It is pouring outside. Not a drop all day and then, just now, a small breeze and a distant grumble heralded the amazing power of water roaring down from thousands of feet above. Gullies instantly formed and rush around the base of the house. The vision and the deafening sound demand attention, silence, and awe. I am sitting at the table in my apartment feeling peaceful. It’s nice to feel small and insignificant when the provocative force also has a similar effect on your problems and preoccupations (as opposed to feeling small in the face of seemingly insurmountable problems and preoccupations – a more common experience for me.) Life. Today I’m quietly observing a deluge and yesterday I was struggling with my internal floodgates, trying to keep the choking waters at bay.
So much has happened since my last entry. I have an apartment, as of last week. It’s a simple boxy structure - one big square for the kitchen and sitting area, two smaller adjoining squares for bedrooms, and a small square bathroom Not very inventive but there are nice big windows in the front that let in plenty of light, there are covered patios in the front and the back, the ceilings are high, and I painted the walls nice soothing colors. There are three identical flats on one plot. The first flat is empty, the middle one is rented by a nice Malawian family, and the last one is mine. There is room and hope for both a flower and vegetable garden. I have my home.
I was able to rent the flat because I have a new paying job, which also started last week. My job with the Italian NGO finished in December and around that time I saw an ad for a part-time RN position at the US Embassy. So, I applied and, after a panel interview, got the job. I will be working at the Embassy 20 hours a week and at Bottom 24 hours a week. I must say it is a bit surreal to work for the US government; I actually had to raise my right hand and swear to some pretty patriot language. Being in the clinic itself is also surreal. The clinic serves only about 100 people (only American Embassy, CDC, and USAID staff and their families). Local hires (myself included) are not supposed to be seen at the clinic. So far it seems the clinic averages about two patients a day with fairly innocuous complaints (of course there is the rare car crash or heart attack, but thankfully those are rare events). To care for these patients there is a well-stocked pharmacy, a lab that runs 24/7 with an experienced and friendly lab tec, and I was told today that the Embassy even has its own blood bank. Meanwhile Bottom exists, not more than two miles away, at the other end of the spectrum. It’s as though we have a little America right here serving as patch test. We can hold it up close to Malawi and really see the disparities. I haven’t done very much in my few days at the Embassy but I have made the rounds and overall the Embassy staff is incredibly warm, welcoming, and interested in my work at Bottom. My fantasy now is to find small ways for the Embassy to serve the people who seek care at Bottom and KCH. My first idea is blood. How beautifully metaphoric. I’d like to organize a blood drive. I’m sure bureaucracy will pose a significant hurdle but I have hope, we’ll see how it goes.
As for other updates, I did go and deliver formula to the baby of the 17-year-old who died in labor ward. I was quite proud of myself. I found my way to the rural health center alone (well with some help from police at a roadblock). When I arrived at the health center the grandmother was waiting for me with the baby and her other daughter. I drove them back to their home in the “nearby” village, which was a good five miles away, with the grandmother giving directions in Chichewa and gestures. The terrain was mostly four-wheel drive worthy roads but my little Toyota Sedan did a great job. When we did reach a muddy impasse, I stopped the car and we walked the rest of the way to the house through the stares of all the neighbors and neighbors of neighboring villages. Finally we arrived at a neat brick and mud home with mud floors and a tin roof. Inside there was one small room with a couple goats and one bare large room, with a large straw mat and one chair. The grandmother offered me the chair and the mat quickly filled with women. I felt honored, content, and uncomfortable. After a few minutes she escorted me back to my car and I promised to return again with more formula. That was two weeks ago.
Doreen started school. I visited her two weeks before she started but have not returned since. She called me to tell me that classes began and said that Dalitso is a big problem. I can imagine . . . trying to express enough milk by hand to keep him satisfied for the day, every day. I am due for another visit. I hope when I see them next that she is still breastfeeding, attending classes, and that Dalitso is gaining weight.
Last week at Bottom was a bit rough. On Wednesday I delivered two babies, one needed resuscitation and one, although it was a vacuum birth, was doing great when the mom left labor ward. When I went to visit the one in the nursery on Thursday I found her with an axial temperature of 105.8F!!! Which means her core body temperature was about 106.8! (normal is 98.6) Of course at any one time there are close to 30 babies in the nursery and one nurse so it wasn’t surprising that no one had noticed her amazing fever but I was still horrified. I gave her a bath in tepid water and then we started her on antibiotics for sepsis. At the same time I also found out that the baby from the vacuum birth had been admitted due to sepsis as well. The nurse said that if the babies did not improve in a few days she would call Peds (otherwise a Pediatrician only occasionally visits Bottom). Thursday, Deb and I also picked up the resuscitation of a baby from a delivery we did not attend. After over two hours of bag and mask we told the 18-year-old mom that her baby would not survive and we stayed and watched the baby die and the mother wail. Friday, a woman walked into the hospital six months pregnant, with her first baby, with a hemoglobin of 2.9 (normal is 12-14). We (nurses, clinical officers, and myself) put her on oxygen and started a transfusion. Apparently she had bled a lot the previous week but only came in on Friday because she thought she had malaria. Hemorrhage plus malaria, not good for maintaining a decent blood count.
Saturday and Sunday passed in a blur, my intention was to go and do my visiting - check on the babies at Bottom, see Doreen and the orphan - but in the end I just wanted to be still, so I did none of that. I cried some. I visited my friend Dawn. I had brunch with Deb and Zack. And, then watched a movie with friends.
Today I was back at the Embassy, good but slow. I sent a message to Deb asking her to check on my babies. She sent a message back saying that one had a temperature of 106.1 axial and that the nurse said the room was hot and many babies were having fevers (?!). Deb asked her to call Peds. I hope the baby will survive the night.
Several people responded to my entry about the mother who died I have now also offered to help two more babies whose young mothers died at Bottom in the last week. Formula here costs about $10 a can. There is a famine here and I can promise none of these families have the resources to buy formula many cannot even buy maize. If you would like to contribute to help these babies let me know.
Monday, January 30, 2006
Thursday, January 12, 2006
The Missing Middle
Tuesday I held a three-day-old baby while his grandmother, supported by the arms of strangers, watched as the maids loaded the body of her 17-year-old daughter into the ambulance. These things are not supposed to happen. I wasn’t in the labor ward when she died. I was in the theatre. When I came back Chipeta, the charge nurse, told me the story. The woman delivered with a traditional birth attendant on the 8th but was experiencing a lot of pain and bleeding and so on the 10th she went to the health center near her home. The health center transferred her to Kamuzu Central Hospital, (KCH has the only ICU in the Central Region of Malawi, but does not have a public maternity ward). Clinicians at KCH for some reason decided to send her to Bottom but as soon as she arrived, before she could even be assessed, she began gasping and then collapsed. The resuscitation attempt was unsuccessful. The clinicians speculated that she had an undiagnosed ruptured uterus, which lead to sepsis and eventually to her death. As she told me the story, Chipeta gestured to an older woman sitting on the bench at the entrance to the labor ward unsuccessfully trying to console a screaming baby.
Before the tears and the formula and hopeless gesture of stuffing a 500 kwacha note into the hand of the woman as she sat alone sobbing in the back of the ambulance with the still body of her young daughter. Hours before that, I sat in my car taking a in few breaths wondering what the day would bring contemplating the irony of how I was never excited to enter the hospital but how it was still the only thing I wanted to do.
The first woman I saw in the morning was in active labor with her fifth pregnancy. I examined her and found that the baby was in a breech position. The rest of her exam was normal. Because her most recent delivery was a c-section the decision was made to do another section. I went to theatre to receive the baby. After the first incisions, a blue and reddish mark appeared as a stain on the typically pearly surface of the uterus – a sign of imminent rupture. Then as the physician moved his gloved hand across the surface we realized that rupture was not imminent, it had already occurred. Part of the baby’s arm was visible through the tear. The baby was quickly removed and amazingly she emerged very much alive, pink and crying. I showed the mom her baby girl. The happy mother who was oblivious to her own close encounter with tragedy told the anesthesiologist that I should name the baby. I named her Mwaye. Her name is Fortune.
Sometime after meeting Mwaye is when I came to the story of the dead girl and her hungry baby and grieving mother. Monday night one of my friends gave me a large can of formula to donate to the nursery. When I was shown the woman holding the crying baby, I took her to the nursery, retrieved the donation, and prepared a small cup of formula while the nurses gave the woman directions. Once she was done feeding the baby and the baby’s eyes were dry and bright, another nurse came to tell us that the ambulance was ready to take her and the body to the mortuary at KCH. I carried the formula in one hand, the grandmother held the baby, my other hand lightly rested on her back. I could feel the bones of her ribs and her shoulder and her hips beneath the layers of tattered chitengis. I noticed her bare feet with their thick soles. I considered the can of formula, at a cost of over ten dollars each, I knew the newborn would not continue to eat this food without significant help. Before we even made it to the door of the hospital, tears began running down her wizened cheeks and her steps faltered. Several women, waiting in the halls for their own daughters, approached her, removed the baby from her arms to relieve the weight, and listened to her story as it came through her tears. I took the baby from one woman and she moved to support the grandmother who appeared close to collapse. She kept repeating, “I am alone, I am alone.” I considered the baby who was crying in my arms simply because he was a baby and wet. He had no concept of how his life was changing nor would he carry any memory of the day forward.
I had the nurses write down the village of the grandmother and tell her that I would meet her at the nearby health center on Tuesday with more formula. The 17-year-old mother died under our noses and now I’m trying to provide hope and help by giving cans of formula. One word - inadequate.
After the ambulance left, I returned to the labor ward and Deb asked me to examine a woman who had not been progressing since early morning. In the end, a clinical officer did a vacuum and I finished the birth. The small girl was blue and floppy but she picked up quickly with a little help. As I stitched the small tear on the mother’s perineum she asked me if her baby was ok. She told me that this girl is now her only living child after five pregnancies. I assured her that the baby was well and she smiled at the little bundle lying next to her.
The day before all of this happened, I went for a run with the large expat group. It was my first run in a long time. It was a nice run. As we ran through a field we passed a family of three. A ten-year-old boy followed by his grandparents. The boy walked in front, the grandmother, clearly blind had her hand on his shoulder. The grandfather, also blind had his hand on the woman’s shoulder.
No one to care for the young.
No one to care for the old.
They care for each other
even though they are not quite capable of doing so.
Even though their desperate need
of each other is a daily reminder of what
and who they have lost.
These visions are too much.
These realities are too much.
I don’t want to look away.
Before the tears and the formula and hopeless gesture of stuffing a 500 kwacha note into the hand of the woman as she sat alone sobbing in the back of the ambulance with the still body of her young daughter. Hours before that, I sat in my car taking a in few breaths wondering what the day would bring contemplating the irony of how I was never excited to enter the hospital but how it was still the only thing I wanted to do.
The first woman I saw in the morning was in active labor with her fifth pregnancy. I examined her and found that the baby was in a breech position. The rest of her exam was normal. Because her most recent delivery was a c-section the decision was made to do another section. I went to theatre to receive the baby. After the first incisions, a blue and reddish mark appeared as a stain on the typically pearly surface of the uterus – a sign of imminent rupture. Then as the physician moved his gloved hand across the surface we realized that rupture was not imminent, it had already occurred. Part of the baby’s arm was visible through the tear. The baby was quickly removed and amazingly she emerged very much alive, pink and crying. I showed the mom her baby girl. The happy mother who was oblivious to her own close encounter with tragedy told the anesthesiologist that I should name the baby. I named her Mwaye. Her name is Fortune.
Sometime after meeting Mwaye is when I came to the story of the dead girl and her hungry baby and grieving mother. Monday night one of my friends gave me a large can of formula to donate to the nursery. When I was shown the woman holding the crying baby, I took her to the nursery, retrieved the donation, and prepared a small cup of formula while the nurses gave the woman directions. Once she was done feeding the baby and the baby’s eyes were dry and bright, another nurse came to tell us that the ambulance was ready to take her and the body to the mortuary at KCH. I carried the formula in one hand, the grandmother held the baby, my other hand lightly rested on her back. I could feel the bones of her ribs and her shoulder and her hips beneath the layers of tattered chitengis. I noticed her bare feet with their thick soles. I considered the can of formula, at a cost of over ten dollars each, I knew the newborn would not continue to eat this food without significant help. Before we even made it to the door of the hospital, tears began running down her wizened cheeks and her steps faltered. Several women, waiting in the halls for their own daughters, approached her, removed the baby from her arms to relieve the weight, and listened to her story as it came through her tears. I took the baby from one woman and she moved to support the grandmother who appeared close to collapse. She kept repeating, “I am alone, I am alone.” I considered the baby who was crying in my arms simply because he was a baby and wet. He had no concept of how his life was changing nor would he carry any memory of the day forward.
I had the nurses write down the village of the grandmother and tell her that I would meet her at the nearby health center on Tuesday with more formula. The 17-year-old mother died under our noses and now I’m trying to provide hope and help by giving cans of formula. One word - inadequate.
After the ambulance left, I returned to the labor ward and Deb asked me to examine a woman who had not been progressing since early morning. In the end, a clinical officer did a vacuum and I finished the birth. The small girl was blue and floppy but she picked up quickly with a little help. As I stitched the small tear on the mother’s perineum she asked me if her baby was ok. She told me that this girl is now her only living child after five pregnancies. I assured her that the baby was well and she smiled at the little bundle lying next to her.
The day before all of this happened, I went for a run with the large expat group. It was my first run in a long time. It was a nice run. As we ran through a field we passed a family of three. A ten-year-old boy followed by his grandparents. The boy walked in front, the grandmother, clearly blind had her hand on his shoulder. The grandfather, also blind had his hand on the woman’s shoulder.
No one to care for the young.
No one to care for the old.
They care for each other
even though they are not quite capable of doing so.
Even though their desperate need
of each other is a daily reminder of what
and who they have lost.
These visions are too much.
These realities are too much.
I don’t want to look away.
Friday, January 06, 2006
A Visitor
My friend Sarah traveled across the planet to visit me. I am lucky. Sarah and I met in volleyball training two weeks before high school started in 1989. I remember thinking that Sarah was kind, worldly, and a bit reckless at 14. Now 16 and ½ years she laughs when I share my first impression and says she remembers me best as a quiet girl with long legs, arms, and fingers.
Sarah is now a social worker; she has worked with children in Appalachia as well as in impoverished sections of Detroit and Austin. She intimately knows parts of the developing world that lie within the US borders. And, has an unfortunately large collection heartbreaking horror stories that never made it to the news, because when “those things happen to those people in those neighborhoods, they are not newsworthy.” Sarah is someone who lives with her heart wide open and someone who sometimes forgets to protect it. Sarah is also someone who enriches the world by living and growing within it.
I have so many amazing people in my life who are supportive and loving and inspiring, I’m certain I could write a book just on you.
There is something special about spending time with someone who has known you so long. Simply by being present she connected pieces of my life, bringing love and reflection from home and carrying it back to friends and family. It also gave me an opportunity to view my life here through a new lens. I have asked her to write something that I will post.
The first morning Sarah was here she volunteered in the nursery at Bottom, which amounted to cleaning the bins and holding babies. In the afternoon we went to visit Doreen and Dalitso, and after hearing they had no food on Christmas she left me money to buy them a couple chickens. The next day we headed to Zomba, a mountain town, three hours South of Lilongwe, where Clement’s father lives. Compared to Lilongwe Zomba is incredibly green and lush but locals still lament the rapid rate of deforestation. From Zomba we traveled to Cape McClear, one of the beautiful destinations points on the lake, where we met Dana and McPharlen and celebrated New Year’s Eve and their two-year anniversary. And then, as though it were all in the span of a single breath, I watched her plane take off towards South Africa. It was a short but wonderful week.
Just so you know, my door is open for anyone else who wants to come.
Sarah is now a social worker; she has worked with children in Appalachia as well as in impoverished sections of Detroit and Austin. She intimately knows parts of the developing world that lie within the US borders. And, has an unfortunately large collection heartbreaking horror stories that never made it to the news, because when “those things happen to those people in those neighborhoods, they are not newsworthy.” Sarah is someone who lives with her heart wide open and someone who sometimes forgets to protect it. Sarah is also someone who enriches the world by living and growing within it.
I have so many amazing people in my life who are supportive and loving and inspiring, I’m certain I could write a book just on you.
There is something special about spending time with someone who has known you so long. Simply by being present she connected pieces of my life, bringing love and reflection from home and carrying it back to friends and family. It also gave me an opportunity to view my life here through a new lens. I have asked her to write something that I will post.
The first morning Sarah was here she volunteered in the nursery at Bottom, which amounted to cleaning the bins and holding babies. In the afternoon we went to visit Doreen and Dalitso, and after hearing they had no food on Christmas she left me money to buy them a couple chickens. The next day we headed to Zomba, a mountain town, three hours South of Lilongwe, where Clement’s father lives. Compared to Lilongwe Zomba is incredibly green and lush but locals still lament the rapid rate of deforestation. From Zomba we traveled to Cape McClear, one of the beautiful destinations points on the lake, where we met Dana and McPharlen and celebrated New Year’s Eve and their two-year anniversary. And then, as though it were all in the span of a single breath, I watched her plane take off towards South Africa. It was a short but wonderful week.
Just so you know, my door is open for anyone else who wants to come.
Resolutions
Here we are in 2006. I’m feeling a bit somber; all too serious for my liking and for the season. I’m living, breathing, smiling, eating, sleeping, laughing, loving, working but I find through it all, the level of my tears holds steady at my cheekbones. Simply tipping my head too abruptly causes them to overflow. Unadulterated joy is desirable but feels a bit out of reach. I find it difficult not to be swept away by everyday desperation here and overwhelmed by the bottomless need. Of course, as friends have told me, suffering is relative and I should not judge the lives of people here by my standards of well-being and happiness but I am unable to turn off the switch.
Small scenes and realizations refill the reservoir in my head. Scenes such as the woman who does not smile or even look at her baby as I place it crying and squirming on her belly and then tells me she does not want to breastfeed . . . now. Or the vision of the woman who I talked to, laughed with, and encouraged day after day for a couple weeks - as she waited with her husband on the hospital grounds for the birth of her child - finally leaving the hospital with empty arms and a re-broken heart (two pregnancies, two deliveries, no living children). Or learning from Doreen’s sister (who also gave birth to a boy “Prince” two weeks ago) as they set out a beautiful meal of nsima, beef, and vegetables for me and my friend that they did not eat Christmas day because there simply was no food. (Doreen said their Christmas was “fine” but her 22-year-old sister Mercy laughed, clicked her tongue and then looking at Doreen but talking to me, said there was no food.)
I am not enough for myself or for others, and aspiring to be a good force in the world does not necessarily bring light. In my typical way of overthinking and analyzing I have been mentally shuffling through my list of my heroes but came up with few to none who could be characterized both as joyous people, as well as people who are/were deeply engaged with life and fully awake in the world. (I’m sure I’m missing many, so help me out if someone jumps to mind). But, through this process my mind did settle on a story . .
A few years ago, one of the midwives I adore told me about her grandmother who became senile before then end of her life. As the grandmother’s mind began to take flight, there was a moment when both she and her family realized with absolute clarity what the future held. At this time my friend, with a heart full of sadness and compassion, said to her grandmother, “It must be difficult to go through this and realize what lies ahead.” But her grandmother surprised her by responding, “Why? I’m going to have fun.” A couple months later at the funeral of her husband, my friend’s grandmother was singing a bit inappropriately (too joyfully) and dipping cookies in her wine. When someone approached her and told her what she was doing, she initially looked a bit shocked but then winked and said, “Well it’s quite good, you should try it.”
I love that story. From that snapshot I see her grandmother as courageous and radiant, and the image releases a bit of the pressure around my heart. Perhaps it is easier for me to allow sadness to settle in my corners but I want to believe that joy is as abundant. I imagine joy demands attentiveness and appreciates an invitation.
So, this is my New Year’s Resolution, to increase that attentiveness, to create an invitation for joy, and in the words of a friend, “to lower my threshold for happiness.”
Small scenes and realizations refill the reservoir in my head. Scenes such as the woman who does not smile or even look at her baby as I place it crying and squirming on her belly and then tells me she does not want to breastfeed . . . now. Or the vision of the woman who I talked to, laughed with, and encouraged day after day for a couple weeks - as she waited with her husband on the hospital grounds for the birth of her child - finally leaving the hospital with empty arms and a re-broken heart (two pregnancies, two deliveries, no living children). Or learning from Doreen’s sister (who also gave birth to a boy “Prince” two weeks ago) as they set out a beautiful meal of nsima, beef, and vegetables for me and my friend that they did not eat Christmas day because there simply was no food. (Doreen said their Christmas was “fine” but her 22-year-old sister Mercy laughed, clicked her tongue and then looking at Doreen but talking to me, said there was no food.)
I am not enough for myself or for others, and aspiring to be a good force in the world does not necessarily bring light. In my typical way of overthinking and analyzing I have been mentally shuffling through my list of my heroes but came up with few to none who could be characterized both as joyous people, as well as people who are/were deeply engaged with life and fully awake in the world. (I’m sure I’m missing many, so help me out if someone jumps to mind). But, through this process my mind did settle on a story . .
A few years ago, one of the midwives I adore told me about her grandmother who became senile before then end of her life. As the grandmother’s mind began to take flight, there was a moment when both she and her family realized with absolute clarity what the future held. At this time my friend, with a heart full of sadness and compassion, said to her grandmother, “It must be difficult to go through this and realize what lies ahead.” But her grandmother surprised her by responding, “Why? I’m going to have fun.” A couple months later at the funeral of her husband, my friend’s grandmother was singing a bit inappropriately (too joyfully) and dipping cookies in her wine. When someone approached her and told her what she was doing, she initially looked a bit shocked but then winked and said, “Well it’s quite good, you should try it.”
I love that story. From that snapshot I see her grandmother as courageous and radiant, and the image releases a bit of the pressure around my heart. Perhaps it is easier for me to allow sadness to settle in my corners but I want to believe that joy is as abundant. I imagine joy demands attentiveness and appreciates an invitation.
So, this is my New Year’s Resolution, to increase that attentiveness, to create an invitation for joy, and in the words of a friend, “to lower my threshold for happiness.”
Thursday, December 22, 2005
Questionable Visions
The belief in witches runs deep. People don't often talk of their beliefs openly but when the subject comes up storytelling begins slowly and then crescendos; contributions follow progressively shorter pauses and the terror quotient increases, leaving everyone present either wide-eyed or nodding knowingly. Most Malawians if pressed will admit to believing in witches regardless of their educational level and/or the fervor of their affiliation with a brand of western religion.
There are the well-known comical stories, which people tell with straight faces but are hard to hear without erupting into hysterics. One friend told me about his encounter with "Bottle Man" - a sort of street performer from the sound of it. He would draw a crowd, ask for money, and then somehow shrink down and get inside a Coke bottle. I had to ask, of course, if anyone ever picked up the bottle to shake it or examine it, and he said the crowd was so horrified that the thought never crossed anyone's mind. Another personal favorite is the story the man who shrunk 60 cattle and tied them to a handkerchief, which he slipped in his pocket before boarding a minibus. Once aboard, the minibus acted as though it was extremely overloaded, sagging to the ground and unable to move. Perhaps suspecting something, the driver then had everyone disembark and searched until the culprit - the man with 60 cattle in his pocket - was caught red handed. I have no idea how the Cattle Man was reprimanded but the implication was that his cattle were not allowed to board and the minibus drove happily into the sunset. To add to this collection are the many stories of witches who fly through the night sky, crossing the continent in moments and always returning before dawn. Their "airplanes" of choice are large wicker baskets usually used for storing grain. Several stories, reported with true journalistic candor, of such "airplane" crashes have made their way into the national newspaper recently.
There are other more frightening stories. One close friend told me of an experience he had as a child of being haunted night after night by a neighbor. The neighbor would appear to him completely naked with menacing expressions, even while he was in the company of his parents and friends. After almost a year of sleepless nights and numerous incidents of describing with terror the approach of this man, whom no one else could see, his well-educated father took him to a traditional healer. From that time on the visions stopped but the haunting permanently damaged his parents' relationship with the neighbor.
Finally, there are the most horrific stories involving murder and trafficking in body parts. Whether or not people chose to belief in the power of black magic and the "success" of its practice, horrific physical evidence exists to confirm its existence. Mutilated bodies found with missing eyes, or fingers, or various internal organs cannot be shrugged off as easily as Cattle Man.
Often when I hear these stories, particularly the comical ones, my reaction is, "You know you're Western when . . . you're the only one in the room with a smirk." But, I believe in questioning judgments and when I thought about it, realized that our Western minds have room for our own brand of ghosts and witchcraft. I imagine that in any room of Americans the percentage of people who may, albeit hesitantly, share stories of ghosts seen or personal unexplained spiritual experiences probably approximates the percentage of Malawians who believe in witchcraft. The difference seems to be that in Malawi this world of spirits is mostly dark and that there is an entire subpopulatiopurporttches who perport to be able to control and/or sell services of this other darker world.
For those who would avidly deny the possibility of any unscientific phenomena, I can say that belief is powerful on both sides (for the believers and unbelievers) and denial is possible in both camps. I remember years ago watching a television program in my aunt's house about the human mind. The narrator was talking about how when we see something that only deviates slightly from what we expect, our mind interprets said item or event to be the expected item or event. In order to illustrate this, a series of playing cards was flashed quickly across the screen and the viewer was asked to say the face of each card. Eight of Diamonds, Six of Spades, Seven of Clubs and so on. The same series was repeated slower and slower but it wasn't until each card remained for a full second or longer that I realized that the Eight of Diamonds was really a red Eight of Spades and that the Seven of Clubs was really a black Seven of Hearts, etc. Doesn't that little test allow for the possibility that we see and experience things that, "should not be," and so we quickly and subconsciously rationalize events and file them away as "normal." That test really stuck with me and every once in a when it comes to mind, it helps me question to my personal truth, whether in regard to how I perceive an individual's personality or a broader more abstract concept such as witchcraft.
Along the same lines, in our developed world so much of our accepted reality is as well understood as magic. I know that if I really wanted to, I could discover how a telephone works. I don't really care to know, but the knowledge that this information exists is enough for me to believe and accept the telephone as a non-magical technology. Although, when I think of speaking to my parents on the other side of the Earth with only a fraction of a second lag-time, it is just as magical as flying in a wicker basket across Africa. During the time of Colombus the physical potential for a telephone existed, science just had to catch up to enable the reality. Could it not be possible that science just has to evolve a bit more to encapsulate and prove the phenomenon of black magic? Could it not be possible that black magic developed from a different path that is actually longer but just as linear and true as western science?
It is difficult to step aside from our way of thinking as the only way or the best way. Most of us, myself included, see our way as the best way, at least subconsciously. Most of the time I walk through life believing I have an open mind but I have to laugh at myself when I smack up against the hard borders of that openness. Who erected that border? With what assumptions? Can it be redrawn? . . . Just thoughts.
There are the well-known comical stories, which people tell with straight faces but are hard to hear without erupting into hysterics. One friend told me about his encounter with "Bottle Man" - a sort of street performer from the sound of it. He would draw a crowd, ask for money, and then somehow shrink down and get inside a Coke bottle. I had to ask, of course, if anyone ever picked up the bottle to shake it or examine it, and he said the crowd was so horrified that the thought never crossed anyone's mind. Another personal favorite is the story the man who shrunk 60 cattle and tied them to a handkerchief, which he slipped in his pocket before boarding a minibus. Once aboard, the minibus acted as though it was extremely overloaded, sagging to the ground and unable to move. Perhaps suspecting something, the driver then had everyone disembark and searched until the culprit - the man with 60 cattle in his pocket - was caught red handed. I have no idea how the Cattle Man was reprimanded but the implication was that his cattle were not allowed to board and the minibus drove happily into the sunset. To add to this collection are the many stories of witches who fly through the night sky, crossing the continent in moments and always returning before dawn. Their "airplanes" of choice are large wicker baskets usually used for storing grain. Several stories, reported with true journalistic candor, of such "airplane" crashes have made their way into the national newspaper recently.
There are other more frightening stories. One close friend told me of an experience he had as a child of being haunted night after night by a neighbor. The neighbor would appear to him completely naked with menacing expressions, even while he was in the company of his parents and friends. After almost a year of sleepless nights and numerous incidents of describing with terror the approach of this man, whom no one else could see, his well-educated father took him to a traditional healer. From that time on the visions stopped but the haunting permanently damaged his parents' relationship with the neighbor.
Finally, there are the most horrific stories involving murder and trafficking in body parts. Whether or not people chose to belief in the power of black magic and the "success" of its practice, horrific physical evidence exists to confirm its existence. Mutilated bodies found with missing eyes, or fingers, or various internal organs cannot be shrugged off as easily as Cattle Man.
Often when I hear these stories, particularly the comical ones, my reaction is, "You know you're Western when . . . you're the only one in the room with a smirk." But, I believe in questioning judgments and when I thought about it, realized that our Western minds have room for our own brand of ghosts and witchcraft. I imagine that in any room of Americans the percentage of people who may, albeit hesitantly, share stories of ghosts seen or personal unexplained spiritual experiences probably approximates the percentage of Malawians who believe in witchcraft. The difference seems to be that in Malawi this world of spirits is mostly dark and that there is an entire subpopulatiopurporttches who perport to be able to control and/or sell services of this other darker world.
For those who would avidly deny the possibility of any unscientific phenomena, I can say that belief is powerful on both sides (for the believers and unbelievers) and denial is possible in both camps. I remember years ago watching a television program in my aunt's house about the human mind. The narrator was talking about how when we see something that only deviates slightly from what we expect, our mind interprets said item or event to be the expected item or event. In order to illustrate this, a series of playing cards was flashed quickly across the screen and the viewer was asked to say the face of each card. Eight of Diamonds, Six of Spades, Seven of Clubs and so on. The same series was repeated slower and slower but it wasn't until each card remained for a full second or longer that I realized that the Eight of Diamonds was really a red Eight of Spades and that the Seven of Clubs was really a black Seven of Hearts, etc. Doesn't that little test allow for the possibility that we see and experience things that, "should not be," and so we quickly and subconsciously rationalize events and file them away as "normal." That test really stuck with me and every once in a when it comes to mind, it helps me question to my personal truth, whether in regard to how I perceive an individual's personality or a broader more abstract concept such as witchcraft.
Along the same lines, in our developed world so much of our accepted reality is as well understood as magic. I know that if I really wanted to, I could discover how a telephone works. I don't really care to know, but the knowledge that this information exists is enough for me to believe and accept the telephone as a non-magical technology. Although, when I think of speaking to my parents on the other side of the Earth with only a fraction of a second lag-time, it is just as magical as flying in a wicker basket across Africa. During the time of Colombus the physical potential for a telephone existed, science just had to catch up to enable the reality. Could it not be possible that science just has to evolve a bit more to encapsulate and prove the phenomenon of black magic? Could it not be possible that black magic developed from a different path that is actually longer but just as linear and true as western science?
It is difficult to step aside from our way of thinking as the only way or the best way. Most of us, myself included, see our way as the best way, at least subconsciously. Most of the time I walk through life believing I have an open mind but I have to laugh at myself when I smack up against the hard borders of that openness. Who erected that border? With what assumptions? Can it be redrawn? . . . Just thoughts.
Saturday, December 10, 2005
No Rain
I'm sitting in an office on the grounds of Kamuzu Central Hospital typing this up. I can hear wailing and singing from the mortuary next door and the sky, which should be dark and heavy with the promise of rain is blue blue blue. The first rains should have come late October. I suppose officially they did come, midway through November. People celebrated and began planting but the rains stopped. Now it's mid-December and Lilongwe is sweltering. I'm sure that whatever bits of green pushed through the earth have now dried and withered back to the red dusty crust. People speak only of the absent rains and the heat. Rain is everything. Rain is hope and life.
Yesterday I was assigned to theatre at Bottom. I went in to receive a baby with cord prolapse and came out with two very small but screaming little boys. I returned to the labor ward for a while and ended up next to a woman whose baby's heart rate kept dropping, but when we called theatre to see if an emergency section for fetal distress would be possible, we found that they were in the process of sectioning another woman. That woman's baby had died in-utero because she entered labor with her baby in an impossible position and didn't get to the hospital in time to have a section while the baby was still alive. I was called back to theatre to receive her dead baby and the dead baby of a 24 year-old woman whose uterus had ruptured after spending three unsuccessful days with a traditional birth attendant. I wish all of you, midwives, physicians, watchers of ER, Americans, could just catch a glimpse of the theatre.
The room itself is small and basic. One wall has windows that open to the outside, though which cracks of daylight and fresh air seep in. A simple bed occupies center stage and a small resuscitare without an overhead heater for the baby stands off to the side. There is a machine for monitoring the patient's vital signs and an electrical suction for the woman. A small foot pump suction sits next to the baby's resuscitare besides two oxygen concentrators . There is a cabinet for various syringes and tubes, a sink, a baby scale, and a couple tables holding gloves sutures, sterile packets, and other assorted items. As for the staff, all of us are gowned in theatre attire made from jean material. Everything is reusable - except for the hats and shoe covers which are always in short supply. Often we use plastic aprons tied around our heads and feet - picture everyone with white garbage bags on their heads and feet. Other times old patient gowns (donated, I imagine, by people who logically envisioned these gowns being used by patients) are used by surgeons when they run out of theatre attire. Sterile draps are also made from the jean fabric and many have quite a few holes. The scene strikes me alternately as commical, a bit depressing, or as a great illustration of people's inventive solution to lack of resources, depending on my frame of mind.
Half-way through the surgery yesterday, the shifts changed so a new anestethist came to replace the one who worked during the day. He received a few laughs as he entered the theatre. His creative solution to the absence of theatre hats was to use a carboard box. (Despite the laughs he didn't change his "hat.")
Lwanja, the senior clinical officer on staff conducted the surgery. After the intial cut through her abdomen the baby's hand emerged, confirming a severe rupture, and a stench filled the room confirming necrosis.
Throughout the surgery the theatre nurse just kept saying, "Poor, Malawians, poor, Malawians."
The room soon filled with flies and I wondered momentarily why there are never flies in the hospitals in the US.
Everything went smoothly and everyone agreed that she was lucky. She is 24 years old, she came close to losing her life but she didn't. She lost her uterus and her unborn child but she has a living child.
(When the surgery was done I returned to labor ward and found that the woman with fetal distress had delivered a healthy girl with the help of a vacuum.)
This morning I went to the hosptial to check on the woman who had the surgery and found her resting in the postnatal ward. The postnatal nurse was passing out medications and told me that the patient was all right but that her vital signs had not yet been taken today. I quickly looked over her chart and noted that Lwanja wrote, "check vital signs regularly" but couldn't find even a single set of vital signs since the time of her surgery yesterday. Considering that there is one postnatal nurse for close to a hundred patients, this comes as no surprise. As I was standing near her bed, the nursing matron (i.e. the charge nurse of the hospital) came and told me that someone tested the autoclave machine (the machine that sterilizes all the instruments used in surgery for both Bottom and Kamuzu Central Hospital) and found that it was actually not successfully sterilizing anything. At this point there is only one autoclave so it cannot be put out of commission until fixed. There once was a functioning autoclave at Bottom Hospital but it has not been working for some time for its intended purpose. However, like so many other things, it has gained another use, while it sits waiting for repairs, staff have been using it as a microwave to warm lunches and fries.
All I can say, with a bit of awe and horror, is that life is certainly tenacious.
Yesterday I was assigned to theatre at Bottom. I went in to receive a baby with cord prolapse and came out with two very small but screaming little boys. I returned to the labor ward for a while and ended up next to a woman whose baby's heart rate kept dropping, but when we called theatre to see if an emergency section for fetal distress would be possible, we found that they were in the process of sectioning another woman. That woman's baby had died in-utero because she entered labor with her baby in an impossible position and didn't get to the hospital in time to have a section while the baby was still alive. I was called back to theatre to receive her dead baby and the dead baby of a 24 year-old woman whose uterus had ruptured after spending three unsuccessful days with a traditional birth attendant. I wish all of you, midwives, physicians, watchers of ER, Americans, could just catch a glimpse of the theatre.
The room itself is small and basic. One wall has windows that open to the outside, though which cracks of daylight and fresh air seep in. A simple bed occupies center stage and a small resuscitare without an overhead heater for the baby stands off to the side. There is a machine for monitoring the patient's vital signs and an electrical suction for the woman. A small foot pump suction sits next to the baby's resuscitare besides two oxygen concentrators . There is a cabinet for various syringes and tubes, a sink, a baby scale, and a couple tables holding gloves sutures, sterile packets, and other assorted items. As for the staff, all of us are gowned in theatre attire made from jean material. Everything is reusable - except for the hats and shoe covers which are always in short supply. Often we use plastic aprons tied around our heads and feet - picture everyone with white garbage bags on their heads and feet. Other times old patient gowns (donated, I imagine, by people who logically envisioned these gowns being used by patients) are used by surgeons when they run out of theatre attire. Sterile draps are also made from the jean fabric and many have quite a few holes. The scene strikes me alternately as commical, a bit depressing, or as a great illustration of people's inventive solution to lack of resources, depending on my frame of mind.
Half-way through the surgery yesterday, the shifts changed so a new anestethist came to replace the one who worked during the day. He received a few laughs as he entered the theatre. His creative solution to the absence of theatre hats was to use a carboard box. (Despite the laughs he didn't change his "hat.")
Lwanja, the senior clinical officer on staff conducted the surgery. After the intial cut through her abdomen the baby's hand emerged, confirming a severe rupture, and a stench filled the room confirming necrosis.
Throughout the surgery the theatre nurse just kept saying, "Poor, Malawians, poor, Malawians."
The room soon filled with flies and I wondered momentarily why there are never flies in the hospitals in the US.
Everything went smoothly and everyone agreed that she was lucky. She is 24 years old, she came close to losing her life but she didn't. She lost her uterus and her unborn child but she has a living child.
(When the surgery was done I returned to labor ward and found that the woman with fetal distress had delivered a healthy girl with the help of a vacuum.)
This morning I went to the hosptial to check on the woman who had the surgery and found her resting in the postnatal ward. The postnatal nurse was passing out medications and told me that the patient was all right but that her vital signs had not yet been taken today. I quickly looked over her chart and noted that Lwanja wrote, "check vital signs regularly" but couldn't find even a single set of vital signs since the time of her surgery yesterday. Considering that there is one postnatal nurse for close to a hundred patients, this comes as no surprise. As I was standing near her bed, the nursing matron (i.e. the charge nurse of the hospital) came and told me that someone tested the autoclave machine (the machine that sterilizes all the instruments used in surgery for both Bottom and Kamuzu Central Hospital) and found that it was actually not successfully sterilizing anything. At this point there is only one autoclave so it cannot be put out of commission until fixed. There once was a functioning autoclave at Bottom Hospital but it has not been working for some time for its intended purpose. However, like so many other things, it has gained another use, while it sits waiting for repairs, staff have been using it as a microwave to warm lunches and fries.
All I can say, with a bit of awe and horror, is that life is certainly tenacious.
Thursday, December 01, 2005
Blessings
Doreen is 18 years old. She gave birth to Dalitso on the operating table on November 3, 2005. That was the last night shift I worked. Like my other nights spent at Bottom, it was an exercise in suffering - watching women in true agony without being able to assit them; my own tailor fit version of hell. I have such a clear image of Doreen, restless, in the fourth bed on the left side of the room, an IV line attached to her left arm, crying inconsolably, pleading for help, tormented hour after hour by strong contractions which failed to dilate her cervix past seven centimeters or move her baby down through her pelvis. Even by generous standards, her labor had already arrested by 4:30pm on the 2nd when I arrived, but Bottom only has one operating theatre and there was a woman with a ruptured uterus, ruptured bladder, and a dead baby ahead of her. Considering that Bottom occasionally shares one anesthetist with Central Hospital and that both the urologist and the consultant had to be called in from home, the first surgery took several hours. Unfortunately for Doreen, during that time a hemorrhaging pregnant woman arrived, bumping her once again to the back of the line.
There was nothing I could do. Every so often I would go and listen to the baby's heart, the quiet contender in the difficult battle. And, I would place a hand on her belly, feel it rise up - a stone under a thin layer of skin - as it ceaselessly tried to remove the now unwanted person from her small body. Finally, sometime after 4am, the theatre staff summoned Doreen. I went with her to receive the baby but when everyone was scrubbed and ready to begin, someone noticed that the baby's head was beginning to crown. Almost instantaneously, the theatre was vacated, leaving me alone to attend the delivery, resuscitate the baby, deliver the placenta, and suture Doreen's tear. I was annoyed by everyone's disappearance while I resuscitated the baby and Doreen lay unattended on the table. I was annoyed when I thought of them sleeping while I searched for everything needed for suturing. But, when the tasks were complete, I was grateful for their absence. I was grateful for the quiet; grateful for the uninterrupted opportunity to witness a woman falling instantly and deeply in love with her baby.
Doreen's transformation was complete. She entered theatre as a woman approaching death and left in a state of pure radiance. While it was just the three of us, Doreen smiled and talked to me rapidly in Chichewa - not at all bothered by the fact that I only understood ten percent of what she was saying. I did understand that she wanted me to name her baby and so with my foggy 4am mind, I rattled off all the Chewa names I could remember. She considered them thoughtfully and continued talking. After a while I took her and her baby boy back to the labor ward. She asked for my phone number, which I happily gave her, laughing to myself as I wondered how we would communicate without the aid of sign language. And then the work resumed. The night continued with all the expected and unexpected difficulties but every once in a while I'd look across the room and Doreen would flash me an enormous white smile.
On Thanksgiving, an appropriate day, Doreen called me. Luckily I was near a bilingual Malawian and with his help we agreed that we would meet the following Tuesday at Bottoam and that she would take me to her home. And so we did. We met at Bottom, me little Doreen, and chubby Dalitso.
When I asked what Dalitso means, she said in English, "Blessings, don't you remember? You named him?" We got in my car and she directed me through familiar and unfamiliar parts of Lilongwe, arriving at last at the house where she lives with 7 people and a handful of children. On the way I learned that her parents died when she was 12, that Dalitso's father is completely out of the picture, and that she still wants to finish secondary school but lacks money for school fees.
It was wonderful to spend the afternoon with Doreen, Dalitso, and their family in the place that envelopes much of their unfolding stories. It is difficult to describe what an honor it is when someone brings me home, introduces me to their family, lets me hold their baby, feeds me, tells me I am welcome, and does it all with joy and pride. It approaches divine. I will certainly return to visit and the school fees . . . covered.
There was nothing I could do. Every so often I would go and listen to the baby's heart, the quiet contender in the difficult battle. And, I would place a hand on her belly, feel it rise up - a stone under a thin layer of skin - as it ceaselessly tried to remove the now unwanted person from her small body. Finally, sometime after 4am, the theatre staff summoned Doreen. I went with her to receive the baby but when everyone was scrubbed and ready to begin, someone noticed that the baby's head was beginning to crown. Almost instantaneously, the theatre was vacated, leaving me alone to attend the delivery, resuscitate the baby, deliver the placenta, and suture Doreen's tear. I was annoyed by everyone's disappearance while I resuscitated the baby and Doreen lay unattended on the table. I was annoyed when I thought of them sleeping while I searched for everything needed for suturing. But, when the tasks were complete, I was grateful for their absence. I was grateful for the quiet; grateful for the uninterrupted opportunity to witness a woman falling instantly and deeply in love with her baby.
Doreen's transformation was complete. She entered theatre as a woman approaching death and left in a state of pure radiance. While it was just the three of us, Doreen smiled and talked to me rapidly in Chichewa - not at all bothered by the fact that I only understood ten percent of what she was saying. I did understand that she wanted me to name her baby and so with my foggy 4am mind, I rattled off all the Chewa names I could remember. She considered them thoughtfully and continued talking. After a while I took her and her baby boy back to the labor ward. She asked for my phone number, which I happily gave her, laughing to myself as I wondered how we would communicate without the aid of sign language. And then the work resumed. The night continued with all the expected and unexpected difficulties but every once in a while I'd look across the room and Doreen would flash me an enormous white smile.
On Thanksgiving, an appropriate day, Doreen called me. Luckily I was near a bilingual Malawian and with his help we agreed that we would meet the following Tuesday at Bottoam and that she would take me to her home. And so we did. We met at Bottom, me little Doreen, and chubby Dalitso.
When I asked what Dalitso means, she said in English, "Blessings, don't you remember? You named him?" We got in my car and she directed me through familiar and unfamiliar parts of Lilongwe, arriving at last at the house where she lives with 7 people and a handful of children. On the way I learned that her parents died when she was 12, that Dalitso's father is completely out of the picture, and that she still wants to finish secondary school but lacks money for school fees.It was wonderful to spend the afternoon with Doreen, Dalitso, and their family in the place that envelopes much of their unfolding stories. It is difficult to describe what an honor it is when someone brings me home, introduces me to their family, lets me hold their baby, feeds me, tells me I am welcome, and does it all with joy and pride. It approaches divine. I will certainly return to visit and the school fees . . . covered.
Monday, November 21, 2005
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.
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.
Thursday, November 10, 2005
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.
Wednesday, November 09, 2005
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.
Tuesday, November 01, 2005
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.
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.
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.”
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.”
Thursday, October 06, 2005
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.
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.
Tuesday, September 27, 2005
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.
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.
Thursday, September 22, 2005
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.
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.
Thursday, September 15, 2005
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.
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.
Tuesday, August 30, 2005
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.
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.
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