A few common refrains in the world of development-focused, service-minded people include “making a mark” and “creating change in the community” and “impacting individuals”. These alliterative idioms may sound attractive, but they encompass a dangerous mindset. Beginning a two month internship with the goal of changing things would have prevented me from being able to learn from, adapt to, and understand the cultural, social, economic, and health contexts that I was about to be immersed in. Reflecting back on this experience, though, I have to admit that marks have been made, so this post is a catalog of the scars, bumps, bruises, and more that I’ll leave Malawi with.

Stubbed toes and hole-ridden shoes

I am by no means the most graceful person, as any of the other interns can attest. The uneven ground around Blantyre often had me tripping around the city as I took in the sights. I had less of an excuse for my clumsiness at Queens. My interest in peering into wards and out through windows often led me into walls and doors, causing me to stub several toes in the process. There were too many colors, smells, sounds, and sights for me to watch where I was going (or at least that’s what I say to save face). By the end of the internship, I was much better at walking the familiar routes in the hospital. I’m going to miss the long walk between the CPAP Office and Chatinkha Nursery, which we sometimes took several times a day. It was probably this trek more than anything that created and widened the ever-growing hole in my shoes.

Papercuts from folder-making

Making folders for the maternity ward was one of the smallest but most rewarding things we did. We noticed early on that the ward needed chart holders, which led to several hours of hand-lamination that left me with some pretty painful papercuts. The best part was being able to follow up on how the chart holders were doing. The nurses and doctors in the ward often recognized us as the “yellow-folder girls” and always welcomed us back with huge smiles and excited chatter about how they were using the chart holders. It was great to see the effect such a small project had on the ward. Don’t get me wrong. We didn’t change lives or make an impact in the traditional sense, but we did make the jobs of clinicians in the ward just a little bit easier. Earning their smiles, interest, and excitement was a great reward.

A semi-permanent dust tan

My personal project during this internship was to learn more about the supply chain of medical devices as it related to the Ministry of Health, Physical Assets Management, the Department of Procurement, and QECH. The best part of the project was being able to talk to a wide variety of people for my research. From contacts in the MoH in Lilongwe to officials at QECH, I talked to a diverse range of people who were extremely welcoming and willing to answer my litany of questions with the utmost honesty. Last Friday, I got to run around Blantyre between QECH, the College of Medicine, PAM, and copyshops as I asked some of my final questions. It left me exhausted, excited, and covered in a fine layer of dust from traipsing across the city.

Scars from playing soccer at Lake Malawi

Visiting Lake Malawi was probably the pinnacle of our cultural immersion in Malawi. We travelled up with the Malawian interns and did everything typically Malawian: eating Kampango (or butterfish), learning to play Bawo (our new favorite game), speaking Chichewa with the villagers. On the rocky shores of the lake, there were roving bands of children (and I do literally mean bands), who played us ridiculous and infectious versions of “Who Let the Dogs Out” and other classics. At one point, we invited the children to an impromptu soccer game (barefoot, of course) which left me with scars all along my feet.

In the end, Malawi probably made more marks on me than vice versa. I’ve learned and experienced more in these two months than I could have ever hoped. I come away with more knowledge about Malawi, a renewed respect for the healthcare professionals who work tirelessly in low-resource settings, and an appreciation for the complexities and challenges of the healthcare system itself. Nearly every intern blog from previous years has ended with a “Tionana” (“see you later” in Chichewa), and I definitely understand that sentiment. I don’t want this internship to be a one-off experience. I want to come back to Malawi, to low-resource health settings, to other countries so I can learn more and do more. I’m not out to make my mark on the world, but rather I want to be marked by my travels, experiences, and knowledge so I can be an advocate for and an agent of sustainable change.

Jaundice is something that affects a lot of the babies born in Queens. Especially in preterm babies, the levels of bilirubin (the pigment that causes the trademark yellow tint of jaundice), are usually a little elevated. Generally, these babies do not need treatment since they will naturally adjust back to normal levels. However, in babies with severe jaundice, the threat of brain damage necessitates treatment with phototherapy lights, which break down bilirubin.

In the past few weeks, Karen and I have gotten a chance to work a lot more closely with the nurses and babies in Chatinkha Nursery on a project involving jaundice. The Poly Interns recently helped fix a broken bilirubinometer (a diagnostic machine that shows the bilirubin levels in the blood). Our first project was to test it’s accuracy against the working Chatinkha bilimeter. The second part of our project involved the diagnosis of jaundice through visual assessment. Chatinkha has a working bilimeter that gives nurses an accurate readout of how severely jaundiced a baby is. In the district hospitals, however, bilimeters are often unavailable. This is why some doctors at Queens are trying to teach nurses about Kramer Scores. The Kramer Score is an old technique to estimate the severity of jaundice by looking at how far down the body the line of jaundice has progressed:

By palpating the skin on the forehead, nose, arms, legs, and chest, the nurse will be able to tell which areas of the baby are affected. Using the chart above, they can then estimate bilirubin levels. We worked with nurses these past few weeks in order to get them to estimate the bilirubin levels of babies without any Kramer Score training. What we found was that nurses were fairly good at telling which babies had jaundice. However, when it came to assessing the severity of the jaundice, they had problems. It is very possible that Kramer Score training will help nurses make better diagnoses when they do not have access to a bilimeter.

Bilirubinometer Readout
Though there is definitely a need for cheaper and better technologies (ex. bilimeter, phototherapy lights), this example also proves that training and education can be an important first step to bridging gaps in healthcare provision. Though neither technology nor education is a magic bullet that will work overnight, in combination they can be very effective. Teaching nurses about how to identify jaundice without technology creates a sustainable way for them to be able to assess patients even if they lack access to technology. Meanwhile, building low-cost technlologies addresses longer-term issues of improving healthcare capabilities and infrastructure even in low-resource settings.

Malawi is an incredibly beautiful country and we were lucky enough to be able to sample some of its natural beauty through weekend trips. Its stunning mountains, rolling greenery, and diverse wildlife can be seen nearly everywhere. A thirty minute drive from Blantyre led us to Mount Mulanje, a massive collection of 21 peaks (one of which we then attempted to climb–something Sarah and I are still recovering from). A little farther away was Satemwa, a tea plantation that sported low hills covered in lime green tea plants.

The View from Mulanje

Dusk at Satemwa

One of our favorite trips took us to Liwonde on a boat safari where we watched hippos and elephants frolic under a melting sunset sky. It was a peaceful  Finally, there was the trip to Lake Malawi, the countries biggest tourist attraction, with the Malawian interns at the Poly.

Elephants at Sunset

Sunrise at the Lake

Natural beauty, though, is not always appreciated and maintained. Our weekend trips often took us to places removed from heavy human contact. There were definitely people living in villages and towns near Mulanje, Satemwa, Liwonde, and Lake Malawi, but their lifestyles were simple enough that the nature around them remained pristine. The situation is completely different in Blantyre, a city where people are crammed together in small spaces and have to use products that are packaged and processed rather than relying on their subsistence farms. Here, trash often litters the streets and the sight of plastic bags and cartons thrown in nearby creeks or gutters is not uncommon. It’s quite the public health problem, especially when families use creeks as water sources to wash dishes, do laundry, or even cook food.

Trash in the Market Creek

The Malawian government, like several others in Africa (1) (2) (3), has started to take measures to combat the pollution. In the two months we have been here, the government has passed legislation that prevents plastic bags from being less than 35 microns thick. Grocery stores now charge 20 to 40 kwacha for a plastic bag, a small price to pay, but ultimately something that could begin to make Malawians more conscious of their choices. In the short run, this will hopefully make places like the Market Creek safer and cleaner. In the long run, this is a progressive step by the government towards fixing environmental factors and practices that can endanger public health.

The advent of Obamacare and the discussion of insurance policies in America has politicized the field of healthcare. The same trend is true in the Malawian healthcare system, albeit in a different way. Politics rules the healthcare system in Malawi at nearly every level. This isn’t always a bad thing–usually it means that the government is genuinely interested and involved in bettering health policy. However, it can sometimes result in the inefficient delivery of healthcare to the people at the end of the chain.

One example of the intersection of politics and healthcare is found in the story of Chatinkha Nursery, where Karen and I have spent numerous hours over the past two months. Gogo Chatinkha, for whom the nursery is named, was former president Kamuzu Banda’s grandmother. While Banda was in power, the nursery was extremely well taken care of. However, when he lost power in 1994, funding and care for the nursery declined significantly. After years of relative neglect, Chatinkha is now being renovated and expanded, allowing it to return to its prime. In Queens, entire wards are donated or sponsored by various donors including corporate sponsors like Sobo (a soda company that financed the Paediatric Oncology ward) or charitable organizations like the Lions Club of Blantyre (a group that helped build the Delivery Suite).

Politics also pervades the system at lower levels than the government. For example, since QECH is a government hospital, it should be run by Ministry of Health doctors and officials. However, since the College of Medicine also uses it as a teaching hospital, they claim some of the leadership responsibilities as well. In effect, every department at Queens has two chairs now: a clinical head and an academic head. This makes the chain of command more complicated and inefficient, but it also allows brilliant Malawian doctors to rise in the ranks and lead departments at the biggest government hospital int he country.

Politics and healthcare coexist in an uneasy but inextricable relationship. The goals of doctors and nurses can often clash with the plans of health policy makers at the top. However, when the clinical and political sides work together, health projects can take on a bigger scope and reach a broader base of customers and patients.

It’s easy to think of places in Africa as a collection of rural villages based on images portrayed by the media. That’s not to say that it’s an entirely inaccurate image. We’ve driven through numerous villages composed of the mud walls and thatched roofs that perfectly echo any foreigner’s idea of Africa. However, too little credit is given to the burgeoning cities of Africa. Blantyre is the perfect example. It’s a relatively small city in terms of geographical area, but the experiences we’ve had here have showcased the incredible diversity and dynamism of Malawi.

Restaurants

Our group likes to daydream about the delicious food scene of Houston and its diverse offerings. But this is not to say that Blantyre’s restaurants are bland or uninteresting. In fact, we have had some incredible food over the past weeks. There’s been Indian food delivered to our doorstep, Italian food enjoyed at a suave new cafe, burgers devoured while overlooking the track at the Blantyre Sports Club, carrot cake savored in the vibrant gardens of Cafe Mandala, warm mandasi guiltily scarfed down outside the CPAP office, and Ethopian curries shared over warm injera bread along with delicious spiced coffee. The restaurants of Blantyre hint at the numerous cultures and influences that shape the city and the country as a whole.

Ethiopian Spiced Coffee

Religion

I was extremely impressed by the diversity of religions in Blantyre. From churches to mosques to temples, we’ve seen numerous houses of prayer throughout the city. Though Christians make up a majority, there are always hints of other religions. For example, we got a day off for Eid, which was a national holiday. Malawians love to boast about how peaceful and kind their country is, and they’re not wrong. More than just tolerating differences, the people here embrace them whole-heartedly.

Grocery Stores

Our group loved to cook our own food in addition to sampling the restaurants of the city. So we became very familiar with the standard grocery stores. Chipiku: the all-purpose store that is a little like a Kroger or an Albertsons. Superior: the meat market, restaurant, and gourmet foods store (they have Nutella and Magnum bars). Shoprite: the South African megastore that, to quote our taxi driver from Lilongwe, “literally has everything.” Game: the electronics/house supplies/furniture store that we call the Walmart of Malawi. These stores demonstrate Blantyre’s international connections and increasingly cosmopolitan nature.

The Market

It wouldn’t be right to talk about grocery stores and food shopping without mentioning the Blantyre Market. It’s an enormous area filled with stalls and booths that has almost everything you could want for day-to-day life. There’s a giant produce section, electronics vendors, bookstalls, and chitenge sellers (my favorite), just to name a few. It also seems endless. While the produce market is in a wide-open area, Sarah recently introduced me to what I now call the labyrinth. It’s a winding maze of stalls that holds suprises around every corner: you’re never sure if you’re going to run into a fragrant booth selling freshly-fried chips, a wobbling light over a covered-up pool table, a stack of fried rodents, uneasy chickens in a giant cage, or a tailor’s shop with beautiful fabrics. It’s one of my favorite places in Blantyre so far and though I tried to take pictures of it, these photos don’t really do it justice:

Stalls at the Market

Inside the Labyrinth

A selection of cacti and chicken coops

What makes you tick? Why do you do the work you do? What motivates you? They’re questions that seem like they should have definitive answers. The time-worn wisdom of the Disney Channel would have you believe that everything you do should lead you to your dreams. After all, what nobler thing is there than to work towards your passions? But as the more hard-hearted economists explain it, a lot of our behavior is motivated by a complex set of incentives (salary, social status, familial expectations, competition, etc.) that can be both intrinsic and extrinsic. In the context of low-resource health settings, the misalignment of these incentives can often be a pillar that props up inefficient systems or less-than-ideal practices.

The Good

I’ve seen several examples of incentives working in favor of the Malawian healthcare system. One example is the health passports, which I talked about more extensively in an earlier post. These passports are a good example of incentives in action. They ensure that doctors will be able to give the patient a high level of care since clinicians can gain full knowledge of a patient’s medical history.  Since families want the best care for themselves and their relatives, they have strong incentives to take care of their health passports and bring them to medical visits.

In another example, the MoH under the administration of Peter Mutharika increased salaries for doctors. It was certainly not an easy decision to make in a country that has a limited budget to dedicate to healthcare expenditures. However, in practice, this may attract more students to the medical field. Higher salaries will hopefully be a good first step in addressing the dire shortages of doctors and medical staff that Malawi currently faces.

The Bad

One obvious example of bad incentives stems from the dominance of public sector healthcare in Malawi. Since the government is largely in charge of acquiring and distributing drugs, equipment, and other medical supplies, there is little to no incentive for private companies to enter the market for these goods. There are private hospitals sponsored by NGOs or religious organizations (see Renata and Nkechi’s blogs about St. Gabriel’s), but even these hospitals often get supplies from the Ministry of Health. What isn’t acquired from the MoH is usually donated by foreign organizations. This system has crowded out the private market, leaving very few opportunities for private medical supply stores to pop up. We visited a medical supply store called Bioclinical Partners, and the owners and managers explained that business was hard to come by. This is largely due to the overwhelming dominance of foreign aid and government-sponsored healthcare.

The Misaligned

CPAP Nurses and Coordinators are a hugely important part of the bCPAP implementation in Malawi. The people involved in this effort are extremely dedicated, hardworking, and passionate about the cause. Nurses like Chrissie and Florence champion CPAP regularly while ministry officials like Norman and Alfred train new CPAP Nurses and disseminate information. However, some of the nurses in district hospitals have less regular interactions with the CPAP project and have less intrinsic motivation and passion for the project. This is not to say that they don’t do a good job–the CPAP project would be lost without them. It’s just that they have little incentive to fight inefficiencies in the system to get good data or correct their colleagues in order to establish better CPAP-related practices. This isn’t necessarily a problem of bad incentives, though. Instead, it’s a problem of misaligned incentives. If there was some additional extrinsic motivation, say a competition for CPAP Coordinator of the Month or achievement-based certificates, it’s possible that CPAP officers in the districts would push for the program just as much as its champions at Queens and the MoH.

I had very little idea of what Queens would look like before this internship began. Actually, it’s more that I had a very incorrect idea. I had pored through past interns’ blogs to find what few pictures of QECH they had posted, but what I saw (zoomed-out pictures of the main building at Queens) in no way prepared me for the sprawling expanse of the hospital and its wards. It would be a herculean task to photograph all of QECH, so I settled for photographing one ward: the Delivery Suite.

The first thing you see upon entering the grounds of Queens is the main Accidents and Emergencies (A&E) building, which is the emergency room for adult patients [1]. However, let’s say you’re an expecting mother going into labour. In your case, you would probably head directly to the Maternity Ward [2]. Walking through the halls of the hospital [3], you would go through swinging double doors and into the Delivery Suite [4].

1. The Main Building

2. The Maternity Ward

3. Hallways in the Ward

4. The Delivery Suite

Once in the ward, you would be admitted to one of the bays [5] on either the non-paying or paying side. If your condition were shaky, you would be placed in a bay on the blue high-risk side of the ward [6]. Your charts would be put together, including your admission information and health passport. These charts would then be placed by your bay [7] (or in one of the new holders that Karen and I recently installed in the ward [8]).

5. Patient Bay

6. High Risk Bay

7. Medical Charts

8. New Chart Holders!

In the event that you were having complications or needed additional care, the tireless nurses would come out from their nurses station [9] to attend to you. Running back and forth between the bay and the stocks of medical supplies [10], the nurses would administer any necessary drugs and dispose of their used supplies in the strategically placed buckets in the ward [11]. They would then wash their hands in the sinks inside the patient bays [12].

9. The Nurses’ Station

10. Medical Supplies

11. Disposal Buckets

12. Sink in Patient Bay

Once you deliver your baby either in the ward or via C-Section in the operating theatre (we can skip the gritty details), your baby may be placed under the radiant warmer to ward off hypothermia while the nurses care for you [13]. The baby would then be delivered to Chatinkha nursery and placed on CPAP, supplemental oxygen, or in a heater as the situation demands [14]. The sheets and blankets would be washed and dried in preparation for the next patient [15], and your delivery would be recorded on the tracking board [16].

13. The Radiant Warmer

14. Babies in Chatinkha Nursery

15. The Laundry Room

16. The Statistics Board

Every day at Queens, this process is repeated numerous times. At one point when we were in the Delivery Suite, 5 mothers were scheduled for C-Sections while another 3 were going into labour within the span of one hour. Moreover, all 8 of these mothers were pre-eclamptic. The caseload is enormous and complex, but the staff at QECH do an incredible job of handling these cases, and they are constantly looking for ways to reduce both maternal and neonatal mortality.

Guidelines are a pretty big institution in the field of medicine. They help doctors identify a course of treatment or set the baseline for the standard of care for a certain condition. They are usually developed after much research and experimentation. They are widely respected in the medical community. The problem is that most of these guidelines just don’t work in low-resource health settings. In conversations with doctors and nurses at Queens, there have been quite a few instances that have illustrated how guidelines go awry on the ground.

APGAR Scores

APGAR scores are used to rate the condition of a baby 1 and 5 minutes after delivery. APGAR is an acronym for Appearance, Pulse, Grimace, Activity, Respiration. In each of these categories, the baby can get a score of 0, 1, or 2 depending on how well they’re doing. Here’s a (somewhat blurry) picture of APGAR guidelines posted in the Maternity Ward.

APGAR scores can be useful in identifying the health status of the baby, but at QECH, given the high volume of babies with Respiratory Distress Syndrome (RDS) and Birth Asphyxia, APGAR scores are often irrelevant and aren’t recorded very consistently. Babies who are blue and barely breathing spur the midwives into action as they try to save the baby rather than record an APGAR score. This doesn’t mean that they’re flaunting protocol on purpose. Rather, it means that they are overstretched and usually don’t have the time to consider APGAR scores when there are multiple complicated deliveries happening at the same time.

Putting Patients on CPAP

Infants with RDS are generally supposed to be put on CPAP. However, a lot of hospitals with the Pumani bCPAP have subpar rates of infants with RDS who are actually put on CPAP. At the CPAP coordinator meeting, some of the coordinators mentioned that CPAP isn’t used in their hospital because nurses feel uncertain about the machine despite detailed guidelines from the CPAP Office about when and how to use the device.

More worrying, however, was one presentation from Kamuzu Central Hospital (KCH). The coordinator from KCH said that the Pumani CPAP was not used at all in the month of January because a few foreign doctors did not think the machine worked effectively (based on their expert opinion rather than evidence), and did not put their RDS patients on CPAP. Though these doctors were eventually convinced of the benefits of the Pumani, this situation highlights a serious problem. Both Alfred and Norman (our Ministry of Health partners) harped on the lack of national guidelines on the standard of care for certain conditions. They explained that each hospital largely sets its own guidelines. This makes it easier for visiting doctors to question the system and try to change practices that have been proven to be effective and useful on the ground.

NICE Guidelines for Inducing Labour

One of the most interesting and challenging dilemmas I have heard about during this internship concerns the practice of inducing labour in mothers. Last week, we got the chance to sit in on a Maternal and Child Mortality Morning Meeting–a special session where doctors from Paeds and Maternity came together to discuss best practices and areas of improvement. A big topic of conversation was the NICE Guidelines on labour induction, which outline the situations in which inducing labour is a good idea. These include a setting with adequate “safety and support procedures,” “facilities… for continuous electronic fetal heart rate and uterine contraction monitoring,” and “availability of pain relief options.”

The problem is that in the Delivery Suite, many of these conditions cannot be met. Yet there are mothers who are post-term or have complications and need to deliver their babies as soon as possible in order to protect the health of both the mother and the child. These aren’t isolated occasions either. Often, many mothers in the ward on a particular day have to be induced. However, given the limited equipment and staff, inducing all of these mothers at the same time can also be a disaster. It’s a fine balance. On the one hand, clinicians don’t want to induce labour unless they know they can give mothers an appropriate level of individualized care. On the other, not inducing these mothers could lead to more complications and bad outcomes for all parties involved. It’s a dilemma that makes the NICE Guidelines a nice guideline, but an unhelpful standard in a ward that has its hands tied by a lack of resources. Instead of looking at the guidelines, nurses and clinicians make their decisions on a case-by-case, day-by-day basis–a method that is occasionally successful and always stressful.

Yesterday, Karen and I travelled to Lilongwe (the capital) with the CPAP Office staff to attend the CPAP Coordinator Meeting. This meeting is an opportunity for the district coordinators for the CPAP project to come together and talk about the progress of CPAP implementation at their respective hospitals. Just before the morning tea break, Norman, our Ministry of Health point person and ARI Programme Coordinator, exclaimed, “Data is Power!” It’s from his bold statement that this post gets its title.

The CPAP Coordinator Meeting is all about data visualization. Every single coordinator is expected to present data about the use of CPAP and the rates of neonatal survival in their districts. It is meetings like this that help make the Rice CPAP project a beneficial effort. Economist William Easterly writes in his book The White Man’s Burden that most aid efforts lack a system of adequate feedback and evaluation, which leads to a disconnect between donors, implementers, and end-users. The CPAP Coordinator Meeting addresses exactly this issue by fostering communication between CPAP project staff and the people who are implementing the project at the district levels. The presentations are impressive–coordinators aren’t afraid to admit that there are weak spots in their implementation efforts and they are happy to put forward solutions and ideas to help their colleagues.

Discussion at the Coordinator Meeting featuring a Portrait of Prof. Arthur Peter Mutharika

Despite the merits of this conference of coordinators, what is equally evident in the meeting is how hard it is to collect, record, and archive data in an accessible way. Numerous presenters talked about how entire months of data on neonatal mortality rates were unavailable to them because of missing logbooks, locked storerooms, insufficient monitoring forms, or incorrect data entry. It makes evaluation extremely hard, especially since the CPAP project is now operating in almost every Malawian district. Each district and each hospital is independently in charge of recording data, which makes it easier for human error and logistical malfunctions to corrupt data collection. Norman’s exclamation this morning was in response to the fact that hospital after hospital came up to present only to show missing data or poorly collected metrics. His frustration is definitely warranted. ‘

The final piece of the breakdown in data collection is the lack of reliable communication technology. In several districts, supplies and data collection materials were in short supply mostly because district coordinators failed to contact the CPAP Office in Blantyre in order to inform them of the situation. In other instances, broken CPAPs were left unfixed for months because of miscommunications. There are shaky channels of communication between district hospitals, PAM, and the CPAP team, which adds another barrier to effective data management.

The CPAP project is extremely good at training, motivating, and following up with district-level data collectors. However, there are inherent obstacles int he Malawian healthcare system that hinder evaluation efforts. Once again, this is an opportunity for an EMR system to be effective. It would prevent data loss and could aid in communication, making research on healthcare interventions far more feasible. If data is power, then EMR systems are keys to the kingdom, since they will open up a whole new realm of easy data collection and management.

I’ve posted a lot of photos and descriptions of my work so far, but I don’t think I’ve painted a true-to-form picture of the place I live. Blantyre is a city with a lot of sights to take in, but even more so it’s a place that’s filled with sounds. The noises are many and varied: minibus drivers peddling their hundred-kwacha fares, honking traffic screeching to a stop in front of unconcerned pedestrians crossing the street, the low hum of chatter in the courtyards at Queens occasionally punctuated by bursts of unconstrained laughter. More than just sounds, it’s the music that has captured my attention on numerous occasions. I’ve chosen to highlight a few of those occasions here.

We went to church (actually a megachurch) last weekend and it was quite the experience–4 hours filled with song and dance. The congregation was on its feet for nearly the entire service and the melodies they sang were infectious. The one song that remained stuck in my head, though, was a Chichewa song of praise. I left the service with an echo of the tune ringing in my ears, disappointed that I hadn’t recorded it when I had the chance. Two days later in the CPAP Office, my ears pricked up as I heard the familiar chorus. It was the women in the sunken amphitheatre outside, the ones who were waiting to attend to their sick children in the Paeds ward, raising their voices under the direction of a pastor. The clip I recorded of their spontaneous song is a glimpse into daily life at Queens and the people who populate its walls.

Lyrics
Kumadze ake odikha,
Anditsogolera,
Ndimoyo wanga wofoka
Awulimbikitsa

(A rough translation of Psalm 23 from the Bible: “he leads me beside quiet waters, he refreshes my soul”)

This past Thursday, we visited the Jacaranda School, an institution 20 minutes outside of the city that provides education for children who are orphaned by HIV/AIDS. We were welcomed with open arms by a group of bold, outspoken, and whip-smart kids. Bright murals adorned nearly every wall of the school and neatly planted vegetable gardens were tucked away in every available nook. We were invited to come speak about our technologies, about women in STEM, and about pursuing higher education. It was an incredible experience to engage the Jacaranda students and answer their questions about our devices, the program, and our fields of study. Christina, speaking about her own experience as a Malawian woman studying Electrical Engineering at the Poly, gave one of the most empowering speeches I’ve ever heard. After her talk she was immediately surrounded by a huddle of wide-eyed girls who were interested in being doctors and scientists. Though Christina’s speech was definitely the highlight of the trip, my personal favorite moment was when the girls acapella group (Jacapella) sang us a song called Malaika to showcase their talents and welcome us to the school:

Yesterday, we dropped by a wedding we were invited to by Henry the Honey Man. He’s a professor at the Polytechnic who sells us amazing honey that he makes in his village. His nephew was getting married and he knew we were interested in learning more about Malawian traditions, so he invited us to the reception. There were a lot of similarities to American weddings: a bride in white, stunningly color-coordinated bridesmaids and groomsmen, middle-aged relatives videotaping the ceremony on iPads. Yet there was definitely a lot of Malawian flare, especially when the bride and groom walked into the room strutting down a rose-petal strewn red carpet to dance with their wedding party while relatives ululated and threw money in the air. The “money dance,” as we started calling it, is a way for relatives, friends, and visitors (we were singled out, of course) to come dance with the bride and groom. You’re supposed to exchange your money into small bills (20 or 50 kwacha) and then throw money at the beaming couple for the duration of the song. This entire process was repeated for about 5 hours. There were a range of songs including autotuned, reggae dance hits and a Malawian rendition of “Little Drummer Boy” that were blasted from stacks of speakers 15 feet high. The best, though, was a drum song played live by the band. It was a song that everyone seemed to know and that they all sang along to: