This week we are on week 3 of implementation and training. We trained nurses and doctors from KCH and Bwaila, and then the whole team went up in different waves to Lilongwe to bring 8 CPAPs, 4 oxygen concentrators, 2 carts and a lot more other supplies. The truck-load was a bit intimidating but our driver, German, is great and managed to get everything up to Lilongwe safely. These trips are great because its very exciting to see CPAP at places for the first time and how thankful all the staff are for having these new machines. But they are also really fun because of all the wonderful people that I get to spend time with.

The CPAP team here is a combination of a wide variety of unique characters from wise and experienced Malawian nurses, to the powerful Ministry of Health representative, to naive college interns that are experiencing Africa for the first time. We have all spent A LOT of time together this summer in long car rides to hospitals all over the country, for long nights of going through hundreds of patient charts, and just simply working alongside each other to make CPAP available to babies all over Malawi. Through this we have shared many great memories together and to think that my summer with this team is winding down makes me very sad. Here are a few funny quotes.

Car Ride to Lilongwe

Glyssie and Florence are two retired nurses that have been working on the CPAP project to help train other nurses. They are very motherly, but also have a great sense of humor.

Glyssie (while eating fries in the car starts choking): “Someone quick! Slap me on the back.”

Florence (looks at her and says): “You need CPAP. Quick! We should put her on CPAP.”

 

Training

Alfred is the representative from the ARI (Acute Respiratory Illnesses) Program from the Ministry of Health that has been helping with Training. He gives very intense and motivational speeches about the difference that CPAP will make for babies in Malawi. His words are always very powerful.

Alfred (while lecturing the trainees on the importance of CPAP): “First you save lives…. then you can have your Fanta”

Malawians LOVE their Fanta. 

Girl Power

For the CPAP study, the Rice side includes MK, Jocelyn, Sam and I. What this results in is a lot of girl time. And inevitably with girl time, we have spent some time pondering about boys and spirit animals.

MK (over any lunch break): “Guys! I’ve got it! I need a blue-grass violinist slash ex-masseuse slash chef. And Jocelyn, you will end up with a country-boy slash computer programmer.”

We clearly have our lives figured out

 

Anyways, here are some photos from the week.

In this day in age, it seems like everyone has a digital camera, iPhone, iPad, or Android to snap photos of nearly every moment in their life. Through Facebook, Instagram, and Twitter, pictures are infiltrating our lives. It is hard to imagine a life without photos. They capture moments in our lives that we cherish which is why I think we love pictures.

Most Malawians, I presume, have never had a photo taken of them. This first struck me when Sam and I visited the Palliative Care Unit (for patients who are terminally ill) and saw a poster about making memory books. This poster described a project where people taught patients who were near the end of life how to make a memory book full of letters to loved ones and other items. This is to help the family prepare so that when a loved one passes, the children and family have something to remember them by. In somewhere like the US, we have plenty of photos to remember people, and it’s hard to imagine not having them.

  

Since people don’t get photos of themselves taken very often, they are always eager to see photos. I am constantly documenting my time here with photos (to put on the blog). Sometimes, random people on the street will ask you to take a photo of them so that they can see it. Once you show them the picture, they just crack up in laughter. Malawians love seeing photos of themselves!

This morning, I arrived sharply at 8 am for peds morning handover meeting. They went through deaths and cases from the last 24 hours and at the end someone said “Oh… and by the way, pharmacy is on strike.” I thought I had heard wrong, but nope, apparently pharmacy was actually on strike. I couldn’t really understand the whole story, but I think it had something to do with 2 people were supposed to take an exam but refused to. So the government suspended their license or stopped letting them work and then the rest of pharmacy decided to stop working too.  I asked one of the doctors and he said that they had problems getting some drugs yesterday, but thankfully they had most of the drugs they needed in the wards themselves.  I was shocked that the pharmacy at the largest hospital in Malawi could go on strike. Thankfully, when I visited later in the afternoon it looked like it was fully functional.

  

Also, this morning, when I went to Chatinkha nursery there was a baby with birth asphyxia with very high respiratory rate and chest indrawings. Florence started putting the baby on the new pumani bCPAP machine; however, we soon realized that there were not enough oxygen concentrators to hook it up. I knew that there was an extra one sitting in the peds office so I ran to the admin office and brought it to Chatinkha nursery. Thankfully there was an extra oxygen concentrator at Queens; however, I know there are many other situations where that is not the case and the doctors and nurses just have to make do. Normally, an oxygen concentrator is split 5 ways and then can be split even more further down the line before it even reaches the patient. So the amount of oxygen that each patient really gets is not very much at all.

There was also a baby that weighed 660 grams that was born today. One of the nurses from the UK said that the baby would have a chance of surviving if it was in the UK, but it was nearly impossible here. Its really disappointing to know that there are other places in the world that could offer these patients more. This is what doctors and nurses have to face here daily.

 

To end on a more uplifting note, here is a photo of a baby giraffe that I saw a few weeks ago.

I love all the colorful outfits that all the women have here, so I thought I would dedicate a blog post on the way women dress in Malawi. If you are curious what Malawian men wear, they basically just wear pants and a shirt, nothing horribly interesting.

(I feel awkward taking photos of random people on the streets, so most of these photos are from Google)

Step 1. Choose multipe chitenges

Chitenges are brightly colored and patterned cloth that is used for all aspects of life by women in Malawi and all over Africa. They are used as skirts, blankets, headpieces, baby sling, blankets, suitcases, and more. Many women also get elaborate outfits tailored out of chitenges. These cloths are sold at stores and stands in the market by the meter. Usually they cost around 1500 kwacha (~4 USD) for every 2 meters. You can find all sorts of patterns  including ones with the faces of political figures such as Obama and Malawian President Joyce Banda. In the US, people often give out t-shirts for political campaigns and events. Here, they give out chitenges instead. They even have a chitenge for when the Pope visited Malawi.

 

Step 2. Wear a shirt and a skirt

Any shirt and skirt will do. These are not the important components of your outfit.

Step 3. Tie a chitenge around your waist

Choose one of your chitenges and wrap it around your waist over your skirt tucking it in on one side. I found a video on Youtube.

Step 4. (Optional) Tie on a matching chitenge headpiece

Many women here wear chitenge headpieces that matches their chitenge skirt.

Step 5. Tie a baby to your back with a chitenge

Malawian women have very high fertility rates (an average of 5.98 babies per woman) so it seems to me that every other woman here has a baby on their back. Sometimes in the hospital, the babies are tied to the front and are breastfeeding while the mother is casually strolling through the hallways. I have seen it many times here, but it still amazes me everytime.

 

Notice in the photo above that almost all the babies are leaned to one side because they are peaking forward. They are always so adorable.

Step 6. Place a large item on your head 

This large item can be anything: a suitcase, a bucket of water, a collection of pots and pans, or a large bundle of firewood. Regardless of how large the item is, it seems like women here are insanely poised and balanced and are able to walk effortlessly.

 

Congratulations! You have just finished learning about how to dress like a Malawian woman. Does this seem difficult to you? It seems extremely difficult to me. I have so much respect for Malawian women and all their responsibilities of the primary caretaker at home. They not only are able to walk long distances while carrying a child and a large load on their head, they also have a lot of strength from cooking, espeically nsima (a very dense stable food that requires constant stirring), on open fires.

We have entered the implementation phase of the CPAP Clinical Trial! Previously, we have been collecting data at 8 hospitals around Malawi for baseline data to see what kind of respiratory problems are affecting neonates and their survival rates with treatment on oxygen. Starting this week MK and Jocelyn along with the rest of the CPAP team will be training nurses, clinical officers, and doctors when and how to use the bCPAP and be bringing the bCPAPs to each of the hospitals that have received training. Training/implementation will continue over the next few months until all 8 hospitals have staff trained and equipment at their site. With the bCPAP, we are also bringing a lot of other equipment including a suction machine, an oxygen concentrators, nasal prongs, suction catheters, OG feeding tubes, and a cart to organize all the machines and supplies.

Monday + Tuesday = Training

This week we trained three nurses and clinical officers from Zomba, Machinga and Mwanza. Monday morning, we arrived extra early to set-up for training, and then we sat there anxiously hoping that trainees would actually arrive. This was the first week so we were all a bit nervous. Training ended up going very well and by the end of the second day, I think the trainees had really understood what they had learned and were ready to teach others back at their respective hospitals.

  

  

Wednesday + Thursday = Implementation at Zomba

On Wednesday, Jocelyn, MK, two CPAP nurses, Sam and I hauled two carloads of equipment, including 4 bCPAPs, 2 wooden carts, 2 suction machines, and an oxygen concentrator through bumpy dirt roads to Zomba Central Hospital. When we first arrived one of the trainees came out to meet with us. About 15 minutes later, a dozen other people showed up all very excited to see new equipment. They were so excited that they demanded a photo in the parking lot before we even got a chance to move the equipment in.

  

We put these carts into the ward and all the nurses started crowding around to see this new machine. As we were setting up one of the carts, a nurse had asked me about what we were doing. I explained to her about the CPAP project and she asked if the CPAP was going to be brought to the rest of Africa. I told her just Malawi. She smiled with gratitude and said “We are very lucky then.”

Throughout the morning I was walking around the hospital to get things set up. And I one point I returned to the nursery and found that a giant crowd of nurses were all crammed into the already crowded nursery to watch of a demonstration of how the bCPAP works from our nurse Florence. It was great to see the enthusiasm and interest that everyone had. And then when we were heading out, I peaked around the corner and saw that at the nursing station, they had set up an assembly line to make the stockinette hats! I’m really excited for Zomba to have these bCPAPs and I can’t wait until they start using them.

Reflections from the Week

Working day to day here, I feel like I don’t really think about the big picture impact that the CPAP project truly has. But this week through training and implementation I have such an appreciation for everyone who is making this happen. I don’t even know everyone who is involved but just to show how many people and different institutions this takes, I am going to try and list the key players.

• Queen Elizabeth Central Hospital: First hospital to use bCPAP, and where the clinical trial last year was done to show the effectiveness of bCPAP. Also, many doctors and nurses from QECH are involved in training people from the other hospitals.
• Malawi College of Medicine: Where the CPAP project idea was first conceived.
• Texas Children’s Hospital
• Malawi Ministry of Health: Norman and Alfred who are helping us collect data through their ARI (Acute Respiratory Infections?) Program
• District and Central Hospitals around Malawi: They have been collecting baseline data and are now starting to send trainees on how to use bCPAP
• Rice University: Dr. Richards-Kortum and Dr. Oden are spearheading the project from Texas. MK and Jocelyn have been amazing at coordinating the entire study here on the ground and making this actually happen.

From what the nurse at Zomba said, I truly think Malawi is a very lucky place to be able to receive these CPAPs. Oxygen has been the most that majority of Sub-Saharan Africa could offer to babies with respiratory problems. Now with the bCPAP in Malawi, babies with respiratory distress will have a better chance of surviving. From helping out these last few weeks, I have experienced first-hand the complexity and level of difficulty that this project truly is. But we are all very lucky to have so many people who are so passionate and dedicated to making this CPAP project happen. Congrats to everyone on the first successful week of implementation and training!

“Asungu” is the Chichewa word for “white person” or “foreigner”. In Blantyre, there are quite a lot of “asungu” people. Here, there are doctors who are saving lives at the hospitals, volunteers taking care of babies at orphanages, videographers documenting projects for donors in the States to see, NGO directors coordinating renewable energy projects, or lodge-owners that have created their own little haven in a hidden corner of the world. Every asungu here seems to have a fascinating reason as to how they ended up in Malawi. Meeting people from all walks of life and learning about their stories is one of the things that I love most about travelling. There is also quite a substantial population of Indian people here. They are mainly the business and restaurant owners here. There are so many Indian people that the only movie theater in town plays 2 American and 1 Hindi movie here at all times.

As an asungu in Malawi, people expect you to be rich. If you go to the market here, they will give you higher prices. In addition, the moment you step into the market people will try to offer all sorts of services to you. They’ll hold your bags, watch your bike, or even get groceries for you all with the expectation that you will pay them good money. And if you’re an asian, they will also yell “konichiwa!!” at you for the hopes that it will catch your attention. At first having dozens of people hollering at you to buy their products was a bit overwhelming, but by now I find the market and the game of bargaining quite enjoyable.

This past weekend, Sam and I met up with the St. Gabe’s interns to spend a weekend at the beautiful Lake Malawi. This lake seems more like an ocean and lines nearly the entire eastern border of Malawi. The lodge that we stayed at was hidden amongst the local villages of Senga Bay. Our first day there, we walked through the village to go to a local market. The way that the villagers behaved towards asungus was quite different than what we were used to in the city. As we walked through the villages, tons of children, excited to see a group of asungus would eagerly run up to us to say hello, which sounded more like “Ah – Lo!!!” They would also give us the thumbs up as we walked by and a few even came up to fist-bump us. I’m sure some previous volunteers had taught them that. And once we were a the market, everytime I turned around I could see an entourage of kids trailing about 10 feet behind us. It was quite adorable how intrigued they were by us.

Overall, I think that the Malawians like asungus. Or at least I hope so. When I have explained to Malawians what we are doing here, many respond to us with gratitude. For example, when we first arrived to Malawi, the lady at customs was questioning our twelve suitcases. Sam showed her a letter from Rice saying that these suitcases were filled with donated medical equipment. She said “Thank you so much for helping our country” and let us through with no further questions.

Time for bed now. Tomorrow is the first day of training for the bCPAP!

For the CPAP study, we have deal A LOT with medical records. Dealing with medical records here is a very daunting task because once the patient has been discharged or died, tracking down the charts is always an adventure. Thankfully, Sam and I have become very good friends with the people who work at medical records for pediatrics and they look out for the charts that are marked for the CPAP study. They are our main teachers for Chichewa. However, only the files of patients who were discharged an go through pharmacy end up at medical records. For all other files, we have to look through an assortment of boxes that are placed around the wards. But there are times when files simply get lost. For example, every Friday at morning handover meetings, someone will summarize the deaths from the previous seven days. There was one week that out of the ten deaths, the presenter could only track down four of the files.

Almost all of the wards that I have seen here don’t have staplers, so most of the medical charts are held together with whatever they can find in the wards. The most common methods I’ve seen is tying together stacks over paper with gauze, or bandaging them together. People get quite creative. The typical common method of filing these records are to tie with gauze all the death files from a certain month together and all the discharged fileds from a certain month together. And then these tied up stacks are put somewhere.

To keep track of patient history, all patients in Malawi are given a health passport in which their medical history is recorded each time they receive medical care. The patients are quite good at bringing these with them. Thankfully this system works because tracking down their patient charts from more than a week ago would be a nightmare.

Medical Records

Pumani bCPAP

In 2010, a team of Rice students (including Jocelyn) designed a low-cost bubble CPAP from a shoebox, water bottle, and two aquarium pumps for their senior design project. Just a few years down the road, this device has been successfully implemented in Queens, gone through a second generation design, and received a $2 million grant to implement it in all public hospitals in Malawi. Today, we brought in the Pumani bCPAP, the latest version that is now being commerically manufactered by 3rd Stone Design, to the Chatinkha Nursery and the Peds High Dependency Unit. Pumani means to breathe in Chichewa, the most common language in Malawi. This was really exciting because from here on out, we will be bringing the Pumani to all the other hospitals.

In addition to the machine itself, we also distributed supplies including hats, nasal prongs, suction catheters, pulse oximeters, and feeding tubes. When we gave Chrissy, our awesome CPAP nurse in HDU, all the supplies, she proudly hid them in the bottom of the cupboard so no one else could find them. She said that if we don’t hide it, the supplies which are meant to last the next 6 months will be used up in a week. While it was quite amusing to watch Chrissy proudly show me that the supplies were hidden on the bottom shelf, it made me uneasy to realize how precious medical supplies are here since they never know if something that runs out will be re-stocked.

Presentation at Morning Handover

We also presented all the technologies that we brought at the pediatrics morning handover meeting. The technologies were the phototherapy light stand, a manual breast pump, the bCPAP heating sleeve, and the blood pressure monitor. At the end of the presentation, we spoke with a doctor from America that has been working in the district hospitals in Malawi as a Fulbright scholar. An interesting point that she made was that devices that we make should be designed in such a way that it is difficult to remove the power cord or batteries because it is not uncommon to have people steal them. She said it was really frustrating when someone wasn’t able to deliver oxygen from the oxygen concentrator simply because the power cord was stolen.

Later on in the day while Sam and I were collecting data in the nursery, a medical school student came up to us to tell us that we should design devices that can be made in Malawi. He pointed out that even if these devices are low-cost, the shipping cost to Malawi is very expensive. With so much international aid pouring into Malawi, I’ve realized that in order for a country to truly be independent and improve itself, the drive needs to come from within. 40% of Malawi’s government budget comes from international aid. Ambitious and kind-hearted volunteers come and go, and a project is very difficult to sustain when it is powered by an outside source. Hopefully one day in the near future, Malawi will be able to produce its own affordable medical technologies.

 

Here is a brief and interesting article about Malawian politics:
http://news.yahoo.com/impoverished-malawi-sells-presidential-jet-15-mln-095422594.html

 

Sam was away all week travelling around to the hospitals with MK. While she was away, I stayed in Blantyre and continued to work on the new bCPAPs with Pelham. We took out the tubing of all of them and replaced them with new ones. I continued data collection at QECH as well this week.

In the upcoming weeks we are going to start training! This means that the other hospitals around Malawi are going to send people to be trained on how to use bCPAP. And then after they are trained we are going to be introducing the deivces to the hospitals for the very first time. So in order to prepare for that, we needed to decide how much supplies each hospital should get and pack it all up! These were the supplies that Sam and I brought over to Malawi in a dozen suitcases. Last night we each chose a hospital, blasted some Kesha, and started packing up the supplies. With eight people (the St. Gabe’s interns are also here visiting for the weekend), it took under 2 hours to finish it all.

Around Blantyre

Kentucky Fried Chicken

KFC is a big deal here. They recently opened one up and it is very fancy. We went there for lunch the other day and it was quite exciting. There are really no other American fast food chains here, which is surprising since it seems like McDonald’s has managed to touch every corner of the world. Fun fact: apparently, saying that you work at KFC is a good way to pick up girls here.

Taxis

Although friendly and nice, taxi drivers here are not the most reliable people. It is definitely not uncommon for a taxi driver to run out of fuel in the middle of the highway and ask you to push their car to the nearest gas station. Thankfully, I have not experienced this.

I miss Betty Crocker

We found Betty Crocker here! Except…. it costs almost $10 for a box of cake mix. Nevermind.

The Lion King

We went to a production of the Lion King produced by a couple of British and German volunteers. It was quite good. Disney has epic music.

Hello! After nearly a week at home and sleeping, I have finally recovered from strep throat! In this past week I have gotten quite good at taking photos of my throat. They are available upon request, but I will spare the rest of you who are probably not interested.

Here is a quick few points of what has happened since I last wrote:

• Sam and I presented technologies to Dr. Queen Dube and received some good feedback
• Presented the Sphygmo to people in the maternity ward
• Scheduled a day to present all the technologies to the pediatrics department!
• Jocelyn brought batteries from the US and now all the thermometers in Chatinkha work again!
• Dr. Richards-Kortum and Dr. Oden came to Malawi and treated Sam and I to Bombay Palace, the best restaurant in the country.

This medical equipment broke…

For a long time, Sam and I heard rumors of this mysterious place where broken medical equipment goes and never returns. Essentially, Physical Assets Management (PAM), aka the engineering department, is known to be a one-way street. Curious, we spent a morning searching for this place and exploring it. We were surprised to find a relatively organized warehouse with few nice Malawians who showed us around. After an hour or so, we learned about various reasons why machines are so difficult, nearly impossible to repair.

First off, donated machines sometimes simply come broken. And then there’s the problem that US operates differently from the majority of the world and uses 120V instead of 220V. This causes damage in the machine if there is no transformer. In addition, there is no standardization of brands. So if there are 10 broken autoclaves, you might need to order parts from 10 different companies to fix it. And a huge barrier to repairing these machines is that there is often times a single part that is needed. However, this part must be ordered by someone higher up. They said that they will submit requests for ordering parts, and never hear back again. And that is how dozens and dozens of oxygen concentrators end up being collected over at PAM.

Also, the hallway connecting Chatinkha and the rest of the hospital has been under construction since before I got here, which is over a month ago. And last week, two babies from the NICU here needed an X-ray. So what did the nurse do without this hallway? She packed these two babies up in a semi-stable rolling cart, and rolled them through gravel paths to the hospital. When I volunteered to help her, I was shocked to realize taking them to get an X-ray involved helping her navigate the cart through rocks and various other barriers.

Other than that, Queens has been the usual and we have collected data for over 100 babies now!

Emails from my dad
For those of you who don’t know, my dad always sends me caring, succinct, and funny emails. Here are a few that I have received since being in Africa.

After a week of being sick:
Ariel,

I have ordered some ebooks of meditation for you.

Try to find one that suites you and practice. It will heal you.

After I posted a photo from the safari:
Special comment on the Safari post. Is your iphone inside the purse on your lap? Please don’t leave it inside Safari.

After I mentioned my mom as a loyal reader in my blog:
Ariel,

Daddy checks you blog every day as well.

Malawi’s Island in the Sky
Last weekend, Sam, Amber (a doctor who has been taking a tropical medicine course), and I spent a beautiful weekend hiking. Here is a photo of our group with our guide and porters.

Also Pelham (the grad student) has arrived and seems to be enjoying Malawi. 🙂