Turkey Day

The rains have come to Malawi. Every morning huge billowing cumulus clouds congregate in the sky, and as afternoon comes they coalesce and darken, until the sky cracks open with a bolt of lightening and rolling thunder. No wonder people believe that rains are a direct communication with God, because it doesn’t ever sprinkle here. Torrential sheets of water turn the roads into rivers, and women take off their shoes and put plastic shopping bags on their heads to protect their weaves and god-awful wigs. It usually only rains for 30 to 40 minutes, but it is down right biblical. When it stops, the temperature has dropped 10 degrees, and everything smells fresh and clean and new.

The rains have brought many changes. The majestic purple of the jacaranda trees has given way to the fiery orange of the flame trees, and what used to be a dry dusty brick-red country is now bursting with green green green. The termites emerged two weeks ago. The first rains were their signal to climb out of the ground with their new wings and fill the air with their brief dance of flight. Brief indeed. Where the night before it was like a blizzard of snowing insects, by the morning there are large drifts of shed wings and no termites to be seen. The spiders and millipedes and ants have forged onto the scene as well. Last week there was a tarantula in my kitchen. A couple of days before, I was presented two baby black mambas (deadly poisonous snakes) smashed with the shovel by my guards, proof that they had been doing their job and were not sleeping on their shift.

It’s technically summer here now, but there are still tacky Christmas decorations in all of the shops, and I even went to sing carols the other night in preparation for the holiday season. We celebrated Thanksgiving two days late here, because you really can’t do the holiday right if you can’t be in the kitchen cooking all day. Thursday was just like any other day in Lilongwe, except that my friend Brendan was driving around with two live turkeys in his car. Teeny and Thomas could have used some fattening up before we ate them, but I don’t think one can ever felt as connected to (and grateful for) a meal as when you watch it meet its end and then pluck out all its feathers. (Turns out they come off much easier if you pour boiling water on it first.) Turkey feathers are actually quite beautiful, and look lovely in a glass bottle as a centerpiece on the table.

I hosted 50+ people for our Thanksgiving feast, many of whom (at least those from the UK, Europe and South Africa) had never before experienced this quintessential American tradition. They caught on pretty quickly though, and one British guest even went so far as to bring cupcake–sized sweet buns decorated with red and white stripes with blue gumballs for the stars. He is welcome back to Thanksgiving any time J. The food was delicious, the company fantastic, and the only complaint is that there was no stuffing left over for me to eat for breakfast. But it is no wonder that the Bourbon and Bacon stuffing was popular. I think even the vegetarians and the Mormons ate it. I knew it was a success because most people went home clutching their bellies and claiming that they wouldn’t eat again for a week.

I love Thanksgiving. I love being surrounded by family and friends (and here in Lilongwe, your friends ARE your family) and feeling blessed by the fun and warmth that they bring to my life. I miss all of you at home and hope you all had a great thanksgiving :)

*no birds were harmed or eaten in the taking of the photo above.

Cash Economy

There is no such thing as a credit card in Malawi. Everything here operates in cash. Not only that, but there is no such thing as a $10 bill, or a $20 bill, or even a $5. The largest denomination bill is 500 kwacha, which is about $3.50. So when I pay my guards and housekeeper their salaries every month, I hand them a wad of cash. When I pay my internet bill, or the security alarm (3 months at a time), I fork over a wad of cash. Going to the ATM is like hitting the jackpot. You can't take out more than 20,000 kwacha at a time, which sounds like a lot, but is really only $142.50. So at the end of the month, when it is pay-day and bills are due, I have to hit the ATM like 3 times a day, 3 or 4 days in a row. Carrying around $500 in $3 dollar bills makes me feel like a gangster. The wad of cash is so big that it doesn't fit in my wallet, so I carry around rubberbands and folio clips to contain it in neat bundles. A recent grocery store run to stock up on beer (bought by the case - you have to bring back the empties to get new ones), cleaning products, and other sundries ran me 11,000 kwacha. It took me 6 minutes just to count out the cash. For some reason there is actually a denomination smaller than the lowly kwacha - 100 tambala makes 1 kwacha. Which is ridiculous, because even though there is a 1 kwacha coin, no one ever uses them, so why you would need tambala is beyond me. In fact, often in the grocery store, instead of getting your 3 kwacha in change, they give you a piece of candy. Only in Malawi :)

Pictures of Malawi (at long last)

Me and Claire.

Precious, 7 yrs old. He is Mohamed's older son, and so so sweet. He is in 1st grade and speaks perfect English. I think he is going to be a professional soccer player some day (or the president).

Kelvin, 2 yrs old. Mohamed and Matilda's younger son. A roley-poley toddler, who laughs and squeals and jumps up and down every day when I come home. He can't figure out if he loves or is terrified of Claire (the dog).

Sarah, my Canadian roomate (who is 6 foot 1) and the boys, who are not freakishly tall - they are standing on a wall.

My good friend Carrie at the market.

Kids playing at the market.

A view of Sapitwa Peak (translation = "don't go there"), Mount Mulanje. I went there, and it was great! 3,000 meters (almost 10,000 feet), straight up. There are huts on the top with sleeping pads, a wood fireplace, and cooking utensils. And a hut keeper that makes your fire, heats up water for bathing, and washes the dishes. Oh, and beer you can buy, so you (or the porters) don't have to lug it up the mountain. Best camping ever.

Our fearless porters who carried all our stuff up Mount Mulanje.

Kevin, Carl, Rachel and Sarah. Throwing some Malawi signs.

On the Mulanje plateau.

Beautiful woods at the base of Mulanje.

Sarah and the Baobab.

I'm not dead

I have got to be the most negligent blogger ever. My humble apologies. Do not fear, I have not been eaten by a hippo, contracted some terrible flesh-eating tropical disease, fallen madly in love with a native or adopted any small children/pets. Just been busy. Somehow, "there's not much to do in Lilongwe" turned into spirit-infested mountains to climb, international film fesitvals to attend, dance clubs to party at til 4am, new friends to have drinks with, major gajillion dollar grants to write, anti-retroviral trainings to attend, vegetable gardens to plant, frisbee games to play, outreach sites in villages to visit, and all number of other things. So, in my usual fashion, I have gotten myself quite a calendar, and sitting in front of the computer is low on the list. This weekend I am off to a three day British-Malawian music festival/drunk-fest at the lake, which is apparently the social event of the year. I PROMISE blog updates when I get back.

Labor Management

This one is dedicated to Ms. KG :)

I didn't realize that when I moved to Africa I would become The Boss. What??? I just spent the past two years on the Executive Board of a labor union for god's sake. But all of a sudden I find myself living the life of the wealthy uber-elite, with 5 employees whose livelihoods I am responsible for, and whose sole purpose is to keep me safe and comfortable. Geez, I came here to help people. I took a huge pay-cut, left friends and family, and moved half-way around the world to work for the underserved and the stigmatized and the people that don't have an advocate standing up for them. I did not come here to have my supper cooked for me every night, or my car to be washed, or my bed to be made every day. Some people might think that it sounds like the life, but honestly, I would rather live in a mud hut.

That being said, I have some of the most honest, reliable and downright friendly employees one could ask for. And it makes me happy to know that I am providing good jobs and good salaries to 5 people that otherwise would be shit out of luck. But man, they don't know the principles of the bargaining table.

Part of the problem is that I was totally unprepared. No one really told me that living here involved guards and housekeepers and gardeners. No one explained what a typical salary was or what the usual benefits are. But, being a true believer in the process of negotiation, I told them that we were going to have a contract. I wrote up a document that spelled out work hours, base salary, incremental pay raises, sick/vacation time, benefits (guards get a rain suit, a warm jacket, a pair of boots, tea and sugar, plus a small fund to be used towards educational or medical expenses) and the rules and expectations of the job.

I think they were a little surprised. Especially about the part where is delineates what will get them fired (like repeatedly being found asleep, or the house getting robbed). You have to understand that in Malawi it is basically impossible to get fired, even for being egregiously incompetent. I think this goes back to when Banda (the first "president" i.e. dictator) was in power, and stocked the ranks of the government and business worlds with his friends and nephews. There are actually quite strong labor laws in this country and you can easily get taken to labor court for "inappropriately" treating an employee. (I heard a story about another expat who fired their guard after they were caught stealing and ended up in court for not continuing to pay the salary after the incident.) This results in a whole lot of disincentives for doing a good job (or even showing up), and a whole lot of nothing productive ever getting done.

But I digress. This is certainly a problem with some of the Malawian employees at the clinic where I work, but my guards and housekeeper are incredibly hardworking guys with a tremendous amount of integrity. They may not have ever signed a labor contract before, but man, they caught on quick. Once they saw the details in writing, they had a lot of suggestions. Like giving them their whole raise upfront, instead of incrementally as incentive for good work. Like death benefits ("what if I were to die while I was working, would you provide for my dead body?"). Like a year-end bonus. Like school fees and healthcare for their children. Like funeral costs for their children or their spouses. (Oy! I guess these things are part of everyday life here). The whole thing made me SO uncomfortable.

These guys make $100 a month working 12 hour shifts for 23 out of 28 days. Of course I want to provide all of these other things for them. But the truth is that they already make almost double what most house guards make, and their benefit package is generous in comparison to many others. I don't want to get caught up in the whole colonial caste system here, but I also don't want to be manipulated or persuaded through my fairly generous nature to provide a way of life that is not sustainable. No matter if they were to make $50 a month or $500, they would still be living hand to mouth, because in Malawi, if you have more money, you take on the care of more relatives, neighbors and friends, because there are always those who have less. And they would never be able to get hired for this same job at this salary by someone else. I am more interested in investing in their human potential - by funding them to finish high school, get trained as a driver, or take cooking classes, so that they don't have to work as an unskilled guard at a low-paying wage again.

In the end I gave them most of the things they asked for. We compromised a little. On a couple of points I held my ground, mostly to remind them that whether I like it or not, I am still the boss. You can't blame them for taking the opportunity to get what they can out of an arrangement that is so inherently imbalanced. What did they have to lose?

A Day In the Life of the Pediatric Wards at Kamuzu Central Hospital

Disclaimer: I initially sent this out only to my doctor and medical friends. I didn't post it to the blog because it both contains a lot of medicalese (some of which I have tried to translate), and because it is fairly graphic and disturbing. So if you are easily traumatized by medical horror stories, do not keep reading. But the truth is, this is what medical care is like on most of this planet, and I think it is important for us all to realize (debates over single payer vs. public option vs. non-profit healthcare collectives aside) that we are extraordinarily lucky, and that life is a lot harder when you are poor in the developing world.

The clinician on duty walks into the High Dependency Unit (HDU) and begins the day by saying “Is everyone still alive?”. 4-6 children die every night in the hospital’s 200+ pediatric beds, spread over 5 wards. The HDU only has 5 beds, but they are reserved for the sickest, most complicated kids. In any hospital in the developed world, these children would be in an intensive care unit. The fact that all of the patients that were here when we left last night are still here is a small miracle. One is a 16 year old boy who was admitted yesterday in DKA (diabetic ketoacidosis). Or so we think. He has a history of recurrent abdominal pain and vomiting. He is severely malnourished. And his blood sugar was over 600. There is no way to measure pH. STAT electrolytes take 4-6 hours to return (which is amazing, since usually they take a week), and there is no such thing as measuring IV fluid rates or giving meds by drip. His blood sugar has come down to the 300s with IV fluids (measured by drops/minute) and subcutaneous insulin. His mental status has improved. He is lucky.

Next to him is a 10 year old boy who presented with body swelling and respiratory distress. We did a thoracentesis (stuck a needle into the space between his chest wall and his lungs to remove fluid) in the treatment room 2 days ago and got mostly blood. We were thinking that maybe he had some kind of heart failure causing his pleural effusions, ascites (fluid in the belly), and hypertension, but his electrolytes came back showing massive renal failure, revealing his diagnosis of underlying kidney disease. We put him on prednisone (no albumin available here, and lasix might dangerously dehydrate him further). Miraculously, the adult dialysis team comes and says they could manage to do peritoneal dialysis on a child if the surgeon would kindly place the pigtail catheter. Sure, no problem. So far so good.

The 4 yr old patient across the small room in Bed 4 can be heard wailing under the iron cage that keeps the blankets from touching her body. She has full thickness burns covering over 50% of her body, including her face, both arms and hands, and torso. She was burned because some other kids in her village locked her in a thatched hut and set it on fire. There are no plastic surgeons in Malawi, no opportunity for skin grafts or physical therapy or even adequate dressings. Topical treatments include penicillin powder and mashed papaya. We are waiting for her to die.

And yet, it has been a successful morning in the HDU. Labs that were ordered have come back. Consults have been answered. Children are still alive. Then we start rounds on the HIV patients, and we enter Ward A.

Ward A is a long narrow room with 10-15 cribs or beds lining each wall, which are painted with chipped murals of safari animals. There are 2 children in each bed. (And this is the quiet season. When the rains start, and malaria runs rampant, there will be 3-4 children per bed and you won’t be able to walk to the end of the ward). Large cumbersome oxygen concentrators are mounted to the wall and look like prehistoric octopi with as many as 6 different tubes snaking to the many children with respiratory distress. Mothers dressed in the same bright traditional fabrics they have been wearing all week look hopefully up through exhausted eyes, hoping that you, the azungo (white) doctor are here to see their child. Occasionally, the nurses wind the crank on the Grundig radio and some lilting African music or Christian bible preaching temporarily drowns out the crying and coughing of sick sick babies.

Mphatso is almost 2 yrs old. She is HIV +, and has massive generalized lymphadenopathy, Making her neck so swollen that her head is shaped like an eggplant; the lymph nodes so large they are impinging on her airway making it hard to breath. Her saturation today is only 87% on O2 (though the 2 litres/min she is supposed to be getting is being shared with 2 other kids through endless splitting of the O2 tubing). She looks tired, and ready to be done with it all, though she is dressed in her best Dora sweatshirt and shiny pink skirt. We are holding her chemo (Vincristine and Bleomycin are the only drugs available, whether you have KS, ALL, or lymphoma, any of which may be her diagnosis) because she is febrile and neutropenic. She shares a bed in the open ward with two other babies.

We don’t round on George, the 13 year old with relapsed cryptococcal meningitis, because he died overnight. His bed has quickly been filled by someone else. It is unclear who covers the hospital at night. Technically there is a Clinical Officer on call (which is basically the equivalent of a paramedic, but who provide the bulk of the medical care in Malawi). There is no routine taking of vital signs, meds are only given three times a day, and Mums do the vast majority of the “nursing” care. They sleep on the wooden benches or on the floor, so that they can breastfeed their children, and attend to them during the night.

We move on to the nursery, which is comparatively quiet, with lots of sunlight streaming in through the windows. Beyond the faded, grimy curtains, are rows of laundry hanging to dry, Mum’s washing their naked brown children with swollen bellies, and people resting on the ground in the fresh air. As we try to figure out what is going on with this HIV-exposed infant who has supposedly had fever x 2 weeks, I notice a Mum sitting on the floor holding a tiny tiny infant who looks like he is minutes away from death. He is one month old but weighs 2 kg (less than 5 pounds) and has the appearance of a small frightened aquatic alien who has been thrust into the air and forced to make do with ill-equipped biology. He is severely malnourished, his eyes are wide and unseeing and frightened, his tiny hands are squeezed into balled fists and shaking as if in protest to this cruel cruel world. Someone has admitted him to the NRU (nutritional rehabilitation unit), but failed to notice that he is also severely dehydrated, a febrile neonate, and on death’s door. Or maybe they did notice, but he is not so different from the hundreds of other children that pass through this hospital on a daily basis. There is no triage system here.

I take him to the treatment room and place an IV in his scalp. I give him a 10 ml/kg bolus, not wanting to overload him, since it is difficult to assess for dehydration in a patient that is so severely malnourished. But his heart rate quickly decreases from >200 to 140, and he seems a bit less agitated, though when you pinch his belly skin, it stays tented for a good 3-5 seconds. I run some more fluids, and offer him some oral rehydration fluid through a syringe, which he tries to swallow. Good sign. I let the medical student do a spinal tap, which he gets, but which is grossly bloody. HSV meningitis? Hypoxic brain injury causing a bleed? I will never know, because I can’t order a PCR, and the closest CT scanner is 6 hours away by bus and is currently broken.

Despite a respiratory rate of about 12, the tiny baby seems to be staying alive, and I am relieved. The other children in the treatment room are not so lucky. One is a 7 month old febrile child who has been seizing since this morning. Her fontanelle is so bulging that her forehead is soft and squishy. I give her intramuscular diazepam and try desperately to get IV access. Multiple peripheral sticks, 2 intra-osseous (IO) attempts, 2 femoral line attempts (both IO and fem lines tried using a regular 22g IV cannula) later, I find some Ceftriaxone at the clinic (the hospital has completely run out) and give her a whopping dose IM. One of the medical students has inserted a nasogastric tube, and without IV access, that is going to be her only source of fluids. She is not my patient – she just happened to be in the treatment room (the closest thing to a Peds ER), was in status epilepticus, and I happened to be the only clinician in the room – and so I did the things I knew how to do to take care of her. I write down the lab tests and medications that she will need in her chart, and hope that someone will actually look at it before tomorrow morning.

Another baby, who actually is my patient (being an HIV-exposed infant) has come into the treatment room with one of the clinical officers. He has had fever, vomiting, diarrhea and respiratory distress, and looks lethargic. The CO is working diligently on getting an IV, giving Quinine for presumed malaria, antibiotics, oxygen, IVF, etc, so I focus my attention on the others who are precariously hanging on. The next thing I know, the mother is wailing “lululululululululu” and a blanket has been pulled over the baby’s head. This one didn’t make it.

I look around. It is 5:00pm. There are 10 children on the bench being cradled by their mum’s, holding the IV bags in their free hands. At least 3 of them look like they are about to sink into unconsciousness. There are no other doctors or clinical officers in the room. No nurses to be seen, only the two orderlies dressed in masks, gloves and plastic aprons who have come to take the dead baby to the morgue. I realize that if I choose to stay, I will never leave tonight. Tomorrow is another day. I slowly back out of the room, trying to avoid the pleading but silent gazes of the mums who seem resigned to the inevitability of waiting. Right now, their children are still alive, and that is something to be thankful for.

I may be pan-spritually, ethnically Jewish, but I find my fingers making the sign of the cross as I slowly walk across the yard of the pediatric ward, my eyes raised to the glowing orange orb of the setting sun, silently mouthing a prayer to protect these poor babes and their mum’s; and that if they must die, to let it be quick and painless, without suffering.

But do not fear my friends!! Life in the clinic is a whole 'nother story. Kids with Stage IV HIV get put on anti-retroviral medications and gain weight, fight infection, and recover. We hand out prescription peanut butter fortified with vitamins and minerals and lots of good calories ("ready to use therapeutic food") and large-headed, swollen-bellied, skinny-limbed kids come back fat and happy. Teenagers attend our monthly Teen Club and play soccer, act out skits about HIV and have fun with their friends without having to worry about being stigmatised for having a disease.

The hospital is an unfortunate, sad place that is chronically understaffed, under-resourced, and the referral center for all the district hospitals who send all of the super-sick patients who aren't getting better. We have instituted universal HIV testing for all kids that get admitted, so that if they do get better, they can be identified and referred into appropriate care. I am optimistic about this year, and am looking forward to the challenging work that lies ahead. This week was just an eye-opener into the reality of life in Africa. I am realizing that I am going to forget most of what I learned in residency while I am here, but will learn so so so much more.

Chifue, Chifine

Chifue (Chee-foo-aye) = cough

Chifine (Chee-fee-naye) = runny nose

I've had both for the past week, which may explain the lack of recent blog posts. No worries, I am on the mend, and even scored a couple of times at frisbee the other day.

Despite the head cold, I've been fully able to appreciate the sensory experiences that Lilongwe has to offer.

SOUNDS:

I awaken every morning to the chirping of birds, and the "squuuuuaaaaaaaaccck" of this huge black and white raven-looking bird that seems to be the pigeon of Malawi. I wonder if Grandpa George would call it a raven or a crow, since I have no idea which side of the Mississippi we are on. Mohammed called it something like kwangwa, or maybe I am just making that up since that is sort of what it sounds like. At night I go to bed to the sound of crickets and a symphony of dog barking that starts at one end of the neighborhood and waves its way around and around until I guess they all get tired, or realize that they aren't really barking at anything at all. Today I found out that Clare (my dog) can howl in perfect harmony with a car alarm. Turns out she has a lovely voice :) Occasionally I hear the whining protests of Kelvin, the almost 2 year old rotund little boy who is Mohammed and Matilda's younger son, who appears to have quite a developed sense of right and wrong.

SIGHTS:

The earth is brick red and dusty. Succulents and tropical vines grow side by side. Purple, pink and red flowers are just starting to bloom on barren trees (yes, it is winter here, despite temperatures in the 70s). Women come to clinic draped in three of four different layers of chitenje, the traditional brightly colored block-printed cloth that is used to strap babies on their backs . The girls on the other hand (from infants to teens) wear their best outfits to come to the doctor, so it feels like the prom every day, with ruffles, bows, gauzy fabric, and occasionally tap-shoes. The air is hazy and grey from the smoke of burning fields and garbage fires (see SMELLS). Every night the sun sets as a flaming crimson orb sending out florescent pink tendrils into the tangerine sky. Pollution makes for some pretty amazing sunsets.

SMELLS:

This should probably should have been the first category, as the smells are probably the most striking sensory experience here. Mostly there is the smokey, rich, earthy smell of fires. This time of year, fields are burned in preparation of the rains and planting season. The organic smoke mingles with the slightly acrid smell of burning trash in pits on the sides of the roads, and the turpentine smell of diesel fuel. The most amazing smell is the B.O. It is beyond onions, or sweaty socks, or unshaven French girls, or anything I have ever smelled before. I don't know if it is something in the diet, or the fact that most people seem to wear the same clothes for days and days in a row (due to lack of something else to wear, or resources to wash clothes, or a genetic mutation that doesn't register the sebaceous gland emanations, or what), but none of the locals seem to notice. Meanwhile I am choking back a cough and rushing to open a window. Then yesterday, my friend Carrie came into the room where I was seeing a patient and said "did you check her ear, because it smells like it is draining". Sure enough, she was right.

TASTES:

Malawian cuisine is nothing to write home about. Nsima (see-ma) is the staple food of locals, which is finely ground maize meal made into a polenta-like substance and eaten in enormous mounds with a garnish of chicken or vegetables. Fish is plentiful, due to our proximity to Lake Malawi, and when eaten fried, is called chambo but I haven't tried it yet. My housekeeper Mohammed makes me dinner everynight, the highlight of which has been homemade chapati's (basically flour tortillas) and refried red beans, made with tomatoes, onions and fresh herbs. He also made the left-over chapatis into pizza, with spicy tomato chutney, bacon, and veggies. Yum! I showed him the one cookbook I brought with (Molly Katzen's Vegetable Heaven) and he was immediately engrossed. That night he made potato and chard soup. However, I think I need to give him a few pointers on the finer points of medium rare, as most of the meat has come out tasting a bit like leather. Perhaps he is just protecting my mazungo stomach from the local critters? Today's treat was straciatella gelato, from the italian cafe. Delish. The main thing that I can't seem to find in the grocery stores here is good chocolate (preferably of the dark variety, if anybody happens to be sending any mail to Malawi...)

FEELINGS:

The air here is heavy with smoke and dust, but is almost always perfect body temperature. Whether I am wearing a t-shirt or a cashmere sweater, I always feel comfortable. At night my favorite thing is to put on a certain pair of brightly striped handmade socks. My shower has astonishing water pressure and the bath gets so hot it is like being in a hot-tub (which is especially nice after frisbee). When I get home at the end of the day, Clare bounds up to greet me and tries to give me a tongue bath, which I politely decline, even though her tongue is soft and her breath doesn't smell. I feel happy to be here and it increasingly feels like home. I feel overwhelmed by the amount of disease and poverty, but optimistic about actually being able to do something to help. I am finally starting to not feel tired all the time (N.B. I did not say that I feel rested) which may have something to do with going to bed at 9:30 every night. I don't feel lonely at all, but I miss my friends and my family and especially my grandparents. So stay in touch!!