Having been back in the US for almost a week now is a bit…disorienting is putting it mildly.

I miss St. Gabriel’s so much! That hasn’t changed in a week, and I don’t think that this ‘homesickness’ will dissipate anywhere in the near future. But what a little bit of time and space has given me is perspective on what I truly miss the most about life in the hospital and in Malawi.

 

What’s super convenient is that what, or rather who, I miss the most also serves to illustrate the most important advice I can offer to future interns:

Respect the amazing people who work at the hospital, and make friends when you can!

 

Previous intern blogs have taught me that the roster for each ward can change on a dime; rapid staff turnover is a huge issue at hospitals throughout the developing world, and St. Gabe’s is no exception. With any luck, however, most (or at least some) of these friendly faces will be around to enrich your experiences at St. Gabe’s, both personally and professionally.

There are tons of other people who we didn’t get the opportunity to take pictures with, but the moral of the story is that the staff of St. Gabe’s have really made our experiences during this internship special, and hopefully our friendships will endure in the forms of memories and lessons learned.

 

P.S. Second lesson I’ve learned from looking at these pictures: by Malawian standards, I’m practically a giant. Being a 6ft Caucasian woman has definitely gotten me innumerable intense stares.

It’s completely surreal to me that today marks my last day in Malawi. All the clichés about time flying and such: completely accurate. I guess that it hasn’t completely sunk in yet, which is probably a good thing. Instead of dwelling on the fact that tomorrow I will be leaving behind wonderful friends and this gorgeous place that has come to feel so much like home, I’ve been doing some happy reminiscing.

 

My family has a tradition of concluding our travel with a ‘top moments’ list, and although this has been far too immersive an experience to sum up in one list, I can attempt to break it down into facets. Some of them are funny things, others serendipitous elements of living in Malawi, and still others insights into global health. But for each category, I’m going to give you my top three. There are stories and context behind each choice, so if you’re interested, send me an email or ask me for details. I promise, I’ll be more flattered that you read this than creeped out by the random questions.

 

Top 3 Malawian Names

1. Chimwemwe
2. Mphatso
3. Various English words that aren’t typically used as names state-side (we’ve met people named Happy, Bright, Gift, Comfort, Charity, and more)

 

Top 3 Ways to Eat Nsima

1. With black beans
2. With hard-boiled eggs and sauce
3. With cabbage and greens

 

Top 3 Chichenge Fabrics

Yeah, this needed to be a category. Please don’t ask how many I have to choose the top 3 from…

 

Top 3 Best Malawian Sweets

1 .Ndazi

2. Tangerines

3. Sugar cane (I’m not a fan, but it’s still a cultural experience)

 

Top 3 Crazy Medical Happenings

1. Clinical officer performs CPR on an eclamptic woman in labor, and then performs an emergency C-section in the labor ward (not the operating room). Both mother and child survive.
2. A child is born with their intestines outside their body.
3. Someone goes almost a week before they are referred from the health center with a likely subdural hematoma following a car accident.

 

Top 3 Medical Field Trips

1. Visiting NdiMoyo Palliative Care clinic
2. Home-Based Palliative Care visits with community health volunteers
3. Under 5 and Antenatal Outreach Clinic

 

Top 3 Ridiculous Occurrences

1. Dogs kill a goat in our front yard, and we have to figure out what to do with it.
2. I accidentally call the hospital director’s cell phone… while he is sitting in our living room.
3. My persistent yet unsuccessful attempts to pick up a baby chick (they’re so fluffy!)

 

Top 3 Crazy Things People Have Said About Americans

1. “So is it true that President Obama is putting microchips in everyone’s brains?!?” – from a random vendor in the market.
2. “I had a theory that all Americans only speak one language”- after I talked to a German medical student auf Deutsch.
3. “You can go to LA and become a movie star, right?”- from a nurse at the hospital.

 

Top 3 Instances of Hypochondria

****Disclaimer: As far as I know, I haven’t actually contracted any of these diseases.

1. Shistosomiasis
2. Malaria
3. Chicken Pox

 

Top 3 Favorite Animals Seen at Liwonde

1. Elephants (we probably saw 75!)
2. Baboons (intelligent and entertaining)
3. Warthogs (they’re the most hilarious-looking animal ever)

 

Top 3 Lessons Learned

1. Just because you have a great device doesn’t mean it will be used. Implementation is a long road involving education, training, and a strategic plan for consumables and repair.
2. Time is perhaps the most precious commodity that medical personnel have here, with education and experience coming in as a close second.
3. Friendships can transcend cultural differences and geographical separation. I have been so lucky to call people at St. Gabe’s my friends.

So let’s say you’re reading this blog. Let’s say that you’re maybe even enjoying it. OK, maybe not MY blog specifically- this one person’s opinion based on a singular experience working on technologies for global health. But perhaps more realistically, let’s say that the topic of one of my posts tickles your fancy. You want to learn more about development and healthcare and Malawi. Now what?

 

Well, when curiosity strikes, my recommendation is almost always to go read a book, and this is certainly no exception! I tend to devour books on development and healthcare in low resource settings, and public health. Before I left, I got a little… inspired. Okay, so I went a bit crazy on the books. But that’s to your benefit now, because I am armed to the teeth with suggestions. The following are all titles that I’ve read during my evenings and plane rides here in Malawi. So look no further! Here’s my suggestion list for anyone who wants to learn more about Africa (especially Malawi), global health, and/or epidemiology:

 

Poor Economics by Abhijit Banerjee and Ester Duflo

Poor Economics is probably my favorite book that I’ve gotten the chance to read here in Malawi. It causes us to radically rethink several of the most common development tropes, such as microfinance and free provision of public health infrastructure like malaria nets. It also allows us to consider decisions that the poor make from their own perspective- actually taking the time to ask people why they are or are not willing to make changes to their lives, even if in the long haul, those changes will be beneficial. The section on nutrition I found particularly interesting- it turns out that once people move out of abject poverty, they don’t actually use it to buy more foods that are healthier or the most calorically dense (the most bang for their buck, as it were). Instead, people move towards more expensive, better tasting calories: things that make them happier! Although this very much a research book, it has a sharp personal slant. Banerjee and Duflo remind us that this nameless group we call ‘the poor’ are individuals with goals and thoughts and personalities. They remind us that although people’s decisions may appear backward from the outside, they have a logical grounding in helping people achieve their dreams.

 

The Boy Who Harnessed the Wind by William Kamkwamba

William Kamkwamba gained fame as the self-taught Malawian inventor who built a windmill to power his family farm. He has a great TED talk that you can watch here:

http://www.ted.com/talks/william_kamkwamba_how_i_harnessed_the_wind?language=en. But if that wasn’t enough to blow you away, his book is enthralling. Threaded with his trademark humility, Kamkwamba also gives insight into everyday Malawian life. This is where I learned that “bo” and “sharp” are casual greetings for friends or children. This is where I first heard about the terrifying native dancers who harass people on the streets and are rumored to steal children- and then a painted troop of them was in Namitando last weekend. It also gives perspective on the power of agriculture in dictating people’s futures: in Kamkwamba’s telling, a famine had power to not only push their family near starvation, but prevent William from attending school and tear apart the village’s society at the seams. This is a quick read, an uplifting story, and a great perspective into life in rural Malawi.

 

The Bright Continent by Dayo Olopade

This book is for the optimists. The basic premise is that we hear so much about outsiders coming in to ‘fix’ Africa; however, Africans aren’t just sitting around waiting to be rescued by foreigners. Olopade examines innovations that are occurring both through formal programs and the informal economy within Africa. It celebrates the leaders within education, healthcare, technology, and youth development. It also celebrates “kanju”, a sort of defiant libertarian spirit of innovation that can be found among average people anywhere on the African continent. I’d say that you should pick up The Bright Continent if you want to change the record- if you’re tired of the same old same dog and pony show, and you want a new perspective on true forward momentum in Africa.

 

HIV/AIDS in Africa: Beyond Epidemiology ed. by Ezkiel Kalipeni, Susan Craddock, Joseph R. Oppong, and Jayati Gosch

So this is an anthology that examines pretty much exactly what the title would lead you to believe. Each chapter explores a different facet of the complex relationships between culture and the HIV virus. Even if you’re not into the idea of reading the entire book, you can easily glean some valuable takeaways from a chapter or two. First, many of the chapters are regionally specific, which serves as a great reminder of Africa’s cultural and historical heterogeneity. What’s especially great is that they have an entire chapter on how various definitions of ‘traditional values’ in Malawi have influenced the virus’ progression. This is also a book that isn’t afraid to speak about historical and political shortcomings, from colonialism to government denial of the AIDs crisis in the 1980s. Woven throughout are stories of local customs, traditional health practices, and tribal affiliations that cross the continent in defiance of national borders. This book is for you if you’re interested in discovering how truly complex healthcare in African nations can be.

 

The Hot Zone by Richard Preston

One of the things that surprised me the most about flying into Malawi was the presence of thermal imaging technology and Ebola warning posters, both in South Africa and in Lilongwe. Why would they have such stringent security towards the end of an epidemic in a region where cases hadn’t been reported?!?

After reading the Hot Zone, I understood why. In detailing the events of an outbreak of Marburg (a close cousin of the Ebola virus wreaking havoc in western Africa), Preston gets fairly graphic. By the middle of the book, you have a decent understanding of how the virus spread, an idea of governmental efforts to contain it, and a strong sense that you should never ever mess around with this virus.

The great thing about the Hot Zone is that although the events are true- and provide keen perspective on intersections between epidemiology and government policy- it reads like a novel. The scenario is like a train wreck, and you can’t hope to look away until you find out how the outbreak is suppressed. If you’re interested in epidemiology, but just want to get your toes wet, this is your book. If you don’t know that much about the current Ebola crisis, this may be a good way to get started. And if you would like to learn how health in developing nations could influence the world at home, you will probably enjoy the Hot Zone.

 

Development as Freedom by Amartya Sen

Amartya Sen‘s work is quite cerebral (he DID win the Nobel Prize in Economics), but worth a look if you are willing to dive in. He takes what often seems like the sterile aloofness of economic policy and turns it on its head, defining international development in terms of the humanizing and logical idea of enhancing people’s freedoms. His main thesis is that improving individual freedoms is both the end goal and a major tool of development. On one hand, it encourages critical thought about development- a topic that all too often has its flaws glossed over in the name of ‘doing good’. On the other hand, it’s quite empowering, especially for people who have seen or heard of the many ways in which development efforts can fail. Sen tells us that improving the lives of the world’s disadvantaged individuals can be accomplished, as long as we are setting our sights on the correct goals.

 

Pediatric Infectious Diseases by Samir S. Shah

This is the kind of book that made me feel woefully inadequate while reading it, but it seems to have potential as a primer for the basics of infectious disease management in children. It’s arranged by system, giving a good opportunity to move through potential causes of illness systematically. It gives an overview of epidemiology, symptoms, treatment, and common co-morbidities and complications. Many diseases share symptoms, making it challenging to recognize the correct ailment. However, as the warnings peppered throughout the chapters indicate, failure can have devastating consequences, as children prove most vulnerable to illnesses that might hardly faze an adult. Just thumbing through it can be enough to give an idea of how challenging the treatment of infectious diseases can be in children. It also encourages our pursuit of pediatric medical technologies focused on diagnosis (such as the respiratory rate timer) and treatment (such as the bCPAP heater), as making a positive impact for these most vulnerable patients could prove to have tremendous payouts in terms of reducing mortality.

 

Honorable Mention: Twelve Diseases That Changed Our World by Irwin W. Sherman

This one has been relegated to a separate category because I didn’t read it in Malawi, and it seemed like adding it to the list would be cheating. However, this is an incredible work that makes epidemiology accessible to the masses. Exploring everything from hemophilia to cholera, the book takes you through how various epidemics have influenced history and modern events. Although the entire book is a great read, the chapters on cholera, malaria, TB, and HIV/AIDs are particularly important to modern Sub-Saharan Africa. Malaria and HIV especially a large number of patients at St. Gabriel’s each day, and coming to understand these maladies better can only contribute to an increased ability to combat them. I think this is a good option for people who are interested in the social and political context for global health; it definitely keeps the big picture in mind, while also giving a decent overview of the science behind the illnesses.

 

Honorable Mention: Being Mortal by Atul Gawande

Again, this book has only been demoted because I didn’t read it in Malawi. If you’ve never read Atul Gawande, I kindly suggest that you start. Immediately.
Being Mortal is particularly relevant to the work that we’ve been doing with the palliative care ward at the hospital. Although Gawande’s work doesn’t focus on global health settings, it provides perspective that transcends location. He explores the big questions of how we approach death with dignity in a way that is tremendously personal and deeply moving. You don’t have to be a medical professional for this book to move and inspire you to understand the importance of the ‘unsexy’ practice of palliative care.

 

Hopefully I’ve given you enough information so that if any topic on my blog has peaked your interest, you have a bit of an idea how to learn more. I promise that I’m not quite boring enough to have spent my ENTIRE summer reading books on medicine and development. That being said, if you want confirmation that there are some of Stephen King’s books that won’t give you nightmares, need to hear a rant on the ending of House of Mirth, or want to meet the last person on Earth to finally read Tina Fey’s autobiography, I’m your gal.

 

Note: As always, I welcome your additions to this list. If you’ve read an interesting and relevant book, feel free to shoot me an email; I’d love to hear more about it!

On Wednesday we took a road trip!

What made this road trip so newsworthy, you ask?

Well, for starters, it was a work-related road trip.

Curious yet?

What if I told you that this road trip changed the way we look at Morphine Tracker?

Okay, maybe I lost you on that last one.

 

Fine, I’ll tell you already!

So this past week we went to NdiMoyo Palliative Care Clinic in Salima. It’s one of the first places in Malawi to focus entirely on pain management in terminal patients.

The story of how this came to be is pretty involved, but I’ll try to stick to highlights. NdiMoyo has a previous relationship with Rice BTB interns; people came 3 years ago to share the Data Pall Electronic Medical Records System with the clinic. Last year, Morphine Tracker made a similar debut. Unfortunately, we weren’t aware of this connection until last week, when one of the St. Gabe’s clinicians, Suave, mentioned NdiMoyo. With a seed of curiosity but fairly low hopes, we shot off an email to the address on the clinic website.

 

In only a few hours, we had gotten a response (remarkable by American standards, not to mention Malawian timing!). Over the next few days, we got pulled into an in-depth email thread that taught us more and more about NdiMoyo. We met Lucy, the Malawian lady who has given her life to promoting the fledgling practice of palliative care in her country. Then we talked with Tony, Lucy’s husband and a whirlwind of force for the planning and promotion of the clinic. Finally, we talked with Linly, the clinic manager, about many of the details of our project.

 

We were simply blown away by NdiMoyo’s responses. Turns out, they have been using BOTH Data Pall and Morphine Tracker! Although they faced similar challenges to St. Gabe’s with staff leaving before other people could be trained, Linly took it upon herself to learn the program. They were super excited to get our updates and training resources. It seemed like before we could blink, we had been invited to visit the clinic and train more of the staff!

 

So less than a week later, we found ourselves on the road to Salima. It was a wild ride (not literally- the driver was quite safe). Over the course of about 10 hours, we got a crash course in goings on at NdiMoyo, a face-to-face meeting with all the incredible people we’ve been corresponding with, and a chance to train two more nurses in Data Pall and Morphine Tracker. It was especially motivating that we left with a veritable laundry list of changes to make to Data Pall and Morphine Tracker. One of the key takeaways from our visit is that NdiMoyo and St. Gabriel’s have very different needs with respect to record keeping. Although they both are doing an incredible job of promoting pain-free dignity for individuals facing chronic illness, they’re doing it in some drastically different ways. All of these differences mean that the two organizations are in a position to have separate needs and goals, especially in terms of record keeping.

Here are a few of the key differences that I took in at NdiMoyo:

 

Patient diagnoses: Tony told us that close to 90% of patients at NdiMoyo are being treated for some form of cancer. Although the most typical is Karposi’s sarcoma (1), cervical cancer comprises a large percentage among women, with esophageal cancer not far behind. As a result, many patients at NdiMoyo are in advanced stages of illness. They will likely die within a relatively short time of beginning the palliative care program. St. Gabe’s sees a lot of cancer patients, true, but also commonly treat heart failure, stokes, and sickle cell anemia. These tend to be conditions that are treated for the long haul; although the conditions may be largely untreatable, patient’s pain and limitations may be controlled with medications like morphine and treatments like physiotherapy.

 

Patient volume: NdiMoyo’s clinic volume has stabilized around 300 patients per year. While I don’t have exact numbers for St. Gabe’s palliative care, the inpatient ward typically holds between 2 and 8 patients in a day. The outpatient clinics, where patients typically go once a month to receive medications and check in with Alex, can see 35-80 patients in a day. Two clinics a week would mean between 320 and 400 patients in a month. Add maybe 30 inpatient treatments and another 50 home based care visits (I’m completely guessing on these numbers), and we’re seeing probably upwards of 450 or 500 unique patients in a year. What I think the difference in caseload primarily contributes to are different needs in terms of record keeping. Because NdiMoyo is a smaller clinic that is exclusively focused on palliative care, comprehensive patient record keeping can prove tremendously important for training staff to meet specific needs and reporting to donors. For organizations like NdiMoyo that may have more of the luxury of time, systems like BTB’s Electronic Medical Records System (EMRS) Data Pall can be an incredible tool. For places like St. Gabe’s, where the sheer patient volume makes it difficult to keep detailed records, systems like Morphine Tracker are down and dirty ways to keep track of what’s most important: the pain management drugs available to the patients who need them most.

 

Use of herbal medications: Lucy’s pride and joy is her garden. Beautiful, sprawling across most of the clinic grounds, most every plant also has medicinal functions. Clinic staff will prescribe these medicines in combination with pharmaceuticals in order to increase benefits to the patient. Different plants can soothe the stomach, act as a salve for skin rashes, and even contained some active ingredients for antimalarials and chemotherapy drugs! Probably my favorite is the popo tree (papaya)- it seemed like everything could be used, from the seeds relieve constipation to the skin of the fruit, which can be used to clean debris from an infected wound. And of course, the fruit provides essential vitamins and minerals!

According to Lucy and Linly, patients are usually very accepting of these treatments, eager to use things that they know as a part of a more traditional form of healing.

 

Inward vs. outward focus: St. Gabe’s has a HUGE catchment area, with patients coming from as far as past Lilongwe and across the borders into Zambia and Mozambique. Ndi Moyo, on the other hand, just serves the district of Salima. There’s a reason for this difference, and it largely comes down to the goals of the organization. St. Gabriel’s understands that there is currently a HUGE gap in palliative care provision throughout Sub-Saharan Africa. As such, they’re using the hospital’s resources to allow as many people as possible to face chronic illnesses with dignity. NdiMoyo’s focus for the future is largely on being a role model for aspiring palliative care providers; they specifically have chosen to not expand in favor of instead forming mentorships with hospitals and clinics in other districts. NdiMoyo’s founders, Lucy and Tony, speak of holding brief clinical trainings to allow practitioners from all over the region to get hands-on experience with palliative care. While this scale-up process is still in the early stages, I admire NdiMoyo’s ability to acknowledge the limitations of their clinic.

 

Methods for provision of services: St. Gabriel’s takes care of their patients in three main ways: through inpatient services in the FCCU, through biweekly outpatient clinics, and during home based care appointments with staff and community volunteers. NdiMoyo philosophy doesn’t focus on inpatient services; they believe in seeing patients wherever allows them to live the happiest and most comfortable life. This usually means at the clinic, at outreach clinics, and in the patients’ homes, but it can often expand to include Salima District Hospital or even the side of a road! Both of these systems have merits: some people are sick enough to require the reound-the-clock care of inpatient treatment, while others appreciate the flexibility of mobile visits. The way I see it, they’re two sides of the same coin, trying to provide palliative care with quality and compassion to their patients.

 

I think that perhaps the most telling thing about our trip to NdiMoyo is NdiMoyo means something along the lines of “the place giving life” in Chichewa. From what I’ve seen, that’s an accurate representation of their service. They take people who have lost hope in the face of devastating diagnoses and give them an opportunity to truly live in their last days. NdiMoyo is providing people with a chance to live a fulfilling life- to feel supported, to live pain-free, and to be at peace. I’m very optimistic about the role that Rice BTB software can play in encouraging this goal, and I hope that we have the opportunity to build further on our relationship with NdiMoyo in the coming months and years!

 

(1) A cancer that often arises as a result of being immunocomprimised, as is characteristic of HIV+ patients.

I had originally intended this post to be a sort of overview of our current projects, an answer to the unspoken question of what all we’ve been working on in Malawi during these past months. But when I sat down to write, the phrase in the title kept rattling around my head.

 

What do we do when it’s not working?

 

It’s a question that has actually been forming in my mind since Week 1. Not the cheeriest of things to think about, but definitely something that has become an increasingly salient issue during our time at St. Gabe’s.

You see, we arrived loaded with potentially life-saving technologies- including two devices that Nkechi and I helped design ourselves. In the warm glow of the OEDK and the BRC, our solutions seem to address pressing global health needs almost perfectly.

 

Unfortunately, the real world is a great deal messier than life inside the hedges. We arrived at St. Gabriel’s to discover, almost immediately, that two of our star technologies were being underutilized. Morphine Tracker and Data Pall, the brainchildren of previous summer interns (1), have not been updated regularly since last September. Also, although the hospital’s Rice bCPAP (2) is functional, and there is one nurse and a foreign doctor who are trained in its use, this life-saving device is not always used. We remain unsure to what extent this is due to lack of training, and how much is simply that there aren’t as many babies as we imagined who can benefit from the device at this particular hospital.

 

I’m not going to lie, it was tremendously disheartening to see our beloved technologies in have not been used as much as we anticipated. However, I have a semi-ridiculous combination of optimistic and Type A tendencies, and thus was not content to just mope about the problem. Instead, we have been using these setbacks in order to take a step back and reevaluate. So what do we do when it’s not working?

 

Here are the answers so far:

1. Don’t assess blame.
   BTB was not being unrealistic by sending us here. Nor are the St. Gabriel’s staff shortsighted for not using our devices to the extent that we originally thought that they would. We just haven’t yet arrived at an optimal solution. Playing the blame game represents a lack of generosity towards all members of this program. Moreover, anger is not a productive emotion. People can sense your frustration, hindering collaboration. End Yoda rant.

 

2. Ask questions. Even hard ones. To everyone.
   In our very first week here, we launched ourselves into this process with Morphine Tracker. Not only did we learn more about the palliative care nurses’ opinions on the software, but we also asked nurses about the record-keeping practices. We asked the HIV clinic’s data manager about differences between palliative care and the highly successful ART (3) program. Upon doing this, we’ve learned that a lot of things that initially seemed rather counterintuitive actually play an important role in the palliative care system. As our internship has progressed, we’ve developed closer ties to people throughout the hospital. They’ve had good times with us- teaching Chichewa, sharing jokes, playing pool at the hospital cafeteria, even sharing meals- and they’ve seen us buckle down and work- doing everything from the unglamorous tasks of paperwork and pills to becoming flies on the wall in order to get a better ideas of how things (and people) work here. As the weeks have progressed, our message has come across loud and clear: the BTB interns care about St. Gabe’s. We’re here to learn, and we want more than anything to help the staff treat patients successfully.
   And lo and behold, because we’re starting to understand and continuing to care, people have responded with refreshing honesty. We ask why Morphine Tracker or the bCPAP aren’t being appropriately utilized, and people are willing to give their two cents without being offended or afraid of retribution. In this way, we’ve learned that hard questions require solid foundations of trust and sincerity.
3. Focus dually on people and systems

Call me biased, but Morphine Tracker is a pretty great system: easy to use, and addressing a vital need that (as far as I know) no other program in Africa is addressing in quite the same way. Unfortunately, the few people who knew how to use this tool left palliative care around the same time (either for work on another ward, or for a different hospital altogether). This is kind of a freak occurrence for a ward that usually boasts relatively low turnover, but it still illustrates an important truth about medical technologies: implementation requires both a decent system, and a team of rock stars to champion it. In response to the discovery of this dual nature of tech implementation, we’ve both redesigned elements of Morphine Tracker and put an emphasis on training people to use it. A huge part of this training actually isn’t that technical- it instead focuses on discussions within Hospice about why this will improve their jobs and increase quality of care to patients. This approach to education acknowledges the tremendous role of personal agency in creating sustainable change (4). Even if our database remains less than perfect, the idea of having people who are knowledgeable and enthusiastic should translate to better outcomes in the future.

 

4. Remove as many barriers to use as possible

To do this for Morphine Tracker, we’ve adopted a three-pronged approach. First, we have altered the tool itself to better suit current needs. This has involved labeling parts of the database more intuitively, changing the charts types to facilitate use for quarterly reports to the Ministry of Health and donors, and redesigning paper records to include the information needed for Morphine Tracker.
Secondly, we’ve been talking about Morphine Tracker with doctors, clinicians, nurses, and other team members- even those outside of palliative care. The hope is that by making Morphine Tracker a name that is recognized hospital-wide, support for its use will increase. Time will tell on that part, I suppose.

Thirdly, we are working to ensure that training for Morphine Tracker is as sustainable as possible. If the Morphine Tracker ‘experts’ are sick, on holiday, or take a new job, people should still have the opportunity to learn. This training should be independent of the BTB internship schedule as well, allowing people to develop skills or just answer a question in the quickest way possible. To do this, we have written a user manual, something that was previously not available for the program. This picture-heavy manual features a hefty FAQs section, and will be left behind in hard copy and digital edition. On top of that, we’re currently developing video tutorials, giving people the option to learn or refresh on Morphine Tracker at any point to come.

 

5. Smile!

Yeah, it stinks when things don’t completely go as expected. But that’s life: life in a hospital, life in Malawi, life in engineering, I suppose. After a particularly challenging day, I love to unwind by having a dance party with neighborhood kids or making some pancakes for dinner (5). But even just walking around the Family Centered Care Unit, I find that it helps tremendously to smile! Smile at the nurses and clinicians, smile at Nkechi, smile at the patients. Everyone here is working towards the same goal of alleviating suffering and preserving human dignity: isn’t that something that deserves a few pearly whites?

 

(1). http://malawi.blogs.rice.edu/2014/07/28/morphine-tracker/

(2). http://www.rice360.rice.edu/bubbleCPAP

(3). Antiretroviral therapy, the current standard of care for patients who are HIV+.

(4). Holy buzzwords, Batman! Sorry about that.

(5). Which I’m sure my mom is super happy about.

Hey! So this is Part II of my lengthy (and yet not at all comprehensive) comparison of Malawi and Haiti. You can read Part I with the similarities here:

http://malawi.blogs.rice.edu/2015/07/19/malawi-vs-haiti-part-i/

Differences:

Language: So this one seems like a no-brainer. They don’t actually speak the same language in Eastern Africa as they do in the Caribbean. Surprise!
My brain’s been having a harder time with this one, probably because my Kreyol vocabulary is more extensive and esoteric (I can’t ask about someone’s water filtration habits or vitamin use in Chichewa, unfortunately). I’ve definitely tried to say something in Kreyol to a tomato seller in the market. It was pretty embarrassing…

The interesting thing about Malawi is that while Chichewa and English are the official languages, they are by no means the only ones spoken. Most people in the Central Region (home to both Namitete and Lilongwe) speak Chichewa, and many conduct business at the hospital and elsewhere in English. However, many people also speak a third language. Malawi is home to several different tribes, or ethnic groups, each possessing a unique language and culture. It’s not uncommon for children to speak Chichewa in the village, English at school, and their local language with their family. My question asking and readings have both suggested that major tribes include the Tumbuka (in the North), Chewa (in the Central Region), and Yao (in the South and along the lakeshore) (1). Given Namitando’s proximity to the borders with both Zambia and Mozambique, this melting pot is further complicated by the introduction of Portuguese and various local languages. In the face of this complexity, Chichewa serves as a bridge, creating social unity and facilitating trade. In contrast, Haiti is all Kreyol all the time. Unless, of course, it’s a formal setting, and then it’s French. Which leads me to…

 

Schooling: The school systems in both countries are far from peachy. Nonetheless, I’ve been comparatively impressed by Malawian education. As Dayo Olopade points out in her book “The Bright Continent”, Malawi is significantly closer to achieving universal primary education than many other Sub-Saharan African countries (2). Although both countries struggle with the still-prohibitory expenses of primary school (uniforms, books, school fees), Malawi is poised to have a better chance of accomplishing the UN’s Millennium Development Goals related to primary education (3). Of course, just because students have the opportunity doesn’t mean that the curriculum is good, that they will have capable (or even present) teachers. But one way that I think Malawi has the leg up on Haiti in this situation has to do with something that seems fairly intuitive: children are taught in their native language. In Malawi, students learn in Chichewa throughout primary school (excepting English class), and then switch to an emphasis on English in secondary school. In contrast, Haiti’s education system is focused on French, the colonial language that is considered a mark of the educated and genteel. Kreyol is widely considered to be a crude or illegitimate language, and people didn’t even bother recording the grammar and vocabulary of this unique French-African hybrid until the last 50 years or so. Having worked in Haitian schools, however, it’s easy to see that teaching in French is holding Haiti back. Students stare blankly, blindly copying lessons written in a language they’ve never spoken and never been officially taught. Pupils simply turn up for the first day of kindergarten and BAM! Now it’s time to speak French. While some groups are lobbying for a change in this seemingly backward system (4), I fear that Haiti has some major catching up to do if increasing primary school enrollment will actually mean anything.

 

The public medical system: In Malawi, if you go to a public hospital, it’s (*theoretically) free of charge. You can also be referred to a public hospital from a health center or private hospital –like St. Gabe’s- that lacks the equipment or personnel for adequate treatment. We’ve seen patients referred to Kamuzu Central Hospital (KCH) for everything from blood transfusion when there’s none to be found in the blood blank (5) to the necessity of a CT scan to plan surgery to relieve a subdural hematoma (bleeding into the brain) following a automobile accident. In Haiti, on the other hand, the public hospital is the last place you’d every want to be. Reserved for those individuals whose abject poverty is so stark that they have no other options, public hospitals like Lopital Jeneral in Les Cayes are dramatically under resourced. Power goes out during surgery, and I once saw a woman going into labor on the hospital steps because there was no delivery room available. Moreover, service in such hospitals is pay-as-you-go; you can’t get so much as a physical exam until you purchase a pair of latex gloves for the physician. What’s important to note is that both countries’ systems afford significant opportunities to fail their most vulnerable patients; simply getting patients to come to the hospital can involve complex webs of social and income-related challenges, not to mention the day-to-day care and feeding that in both systems requires family members to drop their work to nurse the patient.

 

Cholera, chikungunya, and dengue (oh my!). Haiti has some unique epidemiological events occurring at the moment. The story of cholera is both increasingly complex and worryingly political (6), while chikungunya has infected tens of thousands (myself included!) over the past year (7).

 

Climate: Haiti’s tropical locale makes pretty much every day prime time for catching malaria and other mosquito-borne diseases, while Malawi’s seasons make such illnesses relatively seasonal (like catching the flu in November in Chicago). This also produces differential effects on agriculture, which serves as the backbone of both of these largely rural societies. While Haiti’s crops do have seasons (such as mango season, my all-time favorite!), it’s possible to be growing year-round. This says nothing of the influence that NAFTA has had in prompting much of the nation’s food to be imported instead of grown, but still, it provides some stability to know that people can theoretically grow food (or catch fish) year round. Malawi, on the other hand, gets one main shot. Maize harvest occurs once a year, meaning that if a year happens to be bad (low yield due to disease, natural disaster, or lack of seed and fertilizer subsidies), people are pretty much up a creek without a paddle. The implications for malnutrition, especially among youth, are alarming.

 

Expectations about language: So in both countries, it is assumed that foreigners (azungu/blan) don’t necessarily speak the local language. However, I was warned that you would still be considered rude if you don’t greet everyone with a “Bonjou/bonswa” along the roads in Haiti. I haven’t encountered such customs in Malawi (or if they exist, no one has alerted me that I’m being impolite). Instead, “Mwadzuka/maswela bwanji” is used for acquaintances you meet along the path or people you randomly make intense eye contact with (to the point where it would be rude to ignore it). The bar for me to know these Chichewa greetings appears to be lower as well; on countless occasions, I’ve had my greetings met with peals of laughter or whispers after they think I’m out of earshot (talking in Chichewa about the weird azungu who spoke in their language).

 

Foreigners: The azungus/blan- or more broadly, the expatriates- form different communities and relationships in Malawi than they do in Haiti. For one, there seem to be a significantly larger number of Europeans in here. Whether this is due to the relative proximity (Note: RELATIVE. Malawi is still a 10-15 hour trip from Germany or Ireland), or the fact that we’re working with hospital that’s supported by a Luxembourgish Catholic order, I have no idea. Nonetheless, while Haiti is teeming with Americans, we appear to be the minority among the minority here. Additionally- though this may again be due to the fact that we’re in a rural community here in Namitando- I get the feeling that expats working in Malawi are here for the long haul, whether as development workers, medical professionals, or traipsing around Africa looking for adventure. A lot of the non-Haitians I met were staying in Haiti quite temporarily- journalists on assignment for 3 days, or large groups of tee shirt clad missionaries. I’ve met exceptions to these rules in both places, no doubt, but it’s an interesting contrast, nonetheless.

 

National identity: Haiti was the first black republic, founded through a bitter and bloody revolution against France. Malawi has never been involved in a war. Even these simple statements tell you a great deal about the differences between national identities for the two countries. I’d venture to say that I’ve heard most Haitians brag about their independence- their abilities to persevere under trouble and maintain their sense of self in times of trial. Malawians love to remind us that this is the “Warm Heart of Africa”- a place where the people are friendly and giving like no one else on Earth (*probably).

 

Water: In Haiti, you can’t go all that far without seeing a way to get water. Kids sell water in hand-held plastic bags by the side of the road (a pretty ingenious answer to the costly disposable water bottle), and Culligan filling stations line the road. There is also a significant push from development organizations to focus on clean water, perhaps in light of the cholera outbreaks of the past few years. The village where I worked already had a town pump and several filling stations, and I was working on a water filtration project! In contrast, water doesn’t appear to have anywhere near the same level of ubiquity in Malawi. Although I’ve seen a pump at the primary school, the village has limited retail options for water- the only things I’ve seen is the expensive bottled stuff. While I haven’t really thought to ask about water procurement until I started writing this blog, I feel like it says something that I haven’t been able to observe potable water in passing. I’d hypothesize that this has to do with the frequent consumption of beer and soft drinks by most Malawians I’ve met, and I definitely wouldn’t hesitate to draw connections between the consumption of sugary beverages and the alarming prevalence of diabetes and hypertension at St. Gabe’s.

(1). http://www.earth-cultures.com/cultures/people-of-malawi

(2). The Bright Continent- Dayo Olopade

(3). http://www.unesco.org/new/en/education/themes/leading-the-international-agenda/education-for-all/education-and-the-mdgs/goal-2/

(4). http://www.nytimes.com/2014/08/02/opinion/a-creole-solution-for-haitis-woes.html

(5). A situation that’s significantly more common than you’d imagine- patients in need of a transfusion typically need to recruit friends and family as donors.

(6). http://edition.cnn.com/2013/10/09/world/americas/haiti-un-cholera-lawsuit/

And this is just the tip of the iceberg. Just Google UN + Haiti + cholera to see how contentious this is.

(7). http://www.cidrap.umn.edu/news-perspective/2014/06/haiti-dominican-republic-cases-push-chikungunya-total-past-260000

Haiti has been my ‘first love’ in terms of global health, so it’s only natural to me to try and compare it with Malawi. Throughout my internship so far, there have been many times when I start a sentence with “Well, in Haiti…” And in my defense, for every time that I’ve drawn a comparison, there are three other times when I could have done so, but kept my mouth shut. After all, I definitely value my time in Malawi as a unique learning opportunity and a chance to fall for another part of the world.

Nonetheless, the similarities have been uncanny; the differences, even more striking.

So, I just can’t help myself. I’m going to share some comparisons of my experiences and views of Malawi and Haiti (each in more or less detail, depending on how self-explanatory it is). Keep in mind that these are my sweeping generalizations, and should be recognized as such. The lines that I’m drawing are hardly as clear as I may make them out to be, and both cultures are far more complex than I can hope to capture in a few thousand characters.

 

Similarities:

Public transport: Malawian Minibus=Haitian Tap Tap. The main differences are aesthetic-Tap Taps are brightly adorned pick up trucks, often with speakers blaring kompa out the back, while Minibuses resemble 15 passenger vans in the States. Both, however, will be packed with 20+ people, chickens, crops, and other cargo, and both will allow passengers to get from pretty much anywhere in the country on a modest budget.

 

Colonialism: Malawi was part of the British Empire, while Haiti was under French control. Nonetheless, the influences that these outside cultures have made appear like a little kid’s fingerprints: subtle, but smudged over pretty much everything.

 

An azungu in Malawi= a blan in Haiti. Both are terms for foreigners or outsiders, with the Haitian term in particular implying Caucasian heritage. I’ve heard ‘azungu’ a fair amount, especially at village events (like the football game this afternoon) and in the market. Not all that shocking that I get labeled this way, considering that I’m the WASPiest thing since Wonderbread.

 

Religion: Religion seems to play a pivotal role in the life of most Haitians and Malawians. Again, my perspective may be skewed by the fact that I’m currently working at a Catholic mission hospital, and that I worked with mainly faith-based groups in Haiti. Nonetheless, I think that all you need to do is take a glance around to start understanding the role of faith in people’s lives. In Malawi, women sport chichenges festooned with patterns for their local dioceses or evangelism conference. Rosaries stay around people’s necks during exams, and people in both places name their businesses in a way that acknowledges God’s role in their success. In many places, it’s less than a stone’s throw between churches, and Sunday services are a capital E Event that requires the majority of the town to turn up in their finest. People are eager to turn inward and pray in times of trouble, and frequently focus on evangelism (questions about my religious beliefs frequently become a matter of conversation with casual acquaintances or hospital staff). However, ‘ancient’ or ‘tribal’ religions also play a large role. For example, there’s a joke about Haiti being ‘90% Catholic, 90% voodou” that’s not too far from the truth. Many patients we’ve seen at St. Gabe’s run into trouble because they’ve come in days after their chief complaint first manifested. They try the local healer first, only turning to biomedicine after traditional methods fail. Similarly, hougan (voodou priest) practices often run counter to the way a hospital doctor would treat a patient. Treating a pregnant women with turtle blood may not be conventional, and not nearly as effective (read: NOT effective) at preventing HIV vertical transmission as ART. However, in the minds of the patient, the old ways may be even better, adding a layer of complexity to treatment in both Malawi and Haiti.

 

Malaria, malnutrition, HIV, STIs, and much more. Diseases of poverty run rampant in both places, which makes sense if you look for each country on the Human Development Index (1).

 

Music! Kompa and Rara are the soundtrack of Karneval, beach trips, pub nights, and even tap tap rides in Haiti, while Malawian urban music plays alongside Nigerian imports from cell phone radios to massive speakers. Although these are still wildly different styles, both feature heavy drums laying down a beat that just won’t quit. I also appreciate the diversity of music in Malawi and Haiti: topics range from the typical American party song (bragging about partying and girls) to protest music against government corruption, to uplifting ditties about changing the future through unity (very “We are the World”). So I guess when I say that music is ‘similar’ in both places, I really mean that I like it better than whitewashed American pop. It’s certainly better to dance to!

Note: So I got too excited (surprised?) and verbose (even less surprising…), so I’ve decided to break this post up and spare you the novella. Stay tuned for Part II with the differences (and oh goodness, there are many!)

 

(1). Human Development Index  (which is a very interesting metric, by the way): http://hdr.undp.org/en/content/table-1-human-development-index-and-its-components

You know that thing that Netflix or Kindle does that goes something along the lines of “If you enjoyed this title, here are some other suggestions that you might enjoy”?

I mean, it’s not like I’m super familiar with the message at the moment, as life in Malawi is Netflix-free. But you get my drift, I hope.

 

Well, what we’ve been figuring out in our free time (like this weekend) is that there are some things that you simply MUST do if you visit Namitando. Some of them are pretty obvious components of the experience, while others… not so easy to discover. So much like Netflix, pushing indie versions of your box box office favorites, I’m going to share some of my Namitando suggestions. Whether you’re a BTB intern hopeful, or are simply interested in learning a bit about village life, I hope this paints a better picture of our home.

 

***Note: EVERYTHING on this list is worth doing! I’m just pointing out the less obvious suggestions.

 

If you enjoyed: Visiting the Namitando market

You may also like: Taking a walk through local villages

Although the market gives some perspective on local life, it doesn’t tell you everything about life in rural Malawi. Especially given the relative privilege of living in houses near the hospital compound, it can be easy to lose sight of what ‘home’ means to our patients. Lucky for you, this one is pretty easy to remedy. Setting off in along any of the roads branching off before/after you reach the Namitando market will take you into small villages interspersed with maize fields and bush lands. Look around: the homes, the people, and the daily tasks all speak to public health conditions for the villagers. Just head out and prepare to get (somewhat) lost in pockets of village life that surround the hospital. Things to bring with you include a cell phone (in case you get too lost), a smile, and basic Chichewa vocabulary words (you need to say “Mwadzuka bwanji” to EVERYONE you meet!)

 

If you enjoyed: Getting groceries from the supermarket in Lilongwe

You may also like: Finding (almost) everything in the back market of Namitete and Namitando

The first time that we went to Lilongwe for groceries, we nearly broke the bank. This past time, we just topped off on a few imported products. The major difference between the two occurances is our familiarity with the local market system. The markets in Namitando and Namitete are both lined with small brick shops, usually advertising Airtel or TNM phone service and generally having a name like “God’s Favor Shop”. Although it’s easy to disregard these establishments, they actually present a fairly impressive variety of goods. After looking closer, we’ve managed to find everything from staples like bread and eggs to fancier items like toiletries, biscuits, and peanut butter. Some shops even sell chichenges (the colorful fabric that constitutes 75% of female fashions and tools in Malawi) at very reasonable prices! The main thing to keep in mind here are that it’s always okay to poke around and explore, whether that means doing a double take inside a small shop or going down the back alley to find a new part of the market.

 

If you enjoyed: Playing with kids around the Zitha house

You may also like: Teaching the kids something

A lot of the local kids are children of hospital workers or their friends from the village. I don’t like to brag, but I’ve developed quite the posse over the past few weeks- I’ve made it quite clear that I want to be friends, and after a hard day’s work, there really is nothing more fun than goofing off and acting like a kid for a few minutes (or hours). Because we’ve started to be better acquainted (read: I’m on first name terms, they only call me ‘azungu’ sometimes), I’ve started to take advantage of their friendliness. One day, I came home as usual and sat on the front porch of the guesthouse. Sure enough, not five minutes later I saw a10 little pairs of hands grip the wall and pull themselves up. This time, I was ready. I put on some music and started my best dancing (note: I’m using the term ‘best’ very loosely here). Chortling, the kids joined in. After I’d done the Chicken Dance, Macarena, Hand Jive, and Egyptian, I’d pretty much ran out of ideas. So I laced up my running shoes and started to do exercises. Although the sight of the crazy azungu doing crunches was even funnier than the dancing, the kids’ curiosity soon got the better of them. I showed them bicycle crunches, jumping jacks, suicide sprints, chair dips, planks, and tons of other fun exercises. Each time, I’d demonstrate, then my posse would immediately join in for a few sets. Although I didn’t necessarily think of it as anything more than a fun experience, a few days later I met one of my friends on the road to the hospital. He immediately dropped in the dirt and did bicycle crunches. Just goes to show that even demonstrating healthy habits can be a party!

If you enjoyed: Learning basic Chichewa phrases

You may also like: Getting Chichewa lessons

To live in a village or work at a hospital in Malawi, there are a few key phrases that you simply have to know:

good morning, good afternoon, how are you, have a good day, what’s your name, how much does it cost, your baby is cute (1), etc.

With your Malawian friends, however, you need a completely different vocabulary: Are you tired? What’s up? I’m confused, Do you like to dance?

You know, typical friendship stuff.

Having each of these vocabularies is pretty important, but you develop them in drastically different ways. For the former, it will suffice to skim past intern blogs, run some Google searches, and maybe pick up a trusty Chichewa 101 book (2). For the latter, you need to dig a little deeper. Sometimes that means asking a friend how to say something that’s relevant to the situation. Other times, it means taking advantage of some free time and trading snacks for Chichewa lessons at the hospital cafeteria or in the Zitha House kitchen.

Having started to develop the latter Chichewa vocabulary a little later, I’m still finding it to be tremendously helpful. Learning someone’s language is a great way to become a part of their world, even if you can only string together a maximum of 3 words. It’s the effort that supports the development of a relationship.

If you enjoyed: Going to mass at the Catholic church

You may also like: Going to mass at the Catholic church… in a chitenge!

I bought my first chitenge last week (!!!) and have been itching for the opportunity to wear it. However, my enthusiasm has been tempered by the knowledge that it’s very much a cultural symbol, and wearing it with respect is of utmost importance. For example, wearing a chichenge to work or the supermarket= pretentious foreigner.

At church, however, the chichenge reigns with sartorial ubiquity. As God’s house, the church is the place in Namitando that likely has the greatest respect for tradition and modesty. As such, putting a chichenge over my dress was not viewed as inappropriate. Rather, a Malawian friend told me that wearing a chichenge was sending the message that I love Malawi and appreciate its culture; that I respect its traditions and desire unity with the community of believers at the church. He told me it was a sign of loyalty.

Well, I’m not entirely sure if that’s all true, but I believe that my chichenge-wearing was well received. I definitely had more Chichewa conversations before and after the service, and I shook a TON of hands during the sharing of the peace. I was also a definite plus that chichenges are gorgeous and fairly comfy (when you can keep it wrapped tightly enough to stay put).

 

(1). I’m not a creep, I promise! When you pass mothers carrying their children almost CONSTANTLY in the hospital, it becomes a better alternative than just smiling at their kid.

(2). Neither BTB nor I is being paid to endorse Chichewa 101. It’s just the only Chichewa book on Amazon at the moment.

 

Since we’ve been spending a hefty portion of our time at St. Gabe’s in Hospice, I wanted to take a few minutes to introduce you to some of the palliative care team. Because even if I’ve said it before, it definitely bears repeating: the hospital workers are AWESOME! I feel like I’ve been reminded of this in 3 distinct scenarios this week. Yeah, it’s been a busy one, and a particularly Morphine Tracker-heavy one to boot.

 

Thursday was one of the hospital’s biweekly outpatient palliative care clinics, and we had the opportunity to observe and assist Alex, the palliative care nurse and resident Superman of the Family Centered Care Unit (FCCU). We popped over to the FCCU as soon as morning meeting was over (around 8 AM) and found that the benches outside were already FULL of people. Inside, a line stretched down the wall, all the way to the treatment room. As we met up with Alex, he didn’t even bat an eye at the people cueing up. Instead, he got straight to work. Now, when I say work, I mean it in the truest sense of the word. This guy does everything: read patient records, perform exams, collect vitals, write in the patient’s health passport, provide injections, count pills, dispense medications, schedule follow-up visits, and keep records for the pharmacy staff. That day, he enlisted our services to help pack pills, track down one of the hospital’s 3-4 functional blood pressure cuffs, fill out pharm records, and greet patients (woooo, Chichewa practice). After an endless stream of heart failure, sickle cell, Karposi’s sarcoma, and stroke cases (among others), lunchtime hit and the clinic was finally over. As out last patient shut the door, I couldn’t help but exclaim “Alex, why didn’t you tell us that you’re a SUPERHERO!” The man seriously does it all, and the fact that he can navigate the busy clinic solo and maintain the sensitivity required for hospice care just goes to further highlight his incredible contribution to the hospital.

 

The second ‘ah ha!’ moment came while we were delivering a presentation on Morphine Tracker. During lunch on Wednesday, we invited the entire palliative care team (a mixture of 8 clinical officers, nurses, and other health care workers) to learn about how our software can improve quality of care for patients with chronic conditions. We overviewed the importance of keeping careful records of morphine use (morphine shortages are common, and the drug is heavily regulated by the Ministry of Health and various nonprofit donors), and then presented Morphine Tracker as a tool to make that process easier. I was encouraged by the fact that 5 team members were in attendance (during lunch, no less!), and that we had some valuable discussion on marrying the system with existing routine. But perhaps the most uplifting moment was when Collins showed up to the meeting. Collins is the first person we’ve trained to use Morphine Tracker, and he has taken to it with remarkable ease and an optimistic attitude. To get why it’s exciting, though, you need to know 2 things about Collins:

1. He’s on holiday right now. Collins is actually leaving to visit his family in Zambia next week. But what did he decided to do with his day off ?!? (a day I’d use to eat popcorn and binge watch Netflix): HE CAME TO SUPPORT US!
2. Collins is technically on the cleaning staff. He has no medical experience and little computer training. Yet, his superiors recognized his potential (rightly so!) and have designated him as one of our new Morphine Tracker data entry ‘point people’. Despite the fact that he’s comparatively low ranking in the hospital staff, he has adopted his role with Morphine Tracker to such an extent that he feels he has the agency to contribute to meaningful decisions about its use in the hospital. How incredible is that?!?

 

Our third palliative care superhero is Mary Kaminga, one of the health workers who typically is found in palliative care. Like Collins, Mary hasn’t had extensive computer training to this date. Nonetheless, our first lesson yesterday went swimmingly! After listening with a quiet consideration, Mary would be able to execute the Morphine Tracker commands like she’d been doing it for weeks. We made a fair amount of progress in our 40-minute lesson, and scheduled more tutorials for early next week. I was afraid that our earnest praise of Mary’s work was getting brushed off (she’s incredibly modest). However, my heart did a little dance when Mary stopped us on our way out of the ward that afternoon. “Hey, Mary, we’re just heading to outpatient. Do you need any help?” She spoke shyly, but with a twinkle in her eye. “I just need to learn more”. Mary has a heart of gold, and she and Collins’ dedication bodes well (I hope) for the future of morphine records at St. Gabe’s.

 

Our experiences with the palliative care team this week have only given me increased respect for some of St. Gabriel’s finest. This insight comes with perfect timing, as we have spent this past week presenting on Morphine Tracker and starting to put it into play for the ward. As we make some final tweaks, the importance of factors like ease of use and ability to quickly integrate the software into existing routines become crystal clear. After all, the superhero’s tools only help them defeat the powers of darkness if they’re handy enough to come into use.

This past weekend marked both American and Malawian Independence Day (1), making it one for the books! As the weekend approached, I was reminded of a conversation that we had with our taxi driver, Alex, the first weekend after we arrived. We inquired about what Malawians typically did to celebrate their independence from Britain, and our question was greeted with a knowing chuckle.

That, Alex told us, was a long story.

 

Apparently, under the previous administration, Malawian independence was a capital B capital D Big Deal. The government would sponsor a massive party and would pull out all the stops: live music, football matches, traditional dancing, free meat and snacks, unlimited beer, and much more. They would hold this party in a different city each year, and would provide transportation (i.e. train passes and bus fare), so that even the poor could come take part in the festivities.

 

But a few years after the HIV/AIDS epidemic came to establish a firm foothold in Malawi (2), the government was forced to face the facts. Their celebration was permitting the spread of the virus. The provision of free transportation facilitated the unfettered movement of HIV + individuals, and the gathering tended to feed the fires of prostitution in the city where the party was taking place. As a result, HIV epidemics would pop up in villages across the country after each year’s celebration.

 

Alex’s story got me thinking about the intersections between bioscience and culture, especially where HIV/AIDS is concerned. That in particular is a kind of touchy point, since preventing transmission often involves talking about sex, everyone’s favorite topic for discussion in the public sphere (3). Our experiences in the ART (4) clinic have shown us that St. Gabriel’s does a reasonably good job of reducing social barriers to receiving treatment for HIV, providing services free of charge to anyone who is seropositive or is referred from another clinic. I was particularly impressed with the way that they handled discussions about transmission. Patients became aware about the importance of using contraceptives during pre-clinic education sessions, and then were asked by the ART nurse about their habits. The Malawian government has also done a surprisingly good job of avoiding the politics of blame with their Plan B+ program. In this program, all pregnant women who are found to be HIV+ are placed on ART, regardless of their CD4 count or how they contracted the infection (5). Such initiatives are exciting, as they seem to prioritize the wellbeing of the vulnerable above any sort of judgment call, either on HIV or methods of its transmission. Moreover, St. Gabe’s ART clinic is so incredibly well run (hands down the best use of technology in the entire hospital, not to mention the only comprehensive use of Electronic Medical Records) that it makes me hopeful for the future of HIV treatment and prevention in St. Gabriel’s catchment area.

 

As optimistic as I am about this particular hospital, a book that I’ve been reading recently keeps reminding me that the story of HIV/AIDS in Malawi is infinitely more complex that I could hope to imagine. In his essay “Politics, Culture, and Medicine: An Unholy Trinity? Historical Continuities and Ruptures in the HIV/AIDS Story in Malawi”, John Lloyd Lwanda unpacks the relationships between Western medicine, tribal tradition, and public policy in Malawi (6). His thesis is that upon the arrival of colonial powers in Malawi, traditional practices and healing were not eclipsed European ideals. Instead, Malawian culture has persisted in a ‘duality’ where political and broad social thought tend to reflect the influences of the British Empire, but village and family life allows for the transmission of tradition and resistance to colonial homogeneity. Merits of either perspective aside, this ‘duality’ holds significant implications for the transmission of HIV in Malawi. As Malawi came to be viewed as a very puritanical society with ‘traditional’ family values, traditions involving the ceremonial deflowering of young women or the prescription of intercourse with a virgin to cure AIDS continued to be practiced in rural areas especially. Essentially, what Lwanda is suggesting is that risk behaviors in Malawi aren’t absent by any means; instead, they’ve gone ‘under the radar’, found mainly in enclaves of tradition that are perpetuated by the village or family. In the face of this reality of dualism, a fight against HIV transmission will require locally and nationally sponsored efforts to redefine ‘tradition’ in a way that prioritizes the safety of all involved in various practices. Although my experiences with traditional medicine and culture have mainly been limited to a few hushed stories on the ward or with Malawian friends, this intersection indicates that HIV transmission may be more firmly embedded in Malawi than I would hope to admit. Within this context, St. Gabe’s efforts at HIV management are even more impressive than what their clinic conveys.

 

Talking about a more fun type of intersection, this past weekend we traveled to Lake Malawi to meet up with the Blantyre interns. It was a fantastic opportunity to swap stories, compare experiences, and meet some fantastic new friends! If you haven’t done so yet, please take a look at the Malawian Polytechnic interns’ blogs (7): they’re some pretty great people, and the collaboration between Rice and Poly students is truly admirable in its benefits to both sides.

PS: Sorry for the delay in posting! I feel like it’s been a while, but that could be interpreted as a good thing, right? In my case, it means we’ve been busy, both at work and with efforts to absorb Malawian culture like a sponge. I’m happy for the chances to share our experiences with you all, even if they show up a few days later than planned!

 

(1). July 4^th and 6^th, respectively. Both were from Britain, actually. Malawians find it surprising and hilarious that the US was originally a British colony as well. Read more about Malawian independence HERE: http://www.bbc.com/news/world-africa-13881367 . And http://www.english.rfi.fr/africa/20140706-malawis-50-years-independence-maturing-democracy-not-enough-says-analyst.

(2). http://dhsprogram.com/pubs/pdf/HF34/HF34.pdf

(3). Please note the strong sarcasm here. Please.

(4). Antiretroviral Therapy

(5). http://www.nyasatimes.com/2013/07/13/malawi-reduces-hivaids-prevalence-rate-to-10-percent/

(6). All this from a super interesting book entitled “HIV/AIDS in Africa: Beyond Epidemiology”. I understand that it might not be everyone’s cup of tea, but definitely a unique take on what’s typically a very cerebral topic.

(7). Here are their blogs:

http://malawi.blogs.rice.edu/author/fmasi/

http://malawi.blogs.rice.edu/author/andalama/

http://malawi.blogs.rice.edu/author/csamuel/

http://malawi.blogs.rice.edu/author/cnyaluwe/