This is something I’ve always wanted to learn. Thanks to Regina, an old family friend, I now officially know how to tie a baby to my back the Malawian way! Why do we need fancy baby carriers anyways??

http://www.youtube.com/watch?v=1JiG1u5EGo0&feature=player_embedded

In Malawi, we often joke that we’re “waiting to wait”. Malawi time isn’t always the same as American time, and it’s easy to find yourself waiting all day – for a person, for a meeting, in line, or just to wait. I think I do this “waiting to wait” more often in life than I notice. It seems that I’m always waiting impatiently for whatever is coming in the future. Waiting to get into college, then waiting to hear back about medical schools, then waiting to go to Malawi, then waiting to come home, then who knows what’s next.  When does the waiting stop and the awaited arrive? Or, am I too busy waiting again to embrace the awaited? I was reminded today to do less waiting and more living, less enduring of the moment and more relishing in the moment.

I’ve been thinking a lot about joy recently. Six months ago, my medical school interview at UCSF started with a simple but confusing statement:

“Please discuss the fluidity of joy.”

Come again? The fluidity of joy? I must be in California, I thought. Since my stumbling and confused interview answer, I’ve thought a lot about the fluidity of joy.

I suppose a fluid is defined as something that flows under applied shear stress. It’s not breakable, or conformed, or disappearing. I think joy must be fluid – how else would it survive the pressures of stress, and anger, and anxiety, and sadness. It’s not quite solid, like happiness. We know what makes us happy – puppies, and ice cream, and sitcoms, and jokes. It’s predictable. It’s conformed. It’s fleeting.

Joy comes from a more fluid and indescribable place, and it must be different for every person. I think joy must be the great-grandmother of happiness. Happiness is still lacking the wisdom that sustains joy.

When I think of joy, I think of my grandmother, Nana. She’s the kind of person who chooses joy in every circumstance. She has taught me to choose joy, even in the toughest of circumstances. Joy is a whole note sustained in background of a symphony. It’s always there, whether we choose to hear it or not.

I’m so thankful for the JOY that the past few weeks in Malawi has brought me. In its fluidity, it has truly withstood the shear pressure of failure, and tiredness, and confusion, and at times chaos. I’m not sure why I included a picture of Grace – maybe because she brings me joy. I hope her picture helps you to choose sustaining joy today.

An enormous burden rests on Africa’s few health care workers. In the midst of the emergence of HIV/AIDS, the resurgence of tuberculosis and malaria, the increase in diarrheal diseases, and the rise in chronic disease, sub-Saharan Africa is 4.3 million health care workers short of the number needed to manage the health situation. While the country of Malawi illustrates the challenges of providing health care with too few workers, it also provides many examples of the success of community-based initiatives in the alleviation this burden.

The Gross National Income per capita in Malawi is US$280, making it one of the poorest countries in the world. A majority of mortality is a result of communicable or preventable diseases such as malnutrition, pneumonia, anemia, or diarrheal disease. Malawi currently has only 266 physicians and 7,264 nurses and midwives for a population of 15 million. These hospital health care workers alone are not able to provide for the extensive health care needs of the country.

Malawi’s government, as well as many non-governmental organizations, is in support of a community-based health care approach, and has trained over 11,000 paid community health workers, known as Health Surveillance Officers (HSA’s). This group of trained, paid community health workers is on the frontline of the battle against many preventable diseases, and serves as a bridge between communities and health care institutions. The main goals of the HSA’s are immunization, growth monitoring, disease investigation, water and sanitation, and health education. The global shift from hospital care to community care is driving an initiative to provide communities with the workers and tools they needed to help improve health indicators. As a result, community health workers such as HSA’s are becoming the primary deliverers of community health care in many rural an underserved areas.

These HSA’s are directly observing the administration of tuberculosis and HIV medication, are vaccinating children and pregnant mothers, they are providing home-based treatment of malaria and diarrhea, and are administering antenatal care and prevention of mother to child transmission programs. The services provided by these HSA’s match with the country’s goals to provide for local health care needs, are less expensive and more sustainable, and provide a more accessible form of health care at the community level. Despite the success of community-based approaches, the lack of appropriate diagnostic, treatment, and prevention tools remains a major obstacle in the delivery of community health care. Often, the necessary tools are not available, are too expensive, or require extensive training for use. In response to this need, the purpose of the HSA Backpack is to equip this army of paid, trained HSA community health workers with the tools they need to provide basic diagnostics, first aid treatment, and prevention to their communities in a way that is portable, sustainable, and effective. Because HSA’s receive the most standardized and high-level training of any community health workers, they are potentially the best end-users for the backpack.

Twelve of the second-generation HSA backpacks are being used by teams of trained community health workers spread through the entire 100 mile catchment area of St. Gabriel’s Hospital. A team of 15-20 community health workers, who visit approximately 10 patients per week, is using each backpack. The backpacks are mostly being used for home-based palliative care. With the tools in the backpacks, community health workers are able to take vital signs, dress wounds, monitor infant growth, and distribute medications.

These community health workers need at least twenty-five more backpacks, so that they can travel in teams of five, rather than teams of twenty. There are thousands of other trained HSAs throughout the country who could (and hopefully will) benefit from the kit as well. With partnerships with organizations such as Save the Children, GAIA, UNICEF, Concern Worldwide, and the Ministry of Health, every HSA in the country could have the tools they need to fight preventable and curable diseases in their communities.

These community health workers are able to restock their backpacks during their monthly visits to St. Gabriel’s Hospital, and the backpacks are stored in the chief’s house for safekeeping. These backpacks provide the community health workers with everything they need to provide care for their communities. They are honored and recognized in their communities as legitimate health care workers.

There are several limitations of the backpack. First, there are several items in the backpack – such as the wound dressing materials, the first aid supplies, and the antiseptic – that must be replenished when the backpack’s supplies run out. The community health workers associated with St. Gabriel’s Hospital return to the hospital every month to pick up their own medications. During this time, they are able to restock their backpacks according to the availability of the supplies at the hospital. This limitation is one of the reasons that HSA’s were chosen as the end-user community health workers for the backpacks. They are highly affiliated with their nearest district hospital, and will likely have access to supply replenishment. However, even in programs where HSA’s are well supported by their health centers, supplies are often limited.

A second limitation of the backpack is the need for user training. Currently, the backpack is designed for use by trained community health workers. This is a second reason that HSA community health workers were chosen as the end-users for the backpack. They have already received standardized training in the use of all of the tools in the backpack. The HSA backpack provides a way for community health workers with specific training to expand health care, diagnostics, treatment, and prevention to rural communities in a way that they would not otherwise be able to. With the HSA backpacks, community health workers are being recognized and honored in their communities as legitimate health care workers, and are receiving the support and tools they need to provide health care at the community level.

The statistics on the Maternal Mortality poster hanging in the gynecology and obstetrics wing of the University of Malawi were from over a decade ago, but the situation is just as dire in 2011. A few images from the WHO’s 1996 poster on Maternal Mortality:

This thought is a work in progress.

What do you think of when you hear the word “poverty”? Do you think of rags, beggars, or dirty feet? Maybe you think of familiar faces in Malawi, or Honduras, or Haiti. Maybe you think of starvation, sickness, or sewage.

I was thinking this morning as I was running. Everyone here has shoes. I don’t know why I’ve been fixated on this the last few months. No one in Namitete wears shoes. But in Blantyre, everyone has shoes.

I started to think – people here must be richer, more educated. Then it hit me – perhaps poverties aren’t more or less, only different. Just because the people in Blantyre have shoes, are they richer than the people in Namitete who walk barefoot? How do we measure wealth? How do we measure poverty? Is it in coins, or assets, or fertility, or days of life? Is it in happiness, or in strength, or in wisdom? Is it in dollars per day, or per capita income, or some other measure?

I might even venture to say that some of the deepest and most intense poverty exists in the wealthiest parts of the world. Perhaps, for many, poverty has nothing at all to do with money. After all, I can think of hundreds of people with all the wealth in the world, but who are in desperate need of love. This poverty is absolutely comparable to a lack of shoes or clean water. If you’re living in the States, look around you, at your work and in your family. Although it might be shadowed by expensive shoes and heavy wallets, I wouldn’t be surprised if you came across some of the world’s most intense poverty.

Poverty (n, v, adj) – to be in desperate need; physical, emotional, spiritual

“Those in humble circumstances ought to take pride in their high position.” -James 1

After only a few days at Queen Elizabeth Central Hospital in Blantyre, I’m already learning the importance of patience. Things don’t always (or often) work out in the way or timing that you expect them to. Some days you spend all day in pursuit of something that doesn’t work out in the end. Some days you spend all day in pursuit of something that doesn’t work out until the last minute. Some days you spend all day in pursuit of things that fall right into your lap. I guess that’s life.

I spent the entire morning yesterday calling every number I could possibly find for every nursing or midwifery program in the southern region of the country. Not a single one of the numbers worked. When I finally got through to someone at the University of Malawi College of Medicine, the call was dropped after 5 transfers. I didn’t even know the name of the man I was talking to. Alas, I decided to start again anew in the afternoon.

Instead of calling this time, I decided to just show up at the School of Nursing and knock on some doors. It was only a few minutes before I met Ursula Kafulafula, a Malawian midwife at the School of Nursing who had studied at UPenn years ago. We chatted for a while, and within a hour, I was able to set up a meeting for Friday with the directors of the midwifery program who will be in town for a meeting before heading back to the main campus in Lilongwe. Several midwives from the School of Nursing in Blantyre will be in attendance as well.

I should’ve known, in Malawi it’s always about real interactions with people. Here, you can’t expect to just make a phone call and accomplish your goal. No, they want to see your face. They want you to be there in person to stick up for your proposal. And more than anything else, they just want to chat. While this is not as fast and efficient as scheduling a meeting in the States, it brings a different sense of accomplishment. I didn’t just schedule a meeting with the School of Nursing. I made a new friend – Ursula Kafulafula – a mother of two teenage boys, a wife of a recently deceased husband, a woman with a deep and faithful love for God, and a graduate of UPenn’s PhD nursing program. Oh, and I learned a few lessons in patience. J I’d say that makes for a pretty “accomplished” day.

No one in my life exemplifies the beauty of giving back to a community like the nuns at St. Gabriel’s Hospital in Namitete, Malawi. They left the comfort of their Luxembourgian communities at 18, and travelled without hesitation to Malawi, Africa. Two years ago, these three nuns celebrated 50 years of service to this foreign community that has become their own. Freely hardly describes the sentiment of their service. What they give to their community was more than simply free – it is full of love, joy, compassion, and gratitude. They have abandoned the comforts of their community to pour into a foreign and abandoned village without hesitation or expectation that the community will return to them what they have sacrificed.

These nuns live out the beauty of charity with the utmost integrity and importance, carefully including this belief in every small decision. When I travel to the hospital, I am very careful not to take from the community – as tourists so often do. I am there to give, not to take. So, when my mom became sick and in desperate need of antibiotics, I could hardly bear the thought of asking the Sisters for a few pills from their precious supply of medicines. As I accepted the bag of pills – more than the hospital could afford to give away – I tried to repay the Sister with a few kwatcha. I will never forget what she said to me in that moment. “Please, don’t…” she said, refusing the kwatcha, “We owe each other too much.”

We owe each other too much. How truly that statement rang in my heart, and how beautiful the dynamic was proven to be. During the five years that my family has been serving the hospital, we have grown into a community that truly owes each other far too much not to serve each other freely.

This is my hope for the future – that I will practice medicine in a community that I have learned to serve freely, and that I expect nothing from in return. I understand deeply the importance and value in serving a community freely. This is just as important for a physician as it is for one of the Sisters, for the patients they serve, for the manufacturer that freely donated the drugs, for the priest that prays at the beds of every patient, for the maid that changes the sheets, and for the volunteer that receives the antibiotics. We all owe each other far too much not to return freely what we have been given.

Today’s adventure provided the most exciting news yet. A year and a after they were sent to Malawi, I’ve finally had a chance to follow up on the 12 Community Health Outreach backpacks. This was a project than began two years ago in a sophomore design class at Rice. The backpack struggled through several design iterations, and finally ended up in the field at St. Gabriel’s Hospital for the summer. The original intended end user was a group of trained community health volunteers, known officially as Community Health Workers (CHWs). After a summer of using the backpack in the communities surrounding St. Gabriel’s Hospital, the backpack was redesigned to accommodate the feedback. Twelve new and improved backpacks were sent to be used at St. Gabs:

Several teams spent months trying to identify the appropriate end user for these backpacks. Little did we know, the end user would find the backpacks. The backpack was originally designed for use by Community Health Workers. It was quickly assumed that these volunteer members of the community (sometimes with no more than a middle school level education) would not be able to use some of the more technical items in the backpack. We thought that perhaps the backpack would be most useful in the hands of an outreach nurse with professional training and a nursing degree.

When I arrived at St. Gabs this summer, I was surprised to find that the backpacks had made it into the hands of 12 of the hospital’s most trusted Community Health Workers. Alex, the hospital’s chief Home Based and Palliative Care nurse, used Frontline:SMS to call 12 of his most reliable CHWs to the hospital to be trained to use the backpacks in their community. Each of the 12 CHWs was trained in palliative care (an approach that includes both the family and the community in end-of-life chronic disease care, and take a holistic approach to medicine). They were then designated as leaders of teams of 15-20 CHWs in neighboring communities as a Palliative Care Team. So, each Community Health Outreach backpack is shared by a team of 15-20 CHWs, and they travel as a team with the backpack to care for patients in their communities.

I’ve been able to visit several of these teams of CHWs, spread as far as 100 km from the hospital. They are using the backpack 2-4 times per week, to visit an average of 10 patients per week. They’re keeping detailed records of every item they use (including every time they open the snapware boxes!), and store the backpacks in the village chief’s house for safekeeping. I won’t bore you with the details of the data collection, but some of the results and suggestions were absolutely fascinating. Several teams highly suggested the inclusion a tooth brush and toothpaste, to increase the appetite in some of their patients, and to promote oral hygiene. This suggestion hasn’t come up once in 2 years of tens of university students studying the possibilities for this backpack.

Besides the fact that hundreds of CHWs and hundreds of patients are benefiting from these 12 backpacks, by far the most encouraging discussion was how the backpacks were affecting the CHW’s roles in their communities:

“Before we had these packs, we used to travel with our drugs and tools in plastic bags. If I fell, the drugs would be scattered. In this bag, they will be protected.”

“These bags have given us an identity. The tools and drugs are now secured. We are well honored in our community.”

“Patients are feeling well cared for because the tools are well arranged. When they see that they are being well cared for, they get their appetites back.”

“This should just be the beginning. We need more packs.”

“These backpacks have given us an identity. Before, members of the community were not recognizing that we are legitimate workers for the hospital. With these bags, we are well recognized.”

“Our patients will see us coming with the packs, and they will say ‘Oh yes, our doctor is here.’”

“The bag has brought unity and transparency among the volunteers. We are now working as a team to treat our patients. Volunteers who were previously inactive are motivated by the hospital’s willingness to support us with the tools we need, and have now become active again.”