I met Martin three weeks ago. He was standing outside Shoprite (the South African grocery store chain) holding a thin stack of papers. As I was pulling out of the parking lot he approached my window and timidly said, “Excuse me I’m looking for a well-wisher.” I eyed him suspiciously and asked what he meant. He explained that he was looking for someone to pay his school fees. He had been accepted into a program at the Natural Resource College but had no one to pay his fees. His father is a farmer in the South, his mother died last year. He is one of 9 and has only one employed brother who is a primary school teacher. I told him to meet me at Bottom later in the week.
I thought about Martin occasionally during following days and decided without much debate that I would find a way to pay his fees. From our three minute conversation I had strong sense that he would excel if offered the opportunity. On Thursday afternoon Martin arrived at Bottom still carrying copies of his final grades, the results of the MSCE (the national test taken after high school), his acceptance letter from NRC, and a form listing the fees. We had planned to meet at 4:30, when the shift at Bottom ends, but on Thursday just after 4pm – as it often does – everything happened at once – hemorrhages, births, resuscitations so I walked out into the dark at 5:30 to find Martin waiting for me on the curb near my car.
We stopped by the bank and then I drove him home to the one bedroom house he shares with his brother, his brother’s wife and their three children. After a few minutes we all began to relax. Laston teased Martin and his wife, everyone laughed easily. Rosemary added to the conversation from the kitchen while cooking fish and nsima. Three year-old Roseby fell asleep on her dad’s lap before dinner. I left two hours later.
Saturday I returned to their house to check in with Martin about his first week and to give him the rest of the money for fees. He said it was a good start, he is getting used to the 7 kilometer bike ride he must make twice a day but it doesn’t leave him much time to visit the library and there are no books to take home. I promised that I would do everything possible to find funds for boarding next term (day classes are US$325/term while boarding is US$740/term).
I happened to have my computer in the car so we looked at pictures of the US and then Malawi, we all agreed that Malawi is a beautiful country. Martin and Laston have never been to the lake so we decided to make a trip in December. I laughed so much that my cheeks hurt (a rare feeling) and I left their house feeling light and happy. The kept telling me how grateful they are for my assistance to Martin but I feel equally blessed to have met them.
Tuesday, September 18, 2007
Suggestion for the EU
Bottom continues much as it has the whole time I have been here. Two weeks ago I had one day during which I attended 9 deliveries. That day we were particularly short-staffed - just two nurses - and there were a few hours during which I was alone with four students and 14 laboring women. In general, most development organizations are focused on capacity building and training; less on salaries/staffing/recruiting/retention of staff. With money spent in this way the few nurses and clinicians assigned to maternity (of course it is the same in all medical wards) rotate through one training program after another to improve their individual skill sets. There is a great deal of repetition among the topics but each organization teaches a slightly different protocol. As a result, I notice that people often revert to their own “non-standardized” techniques as soon as the trainings are completed. I do not believe training and capacity building are unnecessary, but with this as the primary approach the situation becomes almost comic. We can talk about monitoring labor and managing emergencies but when you walk into a labor ward and see two nurses with 14 patients, there is no feasible way all 14 women will receive good care, even if the nurses run frantically between the beds all day.
Last week while driving I heard a story on BBC Africa about the EU’s creation of Blue Cards. Apparently, with the aging of the European work force and the declining birth rates in many European countries it has been determined that Europe will need to attract skilled workers in order to support and build its economy. The Blue Card scheme (modeled after the US’s Green Card) will facilitate the entrance of skilled workers from Africa and Asia. While listening I was grateful that the interviewer shared my sentiment – WHAT ABOUT AFRICA AND ASIA?!!!!! - but despite his repeated attempts to engage the interviewee, that question passed unanswered.
How can we – the global community, especially the western world – consider ourselves proponents of human rights on one hand while with the other we skillfully divert the few resources (human in this case) away from the poorest of the world? How can we talk about improving access to health care and education via our development institutions and hope to be believed? In truth, what we are saying with these policies is that we will consider caring as long as it is not an inconvenience to us. Lucky for the wealthy, the poor are in general a silent group; unless you stand by their bedside you won’t hear their cries. Right now, in Malawi, we have a physician to population ratio of 1:6,500. Even with rocket boosters on their heels, the impact of training and capacity building will be limited.
I have another thought – perhaps a brilliant solution. I am just remembering another BBC story about training individuals with lower levels of education, skills that are normally provided by highly educated individuals. There are many examples of this in the health care sector in Africa, for example small shop owners in rural areas are taught how to diagnose common illnesses and to prescribe the correct medications. Ok, here’s the idea . . . why don’t we allow the unemployed unskilled people who are literally dying to get into Europe in, with these Blue Cards and train them to do these skilled jobs there. This way we are providing training, capacity building, and employment opportunities for many would remain unemployed in Africa and Asia, we are adding to the European work force, and we are not stealing doctors, nurses, or other “best and brightest” individuals away from their home countries where they are most needed.
Last week while driving I heard a story on BBC Africa about the EU’s creation of Blue Cards. Apparently, with the aging of the European work force and the declining birth rates in many European countries it has been determined that Europe will need to attract skilled workers in order to support and build its economy. The Blue Card scheme (modeled after the US’s Green Card) will facilitate the entrance of skilled workers from Africa and Asia. While listening I was grateful that the interviewer shared my sentiment – WHAT ABOUT AFRICA AND ASIA?!!!!! - but despite his repeated attempts to engage the interviewee, that question passed unanswered.
How can we – the global community, especially the western world – consider ourselves proponents of human rights on one hand while with the other we skillfully divert the few resources (human in this case) away from the poorest of the world? How can we talk about improving access to health care and education via our development institutions and hope to be believed? In truth, what we are saying with these policies is that we will consider caring as long as it is not an inconvenience to us. Lucky for the wealthy, the poor are in general a silent group; unless you stand by their bedside you won’t hear their cries. Right now, in Malawi, we have a physician to population ratio of 1:6,500. Even with rocket boosters on their heels, the impact of training and capacity building will be limited.
I have another thought – perhaps a brilliant solution. I am just remembering another BBC story about training individuals with lower levels of education, skills that are normally provided by highly educated individuals. There are many examples of this in the health care sector in Africa, for example small shop owners in rural areas are taught how to diagnose common illnesses and to prescribe the correct medications. Ok, here’s the idea . . . why don’t we allow the unemployed unskilled people who are literally dying to get into Europe in, with these Blue Cards and train them to do these skilled jobs there. This way we are providing training, capacity building, and employment opportunities for many would remain unemployed in Africa and Asia, we are adding to the European work force, and we are not stealing doctors, nurses, or other “best and brightest” individuals away from their home countries where they are most needed.
Personal Updates
Clement is now gone. He left for Ghana on August 16th and so we are already one month closer to our reunion. As for my prospects there, it seems that midwives are in great demand so I have already been told that it will be very easy for me to get a job in the hospital or even as a lecturer at the University, the only problem is that the salaries hover somewhere around $500/mo. We have received about half of Clement's tuition for this year, for which we are incredibly grateful, and our search for funding continues.
Clement started classes a couple weeks ago and has made a few friends. He says Kumasi is beautiful, green, hot, and busy. He is not such a big fan of the food but personally I’m excited about the spicy stews and fufu. We talk for a few minutes a couple times a week; it’s never enough. I’m eager for December and I am trying to remember that four months is not an eternity.
We have set the wedding date for December 29th, the middle of the rainy season. It will be held in the village where Clement’s paternal grandmother lives. My parents will come. Clement’s dad has promised to buy a cow. I could never visualize myself with the typical wedding but now this picture . . . drums, rain, mud, feasting, dancing, my parents, hundreds of villagers, friends, and my beloved, seems perfect.
After Clement left I got pneumonia. I never had a fever just a persistent worsening cough. I finally realized that I needed treatment when walking ten feet made my heart race and left me short of breath. It took me a couple weeks but I am now finally back to my usual routine with my usual energy/fatigue.
Clement started classes a couple weeks ago and has made a few friends. He says Kumasi is beautiful, green, hot, and busy. He is not such a big fan of the food but personally I’m excited about the spicy stews and fufu. We talk for a few minutes a couple times a week; it’s never enough. I’m eager for December and I am trying to remember that four months is not an eternity.
We have set the wedding date for December 29th, the middle of the rainy season. It will be held in the village where Clement’s paternal grandmother lives. My parents will come. Clement’s dad has promised to buy a cow. I could never visualize myself with the typical wedding but now this picture . . . drums, rain, mud, feasting, dancing, my parents, hundreds of villagers, friends, and my beloved, seems perfect.
After Clement left I got pneumonia. I never had a fever just a persistent worsening cough. I finally realized that I needed treatment when walking ten feet made my heart race and left me short of breath. It took me a couple weeks but I am now finally back to my usual routine with my usual energy/fatigue.
Manliness
Last weekend I visited a friend. When I saw her the previous week, she was recovering from malaria. This week as I got out of the car I noticed that her entire face was swollen. L is an extremely jovial person by nature despite the many tragedies that have scarred her life. Normally her eyes sparkle while she talks and punctuates her stories with laughter. Today when I asked her what happened she looked down and quietly said that her young brother beat her up. Her mother died some years ago and now both she and her brother live with their father. L is near 30 she was married and home raising her two children but after the death of her husband, she moved back with her father, and started school again. She is now one year away from her goal of finishing high school. Her 19-year-old brother dropped out of school after 6th grade, he is unemployed and according to L he passes time drinking and causing disturbances. Apparently their fight began when she put her body between his fists and her children.
While we were talking she pointed him out as one of two boys who stood talking a short distance in front of us. He was standing near my car and I asked her if she’d like me to run him over. She gave a weak smile and shook her head. I could feel my blood pressure rising as I watched him – still a child in appearance – approach a friend with a cocky swagger.
She said this was the second incident. The first time, he threw burning coals at her. I asked her if she wanted to call the police. In halting English she explained that it was very possible that the police would beat him to a state near death; this was a family matter; it was better that she just find another house and move. Of course that requires money which she doesn’t have. Her father won’t intervene because he considers her and her children a burden. Actually what she said with a shake of her head, when I asked if her father would help was, “He’s a man.” She used the same phrase when talking about her brother’s abusive behavior. I understand that L’s family is poor. I understand that her brother even with a high school education, would have minimal employment opportunities, and little hope of rising from the endemic poverty that defines his life. I understand that the system he was born into is structured to guarantee struggle rather than survival. I can understand that whether recognized consciously or experientially this social emasculation breeds anger. But, I cannot accept that this anger effects the concept of manliness such that the defining trait becomes physical strength and ability to force others into submission.
From L’s home I went to visit another girl whose baby I delivered two years ago. She is now 20 and over the past years has lived with three different relatives, all barely older than herself, all orphans with low levels of education, all with their own children to support, all finding her - at times - too much of a burden. That Saturday we met at her cousin E’s house. E is now 24, she has two children, no parents, and no high school diploma (I’m not sure if she has a junior high school certificate). M and I chatted and played with her son while waiting for E who also wanted to see me. Within 30 minutes E arrived wearing a strapless open-back shirt and glittering make-up in the company of three men who all drank beer out of opaque water bottles. E sat in a chair opposite me smiling warmly but looking visibly uncomfortable. The oldest of the three men engaged me in conversation; in a confident tone with polished English he told me about his job, his studies and his travel experiences in Europe. After a few minutes M abruptly stood and led me outside. She said she had not wanted to tell me because she didn’t think I would believe her, but she was glad that I could now see with my own eyes. M said she would not prostitute herself; she said when there is no food she doesn’t eat and her thin body corroborated her statement. E soon joined us outside; rushing to express bubbling emotions with her limited English she tripped over words for a few moments, then shrugged her shoulders sadly and said, “It’s a problem.” I just hugged her. Starvation is not a viable option.
After leaving I drove to Foodsworths to buy some bread and eggs. Foodsworths is a small grocery that carries many items which are otherwise difficult to find in Malawi (e.g.cake mix, oreos, sushi wrap) as well as common items. By western standards the grocery is quite basic, but on that Saturday morning it struck me as flagrantly extravagant. Expatriate families wandered the four aisles casually chatting and filling grocery carts with a sampling from the shelves. I bought a dozen eggs, flowers, and a loaf of bread. For hours afterwards I felt guilty about the dozen roses for which I paid $3. I felt exhausted, struggling in the middle, so aware of my privilege, my inadequacies, my fears, my desires to cling to comfort, my longing for joy not just for myself but also for L and M and E.
A few days later M called to tell me that E wants to start a small business but she has no capital and only an idea of what she might do. Tomorrow I will meet with a Malawian woman who used to run a vocational training center for former prostitutes.
While we were talking she pointed him out as one of two boys who stood talking a short distance in front of us. He was standing near my car and I asked her if she’d like me to run him over. She gave a weak smile and shook her head. I could feel my blood pressure rising as I watched him – still a child in appearance – approach a friend with a cocky swagger.
She said this was the second incident. The first time, he threw burning coals at her. I asked her if she wanted to call the police. In halting English she explained that it was very possible that the police would beat him to a state near death; this was a family matter; it was better that she just find another house and move. Of course that requires money which she doesn’t have. Her father won’t intervene because he considers her and her children a burden. Actually what she said with a shake of her head, when I asked if her father would help was, “He’s a man.” She used the same phrase when talking about her brother’s abusive behavior. I understand that L’s family is poor. I understand that her brother even with a high school education, would have minimal employment opportunities, and little hope of rising from the endemic poverty that defines his life. I understand that the system he was born into is structured to guarantee struggle rather than survival. I can understand that whether recognized consciously or experientially this social emasculation breeds anger. But, I cannot accept that this anger effects the concept of manliness such that the defining trait becomes physical strength and ability to force others into submission.
From L’s home I went to visit another girl whose baby I delivered two years ago. She is now 20 and over the past years has lived with three different relatives, all barely older than herself, all orphans with low levels of education, all with their own children to support, all finding her - at times - too much of a burden. That Saturday we met at her cousin E’s house. E is now 24, she has two children, no parents, and no high school diploma (I’m not sure if she has a junior high school certificate). M and I chatted and played with her son while waiting for E who also wanted to see me. Within 30 minutes E arrived wearing a strapless open-back shirt and glittering make-up in the company of three men who all drank beer out of opaque water bottles. E sat in a chair opposite me smiling warmly but looking visibly uncomfortable. The oldest of the three men engaged me in conversation; in a confident tone with polished English he told me about his job, his studies and his travel experiences in Europe. After a few minutes M abruptly stood and led me outside. She said she had not wanted to tell me because she didn’t think I would believe her, but she was glad that I could now see with my own eyes. M said she would not prostitute herself; she said when there is no food she doesn’t eat and her thin body corroborated her statement. E soon joined us outside; rushing to express bubbling emotions with her limited English she tripped over words for a few moments, then shrugged her shoulders sadly and said, “It’s a problem.” I just hugged her. Starvation is not a viable option.
After leaving I drove to Foodsworths to buy some bread and eggs. Foodsworths is a small grocery that carries many items which are otherwise difficult to find in Malawi (e.g.cake mix, oreos, sushi wrap) as well as common items. By western standards the grocery is quite basic, but on that Saturday morning it struck me as flagrantly extravagant. Expatriate families wandered the four aisles casually chatting and filling grocery carts with a sampling from the shelves. I bought a dozen eggs, flowers, and a loaf of bread. For hours afterwards I felt guilty about the dozen roses for which I paid $3. I felt exhausted, struggling in the middle, so aware of my privilege, my inadequacies, my fears, my desires to cling to comfort, my longing for joy not just for myself but also for L and M and E.
A few days later M called to tell me that E wants to start a small business but she has no capital and only an idea of what she might do. Tomorrow I will meet with a Malawian woman who used to run a vocational training center for former prostitutes.
Tuesday, August 07, 2007
A Weekend Away
Saturday morning we set off early to Clement’s mother’s village north of Salima to attend the initiation ceremony of his stepfather as chief. We arrived in Salima by 10am and while rushing around buying sugar, salt, cooking oil, and changing money to take to the village, someone called asking for a ride to the ceremony on Sunday. In our excitement we had set off a day early. Although a bit annoyed with ourselves we decided to enjoy the extra time. We spent several hours lounging on the beach and then left for the village by mid-afternoon.
Clement’s mom, sister, grandmother welcomed us with hugs and laughter and while they prepared the grilled fish, nsima, and okra leaves for our dinner we sat with Clement’s stepdad James, drank tobwa (a fermented, but in this case non-alcoholic, drink made from sprouted maize or millet and sugar), and discussed the ceremony. Apparently when the population of a village grows past a certain point, it is common that a certain group requests to break away and become their own village. Representatives of the group approach the chief with their request and offer the name of the individual they want as their chief (either a man or a woman). If the chief approves, the request is passed on to the Traditional Authority. Once they have the approval of the TA, preparations are begun, the initiate must pass through a training and counseling process, and must arrange for the food and entertainment during the ceremony. In James’ case the process took more than a year. Every now and then my attention would drift from the conversation to the dogs chasing and wrestling each other, a little girl skipping across to her home, a man arriving with a live goat and chicken tied to his bicycle, a cat hunting flies, a girl in a green dress hopping on one foot shadowed by a little sister trying to do the same. These were sweet scenes.
It is winter now in Malawi and the sun sets early; by 6pm the only visible light came from the flickering cooking fire around which the women chatted and the children coughed. We were served dinner inside by a paraffin lantern and then Clement’s grandmother joined us to talk. The majority of what they said slipped by me but I loved watching her wrinkles gather into a conspiratory grin as she spoke and then watching them both convulse with laughter. When he translated her stories they came across more tragic than funny but I realize that transforming sad stories into entertainment is a common skill among survivors, irrespective of their cultural context. She said her house collapsed on her during the winter and now there is only one corner remaining that shelters her from the weather. She sleeps in that corner but sometimes, during a hard rain, even that corner floods and she wakes up and fetches a bucket to chase out the water. Smiling she said she is ready to die; she is ready to rest.
That night Clement and I slept in his mother’s two room hut on a grass mat on the floor. As I drifted off a group of men and a group of women took turns singing outside and I wished I had brought a tape recorder.
In the morning we took his grandmother to town to buy her shoes, a head scarf, and some other small items, we also gave her the 5,000MK (US$35) she said it would cost to build her a new sturdy house. When we returned I left Clement in the hut and wandered towards the women. I photographed them cooking, chicken, goat, nsmia, and rice in a long row of pots over open fires. They teased me and asked me to cook nsima but Clement’s relatives efficiently and repeatedly guided me away from the work towards a chair or mat.
Clement’s mom, sister, grandmother welcomed us with hugs and laughter and while they prepared the grilled fish, nsima, and okra leaves for our dinner we sat with Clement’s stepdad James, drank tobwa (a fermented, but in this case non-alcoholic, drink made from sprouted maize or millet and sugar), and discussed the ceremony. Apparently when the population of a village grows past a certain point, it is common that a certain group requests to break away and become their own village. Representatives of the group approach the chief with their request and offer the name of the individual they want as their chief (either a man or a woman). If the chief approves, the request is passed on to the Traditional Authority. Once they have the approval of the TA, preparations are begun, the initiate must pass through a training and counseling process, and must arrange for the food and entertainment during the ceremony. In James’ case the process took more than a year. Every now and then my attention would drift from the conversation to the dogs chasing and wrestling each other, a little girl skipping across to her home, a man arriving with a live goat and chicken tied to his bicycle, a cat hunting flies, a girl in a green dress hopping on one foot shadowed by a little sister trying to do the same. These were sweet scenes.
It is winter now in Malawi and the sun sets early; by 6pm the only visible light came from the flickering cooking fire around which the women chatted and the children coughed. We were served dinner inside by a paraffin lantern and then Clement’s grandmother joined us to talk. The majority of what they said slipped by me but I loved watching her wrinkles gather into a conspiratory grin as she spoke and then watching them both convulse with laughter. When he translated her stories they came across more tragic than funny but I realize that transforming sad stories into entertainment is a common skill among survivors, irrespective of their cultural context. She said her house collapsed on her during the winter and now there is only one corner remaining that shelters her from the weather. She sleeps in that corner but sometimes, during a hard rain, even that corner floods and she wakes up and fetches a bucket to chase out the water. Smiling she said she is ready to die; she is ready to rest.
That night Clement and I slept in his mother’s two room hut on a grass mat on the floor. As I drifted off a group of men and a group of women took turns singing outside and I wished I had brought a tape recorder.
In the morning we took his grandmother to town to buy her shoes, a head scarf, and some other small items, we also gave her the 5,000MK (US$35) she said it would cost to build her a new sturdy house. When we returned I left Clement in the hut and wandered towards the women. I photographed them cooking, chicken, goat, nsmia, and rice in a long row of pots over open fires. They teased me and asked me to cook nsima but Clement’s relatives efficiently and repeatedly guided me away from the work towards a chair or mat.
The ceremony itself was not very exciting my standards, mostly because I could not understand what was being said. I enjoyed watching the crowd of a few hundred people and befriended several children seated near me who evidently found my presence more captivating than that of the TA. Clement told me later that the TA spoke about the roles of the chief, the importance of humility, the need to work with the people and to serve the people, the role of the chief’s spouse, and a bit on HIV/AIDS. Money was gathered for the new chief and for the Traditional Authority, Clement’s mom and stepdad were ceremoniously guided back to their hut, and the day concluded.
I know life in the village is difficult; it is also beautiful. I am grateful for the food and love and hospitality I was offered. I appreciate the value of each gift and will continue savoring them for time to come.
Monday, August 06, 2007
Punctuation
Thursday morning as I approached the door of Bottom Chikoti, one of the clinical officers, met me and told me that he had been called to see about a woman with a stuck breech. We walked in to find Msiska working with difficulty to extract the head of a baby whose limp body hung from it mother. The mother pushed, every vein in her face and neck expanding with effort, Msiska twisted and pulled, and a small crowd of students encircled them both. Finally Msiska was able to free the baby, the mother fell back, the crowd dispersed, I placed my stethoscope to the baby girl's cool chest and heard silence. I tried resuscitating her for a few minutes but after hearing about how long she had been stuck, I put down the bag and mask, wrapped her in her mother's cloth, and brought her to the bed for her mother to see.
Somehow as her body was born she rotated belly up; for a breech baby to deliver safely, she must be born so that as she emerges her belly is closest to her mother's spine. I was not in the room so I can't say why this happened, maybe the mother began delivering quickly without assistance, or maybe she was assisted but the midwife could not guide the baby to the proper position, or maybe she was simply left alone and found later with the baby in this position. I don't know how it happened but standing there in front of that pale motionless little girl I felt a wave of anger and hopelessness. This was the third baby who died in my first five days back in the labor ward. (Not counting a couple others who died later after surviving for a while in the nursery.) Each of them were preventable deaths. Each so final, so heavy. Each a permanent scar on the mothers' heart. More sadness, more pain in a world where life is already difficult. It is not my personal pain but the exhaustion and sorrow rested on my shoulders.
A few minutes later I found Rabecca sitting up on the first bed. I glanced over her chart. She was 24 years old, this was her fourth pregnancy but her previous three babies were all born very prematurely and died. The problem seemed to be that for some unknown reason Rabecca's cervix always began dilating early thus ending the pregnancy before the baby was ready to live outside of her. Fortunately this pregnancy, she was seen early on my Dr Meguid who had stitched her cervix closed and then removed the sutures only once the baby reached 37 weeks gestation. Just seeing her on the bed with her big belly was a hopeful sign.
The progress on her labor chart was not as hopeful. It seemed she had been stuck at 5 centimeters for some time and when I examined her - three hours after her last exam - I found her cervix still at five centimeters. I thought about the probable course, pitocin, possible c-section, days in the crowed post-natal ward. I put the thoughts aside and closed the curtains around her bed. I couldn't stand the thought of another sad story, regardless of the degree of sadness. I rubbed her back, watched her, and realized that her contractions were not very strong. I showed her how to stimulate her nipples (this helps release oxytocin, the hormone that causes uterine contractions). I stayed with her, kept the curtains closed, gave her water, and encouraged her. As we continued the nipple stimulation her contracts became stronger, I could tell she was exhausted, but she released herself completely to the waves of her body. Within 40 minutes her daughter was born, beautiful and pink. She let out a small cry and then looked around with calm. Rabecca beamed and snuggled her in close. I cleaned her up, helped her breastfeed then closed the curtains around them. Rabecca's birth carried me through most of the day. Everything I did was seasoned with the sweetness of knowing that woman can receive good care in this environment and they can have not only safe births but joyful and beautiful births.
Towards the end of the day, I noticed Ivy crying loudly on the last bed in the room. She labored with her third baby and a student stood by monitoring the baby's heart rate. At Bottom it is unusual for a woman laboring with her third baby to be so vocal. I placed my fetoscope on her belly and heard nothing but her own pulse. I asked two other midwives to check, they also heard nothing. I brought in the ultrasound machine and saw the baby's heart beating slowly maybe at 40 beats per minute, maybe at 20. I lost hope for the baby but an emergency c-section was ordered.
Thirty minutes later I was handed her baby; a large boy with no pulse. He did not respond to resuscitation. His head was molded in an unusual way and I thought for a minute that he had been positioned incorrectly inside but then the clinical officer conducting the c-section told us that the mother's uterus was ruptured. The uterus even as it was ripping continued contracting, pushing the baby - not out of the cervix - but out of the tear. This mother escaped with her life. I met her sister outside the theatre and asked a nurse to explain the situation. She was grateful. She saw the dead child. I went home ungrateful trying desperately to recapture the joy I felt with Rabecca. Trying desperately to make her the center and not merely punctuation.
At home I found Clement subdued. He said one of the students from his school had been hit by a car and killed the previous evening. He was a year behind Clement and they were not close, but friendly acquaintances. The students had just finished their final exams and this one had gone home to drop his belongings, then as he was returning to school, walking along the road in the dark, was struck by a car and killed. The driver brought him immediately to the emergency room and was met there by three close friends of the young man who happened to be on duty. They were unable to resuscitate their friend. He was one of four children, the only one to go to college, the hope of his parents.
Somehow as her body was born she rotated belly up; for a breech baby to deliver safely, she must be born so that as she emerges her belly is closest to her mother's spine. I was not in the room so I can't say why this happened, maybe the mother began delivering quickly without assistance, or maybe she was assisted but the midwife could not guide the baby to the proper position, or maybe she was simply left alone and found later with the baby in this position. I don't know how it happened but standing there in front of that pale motionless little girl I felt a wave of anger and hopelessness. This was the third baby who died in my first five days back in the labor ward. (Not counting a couple others who died later after surviving for a while in the nursery.) Each of them were preventable deaths. Each so final, so heavy. Each a permanent scar on the mothers' heart. More sadness, more pain in a world where life is already difficult. It is not my personal pain but the exhaustion and sorrow rested on my shoulders.
A few minutes later I found Rabecca sitting up on the first bed. I glanced over her chart. She was 24 years old, this was her fourth pregnancy but her previous three babies were all born very prematurely and died. The problem seemed to be that for some unknown reason Rabecca's cervix always began dilating early thus ending the pregnancy before the baby was ready to live outside of her. Fortunately this pregnancy, she was seen early on my Dr Meguid who had stitched her cervix closed and then removed the sutures only once the baby reached 37 weeks gestation. Just seeing her on the bed with her big belly was a hopeful sign.
The progress on her labor chart was not as hopeful. It seemed she had been stuck at 5 centimeters for some time and when I examined her - three hours after her last exam - I found her cervix still at five centimeters. I thought about the probable course, pitocin, possible c-section, days in the crowed post-natal ward. I put the thoughts aside and closed the curtains around her bed. I couldn't stand the thought of another sad story, regardless of the degree of sadness. I rubbed her back, watched her, and realized that her contractions were not very strong. I showed her how to stimulate her nipples (this helps release oxytocin, the hormone that causes uterine contractions). I stayed with her, kept the curtains closed, gave her water, and encouraged her. As we continued the nipple stimulation her contracts became stronger, I could tell she was exhausted, but she released herself completely to the waves of her body. Within 40 minutes her daughter was born, beautiful and pink. She let out a small cry and then looked around with calm. Rabecca beamed and snuggled her in close. I cleaned her up, helped her breastfeed then closed the curtains around them. Rabecca's birth carried me through most of the day. Everything I did was seasoned with the sweetness of knowing that woman can receive good care in this environment and they can have not only safe births but joyful and beautiful births.
Towards the end of the day, I noticed Ivy crying loudly on the last bed in the room. She labored with her third baby and a student stood by monitoring the baby's heart rate. At Bottom it is unusual for a woman laboring with her third baby to be so vocal. I placed my fetoscope on her belly and heard nothing but her own pulse. I asked two other midwives to check, they also heard nothing. I brought in the ultrasound machine and saw the baby's heart beating slowly maybe at 40 beats per minute, maybe at 20. I lost hope for the baby but an emergency c-section was ordered.
Thirty minutes later I was handed her baby; a large boy with no pulse. He did not respond to resuscitation. His head was molded in an unusual way and I thought for a minute that he had been positioned incorrectly inside but then the clinical officer conducting the c-section told us that the mother's uterus was ruptured. The uterus even as it was ripping continued contracting, pushing the baby - not out of the cervix - but out of the tear. This mother escaped with her life. I met her sister outside the theatre and asked a nurse to explain the situation. She was grateful. She saw the dead child. I went home ungrateful trying desperately to recapture the joy I felt with Rabecca. Trying desperately to make her the center and not merely punctuation.
At home I found Clement subdued. He said one of the students from his school had been hit by a car and killed the previous evening. He was a year behind Clement and they were not close, but friendly acquaintances. The students had just finished their final exams and this one had gone home to drop his belongings, then as he was returning to school, walking along the road in the dark, was struck by a car and killed. The driver brought him immediately to the emergency room and was met there by three close friends of the young man who happened to be on duty. They were unable to resuscitate their friend. He was one of four children, the only one to go to college, the hope of his parents.
Monday, July 30, 2007
Thinking of African Mothers
While I was home in the States, visiting my wonderful friends and family I had several conversations with people about starting a non-profit. I am not an organization person. I am a midwife. I love being a midwife. I feel passionately about caring for women, especially for women who often find care in scarce supply. I am not a manager or an administrator. (I feel that statement can and should be followed by a line of exclamation marks.) Over the past two years I certainly feel I have been a funnel for many people’s goodwill and resources but my efforts have lacked order. I described to one friend all my little projects as a spewing, simmering, cauldron; there is a lot of good stuff happening but it is a bit out of control. Still the thought of starting a non-profit scared and, honestly, scares me.
When I reached Austin, I reviewed my mother’s account of all the unsolicited contributions made by family, friends, and strangers over the past two years. The shocking grand total was US$20,000. My immediate thought was, "there is no way that I can handle that amount amount of money in an informal way." While in DC I talked to my friend Leanne who, I must interject, was the person who told me to be a midwife in the first place, meaning she has great instincts. She responded to my fear with excitement and said, “I am an organization person.” Her enthusiasm gave me a push. I returned to Austin and told my friend Sarah about my thoughts; she mentioned that in the building where she works there is a Non-Profit Center that helps people set up non-profits. She made me an appointment. On Tuesday morning I met Sandy who has been setting up non-profits and assisting them for 25 years, surprisingly he also knew quiet a lot about Malawi and midwives. That night, serendipitously, I opened a donation check from a friend for $2,000 - more than enough to cover Sandy’s fees and the IRS fees. The next requirement was a volunteer board of three. I had myself, Leanne, and I called my friend Heidi who is a social worker and has experience with blossoming non-profits as well as community work with teens and moms. She agreed. The stars aligned and the African Mothers Health Initiative was born.
At the moment we have a bank account with almost $12,000. (Sandy has applied for tax-deductible status which he says may take up to nine months but will be retroactive to the date that we filed.) We are working on a website. I need to set up a sister organization here in Malawi before I leave to carry out the work legally. My friend Mrs. Namaleu – the nurse who works on the malnutrition ward – has agreed to continue the projects I have begun. She is two years past the date when she intended to retire but had no other alternative for employment. For the moment we will continue supplying formula for infant orphans, visit those little ones at home as well as any severely ill women during postpartum period, continue the feeding program, and pay school fees. This is where we will start and depending on how things develop I would like to expand. My vision is broadly and basically to provide women with quality care during pregnancy, delivery, and in the postpartum and to ensure that children also receive such care – with particular attention to the ages 0 to 5. At the center of this work I also want to hold the value of honoring people above numbers, lives above cost-effectiveness, and care for women and children above all else.
If anyone is interested in donating. You can send checks made out to the African Mothers Health Initiative to 6808 Belford Dr. Takoma Park, MD 20912. A couple friends are helping me with a website so hopefully that will be up within the month. There is a lot to be done before December.
When I reached Austin, I reviewed my mother’s account of all the unsolicited contributions made by family, friends, and strangers over the past two years. The shocking grand total was US$20,000. My immediate thought was, "there is no way that I can handle that amount amount of money in an informal way." While in DC I talked to my friend Leanne who, I must interject, was the person who told me to be a midwife in the first place, meaning she has great instincts. She responded to my fear with excitement and said, “I am an organization person.” Her enthusiasm gave me a push. I returned to Austin and told my friend Sarah about my thoughts; she mentioned that in the building where she works there is a Non-Profit Center that helps people set up non-profits. She made me an appointment. On Tuesday morning I met Sandy who has been setting up non-profits and assisting them for 25 years, surprisingly he also knew quiet a lot about Malawi and midwives. That night, serendipitously, I opened a donation check from a friend for $2,000 - more than enough to cover Sandy’s fees and the IRS fees. The next requirement was a volunteer board of three. I had myself, Leanne, and I called my friend Heidi who is a social worker and has experience with blossoming non-profits as well as community work with teens and moms. She agreed. The stars aligned and the African Mothers Health Initiative was born.
At the moment we have a bank account with almost $12,000. (Sandy has applied for tax-deductible status which he says may take up to nine months but will be retroactive to the date that we filed.) We are working on a website. I need to set up a sister organization here in Malawi before I leave to carry out the work legally. My friend Mrs. Namaleu – the nurse who works on the malnutrition ward – has agreed to continue the projects I have begun. She is two years past the date when she intended to retire but had no other alternative for employment. For the moment we will continue supplying formula for infant orphans, visit those little ones at home as well as any severely ill women during postpartum period, continue the feeding program, and pay school fees. This is where we will start and depending on how things develop I would like to expand. My vision is broadly and basically to provide women with quality care during pregnancy, delivery, and in the postpartum and to ensure that children also receive such care – with particular attention to the ages 0 to 5. At the center of this work I also want to hold the value of honoring people above numbers, lives above cost-effectiveness, and care for women and children above all else.
If anyone is interested in donating. You can send checks made out to the African Mothers Health Initiative to 6808 Belford Dr. Takoma Park, MD 20912. A couple friends are helping me with a website so hopefully that will be up within the month. There is a lot to be done before December.
Sunday, July 22, 2007
More Good News
Clement has been talking of becoming a Pediatrician since we met. Earlier this year he applied to several medical schools in various countries in Africa. While we were in the States he received news of his acceptance to Moi University in Kenya and then to Kwame Nkrumah University of Science and Technology in Kumasi, Ghana. After talking to many people and doing some research on our own, Clement decided to accept the offer of admission to KNUST. So . . . we will be moving to Ghana.
Classes start for Clement on August 17th this year. There is so much to do but we are experiencing another bureaucratic and infrastructure nightmare. With three weeks left to go, we have not received any additional information from the University. All our emails bounce back, our faxes won’t go through, and phone calls only make it through on average of 1 out of 30. It seems he will need a student visa but the closest Ghanaian High Commission is in Zimbabwe and no one answers the phone there to tell us what he needs or how to get the visa. The High Commission in South Africa, that we can reach, says that he must go through the one in Zimbabwe. We need the visa before buying the ticket. In short we are freaking out. Thankfully we have a small handful of people in Ghana and in the States who are also trying to help us so we are hopeful. We need a minor miracle.
We are also looking for funding for the six year program. Our plans are to return to Malawi and then for Clement to eventually specialize in Pediatrics. Clement wrote a letter to send to organizations/people who might be willing to help fund his education. On the chance that any of you have an idea I am including it below. I’ll feel some peace once I know he is there beginning classes and then I’ll have time to think about how I’ll manage to find work as a midwife in Ghana and wrap up my life here in Malawi. One of my friends, after hearing of all the recent updates, told me that I’m someone who does better on a rollercoaster than a merry-go-round. When my anxiety sits heavy on my chest I take a breath, think of that line, and smile, either way it’s just a ride.
Clement in his words . . .
Since a young age, I have aspired to become a medical doctor. Such inspirations are a result of my own life experiences. As both an in- and out-patient I learned that Malawi’s health care system though free, lacks many resources and this negatively impacts the overall quality and efficiency of care. Perhaps the most significant shortage is that of human resources. Imagine that you fall sick, but with great determination set out early - so that you may be among the first served - and arrive at the out-patient department by 6am. At 10am the clinician arrives and begins reviewing patients but before he reaches you, he leaves for the day. You have no choice but to return home having spent time and energy and perhaps precious money for transportation, without receiving any assistance. Sometimes luck is on your side and you receive a consultation, but once you leave with your prescription you find the dispensary closed, or the laboratory closed. As an in-patient you may stay in hospital for a week but only see a clinician twice and the nurse who may be caring for a ward full of sick individuals alone may not be able to carry out the clinician’s orders in a timely manner. This has been my experience, the experience of many family and friends, and of innumerable Malawians, simply because there are not enough medical practitioners to meet the even the basic needs of patients. Personally, these agonizing experiences ignited my passion to work with the poor and the sick.
After secondary school the path that opened to me was that of a clinical medicine programme. This three year programme was designed to cope with the extreme shortage of medical doctors. The concept of a fast track programme which trains individuals to examine, treat, prescribe medication, and conduct surgery in half the time it takes to train a physician was readily accepted in several southern Africa countries. During the process of obtaining my diploma as a Clinical Officer I came to better understand the problems faced by our health care system and gained a greater appreciation for the importance of pursuing a medical degree.
Malawi is a country of 13 million people of whom 60% are children under the age of 15. Currently there are less than 200 Malawian physicians. Malawi boasts the third worst maternal mortality rate in the world, high infant and child mortality rates, and a life expectancy that hovers around 40. The HIV/AIDS pandemic, although much milder than some neighboring sub-Saharan countries, still affects every industry including education, health, and agriculture as productive individuals fall ill and die. I recognize that I cannot change the system alone and that even though most needs are modest, they are also endless. But, I will provide one more pair of trained hands, and I know with great certainty that for the thousands of patients I will see and treat during my career as a physician, this is a significant contribution. I also understand that after three years of training my knowledge of disease processes and my clinical skills are limited. I see great need and value in further education. Malawians though poor – perhaps because they are poor and more likely to die young - deserve excellent care; I experience a constant thirst for knowledge in order to serve the population more efficiently.
In the course of my departmental rotations I fell in love with pediatric medicine. I feel this is a particularly vital course of study since the majority of Malawians are children and since they are undeniably the future of our nation. Even before I completed the clinical medicine programme I have been seeking a path to pursue my dream of becoming a pediatrician. I am now happy to report that I was recently accepted by Kwame Nkrumah University of Science and Technology in Ghana. Their medical programme lasts six years and will begin August 17th, 2007. My dreams are within sight but one hurdle remains. I am lacking the funds for tuition, which is about US$8,000 annually. For this reason I am appealing to you; for your support of my education. I will be grateful for any contribution and will be happy to send supporting documents and references upon request.
Classes start for Clement on August 17th this year. There is so much to do but we are experiencing another bureaucratic and infrastructure nightmare. With three weeks left to go, we have not received any additional information from the University. All our emails bounce back, our faxes won’t go through, and phone calls only make it through on average of 1 out of 30. It seems he will need a student visa but the closest Ghanaian High Commission is in Zimbabwe and no one answers the phone there to tell us what he needs or how to get the visa. The High Commission in South Africa, that we can reach, says that he must go through the one in Zimbabwe. We need the visa before buying the ticket. In short we are freaking out. Thankfully we have a small handful of people in Ghana and in the States who are also trying to help us so we are hopeful. We need a minor miracle.
We are also looking for funding for the six year program. Our plans are to return to Malawi and then for Clement to eventually specialize in Pediatrics. Clement wrote a letter to send to organizations/people who might be willing to help fund his education. On the chance that any of you have an idea I am including it below. I’ll feel some peace once I know he is there beginning classes and then I’ll have time to think about how I’ll manage to find work as a midwife in Ghana and wrap up my life here in Malawi. One of my friends, after hearing of all the recent updates, told me that I’m someone who does better on a rollercoaster than a merry-go-round. When my anxiety sits heavy on my chest I take a breath, think of that line, and smile, either way it’s just a ride.
Clement in his words . . .
Since a young age, I have aspired to become a medical doctor. Such inspirations are a result of my own life experiences. As both an in- and out-patient I learned that Malawi’s health care system though free, lacks many resources and this negatively impacts the overall quality and efficiency of care. Perhaps the most significant shortage is that of human resources. Imagine that you fall sick, but with great determination set out early - so that you may be among the first served - and arrive at the out-patient department by 6am. At 10am the clinician arrives and begins reviewing patients but before he reaches you, he leaves for the day. You have no choice but to return home having spent time and energy and perhaps precious money for transportation, without receiving any assistance. Sometimes luck is on your side and you receive a consultation, but once you leave with your prescription you find the dispensary closed, or the laboratory closed. As an in-patient you may stay in hospital for a week but only see a clinician twice and the nurse who may be caring for a ward full of sick individuals alone may not be able to carry out the clinician’s orders in a timely manner. This has been my experience, the experience of many family and friends, and of innumerable Malawians, simply because there are not enough medical practitioners to meet the even the basic needs of patients. Personally, these agonizing experiences ignited my passion to work with the poor and the sick.
After secondary school the path that opened to me was that of a clinical medicine programme. This three year programme was designed to cope with the extreme shortage of medical doctors. The concept of a fast track programme which trains individuals to examine, treat, prescribe medication, and conduct surgery in half the time it takes to train a physician was readily accepted in several southern Africa countries. During the process of obtaining my diploma as a Clinical Officer I came to better understand the problems faced by our health care system and gained a greater appreciation for the importance of pursuing a medical degree.
Malawi is a country of 13 million people of whom 60% are children under the age of 15. Currently there are less than 200 Malawian physicians. Malawi boasts the third worst maternal mortality rate in the world, high infant and child mortality rates, and a life expectancy that hovers around 40. The HIV/AIDS pandemic, although much milder than some neighboring sub-Saharan countries, still affects every industry including education, health, and agriculture as productive individuals fall ill and die. I recognize that I cannot change the system alone and that even though most needs are modest, they are also endless. But, I will provide one more pair of trained hands, and I know with great certainty that for the thousands of patients I will see and treat during my career as a physician, this is a significant contribution. I also understand that after three years of training my knowledge of disease processes and my clinical skills are limited. I see great need and value in further education. Malawians though poor – perhaps because they are poor and more likely to die young - deserve excellent care; I experience a constant thirst for knowledge in order to serve the population more efficiently.
In the course of my departmental rotations I fell in love with pediatric medicine. I feel this is a particularly vital course of study since the majority of Malawians are children and since they are undeniably the future of our nation. Even before I completed the clinical medicine programme I have been seeking a path to pursue my dream of becoming a pediatrician. I am now happy to report that I was recently accepted by Kwame Nkrumah University of Science and Technology in Ghana. Their medical programme lasts six years and will begin August 17th, 2007. My dreams are within sight but one hurdle remains. I am lacking the funds for tuition, which is about US$8,000 annually. For this reason I am appealing to you; for your support of my education. I will be grateful for any contribution and will be happy to send supporting documents and references upon request.
Thanks to the Scotts
This past week included my first days back at Bottom. Two months away from birth is long enough. I was eager to witness the covert strength of women surge forth and push their babies into the world. I was eager to see glimmering soft brown eyes as they opened to light and color for the first time. It was wonderful to be back; greeted warmly by the nurses, clinicians, maids, and security guards. The usual chaos reigned: many women, many students, few nurses precepting and overseeing care. Even so, my first three days back at Bottom passed without catastrophe. Wendesday, at some point I encouraged students to get the women up off their backs. Thursday morning I walked in to find two students with their patients in neighboring beds squatting and pushing - pink wriggling babies emerged almost simultaneously within minutes. Friday I assisted students deliver two sets of twins including one breech. I conducted a vacuum for fetal distress - the mother visibly exhausted and the baby’s heartbeat disturbingly slow - but the little girl, once on her mother’s belly, blinked and greeted her mom with a loud cry. The mother asked me for a name, I suggested Mwaye (fortune).
The good days are both gratifying and exhausting. The constant movement and noise in the labor ward at times reminds me of a force of nature, the environment is neither safe nor malevolent. It is the uncommitted energy and space affecting beginnings and endings; expectant mothers face an unpredictable course upon entering the grounds. A hospital should not mimic a force of nature. A hospital should protect dignity and uphold life. It should contain a safe space for women to give birth. It should facilitate necessary interventions (not obstruct them), and offer consistent care in all senses of the word.
There are many reasons why Bottom lingers in a place far from these simple descriptions but happily there will be major changes soon. Last December, Sir Tom Hunter - of the Clinton and Hunter Development Institute - spearheaded a Christmas fundraising drive in Scotland and raised two million pounds to put towards a new maternity hospital. Clinton and Hunter have on-going projects in Malawi but during one of his earliest visits to Malawi, Hunter was whisked off course and directed towards Bottom by an inspired woman who believed that if someone with the means and a conscious saw the conditions, he would feel compelled to help. She was right.
The first quick tour of Bottom led to meetings with the obstetricians, Dr. Chiudzu and Dr. Tarek Meguid, meetings with the representatives from the Ministry of Health, visits from a Scottish media crew to document the progress, and finally approved plans and a full bank account. Saturday a groundbreaking ceremony for a new maternity hospital was held with short speeches from Sir Tom Hunter, The Minister of Health, and The President. Hunter spoke about the construction as a step towards protecting the human rights of Malawian women and mentioned that the money was given with the fundamental understanding that Malawians know best how to care for Malawi.
I have never been as acutely aware of the impacts of a physical structure on human life as I have at Bottom. In the new plans self contained examination rooms will increase possibility the probability of privacy and support. Self contained labor rooms, with enough space for a mother, sister, husband, or friend mean laboring women will have the option of bringing love into space where they give birth. Multiple operating rooms will mean that one life will never have to be weighed against another; a distressed woman over another woman’s distressed baby. The location of the hospital on the grounds of Kamuzu Central Hospital will mean that women who have hemorrhaged will not need to wait hours to receive blood or to be transported to the ICU. The physical structure will make humane care possible. The new hospital will be named after the President’s late wife Ethel waMutharika, a great advocate for Malawian women and mothers.
The good days are both gratifying and exhausting. The constant movement and noise in the labor ward at times reminds me of a force of nature, the environment is neither safe nor malevolent. It is the uncommitted energy and space affecting beginnings and endings; expectant mothers face an unpredictable course upon entering the grounds. A hospital should not mimic a force of nature. A hospital should protect dignity and uphold life. It should contain a safe space for women to give birth. It should facilitate necessary interventions (not obstruct them), and offer consistent care in all senses of the word.
There are many reasons why Bottom lingers in a place far from these simple descriptions but happily there will be major changes soon. Last December, Sir Tom Hunter - of the Clinton and Hunter Development Institute - spearheaded a Christmas fundraising drive in Scotland and raised two million pounds to put towards a new maternity hospital. Clinton and Hunter have on-going projects in Malawi but during one of his earliest visits to Malawi, Hunter was whisked off course and directed towards Bottom by an inspired woman who believed that if someone with the means and a conscious saw the conditions, he would feel compelled to help. She was right.
The first quick tour of Bottom led to meetings with the obstetricians, Dr. Chiudzu and Dr. Tarek Meguid, meetings with the representatives from the Ministry of Health, visits from a Scottish media crew to document the progress, and finally approved plans and a full bank account. Saturday a groundbreaking ceremony for a new maternity hospital was held with short speeches from Sir Tom Hunter, The Minister of Health, and The President. Hunter spoke about the construction as a step towards protecting the human rights of Malawian women and mentioned that the money was given with the fundamental understanding that Malawians know best how to care for Malawi.
I have never been as acutely aware of the impacts of a physical structure on human life as I have at Bottom. In the new plans self contained examination rooms will increase possibility the probability of privacy and support. Self contained labor rooms, with enough space for a mother, sister, husband, or friend mean laboring women will have the option of bringing love into space where they give birth. Multiple operating rooms will mean that one life will never have to be weighed against another; a distressed woman over another woman’s distressed baby. The location of the hospital on the grounds of Kamuzu Central Hospital will mean that women who have hemorrhaged will not need to wait hours to receive blood or to be transported to the ICU. The physical structure will make humane care possible. The new hospital will be named after the President’s late wife Ethel waMutharika, a great advocate for Malawian women and mothers.
Friday, July 13, 2007
A Little More Patience
I know I've been MIA for months and it's really inexcusable but I beg for just a little more patience. I promise stories are on the way. So much is happening, my head is spinning.
Tuesday, May 29, 2007
A Beginning
Clement and I are engaged. We have been talking about marriage for a while, Clement actually asked me before the trip but I requested a re-do which led to several conversations about expectations surrounding the engagement. In Malawi engagement is a process. After the couple decides that they want to become engaged, they each confide in an uncle, the uncles meet and assess the potential partner, then report to the parents, at that point - if everyone is satisfied - there are larger family discussions followed by a formal engagement ceremony. Clement asked me how people become engaged in the States. I told him about the ring and asking the woman's parents for a blessing, then about how the guy kneels down and asks the question, of course in a beautiful memorable setting. Frankly, it sounds a bit silly and regimented. I told him to forget about the ring. Clearly he has my parents' blessing since they've been telling people for weeks that we are engaged. I felt the kneeling part was unnecessary, but I liked the idea of a nice moment in which I was awake. How it happened. . . I was on the couch typing emails, Clement was sitting across from me in a chair studying his new phone and he asked, "So, can we get engaged?" I know he is the one I want to share my life with and I realized that I don't need Hallmark or Hollywood to direct the beginning, I just want to begin. The phone and computer were put aside and the moments after were wonderful.
Sunday, May 27, 2007
Out of Range
Clement and I are in the States. After 26 months I stepped into JFK and back into the whirlwind of life here in the US. Two years is a significant chunk of time and before the trip I worried a bit about the possibility of reverse culture shock. I anticipated at least one emotional breakdown - perhaps in a grocery store or Times Square or my parents' house. But in reality, the joyful reunions with beloved friends and family eclipsed the mundane obscenities of American consumer culture. The humming cities became mere backdrops; familiar and mostly pleasant dreams.
This is Clement's first trip abroad and so he has a greater right to culture shock but because he is such a calm person I tend to forget that everything is new, especially riding the subway and watching Spiderman 3 in an Imax theatre. In general it has been wonderful to be able to show him my world and introduce him to my friends and family. My favorites of his firsts were: viewing New York from the observation deck of the Empire States building, dipping our fingers into the ocean in San Francisco and tasting the sea, and driving through the quiet city streets in Austin at night.
For me the best part has been time with friends and family. I really missed them. Months ago I emailed my eleven midwifery classmates and told them I would be in the Bay Area. They rented a house in Point Reyes and ten of them drove and flew from all over for a four day weekend. Food, chocolate, wine, stories, laughter, and love were abundant. (Clement was spared and spent the weekend with my dear friend Apur and his partner Sabrina). I spent the following weekend camping in Big Sir with three dear friends. The joy exceeds all my pre-trip fantasies. I have amazing friends.
I also missed places. I missed San Francisco, the smells from coffee shops and bakeries I used to bike by in the mornings, the parks, the hills, the ocean, the bridge, the visual feasts. I missed Austin, the warm nights, the sounds of birds and bugs, the green hills (unfortunately now spotted with many more condos and less green). We are in Austin now with my parents; my personal epicenter of warmth and love. Clement will leave Sunday. I still have another month here. I will travel to North Carolina for a wedding, Washington DC, Detroit to visit my dad's family, Austin again, Boston, then New York and finally back to Malawi. I feel blessed beyond words. I also feel that I still belong in Africa but I hope to visit again next year.
This is Clement's first trip abroad and so he has a greater right to culture shock but because he is such a calm person I tend to forget that everything is new, especially riding the subway and watching Spiderman 3 in an Imax theatre. In general it has been wonderful to be able to show him my world and introduce him to my friends and family. My favorites of his firsts were: viewing New York from the observation deck of the Empire States building, dipping our fingers into the ocean in San Francisco and tasting the sea, and driving through the quiet city streets in Austin at night.
For me the best part has been time with friends and family. I really missed them. Months ago I emailed my eleven midwifery classmates and told them I would be in the Bay Area. They rented a house in Point Reyes and ten of them drove and flew from all over for a four day weekend. Food, chocolate, wine, stories, laughter, and love were abundant. (Clement was spared and spent the weekend with my dear friend Apur and his partner Sabrina). I spent the following weekend camping in Big Sir with three dear friends. The joy exceeds all my pre-trip fantasies. I have amazing friends.
I also missed places. I missed San Francisco, the smells from coffee shops and bakeries I used to bike by in the mornings, the parks, the hills, the ocean, the bridge, the visual feasts. I missed Austin, the warm nights, the sounds of birds and bugs, the green hills (unfortunately now spotted with many more condos and less green). We are in Austin now with my parents; my personal epicenter of warmth and love. Clement will leave Sunday. I still have another month here. I will travel to North Carolina for a wedding, Washington DC, Detroit to visit my dad's family, Austin again, Boston, then New York and finally back to Malawi. I feel blessed beyond words. I also feel that I still belong in Africa but I hope to visit again next year.
Friday, April 20, 2007
Water
This morning over my mug of tea I read this in the BMJ,
The Human Development Report estimates that the additional cost needed to achieve the millennium development goals on water and sanitation [i.e. to halve the number of people without access to safe drinking water and sanitation by 2015] is US$10billion a year - half what the developed world spends annually on mineral water.
Eshelby K. Dying for a Drink. BMJ 24 Mar 2007; 334: 610-612.
It’s a short article worth reading, critiquing the development approach which has prioritized healthcare over clean water and sanitation and continues to fumble these goals despite proclaimed intent. [Just as a point of clarification, healthcare deserves to be priority but is inseparably linked to clean water and sanitation.] The article ultimately begs the question that is ever ready on my lips . . . where is our commitment? . . . can we justify these inequalities? . . . do we really want to try?
The Human Development Report estimates that the additional cost needed to achieve the millennium development goals on water and sanitation [i.e. to halve the number of people without access to safe drinking water and sanitation by 2015] is US$10billion a year - half what the developed world spends annually on mineral water.
Eshelby K. Dying for a Drink. BMJ 24 Mar 2007; 334: 610-612.
It’s a short article worth reading, critiquing the development approach which has prioritized healthcare over clean water and sanitation and continues to fumble these goals despite proclaimed intent. [Just as a point of clarification, healthcare deserves to be priority but is inseparably linked to clean water and sanitation.] The article ultimately begs the question that is ever ready on my lips . . . where is our commitment? . . . can we justify these inequalities? . . . do we really want to try?
Tuesday, March 20, 2007
An Anniversary
I remember the months leading up to my departure by the accompanying whirl of emotions. Coming to Malawi was a compulsion. I am not particularly brave. I only knew somehow that life would never be what it should if I stayed, so I bought my one-way ticket and prepared for a death of sorts - purging my possessions, pruning my life, giving my parents a small file with instructions for what-ifs and signing a power of attorney. I knew exactly what I was losing without any idea of what I would gain.
I cried at the airport. My dear friend Megan laughed at my tears reminding me I was following my heart. I, the small child, wanted to walk with her hand-in-hand all the way to the gate. Instead we parted and I remained with only the echo of her gentle laughter for strength.
I knew once I left the States my life would change forever. I could visualize a line – thin and definite – set in space and time. Some days I saw a thread, other days a finger run through sand but regardless of the image I knew my always comfortable and often happy life would change. Perhaps the woman I would become would not want to return to that life, perhaps she would be unable to return. She – that unknown woman and her life – frightened me.
In some ways I was right, there have been many changes. Two years have passed. I miss my friends and family immensely but I feel no need to leave Malawi. I have found great love. I have cried to exhaustion many times. I am content. At times I am devastated, at times angry and tortured, at times humbled, at times filled with peace and light. The force that brought me here roots me to this spot. As I drove last weekend from Lilongwe to Zomba – the road twisting over rolling green fields towards distant blue mountains, neat village homes clustered along the way – I thought, “This is a beautiful country and I am grateful to be here.”
In other deeper ways I have not changed at all. I am the same person I was at five although my eyes have seen much more. My hands have held much more. My heart holds much more. Still inside, the mix of emotions feels the same. The internal voice remains unchanged. The sequence of thoughts leads me along a well-worn path. I wonder how many lifetimes it takes to progress, to transform experience into wisdom, to love without ego, to perceive the world differently, not simply to act differently but to see differently? To believe differently?
I cried at the airport. My dear friend Megan laughed at my tears reminding me I was following my heart. I, the small child, wanted to walk with her hand-in-hand all the way to the gate. Instead we parted and I remained with only the echo of her gentle laughter for strength.
I knew once I left the States my life would change forever. I could visualize a line – thin and definite – set in space and time. Some days I saw a thread, other days a finger run through sand but regardless of the image I knew my always comfortable and often happy life would change. Perhaps the woman I would become would not want to return to that life, perhaps she would be unable to return. She – that unknown woman and her life – frightened me.
In some ways I was right, there have been many changes. Two years have passed. I miss my friends and family immensely but I feel no need to leave Malawi. I have found great love. I have cried to exhaustion many times. I am content. At times I am devastated, at times angry and tortured, at times humbled, at times filled with peace and light. The force that brought me here roots me to this spot. As I drove last weekend from Lilongwe to Zomba – the road twisting over rolling green fields towards distant blue mountains, neat village homes clustered along the way – I thought, “This is a beautiful country and I am grateful to be here.”
In other deeper ways I have not changed at all. I am the same person I was at five although my eyes have seen much more. My hands have held much more. My heart holds much more. Still inside, the mix of emotions feels the same. The internal voice remains unchanged. The sequence of thoughts leads me along a well-worn path. I wonder how many lifetimes it takes to progress, to transform experience into wisdom, to love without ego, to perceive the world differently, not simply to act differently but to see differently? To believe differently?
A Name Change
Several weeks ago I received another unwanted phone call. Just before 7am Mrs. Manga called to tell me that 8-month-old Memory had died. Instantly I felt devastated, exhausted, and furious with myself. Eight months previously Memory’s mother had died hours after the premature birth. Mrs. Manga - the employer of Memory’s mother - kindly took it upon herself to help as much as she could. She gave the grandmother a room, money for food, blankets and clothes for the baby but was still unable to afford the necessary formula. So, I bought the formula, they cared for the baby, and in my periodic visits I watched Memory transform from a delicate baby of 1kg into a healthy infant.
The day Memory was admitted into the hospital, Mrs Manga called me. I visited several days later and found her hot, listless, and breathing quickly. The clinicians had her on a regimen of anti-malarials and antibiotics. I felt satisfied with her care, handed her grandmother more formula and left. A week or so later Mrs Manga called to let me know that Memory had been discharged but that the fever continued. She wanted to take Memory to another hospital. I never followed up. That was one week before I received the phone call.
When I hung up the phone I cried until my eyes were red and swollen, angry at myself and the world for failing once again. I went to her funeral, I sobbed with the women, and watched men lower another tiny casket into the Earth. Why can’t we stop this?!
The same week Memory died, the President came with presidential fanfare to cut the ribbon at the new Lighthouse Clinic. HIV is hitting Malawi hard, of the almost 13 million Malawians it is estimated that 1 million are AIDS orphans and in response donors and the government are rushing to stem the tide, channeling resources to increase access to testing, counseling and anti-retro viral therapy. The original Lighthouse clinic, which serves as a center for counseling, testing, and treatment, was built behind KCH several years ago. It is a well-run but completely overwhelmed clinic (it is not uncommon for someone to wait most of the day to be seen). The new Lighthouse will hopefully relieve some of the burden and provide easier access for those living near Bottom. Structurally it is a simple but beautiful clinic. Clearly well thought-out, the facilities include a snack bar as well as a touch-screen computer system for tracking patients and monitoring their treatment.
HIV/AIDS deserves attention, activism, and research. Individuals suffering with the disease deserve compassionate care and treatment. Families and communities need support and education. Still, somehow I feel bitter. What about the women and babies? Maternal mortality is not a new problem. The outrageously high infant mortality rate is not new. Maternal and infant mortality offer no new and interesting challenges for epidemiology research, no new possibilities for fancy pharmaceuticals. We know what is killing these women and their babies. It is the same constellation of conditions that has killed women and babies throughout time.
The new beautiful Lighthouse is located directly behind Bottom Hospital and to access it you must walk through Bottom, past the collection of buildings whose numerous face-lifts no longer fool anyone. The day the President came, throngs of people lined the path through the hospital grounds to the clinic behind. Women wearing chitinges especially printed for the occasion danced and hooted along side drummers, while police and military personnel kept the crowd in neat even rows monitoring the entrance of those heading towards the clinic. No more than ten meters away from the festivities, women in the labor ward continued their work, focused only on the efforts of their bodies. That day, as usual, most of the women pushed their babies into the world with great effort and pain but without problem. That day, as usual, two women arrived with severe problems their babies dead, their own lives threatened.
I took blood samples from the women for the lab. The police nodded at me in my scrubs, with my stethoscope around my neck, and I walked through the crowd across the path from the labor ward to the lab. Minutes later I crossed back carrying 2 pints of blood.
I heard later that at the opening ceremony the President decided to change Bottom Hospital to Bwaila Hospital. Apparently the river running past the Hospital was once called Bwaila. Certainly Bwaila Lighthouse sounds much better than Bottom Lighthouse. I’m sure that many people will talk and write about the new Bwaila Lighthouse in the papers, hopefully in international news, and most likely in proposals. Bwaila matches the image of the clinic but obscures something else.
Last week I noticed that some of the nurses have started substituting Bwaila for Bottom on forms. I tried it out myself but one of the long-term clinical officers saw my note and with a deep throaty laugh said, “Joanne, Bwaila?! This is still Bottom.” Indeed it is. One of those women died that night. Another died the following day.
The day Memory was admitted into the hospital, Mrs Manga called me. I visited several days later and found her hot, listless, and breathing quickly. The clinicians had her on a regimen of anti-malarials and antibiotics. I felt satisfied with her care, handed her grandmother more formula and left. A week or so later Mrs Manga called to let me know that Memory had been discharged but that the fever continued. She wanted to take Memory to another hospital. I never followed up. That was one week before I received the phone call.
When I hung up the phone I cried until my eyes were red and swollen, angry at myself and the world for failing once again. I went to her funeral, I sobbed with the women, and watched men lower another tiny casket into the Earth. Why can’t we stop this?!
The same week Memory died, the President came with presidential fanfare to cut the ribbon at the new Lighthouse Clinic. HIV is hitting Malawi hard, of the almost 13 million Malawians it is estimated that 1 million are AIDS orphans and in response donors and the government are rushing to stem the tide, channeling resources to increase access to testing, counseling and anti-retro viral therapy. The original Lighthouse clinic, which serves as a center for counseling, testing, and treatment, was built behind KCH several years ago. It is a well-run but completely overwhelmed clinic (it is not uncommon for someone to wait most of the day to be seen). The new Lighthouse will hopefully relieve some of the burden and provide easier access for those living near Bottom. Structurally it is a simple but beautiful clinic. Clearly well thought-out, the facilities include a snack bar as well as a touch-screen computer system for tracking patients and monitoring their treatment.
HIV/AIDS deserves attention, activism, and research. Individuals suffering with the disease deserve compassionate care and treatment. Families and communities need support and education. Still, somehow I feel bitter. What about the women and babies? Maternal mortality is not a new problem. The outrageously high infant mortality rate is not new. Maternal and infant mortality offer no new and interesting challenges for epidemiology research, no new possibilities for fancy pharmaceuticals. We know what is killing these women and their babies. It is the same constellation of conditions that has killed women and babies throughout time.
The new beautiful Lighthouse is located directly behind Bottom Hospital and to access it you must walk through Bottom, past the collection of buildings whose numerous face-lifts no longer fool anyone. The day the President came, throngs of people lined the path through the hospital grounds to the clinic behind. Women wearing chitinges especially printed for the occasion danced and hooted along side drummers, while police and military personnel kept the crowd in neat even rows monitoring the entrance of those heading towards the clinic. No more than ten meters away from the festivities, women in the labor ward continued their work, focused only on the efforts of their bodies. That day, as usual, most of the women pushed their babies into the world with great effort and pain but without problem. That day, as usual, two women arrived with severe problems their babies dead, their own lives threatened.
I took blood samples from the women for the lab. The police nodded at me in my scrubs, with my stethoscope around my neck, and I walked through the crowd across the path from the labor ward to the lab. Minutes later I crossed back carrying 2 pints of blood.
I heard later that at the opening ceremony the President decided to change Bottom Hospital to Bwaila Hospital. Apparently the river running past the Hospital was once called Bwaila. Certainly Bwaila Lighthouse sounds much better than Bottom Lighthouse. I’m sure that many people will talk and write about the new Bwaila Lighthouse in the papers, hopefully in international news, and most likely in proposals. Bwaila matches the image of the clinic but obscures something else.
Last week I noticed that some of the nurses have started substituting Bwaila for Bottom on forms. I tried it out myself but one of the long-term clinical officers saw my note and with a deep throaty laugh said, “Joanne, Bwaila?! This is still Bottom.” Indeed it is. One of those women died that night. Another died the following day.
Wednesday, February 07, 2007
Purpose
It is incredibly difficult to accept that life and death are so intimately entwined. I do not know how to accept. I only stand and bear witness to the play of their relationship with a bit of awe and a bit of horror. As I watch, I notice - within me - respect growing slowly steadily. My hands are ready. I will offer what I can. The result is not of me. I have been told this and tell myself this for motives of self-preservation but I am also taught this by the miracles that happen under my fingers. They are not mine, either. Perhaps the true essence of my role – despite the movement, the internal struggle, the noise – is that of a witness; someone who continues to stand, to welcome, and to bid farewell.
Monday, February 05, 2007
Loss and Love
When I walked into the ward on Friday morning, 15 minutes passed before I saw Malika lying face down on a bare green mattress in a black winter coat and red underwear, still and grunting, her mother squatting to clean a puddle of blood from the floor with an old chitengi. The nurse said she had hemorrhaged. Before she started the next sentence I ran to get an IV, urinary catheter, and tubes for blood samples. Someone else brought the oxygen concentrator and another nurse searched the hospital to find a face mask or a nasal cannula. The whiteness inside her eyelids and of her gums reminded me of fair skin stretched tightly over clinched knuckles. She arrived the previous night, labored until early morning and delivered a stillborn, her second dead child, and then she bled. The few lines in her chart said she was given 10 units of Pitocin (the standard dose of oxytocin given to all women) nothing else. The night had been busy for the two nurses and the single clinical officer and Malika in the farthest corner of the room was dying inconspicuously.
After a few hours, three liters of fluid and 2 pints of blood, she looked around weakly, her original Hb of 2.3 (normal is 12-14) probably hovered somewhere between 4 and 5. Her mother handed her a cell phone which she accepted then returned. We started to hope. I went to theatre for a c-section and when I came back Deb told me Malika called the nurse and to say she had started bleeding again. I looked and saw a slow trickle of blood, the towel between her legs was soaked although Deb said she had just changed it. We called Dr Tarek Meguid. He came quickly, examined her, and then stood for long minutes debating whether to remove the uterus of a 23-year-old with no living children. I went to get more blood and order fresh frozen plasma and returned to find them in theatre. I felt a vague sense relief to know a decision had been made.
At that point I got caught up with Masauko who arrived with his wife and 2-year-old son. His son’s tongue and fingernails were also pale, his face, and hands, and feet swollen. Masauko said Peter refused to eat and had recently weaned. He looked malnourished. I took the family to Lisa who tenderly and slowly examined Peter, drew blood to check his Hb and gave them instructions to meet her in the hospital Saturday morning.
When I took Peter’s blood to the lab I found 3 bags of fresh frozen plasma for Malika precariously placed on the edge of a wooden table. I asked the lab technician what time they had arrived, he said before 1pm, it was now after 3:30. Trying to contain my fury I asked why they were still on the table. He responded that he went to lunch; the other lab technician added that someone from the ward said they would come to collect it. I reminded them that the woman was hemorrhaging and that her life depended on the blood products. They smiled meekly. I ran to theatre and was told that Malika had been transferred to the ICU at KCH. Luckily I found an ambulance outside and once I explained the situation to the driver, he promised he would not go into town to buy light bulbs as planned, but instead go straight to deliver the blood.
That night at dinner with friends Tarek said Malika had started producing urine. A hopeful sign.
Saturday morning I headed to KCH to meet Peter and his mom. On my way down the hall I stopped in the ICU. A concerned anesthetist sat at Malika’s bedside, he said she was no longer producing urine and he could not get the results of the labs he needed because the hospital had no reagents. She looked almost hopeless, unconscious, eyes half open, a ventilator breathing for her. I continued toward Pediatrics but before I found Peter, I found sister Namaleu with over 100 patients in the malnutrition ward on her third consecutive shift with no relief coming for the night shift or for the Sunday day shift. I returned to the hospital entrance and found Masauko’s wife, I brought them to Pediatrics where sister Namaleu stopped everything to weigh and exam the boy. She said he would be admitted for a minimum of three weeks. Confident that he was in good albeit overworked and exhausted hands, I left and went upstairs to the female ward to visit Clement’s aunt who had been admitted the day before. I found her, looking weak and a single nurse caring for the entire ward of over 80 patients. On my way out I met Lisa and together we peaked into the ICU again to see Tarek and the chief anesthetist fretfully discussing Malika.
I left the hospital and rushed to buy a crate of fanta orange and unfortunately a cake, which I planned to bake, my contribution to Grace’s (Frank’s daughter) first birthday party. From there I collected Clement and rushed to meet Deb, Zack, and Johan. Deb and Zack arrived on January 17th for 5-week visit with 3-month-old Johan. I began counting down the days to their arrival months ago but now I refuse to look at a calendar and see the steady approach of February 18th.
We had planned to drive to Ireen’s village and were determined to go despite the unrelenting rain and our late start. Mr. Nanthowa had shown up at Bottom the previous Monday with a bag of mangoes and cucumbers that he brought me on his bike 40 kilometers through the rain (later I learned that trip also involved fording a neck high river while carrying his bike over his head). Unfortunately I was at the Embassy but I asked the nurse who kindly called me to tell him I would come Saturday. I had told him several times that I would bring a surprise the next time I visited. I could hardly contain my excitement at the thought of his family seeing Deb with me.
Zack borrowed a four wheel drive vehicle and we set out. I usually arrive in the village in the morning and was certain Mr Nanthowa had given up hope but Clement insisted, “He still has hope.” The first 34 kilometers were slippery but thankfully uneventful but that 35th kilometer held on to us for a while. After consulting a few people walking the roads, we decided on what they claimed was the less slippery route but they forgot to warn us about the 50 yard stretch of new dirt with ditches on either side. At that point the Pajero slowly came to a stop and sank a few inches. Clement, Deb, and I jumped out of the car into the rain and rising muddy rivulets. We all laughed and Clement said, “Now this is getting good.” We dug with our hands, shoved grass and pieces of bush under the wheels, Zack rocked the car forward and back, and the rain came down. We continued laughing until our lips were blue and the twelve men who had appeared one-by-one struggle and failed again and again to dislodge the car. Finally, after about an hour, the car broke free and we, 14 men and 2 women shouted euphorically. Johan sleepily opened his eyes.
Back in the car Deb and I removed our clothes, wrapped our cold bodies in dry chitengis and laughed at the thought of showing up to a village wrapped only in a cloth. The rain continued but we made the last 5 kilometers without a problem. As we pulled up to the cluster of huts Mr Nanthowa emerged grinning ear to ear to welcome me. I took his arm, gently pulling him to where Deb and Johan were climbing down and said, “Mr. Nanthowa, your surprise. . .” Mr Nanthowa screamed joyfully, grabbed Johan and began dancing saying “CONGRATULATIONS, CONGRATULATIONS!” As the rest of us laughed histerically, poor startled Johan was passed down a sea of arms attached to smiling faces and loud voices.
Within minutes a fire was built. Ireen lent Deb and me shirts. I laughed and struggled to dress modestly - pulling dry clothes over wet skin while holding up the slipping chitengi - in a small room overflowing with people. They gave us hot tea and fresh cornbread. They asked us to stay the night. I wanted so much to curl up by that fire rather than face the rain and road again but I agreed when Deb, Zack, and Clement said it was time to go. They killed and plucked a chicken since we could not give them time to prepare it for us. Mr Nanthowa took me into another room, Mrs Nanthowa handed me a bag of peanuts and he said, “I don’t have the words to tell you how thankful I am.” I thought of him riding in the rain, fording the river, calling me his daughter. I could only smile and shake my head, I didn’t have the words. When I tell Clement about thing things Mr Nanthowa does he says, “that is love.” And I wonder how many people are capable offering such love and how many are blessed enough to receive it.
As the goodbyes were passed round and round Mr Nanthowa explained another route to Clement, but uncertain whether Clement truly would find the way Mr Nanthowa insisted repeatedly that he come with us a certain distance then walk home. We said no again and again and again but somehow he ended up sitting next to me in the car directing us back. At one point he led us straight across a field, and he was right, we would not have found the road. Finally about 6 kilometers from his village, he stepped out into the rain with his bare feet, and stood and waved until he receded in the distance and the fog of the windows and the dark of the setting sun.
On our way home as we passed the hospital we mentioned Malika but hurried towards hot showers and chicken dinner. Sunday I glanced towards the hospital but could not bear the thought of going to the ICU. I did not want to know. Monday morning I learned she had died Saturday night.
After a few hours, three liters of fluid and 2 pints of blood, she looked around weakly, her original Hb of 2.3 (normal is 12-14) probably hovered somewhere between 4 and 5. Her mother handed her a cell phone which she accepted then returned. We started to hope. I went to theatre for a c-section and when I came back Deb told me Malika called the nurse and to say she had started bleeding again. I looked and saw a slow trickle of blood, the towel between her legs was soaked although Deb said she had just changed it. We called Dr Tarek Meguid. He came quickly, examined her, and then stood for long minutes debating whether to remove the uterus of a 23-year-old with no living children. I went to get more blood and order fresh frozen plasma and returned to find them in theatre. I felt a vague sense relief to know a decision had been made.
At that point I got caught up with Masauko who arrived with his wife and 2-year-old son. His son’s tongue and fingernails were also pale, his face, and hands, and feet swollen. Masauko said Peter refused to eat and had recently weaned. He looked malnourished. I took the family to Lisa who tenderly and slowly examined Peter, drew blood to check his Hb and gave them instructions to meet her in the hospital Saturday morning.
When I took Peter’s blood to the lab I found 3 bags of fresh frozen plasma for Malika precariously placed on the edge of a wooden table. I asked the lab technician what time they had arrived, he said before 1pm, it was now after 3:30. Trying to contain my fury I asked why they were still on the table. He responded that he went to lunch; the other lab technician added that someone from the ward said they would come to collect it. I reminded them that the woman was hemorrhaging and that her life depended on the blood products. They smiled meekly. I ran to theatre and was told that Malika had been transferred to the ICU at KCH. Luckily I found an ambulance outside and once I explained the situation to the driver, he promised he would not go into town to buy light bulbs as planned, but instead go straight to deliver the blood.
That night at dinner with friends Tarek said Malika had started producing urine. A hopeful sign.
Saturday morning I headed to KCH to meet Peter and his mom. On my way down the hall I stopped in the ICU. A concerned anesthetist sat at Malika’s bedside, he said she was no longer producing urine and he could not get the results of the labs he needed because the hospital had no reagents. She looked almost hopeless, unconscious, eyes half open, a ventilator breathing for her. I continued toward Pediatrics but before I found Peter, I found sister Namaleu with over 100 patients in the malnutrition ward on her third consecutive shift with no relief coming for the night shift or for the Sunday day shift. I returned to the hospital entrance and found Masauko’s wife, I brought them to Pediatrics where sister Namaleu stopped everything to weigh and exam the boy. She said he would be admitted for a minimum of three weeks. Confident that he was in good albeit overworked and exhausted hands, I left and went upstairs to the female ward to visit Clement’s aunt who had been admitted the day before. I found her, looking weak and a single nurse caring for the entire ward of over 80 patients. On my way out I met Lisa and together we peaked into the ICU again to see Tarek and the chief anesthetist fretfully discussing Malika.
I left the hospital and rushed to buy a crate of fanta orange and unfortunately a cake, which I planned to bake, my contribution to Grace’s (Frank’s daughter) first birthday party. From there I collected Clement and rushed to meet Deb, Zack, and Johan. Deb and Zack arrived on January 17th for 5-week visit with 3-month-old Johan. I began counting down the days to their arrival months ago but now I refuse to look at a calendar and see the steady approach of February 18th.
We had planned to drive to Ireen’s village and were determined to go despite the unrelenting rain and our late start. Mr. Nanthowa had shown up at Bottom the previous Monday with a bag of mangoes and cucumbers that he brought me on his bike 40 kilometers through the rain (later I learned that trip also involved fording a neck high river while carrying his bike over his head). Unfortunately I was at the Embassy but I asked the nurse who kindly called me to tell him I would come Saturday. I had told him several times that I would bring a surprise the next time I visited. I could hardly contain my excitement at the thought of his family seeing Deb with me.
Zack borrowed a four wheel drive vehicle and we set out. I usually arrive in the village in the morning and was certain Mr Nanthowa had given up hope but Clement insisted, “He still has hope.” The first 34 kilometers were slippery but thankfully uneventful but that 35th kilometer held on to us for a while. After consulting a few people walking the roads, we decided on what they claimed was the less slippery route but they forgot to warn us about the 50 yard stretch of new dirt with ditches on either side. At that point the Pajero slowly came to a stop and sank a few inches. Clement, Deb, and I jumped out of the car into the rain and rising muddy rivulets. We all laughed and Clement said, “Now this is getting good.” We dug with our hands, shoved grass and pieces of bush under the wheels, Zack rocked the car forward and back, and the rain came down. We continued laughing until our lips were blue and the twelve men who had appeared one-by-one struggle and failed again and again to dislodge the car. Finally, after about an hour, the car broke free and we, 14 men and 2 women shouted euphorically. Johan sleepily opened his eyes.
Back in the car Deb and I removed our clothes, wrapped our cold bodies in dry chitengis and laughed at the thought of showing up to a village wrapped only in a cloth. The rain continued but we made the last 5 kilometers without a problem. As we pulled up to the cluster of huts Mr Nanthowa emerged grinning ear to ear to welcome me. I took his arm, gently pulling him to where Deb and Johan were climbing down and said, “Mr. Nanthowa, your surprise. . .” Mr Nanthowa screamed joyfully, grabbed Johan and began dancing saying “CONGRATULATIONS, CONGRATULATIONS!” As the rest of us laughed histerically, poor startled Johan was passed down a sea of arms attached to smiling faces and loud voices.
Within minutes a fire was built. Ireen lent Deb and me shirts. I laughed and struggled to dress modestly - pulling dry clothes over wet skin while holding up the slipping chitengi - in a small room overflowing with people. They gave us hot tea and fresh cornbread. They asked us to stay the night. I wanted so much to curl up by that fire rather than face the rain and road again but I agreed when Deb, Zack, and Clement said it was time to go. They killed and plucked a chicken since we could not give them time to prepare it for us. Mr Nanthowa took me into another room, Mrs Nanthowa handed me a bag of peanuts and he said, “I don’t have the words to tell you how thankful I am.” I thought of him riding in the rain, fording the river, calling me his daughter. I could only smile and shake my head, I didn’t have the words. When I tell Clement about thing things Mr Nanthowa does he says, “that is love.” And I wonder how many people are capable offering such love and how many are blessed enough to receive it.
As the goodbyes were passed round and round Mr Nanthowa explained another route to Clement, but uncertain whether Clement truly would find the way Mr Nanthowa insisted repeatedly that he come with us a certain distance then walk home. We said no again and again and again but somehow he ended up sitting next to me in the car directing us back. At one point he led us straight across a field, and he was right, we would not have found the road. Finally about 6 kilometers from his village, he stepped out into the rain with his bare feet, and stood and waved until he receded in the distance and the fog of the windows and the dark of the setting sun.
On our way home as we passed the hospital we mentioned Malika but hurried towards hot showers and chicken dinner. Sunday I glanced towards the hospital but could not bear the thought of going to the ICU. I did not want to know. Monday morning I learned she had died Saturday night.
Tuesday, January 30, 2007
Taken
Today during lunch a friend accompanied me to the headquarters of Chisomo Street Children’s Project. My intention was to talk to someone about Ganizani and friends/brothers who would be able to do a better job of researching their situation and background. Cosmas a nice Malawian in his late 20s greeted us and invited me to tell him what I knew about the boys. I told him about the boys in City Center and their house in Saint, about the conflicting stories of the whereabouts of their families, and the conflicting stories of their relationship to each other. When I finished Cosmas said, “Ganizani Nelson, both his parents are alive. He has been moving between relatives and may have finally left home due to the lack of freedom.” Apparently, he was in their system but preferred smoking marijuana to attending elementary school and was consequently kicked out. Cosmas struck me as a very patient and kind person with a strong no-nonsense streak. I was not really surprised by what I heard; it makes me laugh at myself and at Ganizani. I told Cosmas that next time I saw Ganizani I would let him know that we met – I’m sure he won’t be pleased by that fact. He’s 13. He deserves another chance and another but I need to be a little tougher. I think the new tactic will be the promise of food if and only if he goes back to the program. I am glad that there are social workers roaming the streets trying to get kids back into school and back into families.
Mostly Infruriating but Slightly Hilarous
Last August Clement submitted the paperwork and fees to apply for a passport. Our goal was to obtain it in time for him to travel to Zambia with my parents in October. In December he was told the passport should be ready soon. He went to Blantyre to collect it but after many phone calls and trips to various offices he reached his contact person who told him to go to Zomba. Dutifully he went to Zomba and was told that the person who had it was not around. They said they would bring it to Lilongwe. The guy came but there was no passport. A month later he went back to Blantyre and found out that his original contact left his job and the person who took over the position had been away but, “luckily just came back.” When Clement met that man he was told that his passport simply needed the signature of someone else, who was sick but “should be in tomorrow.” The following day he found the man of the highly desirable signature who then told him there was something wrong with his birth certificate. After some discussion he reconsidered, the birth certificate was fine but Clement needed a letter from the hospital requesting urgent processing of a passport (after 5 and ½ months!). (In my mind I was hearing something like, “How about $100” but Clement insisted that, he just really needed a letter.) While Clement stayed in Blantyre his friend Mavuto spent an entire day running around Lilongwe to different administrative offices trying to convince any other person in possession of an authoritative stamp and signature to sign the letter. The next morning I faxed the letter. This mollified the Blantyre signature man who then said the passport would be out within the week. The following Friday (the third or fourth day Clement called) he was told that the passport was out and that he could come pick it up. Clement called his father in Zomba who said he would go collect it Monday. Monday afternoon Clement’s father called and told him that the man who supposedly had the passport was in police custody. He was told that hopefully the man would be released on bail Tuesday and then would be able to hand over the passport. Clement says if the man is not released he will personally visit him in his cell and demand to be given his passport. (Apparently no one else at the office can find/give him the passport.)
As if that is not enough, another ridiculous drama is running concurrently. Clement - along with the other interns who have been assigned to Kamuzu Central Hospital - is fighting to receive a salary. After graduation, clinical officer interns must complete a year internship at a government hospital or clinic where they are posted by the Ministry of Health. The hospital or clinic in turn is supposed to provide them with housing and a small stipend. Now two months into their internship, those allocated to KCH have yet to receive anything . . . Okay, that’s not entirely true, they have been provided a small house (supposedly for 10-15 interns) located about 5 kilometers from the hospital. The house is furnished with a single twin bed and the interns have not been given any money for transportation, or even food.
Daily, a rotating group of interns visit the various administrative offices at the hospital and Ministry to beg. Of course the people they seek are often in meetings, and when they are caught in the office unaware they point the interns in the direction of someone else in another office across town who points them right back. “Come again at 5pm.” “Come back tomorrow.” “Get a letter from the hospital saying they can’t afford to give you anything,” etcetera.
Without pay or housing the interns are still expected to work 60-80hrs per week. Unlike residency programs in the States - where immediately after graduation you occupy the lowest rung of the medical hierarchy, with layers of experienced physicians above you, accessible for consultation and who ultimately remain responsible for the patients - these intern step into full wards alone. (Consultants are often not present at all or are completely overwhelmed by their own patient lists and responsibilities.) Interns have little to no informational resources, minimal medical resources, and little to no supervision; setting up a precarious situation for everyone involved. But, the alternative is wards full of patients without anyone to assess and treat them.
THE HOSPITAL DESPERATELY NEEDS CLINICIANS and the administration is essentially chasing them away. Several of Clement’s peers have already left KCH and those remaining are already becoming disenchanted by the government system. Hospital administrators should be grateful that they have enthusiastic clinicians willing to work in overcrowded hospitals for as little as $50/mo. I feel like screaming at the administrators, “HAVE YOU SEEN THE WARDS IN YOUR HOSPITAL?! WHAT ARE YOU THINKING?”
Certainly the people who attend KCH need these interns. Just a small illustration of that. . . Clement told me that he had a patient yesterday with pleural effusion who had been pushed from one person to anther without any investigation or treatment. By the time he reached Clement he was breathing with great difficulty. Clement drained the fluid, drew labs, and ordered a chest x-ray. Even without the results, the man was so grateful to be helped that he insisted on having Clement's phone number. Telling Clement that the next time he had a problem he would contact him directly. Clement told him that he might not be at KCH the next time but the man persisted, he said he would come to Clement regardless if he had to travel across the country. He also told Clement that he wanted to visit him at his house to which Clement responded that he didn't have a house. The man unwilling to be put off and still holding out his hand said dismissively, "I'll find you and we'll chat."
Last night when Clement narrated the most recent episodes of these ongoing sagas all I could do was laugh. Clement is applying for medical school in a few other African countries moving closer to his dream of becoming a pediatrician and serving those who have the most difficulty accessing care, but not surprisingly he is also looking forward to a few years outside Malawi.
As if that is not enough, another ridiculous drama is running concurrently. Clement - along with the other interns who have been assigned to Kamuzu Central Hospital - is fighting to receive a salary. After graduation, clinical officer interns must complete a year internship at a government hospital or clinic where they are posted by the Ministry of Health. The hospital or clinic in turn is supposed to provide them with housing and a small stipend. Now two months into their internship, those allocated to KCH have yet to receive anything . . . Okay, that’s not entirely true, they have been provided a small house (supposedly for 10-15 interns) located about 5 kilometers from the hospital. The house is furnished with a single twin bed and the interns have not been given any money for transportation, or even food.
Daily, a rotating group of interns visit the various administrative offices at the hospital and Ministry to beg. Of course the people they seek are often in meetings, and when they are caught in the office unaware they point the interns in the direction of someone else in another office across town who points them right back. “Come again at 5pm.” “Come back tomorrow.” “Get a letter from the hospital saying they can’t afford to give you anything,” etcetera.
Without pay or housing the interns are still expected to work 60-80hrs per week. Unlike residency programs in the States - where immediately after graduation you occupy the lowest rung of the medical hierarchy, with layers of experienced physicians above you, accessible for consultation and who ultimately remain responsible for the patients - these intern step into full wards alone. (Consultants are often not present at all or are completely overwhelmed by their own patient lists and responsibilities.) Interns have little to no informational resources, minimal medical resources, and little to no supervision; setting up a precarious situation for everyone involved. But, the alternative is wards full of patients without anyone to assess and treat them.
THE HOSPITAL DESPERATELY NEEDS CLINICIANS and the administration is essentially chasing them away. Several of Clement’s peers have already left KCH and those remaining are already becoming disenchanted by the government system. Hospital administrators should be grateful that they have enthusiastic clinicians willing to work in overcrowded hospitals for as little as $50/mo. I feel like screaming at the administrators, “HAVE YOU SEEN THE WARDS IN YOUR HOSPITAL?! WHAT ARE YOU THINKING?”
Certainly the people who attend KCH need these interns. Just a small illustration of that. . . Clement told me that he had a patient yesterday with pleural effusion who had been pushed from one person to anther without any investigation or treatment. By the time he reached Clement he was breathing with great difficulty. Clement drained the fluid, drew labs, and ordered a chest x-ray. Even without the results, the man was so grateful to be helped that he insisted on having Clement's phone number. Telling Clement that the next time he had a problem he would contact him directly. Clement told him that he might not be at KCH the next time but the man persisted, he said he would come to Clement regardless if he had to travel across the country. He also told Clement that he wanted to visit him at his house to which Clement responded that he didn't have a house. The man unwilling to be put off and still holding out his hand said dismissively, "I'll find you and we'll chat."
Last night when Clement narrated the most recent episodes of these ongoing sagas all I could do was laugh. Clement is applying for medical school in a few other African countries moving closer to his dream of becoming a pediatrician and serving those who have the most difficulty accessing care, but not surprisingly he is also looking forward to a few years outside Malawi.
Tuesday, January 09, 2007
Pictures
Many people have asked for pictures. Unfortunately, although I have hundreds, I don't have the time it takes to upload them. However, my dad has posted the pictures from their trip on his realestate website www.mikejorissen.com They are not of the best quality, but you can get an idea and if you've been following the stories, you can probably guess the identities of the people featured in the snapshots.
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