Anemia

Friday I saw a 22-year-old girl die. You might not want to continue reading and that's ok, this is a difficult entry. I came into the labor ward at 7:30 and saw her in the high-risk section, sitting upright in bed, breathing fast and hard with obvious effort. The night nurse said she had delivered a stillborn a few hours previously and although she only lost a normal amount of blood, she was so severely anemic that the loss was enough to start her down the road to heart failure. I watched the second pint of blood slowly drip into her vein as I placed my stethoscope against her chest, hearing her heart racing and the sound of fluid filling her lungs. I tried to put an on oxygen mask on her, but even when another nurse translated for me to explain why she needed the oxygen, she refused. I went and found Dr Tarek Meguid.

He examined her and agreed that she needed to be transferred to the ICU at Central Hospital ASAP (Central is maybe two miles away from Bottom and has the only ICU in the Central Region of Malawi). What she needed was to be "knocked-out" and put on a ventilator, enabling her body to rest while she continued to be transfused and hopefully stabilized. At the moment she was running an endless marathon and sooner or later her heart would give out. The fluid in her lungs was a sign that it was already starting to fail. Dr Meguid called Central but there was no available bed in ICU and there was no available bed in the High Dependency Unit (HDU - the ICU step down unit). There was no alternative, so she stayed with us and we watched her all morning. In between deliveries we watched her breathe hard, and we watched her concerned mother stand helplessly at the bedside. Central never called to tell us they had a bed.

Sometime after 11, I was taking a break eating some peanuts at the nurses' station just a few feet from her bed, and noticed that she was now slumped on her side. I went over to her and her mother frantically tried to tell me something about mtima (her heart) - pushing her daughter, who was lying on her side, onto her back and pointing in-between her breasts. I didn't need my stethoscope. I could see each beat of her heart as it slammed into her chest wall fast and hard. I asked the mother if her daughter could understand her. The woman frantically called her daughter's name but the girl only moaned.

Just then Dr Meguid walked in, the situation was clearly worsening but being a midwife (someone who has studied normal birth) I didn't know what we could or should do, I just saw his presence as hopeful. He told me that we could not intubate and ventilate her at Bottom because we had no ventilator and because we didn't have the staff to care for her. He examined her again and asked for a diurectic. I went to the fridge, retrieved one vial, drew it up and pushed the medicine into her vein. He asked for another. But on my way to the fridge someone else called me away to help resuscitate a pale floppy baby. A small group of nurses and clinicians had started gathering at the girl's bedside, so I started the resuscitation and asked someone else to get the Lasix. After a couple minutes the baby started crying and then the order of things became a blur.

. . . I heard Tarek pleading on the phone for a bed, saying "She's DYING," as I stood at the her bedside. I saw her body go completely limp. I saw her eyes roll back in her head. I heard Tarek say, "That's it, W-E L-O-S-T H-E-R." I watched pink frothy fluid pour out of her nose and mouth. I looked at Tarek disbelievingly through my tears and heard her mother wailing from beyond the corners of my vision. Time stopped. The anesthetist appeared and somehow I managed to bring the suction machine from the otherside of the room, connect it, and start suctioning her airway. Tarek started chest compressions. Other nurses and clinical officers drew and pushed medications. The woman on the other side of the curtain unattended, and perhaps unaware of what was happening, called out continuously in the agony of normal labor. I just stood there doing my task, holding the suction catheter as though it contained all hope.

After several minutes her heart started again. She did not regain consciousness. She did not begin breathing. We continued with the bag and mask. A patient was discharged from the ICU. A bed was available. The ambulance was waiting. A stretcher appeared and we moved her from the bed. I bagged her, as the janitors pushed the stretcher down the hall past countless expectant guardians - waiting for word of their daughters and sisters - and countless pregnant patients roaming the halls in early labor. I focused my eyes on the girl's face, but in my peripheral vision I saw their bodies and feet as we flew by and I felt their concerned quiet presence. We loaded the stretcher on the ambulance. The clinicians climbed aboard and then I realized her mother was missing. I ran back to the labor ward and found her sitting on the waiting bench by the door talking in a very concerned tone to two nurses. (Later I found out she was asking about the dead baby, asking if someone from the hospital would bury it.) They told her to go with me and I escorted her, half pushed her, to the ambulance. She was a small thin woman, the top of her head only reaching my shoulder, and as I walked down the hall with my hand on her back the other women stepped closer - each telling her something, offering strength, showing concern - and then parted again as we moved forward. I only understood one, "Osalira" (don't cry?!). I helped her into the ambulance and an equally thin and frail man tried to board behind her (I assume he was the father). There was not enough room and he was told to get out, so he stood in the doorway and watched the ambulance drive away.

The rest of the day I tried not to cry. I went back to the ward, assisted a few students with deliveries, and found a couple small reasons to laugh with Deb and Maureen. (Deb is an American med student who came this week and will be in the ward for 10 months, and Maureen is a Dutch med student who has been here since August and will stay until February.) Clement showed up unexpectedly and I told him about the story as I ate my lunch in a spot of shade outside the hospital. He shared his own recent difficult story from the medical ward. On my way back inside Dr Meguid found me and asked if I was doing all right. We talked about the sequence of events and he said, "Didn't you know she just wasn't going to make it then?" and I said, "I've never seen anything like that before. That was my first time. I didn't know." I felt my tears surge and he gave me a much needed hug.

At the end of the day I mentioned to Dr Meguid that I wanted to go to Central to see her and he said he would call first to find out if she was still alive. Deb and I exchanged glances as he put his finger to his ear and turned his back to the ward. She had died at 2pm. I looked at Deb whose eyes filled instantly with tears and gave her a hug. We left together, and over ice-cream floats we cried and talked about what we had seen, about death, about mortality, and about privilege.

The problem is we did everything we could, but there was nothing to do. If there is no facility, there is no choice; there is no alternative. Tarek often says that maternal mortality here in Malawi today (1,800 per 100,000) approximates what it was in Europe in Medieval times. He says the difference is that then we didn't understand why women were dying, today we know why, but we still can't stop it. Women like the girl who died on Friday are almost beyond hope by the time they reach the labor ward. Their bodies are functioning with no reserves and the smallest insult is more than they can bear. Just to give you an idea, the hemoglobin level of a healthy woman should be between 12 and 14. Women have walked into the labor ward with Hbs as low as 2. Physiologically the problem is chronic anemia caused by parasites (in addition to and including malaria), malnutrition, and other disease. But, there are so many other factors: cultural (e.g. preference for white nsima, which lacks nutritional content), poverty (e.g. not having more than one meal a day, not having money for timely transport), education (e.g. not understanding the risk factors of pregnancy to be personal risks; not knowing when to seek help), infrastructure (e.g. not having enough ICU beds or even iron tablets to distribute), and on and on. The solution to this seemingly black & white issue is one which continues to elude all the dedicated clinicians and policy-makers. In spite of everything, maternal mortality is on the rise in Malawi.

Everything Needs a Disclaimer

The truth is that this blog is my story, my egocentric ethnocentric version of what I see. What I don't see or don't understand has no place here. Unfortunately those of you who read this hoping for some window into what it must be like at Bottom Hospital or in Malawi or in Africa are peering through a very very small window where I am the protagonist. Keep that in mind and your grains of salt close at hand.

I'm just feeling down today. A low grade kind of down that doesn't do any real harm but just leaves me a bit uncomfortable in my skin. I don't believe my life's extreme highs and lows have ever cycled with comparable swiftness and frequency. I find it difficult and exhausting to be present with heart. I find it difficult to comprehend and satisfactorily file away what I witness. All in all yesterday was a good day at the labor ward, all the women and babies I assisted left the ward healthy and happy. But, even on good days there is so much that blows through my mind making chaotic pathways as visions rip through old assumptions and carefully protected "truths". The list of shocking events is endless and ranges from watching a very experienced clinician brutally execute a vaginal exam to the absurdity of categorizing all laboring women as high-risk (including the obviously low-risk, the rational being that anything can happen at any time in labor), but then not carrying out necessary interventions with the truly high-risk women to avoid devastating consequences. Although I know that I will continue to write about these events and although it is certainly therapeutic for me to release all these stories on to these pages, I also doubt the absolute value in doing just that. I wonder if in some way I am also perpetrating an injustice by painting such a clearly lop-sided picture. After reading these stories, can you still have compassion and openness in your hearts not only for the women and babies but also for the nurses and other clinicians?

Despite the frustration I feel when I witness the way in which some of them practice, I do have hope that practice will change. Not only in the distant future, as the next generation of clinicians rises to take posts, but soon. I do have hope that the clinicians practicing now will also improve. A couple weeks ago the charge nurse (the only clinically practicing registered nurse in the entire hospital) told me, "Joanne, I hope that when you go back to your country you will tell them how hard we work. People are always coming here and then saying horrible things about Malawi and our work here." I'm sure she would count my blog among those horrible things. So let me say now, that the nurses and midwives here work HARD. That is the truth. There is no one who sits and chats the day away. These women do work. And, the charge nurse, in particular, is someone I respect. At one point yesterday morning, as we were getting the handover from the night nurse, we stood around a bed with a recently delivered mom trying to breastfeed her screaming baby. The charge nurse picked up the baby comforted him and then put him on his mom's breast without saying a word.

I met Clement for lunch today and told him the most recent stories that left me tearful and frustrated. He listened and then told be about the source of his own motivation for becoming a clinical officer, which helped bring me back to the fundamentals. He said it comes from the experiential knowledge of being a patient here . . . knowing what it is to feel true hunger, knowing how much effort it took to get to the clinic, knowing how it feels to stand most of the day in a long que, believing that you are truly dying, watching clinicians move unhurriedly by, and then when you finally reach "help", having the clinician hand you a prescription for a simple over the counter pain killer without doing any type of exam, before you even finish telling him about your complaint. After saying this, he said he knows he will not change the system, but that he can still provide good care within the system and that is the goal. Personally, I have never experienced any those things, but I suppose if I can prevent a few others from also experiencing them, then I will have done something good.

These days too many of my stories are sad. I want to laugh until my belly aches.

Windstorm

This entry is long overdue. So much happens on a daily basis that sometimes I feel I’m standing in a windstorm just holding out my open hand, not really grasping anything fully but only briefly considering the random pieces of life as they land in my palm before they take flight again.

One of the current fragmented themes concerns the way life beats people here and then returns for another lashing (ok, not an uplifting theme). A few examples (1) Cromwell’s younger brother Jobson was in a minibus accident about three weeks ago. Jobson cared for Cromwell during the particularly difficult early period of his convalescence and now, by a stroke of luck or misfortune – depending on how you frame it – he is also limping. Jobson was on his way to Salima by minibus (about an hour out of Lilongwe) when the driver lost control. Six people died on the spot and most of the other survivors sustained severe head trauma. He escaped with only a broken scapula and broken hip. (2) The man who works in Dana and MacPharlen’s home has been out caring for his ailing wife. His current wife is his second wife, his first wife died sometime back and then, within a year of each other, all six of his grown children – who lived in different parts of the country – died from different illnesses. (3) Last week another friend lost his older brother, the fourth sibling to die in his family. This friend told me flatly that the responsibility and hope of his family now rests with him and if he fails, it will mean absolute devastation for his family. If I weren’t living in the middle of these stories, sharing friendships with the principal characters, I might find them difficult to believe. The disparity of suffering (or perhaps “ability to pursue happiness”) between the average Malawian and the average American (to broadly generalize) is incredibly vast – even for those Malawians who are not affected by personal poverty or disease. Such painful inequalities increase the appeal of disengaging, deadening the senses, and trudging on. But I am learning, experientially - and by being near the smiles and kind eyes of the activists here that I admire and trust - that hope is born in the conscious struggle to improve life and in conscious living.

On the upside, I now have some financial support and a vehicle – both of which instantly improved my quality of life (I’m eating more fruit and am minibus free). From now until December I have a contract with an Italian NGO (CESTAS) whose mission is to promote safe motherhood by sponsoring technical trainings for clinical staff and procuring much needed medical supplies. My job is essentially to help set up the trainings and then to provide feedback as a clinical consultant. Personally, I have very mixed feelings about the trainings but at the moment I am supposed to carry out the previously approved workplan. My hope is that I can help restructure the trainings and that they will lead to other work that may be more deeply beneficial and gratifying. I have already been told by numerous Malawians that trainings like these don’t work. The same people are trained and retrained and frequently content is flawed - some information is repeated, other important items are omitted, and often information in one training conflicts that given in previous trainings - in the end people often revert to their old practice. Trainings also remove staff from their sites for extended periods of time, thereby further taxing an already frail system. Despite these problems, trainings are welcomed as concrete steps taken to improve the atrocious maternal morality rate (the 3rd worst in the world, behind Sierra Leon and Afghanistan!!!) and because the clinical staff depend on the per diems to supplement their paltry incomes. Thus placing an emphasis on action and valuing it above results.

From the two eyes I peer out of, it seems that so much development work is undertaken with god-sized enthusiasm of foreign donors, wanting to fix and solve seemingly black & white issues (i.e. hunger) but in the rush to cure, little is done to understand; the perpetual sense of urgency seems to justify the means. We need more critical discussions carried out with sufficient humility to at least temper the blinding effect of power. As a foreign privileged “do-gooder” (and now as a consultant on this project) I recognize that I am not outside the group I criticize. I am trying to move forward with my eyes open - remaining engaged and self-reflective.

As for the driving, well, it’s getting better. It’s not easy to learn to drive manual on the left side of the road while dodging goats, chickens, and dogs, avoiding wobbling bicyclists with loads of charcoal or firewood stacked to twice their height or straw mats protruding well into the already narrow road. The first day I got the car I watched a very green clinical officer student conduct a delivery and had to smile at how nervous and clumsy he was (nothing dangerous – just things like trying to put the baby on the mom’s belly while one leg was still inside the mom). I just stood by and tried to reassure him to be calm and move slowly. Then a couple hours later I laughed when I found myself, equally nervous and clumsy, sitting behind the wheel of the car, grateful for the medical student who sat next to me reassuring me and reminding me to stay calm and move slowly. I’m no longer breaking out into a cold sweat every time I envision myself behind the wheel so I believe that’s progress.

The labor ward has been not parsimonious with emotional lows but I’m finding enough joys both inside and outside the walls to keep me smiling and coming back for more. Within the past couple of weeks I met two women around town who remembered me from the ward and proudly showed me the chubby babies on their backs, that’s all I need.

Keeping Hope

The small cloud that's been following me around, started to lift a bit yesterday. It was a day that made me feel good once again about myself and about working as a midwife here. First, I happened to be standing in the hall outside the labor ward when one of the cleaners came to tell the family of a laboring woman that she had just pushed a little girl into the world. The cleaner said, "wamkasi" (girl) and small group of women, several with babies on their backs all clapped and hollered in unison, then started laughing and slapping hands. In a place where women, more often than not, get the extremely short end of the proverbial stick, it was wonderful to see and hear such a joyous welcome for a little girl.

Later, towards the end of the day, one of the nursing students who is in the labor ward this week, came to me and said, "The woman in the last bed is pushing and there's a foot coming." I rushed down to the bed and sure enough a foot was dangling from her introitus and with the next contraction legs and bottom quickly followed. Footling breeches (when one or both feet come down first) are more dangerous than frank breeches (when the baby is in a pike position) because the umbilical cord can slip down, become compressed, and cut off the oxygen supply, but thankfully I when I checked the heart tones the little valves were ticking away. I was just focused on the woman but from all the voices coming from behind me seemed that most of the people in the labor ward came to witness and participate in the birth. A nursing student started the delivery, then another midwife helped us with an arm, and I finished by delivering the head. It was so amazingly wonderful to see that sweet pink baby boy and place him screaming on his mom's belly. I turned around to ask for the delivery pack and saw a sea of smiling faces. That was great. Just what I had been missing -support from co-workers, and the opportunity to share the sense of elation that comes from witnessing a beautiful birth.

Convalescing

This weekend I made another retreat to Dedza, sponsored once again by Mac and Dana. Their home - knitted into the beauty of nearby Dedza Mountain by their flower and vegetable gardens - is most definitely a retreat. I left Lilongwe Friday with the ambition of hiking the Mountain, but instead a small uninvited colony of Giardia kept me running from the bed to the bathroom. The Mountain will wait. One benefit of spending the day in bed was that I did have the chance to do a lot of reading. I’m finishing My Traitor’s Heart by Rian Malan. Malan is a white South African journalist who spent years reporting on apartheid and race relations in SA. This non-fiction, which was published in 1985, reflects his personal tortuous process of sorting through horrific imagines and conflicting emotions. He gives voice to victims and perpetrators alike, and convincingly illustrates how virtually all South Africans were complicit in unfathomable atrocities - actions following thoughts, conscious and subconscious, arising from the old putred stew of fear and hatred. It is well written, provocative, and utterly depressing (at least up to now, I’m not quite finished). I recommend the book but it wasn’t the best choice for me following a couple rough weeks filled with frustration and death. I’m feeling better today as I’m sitting here typing but I’ll admit that my path definitely has a few potholes that send me stumbling into a generic existential crisis every now and then.

Sometimes it is so incredibly tiresome to consider life's injustices, the millions of people who dedicate their lives to creating positive change in the world, the millions who do nothing, and how all the roles just seemed to be recycled again and again as we push forward and slide back. At times it seems that both complacency and activism are equally undesirable choices. That’s the line of the very hopeless voice in my head. In more hopefully moments I have to believe that whatever I’m doing is resulting in more good than harm, that I am making a positive impact even if it is only in the lives of a few whom I directly touch. Whatever happens beyond personal interaction is truly in the realm of hope and faith. I found one beautiful and inspiring quote along these lines in Malan’s book. It is taken from a white South African woman who, along with her husband, truly gave everything to understand, share, and ameliorate the suffering of impoverished black South Africans . . . “Any change is so slow as to be imperceptible, and so deep as to be virtually immeasurable.”

My Little Girl

Wednesday I went to nursery as soon as I arrived at Bottom to see my little girl and found that she had died during the previous night. The nursery nurse and Mrs. Phiri both said that she was looking good on Tuesday, acting like a normal baby. Tuesday afternoon the pediatrician came through and started her on antibiotics but early Wednesday morning she starting gasping and soon died. I imagine that she probably needed a much earlier start on the antibiotics but we missed the window.

The little boy was doing well though, and he was discharged home with his mom early Wednesday afternoon.

One True Success

I realize my entries have been splotchy lately and I suppose it's a reflection of my state of mind. I also have not been spending as many hours in front of a computer with internet access as I was previously. Within a single day at the hospital my emotions continue to range from absolute frustration to pure elation. Yesterday was a case in point. I arrived in the Labor Ward to find an intern resuscitating a baby. Apparently the clinical officer was called and told there was fetal distress but no action was taken until sometime later, when the intern appeared. He then delivered the little girl whose only sign of life was a faint heartbeat. When I came in, he was finishing a 24 hour shift and still had another patient to assess, so I volunteered to take over the resuscitation. This is when the frustration began.

At the change of shift in the morning, the ward is full of clinical officers, nurses, physicians, interns, and students. Yesterday morning, many people were busy, but many were just waiting for the rounds to begin. I needed an extra pair of hands, as I was bagging the baby, for a couple minutes, to do simple things like find the larygoscope, turn on the suction machine, plug in the oxygen machine, etc. But, just to get that much assistance at times is a near impossibility. In fact, to do those few things took at least 15 minutes. One person found the larygoscope handle, but left before they found the blade, another found the blade but didn't hand it to me, another got both pieces but wouldn't put them together, and so on. One medical intern asked why I was taking so much time with the baby and recommended that I take the baby to the nursery and just put her on oxygen. (She was not breathing on her own so that would mean certain death!!) Finally, I saw Mrs Phiri and felt such huge relief knowing that she would step in, and of course she did. I spent two and a half hours with the little girl and at the end of that time, she was breathing, sucking, and kicking. I fear that there was significant brain damage due to the unknown period during delivery when her oxygen supply was compromised, but that will only become apparent with time as she develops or misses developmental milestones, as the case may be.

Dealing with emergencies in this setting is one of the great sources of personal frustration. I assume that people's complacency comes from the need to stretch limited human resources, but even so the limited, or lack of response, at times becomes infuriating. Often, if I respond to an emergency no one will be there to offer support. If I call for help and things work out well, people look at me strangely and ask, "what was it that you needed?" To me, if someone is bleeding or seizing or if a baby is being resuscitated that is a serious event that needs the emergent attention of not just one person but several, and it calls for quick steps, and calm, but quick actions.

At the same time that I was resuscitating the little girl another baby was brought in from a c-section that needed resuscitation. I tried not to pay too much attention to his resuscitation, knowing that I already had my hands full. But, after my little baby stabilized, I took over for the nursing student who needed relief (she actually stayed a couple hours doing the resuscitation herself). Unfortunately, in the end the baby didn't make it. Immediately after that death, I found Dr Meguid resuscitating yet another baby who also died. At that point I went to check on an unattended primip (woman with her first delivery) who was screaming at the far end of the ward, and found that the fetal heart tones were also showing signs of distress. The clinical officer, who was in theatre, was called but without assessing her, told us to wait. Instead of waiting I did a vacuum extraction and resuscitated the depressed boy (he was the one true success story of the day). Sometime around 4 I went to lunch and then when I came back was told that there had been a maternal death. A woman, with her 11th pregnancy, came in with a ruptured uterus, a hysterectomy was done, she was stabilized and transferred to high risk postnatal. She was left unattended for 1.5 hours and when the nurse came to check on her, found her dead. That was the fourth maternal death within 5 days.

These events and numbers are unacceptable anywhere, even here in this impoverished environment. I don't understand why so many people seem to preach about the horrors but fail to act or just see them as part of the setting. While it's true that more women and babies will die here because of what we can't do there are many who can live because of what we can do. I try to remind myself that I'm here for the women, that I should fix my eyes on the women and babies that my hands are touching, that I can only do what I can do, but there are days when I can't help but raise my gaze and those days I feel so incredibly lost in and frustrated with the bigger picture.

Updates

Cromwell, my friend who had the stroke almost three months ago, is much improved although still far from where he was. Without the help of physical therapy, he has progressed from needing help to sit up to walking on his own. He has a significant limp and still cannot move his left arm but he has made dramatic progress, so there is hope. The biggest problem I believe is psychological, I have watched him wade through periods of depression as he struggles to adjust to his new disabilities and well as the reality that friends who were once abundant have now become quite scare. The entire series of events is unbelievable. I have a few pictures of him standing, which I will post later, and he asked me to extend his thanks to everyone who is keeping him in thoughts and prayers.

Mrs. Phiri is a powerhouse. I mentioned that she distributed maize flour to orphans a few weeks ago and she brought me pictures of kids carrying bags of maize on their head with expressions of absolute glee. Really, that just food could bring such happiness!? Recently, she bought bundles of clothes for the orphans with the money I gave her and I'm hoping to go out with her when they are distributed and take some pictures that I'll be able to post. A couple days ago I also learned that her in town she keeps her doors open for teens who want to come and talk and she teaches them about HIV. She's wonderful!!

As for the hospital, last week was a bit rough. Unfortunately I gained intimate knowledge of some institutional politics and experienced a cultural stumble, which just left me feeling a bit down. But, everyday things are getting better and the clinical staff assures me that all is well. At the moment there are nursing students in the ward so I'm having the opportunity of precepting them, which I really enjoy. I've also had a couple beautiful births recently, which always give me a high regardless of my general emotional state.

This past weekend I went to Blantyre again for Clement's cousin's wedding. We didn't actually attend the wedding. It seems like this is common in Malawi. Few people actually witness the religious ceremony but everyone who has ever met or is in anyway connected to the bride or groom shows up at the reception. I was told that you generally send out about 30 invitations and then prepared for hundreds. This weekend the dinner after the wedding on Friday was set up for 600 people. This is impressive in itself but even more so when you realize that there are no caterers or event planners. There is a wedding committee made up of representatives from the bride and grooms families who organize everything.

The bride's family took care the meal, which meant that the men rented the tables and chairs then set up the hall and the women cooked the food. I went to the house where food preparation was happening and helped, but mostly watched, cartoonish quantities of food cooking in pots large enough to accommodate several small children. Clement's mom's family is of Asian descent so there were tubs and tubs of samosas, curried meats and vegetables, and many entrees I had never previously tasted. By 9pm Friday the hall was full and people seemed generally happy with the enormous quantities of spicy food. Afterwards I slept in a car with Clement's sister while the men cleaned the hall and stacked tables and chairs well into the night.

The following evening the wedding reception, organized by the groom's family, brought the crowd together again. I have been to a couple of receptions here, usually they are held in an auditorium, the guests all sit in seats facing a stage where the bridal party sits at a table facing the crowd. As the guests enter the hall, they are given a program with the order and timing of speeches, cake cutting, snack serving, pelekanipelekani (which is when the bride holds a basket and all the guests dance up to her and through money in the basket), and other events. Often receptions last all day - literally 8am to 5pm. I have to admit that in general I much prefer the free flow American style of receptions. Thankfully this reception was just an evening affair. Guests sat at round tables, not in auditorium seating, and although there was a stage, the bride and groom's table was on the floor in the front of the hall. There was no printed program and the planned events lasted less than an hour but the music and dancing went on until 2am. Over all it was really nice. I had a great time dancing at the reception and I met more family members, including two more sisters, who were both welcoming, loving, and beautiful.

Ernest

“To live in Africa, you must know what it is to die in Africa” I read this quote from Hemmingway yesterday and although I’m not sure of the original context, it makes sense. Life’s fragility and precariousness are clearly apparent here. Life and death move through this country hand and hand, giving and taking equally and unexpectedly. It is feasible that any seemingly insignificant choice (boarding a minibus, crossing the street, waking up, walking a particular path) may transport you instantly and abruptly from the grasp of the former to that of the latter, irrespective of age or health.

Certainly my personal sense of mortality has increased a hundred fold in the past five months. Death is no longer a distant concept to be considered as a dreaded inevitability, years down the line, in the future of my healthy parents. It is here, all around, every day, touching every life intimately. Life expectancy at birth in Malawi is a mere 38 years. HIV and high infant mortality rates are responsible for this low number in part, but not completely. There is not a lot of gray hair here. I haven’t yet moved beyond acknowledging this fact. Mostly it’s just stunning. The situation is stunning here, and really, now looking back at the US, it's stunning that death there is a distant foe rather than an unwelcome but tolerated relative. I’m not planning on dying soon; I’m not taking any excessive risks. I’m protecting myself as best I can from HIV in the labor ward and careening minibuses on the road, but I’m recognizing that each day is a gift not an entitlement. The 80 years on this planet, which I previously perceived to be my birthright, I now see as a hope.

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