I went to visit Cromwell again yesterday and he's much the same. The doctor told him that all the tests came back normal so far, and that they would do an x-ray (I'm not sure of what). He's still just lying in bed with the glucose drip and aspirin, nothing else, and I'm not sure that anyone has told him that it may take quite a while to recover. He asked me if I was going to run this morning (usually we run Tuesdays), I said of course not, and he smiled a small smile and said that he thought he'd be better by next week. Although he's holding it together, he seems pretty down and the thought occurred to me that it might be nice to flood him with get well cards. If any of you are interested, send cards to me at:
Joanne Jorissen
KCN - Research Center
P/Bag 1
Lilongwe, Malawi
AFRICA
Just write his name on the back so it won't confuse the postoffice or the people sorting mail at the College.
Tuesday, May 31, 2005
Monday, May 30, 2005
Highs and Lows
I had a wonderful weekend, the ALSO group treated me to a divine 24 hours of R&R at the 
lake – sun, good conversation, lots of laughter, swimming, good food, and snorkeling among beautiful fish (there are more than 280 species of fish there). The lake is amazing. It appears so vast that at first glance you might think you’ve arrived at the Ocean; it even has its own gentle waves that lap softly at white sand beaches. This was my first real get-away here in Malawi away and I ate it up. It is only an hour’s drive from Lilongwe, but without a car it has seemed inaccessible. I’m going to have to find a way to get there via minibuses and plan occasional camping excursions, now that I know what I’ve been missing, I don’t want to go on missing it.
Sunday we packed up early so the group could make their flight out of Malawi at 1pm. Some of them will come back in October for another follow-up course and I’m already eager for their return. In such a short time I grew accustomed to the presence of these midwives and physicians around Bottom, I looked forward to their smiles, hugs, and words of encouragement/advice. Just knowing they were around made the difficult experiences a bit easier to bear. They have left the hospital in much better shape than they found it but it will seem emptier without them.
This weekend was great, mostly fun and restful and but it ended on a sad note . . .
Saturday, as we were driving out of Lilongwe I received a call from Cromwell’s brother (Cromwell is my friend who runs with me a couple times a week) saying that Cromwell had collapsed and was in the hospital. He didn’t have any additional information at the time. So, when I returned to Lilongwe on Sunday, I made my way to the hospital around noon and found him asleep in bed with a glucose drip running. The minutes before he opened his eyes were surreal, finding him in that environment, knowing something was wrong but not having any idea of what it could be. I just watched him as he slept and he looked to be the very same healthy and fit friend who meets me at the gate at 5am for our runs. Nothing seemed ominous in the room itself, only one IV running slowly, no tubes or monitors or bandages, no hospital personnel, and yet at the same time two days had passed since he collapsed and he was still in the hospital. The best case and worst case scenarios sprinted through my head, but the minute he opened his eyes and began talking it became clear. The left side of his mouth remained fixed while the right side moved full of words and expression. Initially I hoped it was just Bell’s Palsy but then he said he couldn’t move his left hand or left leg either. He had had a stroke.
Thursday he had called to tell me he would be visiting his brother Friday and wouldn’t make our usual run. He said Thursday was a normal day, he even played soccer for about an hour with a group of kids. But, around 4am that night, he tried to get up and just collapsed because his leg wasn’t working. His brother immediately brought him to the hospital where they gave him aspirin and started a glucose drip. He said they did some tests for his heart and might have drawn blood (I was unclear about that from his story) but they have yet to give him the results for anything.
Why does a 29 year old have a stroke?! And, why is he still waiting in a hospital bed three days after the incident without any sort of assessment, knowledge, or care plan? He said a few times that he would be all right (another example of the staunch optimism of Malawians) and I certainly hope so, but I cannot imagine that he’ll be back to playing soccer anytime soon. I feel so sad. He is my friend. One minute he’s playing soccer and the next he’s a hemiplegic. He’s so young and was so active, and, not that tragedy ever notices but, he’s such a good person. I am learning an unfortunate lesson that is being repeated again and again, which is that all Malawians have had at least one major tragedy in their lives, whether on not it is visible in their outward appearance, you can be sure the story is there.
lake – sun, good conversation, lots of laughter, swimming, good food, and snorkeling among beautiful fish (there are more than 280 species of fish there). The lake is amazing. It appears so vast that at first glance you might think you’ve arrived at the Ocean; it even has its own gentle waves that lap softly at white sand beaches. This was my first real get-away here in Malawi away and I ate it up. It is only an hour’s drive from Lilongwe, but without a car it has seemed inaccessible. I’m going to have to find a way to get there via minibuses and plan occasional camping excursions, now that I know what I’ve been missing, I don’t want to go on missing it.Sunday we packed up early so the group could make their flight out of Malawi at 1pm. Some of them will come back in October for another follow-up course and I’m already eager for their return. In such a short time I grew accustomed to the presence of these midwives and physicians around Bottom, I looked forward to their smiles, hugs, and words of encouragement/advice. Just knowing they were around made the difficult experiences a bit easier to bear. They have left the hospital in much better shape than they found it but it will seem emptier without them.
This weekend was great, mostly fun and restful and but it ended on a sad note . . .
Saturday, as we were driving out of Lilongwe I received a call from Cromwell’s brother (Cromwell is my friend who runs with me a couple times a week) saying that Cromwell had collapsed and was in the hospital. He didn’t have any additional information at the time. So, when I returned to Lilongwe on Sunday, I made my way to the hospital around noon and found him asleep in bed with a glucose drip running. The minutes before he opened his eyes were surreal, finding him in that environment, knowing something was wrong but not having any idea of what it could be. I just watched him as he slept and he looked to be the very same healthy and fit friend who meets me at the gate at 5am for our runs. Nothing seemed ominous in the room itself, only one IV running slowly, no tubes or monitors or bandages, no hospital personnel, and yet at the same time two days had passed since he collapsed and he was still in the hospital. The best case and worst case scenarios sprinted through my head, but the minute he opened his eyes and began talking it became clear. The left side of his mouth remained fixed while the right side moved full of words and expression. Initially I hoped it was just Bell’s Palsy but then he said he couldn’t move his left hand or left leg either. He had had a stroke.
Thursday he had called to tell me he would be visiting his brother Friday and wouldn’t make our usual run. He said Thursday was a normal day, he even played soccer for about an hour with a group of kids. But, around 4am that night, he tried to get up and just collapsed because his leg wasn’t working. His brother immediately brought him to the hospital where they gave him aspirin and started a glucose drip. He said they did some tests for his heart and might have drawn blood (I was unclear about that from his story) but they have yet to give him the results for anything.
Why does a 29 year old have a stroke?! And, why is he still waiting in a hospital bed three days after the incident without any sort of assessment, knowledge, or care plan? He said a few times that he would be all right (another example of the staunch optimism of Malawians) and I certainly hope so, but I cannot imagine that he’ll be back to playing soccer anytime soon. I feel so sad. He is my friend. One minute he’s playing soccer and the next he’s a hemiplegic. He’s so young and was so active, and, not that tragedy ever notices but, he’s such a good person. I am learning an unfortunate lesson that is being repeated again and again, which is that all Malawians have had at least one major tragedy in their lives, whether on not it is visible in their outward appearance, you can be sure the story is there.
Friday, May 27, 2005
Thirteen Babies
I just completed my five days of orientation in Labor and Delivery. Orientation is not quite the right term for this period, basically a nurse took two minutes to show me around the room, pointing out where meds are kept, gloves, suture, IV, etc. and then turned me loose. There is no practice of assigning particular women to a particular nurse. Everything is done on a first come first serve basis or, more accurately, on a whoever-is-walking-by basis. Someone is moaning or calling for help, go there, a head is crowning, glove up and run to make the catch. At the moment, this place represents the antithesis of true midwifery. True midwifery being . . . staying with a woman throughout her labor, offering constant support, encouraging movement, protecting privacy, and in general working in partnership with the women. But, there is hope for change.
The scene: there are eight beds on one side of the labor room (the low risk area) and six on the other side (the high risk area). The beds are simple metal frames high off the ground (too high to get up and down without the use of a step ladder, but still not high enough to protect the backs of those catching the babies) with bare mattresses. Among the items a woman is required to bring to L&D is a plastic sheet (they look just like large black garbage bags and aren't much bigger than that, they don't cover the entire mattress). Once a woman is in active labor, she enters L&D carrying all of her things and is told to find a bed. Finding an empty, and hopefully clean mattress, she spreads out the plastic sheet, puts a chitenge on top, undresses, climbs on to the bed, and covers herself with another chitenge. Those of you who have either experienced a birth or seen one, know how messy it can be and you can imagine that often times the chitenges are soaked not far into the process, leaving the poor woman lying in a cold puddle - the plastic sheet doing nothing to protect the larger mattress on which it rests. The mattress is cleaned and dried only after the delivery and an hour observation period. It is really hard to keep the women warm and dry since there are no sheets or blankets and only a few cleaning rags. Most women are so eager for their shower/bucket bath, which of course is cold but is a better alternative to lying on those mattresses. The women get up, bathe, wash their chitenges, and go to the low risk postpartum room for 24 hours. I'm still not exactly sure how that works since there are fewer beds in that room than in L&D. A lucky few get beds or mattresses on the floor and the rest . . .?
Over the past two weeks the visiting Scottish midwives and OBGYNs did a fabulous job of putting a new face on L&D. They scrubbed from ceiling to floor, painted the walls, cleaned the curtains, had new cupboards made for materials, and donated a bunch of useful stuff like shower curtains to use instead of the plastic - which can easily changed and washed - and sheets. So it's looking much better. Hopefully the improvements will last, and the curtains, sheets, and other items will not walk out too soon. One of my Malawian friends suggested writing, "Stolen from Bottom Hospital," on all the sheets. I laughed, but apparently it's already being done at many institutions and it's still not a strong enough deterrent for theft. Theft is such a complicated issue. Everyone is poor. Who is stealing? employees? patients? guardians? Is it just poverty? A sense of entitlement? Are people earning money by selling stolen items? I have been told that so many people and organizations have donated things over time but the items never stay long, slowly and inevitably they all disappear. I recently heard an interesting theory, "Poverty and wealth both have an equal ability to corrupt." I have many jumbled thoughts about development work, poverty, and charity but perhaps I should come back to them later, on to the births . . .
I caught 13 babies in five days (3, 3, 4, 1, and 2), 8 boys and 5 girls. I was a bit nervous the first day, since almost a year had passed since the last birth I had attended, but it all came back. Everyone left the labor ward in their mother's arms within an hour or two of their birth, even though I did have to resuscitate one little boy who was born blue and floppy. This time I managed to find a bag and mask quickly, warded off all those who wanted to suction, and he was breathing, crying, sucking, and kicking within minutes. I suppose (I hope) each time will be a little easier and that soon, even with the surge of adrenaline, I will be calm, gentle, precise.
I feel good about the care I provided this week, sure it could have been better - especially if I spoke Chichewa - but I did my best, and the moms seemed happy and the babies healthy. On my first day, one of the laboring women was rattling away in Chichewa to me and when I called a nurse over to find out what she was saying, the nurse told me that she just wanted to talk to me as a distraction. I asked if she wanted someone else to be with her since I couldn't understand and she pointed at me and said "Ayi, awa" (No, her). That was nice and she continued talking to me in Chichewa.
All in all it was a good week. Exhausting but good. I am being forced to learn my limits, and recognize when I really physically can't give any more before I've had a break. I've helped convince a few people to change their practices (i.e. no suctioning, less episiotomies, and starting with a lower dose of miso for inductions (they are using 100-200mcg of miso in one dose for induction?!)). And, of course I'm learning a ton too; so many lessons are packed into each day.
This week did also have its tragedies. Friday morning I came in to find one of the visiting OBGYNs resuscitating a baby. The mother had a long difficult labor, an infection, and was delivered by an emergency c-section. The baby had been left for sometime before he was found by the OB who started the resuscitation. In the end, after 50 minutes with a heartbeat but no respiratory efforts (and no other life sustaining options available), the OB stopped the resus and we stayed with the baby until it died.
This morning one of the interns came by the college, where I'm planted doing emails, to return a book and told me that last night they had a maternal death. Apparently the woman had seized at home and was taken to a few traditional healers before being brought to the hospital. On L&D she was given Hydralazine to lower her blood pressure and MgSO4 to prevent more seizures, she was then left alone for about 10 minutes and when people returned to check on her they found that she had died. She may have died from her eclampsia but she may have died from the medication (MgSO4 causes respiratory depression at high doses), no one will ever know.
Bottom Hospital?!
The scene: there are eight beds on one side of the labor room (the low risk area) and six on the other side (the high risk area). The beds are simple metal frames high off the ground (too high to get up and down without the use of a step ladder, but still not high enough to protect the backs of those catching the babies) with bare mattresses. Among the items a woman is required to bring to L&D is a plastic sheet (they look just like large black garbage bags and aren't much bigger than that, they don't cover the entire mattress). Once a woman is in active labor, she enters L&D carrying all of her things and is told to find a bed. Finding an empty, and hopefully clean mattress, she spreads out the plastic sheet, puts a chitenge on top, undresses, climbs on to the bed, and covers herself with another chitenge. Those of you who have either experienced a birth or seen one, know how messy it can be and you can imagine that often times the chitenges are soaked not far into the process, leaving the poor woman lying in a cold puddle - the plastic sheet doing nothing to protect the larger mattress on which it rests. The mattress is cleaned and dried only after the delivery and an hour observation period. It is really hard to keep the women warm and dry since there are no sheets or blankets and only a few cleaning rags. Most women are so eager for their shower/bucket bath, which of course is cold but is a better alternative to lying on those mattresses. The women get up, bathe, wash their chitenges, and go to the low risk postpartum room for 24 hours. I'm still not exactly sure how that works since there are fewer beds in that room than in L&D. A lucky few get beds or mattresses on the floor and the rest . . .?
Over the past two weeks the visiting Scottish midwives and OBGYNs did a fabulous job of putting a new face on L&D. They scrubbed from ceiling to floor, painted the walls, cleaned the curtains, had new cupboards made for materials, and donated a bunch of useful stuff like shower curtains to use instead of the plastic - which can easily changed and washed - and sheets. So it's looking much better. Hopefully the improvements will last, and the curtains, sheets, and other items will not walk out too soon. One of my Malawian friends suggested writing, "Stolen from Bottom Hospital," on all the sheets. I laughed, but apparently it's already being done at many institutions and it's still not a strong enough deterrent for theft. Theft is such a complicated issue. Everyone is poor. Who is stealing? employees? patients? guardians? Is it just poverty? A sense of entitlement? Are people earning money by selling stolen items? I have been told that so many people and organizations have donated things over time but the items never stay long, slowly and inevitably they all disappear. I recently heard an interesting theory, "Poverty and wealth both have an equal ability to corrupt." I have many jumbled thoughts about development work, poverty, and charity but perhaps I should come back to them later, on to the births . . .
I caught 13 babies in five days (3, 3, 4, 1, and 2), 8 boys and 5 girls. I was a bit nervous the first day, since almost a year had passed since the last birth I had attended, but it all came back. Everyone left the labor ward in their mother's arms within an hour or two of their birth, even though I did have to resuscitate one little boy who was born blue and floppy. This time I managed to find a bag and mask quickly, warded off all those who wanted to suction, and he was breathing, crying, sucking, and kicking within minutes. I suppose (I hope) each time will be a little easier and that soon, even with the surge of adrenaline, I will be calm, gentle, precise.
I feel good about the care I provided this week, sure it could have been better - especially if I spoke Chichewa - but I did my best, and the moms seemed happy and the babies healthy. On my first day, one of the laboring women was rattling away in Chichewa to me and when I called a nurse over to find out what she was saying, the nurse told me that she just wanted to talk to me as a distraction. I asked if she wanted someone else to be with her since I couldn't understand and she pointed at me and said "Ayi, awa" (No, her). That was nice and she continued talking to me in Chichewa.
All in all it was a good week. Exhausting but good. I am being forced to learn my limits, and recognize when I really physically can't give any more before I've had a break. I've helped convince a few people to change their practices (i.e. no suctioning, less episiotomies, and starting with a lower dose of miso for inductions (they are using 100-200mcg of miso in one dose for induction?!)). And, of course I'm learning a ton too; so many lessons are packed into each day.
This week did also have its tragedies. Friday morning I came in to find one of the visiting OBGYNs resuscitating a baby. The mother had a long difficult labor, an infection, and was delivered by an emergency c-section. The baby had been left for sometime before he was found by the OB who started the resuscitation. In the end, after 50 minutes with a heartbeat but no respiratory efforts (and no other life sustaining options available), the OB stopped the resus and we stayed with the baby until it died.
This morning one of the interns came by the college, where I'm planted doing emails, to return a book and told me that last night they had a maternal death. Apparently the woman had seized at home and was taken to a few traditional healers before being brought to the hospital. On L&D she was given Hydralazine to lower her blood pressure and MgSO4 to prevent more seizures, she was then left alone for about 10 minutes and when people returned to check on her they found that she had died. She may have died from her eclampsia but she may have died from the medication (MgSO4 causes respiratory depression at high doses), no one will ever know.
Bottom Hospital?!
Thursday, May 19, 2005
The Bright Side
A group came to Lilongwe from Scotland this week to teach a 2-day course on Advanced Life Saving Skills in Obstetrics (ALSO) to a group of nurses, midwives, physicians, and clinical officers here. Of the nine instructors, 7 were midwives. It was a great course for multiple reasons (1) the information was great, very complete, evidence-based, and supporting interventions only when absolutely necessary; (2) there was a lot of practice with dummies and hands-on activities; (3) all levels of providers participated, it was a nice leveling experience; (4) the instructors were all volunteering their time and are still here for another week just cleaning and painting the labor ward. They're trying to recruit people here to teach the course elsewhere in Malawi and they said they would like me to be an instructor after I have a bit more experience (maybe only 6 months). So that is an exciting possibility.
This morning when I walked in, I was told that a mom was about to have a vacuum delivery so I went to watch. When I got there the baby was out, gasping and the clinical officer was calmly standing over it just waiting for a suction. He asked me how I was and I said, "fine, how's the baby?" and he said "not so good." He had just completed the same ALSO course with me where we were taught not to suction, because it does more harm than good (it can damage the baby's throat and mouth in addition to causing a vasovagal response which will drop the BP and heart rate further) and just to start resuscitation and yet there he was standing over this baby who was looking back at him wide-eyed and shocked. I gently reminded him about what we learned but then an OB who had not taken the course came and instructed him to take the baby to the nursery for suctioning and so he started off, picking up the baby by the ankles (another no-no since it can damage the baby's spinal cord and injure the neck). The Scottish midwives saw the scene from across the room where they were cleaning and one came over and gave me a hug, bringing tears to the surface I didn't even know were there. Coming to the hospital is like plunging into ice cold water first thing in the morning, painful at first, but once you're in, you adjust, smile, and begin.
I want to add another thought here about Dr. Meguid. I have been seeing him more and more around the hospital and he also took the course this week. I am so glad he's here. He's constantly reminding me to smile, checking in to see if I'm okay, and reassuring me that change is happening and that it will happen. He makes me believe that it is possible to turn this place around. He told me that he's been working in different places in Africa and that the reason he has chosen clinical as opposed to policy work is because, "At least you can make a difference to one person, even if they forget you the minute they leave, you still made a difference." I agree.
On that note, I checked-in with the 21-year-old today and she was smiling. She motioned from her waist up, showed me her wounds and said, "bwino bwino" (very good). Talk about looking on the bright side.
This morning when I walked in, I was told that a mom was about to have a vacuum delivery so I went to watch. When I got there the baby was out, gasping and the clinical officer was calmly standing over it just waiting for a suction. He asked me how I was and I said, "fine, how's the baby?" and he said "not so good." He had just completed the same ALSO course with me where we were taught not to suction, because it does more harm than good (it can damage the baby's throat and mouth in addition to causing a vasovagal response which will drop the BP and heart rate further) and just to start resuscitation and yet there he was standing over this baby who was looking back at him wide-eyed and shocked. I gently reminded him about what we learned but then an OB who had not taken the course came and instructed him to take the baby to the nursery for suctioning and so he started off, picking up the baby by the ankles (another no-no since it can damage the baby's spinal cord and injure the neck). The Scottish midwives saw the scene from across the room where they were cleaning and one came over and gave me a hug, bringing tears to the surface I didn't even know were there. Coming to the hospital is like plunging into ice cold water first thing in the morning, painful at first, but once you're in, you adjust, smile, and begin.
I want to add another thought here about Dr. Meguid. I have been seeing him more and more around the hospital and he also took the course this week. I am so glad he's here. He's constantly reminding me to smile, checking in to see if I'm okay, and reassuring me that change is happening and that it will happen. He makes me believe that it is possible to turn this place around. He told me that he's been working in different places in Africa and that the reason he has chosen clinical as opposed to policy work is because, "At least you can make a difference to one person, even if they forget you the minute they leave, you still made a difference." I agree.
On that note, I checked-in with the 21-year-old today and she was smiling. She motioned from her waist up, showed me her wounds and said, "bwino bwino" (very good). Talk about looking on the bright side.
To Be A Mother
Last week I began my orientation in the postnatal ward. This ward consists of two large rooms with about 20 patients each, two medium sized rooms of 6 each and two small rooms with 3 patients each. Once again, all cared for by a single nurse and two nurse assistants (a.k.a. auxiliary nurses). The women here are mostly post-cesearian patients but these rooms also house women with preeclampsia and eclampsia, symphasis pubis dyastisis, women with intrauterine fetal demises (IUFD) awaiting delivery (laying on mattresses aside women nursing their healthy newborns).
Today I saw a woman who delivered premature triplets at home. They were all alive when she arrived at the hospital but when I went to see them they were already wrapped and set aside in a corner of the nursery. The nurse said, “They were so cold already and they didn’t stay long.” No one had told the mother yet, the guardians had been told but not the mother (apparently culturally the guardians are supposed to tell the mother).
Then, I saw a 19-year-old who began laboring in Mozambique but who made her way from home to health center, once she or her birth attendant realized the labor was not progressing normally. The health center transferred her to a larger health center, which then transferred her to Bottom. When she arrived at Bottom, three days into her labor, her uterus had ruptured and her baby had died. She survived but her life cost her her uterus and a blood transfusion.
I saw two eclamptic patients. One of whom, when I asked for her clinic booklet, did not have a single blood pressure recorded for any of her prenatal visits. (Preeclampsia is an awful, poorly understood, systemic disease of pregnancy characterized by high blood pressures. A woman with preeclampsia can seize at any time, but women with elevated blood pressures are usually monitored carefully and given medications to prevent seizures, or delivered early. The only cure is delivery. Once a woman seizes it is said that she has eclampsia. Eclampsia is fairly rare in the developed world. One Scottish OBGYN recently told me that in his 9 years of practice he had never seen eclampsia.)
In the last hour of my day I saw a preeclamptic pregnant woman at 30 weeks gestation seize in the hall. Around the same time, the doctor determined that another woman, complaining of abdominal pain, was approaching septic shock and needed to be prepared for a stat uterine evacuation.
This of all really happened, and more. One day. Eight hours. Unbelievable.
There is so much going on, so much to take in, so much to feel. Some of it is only witnessed but some reaches deep inside. At certain moments I can feel a force moving through me, changing the rhythm of my heartbeat, pressing on my chest, electrifying the tips of my fingers, creating a wide empty space in my belly as an experience is permanently and viscerally recorded. Wherever I choose to be in the world, the stories in Malawi will continue unfolding with their drama, passion, and loss. I could be in so many places, but now I want to be here. Even in the most tragic moments there is solace in the experience of sharing the pain and in the hope that just as pain can compress and diminish life, if met with love, it can expand life. That is the hope.
Last week I met a girl 21 years old, who had had three pregnancies, three deliveries, and no surviving children. Her most recent pregnancy ended with a term IUFD and she was delivered via c-section. After waiting a week in the hospital for her incision to heal, she was discharged home but soon returned with a raging infection (peritonitis and a necrotic uterus) and had a hysterectomy. I met her while she was in the ward recovering from her hysterectomy. She is a beautiful girl but her young body takes the form of an old woman when she walks - bending forward, moving slowly, each step cautious and tender. And yet, even though everything about her communicates the depth of her loss, she almost always smiles at me when I enter the ward – warm and genuine. Over the past week, I always looked for her when I came and I watched her wounds, they are healing well. One large untidy line - thick here then thin, puckering at points - stretches down from her navel and a smaller perpendicular scar marks the right side of her abdomen. There is nothing subtle in her story or in its transcription on her small body.
I was with her today when the clinical officer discovered that somehow - in the process of her illness, and healing, and illness and healing - she had developed a fistula between her urethra and her vagina. He found a hole where it shouldn’t be, but there it is, and now urine constantly runs down her legs. They can and will surgically repair the fistula, but she must wait three months before her body will be ready for the operation. Three months after losing her third baby. Three months after losing her uterus. She will wait three months smelling of urine for yet another surgery. As he explained the problem to her, tears began to silently spill from the corner of her eyes. He said she could go back to the room, to her bed, and then she could go home. Just come back in three months.
I followed her back to her bed. In the middle of the noisy room filled with mothers and guardians, visiting husbands, crying babies, nursing babies, she collapsed on her bed in a small heap and began sobbing, “Amayi, amayi, amayi.” I rubbed her back and her head. And, when I realized she was crying “Mother mother mother . . .” the tears I was holding, broke free. We are so much the same in our expressions of pure emotions. We all call for the same person when life ravishes us, the only person whose love can offer comfort in moments of utter devastation - our mothers. I also realized with a bit of tragic irony that here in Malawi where women are raised to be mothers, this small woman had tried so hard to be just that and it broke both her body and her heart. I cried. And, I prayed. I prayed that she did have a loving mother and a loving husband, that she would again find hope and strength. I stayed with her until she fell asleep.
Only once she was still and her breathing deep and regular, did I notice a small wizened woman standing near the bed. She smiled a kind sorrowful smile and said, placing her hands over her heart and nodding at the sleeping girl, “Mwana anga,” my child.
Today I saw a woman who delivered premature triplets at home. They were all alive when she arrived at the hospital but when I went to see them they were already wrapped and set aside in a corner of the nursery. The nurse said, “They were so cold already and they didn’t stay long.” No one had told the mother yet, the guardians had been told but not the mother (apparently culturally the guardians are supposed to tell the mother).
Then, I saw a 19-year-old who began laboring in Mozambique but who made her way from home to health center, once she or her birth attendant realized the labor was not progressing normally. The health center transferred her to a larger health center, which then transferred her to Bottom. When she arrived at Bottom, three days into her labor, her uterus had ruptured and her baby had died. She survived but her life cost her her uterus and a blood transfusion.
I saw two eclamptic patients. One of whom, when I asked for her clinic booklet, did not have a single blood pressure recorded for any of her prenatal visits. (Preeclampsia is an awful, poorly understood, systemic disease of pregnancy characterized by high blood pressures. A woman with preeclampsia can seize at any time, but women with elevated blood pressures are usually monitored carefully and given medications to prevent seizures, or delivered early. The only cure is delivery. Once a woman seizes it is said that she has eclampsia. Eclampsia is fairly rare in the developed world. One Scottish OBGYN recently told me that in his 9 years of practice he had never seen eclampsia.)
In the last hour of my day I saw a preeclamptic pregnant woman at 30 weeks gestation seize in the hall. Around the same time, the doctor determined that another woman, complaining of abdominal pain, was approaching septic shock and needed to be prepared for a stat uterine evacuation.
This of all really happened, and more. One day. Eight hours. Unbelievable.
There is so much going on, so much to take in, so much to feel. Some of it is only witnessed but some reaches deep inside. At certain moments I can feel a force moving through me, changing the rhythm of my heartbeat, pressing on my chest, electrifying the tips of my fingers, creating a wide empty space in my belly as an experience is permanently and viscerally recorded. Wherever I choose to be in the world, the stories in Malawi will continue unfolding with their drama, passion, and loss. I could be in so many places, but now I want to be here. Even in the most tragic moments there is solace in the experience of sharing the pain and in the hope that just as pain can compress and diminish life, if met with love, it can expand life. That is the hope.
Last week I met a girl 21 years old, who had had three pregnancies, three deliveries, and no surviving children. Her most recent pregnancy ended with a term IUFD and she was delivered via c-section. After waiting a week in the hospital for her incision to heal, she was discharged home but soon returned with a raging infection (peritonitis and a necrotic uterus) and had a hysterectomy. I met her while she was in the ward recovering from her hysterectomy. She is a beautiful girl but her young body takes the form of an old woman when she walks - bending forward, moving slowly, each step cautious and tender. And yet, even though everything about her communicates the depth of her loss, she almost always smiles at me when I enter the ward – warm and genuine. Over the past week, I always looked for her when I came and I watched her wounds, they are healing well. One large untidy line - thick here then thin, puckering at points - stretches down from her navel and a smaller perpendicular scar marks the right side of her abdomen. There is nothing subtle in her story or in its transcription on her small body.
I was with her today when the clinical officer discovered that somehow - in the process of her illness, and healing, and illness and healing - she had developed a fistula between her urethra and her vagina. He found a hole where it shouldn’t be, but there it is, and now urine constantly runs down her legs. They can and will surgically repair the fistula, but she must wait three months before her body will be ready for the operation. Three months after losing her third baby. Three months after losing her uterus. She will wait three months smelling of urine for yet another surgery. As he explained the problem to her, tears began to silently spill from the corner of her eyes. He said she could go back to the room, to her bed, and then she could go home. Just come back in three months.
I followed her back to her bed. In the middle of the noisy room filled with mothers and guardians, visiting husbands, crying babies, nursing babies, she collapsed on her bed in a small heap and began sobbing, “Amayi, amayi, amayi.” I rubbed her back and her head. And, when I realized she was crying “Mother mother mother . . .” the tears I was holding, broke free. We are so much the same in our expressions of pure emotions. We all call for the same person when life ravishes us, the only person whose love can offer comfort in moments of utter devastation - our mothers. I also realized with a bit of tragic irony that here in Malawi where women are raised to be mothers, this small woman had tried so hard to be just that and it broke both her body and her heart. I cried. And, I prayed. I prayed that she did have a loving mother and a loving husband, that she would again find hope and strength. I stayed with her until she fell asleep.
Only once she was still and her breathing deep and regular, did I notice a small wizened woman standing near the bed. She smiled a kind sorrowful smile and said, placing her hands over her heart and nodding at the sleeping girl, “Mwana anga,” my child.
Monday, May 09, 2005
One Family
There is a girl who works in the office here. She serves tea and food to employees, does some cleaning and small secretarial tasks. She's 23. She's one of those people who always looks elegant, small and thin with perfect posture. She is quiet, friendly, and always smiling. Last week her sister died. Her mother had six children, but now all but two have died. Each sibling left a few more grandchildren in their mother's care, and now their household includes the grandmother, her 23 year old daughter, and eight grandchildren ranging in age from 7 to 20. The grandmother was the only one of her siblings to get an education, so she has always been the one to give financial support, never the one to receive it. Several of the grandchildren have finished high school but cannot continue on to college because of a lack of money. The 23 year old wants also to go to school but must work to pay school fees for the younger children ($30/term). I gave her some money today and told her I would help pay the school fees, I told her the money was from my friends and family. I just wanted to let you know that you have helped this family. Thank you.
Friday, May 06, 2005
The Little Things
This morning as I stepped out of the car on to the grounds of Bottom Hospital, a woman wearing a bright green chitingi and carrying a red plastic tub of water on her head, smiled and said, "Muli Bwanji, Joanna?" (How are you?). On Monday, my first day in the nursery, the nurse introduced me to the fifteen-or-so mothers in the nursery as they sat on the floor breastfeeding or expressing their milk into small plastic cups. The woman who greeted me remembered my name from that quick single introduction. Her greeting and beautiful white smile made my day.
The nursery at Bottom, like all the other wards is its own adventure. Only the sick babies stay here, the rest stay with their mothers and/or guardians and then are quickly discharged home. The nurse who works in the nursery is responsible for maybe 25 babies in the main room, another 5-10 in an isolation room, and then 5-10 in the kangaroo care room. [Mothers of very premature babies are taught to carry their babies skin to skin between their breasts until they gain significant weight. This process only begins in the hospital and should continue at home, babies are discharged as soon as they demonstrate a steady weight gain - many are discharged home weighing less than 2,000gms.]
The first task after the night nurse hands over the ward is "damp dusting," which involves wiping down all the babies' mattresses and then rewrapping each with a clean sheet. [I love that on my list of clinical experiences, which I will turn into the Nurses and Midwives Council at the end of orientation, the nurse actually wrote "damp dusting."] It's slightly tedious but in the process you also see and touch every baby, which is a good thing since vital signs are only taken once a shift. Today during damp dusting we found a little one under the heat lamp, lying with two others, who had probably died one or two hours before. I rewrapped him and the nurse showed me where to put him while we waited for the mother.
After damp dusting, the mothers come in carrying clean chitingis and plastic medicine cups to tend to their babies. The women fill the room, a few in chairs most on the floor. Many of the babies have problems nursing, so the mothers express their milk by hand into the plastic medicine cups and then slowly pour the milk into the little ones' mouths. It's a tender beautiful scene. Not all of the mothers come at once and of course there is always one or two who are left screaming while their friends feast. So today I picked up a sweet loud little girl not realizing at first that her mother was there breastfeeding her twin . . . These are the little moments that fill my heart - feeling the trust of the mother, watching me, smiling, as she breastfed one twin while the other fell asleep in my arms; then sitting on the floor with this mother, both of us laughing softly as we failed to wake the little beauty for the meal she wanted and needed so badly.
I wish I knew more about caring for sick and premature babies. Yana and Dzung, I wish you were next to me at these moments to give me a little guidance. The mothers and guardians do most of the work, I'm just there holding babies, making sure they're warm and dry, telling the nurse who did or didn't get a meal. Hopefully in time I'll learn more.
The nursery at Bottom, like all the other wards is its own adventure. Only the sick babies stay here, the rest stay with their mothers and/or guardians and then are quickly discharged home. The nurse who works in the nursery is responsible for maybe 25 babies in the main room, another 5-10 in an isolation room, and then 5-10 in the kangaroo care room. [Mothers of very premature babies are taught to carry their babies skin to skin between their breasts until they gain significant weight. This process only begins in the hospital and should continue at home, babies are discharged as soon as they demonstrate a steady weight gain - many are discharged home weighing less than 2,000gms.]
The first task after the night nurse hands over the ward is "damp dusting," which involves wiping down all the babies' mattresses and then rewrapping each with a clean sheet. [I love that on my list of clinical experiences, which I will turn into the Nurses and Midwives Council at the end of orientation, the nurse actually wrote "damp dusting."] It's slightly tedious but in the process you also see and touch every baby, which is a good thing since vital signs are only taken once a shift. Today during damp dusting we found a little one under the heat lamp, lying with two others, who had probably died one or two hours before. I rewrapped him and the nurse showed me where to put him while we waited for the mother.
After damp dusting, the mothers come in carrying clean chitingis and plastic medicine cups to tend to their babies. The women fill the room, a few in chairs most on the floor. Many of the babies have problems nursing, so the mothers express their milk by hand into the plastic medicine cups and then slowly pour the milk into the little ones' mouths. It's a tender beautiful scene. Not all of the mothers come at once and of course there is always one or two who are left screaming while their friends feast. So today I picked up a sweet loud little girl not realizing at first that her mother was there breastfeeding her twin . . . These are the little moments that fill my heart - feeling the trust of the mother, watching me, smiling, as she breastfed one twin while the other fell asleep in my arms; then sitting on the floor with this mother, both of us laughing softly as we failed to wake the little beauty for the meal she wanted and needed so badly.
I wish I knew more about caring for sick and premature babies. Yana and Dzung, I wish you were next to me at these moments to give me a little guidance. The mothers and guardians do most of the work, I'm just there holding babies, making sure they're warm and dry, telling the nurse who did or didn't get a meal. Hopefully in time I'll learn more.
Wednesday, May 04, 2005
A Happy Note
I realize that the last two entries have been less than cheery so I think I need to fill you in on some parts of life outside Bottom. Life is good.
I feel very content here. Of course I miss friends and family from home, but this place is really growing on me and in me. All the sights, and smells, and sounds, and foods that were at first foreign are becoming familiar and comforting. I am really loving my nsmia and am becoming pretty good at eating with my hands. I can hum along with all the popular songs. And, I know a lot of the city - unfortunately you do really need a car to get around this place. My Chichewa is not great but I'm still trying. (I speak so much English now. I realize that the women in the hospital don't speak any English so I'm thinking that I'll hire a tutor again.)
As for my social life. . . I am still running with the expats every Wednesday (and usually feel like I'm dying during the run) and sometimes I run with them on Mondays.
There is a bigger group that runs on Mondays, they call it the hash. Apparently there are hash races all over the world. Anyway, it involves searching for a trail that is set earlier in the day by "the hare" and then afterwards everyone just hangs out for a while drinking and talking. The expats I have met are all really nice and I have received a lot of invitations to different activities and outings but so far the running is all I have done. I'm enjoying my evenings at home with the Kaponda family and I have a few Malawian friends that I spend time with on the weekends. I even met a neighbor who runs so I've been waking at 5am to run with Cromwell a couple times a week. It is pitch black at that time here, since the days are getting shorter and we're entering "winter," but there are few cars on the road so you're not inhaling exhaust with each deep breath.
The Kapondas are wonderful and I still feel great being in their home. Yankho, Dr. Kaponda's daughter, just left this past weekend for Chicago to begin her undergrad there. So, that was a big event. It was nice to be a part of her send off, seeing her nervousness and her excitement made me feel like we were trading places on the planet. Chimwemwe, a niece to the Kapondas, and I go for walks a couple times a week. Janet, their cook, makes me practice my Chichewa daily, with great patience, I should add. And, Tonto, their son, makes sure my weekends are not entirely spent within the walls of the house - last night we went out with a couple of his friends to play pool and eat pizza.
So all this to say, I am living well. People are taking good care of me. And Malawi, which was once a small unknown spot on the map, now has its place in my heart.
I feel very content here. Of course I miss friends and family from home, but this place is really growing on me and in me. All the sights, and smells, and sounds, and foods that were at first foreign are becoming familiar and comforting. I am really loving my nsmia and am becoming pretty good at eating with my hands. I can hum along with all the popular songs. And, I know a lot of the city - unfortunately you do really need a car to get around this place. My Chichewa is not great but I'm still trying. (I speak so much English now. I realize that the women in the hospital don't speak any English so I'm thinking that I'll hire a tutor again.)
As for my social life. . . I am still running with the expats every Wednesday (and usually feel like I'm dying during the run) and sometimes I run with them on Mondays.
There is a bigger group that runs on Mondays, they call it the hash. Apparently there are hash races all over the world. Anyway, it involves searching for a trail that is set earlier in the day by "the hare" and then afterwards everyone just hangs out for a while drinking and talking. The expats I have met are all really nice and I have received a lot of invitations to different activities and outings but so far the running is all I have done. I'm enjoying my evenings at home with the Kaponda family and I have a few Malawian friends that I spend time with on the weekends. I even met a neighbor who runs so I've been waking at 5am to run with Cromwell a couple times a week. It is pitch black at that time here, since the days are getting shorter and we're entering "winter," but there are few cars on the road so you're not inhaling exhaust with each deep breath.The Kapondas are wonderful and I still feel great being in their home. Yankho, Dr. Kaponda's daughter, just left this past weekend for Chicago to begin her undergrad there. So, that was a big event. It was nice to be a part of her send off, seeing her nervousness and her excitement made me feel like we were trading places on the planet. Chimwemwe, a niece to the Kapondas, and I go for walks a couple times a week. Janet, their cook, makes me practice my Chichewa daily, with great patience, I should add. And, Tonto, their son, makes sure my weekends are not entirely spent within the walls of the house - last night we went out with a couple of his friends to play pool and eat pizza.
So all this to say, I am living well. People are taking good care of me. And Malawi, which was once a small unknown spot on the map, now has its place in my heart.
Tuesday, May 03, 2005
The Graveyard Is Too Small
I participated in a training last week entitled Saving Newborn Lives (SNL) along with the new midwifery faculty at the College and this was the name of the course organizer. He asked me over lunch if my name had any meaning when I said no, he asked another student to translate his name for me, "Manda Yachepa," she said, "the graveyard is too small." They both laughed and told me that this is a very typical Malawian name. I didn't catch his brother's name but he said it is something like, "All our days are tearful." Of course I have met others named Blessings, Sunshine, Memory (yes in English), Tontoso (consolation), and Yankho (answer) - most Malawian names have meaning - but many of the names are quite tragic. This of course reflects in part the high neonatal mortality rate here. The student correctly guessed, by his name alone, that Manda Yachepa's family had experienced the death of many babies before he survived and so began giving their children these names, expecting that they would also die.
This past week I had my first glimpse of what this high mortality rate looks like. As you walk from outside into the labor ward you first pass through a small room with a big metal sink and mops and a small metal rack with four shelves. On the shelves are small bundles, colorful chitingis (the cloth that women wrap around their skirts) with women's names written on tape and stuck on the outside. The first time I passed by, the thought occurred to me that these small colorful bundles might be babies, but I quickly banished the thought when I read "package of so-and-so" written on the tape. I learned later that they are indeed babies and Friday when I walked into the labor ward, I counted seven. Seven bundles of various sizes, which once held life and expectations - life known to the mother by her growing belly, by the twisting and kicking and sleep disturbing movements she had been feeling for months - and now here they are inert on a shelf.
Friday I also attended my first delivery here, assisted by a wonderful Malawian midwife. I came into the ward when the young (maybe 18) first time mother was pushing and a small patch of hair was already visible. Both she and the baby were doing well. Of course since I just was coming from the SNL class, I asked about a bag and mask. People began to search but none was located. The baby's head crowned and was born easily. (I successfully warded off the threat of an episiotomy from an obstetrician who wandered through and made the suggestion to the midwife, and the mother's perineum had no tear! a small success.) Then we waited for the baby to restitute (the baby's head usually turns to the side after it is born to realign with shoulders - part of what it has to do to negotiate the pelvis) but nothing happened. Finally the midwife used her hands to birth the shoulders, arms, and body (the baby's shoulders had never turned), and she lay a blue flacid baby boy on the mother's abdomen. The search for the bag and mask resumed at a more rushed pace but the seconds passed like hours, I kept pleading to do mouth to mouth and the midwife kept saying no.
Finally a bag was located but it didn't work. I took the mouth piece off, covered the baby's mouth and nose and started to try to resuscitate the little one. (I was so nervous I'm not sure I did anything at all.) In the meantime people began searching for string to tie off the cord, so we could cut it and take the baby to the nursery down the hall (no string in the delivery pack). Finally string was found, the cord was cut, and we rushed down the hall. By the time we got to the nursery the baby was pinking up, the heart rate was good, but there was still no cry. The midwife continued the resuscitation - with a proper bag and mask - until it seemed that the baby was stabilizing in its own rhythm of breaths and heart beats, and that was it. Still no cry and the baby's posture was looking ominous to me. I could feel the tears welling in my eyes and I just wanted to stay there with the baby but the midwives walked me out and told me that there was a good chance that the baby would recover. I came back three hours and brought the mom to see her little one - she still hadn't seen him. When we got to the nursery he was screaming and I helped her try to breastfeed. At this point there is no way to tell if the baby sustained any permanent damage that will result in developmental problems but I certainly pray that he will recover fully. He is a beautiful baby. Monday he was discharged home from the nursery.
The experience really shook me up. Of course these things do happen and they are never pleasant but the lack of resources and time delay just made it so much worse. The midwives in my class were all very reassuring and encouraging, no one saw it to be as traumatic as I did but they understood my reaction, since it was my first time to witness and participate in such an event. That was just one story. There are so many already. All I can say is that it really is a miracle that so many do survive.
The SNL training in and of itself was good, but a lot of it was review since I'm fresh from school. I think the most interesting tidbit I learned is that the janitors who work in labor and delivery are also trained in SNL because they are often the ones who end up delivering the babies. Just think about that. Really?!!
Today all the nurses at the hospital are on strike (a skeleton staff is working to assist with emergencies) so I have the day to sit and email and journal. There are two issues (1) there are no supplies at the hospital, not even gloves to do surgeries (2) DFID - the British governmental agency that does development work - recently approved funds to increase the salaries of nurses and physicians here but the vast majority of those monies has been given to people holding administrative positions (e.g. Ministry of Health). What has been allocated to the nurses and doctors is being taxed so heavily that they really are not seeing much of a raise. Nurses currently earn something like $140/mo. Hopefully there is room to maneuver. At least the President has a reputation of no nonsense and no corruption, we'll see what happens. These issues are so huge and yet so basic, where do you even start?
This past week I had my first glimpse of what this high mortality rate looks like. As you walk from outside into the labor ward you first pass through a small room with a big metal sink and mops and a small metal rack with four shelves. On the shelves are small bundles, colorful chitingis (the cloth that women wrap around their skirts) with women's names written on tape and stuck on the outside. The first time I passed by, the thought occurred to me that these small colorful bundles might be babies, but I quickly banished the thought when I read "package of so-and-so" written on the tape. I learned later that they are indeed babies and Friday when I walked into the labor ward, I counted seven. Seven bundles of various sizes, which once held life and expectations - life known to the mother by her growing belly, by the twisting and kicking and sleep disturbing movements she had been feeling for months - and now here they are inert on a shelf.
Friday I also attended my first delivery here, assisted by a wonderful Malawian midwife. I came into the ward when the young (maybe 18) first time mother was pushing and a small patch of hair was already visible. Both she and the baby were doing well. Of course since I just was coming from the SNL class, I asked about a bag and mask. People began to search but none was located. The baby's head crowned and was born easily. (I successfully warded off the threat of an episiotomy from an obstetrician who wandered through and made the suggestion to the midwife, and the mother's perineum had no tear! a small success.) Then we waited for the baby to restitute (the baby's head usually turns to the side after it is born to realign with shoulders - part of what it has to do to negotiate the pelvis) but nothing happened. Finally the midwife used her hands to birth the shoulders, arms, and body (the baby's shoulders had never turned), and she lay a blue flacid baby boy on the mother's abdomen. The search for the bag and mask resumed at a more rushed pace but the seconds passed like hours, I kept pleading to do mouth to mouth and the midwife kept saying no.
Finally a bag was located but it didn't work. I took the mouth piece off, covered the baby's mouth and nose and started to try to resuscitate the little one. (I was so nervous I'm not sure I did anything at all.) In the meantime people began searching for string to tie off the cord, so we could cut it and take the baby to the nursery down the hall (no string in the delivery pack). Finally string was found, the cord was cut, and we rushed down the hall. By the time we got to the nursery the baby was pinking up, the heart rate was good, but there was still no cry. The midwife continued the resuscitation - with a proper bag and mask - until it seemed that the baby was stabilizing in its own rhythm of breaths and heart beats, and that was it. Still no cry and the baby's posture was looking ominous to me. I could feel the tears welling in my eyes and I just wanted to stay there with the baby but the midwives walked me out and told me that there was a good chance that the baby would recover. I came back three hours and brought the mom to see her little one - she still hadn't seen him. When we got to the nursery he was screaming and I helped her try to breastfeed. At this point there is no way to tell if the baby sustained any permanent damage that will result in developmental problems but I certainly pray that he will recover fully. He is a beautiful baby. Monday he was discharged home from the nursery.
The experience really shook me up. Of course these things do happen and they are never pleasant but the lack of resources and time delay just made it so much worse. The midwives in my class were all very reassuring and encouraging, no one saw it to be as traumatic as I did but they understood my reaction, since it was my first time to witness and participate in such an event. That was just one story. There are so many already. All I can say is that it really is a miracle that so many do survive.
The SNL training in and of itself was good, but a lot of it was review since I'm fresh from school. I think the most interesting tidbit I learned is that the janitors who work in labor and delivery are also trained in SNL because they are often the ones who end up delivering the babies. Just think about that. Really?!!
Today all the nurses at the hospital are on strike (a skeleton staff is working to assist with emergencies) so I have the day to sit and email and journal. There are two issues (1) there are no supplies at the hospital, not even gloves to do surgeries (2) DFID - the British governmental agency that does development work - recently approved funds to increase the salaries of nurses and physicians here but the vast majority of those monies has been given to people holding administrative positions (e.g. Ministry of Health). What has been allocated to the nurses and doctors is being taxed so heavily that they really are not seeing much of a raise. Nurses currently earn something like $140/mo. Hopefully there is room to maneuver. At least the President has a reputation of no nonsense and no corruption, we'll see what happens. These issues are so huge and yet so basic, where do you even start?
Friday, April 22, 2005
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.
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.
Wednesday, April 20, 2005
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.
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.
Tuesday, April 19, 2005
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.
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.
Monday, April 11, 2005
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.
Best times to catch me...
weekdays: 5am-7am or 9pm-11pm
weekends: anytime 5am-11pm, but early or late may be better.
Thursday, April 07, 2005
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.
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.
Tuesday, April 05, 2005
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.)
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.)
Monday, April 04, 2005
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.
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.
Monday, March 28, 2005
Arrival
After months of preparation, dreaming, and anxiety I have finally arrive in Lilongwe. The journey here was very long and uneventful except for one marriage proposal (I declined, don't worry). When I stepped off the plane at last (36 hours after boarding in DC) my first thought was, "I am definitely a long way from home." My second thought, as the African sun warmed my skin and I took in the 360 degrees of green horizon, was "It feels good to be here." I passed through customs quickly and easily and was met by a man holding a sign with my name as I exited the airport. As he took my cart a woman with kind eyes (who turned out to be a colleague of Dr. Kaponda's not a random stranger) welcomed me to Malawi and gave me a hug.
The drive to Dr. Kaponda's home was short and green. The area around Lilongwe is mostly flat with gentle rolling hills and many of the roads are lined with lush trees some of which are burdened by huge yellow, red, and purple blossoms. In the distance there are a few scattered purple blue mountains that reach up unexpectedly from the mostly flat land.
Dr. Kaponda was home when we arrived and she also greeted me with a warm smile and hug (so much for my worries about not getting enough hugs). She set aside an incredibly nice room for me in her home (a definite step up from my last several rooms - no offense Kristen or Riva) and she and her family have just been wonderful. They are amazingly kind and generous.
So far I haven't done any babycatching, this past weekend was Easter so the city has been shut down and I've been grateful for the time to get over the jetlag. I really don't feel much culture shock yet, probably because all of my needs are being met. Of course I miss my friends and family but it feels good to be here. The biggest change, as you can probably guess, has been my diet. I went from semi-vegan to definite omnivore on Good Friday (sorry, mom, for the timing). I had eggs, chicken, and beef all in one day and so far my body seems to be alright, no major signs/sounds of rebellion. And, I have to admit, that it tasted pretty good too.
As for the work and so forth. Dr. Kaponda and I made a plan today. The first goal is to learn Chichewa. I soon discovered that was a definite must. People do speak and understand English but they pretty much only speak it to me. I've been studying on my own and I can understand a word here and there and say the basic greeting without calling a man a woman (as I did on day 1) but I still have a long way to go. Next week I'm going to hire a tutor for the week to give me a start and then I'll see how it goes after that. The following week I'll be in the hospital observing and then after that I'll start doing clinical practice, with supervision (thank God). I've been told so often how much of a shock this will be that I have stopped anticipating anything. Of course I'll keep you posted.
If anyone wants to write, or if you have any items you want to ship here is the address: Joanne Jorissen c/o Dr. Chrissie Kaponda, University of Malawi, Kamuzu College of Nursing - Research Center, Private Bag 1, Lilongwe Malawi, Africa. (Please be sure to put Africa - I've heard stories of mail being routed through Maui.)
I don't have a phone yet but I will be getting one soon. Apparently you can buy phone cards in the states that will charge as little as $0.10 a minute so keep your eyes open for those - I would love to hear from you.
I'll be checking email and writing sporadically but please do write.
Love,
J.
Wednesday, March 02, 2005
Home
I am here inside. Outside there are blue skies and juniper trees that smell like Texas. Time keeps moving along with the same momentum it always has, but at the moment it seems fast. Rapids of time rush over and push through to the unknown. Each of the bumps and turns reverberate in my head and my stomach but at least my heart is calm. |
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