In this day in age, it seems like everyone has a digital camera, iPhone, iPad, or Android to snap photos of nearly every moment in their life. Through Facebook, Instagram, and Twitter, pictures are infiltrating our lives. It is hard to imagine a life without photos. They capture moments in our lives that we cherish which is why I think we love pictures.

Most Malawians, I presume, have never had a photo taken of them. This first struck me when Sam and I visited the Palliative Care Unit (for patients who are terminally ill) and saw a poster about making memory books. This poster described a project where people taught patients who were near the end of life how to make a memory book full of letters to loved ones and other items. This is to help the family prepare so that when a loved one passes, the children and family have something to remember them by. In somewhere like the US, we have plenty of photos to remember people, and it’s hard to imagine not having them.

  

Since people don’t get photos of themselves taken very often, they are always eager to see photos. I am constantly documenting my time here with photos (to put on the blog). Sometimes, random people on the street will ask you to take a photo of them so that they can see it. Once you show them the picture, they just crack up in laughter. Malawians love seeing photos of themselves!

My parents really liked my last blog post (thanks for reading, Mom + Dad!), so I figured I would follow up. Here are some pictures of the things that you probably wouldn’t see done very often in a lab in the United States: the things that made me do a ‘double take’. On a personal note, happy July 4! We had an American-style feast, and I have to say that mashed potatoes + garlic nali sauce must be the best possible combination of Malawian and American ideals. 

I thought this was smart — they were out of room on the bench, so they dried stain slides on the windowsill. They said there’s minimal risk of contamination because they’ve already stained the slides.

Probably a little less smart. They’d tried to bandage and continue using a pipette when the barrel broke. They must have had a shipment of pipettes after this because they had quite a few extras, and this one had been retired to a half-empty cabinet.

Donated equipment comes to St. Gabe’s from all over the world, so power converters are very important for the hospital. We’ve seen countless blown-out outlets and power strips and a worrying overall disinterest in plug type when people jam things into the wall, but the lab seems to be pretty careful. I’m glad bCPAP comes with the locally-appropriate G type plug and can be modified to use other plug types.

Doom is the name of the most common bug spray here — a name we learned quickly. The bugs are incorrigibly EVERYWHERE here, and I imagine it’s worse in the rainy season. This was the biggest supply cabinet in the main lab.

One of the problems with rotating through donated lab systems is that when one part of one system breaks, the rest can become unusable. This leaves the lab with boxes of system-specific reagents to throw out. There was a box containing CD4 waste tablets in the “Out of Order Machine” cabinet while I was asking them questions about the machines and they immediately started barehandedly tossing the skull-labelled bottles into the trash.

Interestingly, most of the machines in the “Out of Order Machine” closet weren’t actually broken. One needed a part replaced, but a majority of the instruments were operational. They weren’t being used either because (like in the case of the dust-covered ELISA reader) the lab had moved to a different diagnostic method and can’t use two at the same time, or because (like the lab results printers) they were part of a system that had been rendered useless by a single broken part.

“Well-resourced” here is a far cry from “well-resourced” at home. In labs in the States, we’re so thoughtful about so many things — where our waste goes, keeping the bench sterile, preventing workplace risk — here, they have to be thoughtful about different things — not being able to afford much waste, trying to improve throughput, keeping the ants out of the control, how to keep going when the power goes off.

We finally finished working on the back end and manual for DataPall earlier this week! Since the staff trainings are next week, we’ve taken the week to explore the hospital more. On Monday, I got to poke around the hospital lab a bit. I’m pretty sure they thought I was crazy for taking so many pictures, but the technicians were eager to talk to me about what they like and don’t like about some of their equipment.

Before I came here, previous interns told me that St. Gabriel’s has a well-equipped lab for a private hospital of its size. Even still, early on in our time here I was a little surprised to hear in morning report that the hospital was monitoring blood sugar and hemoglobin levels for some of its patients. Two of the most exciting projects that I’ve worked on as part of BTB (yes, I’m biased) are the HemoSpec and its bilirubin analog, and both are based on the need for low-cost point of care blood tests in developing-world settings; I had hoped that St. Gabriel’s would be a good place to see the kind of impact those technologies could have.

I wasn’t disappointed for too long. When I visited the hospital lab this week, I realized that while the lab is indeed fairly well-equipped for a private hospital in terms of what it can test, it has to scramble to make up for what it lacks in how many samples it can test. The hospital has a lot of donated lab equipment, but usually it only has one of a type. Particularly with older machines, the equipment they get often only runs a few samples at a time. Medical wisdom in the States, as far as I know, is that the surer you can be of your diagnosis, the better—therefore, the more tests and the more timepoints, the better. Here, though, real-time patient monitoring is incredibly difficult because of the backlog in the lab. You might only get one shot at getting a patient’s blood sugar level, which doesn’t really tell you much about if your treatment is working.

Before I left, I thought what defined the HemoSpec was its cheapness: it’s designed to replace the expensive, currently used plastic cuvettes with cheap paper ones. When I got here, though, I realized that “expensive” and “currently used” are oxymoronic. They only use the quicker hemoglobin-only plastic cuvette-based spec when the power is out in the lab or if they have a blood donor. Otherwise, they just run the whole panel every time. That means that a simple quantitative check for anemia could easily take long enough for the patient to decide to give up and go to a traditional healer. Most of the providers here have to rely instead on checking the color of the conjunctiva—red, healthy; pale, anemic. I’ve yet to see them find red conjuctiva. The Hemocue is small enough to fit in a doctor’s bag or a generous white coat pocket; what it stands to offer St. Gabriel’s is not a new metric, but a much more dynamic and therefore useful one.

The problem with reagents is they have to be restocked.

The bilirubin analog is much earlier in the design process, but I think the single-question approach can offer the same benefits on the wards here. One of the design questions our team faced was whether centrifuges were available at hospitals in the developing world, but I was pleased to note that St. Gabriel’s actually has 4, two in the main lab and two in the blood donation room.

On the far right: the Dremofuge

I was even more pleased when I saw the fourth one, stationed in the blood donation room. The technician seemed to especially want to show me how this one worked: a wooden base, plastic shield, and battery pack, looked like a BTB device. I asked him the same question I’d asked about every device in the lab: Do you use it? He emphatically agreed. The one next to it, he said, had a broken brake, and this one worked just as well even when the power was out.

Yes, that’s a floppy disk drive on the bottom.

The device the techs wanted to spend the most time talking to me about, though, was the CD4+ counter. CD4+ counting is very important for HIV/AIDS initiatives, and it’s a known problem in the developing world. Even with all its donation connections, though the hospital still only has one running CD4+ counter, and can only run one sample at a time. In busy times, it’s impossible to keep up with the demand. The outpatient HIV clinic has to rely on counting how many pills the patients have left, which is unreliable and imprecise. They are very envious, they said, of hospitals with machines that can run more than one sample at a time.

In a “well-equipped” lab like this one, BTB can’t provide new diagnostic capabilities. What we can do, though, is make what metrics they have more robust and clinically relevant. It’s not about taking clearer or fancier pictures, it’s about putting the camera in a clinician’s pocket so that it’ll actually get used.

Happy 4th of July everyone! Yesterday we took the CPAP gear out to Machinga. We tested out the pulse oximeter on a few babies that had just been born and got everything set up in the nursery. The Machinga trainees were really happy to see the CPAP actually on their ward. Then on the way back to Blantyre, we stopped by Zomba to check up on things and see how everything was going with the new CPAP cart. When we arrived there was a little girl with bronchiolitus in very poor condition and getting worse. Her oxygen saturations were at about 50% even when she was on oxygen therapy (below 90% is not good). They had been waiting on a doctor to get a recommendation, but since we had brought two of our CPAP nurses along with us, Sister Patridge and Glyssie, they decided we should definitely put the baby on CPAP. So our Machinga trainee Roseby went ahead and helped put Machinga’s very first pediatric CPAP patient on the machine. The bCPAP can make such a dramatic difference when small children are in respiratory distress, and yesterday it was really amazing to be able to see the results of so many’s people’s hard work. It’s easy to get caught up in data analysis and mountains of medical charts, but this was one of those days when I feel so blessed to be able to help with this project. It’s crazy to think that Pumani bCPAPs will soon be all over Malawi!

 

 

This morning, I arrived sharply at 8 am for peds morning handover meeting. They went through deaths and cases from the last 24 hours and at the end someone said “Oh… and by the way, pharmacy is on strike.” I thought I had heard wrong, but nope, apparently pharmacy was actually on strike. I couldn’t really understand the whole story, but I think it had something to do with 2 people were supposed to take an exam but refused to. So the government suspended their license or stopped letting them work and then the rest of pharmacy decided to stop working too.  I asked one of the doctors and he said that they had problems getting some drugs yesterday, but thankfully they had most of the drugs they needed in the wards themselves.  I was shocked that the pharmacy at the largest hospital in Malawi could go on strike. Thankfully, when I visited later in the afternoon it looked like it was fully functional.

  

Also, this morning, when I went to Chatinkha nursery there was a baby with birth asphyxia with very high respiratory rate and chest indrawings. Florence started putting the baby on the new pumani bCPAP machine; however, we soon realized that there were not enough oxygen concentrators to hook it up. I knew that there was an extra one sitting in the peds office so I ran to the admin office and brought it to Chatinkha nursery. Thankfully there was an extra oxygen concentrator at Queens; however, I know there are many other situations where that is not the case and the doctors and nurses just have to make do. Normally, an oxygen concentrator is split 5 ways and then can be split even more further down the line before it even reaches the patient. So the amount of oxygen that each patient really gets is not very much at all.

There was also a baby that weighed 660 grams that was born today. One of the nurses from the UK said that the baby would have a chance of surviving if it was in the UK, but it was nearly impossible here. Its really disappointing to know that there are other places in the world that could offer these patients more. This is what doctors and nurses have to face here daily.

 

To end on a more uplifting note, here is a photo of a baby giraffe that I saw a few weeks ago.

This weekend was packed with Namitete adventure.

On Friday afternoon we had some fun with the kids who like to hang out outside our house.  There’s a group of about 10 kids who come to our porch every afternoon and laugh with/at us.  On Friday they took us to Namitete Technical College, which is down the road from the hospital.  The kids like to play with our cameras and take tons of pictures and videos of each other.  After the tour we came back to the porch and a dance party broke out.  The kids were playing music on Daniel’s phone and they were video taping each other dance.  Their favorite songs are by Maroon 5, B.o.b., and T.I.  all of which we conveniently had on our phones and computers.  They stayed on our porch singing and dancing until the sun went down.  That night we took some of our new friends who are also staying in the hospital guesthouse to dinner with the Gray’s (the farmer’s we stayed with the first month).  We’ve gotten pretty close the kids who come to our porch and we see them pretty much every day.

Some of the kids hanging out on our porch.

Saturday morning bright and early Daniel’s friends Hosea and Myamiko took us to see their school in Namitete.  They are both in secondary school and they’re in the middle of exams right now.  Some of their classes are English, Chichewa, bible knowledge, biology, and agriculture.  Their school had a few classrooms, one for each grade, that had some benches and maybe a couple desks.

 

That afternoon Daniel and I met up with our friend Gift to get another village tour.  We walked through some villages to get to Gift’s house, and on our way there we kept accumulating children who somehow knew that we were friends of Gift.  By the time we were at his house we had our very own entourage of children.  The best part was when we leaned over Gift’s gate to see if he was there, and his mother recognized us immediately and was so excited to see us there.  When we met with Gift he told us that we were in luck, there was a chief induction ceremony going on in a nearby village that he would take us to.  When we got to the village, tons and tons of people surrounded a small fort where the chiefs were seated.  One of the main chiefs saw us in the crowd (we’re not very hard to miss because we cause a lot of excitement) and invited us to come and sit under the fort with them where we could see the tribal dancers.  The people there were so excited to have us and were so welcoming as they tried to make sure we had the best view possible.  Then the dancing started.  The costumes alone are worth noting.  Each dancer wears a mask over his face; they are not supposed to be seen as human.  Aside from the dancers, there are people who also come out dressed as animals.  We saw two huge oxen that must’ve had at least three people in them each.  There was also a man who came out dressed as a monkey, this one was trying to scare me and I must say it worked a little bit.  Seeing the tribal dances and experiencing this piece of Chewa culture first hand was definitely one of the coolest experiences I’ve had here so far.

The crowd at the chief induction ceremony.

Some of the traditional dancers.

Monkey!

On Sunday the Malawian sisters invited us to come to the Feast of St. Peter at the church.  It was all outdoors and the archbishop came from Lilongwe to run the service.  The first two hours were pretty interesting, lots of singing and dancing, and everybody brought offerings to give to the Archbishop.  By hour six even the nuns we were sitting with were getting antsy.  After the service there was a sort of potluck at the church where lots of different groups of women brought tubs and tubs of nsima, cabbage, chips, pumpkin leaves, and other typical Malawian foods.  We got to go around and try food from different groups, everyone was very eager to have us eat with them.

One group of women with the food they brought for the “potluck.”

After the exciting weekend, we were ready to get back to work and yesterday we finished DataPall!  We have just sent the user manuals to a printer, and we are now setting up training sessions.  Now that we’re mostly done, some of the other parts of the hospital have been asking if we want to see what they do.  We’re getting to see a lot of different things happening in the hospital and it’s been very exciting!

Training Update

Second week of training has gone swimmingly. Now we have a detailed agenda and have even been running more on schedule than usual! It is really impressive how quickly the trainees pick up the skills. Today we were even able to go down to the wards and have the trainees observe the CPAP in action as the nurses put new babies on the machine. This was really helpful since the trainees all practice on baby dolls. I’d also like to share a couple of great quotations from training. It helps if you read them with a Malawian accent…

Florence (Queens CPAP nurse): Make sure there is space between the septum and the nasal prongs. They will sue us and the baby will need plastic surgery.

Alfred (our Malawi Ministry of Health helper): First you save lives, and then you can have your…Fanta.

 

Weekend

On Saturday we went to a Malawian play about witchcraft. I was expecting it to be super creepy, but it turned out to be a comedy! As far as I could tell, they were basically poking fun at witchcraft and making it seem ridiculous. The cast was made up of only four people who were incredible actors. One of them was also the writer and director and is a very famous actor in Malawi. It started off really funny, but soon the subject matter made me, as well as most other Azungus (white people), uncomfortable. Basically this boy had come to the best witch doctor in order to get something that would allow him to rape girls and get away with it. However, he broke the terms of the original agreement and had to return to the witch doctor for help. The solution required him to rape his mother and kill his father. The second act opened with a big sign over the newly converted witch doctor’s place which read in Chichewa, ” We have stopped practicing witchcraft. We are born again.” There was a couple of dramatic plot twists, but it involved a lot of rape and didn’t seem to have a happy ending. What was surprising to me was really the audience’s reaction to the play. Most of the audience were male Malawians, and pretty much everyone except the Azungus thought it was hilarious. Seeing people laugh and joke about things like rape and HIV was a bit of culture shock to me. But the more I thought about it, it really isn’t all that different from the inappropriate humor found in American media. It’s just that different topics are more relevant in different cultures, and these particular topics were rather uncomfortable for me. Maybe Malawians would find American humor quite offensive. Regardless, it was a good experience, and like I said, the cast was really talented.

On Sunday we attended a picnic for the music program of a private primary school. It was a lovely day and the children’s performances were highly entertaining. Tiny musicians are adorable in any culture! I also got to stock up on African cakes, my latest food obsession. It’s basically just little circles of banana and corn maize mashed into a dough and then fried.

 

Picnic with the housemates

The Season of Leaving

It’s about that time of year when a lot of volunteers are heading back home soon. It’s made me think about how difficult it is, on a person and professional level, to be in a place where people are constantly coming and going. For Malawians I imagine it’s really difficult to have so many volunteer doctors come for a few months to a year, and then have new co-workers all the time. And since the volunteers can come and leave as they please without any set schedule, they often end up with periods of lots of doctors on the wards, and periods where they are seriously understaffed. It also makes it difficult to make lasting relationships with people. A few of our friends here are here for about a year, and I can’t imagine having so many “short-timers” like myself coming through all the time. Answering the same questions to clueless newbies and saying goodbye to so many people throughout their time here. However the ex-pat community here is so small that everyone knows everyone, and you start to feel really popular when you run into people you’ve met. In fact, Ariel and I have not travelled anywhere without seeing people from Queens!

Medical Record Hunt

Our dear friends at Medical Record are on a major hunt to find about 25 files in the vortex of the medical record storage. A doctor gave them a list of patients that needed to be tracked down so they have been diligently going through piles on piles of charts trying to find these patients. They have found several over the last week, so they are very excited about that. Whenever they find one there is lots of whooping and celebrating! Going to medical records, once a daunting task, is often the highlight of our day. They always keep us laughing and also like to teach us Chichewa.

                      

 

The Pediatric Nursery crowded with med students!

The prettiest produce stand on the street.

No Fear Aloe Vera

Well now that I’ve gotten you to read all this random stuff, I’ll now explain the blog post title. One of the nurses in Chatinkha nursery thought I was a doctor, so we spent some time talking as I tried to explain who I was. She couldn’t figure out how to same my name, so I wrote it out. She asked what my name meant, and I sadly replied that it means nothing in particular in English as far as I know. She then told me that in Chichewa, “Sa” means “without” and “mantha” means “fear”. And she interpreted my last name, Olvera, as “a medicinal plant used for many purposes”– aloe vera.  So in Chichewa my name is quite exciting. All this time I thought I was just named after my brother’s childhood stuffed animal…She also has the same name as my grandmother, so it was a good bonding experience overall.

I love all the colorful outfits that all the women have here, so I thought I would dedicate a blog post on the way women dress in Malawi. If you are curious what Malawian men wear, they basically just wear pants and a shirt, nothing horribly interesting.

(I feel awkward taking photos of random people on the streets, so most of these photos are from Google)

Step 1. Choose multipe chitenges

Chitenges are brightly colored and patterned cloth that is used for all aspects of life by women in Malawi and all over Africa. They are used as skirts, blankets, headpieces, baby sling, blankets, suitcases, and more. Many women also get elaborate outfits tailored out of chitenges. These cloths are sold at stores and stands in the market by the meter. Usually they cost around 1500 kwacha (~4 USD) for every 2 meters. You can find all sorts of patterns  including ones with the faces of political figures such as Obama and Malawian President Joyce Banda. In the US, people often give out t-shirts for political campaigns and events. Here, they give out chitenges instead. They even have a chitenge for when the Pope visited Malawi.

 

Step 2. Wear a shirt and a skirt

Any shirt and skirt will do. These are not the important components of your outfit.

Step 3. Tie a chitenge around your waist

Choose one of your chitenges and wrap it around your waist over your skirt tucking it in on one side. I found a video on Youtube.

Step 4. (Optional) Tie on a matching chitenge headpiece

Many women here wear chitenge headpieces that matches their chitenge skirt.

Step 5. Tie a baby to your back with a chitenge

Malawian women have very high fertility rates (an average of 5.98 babies per woman) so it seems to me that every other woman here has a baby on their back. Sometimes in the hospital, the babies are tied to the front and are breastfeeding while the mother is casually strolling through the hallways. I have seen it many times here, but it still amazes me everytime.

 

Notice in the photo above that almost all the babies are leaned to one side because they are peaking forward. They are always so adorable.

Step 6. Place a large item on your head 

This large item can be anything: a suitcase, a bucket of water, a collection of pots and pans, or a large bundle of firewood. Regardless of how large the item is, it seems like women here are insanely poised and balanced and are able to walk effortlessly.

 

Congratulations! You have just finished learning about how to dress like a Malawian woman. Does this seem difficult to you? It seems extremely difficult to me. I have so much respect for Malawian women and all their responsibilities of the primary caretaker at home. They not only are able to walk long distances while carrying a child and a large load on their head, they also have a lot of strength from cooking, espeically nsima (a very dense stable food that requires constant stirring), on open fires.