Getting schooled

Mark here again. This week, I worked on the male ward and, not unlike home, it seems that men here tend to come to the hospital when they are more than “just a little” sick. Often taking a detour through a traditional healer, they arrive to be admitted in pretty grave conditions. I examined a young man in his 30s who was HIV positive and stated that he started poorly about 6 days prior. When I assessed him, he was breathing 5x faster than normal and had a temp of 104F. He indeed had full blown pneumonia and was going into septic shock.  He had a white blood cell count of 1.8 (normal 8-11 or so) and had no way of fighting this due to his HIV. I saw him at 10:30am and we gave fluids and antibiotics, the only real tools we had. When I returned from a short lunch, a nurse stated “that guy you saw this morning is dead,……..but he’s the ONLY one.” It seemed to me that she was used to seeing many more and I realized again that I was not in Missouri anymore. This week I’ve seen HIV, TB, pulmonary embolism, malaria, gas gangrene of the leg, cryptococcal meningitis, psoas abscess, acute respiratory distress, bullous impetigo, alcohol withdrawal and drumroll…….2 crocodile bites. Many of these conditions, which are very treatable at home,  get a futile attempt with an ill-suited antibiotic and a shake of the head as if to say “that’s a real shame”. I’ve also performed several lumbar punctures, removed ascitic fluid off abdomens, repaired a hydrocele and inguinal hernia, and emergently removed fluid from a adolescent’s penis which was being constricted by retracted foreskin. No boring days.

            I’ve become more efficient with my assessment of patients, learned to think quickly about how to best use the limited resources I have, and gained more confidence in procedures. I also know that as a whole, we complain about our health a lot more at home. Also, crocodile bites look very painful and I don’t ever want one.

            We are having a quiet weekend in Mangochi to save some cash and to figure out a strategy to get our visa extensions without paying an exorbitant amount of money. Sweating it out in our hot accommodations will make holiday seem all that much better. On to maternity ward next week. I am excited but nervous as I expect to see lots of complicated births. Stay tuned and stay well.

If you see this sign, pay attention

White gorilla

What will she ever do next??

I feel like I’m at the zoo. The Azungu Zoo. And I’m the star attraction.

We have a lovely shaded, grassy area outside of our hostel building. During the hottest part of the day, we frequently drag out a blanket and rest under the trees (the beauty of the 2.5 hour lunch). However, it is very difficult to do much resting when dozens of schoolchildren are gathered on the other side of the hospital ground's fence, hooting, laughing and yelling.

I felt much empathy for the gorillas at the zoo today as I picked through my rice in the shade. The rice was pretty pebbly and buggy, so I was at the task for quite a while. The kids never lost interest in my fascinating project. Really? Because I know your mom picks through rice at home, too. What could possibly be so intriquing? Then I thought of how we ooo and aah over the poor primates at the zoo…”Mom! Look! He’s eating a banana!” “That is so crazy how he’s just sitting there staring at us.” “Totally adorable! That mom is feeding her baby!”

So, I took a picture of the school kids watching me, which they, naturally, found hilarious.

Safari park

Can you see them?? Elephants! Or as Iris says "Ents!"

Kitchen at Liwonde Safari Camp

Beautiful Liwonde

One of many warthogs

I set my own personal record for minibus travel on the road to Liwonde National Park: nine people, an enormous bucket and three packed bags in three seats. Then we took a bike taxi ride for the last miles, much of which was dirt ruts. Let’s just say the 140 lb Malawian who peddled Mark, Grant and bag earned his taxi money.

Liwonde National Park is home to elephants, monkeys galore, hippos, numerous deer varieties, crocodiles, warthogs and lots of baobob trees. We stayed at Liwonde Safari Camp, a spot which was recently carved out of the jungle along the edge of the park. For $20 a night, we got the dormitory to ourselves (yeah, off season), and lots of attention from the rather bored staff.

The owner took us on a trip through the rustic park, where we encountered all kinds of wonderful wildlife. We didn’t get as close to the elephants as we’d hoped (half a football field, maybe), but it was pretty awesome. We’re going to try to get in another trip at the end of the month in hopes of catching a boat tour this time.

It was beautiful, and the evenings were incredible with delicious meals served by candlelight. We could hear hippos rummaging outside throughout the night, and monkeys cackling at all hours. Late one evening, we went on a candlelit hippo hunt through camp. We never did find one, but we certainly scared ourselves silly in the effort.

The kids at daycare

The kiddos and I have been making the day care a regular part of our morning. We spend a few hours there, working on the English alphabet (especially vowels – aka “VOWELOS!”) and playing. Today I brought books, which were a big hit with kids and teachers. I haven’t seen a book in Malawi yet, outside of the medical school’s library.


The facility is a sandy yard outside of a local family’s home. There’s a shaded structure in the corner of the yard and some nice trees. The educational materials are a few large sheets of paper with letters and numbers written on them and a small chalkboard. The toy selection is comprised of four car tires, a basketball, three stuffed animals and one of those mooing canister contraptions.

When the little ones get tired, there’s one twin plastic mattress in the shade, or they lie down in the dirt and take a nap. The day care provides a cup of tea in the morning, and a hot lunch of nsima (corn porridge) and ndiwo (beans, meat or veggies) that is cooked outdoors on a tiny, hot stove (which, by the way, sits on the ground right in the middle of loads of small children).

It should be noted that the children at this day care all have shoes, clothes in pretty good condition and their families send snacks each day. Basically, these are kids from privileged families who have the means to invest in their children’s education by sending them to a private preschool to prepare them for primary school. These children are in the great minority in Malawi.

It's hot, hot, hot

Ah, another delightful weather day in Mangochi. I try to do my laundry (a pretty vigorous activity) as early as possible. I finished by 8:15 am this morning, a sopping, sweaty mess, which is particularly annoying since this perpetuates the endless laundry cycle. You would think having to hand wash all diapers would lower the birth rate around here (which, by the way, is 6.3 children per woman).

Blackouts are fairly common and though the hospital campus has a generator, it isn’t always reliable. We’ve had a couple of nights with no fan. Combine that with no cross-ventilation in our room and all of us sleeping in one twin- and one full-sized bed and you’ve just defined “steamy.”

This is not a true Mangochi lady. A Mangochi Amayi would have that baby properly dressed in a crocheted hat, polar fleece head to toe and a snuggly polyester velour blanket wrapped around it. For goodness sake, it's only 94 degrees in Mangochi today, a cotton afghan is not going to cut it. I'm calling DFS.

Two nights ago I got caught in the hospital during a blackout. It required very cautious walking to get out of there, I will tell you. I walked to the market in the dark to pick up a couple of Valentine’s Day Fanta treats. Vendors had candles lit in their tiny stalls, I could hear singing and the stars were bright. Not a breeze stirred, but it was pretty cool nonetheless.

The hospital experience

Main signage, hospital layout

Mark here. I decided to hack Sara’s blog to post some shred of evidence that I am actually working while here. My apologies for some medical jargon that may follow, but there may be some folks reading this that are interested in the details…..

The Mangochi district hospital receives local patients as well as referrals from 40 smaller hospitals in the area (25 government, 15 private). For a medical hub, the resources leave quite a bit to be desired. As of writing this post, the hospital is experiencing an antibiotic shortage (oral drugs limited to Ciprofloxacin and Bactrim). They are also out of reagents involved in blood transfusions so many sick children with malaria are stuck with pretty severe anemia. In addition, a major petrol shortage has limited the transport of supplies from other facilities. Pretty rough going but seems to be the norm. Did I mention that electricity works about half time, limiting anesthesia machines and O2 supplies?

The hospital has an outpatient department, an operating theatre, an x-ray department, and clinical wards that provide services for women, men, maternity, pediatrics, nutrition, and male/female tuberculosis patients. I spent my first week on the female ward. This involved general medicine for hospitalized women but also includes going to the operating room for any identified conditions that require such. In one week’s time, I encountered and treated patients with HIV, malaria, sepsis, cirrhosis, congestive heart failure, bowel obstruction, pneumonia, kidney infection, tuberculosis, advanced cervical cancer in the immunosuppressed, and domestic violence-related knife wounds. In addition, I assisted in performing tubal ligations for women who desired sterility and performed quite a few uterine evacuations for women who had miscarriages and retained products of conception. Most patients have advanced disease and may have traveled many hours to get to the hospital. It was a challenging and rewarding clinical week to say the least.

This week, I have been on the pediatric ward and have witnessed a high degree of mortality—more than I had prepared myself for (I personally declared four children dead this week).  Rough estimates show that about 10% of kids under 5 yrs do not leave the hospital alive. This morning I rounded on 3 ward bays, which contain 4 beds each. The math should work out to 12 children, but when I finished, I had seen 62 children, with 4-5 per bed and many on the floors with their mothers. Most of these kids have severe malaria with anemia, interspersed among pneumonias, meningitis, malnutrition, HIV and various other conditions (hydrocephalus, abscesses, kidney disease). Transfusions are limited and IV treatments for malaria and sepsis are not always available, which means doing the best you can and hoping for some luck. Witnessing child death has been a particularly hard experience and it is very different culturally. The process is pronouncement and leave mother for 5-10 minutes. She is left alone and not comforted by hospital staff. After a short time, the child is unhooked from any IVs and the mother wraps the child on her back and there is a procession out of the ward. It is practice to have them buried very quickly.

It has been an incredible two weeks. I have so much appreciation for the health system we have at home and all the things I take for granted while supplying care. I have the pleasure of working with some fantastic colleagues here and I am impressed by the resilience of the Malawian people. There have been many successes among the tragedies mentioned above; I am seeing people get well and leave the hospital; and many of them have a nice smile for the crazy Azungu (white person) who helped take care of them. I’m having a great time.

And on top of all this cool work, I likely will have a chance to see elephants in the wild this weekend. Woo-hoo. 

I hope you are all well.  We are doing great.

Cape Maclear

Must get out of hot Mangochi for the weekend, so we are headed back to beautiful Lake Malawi. This time, we’re visiting a place that’s been called one of the most beautiful places in all of Africa – Chembe, or Cape Maclear. Getting there wasn’t too terrible (though the last 18 k of road are spine-jarring dirt ruts) and apparently a whole slew of people agree because we had trouble finding a place to stay when we got there. At our sixth stop, we found a little bit of paradise at the Mgoza. I could live here forever in a little thatched roof hut with a huge bed and walk-in mosquito net.

Cape Maclear

Aside…Mosquito netting with small children really bites. It’s like living in an A-frame on all sides, and little people are constantly jabbing a limb out of the side or pushing it against the net creating mosquito heaven. Walk-in netting, on the other hand, is lovely.

Makes a twin bed feel very small, especially when you have to share with a child!

Ah, yes. That's the ticket

Lydi and friends

Anywho, we had a tremendous time playing in the water with local kiddos (for whom Lydia’s golden locks had some kind of a magnetism that they couldn’t keep their hands off), swinging in the hammock and generally luxuriating. I began to think this was Shangri La until I woke up in my breezy hut to the sound of waves crashing and the feel of thousands of tiny black ants crawling through my hair and across my upper torso. Ewww.

Ants aside, a wonderful excursion and we will definitely try to get back for a few days at the end of our trip.

Note to all: sorry for the nearly total lack of communication. We have two internet connection options. One is at the hospital – which rarely works – and the other is an expensive internet café (more like a working library, really) across town, which is difficult to get to and my children seem to delight in interrupting the work of all who are there so I feel like an obnoxious Azungo everytime I go. Although, I am here now by myself (a rare treat) and the guy is asking "Where are the children?"

Breakfast on the beach

Hot blooded baby is so happy at the cooler lake!

We’re all safe and happy and having a great time!

Window of Hope

Today I spent my first morning with Window of Hope, a local organization that reaches out to maternal orphans. If you are unfamiliar with the term “maternal orphans,” join the crowd. Here’s the scoop…

When a mother dies while giving birth it is a shameful thing. The husband leaves surviving children behind with his wife’s brother and returns to his home village to remarry. However, since Malawi is largely a matrilineal society, the brother-in-law probably lives in his wife’s village anyway so the raising of the multiple maternal orphans passes to Agogo (grandmother) who has no way of supporting the children. Maternal orphans are even more likely to be uneducated than the general population, and the girls are generally married as soon as they have their first menses.

Window of Hope has a day care, a language center for women, and assists Agogos in keeping their grandchildren in school by helping with tuition, book fees, soap for cleaning uniforms, etc. The Charlotte, the kiddos and I spent the morning at the day care, which has two teachers for the 40 little ones. While we were there, they drilled the kiddos on their alphabet, sang songs and flew like airplanes through the yard.

I’m excited to help out with the day care and on drafting some public relations material while we’re here. Right now, the entirety of Window of Hope’s budget comes from the paying day care attendees.  If anyone has grant ideas, I’d love to hear from you!

Outdoor bath

No running water today and the kiddos needed a bath. Instead of hauling water from the Boro hole to the room, we went for a bath in the laundry sinks. I confidently balanced one bucket of water on my head, took a step, and became drenched. I need a lot more practice.

In a month, I'll be able to do this. Uh, probably not.

Iris and Lydia each occupied a sink, and I enviously watched them splashing nude in the cool water under the trees. Grant, who had adamantly stated he didn’t want a bath, crept closer and closer to the fun, and before you know it, had also stripped down.

The Amayis at the pump smiled at the laughing kids, and Charlotte and I enjoyed the breeze. What a beautiful day.

Hauling water for the day – though for us, it’s only a few hundred feet – reminds me of how much of the world does this every day, and how it consumes hours each day for some woman and girls. How lucky we are, and I am grateful for the opportunity to remember that.

Monkeys and lizards and camels, oh my!

Lydia on Malawian transport

We celebrated our first Sunday in Malawi by taking a minibus to nearby celebrated Lake Malawi. Now, by minibus, I actually mean the back of a ramshackle pickup truck. But, it was that or no transport, so off we went. It started off well, with just 10 of us in the back, but it quickly filled up, to the point where Grant leaned over and commented, “In Malawi, there is no full.”

The Sun ‘n Sand resort was beautiful and weird. It had a water park, opulent outdoor restaurant and cabana-like space for hundreds of people, and huge rose gardens. All this next to a tiny village where people walk a distance of several football fields to get water. We encountered two dozen guests and probably four dozen workers. We also encountered a sign that said “Please do not provoke the camels.” Whhhaaa? But that question was soon answered.

Where am I?

Can you imagine? One day these camels woke up to find themselves in lush, sub-Saharan Africa walking alongside local monkeys.

Little friend

Gorgeous setting, though, and we whiled away much of the day on the beach before setting back to Mangochi, listening to the excited calls of “Azungus, Azungus!” (white people) from children as we walked past their huts.

Houses near Sun 'n Sand

Laundry day

It is time to face Laundry Day. We have laundry facilities, which I am grateful for. As fun as washing laundry at the Boro Hole (pump) might be, I am glad I don’t have to lug my wet, clean(ish) laundry across the hospital campus to the drying lines. Handily, there are lines just out the door from the washing sink. This is what we call laundry facilities.

Washing machine

So, armed with my detergent from the local grocery, I set out to work. But I realize that my idea of hand washing is to fill a sink with suds and water, swish, swish, swish and rinse, but there’s no stopper here. It occurs to me that I am imitating a washing machine, and perhaps it should be the other way around? I scrub the first shirt and then decide that much of our laundry isn’t as dirty as I thought and I refold it. Wah lah! Half of the laundry is already finished!

I observe the Amayis (mamas) at the pump later that day and discover that they plug the drain hole with old plastic bags – aha! That makes the next laundry attempt a bit more effective. But, I’m sure I have a ways to go. Memory, the guard who is stationed outside our building, followed our friend Charlotte into the laundry, stood over her shoulder while she worked and exclaimed “I think you are being lazy!” and pushed Charlotte aside to do it herself. Ironic, I think, since Memory spends the vast majority of each shift lounging in her chair or sprawled on the ground waiting to see what funny thing the Azungus (white people, that’s us) will do next.

Life is in the journey

If life is all about the journey, we are really living! The short of it is that we have arrived in Mangochi, safe and sound after four long days of travel. The long of it is in the paragraphs below…

One of the biggest reasons I wanted to blog on this trip was because I had trouble finding resources for traveling 1. With kids 2. Without money 3. To this area. So, I will start by emphasizing that the best way to describe the journey is to borrow a little vernacular from the tween crowd and say…O  M  G.

We left Columbia Sunday afternoon at 3:30 pm. An overnight in STL and then off to the airport at 5:30 am where we caught our flight to DC. May I recommend the proximate Air and Space Smithsonian (offsite from the Smithsonian campus) for long layovers at Dulles? It’s essentially two ginormous hangers full of flying contraptions, which were pretty cool.

Now, one of the greatest advances in air travel (aside from the Concorde, which is moot now, anyway) is the inflight entertainment system. Except when it doesn’t work, like on this trip across the ocean. No movies, no games, and in an engineering genius move, it also meant that the cabin lights stayed on until 2am because they were controlled by the same system. Yikes. Eventually, we arrived in Johannesburg (happy birthday, Grant!), where we slept at a lovely Inn from 10:30 pm until 2 am, which was when the kids decided to wake up for the day. Double yikes.

On to Malawi on Wednesday morning, where we stayed at a hostel that caters to other long-haired freaky people.

The bus to Mangochi leaves at 6 am, so we were there, bright and early on Thursday morning. In developing nation fashion, we waited until we were loaded with at least 2 people for every seat before we left. Thank goodness, because after 4.5 hours sitting on a hot, fragrant bus listening to Mark singing “I’ve got two tickets to paradise….” we were all ready to move on.

Mangochi seems to be a fine place to reside the next 4-6 weeks. The hospital staff is working to make us comfortable and we are walking a fine line between being culturally reasonable while meeting some basic needs for the kids. Getting a fan is a first order of business today, cost be damned, as we don’t recall ever having been as hot as we were last night.

Early comments from the kids:
Grant: “ It’s a little bit embarrassing, but kind of cool, to always get attention because you’re different.”
Lydia: “I think we should move to Africa until Grant, Iris and me are grown-ups.”
Iris: “Milk.  Milk.”

Be back with an update soon.

The bus ride to Mangochi

Playing in the rain in Blantyre