The ground is wet while the taps are dry. A cyclone came through last week creating extreme flooding that wiped down likely thousands of houses of red mud brick and sand mortar and displaced at least 50,000 from their homes. The local medical students’ dormitory was flooded and some are staying here with us temporarily at Kabula Lodge. Yesterday provided a respite of sun and air drier than the usual bathroom-post-shower humidity and a cheerful boon after two days without electricity or water. Finally, the electricity came back yesterday (delight!) only to go out again a few seconds later, back on, off, and then on for several hours! The rain at least gave us some water to wash and boil for general use.
On being “rich"
I find the divide between the have and have nots here emotionally challenging. Our lodge, as is usual here, employs many very poorly paid helpers to cook, mind the children of the owners, clean, guard/open the gates, and maintain the buildings and “grounds.” Many of these employees have lost their local or village homes including the sister of the owner who works as a receptionist here (in a loose sense of the word). As I pass by these attendants whose bone structure suggest a history of malnutrition and make my way out to the five star manicured terrace of Hotel Mt. Sochi with luxuriously clean outdoor pool and hill view of a nearby hotel, I can’t he]p but feel guilty about my own actions. On the one hand, this week was incredibly emotionally taxing and left me dejected, angry, and feeling helpless and my spirits were restored by swim and sun. On the other hand, I feel that I should be actively throwing myself into relief work for those displaced to tents. The latter seems unrealistic, though, as I found myself on Friday afternoon with a black heart and nothing left to give.
On healthcare
It is difficult to encapsulate the misery of thiose who live here. Access to care is laudable as a network of quickly trained “clinical officers” spread throughout the country provide basic primary care and triage to larger centres such as in Lilongwe, the capital, Blantyre, my city and perhaps Michuri, a northern larger city. This access provides some false hope belied by the almost nonexistence of what I would consider simple and easily provided life saving interventions and perhaps more importantly a limitiation imposed by the lack of education of the caregivers. Parents, either not recognizing the gravity of the situation or maybe not able to leave their farms, other children, or find the funds to make the trip to medical care often bring their children in too late. It is heart-breaking to know that often the limited care that can be offered is no longer effective. For example, in a story becoming more and more common this year of extreme weather, a mother brought her daughter in to the Queens (our hospital) emergency room because she could no longer walk and she wasn’t fully conscious. The real story - either the house fell on her or she fell out of the house, I didn’t understand, she had blood coming out of her ears and nose (this shouts “skull fracture” to the trained) and over the last few days became more and more sedated. By the time she arrived she had a blown pupil, a suggestion of extreme brain damage and/or nerve entrapment. Somehow we (really the on call team) were able to convince the MRI technician that yes he did have to come in for an emergent MRI, though he requested payment of transport (another half hour spent trying to contact the on call “matron” head nurse to authorize taxi), and then once he came, didn’t call the on call doctor and then yelled at her for keeping him there for half an hour when she found out that he had actually arrived. I don’t know the outcome of this child. (note: I have never seen a Malawian yelling at doctors before, although they speak loudly to their help and their children; this seems out of character to what I understand of the Malawian spirit).
Amazingly, there is a neurosurgeon at Queens (not on call that day however), and access to the MRI as you say, sometimes even CT. Interestingy, I recently heard from a visiting Birmingham UK nurse that Capetown has some of the best trauma care in the world and even a super flash fast full body scanner. Why? Well, trauma exists in high amounts though I don’t know how it compares to Southern LA or Detroit, and fast full body scanners served diamond mine owners to scan miners after leaving the diamond mine…. Forget will. Where there is a bill (preferably USD), there is a way.
Though I often feel entrapped by gloom and helplessness (more on that later), the hospital I work in shows me that many children can indeed be helped. The paediatrics service at Queens takes care of approximately 300 children per day divided into the regular wards, the very sick ward (HDU), the not as sick ward (main bay), and the ICU (four beds for the WHOLE huge hospital!!!!!), where a patient only goes if the ICU docs are convinced that the child actually has a chance at survival. Part of this service is also the regular nursery (newborn babies and not too sick babies who need medical attention) and the nightmare Chitinka nursery, basically the neonatal intensive care unit. Okay, I divert, back to good things.
The most common situations that can be helped in pediatrics appear to be dehydration, malaria, HIV (hit or miss though depending on multiple factors such as family compliance, confections, early diagnosis, etc)), seizures, and basic infections like pneumonia, gastroenteritis (stomach flu), and the like. Our hospital, which provides as far as I understand the best or second best public health care in the country, also has paediatric surgeons and the above-mentioned neurosurgeon (adult- trained) as well as a basic oncology ward. Pathology is non-existent as the tissue slicing machine is broken, unless families can pay for a private send-out. The pharmacy dispenses medications (limited) if not pharmaceutical knowledge (thank God for the internet), and the lab processes basic blood samples. Rapid malarial and rapid HIV testing as well as bedside (meaning a small machine in the pediatric offices that one walks to) blood gases that give a brief acid status, some salt levels, and a quick look at the patients’ amount of blood. Anemia is rampant and surprisingly sickle cell disease (a malformation in the red blood cells which actually protects against infection of the blood cell with malaria) not as commonly admitted as I expected - perhaps they are just well managed (kudos to my supervisor who is part of that clinic). Femoral sticks are common as patients are usually skinny and dehydrated so peripheral access for blood gases is difficult. Nursing is another matter altogether - more later.
***difficult passage, please skip to next asterisk if you are sensitive***
As to neonatal care, it is truly survival of the fittest. Congenital surgical conditions have luck if the infant is deemed to have a somewhat normal life after repair and epairs of birth defects such as hydrocephalus (water in the brain), gastroschisis (the abdominal muscles don’t close and the intestines protrude out), and other somewhat advanced operations occur with variable outcome while perfectly healthy if underweight or premature babies die of exposure (hypothermia), treatable infections with available antibiotics, and inappropriate or nonexistent respiratory support (i.e. help when they can’t breath for themselves). On the same rounds mentioned above where we admitted the chid with possible skull fracture, we walked into the Chitinka (very sick/at risk baby) nursery and found a baby blue and gasping for breath. No history available as the mother came in from another hospital and didn’t know how far along she was and the baby seemed the normal undernourished term infant with a common problem of respiratory distress. The on call (amazing) british resident, the Indian-Malawian extremely smart medical student and I (remote from neonatal care) started resuscitating the baby while we tried to bring a nurse into the unit to help. She took her time and started take care of another totally stable infant while I started to bag the infant and asked for CPAP. “we don’t do it for this baby”. I was rude enough to insist on CPAP, a machine that blows pressurized air into the baby’s nose to open up the lungs and push out fluids, as I saw that bagging helped bring the babies’ oxygen level up. (a note- the simplified CPAP at Queens is actually the joint project of my alma maters Rice University and Baylor College of Medicine with Texas Childrens Neonatology participation and is being rolled out allover Malawi). Finally the nurse in charge of CPAP came and we stabilized the infant on CPAP with an unreliable sat reading but at least he was pink, and I had to leave. I walk in the next morning to the daily depressing mortality report of the last 24 hours to hear that the infant had died in the early hours of the morning. Again, last Friday, I walked into Chitinka to help do GI consultation with my limited knowledge, and saw another blue baby, this time a twin. The infant had a very vague common diagnosis of “asphyxia” at birth and was exposed, with low temperature, fighting to breath, and not maintaining appropriate sats. The usual resident was out due to the birth of his own baby and here I replicate my exchange with the covering resident
“why is this baby still cyanotic (blue) on full oxygen by nasal cannula?" Can you start CPAP?”
“No, we don’t do CPAP for this baby.”
“Why?”
“We don’t do CPAP for asphyxia.”
“What do you mean by asphyxia?”
“I don’t know this is my first day.”
“There is a visiting neonatologist (from Texas Childrens working as part of the CPAP rollout), could we ask him what he thinks?”
“He came by this morning.”
“What did he say?”
“He recommended CPAP.”
"Why aren’t we doing it”
“We can’t do CPAP for asphyxia.”
“Did you round with your consultant (boss doctor) yet?”
“No”
“Do you think you might want to call him about this patient earlier?”
(with a face of disgust, as most residents work independently) “No.”
I can’t step more over the toes of the in charge physician so I leave, enraged, walk out to the hallway and get lost as usual, then find myself sobbing as I walk. The trauma of it, two days in a row for these completely helpless babies is not something I can put in a box in a dark recess of my mind. What do I do? I feel utterly useless at this point. I walk into the office of my supervisor and my colleague from the Netherlands also working on Malnutrition for over a year now in Queens tells me “Go find the neonatologist! Talk to him, maybe you can get it to happen!” I find the neonatologist, find out that he has had the same battle, and that this morning he had bagged the baby (take a mouth/nose cover attached to a bag and pushing air manually into the lungs) and found that the infant could not maintain his sats even with bagging. In other words, it is too late, and even CPAP won’t save this slowly suffocating infant from certain death. Of course, this infant has been hypoxic for more than one day, and early intervention was completely missed. In my disgust and frustration at the lack of supervision and basic care and even more the lack of apparent interest or activity of the resident physician (cover the babies!!! they are cold!!!), my colleague talks me up again from a place of deep darkness and helps me understand the following lessons. I have to recognize also that this is not my country and I cannot think that I am always right.
- nurses at Queens, are working very hard and are definitely overworked and completely understaffed. They may work many shifts with or without backup help in a row. One nurse didn’t leave the hospital for two days in the high-risk kids ward, for example.
- they may not cover the babies because it makes diaper changes more difficult when they have no time (diapers here are usually cloth wrapped with a plastic bag). unacceptable but whatever.
- many children can’t get further investigative or assisting care, so some babies are, I would say, marked as doomed and therefore further interventions don’t happen and can be seen as a waste of resources (flawed but true)
- one may work as a visitor to Queens for months without any sense of truly being able to make a difference. The best interventions are often providing physical and emotional comfort to family and patients.
After seeing the extreme malnourishment of our sickest patients at Moyo (the malnutrition unit where I am based), the fate of only slightly ill newborns, the discussions in morning report how a baby with hydrocephalus and not enough brain tissue (water in brain) receiving a shunt (a drainage of the brain fluid into the belly fluid to relieve pressure in the head) would just prolong the parent’s suffering, and listening to a mortality report of a child with intussusception (the intestine collapses into itself, which leads to death the intestine if it doesn’t pop out and can be popped out by air or barium pushed into the rectum if not surgically) and the inability to even do a very old and cheap maneuver of an air enema, I just lost heart.
*********okay to read now************
On self-reflection
This weekend was full of darkness with no water, limited electricity and self-emolliation into the luxuries that I, a mzungu, can afford. Lounging by the Mt Sochi pool in sunshine and having amusing if aggressive conversation (?mild autism) with eight year old birthday party members after a Friday night’s dinner of luxurious steak and wine, I was able to pull down a curtain, however guiltily, on the trauma of my heart. Somehow the weekend did not refresh me and Monday started with difficulty.
What I feel now - What am I doing here? Will I really be of any help? Am I actually more of a hindrance? Do I even have any right to use my remote general pediatric and neonatal knowledge? Am I even a good enough gastroenterologist? Will this environment ever change? Will I be able to harden my heart enough to last another two months?
I could no longer see the victories, the need for me to pull back and observe even if it meant I was taking (knowledge and experience) rather than giving.
Fortunately Bible study this week at the amazing McGrath’s amazingly welcoming, warm house with good food and good coffee and usually power if not water, was about Philippians chapters 3-6.
Whether you like the Christian Bible or not, these words of St. Paul are powerful poetry for anyone in darkness:
Whatever things are true,
whatever things are noble,
whatever things are pure,
whatever things are lovely,
whatever things are of good report,
if there is anything of virtue and
if there is anything praiseworthy - meditate on these things.
So now I lift my eyes upwards, to the light (and the clouds) and tell you the beauty I see:
The hills of Malawi are green verdant with papaya, banana, mango, guava trees and plumeria everywhere. Today on the way to this internet cafe with no internet (and on generator power with no water), a group of eight and nine year old school children on their lunch break followed me and we exchanged some Chichewa and English words, impressions of animals, smiles, and laughter. The Malawians are uniformly kind to mzungu, foreigners, if not expectant of our means. Well off Malawians dress well and of course place value in their beautifully fashioned hairstyles weaves and all. The environments for the wealthy are well taken care of and offer respite. And fortunately for me, Malawi has excellent coffee.
On Stella Maris - an opportunity for change
Most importantly, I have the ability to directly impact the lives of children similar to my own fate-struck patients. Alice, the matriarch of the family running our housing, kindly took my Swiss biking-around-the world-friend, two of her adorable half Malawian half Welsh grandchildren, and me with her to the English language Catholic Mass on my first Sunday (more on that under Church). On the way back, she told us of a project she was working on and invited us to join her in sponsoring girls in a local high-performing Catholic secondary school.
Another day that week, we entered the well manicured grounds of Stella Maris secondary school and walked through the rectangular courtyard to meet Headmistress Sister Mary, a woman of joy and gentleness. As the grandchildren played around the office, she answered my many questions about the school. Well-performing children from district schools in a large catchment area around Blantyre are selected to come to Stella Maris regardless of their income. They are boarded by the school and must supply everything including their own sheets, clothes, eating utensils, etc as the school is unsurprisingly limited in funds. The have and have-nots share communally at the same dorms, the same tables, and clothing is equalized as much as possible, for example, no trousers allowed as trousers are expensive and therefore a status symbol. One girl arrived with only a plastic bag without sheets or soap or the necessities of a nourished life. The headmistress was surprised the next morning to find that her bunkmates had given her their sheets to spend the night. The girls go on to university, vocational jobs, or even back to their villages empowered with knowledge and academic and spiritual strength. Though university government spots last year were limited to about 25, around 80 girls qualified to attend; this year about 40 spots opened up to the 80 or so that qualified yet again. Alice’s own friends who attended this school long ago are now doctors, lawyers, veterinarians. Because of the many girls denied university education due to finances, the school has recently started a vocational program in the businesses of textiles (a large industry here), agriculture, and home economics. The school has little money of its own and sponsors must be found for each child. If a girl is unfortunate enough to go unsponsored, she cannot continue and must return to what often ends up as early marriage, early childbearing, dependence on others, and a borderline and uninformed week to week existence, like many of the mothers I see daily at Queens hospital.
Investment in education is freedom from bondage. Educated girls become educated mothers providing at minimum better care to their children and at maximum, elevation of their families if not their villages by their financial success and their ability to use the potential of their minds. Amazingly, the equivalent of approximately $1000 USD can permanently change a life and even a village by providing tuition for a year. The girls also need much smaller one-time amounts to pay for one set of clothes, utensils, etc., and amounts of any kind are welcomed to buy optional items such as shoes, sweaters, or soap.
Sister Mary presented me with a broken down budget of the cost of a year’s education and answered my questions about each breakdown (PTA, general fund) with candor and to my satisfaction. I have committed to sponsoring one child through her entire high school (three years) as has Alice, her daughter Katrina, and her son Paul (at the boy’s school).
I ask you: will you help change a life?
I plan to use direct transfers of funds to the school’s account which must include a memo with the child’s name. Receipts are available as direct email and phone access to the headmistress should one wish to see report cards or other progress throughout the year. I am happy to do extra work and pay the transfer fees should you wish to send me money to send them.
Even small amounts of money to buy clothes or shoes or soap or taking on just one term of a year would help. The budget is available should you wish me to email you a picture of it.
From darkness and futility in a country stretched further by floods, interrupted access to water and electricity, and the destruction of the homes of many, I see Stella Maris as a young tree pushing further upwards as it adds branch after branch. Some branches may flourish with flowers and useful fruits while others may fall to the ground to be trampled into the earth they came from, but the commitment of the leaders and teachers of this large secondary school will keep fertilizing this tree of developing women, trimming its branches, and pointing each branch onwards and upwards.
Perhaps as the silt of the Nile floods nourished the plants of the year, the floods of this land will grow stronger lives.
One can only hope. Hope and act.
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