Jacinta, Carissa, and I spent yesterday afternoon lesson planning for our second course at the POLY. This course will cover Electronic Measurement Systems from basic breadboard prototyping to electrodes and physiological signals. We are pitching the course to some professors next week, and I hope they like our ideas and give us some good feedback.

Most of our students will again be electrical engineers; however, because of the limited resources here, many of them may not have had much, if any, hands-on experience with circuits. Much of their coursework is very theoretical, and while they may be able to tell you how to design a band pass filter, we’ll see if they can do it in real life. Furthermore, most of our lectures will be focused on understanding physiological systems and how to transform a heartbeat into a voltage. We will be drawing from Systems Physiology Lab, in which we measured heart signals (ECG), muscle signals (EMG), brain waves (EEG), and basal metabolic rate. While we don’t have all the equipment that we had in the States, we brought a whole lot of electrodes, so we’ll do our best. Our goal is to deliver lectures and labs the first week and have the second week focused on personal design projects that we will pitch to them.

Today we met with Dr. Gamula, the head of the Electrical Engineering department as well as one of his colleagues to showcase the equipment that we brought as well as to run through our ideas for the course. They seemed really excited about using the software and hardware we brought, both for the labs we planned and other courses they already have instituted.

 

This week has been pretty busy, so I haven’t had as much time in the wards as I have previously. I have gotten to spend time in the nurseries a couple times, which is something I particularly enjoy. I don’t think I had ever spent a lot of time around babies only days or weeks old before this job. The babies are so small. Their entire hands are no bigger than my thumb, and their rib cages are dwarfed by the width of my wrist. There is rarely a lot of crying in the nurseries, and most of the time the babies are either feeding or sleeping. Last week one of the nurses in the Paeds ward had me help to change one of the babies into a clean onesie, with the permission of the mother. I was scared to death that I would hurt her just by moving her arms or unfastening buttons. The onesie we put on her practically swallowed her whole. It’s hard to believe that any human being could ever be that small. I can now understand even better the importance of technology to help babies in their first few weeks or months of life, when they are so fragile and even the most innocent things can be dangerous.

A CPAP baby in Chatinkha

Yesterday I had the opportunity to do a little bit of traveling to collect some CPAP data from other hospitals. I saw two new hospitals; the central hospital in Zomba, which rivals QECH in it’s size and capacity, and then the small district hospital in Machinga. Machinga was a stark contrast to the other two. Zomba has about 40 patients a month in it’s nursery ward, which is a comparable number to QECH’s two nurseries combined. They have multiple CPAPS that are up and running, and a lot of nurses trained on CPAP use that know how to care for a patient using the machine. Like QECH, the hospital in Zomba gets a lot of referrals of very sick children from other hospitals, and they have more resources for special care available than most hospitals in Malawi. Machinga’s nursery ward had six patients when I visited. They had one CPAP which was not in use and they hadn’t had a patient that needed CPAP in weeks. The small size of the hospital makes it more difficult to maintain the use of the CPAP. When babies that need it come in so infrequently, the nurses don’t have a lot of opportunities to practice their CPAP skills or impart them to new staff. If they can’t practice, the CPAP can be misused and even cause harm to the baby. If a technology that acts as such a lifeline for a patient isn’t used properly, it’s no better than not having the technology at all. The CPAP team has been trying to help Machinga out with keeping up on CPAP use and training, and making sure they have the support they need.

Today Becky was telling Aakash and me about an interesting problem that came up in the Paeds nursery which reminded me of the problems that Machinga was encountering with the CPAP. The nursery just got a very large donation of thermometers, which is something they desperately needed. Unfortunately the thermometers are in Fahrenheit, instead of Centigrade. The nurses don’t know the conversion, so Becky spent most of her morning helping read temperatures and diagnose fevers. While Paeds was lucky to have Becky around to help, this issue highlights an epidemic that has infected Queens as well as a lot of other hospitals in this country.

The people who donated the thermometers had good intentions. They had the determination to get the thermometers all the way to Queens from wherever they were donated, which is a feat in itself; transportation is very expensive and difficult to oversee from afar. But after all of that hard work to get them here, the thermometers are so limited in their use to the hospital. It’s the same way with a lot of donated devices from America; Malawi uses British outlets, so anything with an American or other European plug needs a converter, which is something in short supply. You cannot find fault in the efforts from those who donate supplies, but a device that people here cannot use or don’t understand is not going to make much of a difference. From my perspective, this is the biggest obstacle right now in international efforts to contribute materials-based aid to places like Malawi. If there was a better way to communicate the needs and resources that already exist in the recipient site, than maybe the contributions of the donor site could go a little farther.

The issue with the thermometers made me think about some of the work I did at home with Project Cure. Project Cure is an organization that collects and delivers donated medical supplies to low-income clinical settings around the world- including parts of Malawi. They stress the fact that they are non-political and non-profit; the work that they do is towards the one goal of getting medical supplies to those that need them most. The delivery method that they use is a multi-step process; first, they visit the site which will be receiving the supplies to do an inventory and decide exactly the site needs. Then once they get those supplies from their warehouse they hand-deliver the supplies to the same site. That way they know that the materials they contribute are needed, can be put to use, and are getting to the right people. I don’t know a lot about how much Project Cure works with medical technology, or what the problems are that they encounter in the distribution process, but I think that the deliberation that they use in their practices has resulted in a lot of good. The thermometers and CPAP problems that I have seen here have emphasized the importance of that kind of deliberation.

You’re probably never going to find anyone who objects to donating much-needed medical equipment to developing world clinics. Equipment is expensive and difficult to come by in these areas to say the least. Furthermore, with some the budgets that many clinics have to operate within, there are times when some medical equipment would quite literally not be getting to these clinics if not for generous outside donations. But, after my few weeks here at PAM, it is evident that there are still some barriers to ensuring that medical equipment is donated in a way that way optimizes its benefit to the recipients. Outside aid is incredibly valuable obviously, but shipment after shipment of donated medical equipment is not necessary a sustainable way to address issues in resource management and procurement.

Working with the technicians at PAM has been both enjoyable and educational, and I feel like I’m gaining a better understanding of how QECH manages its donations. Here are some of my thoughts on a few of the current issues I’ve noticed with the medical device donation process.

 1. Lack of regulatory oversight

The World Health Organization has established a thorough set of guidelines and recommendations on donating medical equipment. The document is thorough and well organized and most definitely worth a read (Check it out here: http://www.who.int/medical_devices/publications/en/Donation_Guidelines.pdf) But unfortunately, I’m willing to risk an eyebrow that these guidelines are not strictly followed about 99% of the time, as (for the most part) there are few means of enforcing or overseeing what goes into donation shipments.

After talking to a number of different nurses, doctors, and technicians at QECH, it is clear that this lack of regulation leads to many frustrations with the equipment that come into clinic. While I was in Chatinka a few days ago, I spoke with a nurse who was so excited about the 50 new syringe pumps that had just been donated to Queens. But, once she tried to actually start using the device, she was quick to discover that it would only run on 110V. Malawi runs on 220V. So unless the donors also want to provide a few voltage converters to supplement their shipment, the syringe pumps are essentially useless. And this happens way more times than you can possibly imagine. Sadly, not only does the operating voltage not match up oftentimes, SO many devices are also donated to QECH with plugs that don’t match the outlets in the hospital. Becky (another one of the interns here) was super sweet and gave her own personal outlet adapter to the paeds clinic the other day so that they could use a vital monitor that had been donated from the states. But certainly having interns provide these adapters during their clinical rotations is probably not the best, or most sustainable, way to address this problem in the future.

Oh and just today, a bunch of thermometers came in……in Fahrenheit! Ahhh!! Becky had to go around distributing new Celsius to Fahrenheit charts she had made because none of the nurse know how to work in Fahrenheit.

PAM has had to deal with medical equipment arriving at the hospital already broken, and sometimes devices are sent that are just so outdated and run down that the clinic is better off to having received them at all. If they’re broken and can’t be fixed, they quite literally just end up taking up precious hospital space, sitting there, doing nothing.

But thankfully, I believe that Malawi (and other nations) are starting to take a stand against receiving “useless” medical equipment donations, as seen by a newspaper clipping that sits on the bulletin board outside of PAMs office.

Newspaper Clipping on PAMs bulletin board 

Some countries have even started establishing regulatory bodies to make sure that donated equipment has gone through the necessary compatibility checks and inspections. For example, Ethiopia’s Drugs Administration and Control Authority (DACA) has created some pretty comprehensive checklists for their medical device donations. I’m really interested to see how these changes and new levels of enforcement will impact clinics long term.

But for the time being, I think that another way of complementing the work that can be accomplished through these regulatory bodies would quite simply be to increase communication between donors and their recipients. I think if donors just had a better idea of what would benefit clinics the most and what specifications need to be considered when sending equipment that is manufactured and produced abroad, a lot of these types of “careless” errors could be avoided. 

 

2. No personnel or protocol in place to distribute and manage donations in country

I have spent a good amount of time at PAM for the past few weeks, and the building itself is incredibly crowded. There really isn’t even a whole lot of workspace for the technicians to work on the mountains of equipment that they are supposed to fix.

Although there are lots of medical device donations that don’t work or that aren’t compatible for the setting, there are of course those that are made up of awesome, functional equipment that could very well be put to great use within the hospital! And that’s what brings me to my second point. Hospitals need the personnel to manage these boxes, unpack them, assemble the equipment (safely), and just get them to the right departments. The picture of the boxes below has been sitting there for roughly 5 months now according to Jiwowa, and it is filled with all kinds of things that could be helping all the patients who so desperately need them.

So many dusty boxes!! And this isn’t even all of them

So point one and two ultimately kind of go hand in hand. Before equipment is even sent out, it’s important that it has gone though the proper inspections to ensure that it is appropriate and useful for the hospital in question.  Therefore, part of ensuring that these devices are used to their maximum capacity means that you also have to think through how you’re going to actually put these devices into use once they get to where they’re going! I believe that donations “regulations” should involve making sure that the clinics have the personnel and resources to actually handle receiving the donations before they are shipped, so that working equipment doesn’t end up pointlessly taking up space for months on end.

During our next few weeks, Caleb, Carissa, and I plan on filling in that “personnel/resource” gap and will sort through and distribute some donations within the large boxes at PAM. But, we will also be trying to work with the hospital to try to figure out a new process/protocol that will continue and sustain this kind of work after we’re gone.

 

3. Lack of local capacity to fix equipment

While governments, international NGOs, and non-profits usually handle the actual donations on a large scale — an emerging problem is the lack of local capacity and resources to handle the maintenance and repair of devices as they break.

At Queens, the technicians are all incredibly well trained and obviously know what they are doing. But, many of the districts hospitals in Malawi lack the personnel to be able to troubleshoot/fix the broken equipment at their clinics, and will therefore just send this equipment to QECH to be fixed. So, the broken equipment build up is just horrendous and the ratio of personnel to broken equipment is so ridiculous that it’s really difficult for the repairs to happen within a reasonable time frame.

Malawi is taking steps to provide individuals with the proper tools (both literally and figuratively) to handle more equipment repairs by partnering with Japan’s International Cooperation Agency (JICA). With JICA’s technical support, they aim to train and develop PAM technicians all across Malawi. It’s great to see these kinds of changes taking place, especially after having spent the last week and a half teaching one of these types of workshops at the Poly! It’s been said so many times before that sometimes it almost sounds a little bit cliché, but seriously investing in human capacity is the way to go! The Poly is developing a new BME program and teaching its students valuable troubleshooting and medical device repair skills, and the Malawi Ministry of Health is setting up workshops to train more people already on the ground. Lots of exciting things are underway to address many of the issues related to maintaining the medical equipment in country, and I couldn’t be more excited to playing a little part within this much larger goal.

 Another small paper clip about Malawi’s Ministry of Health’s JICA/PAM partnership

4. Need for spare parts and repair manuals

The technicians at PAM are really good at identifying what is wrong with a piece of equipment very shortly after it is brought into the warehouse. However, 9 times out of 10, PAM just doesn’t have the budget or resources to get the spare parts that are in need of replacement to bring the technology back to life.

The picture below is of roughly 68 oxygen concentrators all in need of various spare parts to get working again. It is both really frustrating and sad.

Instead of having new equipment always being donated, I think that perhaps donations should start shifting towards providing technicians with the spare parts needed to fix the equipment that’s already in country. Getting devices back up and running would clear up a lot of space and also let technicians put their incredible repair skills to use!

Finally, when equipment is donated, the service manuals are usually 1) not included in the mix or 2) get lost along the way. When it comes to more complex pieces of equipment, a manual makes a world of difference, and could make or break a technician’s ability to figure out what’s wrong with a particular device. And then fix it!

All in all, my main take away is that it is not enough for donors to just be thinking about how medical device shipments have the potential to help a hospital in the short term. They should evaluate all aspects of sustaining the service that this equipment provides long term. From the consumables, to spare parts, maintenance, and repairs, etc. a LOT more is needed to sustain these devices once they are in country, and these things should all be considered and addressed well before the equipment ever reaches the hospitals they are trying to help.

I am motivated to learn more about the ins and outs of the donation process at QECH and in Malawi in general, and hopefully can find some creative ways to make a positive difference in this area. I think we have a few good ideas for now, and I will keep you guys updated on what we accomplish in the next few weeks!

After seeing the types of newspaper articles, training programs and classes that are popping up around Malawi, and hearing some of the discussions about these issues around Queens, I am hopeful that changes to the medical device donation landscape are pangono, pangono (little by little) underway.

Tionana zangas!

It’s only been a week since our arrival, but it feels like we’ve been here much longer. After layovers in London, Johannesburg, and Blantyre, we finally arrived in Namitete.

 Layover in London: The London Eye and Thames River

The hospital guesthouse is very nice, we all have our own rooms and bathrooms, and even a mini tv to watch the world cup on!

Here is our daily routine so far:

At 7:30 we go to morning report at the hospital, where the staff goes over the night’s admissions and special cases. Afterwards, Joao, Jesal, and I separate to shadow different doctors in their respective wards. We have already met quite a few of the hospital staff and are hoping to make more friends this way! St. Gabriel’s has many sectors, and on our first day it felt like a maze as Dr. Mbeya, the hospital director, took us around.

12:00 to 2:30 is the afternoon break. Since this is quite a bit of time, we usually are able to go into town or explore the village. Namitondo and the markets are only a five minutes away. At first, we would always try and bargain down the price about 50-100 kwacha, but then we realized that the 5 minutes of exhausting our (very limited) vocabulary of Chichewa was not worth the 25 cents.

Meat market

2:30-5 We work on the technologies that we brought by gaining feedback from the doctors who specialize in that area. I will provide another blog post explaining more on this feedback. The past few afternoons have been DataPall oriented. We are working on cleaning up the records by standardizing the treatments, diagnoses, and symptoms that are entered in with each patient. By doing so, the final reports will be concise and more accurate.

5:30 exercise as a team (yes, it’s true, I exercise)

6:30 cook, we’ve learned how to make nsima and vegetables (traditional Malawian food), but sometimes just resort to ramen and pbj sandwiches.

After dinner, I like to read or try to use the internet (however slow it may be). Sometimes we have little Chichewa lessons as well! Learning Chichewa has been a challenge. No matter how many times we practice the phrases at night, I usually seem to freeze up and forget them when talking to the locals.

It may be a little soon to say home sweet home in Namitete, but this first week has been an amazing start to this summer internship.

Note: I apologize for the lack of pictures and also delay between posts, the internet here is a lot slower than expected and requires a lot of patience.

Over the week that we’ve been in Malawi, we’ve slowly been getting to know St. Gabe’s and Namitete. The people here have all been ridiculously nice and welcoming to us, so that even though we’ve been here for such a short period of time, we’re already starting to feel like part of the St. Gabriel’s/ Namitete family!

     Entrance to St. Gabe’s                                  First time on a bike taxi!                    The goats in Namitete are like the Rice squirrels—                                                                                                                                                 they’re everywhere and know no fear

Under-5 Clinic

Last Friday, we visited the under-5 clinic at the hospital to get a sense of how the community health workers operated it, as well as showing them Jesal’s design, Babymetrix—a single device that can take the height, weight and head/arm circumference of a baby to help diagnosis malnutrition. The clinic itself brought in kids (and their mothers) from local villages who were suffering or recovering from malnutrition to check up on their development (i.e. height, weight and arm circumference measurements). This is incredibly important work especially as up to 46% of children in Malawi are stunted [1]. The community health workers who ran the clinic also gave out some nutritious food and educated the mothers on proper child nutrition.

 

      How babies are weighed                                          Learning about nutrition

All the mothers were so eager to get their picture taken, but given our lack of meaningful Chichewa vocabulary, there was a lot of gesturing followed by all of us laughing at our struggles. A lot of people have been trying to teach us Chichewa (and its been a blast!), but probably the most useful phrase so far has been ndikuphunzila Chichewa pangono (I’m learning Chichewa very slowly) just to get across the extent of our knowledge.

 

 

Lilongwe

On Saturday, we visited Lilongwe (the capital of Malawi), mostly to get desperately needed internet “dongles” as well as some groceries. After we got our dongles, we headed to a large shopping center. Once inside, it was almost as if we had been transported to an American HEB or Target—there were huge flat-screen TVs lining a wall and huge pictures of piles of delicious-looking produce with captions like fresh and value hanging below them.

 

While we’ve only been here for such a short period of time, it seems that Malawi is in a period of flux—the traditional Malawian blending with the western, most noticeably in the city but also extending out into the rural areas. However, the obvious dichotomy in lifestyle between rural Namitete and the up-scale parts of Lilongwe was a bit surprising; while we had learned academically about these harsh realities, it was still emotionally jarring to actually see.

Developing countries are vary rarely uniformly poor, rather it seems that to better understand ‘development’ (a word that I really don’t like, but that’s a discussion for another time), knowledge of the inequality among the population must be included along with the absolute wealth of individuals. The juxtaposition of the multitude of malnourished kids at the clinic with the long aisles of fresh, refrigerated vegetables in Lilongwe especially seemed to reflect the vast structural inequalities of the country.

However, there does seem to be signs that the situation is improving across the country—poverty, hunger and HIV prevalence in Malawi have all been reduced significantly over the past couple years [1]—and programs like the malnutrition clinic that St. Gabes spearheads are doing a lot to continue that trend.

Be sure to check out Jesal’s blog for another great discussion on issues surrounding wealth disparities in Malawi!

Quotes of the day:

“Malawi is a poor country—we don’t have oil or coal or minerals, but that also means that the States have left us alone” – Namitete Resident

“Just in case” -Jesal (always)

[1] http://www.unicef.org/malawi/children.html

Sister Patrice and a mother holding her child on CPAP

At the end of last week I started talking with mothers and nurses about their opinions of a thermometer that was designed in GLHT 360 last semester. The thermometer project has been thrilling for me because it has provided me an opportunity to interact with mothers and babies, and to get to know some of the nurses more personally.

The thermometers are very simple; they contain sheets of liquid crystal that change color when heated to certain temperatures. The thermometers are designed to have a red region and a white region, each of which contains liquid crystal sheets. If the color change occurs in the white region of the thermometer, the user is healthy, and if the color changes in the red region, the user has a fever.

The goal for this device is to eventually be able to send it home with mothers so that they are better equipped to tell when their children have a fever. The fact that the thermometers give a reading based on a color change instead of a specific temperature reading leaves the thermometers more accessible to mothers with less education. My aim in conducting the surveys was to get the opinion of mothers and nurses on whether it would be easy to use the thermometer, and whether it would be helpful to have them. So far there have been some significant trends in my responses, enough so that I was able to draw the following general conclusions:

1. Mothers care strongly about the wellbeing of their children.
1. This leads to mothers paying fairly close attention to the health of their child, so that they can notice subtle changes in body temperature even with palpation, and they will err on the side of caution when they think their child might be sick
2. It also means that something like this thermometer would be highly valued, and mothers would take good care of the device. Even though the thermometer is small, they would be cautious about losing  it because it relates to the health of their children.
2. Mothers come from a variety of educational levels.
1. This means that some mothers are better prepared than others to understand the significance of having a fever, and the use of a thermometer to prevent one. Less education could possibly correlate to something that looks like negligence because mothers don’t know how useful the thermometer could be.
2. Despite variances in education, it would be absolutely necessary for mothers to be well educated about the use of the thermometer and why it is helpful to them. For mothers that don’t know what a fever is, more information would be necessary to catch them up.
3. The primary question lies in whether the thermometer would help mothers be more careful about bringing their children into the hospital.
1. The thermometer would serve to erase doubt on the part of the mothers; it would act as an alarm that they could take seriously instead of wavering when unsure about palpation.
2. If mothers are already cautious and seem to already be able to know when their children have a fever, the device would not make a large difference in the practices of the mothers when they think their children are sick.
3. The general consensus has been that palpation works sometimes, and that a device such as this thermometer would be welcome. However, at this point it cannot be inferred whether the thermometers would be a significant enough intervention to provide a substantial change in the standard of care practiced by mothers and in clinics for children with a fever.

Of course, these conclusions are very general and only highlight trends in the responses I got; they don’t completely encompass all of the feedback I received. I intend on continuing to survey nurses and mothers in regards to this thermometer and the other one that has been brought to Malawi, whose purpose is the same. Everyone in the hospital that I have introduced to the thermometer seems to be highly enthusiastic about the prospect of having access to such a tool, which to me shows promise that with further testing and development this kind of thermometer would be a viable intervention in places like Malawi.

This is already a fairly long post, but as a favor to my mother I wanted to add a sort of glossary for my blog to make it easier to follow. I realize that some of my acronyms or language may not be entirely intuitive for those that aren’t from Rice or Blantyre. Here are some of the terms that I hope will help clarify what I’m talking about in my posts:

QECH or Queens: Queen Elizabeth Central Hospital, one of the large district hospitals in Malawi. This is where I’ve spent most of my time thus far.

Poly: The Polytechnic University of Malawi, where some of the other interns have been teaching classes and helping develop a bioengineering program.

PAM: Physical Assets Management, the engineering department at Queen’s where broken medical devices are sent to be fixed. The other interns have also been spending significant time there helping to repair equipment.

CPAP or bCPAP: The device that was designed a number of years ago at Rice to help neonatal babies breathe. There is a lot of information on the CPAP on the BTB website.

BTB: Beyond Traditional Borders, the institute from Rice University that sent me to Malawi. This is another one where much more extensive information is available on the BTB website.

Paeds: The pediatric ward at Queen’s. Most often when I refer to Paeds I’m talking about the Paeds nursery, which has an average of about 20 neonatal and infant patients.

Chatinka: The nursery at Queen’s attached to the maternity ward which houses about 40 neonatal babies on average, most of whom are suffering from respiratory problems and sepsis associated with prematurity. This and the Paeds nursery are where CPAPs are used at Queen’s.

GLHT 360: A global health technology class offered at Rice where many of the technology we have brought to Blantyre were designed and developed. I took this class last semester.

Palpation: A method of detecting fever by feeling the forehead, cheeks, chest, and neck for excess heat.

Kwacha: The Malawian currency; 1 US dollar is equal to about 400 Kwacha.

Thandie and myself in the BTB office

Time seriously just seems to fly out here in Blantyre! I am having the best time living at the CURE house and working on our various projects with all the Rice interns, and we have made a great group of new friends from the UK and Australia, who make the downtime/adventure time all the more exciting.

For the past week and a half, Caleb and I have had wonderfully packed days, splitting our time between teaching a class at the Poly and working with PAM at Queens. Being in front of the classroom, trying to keep the class energy up, prepping for the following day’s lessons plans, etc. makes teaching absolutely, but wonderfully, exhausting! The oldest students that I have ever taught before in a classroom setting have been at the high school level, but at the Poly we have 4^th year electrical engineering students and three faculty members to top it off. I get extremely nervous before going up for our mini “’lectures” that we start each class off with, and we do our best to make these parts seem more like a conversation/discussion than us lecturing at the class. Even though I’ve taken the troubleshooting class before and Caleb and I put a lot of prep time into learning the materials and organizing our class materials before coming out here, I still feel like I should be the one learning from the students and teachers in Malawi and not vice versa! But, in the end, the teaching and learning has undoubtedly turned into this wonderful two-way street that has led to friendship along the way.

                

Students fixing a suction pump!                             Our class and their workshop certificates

For the past two weeks, we have spent our afternoons at PAM working with Nelli, Timothy, Wiseman, and Jiwowa, fixing the broken medical equipment that have been brought over from Queens and sometimes other hospitals as well. I learn so much about the difficulties with fixing their broken equipment each time I go, and will write a bit more about some of my thoughts on medical device donations in my next blog. We have fixed a suction machine, a few oxygen concentrators, and one of the big hospital autoclaves so far. This week, we will be spending some more time with PAM, which I am very excited about! PAM has been very generous with letting us take some of their medical equipment to the Poly with us in the mornings when we would teach. For the first few days, Caleb and I attempted to draggggg the equipment to and from Queens, but quickly found that it was really quite difficult to keep this up! Thankfully, Dr. Gamula and Jiwowa were super generous is helping us transport some of the heavier equipment in their cars, which definitely saved us a lot of time and muscle soreness!

            

Caleb and O2 concentrators in JiWowas car                           Caleb and JiWowa working at PAM

Work has been so jam packed (Caleb and I usually leave the house by 7: 30 ish and get back around 5 pm). Sometimes I get home after having spent almost 7 hours on my feet, just wanted to sit down with a nice cup of tea and relax. BUTTTTT thankfully we’ve got some serious (positive!!) peer pressure going on within our family that forces me to do an Insanity workout at the end of every day! My new friend Gaby is a physio student and triathlete at the University of Nottingham in England, and she and I have even taken to waking up early in the morning to run and workout at the track just 5 minutes down the road from our house. I guess after all the mendazi and samooooosas that I eat here, I’m quite lucky to have been placed with some ridiculously fit housemates.

I love my job, my friends, and every little thing about Malawi, and am so grateful every day for the wonderful life and home I’ve found here.