that philosophy in this environment!

I will be working my first night shift at the hospital this Wednesday (I'm a bit nervous). The night shift begins at 4:30pm and ends at 8am, simply because after that time it is difficult find public transport and dangerous to travel. I imagine that despite the long hours they will pass quickly, several nights in a row the midwives told me that there were over 40 deliveries (shared between 2 midwives). I'm sure I will have stories after that. At the moment my count is up to 23 (18 boys and 5 girls).

As for my free time, I have been spending less and less time with the expat community but I do have a few close friends. Right next door to the Kamuzu College of Nursing is the College of Health Sciences, which educates clinical officers. Clinical officers are the backbone of the medical system here and Malawi's somewhat ingenious way of dealing with "brain-drain." The program to become a clinical officer is three years plus an internship year, all straight after high school. When they graduate the COs function like general practitioners, even doing surgery, but they only have a diploma, not even a bachelors degree, and their education is not recognized outside of Malawi. Even in Malawi, if they decide to pursue an MD, or even a BS, they must start from scratch, making career changes and emigration less appealing. Anyhow there is always a group doing clinicals at Bottom and early on several of the students took me in, so now I spend a good deal of time with Clement, Fatsani, Mavuto, and friends. I also recently met an American woman around my age who has been here 6 years (4 yrs with Peace Corps) and is married to a Malawian. She is the education coordinator at the nearby refugee camp in Dzowa, and she's great. We spend hours talking, laughing, and catching each other up on a lifetime of stories. She and her husband own a house in Dedza and have invited me for the weekend, it will be my second venture out of Lilongwe, I'm really looking forward to it.

Other updates:

Cromwell is about the same. He's been home for a few weeks, no ongoing care other than what his younger brother is providing. Emotionally, he seems to be coping well. He's determined to get back to normal, and even though he still can't voluntarily move his left arm or leg he is now able to "walk" with the assistance of his brother (quite impressive). Today he left for Blantyre where there he can get a CT an hopefully a bit more information about the cause and/or extent of the problem. I'm going to use some of your money to pay for the CT about 11,000MK ($100).

Venity's family is doing well. With your money I am sponsoring the education of both Ven and one of her nephews. Ven will be starting classes for a diploma program at the Business school here this weekend and her nephew has started a diploma program in Development and Health.

Mrs. Phiri stopped by today with a big smile to tell me that with the money I gave her she bought 10 bushels of maize, 1 sack of sugar, a table and benches, some uniforms, and school supplies . She said she went back to see what was most needed and found that people are literally starving in the project area. Now with the maize they are able to feed the orphans and other vulnerable children. She said children were leaving school to come to the project just to eat and even some of the women in the village were trying to get food for themselves from the project.

Sadly, while people are starving in the villages, today on the news I heard that the President Bingu wa Mutharika just increased his salary by 350% to 20million kwacha/yr (a little less than $200K/yr). This president has been the hope of the country; a powerful force against corruption. He made many enemies initially when he was elected in 2004 firing and imprisoning those government officials who had been accused of mismanaging public funds but this news is definitely disappointing. He has 4 more years in office we'll see what happens. Unfortunately I have been hearing a lot of grumbling about Democracy. Under "President-for-Life" Kamuzu Banda who ruled for 30+ years people were poor, but crime was low (punishment for even petty crimes was often death), the kwacha was stable, and public offices (including health care) functioned better. From what I hear people in general were motivated by fear but there was greater economic stability. Malawi has always been a peaceful country and no one envisions that changing but something needs to happen to strengthen the country in general and the people's appreciation for democracy.

Today after about 10 visits to immigration and trips to other offices around the city, I finally received the two stamps in my passport giving me permission to live and work here for the next two years. Every accomplishment, even successful bureaucratic hoop jumping, is a success worthy of celebration.

A Snap from Bottom

the Namesake

Friday night when I came home Chimwemwe told me that Mr Aisa's (the gardener at the Kaponda's) sister in-law had given birth that day at Bottom hospital to a little girl. I flipped through my mental images of all the women and babies I had seen that day trying to figure out who she might have been, thinking that if only I had known who she was I would have been at her side as much as possible. Chimwemwe didn't know the birth story but she told me that the mother fainted on Saturday and soon before she was discharged. I imagined that she was one of the women delivered by a different midwife.

As it turns out Mrs Black, the sister-in-law, lives only a few houses down the road so Sunday I went with Chimwemwe and Ekari to visit her and to see how she was doing. Mr Black met us at the gate and led us to the small room where he and his wife live behind the main house. As soon as I saw Mrs Black we both laughed, her birth was the vacuum delivery that I had assisted with and I had actually spent several hours by her bedside on Friday before the delivery. With Chimwemwe's help we talked for a bit, I did a brief exam, held her baby (who I was very happy to see was doing well post-resuscitation), and left. As for the fainting, I remember her telling me during labor that she had not eaten since the previous afternoon and Sunday she said that she was just weak from the birth and lack of food. Thankfully it was nothing more serious than that. On seeing her and the baby again the warmth from my heart flowed up to my cheeks and made me feel a bit heady but I also thought, "I wonder if she liked the care I provided?" It's strange to be so close to someone, to see and care for them only as you would a stranger, and then later learn that you have a fairly close connection. Chimwemwe told me that if anyone asked she would say yes, so we didn't ask.

Monday evening when I got home, Ekari told me that Mrs Black had come by to thank me (I had sent her some Ibuprofen). Then Tuesday a while after I came home, Chimwemwe said to me, "Oh, I almost forgot, Mrs. Black was back and she wants you to name the baby." Chimwemwe is often sarcastic and sometimes it's difficult to know if she's serious or not so I laughed but then both Ekari and Mrs. Chirwa confirmed that the story was true.

At first I felt completely overwhelmed (honored but overwhelmed) . . . how could I pick a name for this child? a name that will be heard, spoken, and written thousands of times over her lifetime? what kind of a name should it be? would the parents like it? No one wanted to help me decide, they all agreed it must come from me. So after worrying over it a bit, I decided I would give her the name that was given to me.

Two weeks or so after arriving in Malawi, the four girls at the house (Chimwemwe, Ekari, Maggie, and Yankho) decided that I needed a Chichewa name. So, one night over dinner they spent about 10 minutes deliberating in Chichewa. I heard some names I recognized flying back and forth followed by sounds of general consent and silence. Yankho said, "Ok, we have decided that your Chichewa name is Tianjane (tea-on-JOHN-ny)." Tianjane means something like "we should be friends" or "we should be together" or "we should get along." I like the name very much and now a small handful of people are calling me Tia.

This morning at 7am Ekari and I went to see Mrs Black and give her the name. As we walked in the door Mrs Black laughed, handed me the baby, and asked Ekari if we had come with a name. I told her, via Ekari, that I had been given the name by people I liked very much and that I also like the meaning of the name, so I would give it to her daughter wishing her the best. Tianjane. Mrs Black smiled, rolled the name over her tongue a few names, and said "Cha bwino" (OK). That was it. She left Ekari and me for a few minutes in the room, while she resumed her morning work, free as long as Tia was in my arms. Tia's eyes were wide open when I first took her from her mother, but slowly as I held and rocked her they closed, and as she was drifting to sleep - becoming still and quiet - this 6 day old little girl smiled a big full smile. And then, just in case I had missed the first smile she smile two more times.

Mrs. Phiri's Orphans

Mrs. Phiri is an instructor at KCN and she's a friend. Mrs Phiri is in her early 40s, she stands maybe five feet tall, wears her hair pulled back a bit severely and a skeptical expression over a half smile. She's often quiet in a group but when she does speak her voice is strong and she doesn't mince words. I met her a few weeks back at the Saving Newborn Lives training and now I see her regularly on the KCN campus. I know that teaching at KCN and raising her daughter consumes much for her time, so I was surprised to learn about her third busy and extremely charitable life.

Mrs Phiri and her husband, together and without any organizational backing, have started a foundation for orphans called the "John C. Thomas Children's Foundation." Right now they have three centers in different regions, which do not house the orphans but provide meals, tutoring, and vocational training. When I asked Mrs Phiri about why she decided to do this she said that she was raised without a father, that her childhood was difficult and she related in a personal way to the lives of orphans here. She said, "I want to make being an orphan something to be proud of, I want to give them opportunities and resources that will make the other children in some way wish that they were also orphans."

Two of the centers are doing well but the newest one in Tengani does not yet have a stable funding source. I gave Mrs Phiri several hundred dollars from the money I received from you (and she sends many thanks and blessings) but I anyone who is interested can also send money directly to her, email me at: joanne_jorissen@yahoo.com or see Mrs Phiri's contact info below.

Here is some information about their organization and their current needs in her words:

The purpose of the organization is to reduce stigma among orphans and other vulnerable children with the goal of improving their quality of life by raising their social, economic, education status.

The Area. Nsanje (pop: >200,000; 60% women) is one of the boarder districts of Malawi bordering the Southern part of Mozambique. The HIV infection rate is higher in women in this area and the overall rate (now at 19%) is steadily increasing resulting in higher mortality rates. In the targeted area of Tengani, 2001 statistics indicated that the area had 11,300 orphans in dire need of care and support. This need is compounded by the facts that (1) most of those dying are young girls who die without leaving behind any substantial property to support their orphaned children (parents of these girls in most cases are severly improvershed themselves and do not have resources to care for grandchildren); and (2) the education level in Nsanje is the lowest in the country.

Discussions with the people of Nsanje, including key leaders, revealed that the people deny the presence of HIV/AIDS in Malawi. They believe that witchcraft not HIV/AIDS is the cause of many deaths. Unfortunately, many cultural practices are very risky as far as HIV/AIDS transmission is concerned. The following provide some examples: (1) Polygamy is common especially among chiefs. (2) At puberty, a young girl is forced to have sexual intercourse with an older man, who is specifically appointed by village elders to perform this duty. (3) When a husband dies, elders in the deceased's family along with village chiefs choose one person (usually a brother or an uncle) to have sexual intercourse with the wife of the deceased. It is strongly believed that if she refuses, the whole village will be under a curse and everyone will die. As such the woman has no choice but to submit to this practice. (4) Girls usually marry at an early age 14-15 years, preventing them from pursuing an education. These belief systems in addition to the general disempowerment of women account for the high prevalence rate of HIV/AIDS in Nsanje district.

Project activities under the John C. Thomas foundation have been designed specifically to address these problems. Present activities include:

• Sensitization meetings with local leaders at Tengani
• Identification of 1000 orphans and vulnerable children in the area
• Formation of committees in Tengani
• Procurement of a garden for the community to cultivate for income generation
• Distributions of items to assist the orphans and vulnerable children
• Training 60 volunteers in orphan care
• Sensitizing the community of HIV/AIDS transmission and voluntary testing and counseling (VCT)
• Establishing youth clubs
• Establishing widow/granny clubs

Desired future activities include:

• Paying tuition for 10 needy and vulnerable children
• Connecting 10 orphans with local artisans for aprenticeships
• Conducting sessions on the journey to life to community leaders
• Establishing and running co-operative shops
• Parental training workshops
• Providing sholastic materials to needy children
• Procuring and distributing 10 fish nets to 10 orphan headed households
• Organizing fundraising activities
• Building a resource center

With regard to sustainability, the communities will be encouraged to support orphans and other vulnerable children through the extended family. It is hoped that this will improve the acceptace of orphans and decrease their stigmatization within the communities. This will be done through sensitization meetings with the leaders. As the communities develop an understanding of the plight of orphans and understand the need for and activities of the project they will support its sustainability. Funds raised from the gardens and co-operative shops will be used to run the center. Skills acquired by orphans will empower them and enable them to become self-sufficient. It is believed this will reduce promiscuity and stigmatization among orphans and vulnerable children in the area. Higher levels of education provided to the children are also central to the empowerment process.

Constraints. Currently the foundation has no donor. The activities carried out so far, have been accomplished through small individual contributions. The lack of funding is the main constraint at present.

Requested items (shown in Malawi Kwacha, MK/US$ = 120/1). Mrs Phiri says she will give an account of how donated funds are spent.

• School uniforms for 100 children 50,000MK
• Bags of maize 200,000MK
• Bails of sugar 120,000MK
• Sewing machines 105,000MK
• Bags of beans 130,000MK
• Maize seeds 70,000MK
• Blankets 720,000MK
• 3 bails of second hand clothes 54,000MK
• Soap 31,000MK
• Water pump engine 120,000MK
• Weilding equipment 80,000MK
• Carpentry equipment 30,000MK
• Fertilizer 200,000MK

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1st day as a Malawian Midwife

It's official I'm now a Malawian midwife. I successfully jumped through all the necessary hoops and now I have my badge, which I proudly wore to L&D yesterday. Yesterday was quite a day actually slow but not without drama. In the morning a woman came in with a cord prolapse, so severe that you could actually see about a foot of cord dangling between her legs. On arrival her baby was still alive and preparations started for a c-section. In my mind people were moving so slowly, walking to get the IV, walking to get a catheter, talking in normal voices, walking to get a gurney. I tried to breathe and stay calm but it my head I was screaming and pulling out my hair. Somehow the baby was out within 35 minutes. Initially blue and floppy but after a little resuscitation and she picked up and did just fine. Afterwards I was told that usually there are no emergency c-sections. Usually the baby is left to die and the woman delivers vaginally. Everyone was happy with the end result, including myself, and I was reminded that everything is relative, especially expectations.

The second birth of the day that I participated in was a vacuum extraction. The charge nurse did it and I pumped the vacuum (during the procedure someone acutally has to pump in order to maintain the suction which is an incredibly tiring task). She said next week I'll do the vacuum - see one do one. One thing I won't be doing though, is cutting an episiotomy with a razor blade as she did. It was a necessary epis but with a razor?! Although I heard the midwives do this, this was the first one I saw. Your fingers and the baby's head are both less than a centimeter from the razor blade and lots of possibly HIV+ blood. And if the mother jumps?! I know the ALSO group left scissors and this practice really must change. Anyway the vacuum procedure birthed another blue baby so in one day I did two resuscitations. This little one also did fine and left the ward in her mother's arms.

The third birth of the day was another c-section. The mother, who had 4 previous births, was completely dilated but the baby was still floating high in her belly. I went to receive the baby in the OR. It made me pause to realize that I represented what would be an entire pediatric team at a delivery in the US. Thankfully the baby came out screaming so my job was easy this time.

Lifting Spirits

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.

Senga Bay

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.

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 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.

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.

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.

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.

Mr Billy, Janet, Maggie, and me

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.

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?

Prenatal Care?

Today was my last day in the prenatal clinic and my take home thought was . . . I want to start a clinic here.

For this week I have been in the same room doing belly checks and listening to fetal heart tones. The women when they walk in the room supposedly have had their histories taken, their blood pressures taken, and have been weighed. In reality, many of the women who came to me did not have any medical history recorded in their books and some didn't even have their names written on their books. I was also a little suspicious of the blood pressures, namely because they were always nicely rounded numbers and were often the same numbers. So then, I peeked out the door and, to my horror, saw that the nurse who was taking BPs was not using a stethoscope. When I asked the nurse with me if that was their normal procedure she said that was due to short supplies, but later I found two unused stethoscopes sitting in a box in the lunch room?! Another frustrating piece is that, as far as I can tell, the nurses have tea and lunch for three to five hours each day. True, some work gets done during this period but I haven't observed much. Today for example, we saw 100 patients between 9 and 10:30 (that means each woman was in the room for about 3 minutes and 30 seconds - which includes time spent dressing and undressing). What would happen if those hours were spent providing care?

I just don't understand. In Malawi childbirth is still very dangerous, maternal mortality (per 100,000 births) is among the highest in the world, and yet the few resources that are available are not being utilized to improve care (at least not in this hospital). Leaving today I had the impression that unless the woman herself vocalizes a problem, the only thing that happens during prenatal care is that something is scribbled in her book (and often it is scribble), when it is deciferable it may not even be accurate. Therefore, when she arrives in labor, she can show that she has attended routine prenatal care, she might have 4 to 6 visits documented, but in truth she received NO care. Twins, preeclampsia, bleeding - who knows, and certainly she doesn't know what to do if she begins bleeding or seizing because no one told her about pregnancy risks.

One more story. A 41 year old woman with 7 previous pregnancies came in today saying she was pregnant because she had not had a period for three months. This early on in a pregnancy you can't necessarily palpate the uterus abdominally, and in the US, in addition to doing a pregnancy test, a midwife would size her uterus, one hand internally the other hand on her abdomen. What happened here is that the midwife told her she was going through menopause and sent her home, and then she told me "these women from the village just don't know, they can't even remember all the times they've been pregnant." What?!

Back at the College I mentioned my observation about the BPs to two Malawians who were sitting at my table in the cafeteria and one made a good suggestion. He suggested that I tell the charge nurse what I saw and simple ask (rather than accuse) "Is that the correct way to take BPs?" I think I'll try that next time I'm in that clinic, I was a little too shell-shocked to figure out how to do something diplomatically. Yesterday and today I did bring in my measuring tape and my fetoscope, I didn't say anything but I could tell the nurses were watching me measure bellies.

I am going to study hard and learn Chichewa, the faster I am able to learn the sooner I can begin talking, listening, asking, and educating.

A Thought

Another season of restless waiting has come to an end.
The constant pacing mind calmed by
Peace and happiness that have settled in my heart.

Women here amaze me.
So young
So small, wirey, and strong.
Walking on feet that appear to have circled the world.
Many with a baby on their back
And another growing within.

I wonder about them
And their lives.
The young ones 14, 15, 16
Stepping tentatively into this
Rush rush world of pregnancy and care.
Others of 22, 25, or 29 lifting shirts and lowering skirts
To reveal bellies marked
By the growth and birth of previous passengers.

I know these women from statistics.
These are the ones with anemia, malaria, HIV,
Living lives that would break me.

They smile at me.
Somehow trusting my hands to touch and care for them
Trusting me to care for the fragile life they carry within.

I place my hands on warm bellies
I press gently
And feel the outline of a back, a head, a bottom,
A foot kicking out resisting the pressure I create in its world.

I am here because of them,
Moms and babies.
I will do my best to ease burdens
And soften landings.
I will do my best to be worthy of their trust.
I am grateful to be in their world.

Orientation Begins

The Nurses and Midwives Council received enough paperwork from the States to convince them that I do indeed have a CNM license there and now I can begin the clinical part of getting my license here. I have one month of "orientation" at Bottom Hospital in different areas, an interview before a few members of the Council, and a fee to pay, and then I'll be licensed in Malawi as well. So, this week I began my orientation with antepartum (prenatal) clinic.

The particular building which houses the antepartum clinic also houses the family planning clinic, and the clinic for healthy children under 5. Before the doors open, all the women with appointments for the day (no time slots are given) gather in a covered patio area on rows of cement benches. Several hundred women sit attentively with their babies tied on their backs or nursing at their breasts, as the nurses take turns standing on the steps and giving health talks on various subjects (e.g. signs and symptoms of labor, HIV testing, family planning methods etc.). Then the session ends and the clinic day begins with a type of call and response song. Even though this is just a group of several hundred women from the community and the song is probably just a health message, their clapping and harmonizing sounds as beautiful the music of Ladysmith Black Mombaza (think Paul Simon's African infused music). I would love to record it somehow so you could hear what I mean.

Once the doors open, women are directed inside to sit on benches against certain walls depending on which clinic they will be attending. This morning the four nurses in antenatal clinic saw 150 women. Apparently they can see up to 300 in a morning. (So much for 15 minutes per visit being too short.) Women only come for prenatal care 4 times during their pregnancy. Each time they are weighed, their blood pressure taken, their belly palpated, and fetal heart tones auscultated and that's pretty much it. Depending on where they are in their pregnancy, they are given anti-malarial meds. Oh, nurses also check their tongues and inner eye lids each visit and give iron supplements depending on the shade of pink or red. There are two exam rooms - each with two tables - through which there is a constant flow of women walking-in, handing their small health history books to the nurse, climbing on the tables, uncovering their bellies, climbing down, covering bellies, scooping up children, books and pills, and exiting.

The difference between my training and this environment is stunning, to say the least, and I feel as though this is my very first week all over again, but even so, I am happy to be here. I get to lay my hands on quite a few bellies, ask women "Muli bwanji?" how are you?, "Miyezi ngathi?" how many months?, and try to hear fetal heart tones (FHTs) with the device they use. (It's called a pinard and looks like a miniature trumpet, except envision a flat piece mounted on the mouthpiece. You put the cone side to her belly and put your ear against the flat part.) I found the auscultation incredibly difficult, especially with all the ambient noise, but hopefully I'll get used to it.

I'm sure many of you wonder how the nurse can actually catch and treat problems in such short visits and, well, I'm wondering that too. Yesterday a woman with a fever (probably malaria) was sent to the lab for a blood smear but when she returned to say the lab was closed, she was prescribed medicine for malaria and pneumonia. Another woman at 24 weeks (a complete pregnancy is 40 weeks) who reported contractions, was sent to another hospital in town via public transport escorted by her husband. Both these women came with complaints and although I know the nurses must catch some problems, I'm also sure that many slip through. Especially since they don't use a measuring tape to record the growth of the belly, and since they base the date of delivery on a woman's report of how many months she is, as opposed to a recorded and well scrutinized date for her last menstrual period. Patient education also seems to be minimal, of course there are the health talks and there are posters in the halls on exclusive breastfeeding, anemia, eating iodized salt, and reporting mean nurses (I was excited to discover that I can now read these on my own - pictures help of course), but it seems like there are many gaps. At this point, inspite of my judgments, I am trying to be an observer, I am trying to learn to see as they do first, change will come later.

Yesterday and today clinic wrapped up promptly at 11 and then the nurses set out to cook their lunch. The keep a store of ofa (maize flour) in the cabinet and take turns making nsima for the group on a hot plate in one of the exam rooms (nsima, the staple food, is somewhere between the consistency of mashed potatoes and uncooked dough). Once the nsima is prepared, everyone passes around whatever they have bought from vendors outside out or brought from home (beans, chicken, french fries) and eat. Nomsa, one of the nurses, invited me to share her portion and so the two of us ate off her small plate using fingerfulls of steaming nsima to scoop up beans and chicken.

As I was typing this, a Malawian midwife came and sat at the computer next to me. She is currently getting her PhD at a university in the US but worked here many years in the hospital. She asked me about my days in the clinic and I told her about my observations and she agreed wholeheartedly with everything. Funny enough and totally unprompted, she said, "You can't imagine how I hate those songs they sing. The women sing and dance and they are happy but if you asked them what they learned they keep quiet." She said health education is lacking and even when the message is given, because of cultural dynamics, it makes no difference; the men must also hear. She also said that the midwives are used to working the way they do and are unwilling to change. They want to work half days (afternoons are used to wrap up iron tablets to be distributed the following day), they refuse to see women in the afternoon for various reasons, they say using a measuring tape to check bellies slows them down, and on and on. She said at one point the Ministry of Health even had a program for retraining midwives but none of it worked. The midwives will not lose their jobs because there is such a shortage, there is no change in pay, and so there is no motivation to change. She said, "Wait until you see the delivery ward, you will see all the problems those midwives miss . . . Sometimes you want to tell the women, 'Please have your baby at home, it is not safe here' . . . You will see, the worst is yet to come." And so I will see.

Phone Number

I have a cell phone, at last. The number (dialing from the US) is: 011-265-852-5951. I put a link "call Malawi" to cheap phone cards (looks like "Just India" has the best rate $0.07/min). I am 9 hours ahead of california time, 7 hours ahead of Texas time, and 6 hours of East Coast time. There is no answering message on the phone, so if you manage to get a ring, just let it ring for a while.

Best times to catch me...
weekdays: 5am-7am or 9pm-11pm
weekends: anytime 5am-11pm, but early or late may be better.

1st glimpse of the Bottom

Yesterday, day 13 here in Malawi, I had my first glimpse of Bottom Hospital. I did not run away screaming but I am glad that I spent time at La Maternidad in Bolivia, and that so many people warned me about the conditions before hand. After I returned, Dr. Kaponda told me that she once took an American midwife there - who like myself intended to volunteer - but that evening, a Tuesday, she developed a headache and by Thursday she was on the plane back to the States. I’m sticking it out this week, we’ll talk later about next week : ).

Really, it is a place you must see to understand, perhaps once I’m a familiar face around the joint I’ll bring my camera and put pictures here but that will be later. The hospital itself is surprisingly small, considering it is the principal hospital for the entire central region. It actually consists of a cluster of buildings in various states of disrepair. There are male and female tuberculosis wards and male and female psychiatric wards (these wards are really just a simple one room building with about 20 or 30 beds), a small antenatal clinic, a voluntary HIV testing and counseling clinic (VIC), a polio clinic, and the maternity ward (including inpatient antenatal, an admission room, labor and delivery, postpartum, a kangaroo care room, neonatal, and the operating theatre (I love that term)).

Yesterday, apparently was a slow day for L&D, only six or seven women were in active labor when we walked in, two in second stage (pushing). The nurse greeted me, stepped aside to catch a baby and then returned to lead my tour. L&D itself is small, the size of a standard classroom. The room is painted in turquoise and old matching turquoise curtains hang between the beds, unfortunately not concealing much of anything. Each of the naked women on the bare plastic mattresses glanced up to catch my gaze as I passed through. A nurses’ station - consisting of a wooden bench, two sinks, a small refrigerator with emergency medications, and a cabinet (mostly empty) with delivery packs - divides the room, separating high risk from low risk laboring women. Near the nurses station sits the infamous broken suction machine, as well as two carts for newborns. Only one cart had a heat lamp, which did not seem to be on or working at the time we passed through, but warm or not, its small passenger was contentedly sucking on a fist.

The most impressive part, to me, were the large handwritten signs posted about the room on HIV transmission prevention, steps for managing postpartum hemorrhage, and the importance of hand-washing. Regardless of resources, it’s good to know that those are all priorities for staff. The staff I saw around the place were friendly to me and seemed to be kind to the women they were caring for (a good distinction between Bottom and La Materindad). Dr. Magete was also present and wanted to make sure I saw the suction machine.

Outside, people in bright clothes sitting on mats, or dirt, in spots of shade filled the grounds, eating, sleeping, talking, waiting. These, I was told, were the “guardians” of the patients. They stay to care for their hospitalized family members and to prepare their food in the outdoor communal kitchen located behind the psych ward. I believe the large presence of guardians exemplifies both the cultural importance placed on family as well as the nursing shortage.

My walk through lasted about an hour. I was supposed to return today for observation but we received a letter this morning from the hospital saying that they wanted something from the nurses and midwives council (NMC) before I begin observation. Unfortunately when we went to the NMC we received only a verbal “ok” so now I am here in the office again this afternoon. Paperwork paperwork blah. I suppose the good bit is that I’m sure doing a lot of journaling and those of you who are following probably know more detail about my day to day life than you ever imagined you would (I’m not sure if that’s good or burdensome for you).

Last night I went running with the expat Wednesday night running group. They are intense runners. It was work. The route was only about 6K, but it was on a dirt trail through the bush and in spite the terrain the leaders must have been going at a 7min/mi pace. It involved crossing a few muddy streams, running up hill for a long ways then down, beating through 6 ft high grass, and racing between rows of corn. If I hadn’t been thinking that I was near death for the entire run, it would have been really enjoyable. The sun was setting over the hill and there were flowers scattered among the corn, every now and then we would come upon some Malawians who would stop their work to smile and laugh at the m’zugus (white folk), and the children we passed stuck out their little hands in a line to be slapped as we ran by. I’ll do it again. I’ll look forward to getting in shape so I can keep up with the 40 and 50 year olds in the group (no joke). Only once we were all done did someone mention to me that there are venomous spitting snakes and pythons out there. Great. I’ll still do it again. I won’t be the leader so I figure I’ll be safe.

The expats, as a group, were really nice. I was among the youngest and definitely the newest arrival. I have to say that it felt really good to say, when people asked if I was visiting, “No, I just moved here.” I’m looking forward to developing community. In the group, I found a Brazilian who was so excited to speak Portuguese and already has planned outings for us, and a British woman who may have paying work for me down the line. Jennifer, the American nurse, dropped me off at home around 8. I was happy, happy for all the experiences of the day, for the potential of new friends, and the homey scene that greeted me when I returned – four women in the kitchen cooking, speaking Chichewa, and laughing.

Life is rich.

Amazing People

Perhaps the mere fact that life in extreme environments demands more, foments the development of amazing individuals but whatever the reason, they are certainly here.

First off, I just want to say that Dr. Chrissie Kaponda and her husband Alex are truly incredible. The more I learn of them, the more I am blown away by their perspective, their generosity, and their work. In addition to their professional work, they have a personal commitment to educate as many girls as possible. They know that when women are educated the entire family is better off and here, in this strongly patriarchical society, there are enumerable barriers against the education of girls.

Just to provide a small cultural illustration, women when greeting men actually kneel while shaking hands (this doesn't happen often in town but I have seen it here and it seemed to be standard in the village). Women are also expected to maintain the home, cooking and cleaning for the family. So, while the boys have time to study, girls only study if and when all their other work is complete. Girls' boarding schools have come into being with the purpose of removing the brightest from their homes so they can study. One woman here told me that all professional Malawian women attended boarding schools, so this strategy seems to be working.

I'm not sure how many girls Dr. Kaponda and her husband have put through school. Alex says their have been more failures than successes, but there have been successes and at the moment they have three adolescent women, in addition to their own daughter, who are living with them and studying.

Amazing person #3. This morning I was introduced to Dr. Meguid, a visiting obstetrician who supplements the manpower of the country’s three obstetricians (yes 3). He is a tall man in his mid-40s with sincere eyes and a head full of thick shaggy brown hair. He currently works both at Bottom Hospital as well as at a private hospital. Dr. Kaponda was having a meeting with Dr. Meguid and she called me in to hear the stories he was telling.

He said that yesterday he was called to the private hospital to do a vacuum extraction. Once he arrived and assessed the situation, he determined that an episiotomy would be needed. After requesting scissors, he said it took about 5 minutes for a pair to be located, and then (remember this is at the private hospital where patients pay for care) they were so dull it took eight cuts to cut through the skin. He said to me, "I tortured the woman and she said, 'Thank you,' having no concept that she should expect better care, I felt horrible." From there, he went on to discuss the shortage of gloves. Apparently for the 30-50 deliveries done at Bottom each day, they estimate that they need 600 gloves, but Dr. Meguid said he cannot remember a day when they had enough. He also said that recently the suction in L&D broke and so now when a newborn really needs suctioning, they have to run across the hospital with the baby to the neonatal nursery.

Dr. Meguid, Dr. Kaponda, and the dean of the College were discussing the disempowerment of women here and how this directly effects high mortality rates among women and infants. He said, "They are poor, uneducated, voiceless, and have no one to speak on their behalf." No one seemed to know why basic supplies are in such short supply - mismanagement, corruption, national poverty are possibilities – but irrespective of the cause, the problem is clearly enormous.

After the horror stories, Dr. Meguid assured me that beautiful things also transpire in the hospital and welcomed me to Malawi and to this work. I was very happy to meet him and to know that he is also here, in this system, passionately envisioning and working, against all odds, towards a better reality.

If anyone does want to ship supplies here, the address is:

Dr. Chrissie Kaponda
Kamuzu College of Nursing - Research Center
Private Bag 1
Lilongwe, Malawi
Africa

(I have been told that writing "feminine hygiene products" or "religious items" on the customs slip will expedite the process.)

Week 1

Well, I'm off to a slow start but so far so good.

Friday my heart was fed. Kids are the greatest. First they stand around looking at you like you're some kind of circus freak, giggling timidly and then before you know it you're sharing a chair with a 9-year-old and have a 4-year-old in your lap happily swinging her legs. I went along with Dr. Kaponda and some other folks from the nursing college for a "graduation ceremony" for Mzake ndi Mzake (friend to friend) in a village. Mzake ndi Mzake is a program which certifies men and women living in rural areas in HIV/AIDS peer education. I didn't understand much of the ceremony just a few words here and there - "zikomo kwambiri" (thank you very much), "manja manja" (applause applause), etc. - but, it was just great to get out of the city and be there. The kids were the highlight, they tried out their English on me and laughed as I tried my Chichewa, but there was also a group of women who sang and danced during the ceremony who were wonderful to see.

Apart from that, my week was filled with Chichewa lessons and bureaucracy. My Chichewa is coming along (slow according to me, but well enough according to everyone else). At least I'm picking out words and, with the English people throw in, I sometimes can get the gest of the conversation. People speak Chichewa like people on the border speak Spanglish, okay maybe a little less English but you get the idea. The other part, the bureaucratic part, involved figuring out what hoops I need to jump through to get certified as an RN/CNM here and meeting everyone I may ever need to know or who may need or want to know me. The meetings went well, everyone is really so nice, but everyone, when I told them what I would be doing (volunteering at Bottom Hospital), had the same reaction more or less. Basically, I was told that it is a wretched place where no one would willingly enter for care, that I will be shocked, and that I need a should to cry on, hmm sounds great. Unfortunately, on the other side of things, I found as I imagined I would, that I have a bunch of paperwork that needs to be mailed, faxed, stamped, signed, etc. before I can start actually working. I'm supposed to begin orienting/observing at the hospital tomorrow. I'm not exactly sure how "observing only" will work, if the nursing shortage truly is horrendous and I see things I can do, I'm not sure how I'll just stand by. I'll have to talk that over with Dr. Kaponda.

Life at Dr. Kaponda's continues to go well. As a side note, she was incredibly appreciative of all the supplies that I brought and assured me that they will be put to good use. It's amazing and kind of frightening how excited she was about simple supplies like pen lights and BP cuffs. Thank you everyone who contributed. I still have money to donate so Dr. Kaponda suggested using it to buy cloth to sew hats and blankets for the newborns. Apparently newborns often die of hypothermia because the mother only comes with one cloth (really the clothing she wares over her skirt) and babies are dried and wrapped after birth with this one cloth.

For me so far everything has been so easy that I can forget where I am at times. Every now and then a particular sight will pull me back to reality, like the street near the nursing college which is lined, both sides, with makeshift kiosks for people making and selling coffins. Or like Saturday, when I was driving with the former dean of the college we passed a group of nursing students walking with signs through the streets. Apparently the wards at the hospital are never cleaned so the students were walking to raise money for soap and mops and brooms so that they themselves could clean the pediatrics ward. I realize there are so many levels that I am blind to now but that will be visible in time.

On the other end of the spectrum, I just met Jennifer, another American nurse-practitioner who is living and working here. She gave me a little peak into expat life here and, most importantly, she offered her shoulder if/when I need it. She is working on a capacity building project related to HIV/AIDS. In short, nurses are being brought to Lilongwe from all over, for training so they can distribute anti-retro virals (ARVs) at their home sites and disseminate info and Jennifer is trying to determine if they are actually retaining the info from the trainings. As for the expat life apparently there's tons to do. A running group meets three times a week, there's yoga daily, dinners, and a free weekly movie at the embassy (since there are no theatres in Lilongwe). She also said there is incredible nature stuff to do outside the city - great hiking, the lake is 1 and 1/2 hrs from here, and there are mountains, waterfalls, etc. This is all good. Hopefully, even though I don't have a car, I'll find a way to get to and from some of it. The other piece that she mentioned is all the development work that goes on here. It sounds like, down the line, after I establish myself and get some good experience, I may be able to find some organization that would actually pay me to do something here. So that's good too.

I think that's it for today. Thank you everyone who has been responding to me, it is always good to read your notes.

Love,
J.