Thursday, July 31, 2008

Driving Lessons

Less than half an hour after we saw the “Heavenbound Funeral Parlour” today, we passed by the scene of this matola accident. Apparently a front tire blew and the driver lost control of the minibus. Fortunately no one was killed—which is a miracle when you consider how flimsy the vans are, the speed at which they are usually driven and how tightly packed the people are inside. The injured had already been taken to a hospital when we stopped.

One of the nurses at Kamuzu Central Hospital in Lilongwe told me that they treat groups of injured people from road accidents at least two or three times a day.

Before I left the U.S., I had planned to drive a rental car on the next leg of our venture—south to Mulanje and Neno. But after just a few weeks in Malawi I reconsidered and hired a driver instead for the part of the southern swing on paved roads and accepted a lift from Partners in Health for the section on dirt roads.

It wasn’t so much the driving on the left-hand side of the road that dissuaded me. I had done that in Australia. It’s the fact that there is so much to watch out for—the constant stream of people walking, biking, even running along the side of the main highway. And since there is no shoulder, they usually are right on the road until you come up behind them. And like youngsters everywhere, children have the worst tendency to suddenly decide to dart into traffic.

Add to that the cattle, the goats, the chickens and the occasional stray dog—each with its own predilection for suddenly taking a mind to cross the road in front of you. Well, you get the picture.

At any rate, we’re headed south tomorrow. Probably won’t have much luck connecting to the internet. But will keep filing offline and update the blog when time and access allow.

Wednesday, July 30, 2008

Followup on Nurses at Dae-Yang-Luke Hospital

Two corrections: Last month I was told--and wrote--that most of the 17 nurses who had left Kamuzu Central Hospital since April had gone to work at Dae-Yang-Luke Hospital, which I described as a private hospital run by the Korean church. That accurately reflects what I was told but the information was wrong.

Today I spoke with Abigail Bonongwe, the matron at Dae-Yang-Luke who tells me that just two nurses have come to the hospital from Kamuzu Central--not seventeen. Furthermore, and this I should have realized from the outset, Dae-Yang-Luke is not a private hospital but instead is part of the Christian Health Association of Malawi. Staff salaries are paid for by the government.

Indeed, DYL Hospital has made a concerted effort not to recruit nurses from government hospitals, focusing instead on those working at non-government organizations and who are recent graduates of nursing schools. In other words, they're actively working to address the internal brain drain, not make it worse.

Double-checking what you've learned is one of the hallmarks of journalism. It has taken me this long to get to Dae-Yang-Luke to verify what I was told earlier last month. This is why most of my blog posts are labelled "notes" and not "news."

Individual notes are often the results of conversations with single sources. Over the course of my posts, I am testing different ideas, trying to get at the facts. By the time this gets written up into a published piece, I will have a pretty good idea of what is solid and what is shaky.

I try to identify as much as possible in my blog posts what needs further verifcation but in this case I should have been more explicit and stated that it would take me a while to get the other side.

That's also why I encourage comments so that we can all learn as much as possible about the facts of any situation. Hoarding information, not sharing what you know--including your mistakes--is very 20th century. We're creating a new medium and a new, hopefully more responsive way of reporting the news.

Tuesday, July 29, 2008

More on Maternal Mortality in Malawi

Perhaps one of the most shocking things I learned while at Harvard’s School of Public Health was how unpopular maternal mortality is as an issue in the global health world. I’m told that’s that’s partly a result of internal academic politics—the obstetric and community health folks cannot seem to come to an agreement on what’s required. But people who do this stuff for a living also say that improving maternal mortality rates is just not as popular a cause or as easy to fund as improving child mortality rates. As if children could raise themselves after they were born.

When I got back to Lilongwe this weekend, I learned Dr. Sue Makin of Mulanje Mission Hospital in southern Malawi wrote a guest blog for Nicholas Kristof of the New York Times. She very clearly makes the connection between many Malawian women’s lack of power over their own healthcare—even deciding whether to go to the hospital is often not left to her—and high rates of death during childbirth.

On average, about one out of every 100 live births in Malawi results in the death of the mother. The ratio at Embangweni is about one in every 600—still high but six times better than the national average. Shows what can be accomplished.

Will find out about the situation in Mulanje when we travel there on Friday. Another great benefit of the Internet: Sue invited me to come last spring when I posted my Nieman field project proposal on the web.

A Pregnant Woman’s Lament

Pregnant woman to her husband: why do you want me to have so many children? You are not the one who will die in childbirth.

There is one song in particular that I have recorded at several of the prenatal clinics that keeps playing in my head. Indeed, I have come to think of this as the theme song for the trip. Finally heard a summary translation last Friday.

Although the melody is not at all mournful, the song is actually a lament. The first verses deal with a pregnant woman telling her husband that his desire for more children is likely to kill her. That if she keeps having a child every year, chances are that the children—spaced too closely together, who must be weaned too early—will not survive either. And then how will he feel when she and they are dead?

Subsequent verses or versions address the same issues to a traditional birth attendant. You’re not the one who is going to die if you delay referring me to a hospital or give me powerful herbs to induce labor.

And perhaps this is why the melody is not mournful—because in the final verses, the husband realizes how much he will grieve if his wife and children die and he agrees with his wife to limit the number of children they have.

Can’t wait to get that recording edited and uploaded when I get back to the U.S.

An Experiment in Multimedia

This trip through Malawi has also been about exploring new ways to tell people’s stories—through narrated slide shows, video, geocoding photos and other multimedia. There’s a lot of equipment wrangling involved. Good thing I like gadgets.

Here’s a photo Eileen took of me in full multimedia regalia at the Emazwini mobile clinic on July 4.

I have learned you definitely can’t do everything at once. Even if you’re part of a two-person team, you have to do things sequentially. For example, I can’t record background sound while Eileen is photographing because I pick up the sound of the mirror clicking inside her camera.

The other big thing is data management. Audio, video and high-quality photos take up a lot of space on a card. Unless you bring lots and lots of cards, you have to download your stuff to computer, external hard drives, DVDs. Of course, you should be backing your stuff up anyway.
Keeping track of everything and remembering where you are in the process requires discipline and a good file-naming system. After every recording or photography session I back up the files to the computer and to the hard drive. Have also backed up some of the most critical work to DVDs.

Which reminds me. I need to back up the interview I did yesterday with Wadana Mkandawire. He is a nurse midwife technician who is upgrading his qualifications at the Kamuzu College of Nursing.

Women at Work

One of the things I really admire about Eileen is her determination to keep photographing until she finds the right angle, lighting and composition for each shot. Just before leaving for Malawi, she fell and hurt her knee but convinced the doctor to let her come ahead anyway. So here she is on the Fourth of July on the floor of a room being used to examine pregnant women during the monthly mobile clinic in the isolated village of Emazwini—30-plus kilometers away over dusty tracks from Embangweni.

Of course, Eileen is not the only person hard at work in this photo. Joyce Ngoma (in the dark blue headscarf) examined about 25 pregnant women that afternoon, checking for signs of anemia, swelling in the lower extremities, palpating abdomens to determine the position of the fetus, etc. Florence Mwandira (in pink) is recording the results in a large health register.

You can see the brace on Eileen’s right knee and the chitenje she wore over her jeans. A chitenje is basically a length of cloth that women in the villages wear over their skirts. It keeps the dust and dirt off their clothes.

Women wearing trousers—let alone jeans—is still a pretty uncommon sight in the villages. And we didn’t want to offend, so we wore chitenjes on the first mobile clinic. But several Malawians told us that times were changing and that at any rate, people understood that American women dress differently. So on the next mobile clinic both Eileen and I wore trousers.

Sunday, July 27, 2008

And Then There Were Two

Katherine left as planned today for the U.S. She’s taking the videocamera, recorded tapes and several backup DVDs with her. I had thought of holding on to the videocamera for the rest of the trip but finally decided it is just too much equipment to lug around and be responsible for—along with audio and still camera. The lesson here: if you’re working on your own you have to decided either to do (a) video or (b) stills plus audio, but not both.

Each is a different medium with different requirements. I’m still moving the videocamera too much when I shoot. Still not getting enough B-roll—the shots that you interweave into an interview to cover breaks in the conversation.

But it’s all a learning process—and that’s been the most fun part of all.

Electricity, Satellite Dishes and Cell Phones

How electricity, satellite dishes and cell phones are changing Africa.

Eileen can hardly believe I took this photo. Where's the action? The drama? The human beings?

But I wanted to show how quickly some things are changing in Embangweni, Malawi.

Electricity came to Embangweni Mission Hospital in 2001. Satellite dishes were available starting in 2003 and the two big cell towers (you can see only one of them) arrived earlier this year. The improved communications have made a huge difference in the hospital's ability to network with other health care facilities, contact suppliers, donors, locate that ever-elusive diesel fuel.

Junior Nyirongo, Embangweni's whiz computer person, is now figuring out how to connect to the internet through the cell phone network. Expensive but another link to the world at large.

I promise I'll post some more people-oriented photos soon. But couldn't resist this one. Quite a contrast with the photo of a woman being taken home from the hospital in an ox cart.

Saturday, July 26, 2008

The Sounds of Success

23 July, Wednesday

A welcome sound from female ward—laughter. That means nine-year-old Miriam is really coming along fine. She was admitted a few days before we arrived at the end of June with second degree burns across her abdomen. She was trying to warm herself by the fire at home and her dress caught fire. For the past several weeks she has been lying in bed with a kind of cradle holding the blanket over her wound.

I've watched the nurses cleaning the wound on several occasions. No sign of infection in all this time. Looks like she'll be heading home next week. Would have gone sooner but her family lives so far away that it would have been difficult for them to get to a health center three times a week to change dressings.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

An Ox Cart Ride Home

21 July Monday

Watched as an elderly woman was discharged this afternoon and loaded into a waiting ox cart for the ride home.

You can hardly see her in this photo. She's lying down behind the seated woman. The family was eager for me to take the photo. They were quite pleased with the results on the digital playback. Perhaps also glad to know someone is paying attention?

Other random observations:

The hospital doesn't send ambulances out at night anymore as there have been a couple of attempted hijackings.

There's a guardian with every patient except in the labor ward. Too many grandmothers were giving their daughters or daughters-in-law a powerful traditional medicine to induce contractions and it was leading to many instances of ruptured uteruses.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

A Visit to Thoza

18 July Friday

Katherine and I went with the mobile clinic today to Thoza—about 9 km away. Eileen stayed behind to take some more photographs at the hospital. I took a few photos in Thoza and then had lunch with Mary and Lupenga Mphande. He is a professor of African studies at Ohio State. Small world.

Been thinking a lot about what I hope to get across in the pieces I produce when I get back home. What are the most important points? Which the most important assumptions to puncture?

Keeping coming back to the idea of how easy it is as an American to assume that there is nothing here; how easily my own focus is drawn to what is missing from Embangweni as opposed to what is here. (Although given my experience at Kamuzu Central, must admit that I checked for soap when I first arrived at Embangweni and was happy to see it everywhere.)

Points I want to keep in mind: There are structures in place. People here know what's missing but typically don't get asked for their input. There are no quick fixes. Solutions have to be integrated. Relationships matter. You have to show you care (both for patients and staff).

Along those lines, you don't just plop a family planning program into a community without also providing for the basic health needs of that community. Otherwise, what is the message you're trying to get across? We're afraid you're going to have too many children?

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

A Fall From a Bicycle

16 July, Wednesday

Sixteen-year-old boy today came in with a badly broken arm. He looked about 12--stunting due to longterm lack of food.

The story was that he fell off a bicycle on his way to the hospital to beg for food. Both parents are dead. He is living with his elderly grandmother (although it was an elderly man who was there with him).

Both radius and ulna badly broken. He needs pins to set it right—which cannot be done at Embangweni. So Catherine Ndolo accompanied him in the ambulance on the way to Mzimbe. Then Lindsay Kamanga got on the phone to call to Mzimbe to organize a guardian for him there—to make sure he gets what he needs while in the hospital.

Was impressed by the care with which everyone treated this young man. Eileen got some great photos of Catherine Ndolo escorting the boy to the ambulance.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

A Policeman Calls At Dinner

15 July, Tuesday

Left at 7:30 AM with Wezi to go to Lilongwe to pick up Katherine Bates, who is helping with video equipment. We gave a ride to the wife and child of a local police officer.
Funny, when Wezi came to dinner table last night with a police officer in tow, Eileen thought I was going to get arrested. After it became clear he was just asking for a ride for his family, Eileen let everyone know what she had feared and we all laughed.

Reached Dae-Yang Luke Hospital at 11 AM, where I was scheduled to interview Dr. Douglas Lungu, the hospital director. But the operation he was performing took longer than he suspected so didn't get to talk with him until after 1 PM. Very good interview, if brief. Would like to schedule another. Alas, the only room available was an empty library, so there was a lot of echoing boom in the audio. Left at 1:40 PM in order to be at airport for Katherine's flight.

She arrived with no problem and we took off back to Embangweni after first using the bathroom at the airport. Stopped in Kasungu to stock up on water and some snacks. Made it to Jenda just before the sun set. Wezi showed us how close we were to Zambia—just the tree line to the left of the road.

Beautiful fast sunset as we traveled on the dirt road from Jenda. Wezi drove slowly as it was getting dark. Stopped and was surrounded by three herds of cattle on the way. They were being driven (on foot) to Lilongwe. Wezi explained that the herders would drive the cattle for about 30 km or so, then rest, then another 30 km or so. They will probably arrive on Saturday or Sunday.

Hallelujah! Eileen's husband Mike figured out how to text my Malawian cell phone on Skype. Received the first message on the way back from Lilongwe. I can't reply to his Skype messages but I can text his mobile phone so now we have two-way communication with the U.S.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

Sad News at Morning Report

14 July

Learned during morning report this morning that 12-year old Charity died at 3:30 this morning. She had cryptococcal meningitis and had been on anti-AIDS medication since February. First her father, then her mother died. She was admitted on June 24 and was responding to the meningitis medication but she also had chicken pox and Kaposi's and that's probably what overwhelmed her. Easy to believe that without her mother it was just harder for her to get proper care—particularly with the follow-through on ARV therapy.

Then there's the fact that she was started so late. Most of the deaths during treatment occur during the first three-to-six months; there just hasn't been enough time for the drugs to work.

At least she was comfortable. I also learned a little more about the community that develops on the ward among the patients and guardians. The woman in the bed next to Charity was from Zambia and had no guardian of her own. However she spoke English and so looked out for Charity and explained things to Charity's grandmother. Wonder if the Zambian was perhaps the same age as Charity's mom—if that's why Charity seemed less anxious whenever the Zambian woman spoke with her?

Spent much of the morning in the maternity ward with Godfrey Mdzudzuma, 32, one of four male nurses currently at Embangweni. He started off as a driver but his wife had a heart-to-heart with him about the opportunities for drivers—who are quite mobile—to have multiple girlfriends and all the risks that entails. So together they decided that he should become a nurse instead, find a place where they could both work since she is also a nurse.

Currently Godfrey's wife works at a different hospital but it looks like she'll be transferring to Embangweni in a few months. She has already given her notice.

Godfrey and Madlitso Chosalawa, another male nurse, were helping to orient Jane Chibaka, who just arrived and is on loan for a month from Ekwendeni Hospital. They spent the morning removing caesarean section sutures (no forceps to hold the sutures, Godfrey pointed out. He had to use his gloved fingers) and checking to see if some of the new moms and babies were ready to be discharged and sending them on their way after some brief education on what signs and symptoms should bring them back to the hospital right away.

Then I checked in with Lindsay Kamanga, the hospital administrator to get some more facts and figures about the place. They have between 4,500 and 5000 admissions to the hospital each year and see more than 15,000 patients in the four health centers. The operating budget for entire Embangweni health system for fiscal year 2008-2009 is 90,592,434.96 Malawian Kwacha, which works out to just over $647,000 a year. But this seems like an aspirational budget since more than a third of the income is from donations, which can fluctuate.

Just under 10% of the income comes from fees charged to patients. Mrs. K estimates that about a third of patients pay for their services, sometimes less. To give a few examples, the fee for an evacuation after miscarriage is 5000 kwacha ($35.71), for sepsis is 1745 kwacha ($12.46) and for a course of malaria treatment in the hospital is 1710 kwacha ($12.21)—although "LA" is provided free of charge by the government. LA turns out to be Co-Artem, made by Novartis.

The locum budget for the month of April was 269,529 MK for six senior nurses and 134,764.50 MK for three junior nurses, giving a total of 487,293.50 MK or $3,480. I have heard from several others that the locum pay is 800 kwacha per shift (about $5.70). (Hiring locum means hiring a nurse or clinical officer who is off-duty or on vacation to fill in.)

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

A Scramble For Life-Saving Diesel

13 July, Sunday

Second day without electricity. Embangweni Hospital is running low on diesel because the generator has been running non-stop for two days.

There is a patient with pneumonia on the male ward who is depending on an oxygen concentrator, which does exactly what its name implies—it takes available oxygen out of the surrounding air and concentrates it to a higher degree for a patient to breathe. But that takes lots of electricity—hence the need for the generator to run even during the day.

Lindsay Kamanga (the hospital administrator) skipped church this morning in order to organize the siphoning of diesel from several hospital vehicles to run the generator. With the immediate crisis under control, she got on the phone to find out which of the surrounding towns might have diesel. The closest is Mzuzu--about two hours away across dirt and tarmac roads--and so she has sent a driver with a truck and a check to stock up. (She also commandeered Martha's car, which has a full tank, to serve as an ambulance.)

Which do you focus on? The scramble for diesel, the length of the power outage or the fact that the hospital staff figured out a way to keep the generator going, to keep someone alive who would have surely died otherwise for lack of fuel?

The point is to survive.

Related post: Arrival in Embangweni

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

What I Love About Print

10 July 2008, Thursday

Small tremor last night at about 9:45 PM. Enough to shake the bed. Not enough to cause any damage. Felt sort of like a huge semi-tractor trailer went by. But of course, that's not possible here. Sat up in bed and my first thought was—but Africa is such a stable continent geologically speaking, it's not supposed to have earthquakes.

Eileen went to the homes of several nurses—Brenda, Monica, Nyayele and Emma—to photograph them while I interviewed Prospeline Chipata, who works in one of the farthest of the health centers that Embangweni supports. She was very shy and I fear that the interview didn't come off all that well. A little like pulling teeth to get her to talk. And of course, she was speaking in English, which is at least a second or third language.

But she's been working in that village for eight years. Unmarried. (Not surprising how many women I have interviewed who are not married or whose children had already grown by the time they came to Embangweni.)

In the middle of the interview, I learned that Prospeline has been trying to get the government to provide free bed nets for people with HIV. When I asked how that was going, she indicated it might take a while—she didn't know. Have noticed this kind of sad fatalism before whenever talk of future plans or potential government help comes up.

Also asked Prospeline to describe one or two patients whom she knows she has helped and felt good about. Her eyes lit up with a quiet pride as she recounted the story of a pregnant woman she had examined, who it turned out was carrying twins. Prospeline was able to refer the woman to Mzimbe District Hospital right away and the woman was successfully delivered of her twins. So the fact that all three are alive and well is more than likely due to Prospeline's actions.

This is what I love about print. You can take someone like Prospeline and make a story out of her—give her more of a voice, even if she doesn't sound that confident on the recording. I managed to take a decent photo of her in the small room off the chapel. A happy accident—using light through the door that bounced off a mostly white wall.
Eileen has taught me to open doors to get more light from outside. And to separate the background from the foreground in portraits. So I had Prospeline sit in the chair a little further away from the wall. Very nice portrait.

Classes in HIV and Photography

9 July, Wednesday

This morning attended a two-hour class on HIV/AIDS and ARVs, given by Getrude (that's how she spells it)—in the local language, Tumbuku. A few giggles when she whipped out a wooden phallus to demonstrate how to put on a condom. But the class was very attentive and interacted well.

In the afternoon, I interviewed Brenda Ngoma and Monica Mwale of the ARV clinic. Plus got another antenatal women's group to sing what I'm starting to think of as the prenatal song. Will have to get someone to translate it for me.

Monica said that the oldest person they have put on ARVs so far is 65 or so, the youngest was 1 year and nine months. I noticed Ellie Click's name and cell phone (doctor from Baylor Pediatric AIDS clinic in Lilongwe) on the wall and ask Monica about it. Monica says Ellie came to Embangweni for four days and has been in touch since. Whenever Monica has a question about children and AIDS drugs that she can't answer, she calls up Ellie.

Other notable things from this morning:
1. Flip chart to teach about AIDS with a kind of stylized warrior with a shield no longer being able to defend against the arrows from smaller red bad guys. ARVs are like the army or police. They put handcuffs on the bad guys but they don't kill them (to make the point about suppression not cure.)

2. They make the point that people with HIV should sleep under bed nets to prevent malaria. But although the ARVs are free, the bed nets for HIV patients are not. Only pregnant women's and kids under age of five are eligible for free bed nets—and there's even some question about whether kids under age 5 are still eligible for the government program.

Monica travels by bicycle 8 km every day to and from home to the hospital. Eileen is teaching me how to pan a shot of Monica on the bike so that the background blurs but Monica and the bike are in focus.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

A Mother of Nine with Eight Different Fathers

8 July, Tuesday

Drove up to Ekwendeni with Billy in the driver's seat and a few other passengers in one of the older vehicles. Smaller dirt road than the one to Jenda, then tarmac up to Mzuzu and Ekwendeni.

Great interview with Mphatso Nguluwe, deputy principal at the College of Nursing in Ekwendeni. Just listened to a bit of the audio (which I backed up on the firewire drive). Good quality sound and everything. Also tagged along as she supervised a couple of student nurses in the hospital.

Just before we left, caught up with Esau Kasonda, a Malawian nurse who wrote an essay that was published on He's now teaching at the College of Nursing at Ekwendeni.

Mphatso talked about many things but two I want to remember most. The first is that she is, as she says, "the mother of nine children by eight different fathers" and the second is that she feels like she needs a break from teaching. She is getting frustrating it seems with the quality of the current crop of students.

What she means by saying she is the mother of nine kids by eight different fathers is that she is raising nine children. She actually has never given birth to a child herself. Was engaged to be married once but her fiancĂ© died in 2002—in South Africa. She talked briefly of grief and then wondered whether, had he lived, he would have allowed her to take care of so many children?

I also learned Mphatso likes to tell church groups and gatherings that she is the mother of nine with eight different fathers. And then when she hears a gasp or murmurs of disapproval she likes to say, "What? Aren't we in church? I thought I would not be judged in church."

What you might call a teachable moment.

We stopped at an internet café to update blog. After 45 minutes, nothing went through. Tried twice on Gmail and kept getting server errors. Not sure why. Wonder if Yahoo would have been simpler? Seems to be what everyone else is using.

Thoughts on Expiration Dates and Acute vs Preventive Care

Matron Catherine Mzembe examines expired surgical gloves that have been donated to Embangweni Mission Hospital in Malawi

7 July, Monday

Quiet day today. Several people are off for Malawi's Independence Day celebration. Mrs. Kamanga and Matron Catherine Mzembe spent much of the morning opening and sorting cartons of donations from overseas. One box contained sterile surgical gloves, which was cause for some celebration until Catherine saw that they had expired in 2006 (see photo above).

A shadow quickly crossed her face. They will be able to use them as examination gloves but certainly not as surgical gloves. There isn't one expiration date for the U.K. and another for Malawi, she said in exasperation. Why would anyone send something that they would not use themselves?

Good news this afternoon. The baby with "congenital herpes" actually has chicken pox. Already she is doing much better and probably will be discharged soon.

A happy ending but it brings up a more disturbing issue: in trying to help, the volunteers from Massachusetts actually made things worse—bringing a child with a highly contagious infection into a hospital where many people have very weak immune systems.

After talking with Joyce and some of the other community health nurses here, I have learned something else about mobile clinics in rural Malawi. They work best for doing preventive care: checking expectant mothers to see how their pregnancy is developing, screening for high blood pressure, vaccinating children, educating the wider community about the need to refer someone with a chronic cough to the hospital—that sort of thing.

If you structure your mobile clinic to deliver what is known as acute care—treating someone with an infection, for example—you actually end up making things worse. (And the Embangweni staff should know—they tried giving acute care during mobile clinics before.) Antibiotics that are given out will be shared among family and friends—leading to drug resistance. Plus you are conditioning people to wait for the mobile if they have a major problem—like a headache that hasn't gone away for three days—instead of going to a health center or hospital right away.

Prevention and acute care have to work hand in hand. What's the point of screening pregnant women in the community, for example, if you don't have a hospital to send them to deal whenever you identify a problem? And similarly, what's the point of curing hundreds of children of malaria or diarrhea if you can't work with the community on mosquito control (making sure banana trees, which harbor lots of mosquitoes, are located away from the house, using bednets), clean water and basic sanitation?

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

A New Head of Clinical Staff at Embangweni

5 July, Saturday

Albert Nyirongo, a seasoned clinical officer, arrived this afternoon. He is taking on the responsibilities of the medical officer in charge and is on permanent loan from Ekwendeni near Mzuzu. That has eased the clinical-officer crisis somewhat for Embangweni.

I caught up on notes and logging audio. Talked with some of the other guests at the guesthouse. Hannah and Marie are two medical students from England who are here for a few weeks as part of their tropical medicine course.

Today's the last day for the medical volunteers from Massachusetts. They went out on a mobile clinic and brought back a two-week old baby with a rash from head to toe.

Diagnosis: congenital herpes. Treatment: intravenous acyclovir, something Embangweni hospital doesn't have. Prognosis: not good. The child is likely to die, they said.

Thought Eileen and I might go to the market this afternoon but I felt a touch of unsettled stomach and didn't want to risk it. Took a nap instead.

Not sure if it was the heat or what but the feeling went away. Never got sick. Indeed, haven't been sick yet this whole trip—knock wood. Have eaten a heck of a lot of starch—bread, pasta, potatoes and even nsima—loads of chicken and some delicious cooked mustard greens and even pumpkin leaves, but no fresh greens. Also been scrupulous about hand-washing and using hand sanitizer—before brushing teeth, before eating meals, after going to bathroom, after touching shoes, after returning from hospital.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

Mobile Clinic Plus an Odd Comment

4 July 2008, Friday

Happy U.S. Independence Day! Independence Day in Malawi is on Monday, July 7. It's actually July 6 but since that falls on a Sunday, the country is celebrating it on Monday.
Early morning wake-up at 5:15 AM so that we could catch Hilda before she went off shift. Eileen got quite a few photos before it was time to head for breakfast.

Skipped chapel in order to get ready for the mobile clinic with Joyce Ngoma. Left at 9:05 PM. Stopped first at the market in Embangweni to get some supplies. And then drove a good 45 minutes on bumpy dusty roads to Mhalaunda Health Center, where we took on more supplies and a couple more people.

Our final destination was Emazwini—more than 30 kilometers from Embangweni by dirt road. Have a feeling it's closer as the crow flies but then crows don't deliver medicine or examine pregnant women to make sure they're doing okay.

Already many people lined up in different areas under the trees. One section for weighing babies, followed by the delivery of World Food Program soya flour and palm oil. The women stretched a cloth out on the ground, a bucketful of meal was placed in a heap on the cloth and then a large cup full of oil was poured into the center of the meal, everything then wrapped up and carried home that way.

Learned that Joyce did three years training as an enrolled nurse. Spent a lot of time on the maternity ward "catching babies," then did a year's training at the Malawi College of Health Sciences to be a public health nurse.

She has now served as a public health nurse for 10 years. Says that's the only way to find out what people's health is really about—to see for yourself if their water is bad. What conditions in the home are. She also works with the agriculture agents in the area about what is nutritional food. She trained the community health volunteers—and introduced us to them. "They are our eyes and ears and feet and hands," she says.

Depending on which tree you sat under you either got your babies weighed, blood pressure checked, arm circumference measured or soya meal allocated.

Vaccinations happened in one room of medium-sized building. Prenatal checks in another room with two windows. That's where Joyce spent most of her time—and so where Eileen and I stationed ourselves as well. Thankfully out of about 25 or 26 pregnant women, there was only one complication: a woman had had a previous caesarean section and was over due. She will be heading to the hospital tomorrow.

Eileen got some great photographs. One of my favorites was of Joyce listening for fetal heart sounds with an old-style inflexible metal stethoscope. Reminded me of the old movies in which people put a glass to the wall in order to eavesdrop on a conversation in the next room.

Then came the contraceptive clinic. Fewer women were there but nonetheless, they were there. Most apparently got Depo-Provera injections (you get it in the buttocks—who knew?) I later learned that women in this area seem pretty open to contraception after having five children. They also use contraception to time their births so that they won't have a one year old and a newborn at the same time. Usually that means the older child can't get enough to eat because the mother's milk goes for the newborn.
Lunch was about 2:00 PM at the local headmaster's home. Ate rice, cooked mustard greens and a bit of beef. (And, just to satisfy the curious, experienced no ill effects.) Then another bumpy 30-plus-kilometer ride in the back of the ambulance to Embangweni. Bet I sleep well tonight.

An Odd Comment

There's a church group from Massachusetts staying at the Guest House that includes a doctor, a nurse and a paramedic. They're here with World Relief and have brought a lot of medication with them—including amoxicillin, antacids and Bactrim. The physician excitedly told me they were going to an area where no one had ever seen a doctor before. So naturally I asked where and learned they were going to the Mhalaunda Clinic.

My first thought was, well do they really need to see a doctor from Massachusetts? But figured I was just making polite conversation and didn't want to be rude. Besides, I liked the woman. And yet, her comment stayed with me—although I didn't at first realize why. (Sometimes I'm a little slow on the uptake.)

Later realized what it was that bothered me. They were going to a permanent health center that is staffed by a nurse. The clinic is one of four health centers in the Embangweni health system. Patients are referred to the hospital by the nurse. So they do have access to care—whether or not they have seen a physician at the clinic. And in fact, Mhalaunda is one of the closest health centers to the hospital.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

Success Creates Its Own Problems

3 July 2008, Thursday

Morning report at about 8:40 PM. Tagged along with Catherine Ndolo again. Watched her prepare the operating theatre for an endoscopy. Getting the equipment ready, making sure there was sterile gauze available. The whole room illuminated by natural light. Really quite amazing. There are fluorescent lights overhead and a round surgical lamp. The clock on the wall is stuck at ten past five and hasn't moved since I've been here.

The patient is a Mrs. Jere (a very common last name), who has been complaining of pain after eating for the past year. She has been to the district hospital at Kasungu but they keep sending her away. She decided to get herself to Embangweni to see if they could get to the bottom of things. In other words, she preferred going to a hospital in a rural area, which is at the end of a 45-minute ride on a dirt road, rather than to a nearby hospital on a tarmac road.

In fact, another woman who came in on Monday had an ectopic pregnancy, which was missed at Kasungu Hospital. They performed an ultrasound and said that the pregnancy was proceeding normally. She referred herself to Embangweni, where the ectopic pregnancy was diagnosed and taken care of.

These self-referrals from outside Embangweni's catchment area have placed a major strain on the hospital. Because of course by the time people get here after having been at another hospital, they are in much worse shape and require a great deal more attention and effort to save their lives.

The past four months have been particularly bad due to a critical lack of clinical officers. Apparently, many hospitals have been offering top-ups to clinical officers on their own authority—not as a matter of Ministry of Health policy but as a matter of survival—and so they are getting poached out of the rural areas. One clinical officer who was supposed to come yesterday during his month leave to help bail out Embangweni was forbidden to do so by his home hospital when they found out. He has told to help them out instead.
The nursing shortage continues to be chronic but at this moment, the lack of clinical officers is the crisis.

Yesterday's Malawi Daily Times had an article about a new team of doctors who have just arrived from the People's Republic of China and will be headed to the central hospitals in Lilongwe (where I had visited the pediatric ward) and Mzuzu.

Previously the Mzuzu Central Hospital had been staffed by doctors from Taiwan. But when Malawi switched diplomatic status from Taiwan to the People's Republic, the Taiwanese doctors left and the Taiwanese programs were suspended. I've heard from a couple of people the doctors at Mzuzu were given 48 hours to leave—although it's not clear by whom.

And ever since then the Mzuzu hospital—one of only a handful of central hospitals in the country and perhaps the only central hospital the north (I'm not clear on this)—was basically non-functional. In any event, it's the central hospital to which Embangweni ultimately refers (after the district hospital in Mzimbe).

Here's what The Daily Times article had to say:

Chinese ambassador to Malawi Lin Songtian said the team would be in the country for six months but said another team would arrive after agreements and documents were signed between the two countries.

The ambassador said that on a recent visit to Mzuzu Central Hospital, he found deplorable conditions, especially in the maternity wing so he requested his government to send over a team before agreements were finalized.

"Mzuzu was our first priority because as you know, our brother Taiwan had a team there helping out so when they left, people were left destitute," he said.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

Show Us That You Care

2 July 2008, Wednesday

After chapel we joined Catherine Ndolo, a nurse midwife technician who is rotating through the operating theatre. Wednesday morning is the time for scrubbing down the OR from top to bottom. (They also do it after every procedure.) I think Catherine was a little surprised that we wanted to go into the operating room to document the scrubbing but we assured her that's what we wanted to do and so suited up in gowns and rubber clogs. And from 9 AM to 10:30 AM, Eileen took photographs and I recorded the sounds of the scrubbing, mopping, splashing of water, etc.

After lunch I recorded the audio interview with Catherine Ndolo. She seemed rather shy but she has quite a story to tell. After being a nurse for a while in various urban settings, she came to the Embangweni area to care for her ailing father. And then when she wouldn't leave him, he said she'd better get a job at the hospital. She saw what good care they took of her father in his last days, so felt very grateful and continued even after he died. Then later, when some U.S. friends raised money so she could go to San Francisco to get a carotid tumor removed from the left side of her neck, she figured she had better stay with the hospital. So she's been here for 14 years.

There are drawbacks, of course. Transportation is a big issue and food. It used to cost 50 kwachas to get to Jenda on the dirt road, Ndolo says. Now it's 700 kwachas. By comparison, the whole trip from Jenda to Lilongwe on the tarmac road is 700 kwachas, she said.

Alas, I made a mistake in downloading the audio file and didn't double-check to make sure I had actually backed it up before I erased it from the card. And so will have to do that interview over again. Also, I realized I should try to get a quieter room next time. That could be a bit of a problem around here. Always everywhere, somebody is talking and the sound carries through all the open windows.

Am struck by the sense that Ndolo stays because this is a place that cares for her as a person. How do you put that sense of caring for people—for patients as well as staff—into a strategic plan? The message was pretty clear when I saw that miniscule bar of soap at Kamuzu Central that somebody didn't care what the nurses had to wash with—either there wasn't much soap to begin with or staffers were stealing it.

Of course, not everyone will feel obliged to repay a debt of gratitude. Catherine Mzembe, who is head of nursing or matron at Embangweni Hospital told me the story of three male staffers who were sponsored by the hospital for further education and left before completing their bond—basically an agreement to work for several years after advanced training—and two female nurses who left—one to get married and the other who was hired away by an NGO, which paid for her bond.

Evelyn Chilemba and Diana Jere at the Kamuzu College of Nursing told me two weeks ago they had re-introduced a requirement that all nursing student candidates be interviewed in person as well as pass an entrance exam because they wanted to weed out those who saw nursing as just another paycheck.
And of course, there is a prisoner's dilemma aspect to all of this. You can be the most caring person in the world, but if enough people around—and above you—don't care, then for your own survival you probably should stop caring as well. Otherwise, everyone around you will just take advantage of your compassion. But that just makes a bad situation worse.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

First impressions of Embangweni

1 July, 2008, Monday

Where to begin? Chapel had already begun by the time we arrived at 7:05 AM. Mostly in Tumbuku. Some scripture reading, some extemporaneous exegesis by the sounds of it, a choral selection, sharing of concerns, announcements, a hymn and a benediction.

The Embangweni Mission hospital compound consists of several dozen terracotta-brick buildings and outer buildings surrounded by a terracotta-brick wall. Although the staff have told the community they need to keep the chickens out, there always seem to be a few hens clucking about on the grounds.

Officially, the catchment area is 100,000 people. Unofficially it's closer to 150,000.

Currently, Embangweni has about 130 beds plus mats for about 60 expectant mothers. Each inpatient, however, is typically accompanied by at least one and often two or three relatives. On average, the hospital has about 4500 to 5000 inpatient admissions each year and three times as many outpatient visits. That's not counting all the folks seen by the health centers and the mobile clinics.

Being admitted to a hospital alone is practically unheard of. For one thing, there is no facility to serve meals, so relatives bring food and water (there is a bore hole on the compound). Nurses hand over pills to each patient's caregiver or guardian and watch as the medicine is swallowed with water drawn by the caregiver. As odd as the system seems, it works. Given the personnel shortage, it would be criminal to try to keep friends and relatives out.

Its hospital policy to let one guardian sleep on the floor next to each patient. Others sleep outside the compound in the guardian shelter. Moms sleep with their children in the beds on the pediatric ward. Children six and up are admitted to the adult wards—which isn't ideal and the Embangweni staff know it. There are plans for a new ward for kids 6-to-13 years old—provided funding comes through, etc.

There are four main wards--female ward, male ward, pediatric ward and maternity—and the operating theater which is centrally located. At first glance, the wards seem practically deserted. In fact, everyone—family, friends and patients—are outside on the grounds, enjoying the winter sun. Only the very sickest remain inside.

In total, there are about 200 staff members employed by the hospital, including maintenance crews, laundry teams, drivers, ward maids, data clerks, the accounting team, nurses, clinical officers (sort of like physicians assistants or nurse practitioners), one physician, one matron and one hospital administrator.

Embangweni is a mission hospital—part of the Church Health Association of Malawi, which provides about 40% of Malawi's health care. There is one missionary here from the U.S.—Martha Sommers, who is a family physician—but she is not in charge. That is the job of the medical officer in charge. Right now Smith Mpepo, a clinical officer, is the acting officer in charge. The hospital is hoping a more permanent medical officer in charge will be arriving soon.

As for the rest, Mrs. Kamanga is the hospital administrator. She seems quite formidable—which is important when you're trying to prise amoxicillin or other drugs out of the government's Central Medical Stores. But she also has a wonderful laugh and a generous heart.

Am struck by the enormous size of the trees all around the compound. Some are 80-to-100 feet tall and look for all the world like the live oaks around the Rice campus in Houston. Several 10-to12 foot tall red and white poinsettias here and there and some enormous bougainvillea. Mango trees line several alleys. Not the sort of thing I had expected to see. But speaks to the generations of women and men that have invested in this place. Begun as a dispensary in 1902. Became a rural hospital in 1926.
Reminded me of something I heard from Leon Kintaudi, who was named one of TIME's Global Health heroes in 2005. We were talking about time frames—five-year programs and the like. He argued for a much longer horizon. You have to do things now in order to make a difference 100 years from now, he said.

(NB: This post was written on site in rural northern Malawi and posted now that I again have internet access.)

Arrival in Embangweni

29 June, Sunday

The driver from Embangweni showed up half an hour early—at 8:30 AM. Fortunately, I was packed. Eileen was almost ready but it threw us both a little into a tizzy. Anyway, we got everything in the cab of a Toyota pickup. There was room for four (including the driver, Wezi, which means Grace and is a name used by both men and women) and we picked up the hospital secretary and her 14-month old for the trip back.

Wezi had clearly planned to get diesel in Kasungu but when we got to the BP filling station, there was no diesel to be had. No diesel in either of the other two filling stations in town either. Red cans were placed in the lanes to show they were out.

About 5 minutes further north along the M1 we understood why. The diesel delivery truck was pulled over to the side of the road and the driver was changing a tire. Wezi's body language changed a bit after that. He said we didn't have enough diesel to get all the way to Embangweni. But not to worry, if we got stuck, they could send some diesel out from the mission station (still about an hour and a half away) to bale us out.

And so we went on a diesel hunt, stopping at every little local market along the way. Wezi asked various merchants and mechanics where we might buy some diesel. Various suggestions. But none could be had.

We kept driving. Not sure why I was so calm. Guess I realized it was completely out of my hands. Was already thinking I was glad I had an umbrella against the sun—in case we got stuck on the side of the road.

Suddenly, Wezi slowed down. There was a bottle of orange liquid in a large translucent container propped up on a stand by the side of the road. Clearly it was for sale. (Snapped a photo.) Wezi stopped to find out if it was petrol or diesel (petrol being gasoline). Turned out it was petrol. So we kept driving.

Finally at the next market, Wezi stopped at a mechanic's shack and asked about diesel. Although the mechanic didn't have any, he obligingly phoned ahead on his cell and determined another local entrepreneur was selling it by the side of the road further north.

But, as Wezi told us later, the feeling was the diesel guy might not want to sell to us because what he was doing wasn't strictly legal and he might feel like we would rat him out to the police. So the mechanic counseled Wezi to speak in Tumbuka (instead of Chichewa) and plead with him that we were going to run out if we didn't get any diesel and wouldn't dream of reporting him.

And so that's how we bought about 20 liters of diesel, scooped out of a big old open drum. I now know that diesel is clear and not orangy in color. We paid 6000 kwachas for it—which is probably at least 50 kwachas more than the rate in Lilongwe—but hey, we didn't have to wait by the side of the road to be rescued.

Was told later that the diesel we bought originated with the "broken down" diesel truck. It's also quite possible that several of the filling stations where we had stopped did in fact have fuel but weren't selling any because everyone is anticipating that prices will jump at least another 25% very soon. (They've already gone up 25% since I arrived.)

Arrived at the Jenda road block (can't miss it) and took the first left. Spent about 45 minutes on a fairly bumpy dirt road and then came to the Donald Fraser Guest House. Found our room—basic with two single beds, warm blankets, clean sheets, blue mosquito nets, a flush toilet and shower. First screens on windows I've seen anywhere in Malawi. Much nicer than I had expected.

Made friends with a group of girls (mostly 12 years old) and one younger brother who came by. I took a tour around the compound with the kids while Eileen rested her knee a bit.

Picked up a few phrases of Tumbuku, the language of northern Malawi. "Muli uli" is "how are you," to which you reply "nili makola kwalimwe" ("I'm fine and how are you?") and so on. My young guide, Mercy (very soft r so it almost comes out Macy), was happy to teach me several phrases and wrote them out very carefully in my notebook with the English equivalents next to each one.

Learned from the other guests what the routine was for meals, etc. Will head over to the hospital tomorrow to see Mrs. Kamanga (the hospital administrator), Catherine Mzembe (Matron or head of nursing) and the rest of the staff.

Now to bed after a wonderful day with just enough adventure to make it interesting but not too much so to make it worrisome.

(NB: This post was written a month ago in rural northern Malawi and posted now that I again have internet access.)