1. Going home on a bike taxi at 5:30 in the evening will give you a gorgeous view of the sunset.
The main shops of Namitete are about a 15 minute bike taxi (45 minute walk) from the hospital and Zitha House (where we are living). The main road goes through fields and runs through the village and over small hills. The large pond of the Duck Inn reflects the pink and orange sunset perfectly. Definitely one of the things I’m going to miss the most.

2. Mendasi may be the cheapest snack I’ve ever had.
For 20 kwacha (equivalent to 5 cents), you can buy a ball of dough that has been lightly fried. I can usually restrain myself from buying one every time we go to market, but I can’t say the same for Joao. Kids of all ages will be carrying mounds of mendasi in buckets whether you’re in the capitol city or in Namitondo.

3. “Looking is Free”
Going to the Lilongwe craft market will always be followed up with a much needed advil. On the craft market corner next to the Game complex, dozens of sellers will bombard us once we step into the market’s fifteen foot radius. Good news though: “Looking is free”. I’m not quite sure why but they like to give us fake names. The last person I bought something from told me his name was Chicken Soup.

4. You + Camera = 20 kids fighting to get in the camera’s view
Many of the neighbor’s kids love striking poses for us. Once they see us take out our phones/camera, dozens of kids (seemingly out of nowhere) will push each other to get in the picture. Introducing them to “The Selfie” was a big hit. Poses include cartwheels, karate stances, and pushups.

5. Don’t underestimate the hospital soccer team
Last weekend, we went to see the hospital men’s football team scrimmage against the Namitete Sun Downs team. The Sun Downs are semi professional and players are paid to be on the team. We shamefully thought the game would turn out to be a blow out in favor of the Sun Downs. Although the hospital team did lose, it was only by a differential of one goal (2-1 Sun Downs). The game had a large crowd, and we recognized players on both teams. Football is a common past time for people of all ages. On our way home from the hospital in the evening, we’ve never failed to not see an ongoing pickup game.

6. Knowing a few phrases of Chichewa goes a long way.
Chichewa 101. The phrases I’ve picked up this summer are by no means an extensive list, but knowing the common greetings is a great gesture to the locals. We’ve had people stare at us in shock and then laugh hysterically after we say simple phrases like “Good morning”, “How are you”, or “Have a nice day”.

7. The best time is nsima time
Nsima time refers to the 2 hour lunch break by the hospital. However, when someone mentions nsima all I can think about is the unique staple food that everyone here eats on a daily basis. The interns joke about bringing it to the Rice servery kitchens some day…

8. Tomatoes and onions are all you need
The Namitondo produce market may not provide us with a great luxury of assortments, but we can always rely on it to have plenty of tomatoes and onions. Since we cook for ourselves every dinner and the occasional lunch (if ramen/pbj sandwhiches aren’t sufficient), we try to call out to our creative sides for new choices of dishes. One criteria though: it must contain tomatoes and onions. Joao, Jesal, and I probably consume at least 30 tomatoes and 20 onions every weak.

9. Chitenje— every Malawian woman’s favorite accessory
A chitenje is an African garment roughly 2 meters long with many versatile uses. I’ve seen it used as a head wrap, a skirt, a saddle for a child to attach to the mother’s back, part of a scale, and much more! Our friend Gift said to me, “You become part of Malawian culture once you buy a chitenje”. Needless to say, we all bought ourselves a few chitenjes.

In case you couldn’t tell from all of our last couple blogs, we’ve spent a lot of time in St. Gabe’s Palliative Care ward. More specifically, we’ve been working a lot on palliative care data collection, centering around two pieces of software: DataPall and Morphine Tracker (MT). While we have been making some changes to DataPall over the summer, lately we’ve been focusing on putting the final touches on the software of our own design, Morphine Tracker.

But why is the (morphine) gone?

It all started when the Palliative Care Clinician here, Dr. Suave, approached us with a problem—Morphine is a highly regulated, much needed drug for patients receiving end-of-life care, so hospitals and clinics are required to closely monitor its usage and report that data to the Ministry of Health (MOH) and other funding organizations. However, Dr. Suave and his mentor, Kathryn, recently performed a study attempting to quantify morphine usage in Malawi (which is in the process of being written up!), but they found that the vast majority of palliative care centers are (illegally) not reporting sufficient/correct data on morphine usage. Even hospitals (like St. Gabe’s), who are very rigorous about reporting their morphine usage will still sometimes make mistakes when adding up figures like total amount of morphine used, total patients on morphine, etc.

Home Screen of Morphine Tracker

As Malawi buys the morphine supply for the entire country, this poor data has apparently helped to lead to significant country-wide morphine shortages (some lasting as long as five months). The end result is that patients who desperately need morphine are unable to receive any.

“Have you ever seen a cancer patient cry [because we can’t give them morphine]? It’s very, very sad” -Dr. Suave

Trying to keep track of morphine

This is where Morphine Tracker comes in: we created the database to allow hospitals and clinics to easily track their morphine usage, and automatically create reports that already conform to the Malawian legal standard. Suave seemed very optimistic about how the software could change the way morphine is tracked in Malawi, so earlier this week, he introduced us to his mentor, Kathryn. After briefly showing her the software, she was similarly optimistic about Morphine Tracker (MT), and invited us to do a pilot implementation at the clinic she works at, Ndi Moyo Pallitive Care Center (www.ndimoyo.org/) in Salima. We plan to visit Salima this Wednesday, and we’re super excited about being able to see another site where palliative care has a very active presence.

Entrance to PACAM

We were also able to meet with the Palliative Care Association of Malawi (PACAM) to talk about Morphine Tracker. After giving a short demonstration of the software, the director of PACAM also expressed his support for the software, indicating that it had potential to greatly improve the manner in which morphine is tracked in Malawi. The overflowing optimism from our meeting with PACAM obviously did not help our patience in rolling out the software: we would’ve released it to the whole country, right then and there, if someone let us.

Urgency vs Rigor

However, when working in technology development for low-resource settings, there’s always this double-bind between urgency and rigor. Morphine Tracker is a good example of this. There is an obvious and urgent need to track morphine better in this country, and MT seems like it could be a usable solution to the problem: it automatically keeps track of the hospital pharmacy’s morphine stocks, can generate reports on morphine usage for donors and MOH, and encourages accountability of where the morphine is going.

These features seem to have made it very attractive to all the people that we have talked to, and all have been encouraging us to look into wider-scale, even country-wide, implementation. While we obviously love MT and would be thrilled if it could be implemented across Malawi, there are bugs that can be found in the software, and potential usability problems could still be discovered. The last thing that we want is to let hospitals all over the country use the software, only to later find some horrible bug that throws off the report’s accuracy.

We hope to be able to conduct small, provisional pilot implementations of Morphine Tracker in both St. Gabriel’s Hospital and Ndi Moyo Clinic. We believe that because both institutions have very well-run, organized palliative care centers, we will be able collaborate with them to log errors, complaints and difficulties so that the software may be improved in the future. After all, like Truce mentioned, “if we can’t put a strong foot hold in these two, how will we be able to do so in other hospitals?”.

As I started packing, I have begun to think about the things I will bring back with me from Malawi. I’m not sure I could formulate an exact list because I’m bringing back more than what is in my suitcase or my camera. This is a list of some of the things I will carry home with me:

1. Approximately 2kg of Malawian-grown coffee and 250g of black tea, as well as some dried hibiscus flowers from which you can make tea- something I have started to love doing after coming home from work.
2. Approximately 16 chitenges; 6 pairs of happy pants, 4 bags, 24 napkins, 2 shirts, and a pair of shorts, along with some fabric I haven’t modified yet.
3. Four bottles of Nali, which is Malawi’s own hot sauce made from peri-peri peppers. It’s almost too hot for me, but not for many of the Malawians I have met.
4. 500 pictures; some work-related and some for myself.
5. A recipe for nsima.
6. Some ideas for devices or technology that could serve as future design projects at Rice.  I am more able to provide new ideas now that I have seen a low-resource setting and its constraints, which are very important to keep in mind during the entire design process.
7. A small but strong Chichewa vocabulary.
8. A six-pack from all of our Insanity workouts. Actually that’s pretty far from true (although I’m sure I’m closer now than I was when I left).
9. A number of new mentors and role models. I’ve met some of the hardest working and most compassionate people I’ve ever known, and of anything I take back I hope it can be the inspiration they have given me to work hard and to always treat people as though they are family. Even though I have only had a summer with them, I would consider the people I have met here to be family to me.
10. A worldview with better peripheral. You can’t understand a place like Malawi from a textbook or Wikipedia article. It takes living in the country, meeting the people, and trying to solve problems as they stand right in front of you to know what words like “developing” or “low-resource” mean. I only had two months in Malawi, and my vision or understanding isn’t 20/20, but I see much more clearly than I ever had before. Out of everything on this list, number 10 is probably the lightest- and in some ways the heaviest- thing I carry with me home.

It’s a very bittersweet goodbye leaving Blantyre, and I will miss my new friends and new favorite places a lot. The attachment I now feel to this place only highlights the desire I have to continue working in the global health field. I am grateful for the opportunity to come to Malawi, and I hope that the work I have done here and will do during my time at Rice will be as meaningful to someone else as this trip has been to me.

I guess it can no longer come as a surprise that I have learned far more from continuing my tech surveys than I expected. In the past couple weeks I’ve spent more time talking to clinicians, which has given me different insight than I have gotten from the nurses. Generally the nurses were helpful in figuring out the logistics of using a device at Queens, while the doctors I’ve talked to have illustrated what potential exists for a device to make a difference.

I had a particularly helpful conversation with one of the visiting physicians from the UK who was working in the nurseries and children’s wards. She had a lot of good feedback for all of the devices, but the thermometers in particular. She said that apart from the simple idea of detecting a fever, the thermometers have a lot more to contribute that may be slightly more subtle. A thermometer given to a mother isn’t just a signal of a fever, but also proof to a doctor or nurse that the mother was paying attention. She could give more specifics as to the child’s symptoms, feel confident in her decision to bring the child in, and have a way to keep an eye on whether or not their condition was improving. If she didn’t know before exactly what a fever was, the responsibility of a thermometer would serve as a platform for mother’s education on health in general. In short, as the doctor put it, the thermometers had potential to be empowerment for mothers. Empowerment as such could easily be as important as any technological advancements available.

This conversation tied well into a book I’ve been reading that speaks some about medical interventions in third world countries. Intervention is not a one-step process where we can bring equipment or medication and leave. Awareness and education is key to making any help sustainable in a new environment. Follow-up and continued assistance is necessary to ensure that whatever investments in time or money were made were used to their worth. In the 2000’s when the US and other nations made a large push to deliver antiretrovirals to developing countries, they were not just healing the sick. They were stimulating economic development because fewer resources were being put towards healthcare and more people were able to participate in the economy. They were bringing education about AIDS, but also about healthcare in general, about safe sex, and even about rape (in many African countries, it was commonly believed that the cure for an STD was intercourse with a virgin). I don’t want to argue that the AIDS intervention didn’t have it’s problems and setbacks, only that each change made to global healthcare has ramifications that extend past the goal of the change.

This is also relevant to the feedback I’ve received from the tech surveys about the importance of the nurses’ and clinicians’ attitudes for a new device to be successful. A device like the Chemoseal or Biliquant may have a lot of potential and Queens may have the resources to implement it but if the nurses aren’t in favor of using it in the nurseries or oncology wards it’s no use. The way we present each device is very sensitive; in my surveys I always try to emphasize that the goal of my program is to make the job of the healthcare provider easier by giving them the tools they need. When a device is misunderstood, it won’t be put to use. If it is presented as a lot of work to use or difficult to comprehend, it is less likely that the nurses and doctors will feel positive towards it.

I’m only here for a matter of days more; the people that work in the hospital year round are the ones to whom the responsibility of implementing a technology falls. Without the support of the healthcare workers, a device is next to useless in a setting so far from where it was developed. Sustainability of any intervention is in the hands of the people who will be there when the intervenors have disappeared.

It seems like the days couldn’t go any faster. Now that our internship is coming to a close (less than 10 days left!!) we are finalizing our projects.

A huge portion of our time is being spent on Morphine Tracker. With some minor touches being worked on at the moment, Morphine Tracker (MT) has greatly improved since the last time I talked about it. Yesterday, we went over the functionalities of it with Dr. Suave, the doctor in the palliative care clinic. He is a part of the Palliative Care Association (as mentioned in the last post) and was able to provide us a lot of feedback on what we can add to MT. Today, we ventured to Lilongwe to meet his mentor, Kathryn Hamling. Kathryn runs the pharmacy at Ndi moyo, and both Kathryn and Suave are active members of the Palliative Care Association in Malawi. Kathryn expressed great interest in MT and after going over the database with her, she inquired if we would be able to come to Ndi moyo to further train her staff to allow them to adopt it. Realizing that our time is limited and with Ndi moyo being several hours away, we scheduled our visit for the beginning of next week.

After sitting down with Suave during lunch, he told us about his history in palliative care. Being such an active member for PACM (Palliative Care Association for Malawi), he has traveled to other countries in southern Africa and seen many examples of palliative care systems, including their record keeping. His interest in MT is very strong, but he ensured us that although many others may have the same interest does not mean they have the desire or will to accept it right away. Kathryn exasperated how morphine dispensing needs to be legally, regularly, and accurately monitored– the very opposite of what is happening now. Some hospitals, like St. Gabriel’s and Ndi moyo, take their morphine tracking very seriously. Although done manually, it is kept up to date, even with the painstaking amount of time needed to produce records and count amounts manually monthly, quarterly, and yearly. Not every hospital has the manpower to do so. The greatest hurdle to battle: implementation. St. Gabriel’s and Ndi moyo are ready to implement MT and will do so in the next week. However, they already had the personnel and will to track morphine. But what about the other hospitals that may need an electronic database even more? Suave has told us PCAM has been looking into the problem of morphine usage reports for quite some time, but nothing has been done as a solution. Many problems can come up: lack of computers, lack of personnel knowing how to use the computers, lack of time to input the data recorded from that day or week, and much more. In the next ten days, implementing MT at St. Gabriel’s and Ndi Moyo can provide us with substantial feedback on tackling these problems, because if we can’t put a strong foot hold in these two, how will we be able to do so in other hospitals?

Future plans (for the next 10 days), purchase supplies for the stirrups, create a presentation for the hospital staff about our work during the internship, producing an updated DataPall manual as well as a MT manual, update DataPall reports, finish LCTemp testing, and last but not least, enjoy our final days in Namitete!

Next blog post: Namitete and Lilongwe

I haven’t really talked about this before, but I think it is appropriate to mention some of the things that make this internship sometimes very difficult for me. I am working in one of the poorest countries in the world with one of the highest infant mortality rates. I can’t spend two months in and out of hospital nurseries without learning what those statistics really mean.

Last Friday I was in the nursery for less than two hours total the entire day, but I was still present for the passing of two babies. Both were very sick and had little chances of survival. It isn’t uncommon to become acquainted with a child or their mother one day only to see a new baby in their place the next. While doing some data entry in the past week we’ve spent a lot of time looking at clinicians’ notes. The notes will chronicle the story of the patient’s entrance, their improvement or worsening condition, and often afterwards their death. At every death, the nurse or clinician taking notes will write “so sorry” underneath the notes of their passing.

It’s very hard to play witness to some of the hard facts of the hospital. A lot of times I feel helpless because there is nothing I can do that could give these children better chances than what the nurses and clinicians are already doing. I feel guilty that if the babies grew up where I did, they would have access to so much more that could help. I have to constantly remind myself that what I am doing here is, in it’s small way, contributing.

The difficult sights I have seen illustrate the importance of the work that groups like BTB are doing. Statistics are far more compelling when you’re standing in the middle of them, but they’re as important in Houston as they are in the nursery. I’m so grateful to everyone that has contributed to this program or a similar one, because work like that Rice has been doing is absolutely necessary. As I have now actually observed, interventions like the CPAP have often drawn the line between life and death.

This week, Caleb, Jacinta and I wrapped up our work at the Poly and said goodbye to the many friends we have made during our summer here. I have made so many good friends during my time in Blantyre, and I will miss them all: Shannon and MK – the Rice program associates, Rodwell and Dr. Gamula – Our mentors at the Poly, Carol and Thandi – The Rice CPAP associates from Malawi, Collins – our taxi driver and close friend, Maxwell – a local artist, and Alfred – the keeper of cure guesthouse.

Coming home is definitely a bittersweet feeling. There are so many people I have met that I may never see again, and I will miss the Malawian way of life. Arriving in America things will be much more fast paced, I will no longer be able to haggle down the price of vegetables that I buy, and the street food I have come to love will be replaced by Houstonian food trucks. However, I am looking forward to coming home and seeing my friends and family. I also still have a hope of returning to Malawi one day somehow, to continue building on the work I have done and relationships I have made this summer. Malawi is a beautiful country full of some of the most incredible, unique, and interesting people I have met, and I wish I had more time left!

Another thing I will miss about Africa is the beautiful landscapes and diverse wildlife. This weekend, Caleb, Jacinta, Emily, Aakash and I took a last trip to Zambia to go on a safari. The lodge we stayed in was gorgeous, the food was delicious, and we frequently had elephants walking through our camp! We also learned a lot about Zambian culture, and found that it is surprisingly similar to Malawian culture! The languages are both chewa derivatives, and many of the phrases we had learned in Malawi were almost identical to those in Zambia. We also had the chance to meet a lot of interesting people from around the world and even saw a lion or two!

Our time in Zambia also gave me the opportunity to reflect on all I have learned here. Coming into this internship, I felt relatively well prepared for the challenges I would face, and in some ways I was. I didn’t experience culture shock or homesickness, and I was never caught off guard by the conditions in the hospitals. However, there were times when I was overwhelmed by the amount of problems in health care here, and I struggled to see if my 9-week trip would make a difference. Looking back, I know for certain my time here was valuable. Not only was I hopefully able to make an impact through the projects I completed and data I gathered, but Malawi has also had an undeniable effect on me. I have seen joy and perseverance in the face of suffering and have been inspired by many talented, compassionate, and ingenious doctors and engineers who truly care about their country. I have learned so much from both my Malawian coworker and my fellow interns, and I am incredibly grateful to have had the opportunity to participate in this internship. I look forward to using what I have learned here throughout my next year at Rice and the rest of my life.