I’m not starting this blog post with any intention of having a profound thought at the end- rather I wish to describe likely our most Malawian experience yet. First I must introduce you to Freeman (he’s a free man as he told us many times). Freeman works in the operating theater as an assistant at QECH and his favorite color is red. Conveniently, his favorite football (read- soccer) team is the Blantyre Bullets whose colors are, yes, red and white. Thus, Freeman regularly sports red sunglasses as he rides his candy cane status bicycle with matching helmet. Safety first.

Freeman is also a professional “azungu** wrangler” to use Elizabeth’s phrase. He pushed us onto a minibus and herded us down the slope towards the stadium gates, reminding us all the way, “No money in your back pockets” and “where are your phones?” To this second question I held up my candy bar phone and received a chuckle as he agreed no one would try to take it from me. With hair newly decorated with red and white ribbons, we were ready to shove our way through the iron gate into the sunny boisterousness of the stadium.

As we paraded across the stands, the shouting got louder, and Freeman was loving it. He walked last in line so he could keep us all in his sights and waved his hands over his head welcoming the noise like an excited olympic athlete in the opening ceremony. We found some seats, bought some lollipops, and settled in to watch the match.

The teams were both good and it was a tight game. Every time there was a shot on goal an eeeee-AHHH would follow the ball’s path. Punctuating the shouts from the crowd, and Freeman’s advice to the players “Foward, forward! Go now!” was the “Ssssss, ssssss, ssssss” of people selling everything from tangerines to hardboiled eggs to chips (aka crisps) and sodas to earbud headphones. After a relatively early lead taken by Lilongwe, we got a penalty kick at the beginning of the second half to tie the game 1-1. The crowd erupted. Freeman initiated a group hug and then danced to the music of the crowd. About ten minutes before the end of the game, a second goal slid by the keeper sealing the 2-1 win, Blantyre Bullets.

It was an exciting end to a great game.

After the game, I realized how glad I was that we had won. All of the stores close to the stadium were closed (we had to get pretty creative about dinner) and I realized that in the event of a loss, there would be a lot of drunk and very angry people. I’m glad we won.

**Azungu is the plural of muzungu meaning foreigner

 

Whenever I’m in a new place, I consider it a sign of a certain level of belonging when I am able to give someone directions. It means both that I know where something is as well as that my face no longer looks timidly confused as I make my way to a destination. Well three people have asked me for directions in the last week and I was able to successfully help them all- winning!

But as much as I feel like after 7 weeks I can get myself from point A to point B, eat nsima without making a total mess, and know a decent price for chitenjis at the market, I know there will always be an element of not belonging completely— even if I were to stay for decades. I have been reflecting on those things that would still hold me outside of complete assimilation.

I’ve thought a lot about this idea of never fully being a part of a place in regards to culture- perhaps an idea for another blog post. In this one I want to discuss what happens at the end of the day. Every night I come home from the hospital, drink my boiled/bottled water, take my malaria prophylaxis, and tuck myself into a cocoon of a mosquito net— I have become increasingly aware of the safety net I live in.

Granted, the car I am riding in could crash or someone could decide my purse was in need of a violent change of ownership. This is not to say that life is perfectly safe here (or anywhere). However, there are many small precautions that my education, and frankly my money allow me to take. Beyond these precautions, there is a safety net that would appear should I, or one of the other interns, get seriously ill.

The 2015 Ebola outbreak illustrates my point well. According to a New York Times article, across six West African countries it was estimated that the mortality rate of those diagnosed with Ebola was 40%. In Guinea specifically as many as 66% of those diagnosed died. However, when looking only at the foreigners who contracted Ebola, the mortality rate more than halved, dropping down to only 20%. These foreigners were stabilized and transported back to their own countries- to hospitals where patients don’t die waiting for an ICU bed, medications are consistently in stock, and the standard is to give blood transfusions when hemoglobin is below 10g/dL rather than when it gets down to 4g/dL.

Growing up in the US has given me a mosquito net where I can be in “dangerous” places but be shielded to a large degree. This safety net is no secret, in fact those of us who are lucky enough to have it are probably less aware of it than anyone. The question is what message does this send? Will there always be some sort of unspoken barrier between us knowing that when put in the same circumstances the outcomes can be so dramatically different?

This is complicated, because we can’t say no one should be med-evacuated, or that the people who are evacuated think that they are better than the people they are leaving behind. The safety net isn’t inherently “bad” but it does make a distinction, and, perhaps one could go as far as to say it implies, whether one believes it or not, that some lives are more important than others. This idea of the value of an individual life has been in the news a lot recently, and perhaps there are many overlaps with the issues we are wrestling with in our own country. I want to narrow this idea to specifically working abroad- are we both aware of and ok with the implicit messages we are sending as we live and work from underneath a mosquito net?

Blantyre is a place of many beautiful mountains just asking to be climbed. It is also home to many sick children who are dependent on the medical care provided at Queen Elizabeth Central Hospital (QECH). As mentioned in my last post, there is a considerable lack of funding, leading to shortages in personnel as well as consumables and equipment.

The natural connection? Sponsored climbs. Since arriving in Malawi, I have witnessed the heroic efforts of the Pediatric Department to raise funds for the children they already do so much to serve on a daily basis. Friends of Sick Children (FOSC)  is a charity based in the UK that provides funds for equipment and pediatric nursing salaries at QECH.

On June 25th, and again on July 9th, members of the hospital undertook two physically rigorous courses, sponsored by friends, family, and Blantyre locals. They even took out an ad in the local paper explaining what they were doing and asking for donations on behalf of the children in the wards. The climbs were epic.

First was the Three Peaks Walk. The route started in the heart of Blantyre (3,409ft), summited Mt. Michiru (4832ft), Mt. Ndirande (5288ft), and Mt. Sochi (5019ft) before completing the loop for a total of 28 miles of walking. A number of participants from the pediatric department carried baby dolls wrapped onto their backs to remind them what the walk was truly for.

Two weeks later was the 20th annual Porters Race, “Malawi’s ultimate endurance race.” This run started with a 3k climb of Mt. Mulanji, traversed the 15k of hills along the plateau, and finished with a 5k descent for a total distance of 22k (13.6miles) with the highest point 3280 ft above the starting line. Again, a number of doctors from QECH participated in this race in a continued fundraising effort.

Between these two events the Pediatric Department has raised over $9,000 to improve care in their wards, worth a massive congratulations. They are making a way to maintain high levels of care without enough government funding. The issue is that the need is so much greater.

The problem I didn’t know existed: There are unemployed doctors in Malawi. Fewer students want to go into medicine because finding a job upon graduation is uncertain. I’ve heard about the shortage of doctors in Sub-Saharan Africa and I always assumed it was because of the ever blamed “brain drain” in combination with a lack of medical school graduates- not enough medical schools and primary and secondary school programs failing to prepare students for medical school. These are significant and contributing problems- but having unemployed doctors never even crossed my mind. Countries send doctors to these places in an attempt to fill the human resources gap but what is this gap truly caused by?

The reason (from what I’ve gathered so far): The government does not have enough money to pay the doctors. In fact, many of the doctors or nurses who are employed are not always paid consistently.

The solution: Complicated. Multi-faceted. Far beyond what I can come up with.

My thoughts: Either the government needs more money to be able to set up and fund hospitals or individual citizens need to make enough money to be able to pay for treatments in a self-sustaining hospital model. Preferably both. This means decreasing corruption, increasing GDP, and empowering communities to take ownership of their own clinics. All easier said than done.

How: Carefully. Here again I have no answer, but rather a naive hope. As we work towards solutions I think it is important that the cries for reform and development are coming from the people they will affect. It is important that outside organizations and governments continue consciously taking on the role of partner, not initiator.

So this is a hope for cries, cries for reform and cries for a solution beyond the status quo.

“Come on, cry- just cry. Cry a lot,” pleaded the doctor. A minute passed and the baby still refused to give into the doctors instructions. In the other room, under a heater, nurses took over the task of drawing a cry out of the baby. One nurse rubbed the back of the baby, another fit a mask over his tiny nose and mouth- forcing his chest to inflate every time she squeezed the attached bag.

Every once in a while there would be a pause so that a third nurse could suck mucus and fluid out of the nose and mouth. Two minutes, some gasps, then nothing, three minutes, finally we heard it: a small wail. There was a look of triumph- the baby was still hanging on for the time being. Nasal prongs of oxygen were fit into his nostrils. Emboldened with this extra air, the baby started crying- a good proper cry.

I walked back into the operating theater and observed as the mother was stitched back up from the C-section, comforted by the cries that were still audible coming from next door.

Ten minutes later the command came again, this time from a new set of nurses, “Come on, cry.” The procedure was repeated with a bag and mask forcing the little chest to rise and fall. A few minutes later the cry came, small at first then stronger and more frequent, joining in chorus with the first baby. Each cry a reminder of the lives doctors and nurses are able to save.

My day in the Ob/Gyn surgical suite was fascinating. I witnessed skilled surgeons deftly perform procedures ranging from C-sections to abscess draining to postpartum hemorrhage repair. While I enjoyed being able to observe each of the procedures, the most interesting part was having the chance to talk with the interns and doctors in the brief minutes between surgeries. They validated my observations of various challenges they have to deal with in the wards and also offered additional insights into the experience of being a doctor in Malawi. (Elaboration in Part 2)

On Tuesdays there is diabetes clinic at the hospital. Anywhere from 30-80 people with diabetes, mostly above the age of 65 congregate in a small room of concrete benches. Looking around, you can see the logo of the Diabetes Association of Malawi and old diabetes education posters speckling the walls. Bread, butter, and tea are sold in the back of the room. Soon a scale is brought out to the aisle between the rows of benches and patients line up. One by one they slip off their shoes, hand their health passport to the man in front, and step onto the scale, holding a support pole to minimize unsteady wobbles. Simultaneously a nurse, identified by a small white hat pinned to the crown of her head, came out with a blood pressure cuff and began winding her way down the rows.

At some invisible signal the patients were shooed back onto the concrete rows with a few Chichewa phrases of instruction and mild laughter. Moments later, descending into our crowded room, came suit-clad representatives from the World Diabetes Foundation in Denmark. A Chichewa welcome song rang out received by ten iPhones in front of ten foreign smiles. The “honorable visitors” were instructed to sit in the back row and soon commenced the formal exchange of statements from spokesmen on both sides.

What happened next was the play. The Empires, two Malawian men in their late twenties, emerged at the front. One had wrapped a chtengi around his waist the other sported a pointed hat, like you would see in a rice field, and had stuffed a soccer ball underneath his shirt. Dramatically they acted out a conversation in English that examined the challenge of treating diabetes in a culture where a larger stomach is equated with success.

[Important note, there are many people around the world with diabetes, even type 2, who are not obese. Research however suggests that diabetics who do have a high BMI often find their symptoms lessen if they loose some weight.]

While I’ve been here I’ve reflected on how difficult it is to get very obese without eating processed foods or snacks- even if you’re eating a ton of carbs- rice or nsema (maize) and a fair amount of fat- fried donuts or “chips” aka french fries. It will be interesting to see what happens to the obesity rates as processed bags of chips and other snacks continue to grow in popularity and the types of jobs people do continue to decrease in physicality. Is there a way for a country to develop while avoiding the associated problems of affluence?

So what exactly are you doing in Malawi? An interview with myself about my time in Malawi.

Where are you exactly?

Malawi is a very small country in the south east part of Africa. I’m in Blantyre (denoted by the tiny green dot in the southern part)- the second biggest city in Malawi and not to be confused with the capital city.

How long will you be there?
9.5 weeks total, returning to the US the first week of August

Where are you working?
Queen Elizabeth Central Hospital

You’re not a doctor (yet), what are you doing?
A variety of things!

1. Working on the CPAP study: Elizabeth and Caroline, my two fellow interns, and myself have joined an existing staff of people working on a clinical trial of a medical device (the Pumani bCPAP that basically helps babies breath- let me know if you want a more technical or elaborate explanation). This means that we do a variety of tasks from decomissioning and disposing of old models to entering data in Excel and other random tasks.
2. Shadowing doctors and nurses: Getting to be on the wards has been my favorite part of working at the hospital. We start every day by attending the pediatric handover meeting and then can go watch care be delivered. This is cool because we get to see the CPAPs in use and important for number 3 below.
3. Needs finding: Every year teams of students at Rice develop medical devices for low resource settings around the world. Part of my job as an intern is to keep my eyes and ears open to potential project ideas to present to clinicians and the Rice 360 team.
4. An individual project: Hardest part so far, coming up with my individual project. I have some ideas, and have started researching them to see if they might be good. Stay tuned.

What is it like living in Africa?
Amazing! I have absolutely loved being here. We walk to buy groceries at the market, work on learning Chichewa, the local language here, and avoid the lions that prowl the streets. To clarify for those now concerned about my safety: there are no lions (or really any animals other than chickens) on the streets of Blantyre. We are, however, going to a wild game reserve this weekend!

What’s a normal day like?
Generally I wake up, get ready for the day, and then walk down the road to the main part of the lodge for breakfast. At 7:30 people start walking toward the shuttle cuing the chugging of tea and coffee and inhalation of toast and we leave for the hospital shortly after. (Yes there is a free shuttle from where I am living to where I am working, yes it is incredibly convenient).

At the hospital the other interns and I participate the the variety of activities listed above and stop for lunch (taking the traditional hour and a half off has not been much of a struggle for us)- usually we eat from the Malawian buffet for a full 650MK (less than a dollar). The bus then leaves again at 5pm to take us back to Kabula Lodge.

Evenings are pretty low key as we cook dinner, spend time with the other interesting people staying at Kabula, sometimes watch a movie or read my book, sometimes do work, and occasionally fight an unexpected circumstance such as power outage, minor flooding, or the inability to get keys to our room (a great story there if you’re interested).

Anyway, I’m having a pretty great time here and learning a ton both through conversations and just observing. Thanks for letting me share a little bit with you!

The journey of the oxygen concentrator that took too long.

Oxygen concentrators are important for giving patients oxygen in a place that doesn’t have wall oxygen, this is especially true for babies in the Chatinkha nursery- the closest thing to a NICU here at Queen Elizabeth Hospital. On a visit to Chatinkha, we were told one concentrator was not working. We rolled it through the maze of hallways, bumped it out to the car, and drove it to PAM- the adjoining office of engineers that fix the medical devices for the hospital and more accurately, the graveyard of broken medical devices on gurneys turned to dollies. With a lack of spare parts, donated already broken equipment, and a small staff for the number of devices, the engineers at PAM face an incredible challenge. There we were instructed to return in the afternoon.

Following instructions, that afternoon we tried to find one of the engineers. Though we were successful, the engineer informed us there were two major problems that would prevent him from being able to fix the concentrator. First, the power was out in the building (and given that it had been out for a year, it did not seem to be coming back on any time soon). Second, he could come to our office to fix it there where we had power, because it was already 3:30 in the afternoon and so it was too late to come that day. The next morning the engineer came to our office and fixed the oxygen concentrator.

There are many complicated issues in place here. There is the challenge of identifying broken equipment when there are so many patients per nurse and limited testing equipment. There is a personnel challenge of needing the man power to fix the number of devices that break and the resources to be able to do so. Finally, dusty conditions and old equipment contribute to devices failing sooner and more frequently. All that said, I have been impressed with the quality of care I have found here at Queen Elizabeth Hospital.

 

“A different pace of life” it is common to talk about but is it good or bad? Perhaps neither, or, more accurately, both?

To raise money for the hospital, a team of people put on a Ceilidh with Scottish flags in the corner, an impressive number of kilts for any gathering in Malawi, bagpipes, and a live band accompanied by a caller instructing us on how to skip and twirl and swing around with the time of the music. It was fantastic, and the dancing had a similar feel to enthusiastic square dancing. (Picture below) But the story for this post, though seemingly insignificant in comparison to such an event, is representative of something I’ve been thinking a bit about.

In our attempt to buy tickets for the Ceilidh, Elizabeth and I were directed to an office at the hospital. Hesitantly we knocked and entered. The woman looked expectantly, and, as we started asking if we were in the right place and could buy tickets from her, she interrupted. “How are you?” she asked, in the same tone a parent uses when a child forgets to say “please.” After a quick backtrack we corrected our mistake and exchanged pleasantries before proceeding to buy our tickets.

It is easy to justify skipping the “Hi, how are you” as it is likely you will only ever receive the automatic response of “good” or “fine.” However, this week has been a lesson in both consciously conforming to another culture and also realizing the importance of how a conversation is started. We start by acknowledging the other human before acknowledging the task. Perhaps in this case a slower pace of life is less efficient, but is justified by its other merits.

 

Eleven years ago I was in a land rover winding through the Ethiopian countryside. As we navigated the winding mountain roads, I curiously asked my friend Worku the names of everything I saw. Being in the Ethiopian countryside, I counted a lot of animals, but I soon paused when a herd of hundreds of goats got the best of my Amharic counting abilities. Worku, hearing my silence, supplied the word bazoo meaning ‘many.’ At ten-years-old I loved the sound of the word rolling off my tongue (much much more than my fellow passengers liked hearing it unfortunately), and soon I was christened Bazoonesh. Though initially given to me because of my single word obsession,  there is a certain truth to the name, meaning ‘girl of many choices,’ that far surpasses it’s phonological origins.

A diploma from Rice University ensures many things and choices is one of them. In preparing for graduation my classmates and I debated a number of different options for what to do when we parted but ultimately my choices have brought me here, to the Heathrow airport, on my way to Blantyre Malawi.

In reality we all have many choices- some big and some small, some made in advance and others in the moment. In preparing for the following 9 weeks I have made some choices:

1. I choose to be someone who encourages my fellow interns and the others who I interact with
2. I choose to spend time every day learning about Malawi and practicing Chichewa (the local language) Moni, muli bwanji?
3. I choose to be flexible with plans and attempt to find the balance between staying out of the way and taking initiative
4. I choose to spend time every day to reflect on how I am growing as a person and how these experiences will shape choices I make in the future

I am excited to be returning to Africa, a place that has changed the way I view the world many times, and so thankful for this opportunity. Check in here to see how these next two months play out for all of us Rice 360 interns and see where our choices lead us!