Thirty

I am thirty now. (As of November 14, 2005.) I feel good about the number. No panic. No tears. In my mind I am at last, inarguably, an adult. There is so much cultural weight put on this number that unlike any other birthday, the over night change from 29 to 30 is one I felt. And, the feeling – spurning a few moments of self-reflection – led to two conclusions, each carrying their own sense of urgency. I imagine this development has much to do with societal expectations but believe it is equally affected by two recent events in my life, I just finished reading “Mountains beyond Mountains” the story of Paul Farmer, and last week I attended an Obstetrics and Gynecology conference in Tanzania. So, here’s my list: (1) If I really want to do something good in the world it is time to be serious and start, and (2) I’m ready for a home. No they are not related but they are both broad and open enough to be achievable.

Paul Farmer is an inspirational character. In short he is a tenured professor at Harvard and a general practitioner whose life story illustrates a deep commitment to the provision of equitable health care. In his early 20s he set out to provide quality health care to Haitians and in the process he achieved what many may consider small miracles, becoming an internationally renowned figure (particularly related to efforts against tuberculosis (TB) and HIV) without losing touch with or devotion to individual patients. He has written numerous articles and books (of which I have only read one so far). This particular biography reads like a novel blending the author’s account of time spent with Farmer with pieces about his family, his philosophies, his life, and his epiphanies along the way.

I want to share my favorite story from the book . . . At one point, early in his career a debate arouse at a clinic in Haiti as to why patients in the catchment area continued to suffer relapses of TB despite the provision of adequate treatment. Most of the clinicians claimed that the relapses resulted from non-compliance, arguing that patients would stop taking the medication because they believed the disease was caused by sorcery. But, one clinician told Farmer that he suspected the relapses were due to malnutrition. Farmer then carried out his own study to resolve the debate. He divided TB patients into two groups, both of which received standard treatment, but the second group also received $5 a month to buy food. Farmer questioned all patients about what they believed to be the cause of their illness. In the end he found that all the patients finished all their medications as prescribed, the vast majority of patients in both groups believed their disease was caused by sorcery, and while several patients in the first group relapsed, not a single patient from the second group relapsed. Farmer distilled two lessons from this experience. First, non-compliance occurs on the clinicians’ end and most often the “non-compliant” patient is not receiving something that is essential for their well-being. And second, we are all complex individuals irrespective of our poverty/wealth/education; our actions and beliefs are not always linear.

I know there are many instances when the first group of clinicians “win”; their argument is regarded as truth and patients are simply lectured more and more fervently about the need to do X-Y-Z but the outcomes fail to improve. This story challenges the paternal-/maternalitstic attitudes we often subconsciously harbor regarding the ill and impoverished. It illustrates, simply and eloquently, that people want what is best for them. They want to care for themselves, they want to care for their children, and they will do everything possible to sustain and protect their own health and that of members of their community. The real problem is that they are voiceless. So, rather than assuming the fault lies with them we must first listen to find out what they need. Great, no?

Reading the book complimented my experience of the conference and provided a supplemental illustration of how individuals can make incredibly differences even in the setting of atrocious health statistics. There were some amazing, shocking, and inspirational presentations, some depressing but not surprising presentations, and many encouraging – simple presentations of research done at sites comparable to Bottom by dedicated clinicians working to improve care in small ways. The overall picture is that the situation of health care in Africa is, at best, holding at deplorable, and more likely worsening. Just to paint a picture of the human resource crisis here are a couple statistics from a recent Harvard Report. Africa has a deficit of one million health workers. Africa has 10% of the world’s population and less than 1% of nurses, MDs, and midwives. Africa trains only 5,000 MDs a year while Europe trains 175,000 per year. To me these statistics scream that the problem of health care in Africa is not one that can be solved by Africa alone. And, the provision of adequate care is not simply a matter of training/retraining and improving skills. (To believe this is a bit paternalistic, Tarek often says that these settings demand a higher standard of excellency and efficiency than settings with adequate resources – I’m not saying that all the clinicians are excellent or that many couldn’t profit from additional training but that this is not a solution). The shortage of human resources is a global problem of distribution demanding true commitment from the international community.

The other major theme was that women in sub-Saharan Africa continue to die and suffer from preventable illnesses and conditions; the same preventable causes that the international community has rallied around for decades, emphatically pledging again and again to eradicate. We know why women are dying, we know what we need to prevent their deaths, so why is nothing changing? Is it a question of finding the appropriate sustainable solution? And what exactly does sustainability mean? Does it mean cost effective? And, what is cost effective? Does that mean that the minimum requirement of any solution is that it should not challenge the standard of living in the developed world? We are entrenched in discourses of blame and power and in the meantime we are accumulating overwhelming proof that the problems are sustainable. While not doing much may be cost effective for the privileged, it is devastating for the poor – as mothers die and breadwinners die. Is the perpetuation of the status quo morally sustainable for global citizens?

I’m not sure what to do with all these questions but I am becoming more and more convinced that the solution requires a radical shift in perspective and must be inclusive of the “best for the whole” concept as well as the capacity to care for those who come to you with all the dedication you would show them if they were your mother or sister or daughter. I am also beginning to believe that individual efforts really can and do make a difference. I have a head full of ideas inspired by many people and many of you who read my blog have repeatedly asked how you can help so, I think it’s time to stop stalling and just start and NGO. My basic idea is to create something with a broad mission, a small organization geared towards improving the health of women and children functioning on a do-and-give-as-you-move-along-and-see-fit basis. Although I’m longing for home I don’t have a specific country in mind and home to me doesn’t necessarily mean a fixed location anyway (it’s more of the feeling that comes when you open the door to the place where you live and see the people within and the objects that form the space). I do imagine that wherever I end up it will be in the developing world in a community with some extra needs, so considering that, I’d like to have an NGO flexible enough to spread around. If any of you have ideas let me know, now is the time for dreaming.

Potholes

Clement’s aunt has a little restaurant behind Kamuzu Central Hospital (KCH). The setting is humble; a simple mud brick structure with a thatched roof – through which sun, wind, and rain still find their way – but her food is the best that I’ve tasted in Malawi. During the week she serves lunch to whoever takes a seat at one of the three round cement tables and for less than a dollar she will fill your plate with roasted chicken, beans, greens, a cabbage salad, stewed tomatoes and potatoes, and nsima or rice. Whenever I’m around KCH at noon, I eat her food. Today Clement and I took our places across from a pleasant force of nature disguised as a friendly old man. He greeted us both in Chichewa and let loose a happy surprised laugh when I responded in-kind and answered his simple questions. (I, myself, was very excited to note that I was able to follow the conversation in Chichewa about food, work, and origins.) As it turned out, he was from Mozambique and every now and then he’d toss in a Portuguese word when his Chichewa left a hole (I’m sure that was part of the reason I understood so well). After a few minutes I said something in Portuguese and he practically jumped out of his seat with joy. His smile lit his face and his arms and eyes began moving in excited circles while he hopped around asking a dozen questions, barely leaving space for the answers. When he learned that I am 30 and unmarried, he sobered up a bit, clicked his tongue, told me it was time for me to marry, and asked if I liked ele pointing to Clement with his eyebrows. Before he left, he put his hands over his heart, told me that I was his niece, and wished us all the best. It took us a few minutes to stop laughing. It’s amazing how when love flows from unexpected sources, it can quickly fill and smooth over the emotional potholes from daily wear.

Vacation

A couple weeks ago Tarek came up to me after rounds put his hand on my shoulder and said, “When I look at you I see someone who really needs a vacation.” Laughing I asked him if I looked that bad and he said, “Yes” with only a faint smile. So, I decided to let myself be convinced and then I quickly and easily convinced Deb to accompany me. Sunday we headed North to Mkuzi Beach (about a 4 hour drive from Lilongwe) both of us looking forward to no hiking, no running, just hours of laying on the beach reading books, swimming, and sharing stories. And that’s exactly what we did. We lay in the shade, swam, picked and ate mangos by the pound off a nearby overburdened tree, read, and slept ten hours a night. It was very restorative even if it was not entirely adventure free. Just before we left and I was packing up the car, a woman ran up to me and frantically said in a thick German accent, “Your tent is blowing away.” I rushed down to the beach and sure enough, there was our purple home setting sail on the small waves nearest the shore. Then on the way back to the main road (there is about a 4km dirt/sand road from the beach to the main road) we got stuck in the sand twice. The first time, as Deb assessed the hurdle, I laughed as I glimpsed our savior through the rearview mirror running towards us, her baby’s head bouncing along on her back. The two of them, along with a 13-year-old boy pushed us out of the trap. When we did finally make it to the road, we thought we were in the clear and drove 80km to the nearest Petrol station on our remaining quarter tank of fuel only to find that they, “had gone drought” as the attendant said. So we rolled up the windows to be more aerodynamic, turned off the AC, and amazingly covered another 60km, reaching the next station drenched in sweat but still smiling and with the engine still running.

Mangos

As you drive east, past Salima towards the lakeshore, buckets of yellow and green mangos begin to appear on either side of the road as though they are rising from the land, another sign of the approaching shore just as the red earth gives way to sand. Looking a few hundred yards from the road you see the women who attend these buckets, sitting in the shade of the mango trees, and groups of barefooted children playing, screaming, holding half eaten golden fruits, juice dripping from chins and elbows. For less than a dollar you can buy about 30lbs of mangos. For me this is as good as it gets. I’ve been eating mangos at every meal and you have to keep up the pace because it is such a shame to lose even a single mango to rot. I went to the lakeshore yesterday, the third time since I’ve been in Malawi, but as I headed out the door Dr. Kaponda forbid me to buy any more mangos. She had just returned the day before with a rainbow colored carload.

Unfortunately, for those selling the mangos, mangos are not a special coveted treat but the primary food source during this season. Adults and children of Salima eat mangos morning and night. The result of such a nutritionally limited diet is clearly evident in the distended bellies of joyful children swimming and playing in the water. I was told that in times of famine the mango season is short because people no longer have fruit to sell, they are eating everything, even the unripe mangos are boiled and eaten once soft. I was told that in a few weeks we will no longer see the buckets by the roadside.

On this trip I took Clement, two of his classmates and my friend Esther, the clerk at Bottom. The day was great. Even though desperation runs up to the end of the land, there is something very reassuring and calming about meeting the water. Seeing the light brown sand lapped gently by fresh water waves and the deep dark blue that extends to the horizon, provides the mind with a corner of the infinite. The image of sky and water extending without boundaries or markers gives space to release compressed thoughts, and a sense of freedom that comes with the realization that we are small and that this life is not about us as individuals. After hours mixed with dozing in the shade and floating in the rolling waves, we ate and headed back full and alive to Lilongwe. Despite our best attempt to leave early, when the sun set we still had almost an hour of driving ahead but everyone was awake and the conversation distracted me from my fear of driving the narrow dangerous roads in the black.

The nights here are black. There is no blue emanating from a distant city, giving the odd glow to the horizon or scattered fallen stars created by people reading or eating dinner in small towns. There is just the moon and the stars on a clear night, just your own headlights on a dark one, and an occasional forest fire. (Actually the forests may be more occasional than the fires.) On the way home we talked about magic – the beliefs here are strong – everyone had stories to share about flying fires in the night that don’t burn anything and witches who fly across the country or the globe in an instant. These are common stories, which many people believe to some degree, but are often reticent to discuss.

As we passed a large maize mill, a lone industrial giant lit by a few red lights humming deeply in the night, someone said that at one point US believed it was a nuclear power plant and sent inspectors. Looking at the out-of-place monstrosity it is not hard to see how someone, seeing the world through eyes of fear - with a proclivity for building walls and bombing - could make such an assumption, but the assumption was both absurd and somehow heartbreaking. We all laughed morbidly at the thought of the US bombing this maize mill in one of the poorest countries in the world only to later realize the mistake and attempting to compensate by donating maize to the already starving population.

Just before reaching home we shared our personal highlights of the day and only then did I find out that yesterday was Fatsani’s first time to the lake and only his second swim ever (his first swim at age 5 ended in his near drowning, and was followed by a severe beating). That instantly became my personal highlight, not finding out about the beating, but realizing that in such a simple way I had had the opportunity to make a positive and memorable lifetime event possible for someone.

Of course on the way home we still managed to fill the trunk with mangoes for Esther, Clement, Fatsani, and Sunshine. So as I dropped them in their homes each of them left the car with bags, buckets, and arms loaded with mangos – the makings of rich piles to share with family and friends, tangible sweet memories to extend the beauty of the day.

Hunger

Last Wednesday I helped one of the clinical officer students conduct a delivery. It went smoothly, the little girl emerged screaming as the walls of the only world she knew pushed her into the boundless. A healthy pink small baby. We dried and covered her, the student cut the cord and then we stood waiting for the placenta. Five minutes . . .ten minutes . . . fifteen minutes . . . The charge nurse passed by concerned and asked if she could check. She gloved and followed the cord up and then said, “There’s another baby.” (Note to self – always check for a twin!) The nurse ruptured the membranes, a second little girl came out crying, and the two placentas slid out effortlessly. The students, nurses, and I all laughed at my mistake with the undiagnosed twins but as we laughed the mother looked down at them and then to no one in particular said, “How I am going to feed these two with all the hunger?”

Malawi is facing the worst famine that it has faced in years. In some regions people have already run out of food, having eaten all the maize set aside for consumption, they begin to eat the maize to be used for selling and planting, meaning that (1) they are not generating any income, and (2) next year will be another year of hunger because harvest will again be insufficient. There is food available for purchase in stores but it is priced well above what most people can afford. These day the newspapers frequently run stories of children dying, and people eating seeds and other “inedible” items. A couple weeks ago six children in the same family died from eating a poisonous plant.

While the people are starving, the government is embroiled in the politics of attempting to impeach the President. The full story is long and confusing but the central issue seems to be that once elected, the President created his own party, leaving behind the party that helped him to power. He had a great start, really pushing anti-corruption to the forefront of his agenda but recently he seems to be cracking under the stress of the impeachment process. Meanwhile aid agencies are equally tangled into immobility, debating both the severity of the famine and the best way to alleviate the suffering.

Even being here where the signs of growing anxiety filter into every scene, whether it’s in the labor ward or in the street when laughing children interrupt their play to approach you and say, “hungry,” I still feel personally removed. Some part of me wants to share the pain, believing that the experience would ward against coping mechanisms adopted by the confused and privileged (e.g. general apathy, changing the channel, averting the eyes, etc.). But, I can never truly know life in that way, there will always be distance, and history, and other countless buffers. So, where do we begin as individuals to right so many layers of wrongs? to live every day in a way that leaves space for life not merely to exist but to flourish? (This I see as the difference between a blade of grass fighting its way through a crack in the pavement and a sea of wildflowers covering a hillside.) How do we sustain the belief that global inequalities, national inequalities, individual inequities, the capacity of power to pervert and persuade, the desperation and corrupting force of poverty, are simply stories or patterns that may be rewritten or redirected? . . . I don’t know.

Desperation

About a kilometer from the house is a small business area consisting of a Mobile station, a grocery, a small line of market stands, and a handful of bars. If you drive past this spot in the evening your headlights illuminate the silhouettes of prostitutes, sometimes in groups sometimes alone, waiting for their johns. Last night as I filled my tank at the Mobile station a woman wearing someone’s old evening gown, a long red dress with sequins, walked by and met my glance. She walked without apology but also without the self-assurance of a runway model or a Hollywood hooker. She walked just as a woman who has had a long day walks, a bit hurriedly in the direction of home with the purpose of rest. I saw her and noted that the elegance suggested by the gown did not quite conceal the poverty and desperation beneath. She wore old canvas shoes, shoes that had seen their last days but continued to be summoned for work day and night. I saw her dress, her shoes, her walk and met her eyes and wondered what she saw when she looked back . . . A foreigner? wealth? someone unburdened by the need to sacrifice everything to prolong life one more day?

A Few Forgettable Details

Just above the sink at the nurses’ station there is an old two-way radio that once was used to communicate with healthy centers. When it was functioning, the arrival of women in critical condition being transferred from out lying areas could be anticipated. It was someone’s wonderful idea, but from the looks of it, the radio has been out of service for many years. Someone, perhaps the one with the wonderful idea, bolted it to the counter in a way that made it a permanent fixture. But it is not totally useless. Every now and then a wasp will fly close to your head as you’re washing your hands, its long skinny legs dipped in yellow dangling freely, and then land on the counter and climb into the radio.

A sign posted on several doors in the Lilongwe’s District Health Office warning non-staff not to enter reads, “Out of Bounce.”

In Central Hospital if you want to see someone in 3A and decide to ride the elevator, you push “2.”

Surprises

Last week I spent one afternoon with Sakina, a very sweet and absolutely terrified 19-year-old who was pregnant with her first baby. She was having a difficult labor but refused all vaginal exams. After much time spent trying to calm her, she allowed me to check her cervix, first at 1pm (it was 9cm) and then again at 4:30 (it was still 9cm). Before I left around 6, I told the nurses and clinical officers about her and asked them to be gentle with her.

When I returned two days later I found out that she had refused a section early in the night, a vacuum had been performed at 3am, and then finally she consented to a section the following morning. Her baby boy was born around 6am but his journey into the world was too difficult for him to bear and he died just a few hours later. I was so upset. Yes, it is possible that she stubbornly refused the section after the best of counseling, and yes, the clinical officer who attempted the vacuum is a kind person. But, it was incredibly difficult for me to imagine that she allowed someone to do a vacuum (which in this setting involves inserting a metal cap that is 4-5cm in diameter into her vagina), considering it took several minutes just for her to allow me to touch her with two fingers. It was also difficult to imagine that she would refuse a section if she truly understood what was at stake, and believed that it was a necessity not a threat. Possible, yes, but difficult to imagine. I have seen women held down and threatened, and the vivid horrible memories flooded my mind. After visiting her in postnatal, seeing her silent tears, empty arms, and recent cut, I had a tearful conversation with Tarek about the situation. He listened, tried to help me see this one woman in the greater context of the Hospital and health care here, reminding me that things are improving but also saying that at present, the whole of Bottom Hospital is a human rights’ violation. That didn’t do much to lift my spirits and in the end he suggested that I talk about my observations during rounds on Wednesday morning.

Of course I forgot about my talk until 2am Tuesday night - the time when that internal calendar programs its adrenaline alarms - but I managed to put together some thoughts. In the morning I took my seat among the nursing matrons, the clinical officers and physicians (from day and night shifts, from the maternity units at both Central and Bottom Hospitals), and a handful of interns and clinical officer students. We went through the usual reports from the night shift and then just a few minutes before I spoke, a discussion started about particularly famous traditional birth attendant (TBA) in the area. Everyone seemed to know of her and several people said that even nurses choose to deliver with her rather than come to the hospital. Everyone was laughing, ridiculing a bit what they saw as the oddity of this woman and her following. Tarek in all seriousness suggested that we invite her to Bottom to learn from her, but everyone just laughed harder. The best story related about her was that when the TBA was confronted about some bad outcomes in her practice, her response was that she was extremely short-staffed and needed two nurses – in good humor one of the interns suggested I apply. (Why not? A weekend job? I’m sure I’d learn a lot – I’ll file that idea away.)

After everyone else finished I finally said my piece. I said a bit about how vaginal exams are routine for us (considering we probably do 100/day) but not for the women, how our goal should not only be health but good care, how women who refuse exams or seem “out of control” are not simply difficult but may have a history of sexual abuse, I made a plea to have patience and give care especially in the most frustrating and difficult situations, and I gave a few concrete examples of how we could change our practice. Especially after the discussion about the TBA, I expected silence and then disbursement of the group. But, the response was entirely different. Several people agreed with me quite emphatically and elegantly. A matron mentioned the TBA again – this time in a serious tone - suggesting that it was the TLC that brought women to the TBA and how the care, or lack there of, drove people from Bottom to her. The same male intern who teased me about the TBA said that the male clinicians should imagine themselves lying in the lithotomy position, giving birth at Bottom, and the sense of vulnerability they would feel. Someone else talked about how poverty was exploited, saying that women at Bottom aren't treated well because they are silent, they do not demand better, or even different, care. A few others also chimed in supporting what I had said. The reactions surpassed my most optomistic expectations. They gave me hope and lifted a weight that found its way to my shoulders long before I met Sakina. I am certain that this solves nothing but it is a beginning and demonstrates a receptivity that I did not know existed.

Today's Answer

The times that I think, "What am I doing and how did I get here?" are not infrequent. Usually these out-of-body moments make me smile. And, the answer I give myself varies depending on the day. Here is today's answer: one reason I like being in this setting is that it forces honesty upon you. It is difficult to lie to yourself. It is difficult to believe statistics are merely numbers. It is difficult to believe that the growing gap between the rich and the poor is just a tall tale invented by bored liberals. It is difficult to ignore the contradictions you continue to live. It is difficult to ignore how your daily actions and decisions directly and dramatically affect the lives of others for better or worse. It is difficult to pause the perpetual struggle that rages within, be it against personal, societal, or global demons. Of course it is not impossible to lie. It is possible to break. It is possible to die as your ideologies die, to die as hope and laughter wither in the drought of levity. But, the peace, inspiration, and insight, when they do penetrate your mind here, seem somehow more poignant, brighter, deeper; their roots stronger. I suppose that is what I crave, that hope is what sustains me.

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.