Elephants

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

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

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

Dante's Inspiration

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

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

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

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

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

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

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

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

All of YOU

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

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

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

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

Poverty

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

Lovely

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

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

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

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

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

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

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



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

A Thank You Note

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

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

Yours,
Innocent Chioko

Loss

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

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

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

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

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

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

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

Baby Tally

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

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

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

Fire in Dedza

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

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

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

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

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

20% Chances

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

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

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

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

Other updates:

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

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

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

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

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

A Snap from Bottom

the Namesake

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

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

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

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

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

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

Mrs. Phiri's Orphans

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

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

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

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

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

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

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

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

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

Desired future activities include:

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

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

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

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

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

Contact jctchildrenfoundation@yahoo.com tel: 011-265-8-375-326 or 011-265-8-509-775

1st day as a Malawian Midwife

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

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

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

Lifting Spirits

I went to visit Cromwell again yesterday and he's much the same. The doctor told him that all the tests came back normal so far, and that they would do an x-ray (I'm not sure of what). He's still just lying in bed with the glucose drip and aspirin, nothing else, and I'm not sure that anyone has told him that it may take quite a while to recover. He asked me if I was going to run this morning (usually we run Tuesdays), I said of course not, and he smiled a small smile and said that he thought he'd be better by next week. Although he's holding it together, he seems pretty down and the thought occurred to me that it might be nice to flood him with get well cards. If any of you are interested, send cards to me at:

Joanne Jorissen
KCN - Research Center
P/Bag 1
Lilongwe, Malawi
AFRICA

Just write his name on the back so it won't confuse the postoffice or the people sorting mail at the College.

Senga Bay

Highs and Lows

I had a wonderful weekend, the ALSO group treated me to a divine 24 hours of R&R at the lake – sun, good conversation, lots of laughter, swimming, good food, and snorkeling among beautiful fish (there are more than 280 species of fish there). The lake is amazing. It appears so vast that at first glance you might think you’ve arrived at the Ocean; it even has its own gentle waves that lap softly at white sand beaches. This was my first real get-away here in Malawi away and I ate it up. It is only an hour’s drive from Lilongwe, but without a car it has seemed inaccessible. I’m going to have to find a way to get there via minibuses and plan occasional camping excursions, now that I know what I’ve been missing, I don’t want to go on missing it.

Sunday we packed up early so the group could make their flight out of Malawi at 1pm. Some of them will come back in October for another follow-up course and I’m already eager for their return. In such a short time I grew accustomed to the presence of these midwives and physicians around Bottom, I looked forward to their smiles, hugs, and words of encouragement/advice. Just knowing they were around made the difficult experiences a bit easier to bear. They have left the hospital in much better shape than they found it but it will seem emptier without them.

This weekend was great, mostly fun and restful and but it ended on a sad note . . .

Saturday, as we were driving out of Lilongwe I received a call from Cromwell’s brother (Cromwell is my friend who runs with me a couple times a week) saying that Cromwell had collapsed and was in the hospital. He didn’t have any additional information at the time. So, when I returned to Lilongwe on Sunday, I made my way to the hospital around noon and found him asleep in bed with a glucose drip running. The minutes before he opened his eyes were surreal, finding him in that environment, knowing something was wrong but not having any idea of what it could be. I just watched him as he slept and he looked to be the very same healthy and fit friend who meets me at the gate at 5am for our runs. Nothing seemed ominous in the room itself, only one IV running slowly, no tubes or monitors or bandages, no hospital personnel, and yet at the same time two days had passed since he collapsed and he was still in the hospital. The best case and worst case scenarios sprinted through my head, but the minute he opened his eyes and began talking it became clear. The left side of his mouth remained fixed while the right side moved full of words and expression. Initially I hoped it was just Bell’s Palsy but then he said he couldn’t move his left hand or left leg either. He had had a stroke.

Thursday he had called to tell me he would be visiting his brother Friday and wouldn’t make our usual run. He said Thursday was a normal day, he even played soccer for about an hour with a group of kids. But, around 4am that night, he tried to get up and just collapsed because his leg wasn’t working. His brother immediately brought him to the hospital where they gave him aspirin and started a glucose drip. He said they did some tests for his heart and might have drawn blood (I was unclear about that from his story) but they have yet to give him the results for anything.

Why does a 29 year old have a stroke?! And, why is he still waiting in a hospital bed three days after the incident without any sort of assessment, knowledge, or care plan? He said a few times that he would be all right (another example of the staunch optimism of Malawians) and I certainly hope so, but I cannot imagine that he’ll be back to playing soccer anytime soon. I feel so sad. He is my friend. One minute he’s playing soccer and the next he’s a hemiplegic. He’s so young and was so active, and, not that tragedy ever notices but, he’s such a good person. I am learning an unfortunate lesson that is being repeated again and again, which is that all Malawians have had at least one major tragedy in their lives, whether on not it is visible in their outward appearance, you can be sure the story is there.

Thirteen Babies

I just completed my five days of orientation in Labor and Delivery. Orientation is not quite the right term for this period, basically a nurse took two minutes to show me around the room, pointing out where meds are kept, gloves, suture, IV, etc. and then turned me loose. There is no practice of assigning particular women to a particular nurse. Everything is done on a first come first serve basis or, more accurately, on a whoever-is-walking-by basis. Someone is moaning or calling for help, go there, a head is crowning, glove up and run to make the catch. At the moment, this place represents the antithesis of true midwifery. True midwifery being . . . staying with a woman throughout her labor, offering constant support, encouraging movement, protecting privacy, and in general working in partnership with the women. But, there is hope for change.

The scene: there are eight beds on one side of the labor room (the low risk area) and six on the other side (the high risk area). The beds are simple metal frames high off the ground (too high to get up and down without the use of a step ladder, but still not high enough to protect the backs of those catching the babies) with bare mattresses. Among the items a woman is required to bring to L&D is a plastic sheet (they look just like large black garbage bags and aren't much bigger than that, they don't cover the entire mattress). Once a woman is in active labor, she enters L&D carrying all of her things and is told to find a bed. Finding an empty, and hopefully clean mattress, she spreads out the plastic sheet, puts a chitenge on top, undresses, climbs on to the bed, and covers herself with another chitenge. Those of you who have either experienced a birth or seen one, know how messy it can be and you can imagine that often times the chitenges are soaked not far into the process, leaving the poor woman lying in a cold puddle - the plastic sheet doing nothing to protect the larger mattress on which it rests. The mattress is cleaned and dried only after the delivery and an hour observation period. It is really hard to keep the women warm and dry since there are no sheets or blankets and only a few cleaning rags. Most women are so eager for their shower/bucket bath, which of course is cold but is a better alternative to lying on those mattresses. The women get up, bathe, wash their chitenges, and go to the low risk postpartum room for 24 hours. I'm still not exactly sure how that works since there are fewer beds in that room than in L&D. A lucky few get beds or mattresses on the floor and the rest . . .?

Over the past two weeks the visiting Scottish midwives and OBGYNs did a fabulous job of putting a new face on L&D. They scrubbed from ceiling to floor, painted the walls, cleaned the curtains, had new cupboards made for materials, and donated a bunch of useful stuff like shower curtains to use instead of the plastic - which can easily changed and washed - and sheets. So it's looking much better. Hopefully the improvements will last, and the curtains, sheets, and other items will not walk out too soon. One of my Malawian friends suggested writing, "Stolen from Bottom Hospital," on all the sheets. I laughed, but apparently it's already being done at many institutions and it's still not a strong enough deterrent for theft. Theft is such a complicated issue. Everyone is poor. Who is stealing? employees? patients? guardians? Is it just poverty? A sense of entitlement? Are people earning money by selling stolen items? I have been told that so many people and organizations have donated things over time but the items never stay long, slowly and inevitably they all disappear. I recently heard an interesting theory, "Poverty and wealth both have an equal ability to corrupt." I have many jumbled thoughts about development work, poverty, and charity but perhaps I should come back to them later, on to the births . . .

I caught 13 babies in five days (3, 3, 4, 1, and 2), 8 boys and 5 girls. I was a bit nervous the first day, since almost a year had passed since the last birth I had attended, but it all came back. Everyone left the labor ward in their mother's arms within an hour or two of their birth, even though I did have to resuscitate one little boy who was born blue and floppy. This time I managed to find a bag and mask quickly, warded off all those who wanted to suction, and he was breathing, crying, sucking, and kicking within minutes. I suppose (I hope) each time will be a little easier and that soon, even with the surge of adrenaline, I will be calm, gentle, precise.

I feel good about the care I provided this week, sure it could have been better - especially if I spoke Chichewa - but I did my best, and the moms seemed happy and the babies healthy. On my first day, one of the laboring women was rattling away in Chichewa to me and when I called a nurse over to find out what she was saying, the nurse told me that she just wanted to talk to me as a distraction. I asked if she wanted someone else to be with her since I couldn't understand and she pointed at me and said "Ayi, awa" (No, her). That was nice and she continued talking to me in Chichewa.

All in all it was a good week. Exhausting but good. I am being forced to learn my limits, and recognize when I really physically can't give any more before I've had a break. I've helped convince a few people to change their practices (i.e. no suctioning, less episiotomies, and starting with a lower dose of miso for inductions (they are using 100-200mcg of miso in one dose for induction?!)). And, of course I'm learning a ton too; so many lessons are packed into each day.

This week did also have its tragedies. Friday morning I came in to find one of the visiting OBGYNs resuscitating a baby. The mother had a long difficult labor, an infection, and was delivered by an emergency c-section. The baby had been left for sometime before he was found by the OB who started the resuscitation. In the end, after 50 minutes with a heartbeat but no respiratory efforts (and no other life sustaining options available), the OB stopped the resus and we stayed with the baby until it died.

This morning one of the interns came by the college, where I'm planted doing emails, to return a book and told me that last night they had a maternal death. Apparently the woman had seized at home and was taken to a few traditional healers before being brought to the hospital. On L&D she was given Hydralazine to lower her blood pressure and MgSO4 to prevent more seizures, she was then left alone for about 10 minutes and when people returned to check on her they found that she had died. She may have died from her eclampsia but she may have died from the medication (MgSO4 causes respiratory depression at high doses), no one will ever know.

Bottom Hospital?!

The Bright Side

A group came to Lilongwe from Scotland this week to teach a 2-day course on Advanced Life Saving Skills in Obstetrics (ALSO) to a group of nurses, midwives, physicians, and clinical officers here. Of the nine instructors, 7 were midwives. It was a great course for multiple reasons (1) the information was great, very complete, evidence-based, and supporting interventions only when absolutely necessary; (2) there was a lot of practice with dummies and hands-on activities; (3) all levels of providers participated, it was a nice leveling experience; (4) the instructors were all volunteering their time and are still here for another week just cleaning and painting the labor ward. They're trying to recruit people here to teach the course elsewhere in Malawi and they said they would like me to be an instructor after I have a bit more experience (maybe only 6 months). So that is an exciting possibility.

This morning when I walked in, I was told that a mom was about to have a vacuum delivery so I went to watch. When I got there the baby was out, gasping and the clinical officer was calmly standing over it just waiting for a suction. He asked me how I was and I said, "fine, how's the baby?" and he said "not so good." He had just completed the same ALSO course with me where we were taught not to suction, because it does more harm than good (it can damage the baby's throat and mouth in addition to causing a vasovagal response which will drop the BP and heart rate further) and just to start resuscitation and yet there he was standing over this baby who was looking back at him wide-eyed and shocked. I gently reminded him about what we learned but then an OB who had not taken the course came and instructed him to take the baby to the nursery for suctioning and so he started off, picking up the baby by the ankles (another no-no since it can damage the baby's spinal cord and injure the neck). The Scottish midwives saw the scene from across the room where they were cleaning and one came over and gave me a hug, bringing tears to the surface I didn't even know were there. Coming to the hospital is like plunging into ice cold water first thing in the morning, painful at first, but once you're in, you adjust, smile, and begin.

I want to add another thought here about Dr. Meguid. I have been seeing him more and more around the hospital and he also took the course this week. I am so glad he's here. He's constantly reminding me to smile, checking in to see if I'm okay, and reassuring me that change is happening and that it will happen. He makes me believe that it is possible to turn this place around. He told me that he's been working in different places in Africa and that the reason he has chosen clinical as opposed to policy work is because, "At least you can make a difference to one person, even if they forget you the minute they leave, you still made a difference." I agree.

On that note, I checked-in with the 21-year-old today and she was smiling. She motioned from her waist up, showed me her wounds and said, "bwino bwino" (very good). Talk about looking on the bright side.

To Be A Mother

Last week I began my orientation in the postnatal ward. This ward consists of two large rooms with about 20 patients each, two medium sized rooms of 6 each and two small rooms with 3 patients each. Once again, all cared for by a single nurse and two nurse assistants (a.k.a. auxiliary nurses). The women here are mostly post-cesearian patients but these rooms also house women with preeclampsia and eclampsia, symphasis pubis dyastisis, women with intrauterine fetal demises (IUFD) awaiting delivery (laying on mattresses aside women nursing their healthy newborns).

Today I saw a woman who delivered premature triplets at home. They were all alive when she arrived at the hospital but when I went to see them they were already wrapped and set aside in a corner of the nursery. The nurse said, “They were so cold already and they didn’t stay long.” No one had told the mother yet, the guardians had been told but not the mother (apparently culturally the guardians are supposed to tell the mother).

Then, I saw a 19-year-old who began laboring in Mozambique but who made her way from home to health center, once she or her birth attendant realized the labor was not progressing normally. The health center transferred her to a larger health center, which then transferred her to Bottom. When she arrived at Bottom, three days into her labor, her uterus had ruptured and her baby had died. She survived but her life cost her her uterus and a blood transfusion.

I saw two eclamptic patients. One of whom, when I asked for her clinic booklet, did not have a single blood pressure recorded for any of her prenatal visits. (Preeclampsia is an awful, poorly understood, systemic disease of pregnancy characterized by high blood pressures. A woman with preeclampsia can seize at any time, but women with elevated blood pressures are usually monitored carefully and given medications to prevent seizures, or delivered early. The only cure is delivery. Once a woman seizes it is said that she has eclampsia. Eclampsia is fairly rare in the developed world. One Scottish OBGYN recently told me that in his 9 years of practice he had never seen eclampsia.)

In the last hour of my day I saw a preeclamptic pregnant woman at 30 weeks gestation seize in the hall. Around the same time, the doctor determined that another woman, complaining of abdominal pain, was approaching septic shock and needed to be prepared for a stat uterine evacuation.

This of all really happened, and more. One day. Eight hours. Unbelievable.

There is so much going on, so much to take in, so much to feel. Some of it is only witnessed but some reaches deep inside. At certain moments I can feel a force moving through me, changing the rhythm of my heartbeat, pressing on my chest, electrifying the tips of my fingers, creating a wide empty space in my belly as an experience is permanently and viscerally recorded. Wherever I choose to be in the world, the stories in Malawi will continue unfolding with their drama, passion, and loss. I could be in so many places, but now I want to be here. Even in the most tragic moments there is solace in the experience of sharing the pain and in the hope that just as pain can compress and diminish life, if met with love, it can expand life. That is the hope.

Last week I met a girl 21 years old, who had had three pregnancies, three deliveries, and no surviving children. Her most recent pregnancy ended with a term IUFD and she was delivered via c-section. After waiting a week in the hospital for her incision to heal, she was discharged home but soon returned with a raging infection (peritonitis and a necrotic uterus) and had a hysterectomy. I met her while she was in the ward recovering from her hysterectomy. She is a beautiful girl but her young body takes the form of an old woman when she walks - bending forward, moving slowly, each step cautious and tender. And yet, even though everything about her communicates the depth of her loss, she almost always smiles at me when I enter the ward – warm and genuine. Over the past week, I always looked for her when I came and I watched her wounds, they are healing well. One large untidy line - thick here then thin, puckering at points - stretches down from her navel and a smaller perpendicular scar marks the right side of her abdomen. There is nothing subtle in her story or in its transcription on her small body.

I was with her today when the clinical officer discovered that somehow - in the process of her illness, and healing, and illness and healing - she had developed a fistula between her urethra and her vagina. He found a hole where it shouldn’t be, but there it is, and now urine constantly runs down her legs. They can and will surgically repair the fistula, but she must wait three months before her body will be ready for the operation. Three months after losing her third baby. Three months after losing her uterus. She will wait three months smelling of urine for yet another surgery. As he explained the problem to her, tears began to silently spill from the corner of her eyes. He said she could go back to the room, to her bed, and then she could go home. Just come back in three months.

I followed her back to her bed. In the middle of the noisy room filled with mothers and guardians, visiting husbands, crying babies, nursing babies, she collapsed on her bed in a small heap and began sobbing, “Amayi, amayi, amayi.” I rubbed her back and her head. And, when I realized she was crying “Mother mother mother . . .” the tears I was holding, broke free. We are so much the same in our expressions of pure emotions. We all call for the same person when life ravishes us, the only person whose love can offer comfort in moments of utter devastation - our mothers. I also realized with a bit of tragic irony that here in Malawi where women are raised to be mothers, this small woman had tried so hard to be just that and it broke both her body and her heart. I cried. And, I prayed. I prayed that she did have a loving mother and a loving husband, that she would again find hope and strength. I stayed with her until she fell asleep.

Only once she was still and her breathing deep and regular, did I notice a small wizened woman standing near the bed. She smiled a kind sorrowful smile and said, placing her hands over her heart and nodding at the sleeping girl, “Mwana anga,” my child.