Malawi has been an amazing place to implement our projects. Whether it is because Malawians are simply very open to change or because Elizabeth’s familiarity with the place allows us to find the right people, the institutions I have approached with the bili-lights have been absolutely excited to accept it so long as it works.

I left one bili-light unit with the head pediatrician Dr. Mwansambo at Kamuzu Central Hospital in Lilongwe. I had the opportunity to meet him with the great help of Baylor PAC pediatrician Chris Buck who, in the past, had helped Beyond Traditional Borders test and evaluate the Diagnostic-Lab-in-a-Backpack. With one quick phone call, Chris scheduled an immediate meeting with Dr.Mwansambo. It is an understatement to say I was surprised. I was prepared for the long battle I had in Swaziland, the repeated meetings with hospital heads in order to push for the bili-lights. Even in the case of RFM, I could only force a decisive vote during the last week of my stay, using the fact that I had to leave as leverage. The simple heads-up phone call between Baylor and Kamuzu is a testament of the close relationship the two institutions share, which marks it the real difference from the case in Swaziland. In fact, Baylor is physically attached to Kamuzu and thus, Baylor doctors regularly round the Kamozu pediatrics ward.

Dr.Mwansambo was a heart-warming man, doctor and DJ whom I had the pleasure to meet. He possessed an open, friendly air and an impressive basic engineering knowledge. He was the first person on this trip to know what LEDs stand for and how they work. Throughout our meeting, he was bombarding me with not questions about certification, but technical questions about shock resistance and parallel/series circuits. He grew increasingly enthusiastic about the device, given its low-cost and easy maintenance. The hospital had previously experienced huge issues with high tech technologies being donated or bought, only for them to be broken and unfixable in a short span of time. If the pilot unit is well-received, he is looking forward to using more models when the maternity ward reopens at the end of this year. Currently, all deliveries and neonatal care are referred to Bwaila, an exclusive maternity center that delivers at least 1000 births per month. Once the new maternity ward is finished, most patients would then be transferred to Kamozu—an average of 30 in-labor mothers per day. The bili-lights and incubator would then be huge necessities for neonatal care based on such demand. In the meantime, the bili-lights will be used in Bwaila under supervision by Dr.Mwansambo who rounds there periodically. Moreover, Chris has been wonderfully helpful in eliciting the help of Dr.Eric McCollum, another PAC pediatrician, to check on and evaluate the device along with the Malawian staff. I feel, after the meeting, that I had established some of the most reliable contacts–people who are excited and truly interested in the success of the device. I am excited to hear feedback from them.

We have officially and completely hand over the incubator and bili-lights to St.Gabriel’s this week. Ideally, we wanted do this earlier, but the incubator took a long time to complete, both to build and to test. I am surprised to discover just how inefficient the light bulbs were; we went from 4 100 W bulbs to 4 clear 40 W light bulbs, testing tinted and clear options for each wattage. However, once we demonstrated the devices to Matron Kamera and Dr.Mbeya, they have been quick and wonderfully supportive in helping the devices settle into the hospital (there was never a doubt that the hospital would pilot the technologies since we mentioned them on our first day). Matron Kamera scheduled a maternity ward nursing/cleaner meeting—there is an amazing task shifting to the cleaners as they are very well educated—for us to briefly train the staff on the important issues of usage and safety. Dr.Mbeya helped us gather the doctors so that their knowing the presence of the devices will encourage them to use the incubator and especially the bili-lights when the time comes. We had a check list of all the tasks we had to finish for the devices and Matron Kamera and Dr.Mbeya just helped us cross each one off one after another in less a one day. The people at this hospital do their work with an incredible level of efficiency and dedication that I have not seen anywhere else in Africa. I can leave the technologies here with a peace of mind, knowing that this amazing group of people will use it well and correctly.

I finally had the chance to visit the Queen Elizabeth Central Hospital in Blantyre, the first pilot place of the bili-lights and the founding place of the incubator design. On their two weeks adventure through Africa visiting all the interns, Dr. Richards-Kortum and Dr. Oden visited us at St.Gabriel’s on the last leg of their journey and then took us with them to Blantyre. It was a wonderful three days with them and they arrived just at the right time: we finished building the incubator that week. I am very grateful to the Namitete Furniture Factory. They had gone beyond professionally to help us every step of the way from woodcraft to wiring. We would walk to the factory every morning to “supervise”—more like stand and watch—as the incubator was assembled. We came to know the managers very well; they were such openly assessable people who we would shake hands with as we entered the factory complex, who every so often personally walked to our station to check on our progress and who offered us coffee during the morning tea break. It was a pleasure to work with these friendly, easy-going people and, especially with Eric, the worker put exclusively in charge to help us with the project. We became such good friends with Eric that he invited us to his wedding on August 1^st. I so want to attend, but our plane back to America leaves on the 31^st. I hear from Elizabeth that Malawian weddings are quite the experience. Sadly, as friends, we did not make work easy on Eric. We continuously found mistakes in the incubator directions as we built it–the dimensions in centimeters were wrong, the acrylic cover specification, inappropriate, the electrical wiring, unclear. Our progress was continuously delayed by our need to communicate back to the States for confirmation and the daily power outage we experienced. Through it all, Eric was extremely patient, double/triple checking with us on each step and kindly offering his professional opinion like what type of varnish we should use. In fact, I am pleasantly surprised at the professionalism of this small factory in one of the most rural spot on Earth. It is equipped with all the essential, hefty machines and personnel skill to turn questionable wood into elegant, sturdy products. I have to admit I was at first skeptical of the factory when I first saw the pieces of pine wood—multi-colored, irregular, disfigured with holes– that were glued together to meet the various parts’ dimensions. However, I soon stood corrected. The workers sanded, polished and crafted the wood into a beautiful incubator, so strong that we often joke that not even a baby can break it.

What is amazing is that they helped us cut the wood, built the incubator, installed the electronics, and varnished the entire thing. All for about $120. If the incubators were mass-produced, the cost can be sliced even further. That is truly incredible prospect in a country with a fertility rate of 6 children per woman and infant mortality rate of 89 deaths per 1000 live births. However, that is not to say the incubator cannot be improved. The most costly and inaccessible component of the hot cot is the acrylic glass used as the cover lid. There was no way we could get it here in Malawi (we brought it from US) and it was extremely expensive even in an industrial country like Swaziland. I think glass is a more economically suited substitute although it does present the possibility of shattering on the infant. Moreover, the current incubator design doesn’t take into account the prevalent shortage of nurses that we have seen in Swaziland and Malawi. A Holland nurse we meet here is very surprised at the nurse to patient ratio here. Whereas in her country the ratio is 1:6, here the one or two nurses on duty are in charge of the maternity ward, the labor ward, the post-surgical delivery ward and the post-natal ward all at once. At situations like this, nurses want to be able to see in a sweeping glance that babies in the incubators are there and doing well. Unlike the conventional incubators with transparent sides all round, the hot cot’s wooden sides and rather tall height forces the nurses to walk over to each crib to check on the babies from above. The cost would increase substantially if we were to install clear material on all fours sides of the hot cot, but I think at least transparency one side might be a good option.

Or, we could adapt the ingenious method Queen Elizabeth Hospital (Queen’s) at Blantyre used: cutting the height of the incubators to less than half a normal person’s height. Standing at one end of the room in their busy nursery, I could see a row of babies in their hot cots with one sideway glance. I remember my initial puzzlement at the short height of the incubators when I first looked at the original designs from Malawi a year ago. At the time, I attributed the reason to the possible differences in height. Only when I personally saw Queen’s–experience Africa–did I realize the true reason. My astonishment and my admiration of this simple design is only a small reflection of my deep respect for this amazingly creative hospital. I am extremely grateful I had a chance to visit and meet with the pediatricians I had only corresponded through emails. We were introduced with Dr. Elizabeth, a clear-headed Scottish pediatrician with a stern air but a quirky sense of humor, and her great counterpart, Dr.Kirstin Mittermayer, the German pediatrician with an enthusiastic bordering on bubbly disposition. Together, they were obviously two pillars of strength, two great forward-thinkers, in the maternity ward, one of the busiest places I have ever seen.

Taking a walk through the ward, I saw babies everywhere. Lining in rows at the center of one room, small white cubicles–not unlike the stereotypical salesman cubicles–enclosed upon dozens of wiggling babies. All the available machines in an abutting room were in use, some exceeding the limit of one infant at a time. The difference that separate this ward from others I had seen was the wooden incubators lining the edges of the walls—the originals. They were shrunken versions of our modified version, their small size allowing them to capitalize on the scarce resources. As the room was partially heated, the incubators could also afford to have larger slits. I never had the chance to see the original designs when I first worked on the incubator, but seeing it now, it gave me a sharper focus on the project, a sense of definition. It is just amazing to go back to the very beginning with the knowledge of everything that happened afterwards. I saw the need that prompt the modifications that were made to improve efficiency, but at the time, I also felt there were still much to be learned from the first generation. While our version is better from an engineering prospective, the size and bulkiness of the design is a limiting factor in the social and resource circumstances in Africa. I am definitely interested in the hospital’s response if they decide to follow the revised incubator instructions we left them.

Of course, there were the bili-lights, propped on top of the wooden incubators. I felt honored that that the lights I helped made were being used. It was surreal to actually see babies under the bili-lights I made last summer. I thought about it, dreamed about it, but I couldn’t believe I was actually seeing it in a hospital setting rather than in a research lab. I had forgotten how small the old models were. The doctors were definitely glad about the increased size of the new generation, which gives a larger irradiating area for leeway in case the baby moves. The new feature of intensity regulator was a great plus. In the past, the only way they could adjust the intensity was to pluck off different number of LEDs. Now, in addition to the intensity knob, the electrical components were all sturdier. Walking into the ward, Dr.Elizabeth and Dr.Kirstin immediately wanted to compare the new model with the old. It was a furry of movements—measuring, evaluating, experimenting. I love and appreciate the enthusiasm and interest the two doctors showed toward new technological advances. Within three minutes, they were already suggesting practical features that would make the bili-lights even more suitable to their needs. And the needs are great. They have at least two to three infants under phototherapy each day; they are even expecting the number to increase as they switch to a new meningitis medication that increases the likelihood of jaundice. I am looking forward to exploring into the issues they brought up such as a way to lock the intensity knob and the possibility of hanging the device.

It was a mere two hours at Queen’s but it was an amazing experience to see the founding place of the projects that drew me into the realm of global health. Working on the bili-lights and the incubator during my freshman summer was the definite starting point of my interest in how technology can play a role in healthcare of the developing world. Before, I had an interest, an obscure purpose. Now I have faces to relate, stories to associate, and memories to recall that define what I am doing. It was truly a full-filling two hours.

One thing I really hope to look into more after this trip is a transcutaneous bilirubin detector. Queen’s had recently obtained one, but it is a very expensive piece of equipment. Before, Queen’s method of diagnosis for jaundice is much like that of rest of Africa: physical examination. Even for a hospital like St.Gabriel’s that has full chemistry capabilities, it has trouble testing bilirubin levels because the reagents are hard and expensive to obtain. Government hospitals like the one we visited in Zomba have expressed much interest in this addition to the bili-lights.

As a whole, the three days we spent with our professors were unimaginablely busy and insightful. We jumped from meeting to meeting, hurrying from appointments with PEPFAR and UNICEF representatives to touring government hospitals like the centers in Zomba and Blantyre. On one day, we didn’t even have time to eat until late evening. I don’t know how my professors maintained this hectic pace for three weeks. The level of constant activity, tension and excitement is both exhilarating and draining. It was amazing to meet with so many great people, see so much and learn over the shoulders of giants, all in such a short amount of time. I am grateful that the professors shared with us a little of their incredible lives.

We decided to make a trip to the Baylor Pediatric Clinic in Lilongwe. One of the PAC Doctors, Dr. Chris Buck, has been extraordinarily helpful to both Rice University and St. Gabriel’s Hospital, so we decided to stop by for a visit. We “chatted” for a while – discussing the challenges Baylor is facing with their outreach budget, the shift to start newborns with infections on ARVs during their first few months of life, and the bravery with which the women of Malawi face AIDS.

Soon after, we met with Dr. Mwansambo, the neonatal pediatrician at Kamuzu Central Hospital, located right next door to the Baylor Clinic. Dr. Mwansambo is a wonderful, dedicated, enthusiastic physician. We soon discovered that he is not just a pediatrician. By night, he is a DJ (no, not Dr. Mwansambo MD JD … Dr. Mwansambo MD DJ). He is one of a kind.

Almost before we started talking, he agreed to test the bililights, and was busily chatting with Yiwen about the physics of the LED lights. The bilirubin lights will be incredibly helpful in the new neonatal ward that will open by the end of the year. Currently, 1000 mothers a month (30 a day) are giving birth at a maternity hospital down the road. By the end of the year, at least half of those mothers will be channeled to the Kamuzu Central Hospital maternity ward to deliver.

Both Dr. Buck and Dr. Mwansambo were enthusiastic about the other projects going on at Rice. They just received funding for several oxygen concentrators, but have to hire someone to come test them every 3-6 months, and have no way to determine how much oxygen is actually reaching the patient. Perhaps, Dr. Richards Kortum and Dr. Oden will be able to bring them more bililights, an oxygen sensor, and a pediatric pulse oximeter in October.

Our last few weeks have been filled with adventure. We travelled from Namitete, to Lilongwe, to Zomba, to Blantyre, back to Lilongwe, and finally to Namitete. We were fortunate enough to have the opportunity to join Dr. Richards-Kortum and Dr. Oden on one of their “investigations”, and met with many of Malawi’s most important health care providers. Here are some of the things we did along the way:

1) Our professors arrived in Namitete on Sunday night, “fired up and ready to go”. We took a quick walk to the dam, where we were greeted by playful kids and a smiling sunset. We spent the evening together, as an assembly line, putting bilirubin lights together to bring to Blantyre. Dr. Richards-Kortum and I agreed that our childhood experiences Lite-Bright gave us a strong advantage when it came to inserting the LEDs. After a wonderful traditional Malawian dinner together, we settled down for the night and prepared for the next adventure.

2) The next morning, we met with Matron Kamera, Dr. Heim, and Dr. Mbeya. Dr. Rickards-Kortum and Dr. Oden gave a flawless presentation of the technologies they brought along, and gave us an opportunity to present the lab-in-a-backpack, CHW screening kit, and bili lights. Some of the other technologies that they brought along included an oxygen concentration sensor, that tests the flow rate and oxygen output of an oxygen concentrator, and can be built for <$100, and a pediatric pulse oximeter, with a hinge adjusted to allow for a baby’s entire hand to be placed in the sensor. St. Gabriel’s Hospital was enthusiastic about testing both of these technologies. Since our meeting, Dr. Heim has come up for a different thing to be put “-in-a-backpack” every day. We are undoubtedly thankful for his support and enthusiasm.

3) After a quick visit to the Furniture Factory, and a few tests with the incubator, we began our journey to Lilongwe. There were seven of us in the car, including all of our bags plus seven bili lights, a CHW backpack, and a lab-in-a-backpack. We were quite a Malawian sight, so say the least. In Lilongwe, we met with a PEPFAR representative, and a CDC representative. We discovered that Malawi was not previously a focus country for PEPFAR1, but will be receiving more money now. Here, we discussed the same desperate need for affordable, accessible, and simple point of care diagnostics. The usual issues were discussed – the need for a mobile, cheep CD4 test, early infant diagnosis, viral load, TB and malaria microscopy – along with several other suggestions, including a point of care lactate test, a test for D4T toxicity, and a CD4 machine that uses micro fluidics.

We discovered that Malawi has just started using liquid baby Triomune, and is transitioning to nevirapine throughout all of breastfeeding. Perhaps, with this shift to liquid ARVs, the adherence monitoring system developed by a design team at Rice could be useful. Finally, we discussed some possible focuses for the CHW backpack, now presented as the “Community Outreach Backpack”. The PEPFAR representative suggested that the backpack focus on those who test positive staying linked to care. He suggested an integration of HIV/AIDS care and family planning, and encouraged the integrations of Health Surveillance Assistants (HSA) in the use of the kit.

4) After a wonderful Indian dinner with one of our professors’ friends, we prepared for an early start the next day. Luckily, we left for Zomba before the sun came up. If we hadn’t, we would have missed the sun rising over the majestic Malawian mountains. We arrived at the Baylor Children’s Center in Zomba by mid-day, and sat down with one of the Baylor Clinic’s PAC Doctors, Dr. Kevin Clarke.

Dr. Clarke has been using the lab-in-a-backpack for the past year, and provided us with wonderful feedback about both the backpack, and our current projects. The items that Dr. Clarke are using most often are the glucometer, the urinalysis strips, the pulse oximeter, the sharps container, the basic supplies, and the syringes. Ideally, he would like to include an IV set and a scale in the backpack. Currently, they are using adult scales to weigh infants and children, and have no pediatrician on site. “When you’re dosing an infant that has a 2 kg window, this is sub-optimal.” He expressed his concerns with both the microscope and the centrifuge. While he often doesn’t have time to use these tools, he still likes the idea of the centrifuge. He is only occasionally able to fins urinalysis strips, and hasn’t used the solar panel to charge the backpack yet. Finally, he would prefer a larger bottle for “methylated spirits” as opposed to alcohol swabs.

Dr. Clarke gave us some wonderful ideas about our new “HIV/AIDS and Family Planning Backpack” idea. He suggested that the backpack include space for tests and reagents, a visual aid for what positive and negative test results mean, a chart of family planning methods, space for medicine, syringes, pregnancy tests, visual aids for the disclosure of a child’s status, lancets, gloves, a sharps container, and a DBS collection method (including a method for tight storage of the required humidity cards). He advised us not to develop a rapid drying method, but instead to develop a way to transport the cards to allow for the required six hours of drying time.

Dr. Clarke, like several other doctors in Swaziland and Malawi, discussed the hospital’s need for a drip monitor, “This will reduce deaths, clearly.” Several Rice engineering teams have worked on drip monitor over the past few years. I think this will become a focus for BTB over the next few semesters.

5) Next, we traveled with Dr. Clarke to the government hospital in Zomba. There, we discovered a plethora of technology needs. A few of the ideas that were discovered include: a water bag for handwashing, a DBS kit, a portable x-ray light box, a pill-breaking method, recitation equipment, a nebulizer, a traditional birth attendant backpack, a method for controlling the amount of milk that goes in a nasal gastric tube, a vitals monitor, a device to measure bilirubin load, and a thermometer that can be applied to the skin. One of the German pediatricians working at the hospital made a wonderful suggestion, “A little pill that goes through the entire body, and tells me everything – oh, and doesn’t cost anything.” We’ll be sure to get right on that.

6) Our final stop was the government hospital in Blantyre. We were thrilled to see two babies under the Rice-designed bililights, along with 20+ incubators. After dropping off six second-generation bililights, and presenting several of our current projects, one of the pediatricians sighed and asked (half-seriously, half-jokingly), “Well then… What else’ve you got in a backpack?!”

As the mountains of Blantyre slowly began to disappear, we made our way back to Lilongwe. During the seven hour drive home, I couldn’t help but think – often times, we set out on a path to help people make their way, and they end up helping us along our way. Maybe that’s what it’s all about. Helping each other along the way.

What began as an endeavor to provide Community Health Workers with a screening kit has become a wonderful tool for Home Based Care nurses at St. Gabriel’s. The backpack is not practical for use by CHWs for several reasons. First, CHWs are trained heavily in patient counseling and follow-up, but are not trained to use medical equipment such as blood-pressure cuffs and glucometers. Second, Community Health Worker has a different meaning in almost every region of the world. Often times, like at St. Gabriel’s Hospital, CHWs are involved in specific programs (HIV/AIDS, TB, PMTCT, HBPC) that might or might not involve utilization of the tools in the screening kit. Their responsibilities vary widely, making it difficult to create a uniform screening kit for all CHWs.

I have discovered that almost all of the outreach at St. Gabriel’s Hospital is done by the HBPC team. Twice a week, two Home Based Care nurses (Alex and Matilda) spend the day travelling to communities in the catchment area, providing basic treatment, monitoring vital signs, and doing simple tests (such as checking glucose and hemoglobin levels).

I have been able to travel with both Alex and Matilda over the past few weeks. We travel by motorbike from one community to the next, sometimes spending an hour with a patient. So far, we have used the kit to provide every single patient with some form of care. Some of my favorite cases include:

1. The second patient to benefit from the kit was a 62 year old man who had just lost four of the toes on his left foot to an infection. We used the kit to sterilize the amputation and dress the wound.

2. Soon after, we used the kit to monitor the vital signs and glucose levels of a 100+ year old grandmother. The family said they had stopped keeping track of her age at 100, several years ago. This woman was alive before the benefits of penicillin were known, before we monitored glucose levels, and long before St. Gabriel’s Hospital was in existence. Needless to say, I can’t imagine that, even in her wildest dreams, she ever thought that she would benefit from the use of this screening kit.

3. I was lucky enough to spend the day at the Antenatal and Under Five outreach clinic. We used the hanging scale from the kit to weigh 30+ babies in less than five minutes. The mothers were eager to place their newborns fearlessly in the trust of the cloth sling, laughing as their babies screamed and wiggled.

4. The kit has several compartments that can be used to bring drugs along. Alex and I were proud to provide ibuprofen and multivitamins to a patient who had been incarcerated for seven years after illegally selling 500g of tobacco.

5. Matilda and I visited a textbook end-stage cervical cancer patient, dehydrated with a severe protein deficiency. We sat with her and her ten guardians in her hut as the HBC CHW explained to them how to prepare Oral Rehydration Solution, using the cards from the CHW screening kit.

After presenting the backpack to the matron of the hospital, we discovered that St. Gabriel’s has been given funding to pay for ten more outreach nurses to join Alex and Matilda for, at least, the next three years. Hopefully, we will be able to provide them each with an “Outreach Kit”. With feedback from Alex and Matilda on the first three months of the pilot, we will be able to scale the project up, and provide the hospital with tailor-made outreach packs, designed specifically for their outreach needs.

I haven’t been writing as much in Malawi because time just seems to fly here. There is so much to do, so much to experience that I can’t really make myself sit down and write.

So far, to me, Swaziland and Malawi have been two very different experiences. Maybe this is inaccurate on my part as I am comparing a rural Malawian village to the capital of Swaziland. However, I have briefly visited a Swazi homestead and my mind pulls up such huge contrasts. I remember the rolling mountains of Swaziland, imposing compilations of withered granite rocks and persistent greenery. Homesteads perch in this landscape are islands of impressive cultivated land seemingly miles apart from one another. It is a quiet image; I only remember the howl of the wind. Here in Malawi, I am surrounded by sound, music, activity and flat expanses of red dirt. Chickens, goats, cows room freely, offering great amusement to the guard dogs at St.Gabriel who often playfully chase after the goats to nip their tails. I hear the constant chatter of Chichewa outside my window as Malawian woman wearing traditional cloth wraps walk barefoot to the hospital. In the afternoon, the shouts of children asking us to play soccer with them would drown all else. The villages are just teeming with kids, running freely—whether it is school time or not. Malawians love to have big families where there could be as many as ten children whereas in Swaziland, women are embarrassed, if not ashamed, to have more than two or three. The village kids’ favorite activity when they see us is to jump up and down and shout “azungu” meaning foreigner. Then a herd of them—15 to 30 kids—would gather behind us as we walk and follow us to our destination. Foreigners are huge, fun, open-eye, finger-pointing spectacles here, much different from the discreet glances we received in Swaziland. Overall, I think Swaziland is a much more westernized nation where Elizabeth and I have to pay to go to a special cultural village to experience the Swazi old way of living. In Malawi, people embrace and live in their culture, speaking their own language—barely knowing English–, dressed in traditional garments and living life in ways passed down from generation to generation. Their openness of their culture makes us become easily incorporated into theirs.

The Malawian culture is such a friendly one, full of some of the sweetest traditions. I have not been into a village so open to each other and to foreigners. If we do not initiate “Muli bwanji”—how are you—, mothers wrapped with babies on their back and grandmother in head wraps would stop randomly on the street and greet us, maybe to shake our hands as well. It is such a special greeting because they would not ask it to the group but would repeat the question to each person, individually, one at a time. Looking back, it can be a time-consuming process, but really, I love the intimateness of the gesture, the valuing of each person personally. On top of this, Malawians are also very polite. Zokomo, meaning thank you, can be used or heard everywhere. You can pass someone on the street and say Zokomo. There is no excuse me, but zokomo. There is also no “you are welcome”, only zokomo as the response. The decorum of respect to individuals is quite heart-warming; here, people take the time to show a little care and respect to their neighbors and passbyers. Like many traditional societies, relationships are important, as can be seen in introductions. Here, Elizabeth isn’t Elizabeth, but the sister of Joshua (her brother who implemented FrontlineSMS). Mrs.Nesbit isn’t only Casey, but the mother of Joshua, Elizabeth and Daniel. I am not just Yiwen, but friend of Elizabeth and the Nesbit family. Relationships here define a part of you and help others relate to you. What is interesting is that relationships appear to matter more than your social position—your profession, property or education. Although in those aspects, the villagers are mostly homogenous. Almost all families are in some ways subsistence farmers. Even the workers at St.Gabriel who lives in Namitondo have small plots of land they farm for maize and vegetables. Most kids attend primary schools; secondary education requires money and thus is harder to obtain. No one I know has received a college education, whether it is because of money or that most secondary schools do not prepare a student adequately for university. There are technical schools, though, that train people after secondary school in specialty areas such as secretarial work, carpentry, medical assistant and such.

It is not only the Malawians who are especially nice; I have had a wonderful time living with the Nesbit family. I had a wonderful July 9^th birthday with them. Despite my being with them almost every minute of the day, they still surprised me with cupcakes they ordered from a neighboring cafeteria and a gift—a beautiful traditional cloth Malawians use to wrap around their waist as a skirt and protective wear to keep what is underneath free of dirt. We shared the cupcakes with our neighbors: three medical students from Luxemburg, an American pre-med student and Joanna who is in charge of the mobile CD4 machine. It was a great opportunity to have a chance to talk with everyone and take pictures of course. Earlier during the day, Elizabeth also personally cooked one of my favorite breakfasts: scrabbled eggs with oven-toasted bread. For dinner, traditionally at home, my mom would always cook noodles for me as noodles signify long life. By pure chance, the dinner Mrs. Nesbit had long ago planned, without knowing the date, was oven cooked ramen noodles with vegetables. The coincidence! It was a great, unforgettable birthday. I am so happy that I had it in Malawi and grateful that I shared it with the Nesbit family and a delightfully unusual gathering of individuals.

I really love the villagers around here and I am comforted that St.Gabriel Hospital is here take care of them. The HIV/AIDS service inspected periodically by the government ministry of health is consistently rated number 1 in the region. HIV is a problem here, but it is not a staggering shock as it was in Swaziland where it seemed like one in two was HIV positive. Especially in a rural areas like Namitondo and Namitete, HIV one of the serious problems next to malaria, tuberculosis and malnutrition but not THE problem. It is interesting to see a slight change in HIV treatment here. In Swaziland, the two popular first line medications are AZT and Nivarapene. Here, AZT is used as a substitute because of its dangerous side-affect of anemia, given the constant danger of malaria here. Moreover, second line drugs are extremely hard to obtain. There are only a handful of patients on it. As mentioned before, the hospital has one of the most extensive community health worker programs I have seen with trained staff going almost everyday to even more remote areas to do follow-up care. I have yet to go on one of these outreach trips because the staff can only take one extra passenger on their motorbikes (!). Elizabeth gets priority because she needs to work on the community health worker backpack, but I hope before I leave, I will get to go on at least one trip. I heard that the motorbike ride is quite thrilling. In terms of lab equipment, the hospital has the capability to run full blood chemistry tests and provide ultrasound, x-ray or microscopy services. However, whether there are enough trained technicians to fully use the capabilities is uncertain. The hospital is constantly making the effort to improve itself. Whereas in the past they had to refer—in essence abandon—patients who needed surgery, whether it is for biopsy, tumor resection or amputation, now they have a retired German orthopedist here to guide and train the surgery department. They have one theatre and will open a new one later this year. Patients being retained in the hospital are already constantly maxing the hospital’s current capacity due to the number of surgery patients. It’s feels great to be here!

Malawi—we learned from Alex, the head nurse—means the land of flames. Fitting for this land where the wind blows the red dirt to paint all things, where decrepit red brick shacks dot the landscape, where the kindness and generosity of its people burn for all to feel their warmth.

The people are just so friendly and welcoming. They have such beautiful smiles. Their faces crack along the laugh lines at our first greeting in Chichewa; it seems as if they become your friends with the first hello. Since very few villagers know English and as we know only the basic exchange of “how are you” and “I am fine”, we would walk away soon afterwards, hearing giggling and chatter behind us. Looking back, we would see them waving and laugh with them at their exuberance and at our own lack of understanding of their language. It was a spectacle when Elizabeth took me to explore the village of Namitondo for the first time. We would say hello to a woman drying her maize in a field and immediately, the surrounding women rushed toward us, bring and calling their kids, to shake our hands and exchange greetings. Walking away, we would leave a mass of Malawians in their tattered shirts and traditional wraps weaving madly at us. We were apparently quite the entertainment to them, but there was no feeling of isolation or mockery. Just friendly curiosity.

The people here may walk around with no shoes, live in one-room houses with patched roof and huddle outside around fires at night, but they are proud of their culture and their traditions. It is nice to feel included, welcomed, to their land. We find a willing teacher of their language and tradition in everyone. When Elizabeth, her brother Daniel and I were at the Lilongwe craft market, a vendor actually rescued me from the a swarm of sellers—the stall owners would literally surround you, shouting and negotiating prices over one another in you face. He pushed me into an old chair in front of his pile of works and taught me how to play a very popular stone board game of mathematics, attacking techniques and luck. We exchanged life stories and he even invited me to a Malawi Independence Day celebration where I could experience the traditional music and dances. Unfortunately, we did have time to linger in Lilongwe, which is quite far from Namitete. Our closest friends are the village kids who live in the nearby village of Namitondo. Even though they barely speak English, we are connected by our love of soccer and pictures. The kids would hang outside of St.Gabriel in the afternoon, waiting for us to play soccer with them at five. I have to admit that though I am an avid soccer fan, coming here is my first time playing soccer. Elizabeth and Daniel captain each team as they are college soccer athletes and I mainly cheer for everyone. Even to my eyes, the kids—ranging from 6 to 13 years old—are great runners and soccer players. They are unbelievablely fast and agile, sprinting with their bare feet hitting the barren ground. They are a goofy bunch; you can never get a nice picture with them. They always distort their faces at the last minute and then clamor to see themselves on camera. I am so happy to have met these kids. I can’t believe I can form these great friendships when we can barely exchange a few words.

The Carmelite nuns that run much of the hospital’s operations are wonderful. The Malawians nuns live in a separate convent from the original three Luxemburg nuns who have been here since the hospital’s beginning. We had been welcomed in both. Our visit to the Malawian nuns’ residency has been partially eye-opening. It was a nice complex with not elaborate, but comfortable and economical furnishings. We sat in the main dining room with the sisters and watched the televised special celebration of Malawian Independence. There, I had my first taste of a traditional Malawian meal, specially prepared by the nuns: nsema, fish and chicken. nsema, made from maize flour, is the main staple of Malawi. The maize flour is cooked into soft chunks—like bread—so that it can be eaten with hands, which I did for the most part of the meal. The nsema to me tasted bland with a slight bitter after-taste. However, it goes well with the fish and chicken. Z was impressed—as was I—that I ate the four-inch fish cooked whole with head, eyes and skin. It was not an unpleasant experience, just out of the ordinary for me. We took a tour around the covenant, including the sisters’ private chapel, their huge garden and livestock area. The sisters seem to farm everything they need: lettuce, papaya, potatoes, oranges, many native species we have never seen and a lot of corn for nsema. Everything was growing, healthy and huge. I admire the sisters’ productivity because farming is difficult because of the drastic change in seasons. I imagine the rainy season is the flooding type of rain because when we do have pretty heavy rain here—or what I would say heavy rain—the Malawians just call it showers. That and the prevalence of ditches spanning everywhere. Then when it is winter, there is no rain. For livestock, they breed rabbits for meat. White, fluffy, red-eye rabbits! Life here is so different. I can’t imagine a more unique place in the world.

When we arrived at St. Gabriel’s Hospital late Monday night, we were greeted by old friends. Grace (6) came running into my arms, wearing the blue dress we gave her last year, and a gigantic grin on her face. Roderick (10) followed closely behind, wearing my RFC shorts and Bradock Road Impact t-shirt. Alec (8) and Malifa (12) came next – Alec in my Loudoun Valley Viking basketball shorts, and Malifa in the red skirt I left her last year. All the kids were safe and healthy – only a few inches taller. By Tuesday, they were yelling into our window at 5pm sharp, “Eliza! Eliza! Futbol! Eliza!” They have continued this patter relentlessly ever since.

My mom, Casey, and little brother, Daniel, are staying at St. Gabriel’s Hospital as well, and my older brother, Josh, is in Neno. We all planned our summers separately, but ended up in the same country during the exact same time. Home is where your family is. My mom is a physical therapist, certified to practice in both the States and Malawi. She has had her hands full this summer, working on a rehabilitation program with Dr. Heim, a surgeon from Germany who will be at St. Gabriel’s for the next five years. On top of seeing patients every day, she is training two hospital workers to carry on her work after she leaves in August. Daniel is busy helping her create rehabilitation DVDs to leave behind for these workers.

St. Gabriel’s provides a perfect example of “task shifting”. With a new HIV ward opening this year, a renovated malnutrition unit, and a growing pediatric ward, the staff is spread thin. Cleaners are being trained to provide community health care, hospital workers are being trained to help nurses and physicians, nurses are being trained to help clinical officers, and clinical officers are handling almost all of the OPD (Outpatient Department) patients, leaving the doctors to round in the wards (Male, Female, Labor, Postnatal, Private, and Pediatric). Still, St. Gabriel’s is improving every year. By next year, all HIV care will be moved from “Room 16” (practically, a closet), to a new, spacious, enormous HIV ward at the back of the hospital. When I first came to St. Gabriel’s, the malnutrition ward was a collection of five mats outside the pediatric ward, where mothers sat together and cooked nsima over a fire. Now, the malnutrition ward includes its own building, with four trashcan-size metal cooking pots for mass production of nsima.

There is much to be done at the hospital. So far, I have spent my time helping in the pharmacy every day, helping at the ART clinic three afternoons a week, updating the pharmacy stock system, helping my mom with her physical therapy endeavors, attending training sessions for Community Health Workers, building an incubator, and testing the Community Health Worker Screening Kit in the communities.

While our weeks have been full of hard work and soccer games, our weekends have been adventures. We spent our first weekend in Malawi in Lilongwe, navigating our way from the center of town, to the market, to every bank in the city – including “the black market” – looking for someone to exchange Swazi currency. The craft market in Lilongwe was excited to see us. “Azungus” (white people) provide a perfect opportunity for the craftsmen to manipulate their prices. We weren’t going to be fooled. Not this time. Although every craft shop was “the discount shop”, and the craftsmen were intent upon being flexible with their pricing, we made it clear that we were just looking. Luckily, every craftsman kindly told us that, “looking is for free”. Good thing.

On Sunday, we visited the Malawian Carmelite Sister’s convent. Twelve Malawian nuns live together in a convent next to the hospital. Five of them work at the hospital (as chaplains, in the pharmacy, or in the communities), two of them work at the maize mill, and the others work in the convent, maintaining the garden and grounds. The convent is a wonderful place – overflowing with peace, grace, and patience. Sister Justice and Sister Honest gave us a tour of the garden, a wonderfully huge eden of papaya trees, tomatoes, corn, onions, lettuce, and orange trees – every fruit and vegetable you could possibly imagine (and several that I have never in my wildest dreams imagined). They raise cows, chickens, and rabbits for meat, and kindly offered us nsima and pinky-sized fish for lunch. The Sisters can only be described as gentle souls. I am lucky to know them.

St. Gabriel’s Hospital can be found 60 kilometers from Lilongwe, the capital of Malawi, and serves over a quarter of a million people. With a catchment area of 100 miles, communication is critical for health care delivery at this rural. Patients have to travel miles by foot, bicycle, or even oxcart to reach the hospital, and, Community Health Workers (CHWs) must travel under parallel conditions simply to report patient adherence, seek medical advice, or check a drug dosage.

The target populations for implementation of the Community Health Worker Screening Kit are clinics that utilize CHWs in order to provide healthcare to communities. According to WHO, “among 57 countries, mostly in the developing world, there is a critical shortfall in healthcare workers, representing a total deficit of 2.4 million healthcare workers worldwide.” The 2008 UN report on progress toward the Millennium Development Goals indicates dire need in many public health areas including infant mortality, HIV, and other communicable diseases.

With roughly 2.5 billion individuals around the world living on less than $2.00 a day, the CHW Screening Kit could help bridge the gap between the millions of health care providers in the developing world and these billions of people living in poverty (World Bank 2007). According to the most recent WHO census from 2006, these 2.5 billion people living on less than $2.00 a day are under the care of approximately 22.9 million health care workers (World Health Report 2006). Of these 22.9 million health care workers, only 4.4 million are physicians, and 7.0 million are nurses. Because of human resource constraints, the bulk of health care providers are CHWs, the primary health care providers in rural communities of developing countries and the end-users of the CHW Screening Kit.

The CHW Screening Kit includes several basic diagnostic tools, as well as a glorified first aid kit. The basic diagnostic tools include: a glucometer, pediatric and adult blood pressure cuffs, a thermometer, uranalysis strips, pregnancy tests, a stethoscope, a scale, a tape measure, and a MUAC band. The first aid kit includes: matches, face masks, cotton balls, band-aids, sterile gauze, hand sanitizer, bandage scissors, medical tape, iodine, gauze rolls, alcohol-prep pads, tweezers, and antibiotic ointment. Other tools include: a biohazard bag, a teaspoon, ORS, a swiss army knife, gloves, extra batteries, a notebook, a backpack cover, and a flashlight.

St. Gabriel’s Hospital has three tiers of Community Health Workers. The first, and most highly trained group of CHWs are the hospital nurses. Twice a week, two nurses take a motorbike to outlying communities, in order to continue to establish a relationship between the hospital and the communities. They bring a brown cardboard box of supplies with them. Their supplies include gauze, medical tape, vitamins, Panadol, and several other basic treatment items. The second tier of CHWs includes hospital workers that are not trained in a medical profession. These CHWs include cleaners, nuns, and village role models, all diligently and eagerly edging their way into the medical community. The final tier of CHWs includes all other CHWs – role models in communities, expert patients, mothers, fathers, volunteers. For now, the backpack will be used by Alex – a nurse, the chief HBPC officer, the director of the ART clinic, and the nurse that does most of the hospital’s outreach trips. He will be able to assess which tools are appropriate for CHWs, and which require a stronger medical background. He is excited to begin using it on Friday, and we are excited to begin to get feedback on the pilot of this project.

In the meantime, the Namitete Furniture Factory has begun (and almost completed) work on an incubator prototype. After spending a day gathering wood, and another day building the frame, we will be ready to put all of the pieces of the crib together tomorrow morning. Eric, the carpenter who has been helping us build the incubator, is a kind, gentle man. Perhaps gentle is the best way to describe Malawians. Greeting Malawians reminds me of Paul the Apostle’s subtle insinuation, “Do not forget to entertain strangers, for by so doing some people have entertained angels without knowing it.” (Hebrews 13:2)

Eric whistles while he works, is constantly smiling, will be married next month, and speaks softly to his elderly assistant, who hurries around diligently with his worn-down fisherman’s hat and missing teeth. Places like the Namitete Furniture Factory make you want to pick up a vocational skill.

Elizabeth was right: there is not place on earth that is like St.Gabriel’s Catholic Missionary Hospital. It is an amazing and inspiring place. For me, there are no words or no amount of words that can express what I love about this place.

The hospital is a community in itself. The ever-expanding hospital complex lies at the heart with red dirt roads spiraling outwards, lined with red-brick houses with flower beds and green lawns. The houses are not only for the nuns and guests, but also for the hospital workers and their families. The arrangement truly fosters a sense of community and teamwork amongst its members that allow the complex to operate as one team, one family. Everyone attends to their work diligently and most of all, cares about the hospital. There are always cleaners religiously mopping the floors, workers meticulously sweeping the incessantly falling leaves from the hospital grounds and doctors and nuns hurrying from place to place to meet the demands of hundreds of patients the hospital serves each day. It is amazing how self-sufficient the hospital is. The hospital funds a nearby primary school (grades 1-8) that all the kids in the surrounding villages attend. There is a library and carpenter furnishing shop next to the church. Fresh fruits and vegetables and other basic necessities are available in the market place of Namitondo, a literally three-minute walk from the hospital. Everything fits in this rural setting beset with poverty where I would have expected insanity in any other parts of the world.

St.Gabriel is such a wonderful model of what can be and still be accomplished through pure goodwill and generosity. The hospital is entirely run through donations; they do charge their patients but it is based on the “pay as you could” policy so that the patient can have control—not abuse– of his health. This year is actually the 50^th anniversary of the hospital so I had an opportunity to see its development through a series of compiled photographs. From a small house-like complex started by a few nuns from Luxemburg, the hospital has grown so much in recent years in the continuous attempt to offer the best possible care for the a-quarter million people it serves. The hospital has recently opened a huge pediatric ward with every bed equipped with mosquito netting (malaria is a serious concern here). A sprawling HIV clinic will be opening at the end of this year to meet the demands of the high prevalence rate in region (around 25%). In addition, the hospital is attacking malnutrition rampant in young children by improving its kitchen capacity to include four huge high-tech, boiler-like pots. The excellence of service and spirit has already drawn many international eyes; nursing students from Ireland and Belgium are with us this summer. A German orthopedic surgeon has also arrived and is piloting the improvement and training of the surgery department. I hope the hospital will continue to draw interest; it is a standing proof that an inefficient, professional hospital can function in a rural setting.

In the midst of everything, St.Garbiel continues to improve its services and increase its reach into the community. They have an extensive community health worker (CHW) program. In fact, we were fortunate to arrive at the time the new group of CHWs was being trained. We sat in one of their lessons. They cover a serious amount of material, from drugs to causes of fever. The notes of one trainee-one of Elizabeth’s many friends here—filled almost an entire notebook. We learned from head matron Chimera that the hospital is also expanding the program to include nurse practitioners in the villages, trained personnel who can take blood pressure and glucose level in the next three years. This is an amazing opportunity for the CHW screening kit that Elizabeth is piloting.

It is amazing to come here with Elizabeth. In fact, almost her entire family is here; we are living with her brother and her mother who works as one of only two physical therapists in Malawi. The Nesbit family is famous around the hospital; for the five summers the family has been coming here, they have always helped and donated to the hospital in whatever ways they could. Elizabeth’s older brother Joshua is a rock star here. Everywhere we go, we were asked “where is Joshua?” Joshua is in another part of Malawi but I am told I will have a chance to meet him, the person who pioneered Frontline SMS here. It is a software that enables large groups of people to send and receive text messages. More specifically for St.Gabriel, FrontlineSMS connects the cell phones of CHW to a central laptop at the hospital so that there is a fast, reliable communication network that doesn’t rely on internet. Elizabeth seems to know everyone around here; the village kids call her name on the streets and she has Malawian family friends whom her family visits. It makes assimilating into life here easy for me; making friends, establishing relationships are faster.

It definitely makes the incubator and bili-lights project start up faster. On the first day, when matron Chimera was giving us a tour of the hospital, we visited the neonatal ward. There were no incubators; the matron explained that she felt that they were too hard to maintain and she gave them away. In replacement, the kangaroo method is believed to be a much more suitable means of treating neonates; although this is true, the method is not hitting off well with the mothers as it greatly inconveniences the mother. In terms of jaundice phototherapy lights, there is one unit in the ward, but it requires that baby be placed at the provided unheated mat underneath the lights. As the ward temperature is not regulated (it is quite cold) and the baby must be stripped when being treated under the lights, the infant has a high likelihood of catching a cold or pneumonia when undergoing phototherapy. When the incubator and bili-lights were mentioned as cost-effective, alternative technologies, the matron is interested in a demonstration. There was almost no hesitation from her, whether it was because of the trust the Nesbit family has built or that the hospital is not directly below the government’s eyes. Either way, I was relieved because the projects can begin as soon as possible, which it did. We talked with the manager of the wood furnishing store already and they are helping us cut the pieces and assemble them this week.