Water

Ernest told me yesterday that there is no central water supply in Kumasi, no water treatment plant. Homes and buildings all pump water from the ground. This is pretty incredible for a city of 1.5 million. It makes sense why the water so often goes off but I’ll have to check out the facts. Our water has now been off for going on four days. The problem is not the source but the pump. There is plenty of water we just have to go down stairs and carry it up in buckets, but the water is not the same water we usually have running through the tap. On the second day of no running water I met the landlord downstairs and he showed us where we could fill buckets from a large tank. He helped us fill our buckets and I eyed the suspiciously murky water but carried it up. We have separate water for drinking and cooking but we still need water for bathing and flushing the toilet and washing our hands and . . . washing our plates. Now I have giardia. I have had it so many times before that I instantly recognized its undesirable presence. I know as soon as I can get meds from a pharmacy I will improve but it’s Sunday so this means one more day of nausea and running back and forth to the toilet. I think I also now need a doting relative to help fatten me up. Those pounds gained bite by bite with Blue Bell ice cream in Texas are now just a memory. Ghana why are you being so difficult?

Clement just came up with a bucket of water (I finished off the rest with all my toilet flushing) and says that now the tank is dry. We are completely out of water both dirty and clean. This is not a personal torture, this is not a personal torture, this is not a personal torture . . . .

Health Care for Women of the World

In the national newspaper today there was an article specifically about the health care crisis brought on by the National Health Insurance Scheme (NHIS). NHIS was introduced last year with the goal of providing affordable health care to the population at large. A nominal fee is charged at the time of enrollment but then, once enrolled, services are essentially free. The government is supposed to reimburse hospitals for the actual cost. The recently established policy of free antenatal and delivery care goes a step beyond NHIS. According to the article, within just one year of instituting NHIS, the government already owes hospitals millions of Cedis (US$1.00 = 1.14 Cedis) and as a result many public health centers are on the verge of collapse. The article also stated that the government expects hospitals to cover much of their operating expenses but at the same time has created a system in which hospitals do not generate income. Effectively one problem has been traded for another, a great percentage of the population were unable to access health care and now they have been granted access but the care available is rapidly deteriorating.

Today was my second day in the Prenatal clinic at MCH. The process is very similar to that at Bottom with some slight improvements. Women arrive in the morning and pass through a series of stations - history taking, blood pressure, weight, belly checks, dipping urine for protein and glucose, and treatment (here there are a couple extra stations). All women have labs drawn twice during the pregnancy, all women are tested for HIV (done confidentially by specially trained counselors), and all receive one ultrasound during the pregnancy. Within the prenatal care clinic, the only space with relative privacy is reserved for the belly checks, the rest of the stations are located within the large open waiting area. There is a constant flow of women around the room, which is maintained by the staff and it seems that unless a woman is very determined to mention an issue to a nurse, it might be overlooked. The clinic continues until the flow stops. Today that was around 11:30am (it was teen clinic so there were not as many women) but apparently on Fridays and Mondays clinic closes around 4pm). I have been in the belly check station. I was happy to see that measurements are made with a measuring tape. If women have an accurate date of delivery (based on either their last menstrual period LMP or dating by ultrasound) the uterine measurements should correspond fairly closely with the gestational age. If the measurement is off by more than 3cm in either direction then we would refer the woman for further investigation (e.g. if the gestational age is 24 weeks the measurement from the pubic symphasis to the fundus should be between 22 and 26cm). But ironically, even with possibility of calculating an accurate date of delivery, gestation is measure by hand. So, for example, if the top of the uterus reaches her belly button the nurse will say she is 20 weeks and then perhaps on her body the measurement from her pubic symphasis to that point is only 16cm. This method severely limits the value of obtaining a specific measurement. I have also already been told that the women do not know their LMPs. I was told this at Bottom too but I found that if you ask a woman and give her a few seconds to think about it she can usually come up with an exact date. I had the same result here with one woman, we’ll see how it goes.

Most women who come to MCH are quite poor, many of them work as vendors in the nearby Ketejia market. Dr. Annie said that because they would rather save the little money they earn they will not eat for the entire day, until they return home. Around town one of the most common items to sell is water (water and handkerchiefs since everyone is constantly sweating). Women buy a satchel containing 30 individual water bags (500ml each) for 1 Cedi and sell - eventually one by one, walking back and forth between traffic with a basket of water their heads, competing with each other for customers - for a grand total of 1.50. Will 50 pesewas even purchase enough food to replenish the lost calories? Due to the poor diet, as in Malawi, anemia in pregnancy is a common problem. Yet, even with severe anemia by US standards women are transfused rarely. Dr. Annie says that the blood is supposed to be free but if you get the free blood it means unscreened blood, to obtain screened blood each pint costs at least 15 Cedis (you if transfuse a child and use less than one pint, the price is still 15 Cedis).

I am not surprised by the conditions. The summer between nursing school and midwifery I went to Bolivia and spent and few weeks in a public maternity hospital there La Maternidad. I wanted to see what birth was like for poor women of the world. There I was shocked. A midwife mentor in the US set me up to observe at a clinic in Santa Cruz that she herself had helped establish. The clinic was immaculate, well stocked, and the staff were welcoming but the births were few. So, after hearing about the public hospital with 50 births a day I decided to go there. I walked into La Maternidad wearing scrubs, bearing a letter of introduction from another physician, and carrying my nursing school ID, and asked if I could observe. I was given permission. La Maternidad is a large teaching hospital with many staff and numerous medical students.

At that point I had already seen many births in the US but birth was very different in La Maternidad. As I witnessed my first birth there I felt myself start to lose consciousness several times and each time I had to either sit on the floor rush to the hall. For a few hours afterwards I doubted whether or not I had chosen the right profession until I realized that the trigger was not the birth but the violence. When the laboring women arrived in the hospital they were examined in a room with four exam beds. The women could not see each other as screens were set up between beds but from the desk in the center of the room where groups of 10 or more students and staff often gathered, you had full view of all exposed women. If someone determined that the woman was in active labor she would be sent to the labor room, which consisted of about eight beds pushed against the wall, no screens, no privacy. Women were made to undress and lie or sit on the beds. In the event that there were more than eight laboring women their shared beds.

Once a woman was fully dilated and read to push she was made to crawl off the bed onto a gurney which would be pushed hurriedly across the hospital to the delivery room. Once in the delivery room she crawled from the gurney onto a delivery table, her legs were tied into stirrups with pieces of IV tubing and then staff yelled at her to push. All women delivering for the first time received episiotomies as well as many second time mothers. If the woman was not pushing to the liking of the person sitting between her legs, they might yell insults, slap her legs, or a nurse would stand on a stool besides her and apply fundal pressure with her forearm by jumping into the woman’s abdomen as the woman pushed. As soon as the baby was out it was whisked away to lie under a heating lamp in the next room and await a pediatric exam, which was sometimes a very long time wait. No one told the woman anything about the baby. Once when a mother asked whether she had had a boy or a girl the doctor quipped, “They always want to know the gender as though nothing else matters.” That hospital was a nightmare.

I did meet a couple physicians and students who were kind to the women and understood my sense of horror but they were in the minority. Women were shouted at when they cried while their poorly anesthetized perineums were sutured. I had one physician call me away from the bedside of one young woman in the labor room who was terrified of the pain and the nearing delivery to tell me that I should not touch the patient or stand too close because, “These women are dirty and you never know what you might catch.” I remember another woman who had four previous deliveries which were all conducted at home. She was a poor indigenous woman who was now coming for her first hospital delivery with her fifth pregnancy (probably as advised by a traditional birth attendant who was trained to refer all grand-multips to the hospital). The physician asked then who had conducted the previous deliveries when the woman responded that it was her husband the physician laughed sarcastically to a colleague, “Oh is he a physician too?” It took all my restraint not to punch her. Who would want to deliver in such an environment regardless of risk? Another day I found a teenage girl left alone to miscarry her fetus of about 20 weeks. There was only one sink at the end of the hall which separated the delivery rooms from the post-miscarriage care ward. Rosa was lying on a bed in stirrups crying, “mi bebe, mi bebe” with a small inert body half exposed between her legs. Anyone washing their hands had a full view. I went in to sit by her. If I had had any midwifery training I would have completed the delivery and sat with her but I had not so I just sat with her and talked with her while she waited there with her baby between her legs and nurses next to her, separated by a curtain, ate their lunch, laughing and chatting completely deaf to her cries. At one point a student walked over after taking in the view from the sink and yelled at Rosa, “Did you do this to yourself?” I gently asked her to leave and then I closed the door. I had reserved 6 weeks to spend observing but I barely made it through three. I will never forget those women.

When I returned to San Francisco I began asking the Latina women who had previously delivered in either Central America or Mexico about those deliveries. Their stories were depressingly similar. At least with regards to the humanity shown laboring women, Bottom is leaps and bounds above La Maternidad, and MCH seems to be a little better staffed and stocked than Bottom. But in general they all fall way below acceptable. If we consider that these are not three individual cases but examples of hundreds of thousands of similar facilities, what do we do? Do we just get overwhelmed and close our eyes? Do we critique and blame? Do we stand and hand hold within a crumbling system? Do we build up a collage of private clinics? It seems something more fundamental must change to really transform these places. All these places are health care facilities which cater to the poor; certainly no woman with a choice would choose to deliver in such a place (unless granted some control over the situation, like hand picking her midwife and physician). Our attitude towards the powerless and the poor must change. If we considered the poor and powerless our equals these places would not exist. Evidently many physicians at La Maternidad despised the poor indigenous women with outright passion but what do I share with those physicians? What judgments do I hold about the homeless on the streets of San Francisco? Why do I quicken my pace when I pass the man sitting in a heap dressed in rags black with filth? What do I fear? What could be different if I address my own fears? Is not the existence of La Maternidad, Bottom, MCH, and countless others proof enough that globally we believe the poor are dispensable? That our commitment to international aid is superficial or politically motivated? Why are governments and leaders who prioritize the well-being of their citizens over the strength of political alliances demonized? What do we fear? What could be different if we address our fears?

Beauty

Ethel, the Cameroonian wife of one of Clement’s friends is on vacation from class at the moment and we have been spending a good amount of time together. She makes me laugh. Her biggest complaint with Ghana is the food (the lack of her familiar foods and the high cost) and apart from earning her degree, growing fat is her biggest priority (she has quite a ways to go). I tried to encourage her by saying that she will probably gain a good amount of weight when she is pregnant but she just shook her head and said, “There’s not enough food.” Apparently in Cameroon for the first three months after the baby is born the new mother stays in the house, eats, and does nothing other than nurse the baby. According to Ethel when she emerges she is nice and fat her own fat now, not just weight from carrying the baby. I promised to play the role of her doting relative when the time comes and fatten her up to the best of my ability.

Back to Birth

When we returned from the States we found new neighbors living in the room next door, a physician and her two daughters. About a month ago they found a house and moved out but yesterday they came by for a visit. Dr. Annie Opoku is from Madagascar but attended medical school in the Ukraine, there she met and married her Ghanaian husband and she has been living here in Ghana now for more than 20 years. Yesterday I learned that she is the medical superintendent of the Maternal and Child Health public hospital here in Kumasi. When she asked what I am doing and I told her that I am still waiting, she offered that I come and volunteer at the hospital a couple days each week. She said she does not mind if I am not officially registered and I will find plenty to do, though no pay. I am so excited. I thought it would be mid-2009 before I again assisted a mother bring her baby into the world. I will go for the first time tomorrow.

Her description of the hospital began with a litany of problems: the high nurse to patient ratio, the high rate of HIV (6.9%), and general lack of resources, etc. Unsurprisingly, Ghana and Malawi seem to share the same set of problems though health indicators speak to some difference in severity. From the way she was talking it seems this hospital is quite small, they only conduct 100 deliveries per month (as compared with Bottom’s 1,000) and they refer their complicated cases out. It was not clear to me whether they even have the capability of doing c-sections. Dr. Opoku did say they do not have a vacuum extractor. (That will top my mental list of necessary donations.)

This past July the government started offering free prenatal and delivery care in an effort to decrease the maternal mortality rate which is over 800 per 100,000 (astoundingly high compared to the US’s rate of 7 but much better than Malawi’s rate of 1,800). This idea sounds wonderful in theory but Dr. Opoku says that it is devastating the health sector. The system is not set up to cope with the numbers of new patients flooding the hospitals nor has the government established a way to efficiently reimburse the hospitals for the increased operating expenses. Hopefully these problems will be addressed relatively quickly (the policy has only been in effect for two months). However if they are not addressed soon and limited resources are consumed and not replaced, the care women receive at public facilities will be no improvement over no care at all. This seems to be another example of how emphasis on numbers, elevates them to the position of an independent goal and obscures the actual desired outcome. The World Health Organization collects statistics on the percentage of births attended by skilled birth attendants, the percentage of women receiving prenatal care, and the percentage of deliveries conducted in hospitals. The assumption is that the higher these figures, the lower the maternal mortality/morbidity and infant mortality/morbidity rates. (As a midwife I know that in all settings whether here or in the US, hospital births are not inherently safer births.) These numbers also provide a clear marker for comparison between countries. Because of this new policy Ghana will soon be able to boast an increase in all these figures but is this increase significant when women will labor in hospital beds alone because there are too few nurses to adequately monitor the laboring women? Or if laboratory tests or medication are unavailable for those who need them because they cannot be stocked regularly? I will see.

At the moment I am just excited to be around birth again. There is nothing that compares to it. One of my favorite experiences is the moment when a baby quiets after his first few cries to attentively take in his world. We exchange awestruck expressions, me at this new person, so complete unique and beautiful and he, I imagine, at the strange beauty of this place. The expression is always something like a tourist gazing at the ceiling of St. Peter’s Basilica. Wide eyes experience color and light for the first time, the quality of sound, the perception of his body and its movement are all different. But there is no fear. Being held securely, warmly, and then the presence of his mother are enough. She too is now completely transformed in his perception but he recognizes her and trusts her without needing to know what trust entails. I am so privileged to bear witness to these moments again and again, to be reminded that there is great beauty here in what we so quickly come to call mundane, and to learn again that miracles happen every day.

Accepting Happiness

I still don’t have many friends. Clement supplies me with my necessary quota of hugs but despite the lack of friends my harvest of smiles and friendly waves has never been more bountiful. This morning as I walked along the road a boy about three and his older sister yelled “oblonie” ecstatically to me. When I turned and waved he let out a squeal and started running towards me as though I was his favorite aunt. I laughed as his mom sternly called him back. Children are the most effusive in their expressions of warmth but even adults along the street, in the bus, or in the market will quickly and easily return a smile.

As an American accustomed to the anonymity of city life in the US it took a while to adjust to the constant attention - little voices shouting “mzungu” or “oblonie.” When we first returned to Ghana I met a Dutch woman walking along the road in the same direction. We joined paths and chatted as we walked. The usual chorus of children shouting “oblonie” greeted us along the way and when I turned to wave she asked, “You still wave?” I have definitely had my moments when I tired of the word, “mzungu” and thought in my head, “yes, I’m an mzungu, what’s the big deal?” But when she asked, I realized with new clarity how absurd it would be to consider any other response. She said, “Sometimes I just want to be invisible.” Certainly I have shared the feeling but it is comical to think that anyone other than someone who looks African would ever be invisible here, walking with your head down does not change that. All the children want is a smile and a wave. It makes them happy and it makes me really happy to see how such a little gesture can give someone such great joy. So maybe I’m feeling down or thinking deeply about something and on a certain level I want to stay in that pensive spot but why not rise out of that and harvest the joy?

Day by Day

Thank you for your responses to the last post, I have received several good ideas which we will pursue.

Life continues with its difficulties. Last week Clement and I both came down with malaria. It was the first time for me and an interesting experience that I do not hope to repeat. In the morning I felt tired by noon my body was mildly aching and by five I had a splitting headache, chills, and a fever of 102. I started taking anti-malarials right away (we always carry a couple doses with us) and by morning I was feeling 80% better. I went out and bought a treated mosquito bednet and hung it the next day. Clement’s symptoms started a day after mine and hung on a little longer but we are now both fully recovered and are enjoying mosquito free nights under the net. Then for the cherry on top, my computer crashed. My dad says that several friends have left his company feeling better about their day-to-day problems after inquiring about us and hearing some of ours. I suppose even knowing that is reassuring, at least some good is coming out of all of this.

The high of the week was seeing a little girl about two years old in the market with a calculator pressed against her ear wobbling in circles in the midst of the market chaos yelling “Hello? Hello? Hello?”

I also met with Abigail Kyei. She is the Ghanaian midwife I originally met in Malawi. She was working and living there for three years but just recently returned to Ghana and is actually opening a nursing college next door to our hostel. She is one of those people who lifts your spirits just by sitting with you and looking in your eyes. She listened with compassion to my worries, offered some assistance, and reminded me - once again - that she and her husband know what it is like to live in a foreign country and that they will always do what they can for us. A burden lifted. We are not alone.

Malawi Updates and a Request

The assistance to mothers, the feeding program, the school fees, the assistance to families caring for newborn orphans continues in Malawi. I never anticipated starting this handful of little projects but they naturally sprouted from working in the hospital and certainly when I left I could not drop them. I could not find a pre-existing organization in whose hands I could place them and though the activities are few and assist a relatively small group of people they do help. So, last June I organized a board of directors and filed the paperwork in the US to set up African Mothers Health Initiative (AMHI). Finally this June we received our 501C3 (legal non-profit status) letter of determination from the IRS. www.africanmothers.org

Before leaving Malawi, with the help of my dear friend Beatrice Namaleu – a Malawian nurse with 28 years experience in maternal and child health – I set up a sister organization (and board) in Malawi to carry out the activities called Chimwemwe mu’Bereki or Joyful Motherhood. Beatrice retired from the government in December and is now heading Chimwemwe mu’bereki. Beatrice is the only employee and at the moment she is working out of her one bedroom house (where she lives with five of her six daughters, her husband, and nephew). She has no car and travels through town and surrounding villages by a combination of minibuses, bicycle taxis, and walking. She keeps the nursery at Bottom stocked with formula for those babes whose mothers die or who cannot breastfeed, she coordinates with the nurses there and visits the babies at home; she oversees the feeding program working with Thoko and Melai who volunteer to run it from their homes three times a week; and she distribute tuition to about 10 teens and keeps tabs on their progress by visiting their schools and talking with their teachers. The wonderful piece is that the vast majority of money – everything except Beatrice’s salary and a little money for phone, fax, copies, etc – goes directly to the projects. But, for one person it is a big job without much support.

The fundamental idea is to provide quality care and assistance to the individuals enrolled in the project. We want the children to survive childhood, we want to assist women and families move from devastation to joy, we want to focus on stories rather than numbers. I want the money to go to Malawi, I want to support Malawians caring for these projects, I want any employee to have what they need to make it possible to enjoy this work and do it creatively while always prioritizing our clients.

Just limiting ourselves to the few projects we currently have, there is still a lot that needs to be done to ensure that roots set deep. This coming year in Malawi we want to rent land to for a garden which will be cultivated and used by the feeding program, we also want to increase the number of meals provided and work on making sure the children are growing well (kids are weighed and measured monthly), and we would like to create opportunities for the women who volunteer cooking and cleaning to organize a small business; for the newborns we want to improve our monitoring system and make sure that resources are enough to provide intensive support during the first year; and for the adolescents we want to continue assistance for those excelling and find vocational programs for those struggling.

We need people who are interested in becoming involved in the US or at least from somewhere regularly accessible via email. We are looking both for volunteer assistance as well as more formal affiliation. AMHI activities are focused on fundraising and project support. Up to this point, everything has been funded by donations from friends, family, and blog readers, which is wonderful and amazing but we do go through periods of financial drought. I am not a manager, I am not a fundraiser, but I am trying to develop a few new skills and stay on task. Please, if you have resources, ideas, a few hours a month to donate let me know, I have open ears. joanne_jorissen@yahoo.com

Kumasi

Clement and I are back in Ghana and as we wait - life again paused by the great force of bureaucracy – I have to remind myself occasionally that this is not a torture designed especially for us. Clement’s classes resumed today but after visiting administrative offices daily for weeks he is still not registered. I spoke with the Nurses and Midwives Council when we arrived and was told that in order to register I must take an exam in December and then after the results are out, I will have to do an orientation of several months before I can practice as a midwife. And so we wait. At present the water has been turned off for five hours and the power has been off for three days. I just finished my daily excavation in the fridge, tossing half of our remaining vegetables and washing out the mold that appeared over night.

Thich Nhat Hanh says happiness is accessible right now. Presumably that means without running water, without electricity, and without a job. Love exists and can flourish without those things. At times metaphor of a prison comes to mind but I consciously exchange it for the image of a cocoon. I am in a cocoon awaiting metamorphosis. I realize the world will remain the same but I’m encouraging and waiting for something within me or my life to shift so that the world will be available to me in a new way. Inside the cocoon I have little but still much beyond the basic necessities; I have my husband, food, some books, often water, a few movies, and then of course the true source of both my torture and joy – my own spinning mind. I have my freedom and when the entropic forces begin climaxing I can step out.

From the balcony at dusk, the world invites me to quite my mind. Immense sky, supporting thick purple cumulus clouds, is lit by tendrils of pink, the ends of the sun’s rays inviting night to bloom as they follow their mistress below the horizon. The calls of a few dozen birds reach my ears from different distances and directions. A choir warms up for an all night prayer service and from somewhere beyond their church, the adhan begins, “Allah Akhbar” calling Muslims to prayer. Just in front of the gate a woman walks by, flip flops tapping the Earth, her baby on her back, a small package on her head, her young son trailing a few steps behind with a package on his shoulder. Downstairs on the pavement my neighbor is out of sight but I can hear her grinding pepper – the sound of a clay pot rolling on the ground - and smell the faint aroma from her cooking. On the other side of the fence men chat while they pound fufu – the methodical deep thumping a familiar sound - one man raises and pounds the giant pestle, the other squats at the mortar dexterously turning the yam and plantain in between the thumps. Enormous leaves of banana trees cast even larger shadows in the dimming light. A few televisions and radios talk unintelligibly and a car door closes is in the distance. Our individual dramas diminish to a handful of colorful stories set against the enormity of the universe; the proximity and pulse of life is reassurance.

Lettuce

Last week I unexpectedly found myself hopping through a large field of lettuce. Jumping from bed to bed trying to avoid both the tender leaves and the rivulets of algae and mud. I started off from home going nowhere but somewhere new needing space to ventilate my thoughts. The main roads are paved but all the roads with in the residential area where we live are dirt, some better, others quickly degenerating into narrow bumpy footpaths. From the balcony of our hostel the area at night is filled with lights, buildings seem almost to touch but between them and often in the center of those sitting unfinished there are banana and papaya trees, maize stalks and apparently a couple acres of lettuce. At the time I felt foolish, imagining dozens of unseen eyes fixed on the silly foreign woman hopping through lettuce and mud rather than taking the “obvious” path, which I’m sure ran somewhere nearby. The experience gave me what I needed, it brought my mind down to my feet and then to the bright blue sky.

Home in Texas

I'm home in Texas. The air-conditioner says it's 75 degrees inside. The plastic thermometer with the red hummingbird stuck on the window says it's 87 degrees outside. Clement is asleep in the other room. Mom is downstairs organizing papers, moving them from one pile to another to the trash, fighting and losing to their fiercely swift reproductive rate.

About two weeks after arriving in Ghana, Clement was told that he would have to wait until August to resume classes. For a couple days the dean of the medical school said he might be able to continue this term but in the end he was told, "Sorry, come back in August." Since I had not yet started working we decided to try to come to Texas. My cousin Jon's wedding was scheduled for April 5th in Austin and I desperately wanted to attend. We booked the first available visa interview which was over a month away (March 26th) and bought - as we were told by the travel agent and believed after trying four different agencies - the last two seats on any flight heading to the US after March 26th and before April 5th. Then we waited and sweat.

Every day Clement walked to campus and entered the human pin ball game of trying to obtain a letter addressed to the consular at the US Embassy saying that he was enrolled in the fall term. The dean referred him to the registrar, the registrar told him to return tomorrow and then tomorrow and then tomorrow and then finally told him to go to the international student section. At the international student section they did not have the correct letterhead he was told, “Come back tomorrow” for about a week. Then once the letterhead arrived they told him he needed a letter from the registrar addressed to the student section. The registrar said it wasn’t her responsibility to write the letter; finally a secretary from the dean’s office copied a letter from his file which had already been sent to the student section. The man in the student section was satisfied with the copy but then asked if Clement had paid the fee associated with the letter they would write. Once the fee was paid – involving of course visiting another office and waiting in another line – the man at the student’s section told him he needed a passport picture. When I very calmly (much more calmly than I wanted to) reminded the man that Clement had been visiting the same office daily for weeks and suggested that it might be a good idea to explain on the first visit what is needed, the man became indignant, told me not to tell him how to do his job and with a mix of passion and anger said that his job is to help students – at least we agreed on that point. Finally, five minutes after the University officially closed, the day before we had to leave for Accra, Clement was handed the letter.

In Accra we stayed with a cousin of Peter and Abigail Kyei – friends from Kumasi. Having never met us she welcomed us hugs, cooked for us, and refused all help. In Kumasi we had been frustrated by the weekly unannounced interruption of our water supply but in her neighborhood we learned that for at least the past 15 years, water has only flowed through the taps on Wednesdays. For the rest of the week people buy water and fill tanks behind or above their homes. Without intending to do so, I have become very good at bathing with surprisingly small volumes of water. It seems to me that in the US our wealth as a nation buffers us from so many “coming” hardships due to global warming and population growth that have already arrived in many countries. After a few more days of waiting, on March 27th Clement was given a ten year tourist visa and on March 28th we arrived tired but happy in Austin to the loving hugs of my parents, a cool night, a quiet drive home on a wide highway, a hot shower, and clean soft sheets - I don’t remember ever feeling so grateful.

I am eager to work. I miss birth. I miss feeling useful. I'm driving Clement slightly crazy by asking him 1,000 times a day "What do you want to do now?" Still, it is wonderful to be here. I adore my parents. They are generous, wise, kind, and aging. I love my family. My cousin’s wedding was beautiful, the love professed deeply rooted, and my heart skipped an entire measure of beats from the excitement of surprising my paternal aunts, and uncle, and cousins who flew down from Michigan.

Two weeks later we also spent a weekend with my mom’s family in Houston and Raywood. Raywood is a small farm town in East Texas where the vast majority of residents are direct relatives of my mother’s. Once Clement assessed the place he leaned in close and said with a smile, “You never told me that you have a home village.” We started our visit with an entertaining tour of the cemetery, learning which deceased married couples were first cousins, hearing the story of two who hid under an overturned wagon to wait out a storm and then emerged alive and pregnant, we learned who was an infamous womanizer, who died from tuberculosis, who died from syphilis, and who died in childbirth. We ate a big lunch then concluded our visit by dancing Zydeco with my mom’s cousins in someone’s den. I let the joy flood every cell - sitting with Clement, watching my mom laugh out loud with her cousins, then turn around after each song to pull someone else to the dance floor. She was radiant and our time together is rare and precious.

The future as usual is uncertain, Clement and I will live 4 months of our first year of marriage with my parents, hopefully I will find a per diem nursing job while we are here, then we will return to Ghana August 1st, leaving all the trappings of middle class America behind. When I consider the future I feel the responsibility weigh on me as the sole provider for a new family. I wonder if my career as a part-time volunteer will be enough. I still refuse to spend any more than a fraction of a second considering job possibilities that would be more lucrative than midwifery.

Suffering and Joy

If we grow up in a secure household in America we learn – and may come to believe – that everyone has the right to pursue happiness. Although we are not told this explicitly, in America, in our consumerist culture, this most certainly means a right to the external pursuit of happiness. It is highly debatable whether in actuality all Americans share this right but I won’t get into that. The thought that captivates me is the simple idea of being free to pursue happiness. It is beautiful. Happiness as a sustained state of being in the world – as opposed to on a remote tropical island in a four star facility but rather in life around people, with all the pain, despair, and suffering that involves – must be an internal state. This pursuit of internal happiness is truly open to everyone but the path towards its achievement is far more difficult. I am beginning to think that the only people who achieve internal happiness are highly evolved spiritual beings. For the rest of us here on this planet, so distant from God, we are left mostly to our own devices to increase our compassion, learn grace, and find joy. Our relationships with ourselves are often tragically flawed not to mention our relationships with each other. We create pain, witness pain, experience loss, and misplace priorities. Living in Malawi and working in the labor ward there over the past few years has had a profound impact on my spirit. I am still unsure of how to characterize this impact; at the moment perhaps I can say it has left me with a greater sense of surrender. I have seen much inequality and cruelty; I have gained no understanding its purpose. We might grandly hypothesize that spiritual evolution requires suffering but when so much suffering is merely a degradation of life, the conclusion that most readily arises is that we as a global community are responsible for its unnecessary existence. I am exhausted, I feel a desire to rest but an inability to turn away. Certainly, I have deepened my respect for those who walk through life with their eyes open and radiate joy. I wrote before that I want to find more joy in life and I am renewing that intention.

Home?

We are now in Kumasi. Initially we stayed at the home of one of the lecturers from KNUST who has been a friend to Clement. He took us around to see the housing options and we made a decision. Of course before we made the decision I had a few hours of panic. Flats are difficult to find around the University as most homes and buildings have been converted into hostels, which are essentially private dorms. We saw a very nice hostel within walking distance from the University and a lovely simple two bedroom apartment for the same price at a significant distance from campus. We chose the hostel. So, here I am 32, newly married and living in a dorm with my husband. We have a single room with an attached bathroom (which it seems we share with a family of small mice), we sleep in a single bed, share a “kitchen” - consisting of a sink and two burner hot plate - with four to six others, and wash our laundry in the shower. There is no common space inside, no garden outside; there is no place to sit with friends or breathing room when Clement and I need a few minutes apart. I keep asking myself, “How did I get here and what am I doing?” then I argue with myself for the underlying sense of entitlement. After each wave of panic Clement gives me the needed hug and reminds me that I am just going through culture shock and will adjust. I need to find a source for good chocolate and ice cream then I'm sure I will be able to live happily.

Arrival in Ghana

Clement and I have arrived in Ghana. Like so much of life, it was an adventure getting here - of course there was the necessary and sad bit of saying goodbye to good friends, moving out, selling our things, and packing. Then there was the unnecessary bit of DHL losing my passport when I shipped it with them to the Ghanaian High Commission in Harare, Zimbabwe to get a visa. They were very apologetic but the extra stress led to a few tears and a delay of a week. Finally we left Lilongwe on the 8th of February and, after a night in Addis Ababa, arrived in Accra in the afternoon of the 9th. During the trip as I considered what I was leaving behind and the unknown towards which I was headed, my excitement and anxiety seemed to counteract each other and left me feeling empty.

As soon as we passed through immigration in Accra we found Clement’s classmate Moses waiting for us at the baggage claim with a warm smile. He brought us home to his wife and two little boys. So here we are in their home with all our earthly possession in four bags. We have no home and little idea of what will come in the next days, weeks, months. I must consciously remind myself that beginnings are always difficult but they always pass. I remember my first days in Malawi at the Kapondas’ home filled with excitement but also loneliness and boredom. Now, here I am again in a similar predicament. This need to start life over again and again, to experience new countries and cultures, is at times a burdensome compulsion. However, I doubt this realization will prevent future reoccurrences. At least this time we are two and at least Clement survived culture shock and successfully made a few friends last semester.

Ghana is lot hotter than Malawi. The heat feels like Texas but Accra lacks the ubiquitous air conditioners present in nearly every home and shop in Austin. I don’t mind the heat. I much prefer this climate to the cold but Clement struggles with it. The streets are busier than Malawi; people move faster, are more assertive, more willing to express their opinions, and more likely to start a conversation. There is a wide variety of street food, of which I can only identify a handful, but I’m eager to taste it. In general the food is delicious and spicy but our encounters with vegetables have been minimal. I have only seen three green vegetables in the market – okra, a local green leafy vegetable, and lettuce and usually when they end up on your plate you must search for tiny flakes of green. Vendors flow up and down every street hurrying to make transactions through car and bus windows during pauses at intersections then swiftly jumping aside when the traffic movement resumes. Unlike Malawi the vendors here on the street and in the shops are mostly women and girls. I wonder about their education and their safety. The predominant local language is Twi (pronounced tree) but many people do speak English. Although there are very few faces which are obviously not African people don’t seem to take much notice of me and Clement. There are definitely fewer beautiful development aid vehicles cruising the streets than in Malawi - perhaps a sign of a more independent economy.

The most difficult part of moving is always the lack of friendship and this of course takes time. Wherever I walk small children shout oblonie (white person) and wave. One day as I was walking home with groceries in my arms I heard a small voice yell, "Can I help you?" followed by the patter of small feet. A group of young students in the school uniforms took my bags and escorted me home. Another day when Clement and I stopped to discuss directions on a street corner and a group of five little girls maybe 7 and 8 years old all came up to me and gave me hugs one by one, the last one planted a kiss on my belly. Not a bad welcome.

Cromwell

Cromwell has been living up north with his parents since shortly after his stroke. Over the past two years he managed to recover some of his strength but he was still walking with a notable limp. He came to our wedding in Mangochi and I saw him a couple weeks afterwards for a goodbye before our departure to Ghana. He was laughing as he recounted his experiences at our wedding, Cromwell does not laugh often and I was glad to leave with happy images of him fresh in my mind. Last night Cromwell's brother Jobson called to tell me Cromwell died on Friday and was buried on Monday. He had been watching football (the African Cup of Nations is going on in Ghana) when his heart started racing. An ambulance was called to transport him to the hospital. He died in route. He was 32.

The Unabridged Wedding Story

Clement’s sister Gladys arrived from Sudan in October she had left three years previously - three months before I arrived in Malawi – and this was her first visit home. I immediately liked her warm and talkative ways. Effie, Aisha, (two of Clement’s sisters) and I stayed up the first night listening to her stories. In 2004 Gladys was sponsored by a Malawian Islamic organization to study business management. Higher education opportunities are limited in Malawi and her sponsors promised her a rare straight path to a degree. They assured her that the school possessed good facilities and they promised that she would be taught in English. Thirty Malawians accepted the scholarship including Gladys and her best friend. Although anxious about taking such a blind step, Gladys and her friend allowed their anxiety to be replaced by excitement once in Khartoum as they drove to campus past modern high rises and wealthy neighborhoods with manicured gardens. Finally they reached campus and were deposited in front of several large plastic shipping containers, which had been converted into dorms but in the heat functioned more like ovens. Tears spilled over and continued flowing for days. They could not return to Malawi; everything had been paid for by the organization and their families would never be able to cover the expense of a return ticket.

The second disappointment came with the discovery that classes would be taught in Arabic. Without an alternative, Gladys and her cohort spent the first year studying Arabic. At the end of that year, still not fluent in Arabic, Gladys managed to negotiate with her sponsors to allow her and her friend to transfer to another school where classes were taught in English. (The remainder of her cohort stayed at the original school.) During her first true academic year Gladys performed well, obtaining A’s in all her courses, but at the end of that year her sponsors transferred her to yet another school which would not accept any credit for the courses she had taken. Gladys arrived in Malawi after three years away with only one year of academic credit. That first night she told me, “Joanne, my dream is to obtain a masters degree.” Gladys is a bright woman, someone who in the States would probably obtain her PhD by her mid to late 20s, but given the tortuous trajectory of her education, a masters will be a significant achievement.

Gladys also told us stories about the treatment of the Southern Sudanese by the government, the little she knew about the war that filtered through to eyes and ears despite censorship, her distressing encounters with members of the poorly trained and poorly educated police force, and the heat. Apparently the heat is so intense in Khartoum that people are warned not to directly enter a cold shower when coming from outside. During each year she spent in Sudan one or two foreigner students died this way from shock.

In celebration of Gladys’ return and in anticipation of Clement’s arrival more and more family and friends poured into the little house. The cooking and cleaning always got done, there were always plenty of stories and laughter, and somehow I still managed to find a quiet corner whenever I needed retreat. My friend Meera, a fellow midwife, arrived on December 17th. We spent long hours trading stories of the past months and then Clement arrived on December 19th. I had been counting down the days to his return for months but when he stepped out from the baggage claim in his tee-shirt and jeans he was so much more handsome and my love for him so much more overwhelming than I had expected.

My parents arrived on the 24th. They are both in their 70s and, though healthy for their age, were visibly exhausted by the two days of travel. My sweet little mother appeared to be on the verge of collapse as she stepped out from the baggage claim wearing a sweater, jacket, hat – in the summer of the southern hemisphere – and carrying two small bags. Clement and I hugged them both and my mother asked him to hold her on our way out to the car. The following days, leading up to the wedding, passed quickly. We celebrated Christmas with wonderful friends and food, wrote and designed the wedding program, arranged transportation to Mangochi for friends, met with the priest, and cherished our ordinary evenings with my parents, Meera, and Clement’s sisters.

Finally, the Thursday before the wedding, we packed my little sedan with five people and their luggage; Clement’s, his best man’s, and my father’s suits; my wedding dress; food; and the flowers. (Amazingly we bought all the flowers for the wedding from at Zikomo flower farm for $20.) Around 7pm, a couple hours after sunset, we arrived at Clement’s father’s house in Mangochi, peeled ourselves out of the overcrowded car and stepped into the overcrowded candle-lit house. Space was made on the couches and we were fed nsima and eggs. Clement’s father wanted to take my car to the village to deliver fuel to a truck which was waiting to drive the recently slaughtered bull to the cottage where my parents would stay, so it could be packed in the refrigerator. I handed over the keys but my car wouldn’t start. My parents and Meera were transported by another vehicle to the cottage. After about a half an hour several boys managed to push-start the car. Clement and friends departed to celebrate his penultimate night as a bachelor. I feel asleep on the couch. When Mr Chiwaula arrived with the cow in pieces in the back of the pickup, I followed them in my car to the cottage 20 kilometers out of town. While on our way Clement called, extremely disappointed, to say that the lodge/bar where the guys had planned to party with him (the only bar in town) had unexpectedly closed early. I headed to bed while five men packed an entire cow into two medium sized refrigerators. Meera laughed and said when she went to get water she tried to ignore the puddles of blood collecting under the fridge.

Friday was a blur, I met Clement, we picked up guests dropped them off, we forgot to eat and drink, everyone told us what was going wrong. The rehearsal, scheduled to begin at three began at five, Father Sax arrived at 6:30. The rehearsal consisted of dancing down the isle again and again. I was told that usually the bridal party rehearses for several days before the wedding, but we were apparently quick learners as we polished it off in just three repetitions. When Father Sax arrived we spent a few minutes discussing some of the components Clement and I had added and then, at last, we left the church to eat. At 4pm I had called the hotel, where we had booked our dinner a month previously, to tell them to expect us around six, the receptionist said they would be ready. Twenty of us arrived at the hotel at seven and the shocked waitress quietly asked, “That was for today?” I tried to be optimistic when she said they only had one cook and nothing was prepared but a friend called at that exact moment to ask how I was and the tears broke free. Thankfully Father Sax produced the desired miracle, he sat us all down, took drink and meal orders and within 30 minutes everyone was eating.

Saturday morning was lovely. The sun shined through a light rain. My dad drank coffee on the table outside facing the lake where Meera and I worked on the flowers. Little girls ran through the grass and then to the water’s edge. Fishermen mended their nets on the sand. The older girls and women sat inside slowly transforming the cow into samosas and snacks. I made the bouquets for me and Effie, as well as the corsages and boutonnières for the men and the parents. My heart calmed. Around 11am we drove to the hotel, which was a block away from the church, to get ready.

Once at the hotel I kept meeting people who needed to eat, others who needed rooms, and I still needed to deliver the flowers to the parents and candles to the church. I lost track of time. The wedding was set for 3pm. At 2pm I had a head of wet hair which I was desperately trying to towel dry. Thankfully four friends miraculously appeared with a hairdryer (I had never previously seen a hairdryer in Malawi) and they set to curling and pinning the masses while I put on my makeup. At 3pm I slipped on my dress and called Beatrice asking about our ride to the church. The car arrived after 30 minutes. I took a few deep breaths and got in next to Effie.

As we pulled up to the church everyone was standing outside, women singing Chewa wedding songs ran to encircle the car. Slowly the crowd filtered into the church and I was given permission to step out. I glimpsed my handsome joyful parents and then took their arms as Effie started dancing down the isle between the overcrowded pews. The choir’s voices flowed over heads filling all remaining space, and my eyes fixed on Clement.

Clement and I are both Catholic but have been raised in environments which made it impossible to believe any single path has a monopoly on truth. We are a Malawian and an American. Half of Clement's family is Muslim, the other half Catholic. Clement’s mom is Chewa, his dad is Yao. My mom's family is black American, my dad's family of German descent. Clement and I are accustomed to sitting in the middle, we respect and honor differences while always finding pathways to unity. We wanted our ceremony to embrace diversity and warmly involve all those in attendance.

The final result was a Catholic ceremony with our additions, our vows, and a lot of spontaneous ululating, harmonic singing, and movement. It was beautiful and basically unscripted. Through it all – sitting, standing, walking next to Clement – I felt incredible joy, deep calm, and complete awe that I could be blessed with such a life partner.

As we faced each other holding hands, Father Sax read “Blessing of the Hands," by Rev. Daniel L. Harris,

These are the hands of your best friend, young and strong and full of love for you, that are holding yours on your wedding day, as you promise to love each other today, tomorrow, and forever. These are the hands that will work alongside yours, as together you build your future. These are the hands that will passionately love you and cherish you through the years, and with the slightest touch, will comfort you like no other. These are the hands that will
hold you when fear or grief fills your mind. These are the hands that will countless times wipe the tears from your eyes; tears of sorrow, and as in today, tears of joy. These are the hands that will tenderly hold your children, the hands that will help you to hold your family as one. These are the hands that will give you strength when you need it. And lastly, these are the hands that
even when wrinkled and aged, will still be reaching for yours, still giving you the same nspoken tenderness with just a touch.

and then we exchanged vows,

I, Clement, affirm my love to you, Joanne, on this day of our wedding in the presence of our dear friends and families. I promise to embrace, respect, and honor your love. I promise to be a faithful companion on this walk through life. Today I humbly offer you my heart and ask you to take me as your husband.

I, Joanne, affirm my love to you, Clement, on this day of our wedding in the presence of our dear friends and families. I promise to embrace, respect, and honor your love. I promise to be a faithful companion on this walk through life. Today I humbly offer you my heart and ask you to take me as your wife.

Sometime later Father Sax asked us to move down the isle and offer the sign of peace to people, but before we could take a step the church enveloped us; a tidal wave of arms and bodies pulling us from one embrace to the next. It seemed to be a dramatic finale featuring all the major characters of our story in their best clothes and most joyful expressions Cromwell, Doreen, Memory, Msiska, the Nanthowas, maids from the hospital, Innocent and Ven, Tarek and Lara, Masauko, the Namaleus . . . In-between the moments of activity I sat next to Clement, my hand in his, awash in love.

We signed our marriage certificate and Father Sax concluded the celebration with the Apache Marriage Blessing,

Now you will feel no rain, for each of you will be the shelter for each other. Now you will feel no cold, for each of you will be the warmth for the other. Now you are two persons, but there is only one life before. Go now to your dwelling place to enter into the days of your life together. And may your days be good and long upon the earth.

From the church Clement and I were escorted to the village in a Mercedes in which we were instructed to standup through the sun roof – a hilarious and slightly embarrassing experience. The village welcomed us with drumming and singing and, though eager to join the scene, we were instructed to remain in the car until my parents arrived. We later learned that Father Sax had given them a ride but before joining the reception made a series of stops. The consequence was that Clement and I were trapped in the Mercedes for about an hour. Waves of faces undulated from the darkness to the car and back into the dark. Every once in a while a friend would approach and we would plead for news about my parents’ whereabouts and beg for snacks. Finally my parents arrived and to the dismay of those trying to choreograph our entrance, we claimed our freedom and leaped from the car.

The reception took place in Chiwaula village in front of the chief’s house, under tents, between enormous mango trees, in candle-light. Traditional dancing and drumming was followed by a couple short inaudible speeches and then a mob scene that masqueraded as the cutting of the cake. The cake was delicious; worthy fuel for a small battle. Clement and I enjoyed a few minutes of dancing and then, when the exhaustion that had been marinating our bodies over the past week reached the saturation point, we decided to return to the hotel for sleep.

A man placed the car keys in Clement’s hand, said, “Sakuyenda [It won’t start],” and disappeared. We gathered a few boys to assist but there was a moment when I was actually pushing the car in my wedding dress before a friend told me to stop. The car started and at last we drove back to the hotel, dropping Effie and a friend home on the way. As we pulled into the hotel parking lot we were greeted by a raging party on the lawn just feet outside our beautiful room. A few more people called asking about transportation and finally Meera kindly took my phone to her room. Clement and I, giddy and exhausted, shared the same sentiment, “thank God we NEVER have to do that again!!” Sometime between 2 and 3am the music stopped and I drifted into a shallow sleep, happy and comforted by the breaths of my beloved at my side.

Oh God
Let all lovers be content
Give them happy endings
Let their lives be celebrations
Let their hearts dance in the fire of your love.
—Rumi

We are grateful to all our beloved friends and family who honored us with their presence and to those who were with us in spirit. Our union has grown on the foundation of love and support you have given us over the years; our wedding day was not ours alone but also yours. May God perpetually bless you all.
With genuine gratitude,
Joanne and Clement

Birth Outside Bottom

Thursday was a rare slow day in the labor ward at Bottom labor. There was time to sit and to chat. I have seen much and learned much at Bottom but from the beginning I have also wanted to see birth outside the hospital in Malawi. (Over 50% of women in Malawi still deliver with traditional birth attendants (TBAs).) Thursday I mentioned this to Msiska and she told me about Mrs Msumba. Mrs. Msumba is a famous midwife working in a village on the periphery of the city. As Msiska described her, I realized that she was the same midwife mentioned by several of the clinical staff over a year ago in a derisive conversation about nurses who preferred to have her attend their births rather than deliver at Bottom (it sounded reasonable to me then and now). Msiska said Mrs Msumba had a lot of patients and always referred in time, and unlike other TBAs always accompanied the transferred women to the hospital. I was eager to meet her and asked Msiska how I could find her, in response she said “ukachula mkango udzikwera mtengo [if you mention a lion you must climb up the tree], she is probably on her way now.” I was skeptical since we had never met during all my time at the hospital but within a couple hours Mrs Msumba appeared with a patient and of course Msiska was not surprised. Msiska explained my interest to Mrs Msumba and I gave her my telephone number. Mrs Msumba said she would call when she had a laboring patient.

Sunday night Beatrice and I compiled a list of things to get done for the week for our little non-profit. Monday morning, thinking of nothing else but the non-profit, I woke up and opened the computer but within minutes woman called speaking in rapid Chichewa. I heard “TBA” quickly tossed in and figured it out. I asked if I should come and she said yes. The plan had been that one of the maids from labor ward would escort me but when I phoned her, her phone was switched off. I called Beatrice. She was at Kamuzu Central Hospital and said she would find someone who knew the way and accompany me. When I arrived at Kamuzu Beatrice was waiting with two women from Mrs Msungu’s village who had been delivered by her a couple months previously. The two women directed us through the village and then instructed us to stop at a hedge (a few green leaves budding on top a mound of dirt). From there they led us down a narrow muddy path at once widening and ending at a pen filled with fat guinea pigs eating palm leaves. Mr Msumba was cleaning the pen and after greeting him, the women who led us there called out to Mrs. Msumba who was next door at the her clinic. Mrs Msumba greeted us warmly and led us inside.

Her small clinic was divided into four rooms, the main room which contained a small cabinet with delivery supplies and gloves as well as two “bush” ambulances (tricycles with extended carts used to transport laboring women); a small empty room for prenatal examinations, a recovery room with a single bed, and a tiny delivery room containing only a basic cot for the baby. The building was made of unbaked brick painted with a cement floor and metal roof, it smelled faintly of floral body soap. Two women, having come for prenatal care, sat on the floor in the main room, the first was pregnant with her second child and had no living child and the second woman was pregnant with her fifth. Mrs Msumba counseled them, she talked to them about danger signs, she told the woman with her fifth pregnancy that she must deliver in the hospital (TBAs in Malawi are only supposed to attend second to fourth pregnancies). Every now and then I could hear the woman in the labor room moan and Mrs Msumba occasionally stood and peered in the delivery room. She examined the bellies of the two prenatal patients and let them leave.

During the month of November Mrs Msumba said she had had 62 deliveries and 19 transfers to Bottom. Only after looking through her record book and counting the names could I completely grasp that she alone had cared for 81 laboring women within a single month. Mrs Msumba began working as a midwife in 1975, apprenticed by her mother and grandmother. She laughed and shook her head when I asked if she knows how many deliveries she has conducted. She strays further than walking distance from her home and clinic only when transferring patients. There is no electricity at her clinic so some nights she conducts as many as three deliveries by candle light. She charges 500MK for her services (about US$3) but still many of the women cannot pay, so she often works for free, pays the transportation costs with her own money when women must be transferred, and sustains her family with small businesses such as raising and selling guinea pigs.

In the hospital the women must bring their own caretaker to cook and wash for them, if they have no one they do not eat, and they wash their own clothes after delivery. If the women come alone to Mrs Msumba she cooks for them, she heats bath water for them, she gives them water while they labor, and leaves a covered bucket by their side in case they need to vomit. The women bring a plastic sheet and a few cloths to place on the bare ground in her small delivery room. They labor there, Mrs Msumba encourages them to lie down. She does not yell. When I asked Mrs Msumba about vaginal exams she says she does not check regularly. She takes her time. She watches the women, their bodies and their body language. She palpates their abdomen to feel whether the baby’s head is descending into its mother’s pelvis. She can tell from a woman’s labia if her birth will be difficult. She says she takes her time. She says this way the woman only pushes once or twice and the baby is born.

Stella was laboring with her third baby. I sat next to her on the cement floor as she moaned and turned from side to side. Mrs Msumba walked between the rooms, attentive to Stella but calm. She listened to the baby. As the birth neared she changed clothes, put on gloves, and prepared her delivery kit – a cord clamp, a razor blade, and a piece of string set in her single kidney dish. Stella’s moaning intensified and Mrs Msumba instructed her to move from her side to her back. After two physiological pushes Mrs Msumba held Stella’s baby boy in her hands. She immediately put him on Stella’s breast and in another five minutes the placenta followed with barely a drop of blood. Mrs Msumba cleaned Stella and the room. It was an amazing birth to witness, we thanked Stella and Mrs Msumba but before we were allowed to leave Mrs Msumba ushered us to the steps outside where a lunch of eggs and nsima was waiting.

I asked a few more questions and then Mrs Msumba gave me her list of requests: electricity, a mattress, more metal kidney dishes, and a few blankets. As we were finishing lunch another laboring woman arrived. Mrs Msumba asked us to wait while she examined her just in case the woman needed to be transferred but within minutes she also delivered. We left feeling joyful. It is no mystery why women choose to deliver with Mrs Msumba rather than at the hospital. The care that women receive with Mrs Msumba is impossible to replicate in a hospital where the ratio of laboring women to nurses can be as high as 10:1.

Last Day

Yesterday was my last day at Bottom. It was as I anticipated - just another day. I conducted one vacuum delivery and two normal deliveries. I sat and talked with and rubbed the back of a frightened 19-year-old as she labored. I helped resuscitate two babies. No one remembered that it was my last day except Msiska. She told me they’ll miss my skills. “Any time there is an asphyxiated baby we always wish you were here,” she said. She said she will miss my presence and my friendship. I bought a cake and it was eaten. After three years at Bottom I know, without self pity or drama that my presence had the minimal impact of a drop of water in a pool. That does not bother me. I know it was different with the women. And, I am ready for a change. I am looking forward to the future. I’m sure someday I will return and work again in the new maternity hospital. I hope to find the conditions better. I hope I will have more to give.

Hassan

The quadruplets looked wonderful two weeks ago when Lisa (an Australian Pediatrician and dear friend) and I, along with a community nurse and a nutritionist visited them at home. We turned off the main road at the small green mosque and then stopped to ask directions from a neighbor who pointed toward a small mud brick house with a line of baby clothes flapping out front. We found Patuma and her mother sitting on a mat next to the quads who were all bundled in layers of blankets and covered with a single sheet. Slowly Patuma and her mother lifted each one and unwrapped them for inspection. Everyone laughed when I identified each baby by name. Happily we found that Mohammed, Hassan, Hussein, and Hamida had all gained weight. We took pictures and four of the other children joined us. The three year old twins sat in front of their mother, the little girl considering us seriously and her brother hiding behind his hands. Patuma walked us to the car and as we drove away I watched her sweep the twins into her arms and head towards home.

On November 10th Lisa told me that Hassan had been admitted to Kamuzu Central Hospital with fevers. He was the smallest of the four at birth. She said he was on several antibiotics and that they were feeding him through a nasogastric tube. She visited him daily and monitored his care. On the 12th she told me the fevers persisted. I stopped by the hospital on November 13th. When I saw Hassan in his mothers arms I tried not to appear visibly shocked. He looked like withered leaf; I could see his sutures clearly through the thin skin of his scalp – a clear sign of dehydration – and I sadly remembered Gabriel. Patuma handed him to me and as I cradled him, watching his chest rise and fall quickly, his eyes open and close slowly, she told me that he was improving. She said he was inconsolable at first but now he was quiet and eating well. I wondered if he was quiet only because the exhaustion was becoming more than his little body could bear. He made sucking movements with his mouth and I returned him to Patuma’s arms. Mildly astounded I watched him finish about 100 mililiters of formula from a cup and I felt hope rise again. I told them I would return on the 15th, I said goodbye and left.

Lisa called me on November 14th, my 32nd birthday, and told me Hassan had died at 9am. He was one month and two days old.

Shortage of Hands

Today I walked into the labor ward to find Msiska alone with all 14 beds full and women lined up on the benches. She laughed, twirled her arms over her head and said, "Welcome, my friend." When I asked, "Who is working with you?" She said, "You are. Aren't you here?" Where to start?! Six of the 14 women had not been examined at all, a few others had been transferred from clinics due to prolonged labor but hours later they continued to moan and shift on the beds, their IV lines clogged. After the morning rounds finished the situation improved somewhat, the clinical officer, medical intern, nursing students, a medical student from Holland, and a general physician from Palestine joined the fray. By the time I left at 1:30 I had conducted one vacuum extraction, had assisted with two others, diagnosed an IUD (intrauterine demise), initiated the resuscitation of two babies, and examined a handful of patients. I had passed through the full range of emotions, walked several kilometers, discussed the effect of American/Bush's politics on the world with Ahmed, laughed with Elske about a patient calling her Oscar, and visited the quadruplets. Msiska said, "Some day I will write an article about working at Bottom - sometimes you cry, sometimes you laugh." "Sometimes you laugh so that you don't cry," I added (we all laughed). I told her this is not an article but a book. I had to leave for work at the Embassy in the afternoon but patients and referrals continued to arrive. I told Msiska we'd meet tomorrow, "I will have drowned by then," she laughed.

Angels

Sunday morning I went to Bottom. I don’t usually work on the weekends but Friday my friend Msiska said she would have to work 12 straight days because of the shortage of nurses so I volunteered to come in for her. Saturday she sent me a text at 5:30 saying it was a horrible day, at the end of the day they had a stuck breech and the baby died. The whole of last week was bad, I resuscitated several babies who died, there were several severely asphyxiated babies, and there were several very premature deliveries. A cord prolapse that I assisted with was the one significant happy ending – they were twins and the presenting little girl needed some resuscitation but her condition improved quickly.

Sunday morning I arrived at 7:35, grateful to see that the ward was not full. The clinical officer and nurse were busy doing a vacuum extraction and she quickly told me that there was a delivery in progress on the next bed. I rushed to put on gloves and found Yasintha lying on her back with her knees pulled to her shoulders and a palm-sized portion of her baby’s head crowning. I quickly noted the vacuum sitting on the corner of her bed and took it as a sign that this was either a very prolonged second stage or that there had been fetal distress or both but for some reason – probably the neighbor requiring urgent attention - the intervention was not done. I watched Yasintha struggle through two contractions without moving the head any further then grabbed lignocaine and scissors and cut a small episiotomy. Yasintha pushed her baby out into my hands at 7:42, I clamped and cut the cord and rushed him to the resuscitare.

The boy lies flat at first but then, after several minutes, he blinks and begins moving his arms in wide slow circles. When I tilt him upright his eyes open like a doll’s but he is not breathing. I ask the other nurse to draw up some glucose and I give it to him through his cord. I continue with the bagging. Other staff arrive and greet me warmly, “Mwadzuka bwanji?” “So, we’re together today, great.” No one pays much attention to the baby as I bag it. It is not an unusual scene, me standing at the resuscitare over a limp baby first thing in the morning. I am so tired of this. My heart is tired, and what about the mother? She is now silent behind closed curtains. This is her first baby; does she know what is happening? Is she fearful or exhausted? Does she realize now that her baby may die or that if he survives he may have severe developmental problems? I blink away a few tears and consciously pull my thoughts away. I think of Clement in Ghana, we talked last night, he said he is losing weight, his classes are far apart and they last all day, he is walking constantly and not eating much. His trousers fall from his hips even with the belt cinched to the smallest notch. The baby kicks at my hands. He is still not breathing. I hold him up to the heat, he blinks, I plead with him softly, he still does not breathe. I plead with God. Yesterday Effie and I went shopping for zitengi in the market. For a Malawian wedding the couple is supposed to select an African cloth and then people will buy the fabric and have clothes made from it for the day of the wedding. We chose three different cloths, next weekend when we visit Mangochi we will see which is most readily available there and make the final decision. It feels good to have accomplished something. We only have ten weeks remaining before the wedding.

The woman in the bed closest to the resuscitare calls to me in pain, I look up and she says, “Come here.” She can see me with this baby but her baby is close now, her entire body involuntarily contracting to push her out. She needs hands to catch her daughter. I am the only one she can see. The little boy’s heart beats strongly but he only takes an occasional gasp – nothing very hopeful. I think about when I should stop, it has been 40 minutes, I will continue for an hour. It is a horrible torture to be the one who must decide when to stop. One hour passes. I am not ready to stop, maybe two hours. The woman at the near bed has delivered; a midwife arrived just in time. Her daughter lies wrapped in a cloth in her arms, the mother is quiet. I hold the boy again to the warmer. Watching his abdomen I see shallow breaths, he blinks. I stand over him now, caressing his forehead he breathes like a sleeping baby. After a few minutes I take him to his mother. She is asleep and I wake her to see the baby and tell her I will take him to the nursery. She looks concerned, “He hasn’t cried?” “No, he hasn’t.” According to her chart, Yasintha was tranferred hours ago for prolonged labor. I place the baby in his own cart in the nursery and explain the situation to the nurses.

There are two nurses working in the nursery, they are the same experienced nurses who worked all week. They will retire soon. Tereza walks me around the nursery. She says there are now twelve babies depending on formula. There are the quadruplets, a set of triplets, twins whose mother died, a singleton whose mother is suffering from postpartum psychosis, and two others whose mothers are severely ill. She is changing and weighing the quadruplets as she talks, she says the father and an elder from the mosque came and held a naming ceremony. They are now Mohammed, Hussain, Hassan, and Hamida. Hassan smiles periodically in his sleep, Tereza laughs and asks him, “Are you seeing angels now and then?” She says they are losing weight but their condition is good the only problem is that the mother wants to return home. It is planting season and the garden is waiting. The four will not survive if she takes them now. Tereza tells me that the triplets are in the kangaroo room (where the mothers wrap their babies tightly to their chests) she says they are not gaining weight yet but they are strong and clever, she says they will survive.

At the end of the day I return to see the boy. I find his mother sitting on the floor watching other mothers express their breastmilk by hand into small medicine cups. Her baby is screaming, his hands clasped into tight fists, he kicks and punches with what would be fury if her were older. I pick him up and try to soothe him. I tell his mother he is hungry. I know this cry; it is the cry of a baby who has suffered oxygen deprivation. I hold him while she works at expressing her milk. The milk has not yet come in, she manages to catch only two or three drops. I place him back in the cart he now shares with a premature boy who lies quietly, his thin arm resting over his eyes like an old man. We all need more angels.