In Chichewa, they say “congola”. It means “beautiful”. Today’s blog post is in honor of a dear friend and sister, Natalia Lopez.

Natalia wanted to be a dancer, a nurse, a mother, and an artist. She had a smile that shone almost as brightly as her heart. It wasn’t until my third visit as a volunteer on the Cancer Center inpatient unit that I found out Natalia was diagnosed with Acute Myeloid Leukemia. It was almost a side note in comparison to her exuberant life and infectious personality.

In a moment of glorious sadness, Natalia earned her angel wings on October 28^th, 2009. Natalia was a light shining in the darkness. Even in the midst of the toughest treatment that a kid can face, she touched every person she met – with a contagious light that refused to stop shining, even after she passed. Although she was only one person, her light reached thousands of people. Natalia taught me that intensive care units are not made of machines, but from people caring intensely. Good medicine is not defined by technology, but by caring. What kept Natalia strong was her spirit and the love and caring she received – not just the medicine.

I know that Natalia would love to be here in Malawi. I think in a way she is. She never missed a chance to serve even random strangers. For the past two years, an event has taken place to honor heroes like Natalia. The event is called “Bald is Beautiful”, and people of all backgrounds and battles come to get their heads shaved to raise money for the fight against childhood cancer. The event is a declaration that baldness is not something to be ashamed of. It’s a declaration that fighting cancer is bold, that bald is beautiful. Congola. I couldn’t be in Houston for the event this year, but I thought I would share the beauty from Malawi. So, I invite you to celebrate these beautiful kids with me, an ocean away but just as beautiful:

This morning’s meeting had a mixed sentiment of fascination and horror. The hospital clinicians spent the better part of the morning discussing the challenges they are facing in the realm of pregnancy care at the hospital and in the community. I hardly know where to begin.

The discussion began with a case presentation. A thirty-two year old woman was admitted to the Female Ward with complaints of lower abdominal pain. She was HIV Reactive, and was coughing up blood from a tuberculosis infection, but insisted that the abdominal pain was her primary complaint. The attending clinicians soon discovered that the woman was 18 weeks pregnant with her sixth child, supposedly to her surprise. She denied the pregnancy “diagnosis”, despite admitted sexual activity. She was transferred to the treatment room, where she quietly asked the clinician to remove the fetus that was causing her abdominal pain. The examination in the treatment room revealed both the baby and mother to be healthy and alive. It became clear to the clinician that the woman arrived at the hospital with a complaint of abdominal pain in an attempt to receive an abortion. This is a frequent occurrence at the hospital, especially since the community’s two known traditional abortionists have been arrested.

Typically, the women who arrive at the hospital seeking to terminate pregnancy are very young (14-15) and unmarried. The common procedure is to first visit the village Traditional Birth Attendant (TBA), where a cassava stick is used to abort the pregnancy. Often, women will arrive at the hospital with the sticks still lodged in their cervix. The TBA will ask the woman to travel to the hospital when bleeding begins. Upon arrival at the hospital, it’s near impossible for the clinician to tell whether the abortion was spontaneous or intended (as both present with bleeding), leaving them no choice but to remove the fetus. According to the hospital obstetrician who works closely with these TBAs to facilitate safer pregnancy care, women in the community do not associate any risk with abortion, despite the incredibly high associated maternal mortality and infertility.

One clinician suggested that the hospital advocate prevention through contraception rather than termination following pregnancy (quite an interesting discussion at a Catholic mission hospital). It was noted that contraception is not highly favored in the community, as women will often attribute unrelated back aches, colds, or other sickness to the contraception shots. The situation is complicated, to say the least.

So, it seems to happen most often like this – If she has an unwanted pregnancy, the mother will first visit her community’s Traditional Birth Attendant. When the bleeding starts, she will travel to the hospital where the clinician will not be able to determine that the abortion was preformed illegally. If her community’s Traditional Birth Attendant has been arrested, or if her experience and education tell her that the TBA’s method of termination is unsafe, she will arrive at the hospital with a complaint of lower abdominal pain. She will deny knowledge of pregnancy until she has reached the treatment room, and will ask to have the fetus removed as a means to alleviate her abdominal suffering, as the clinician is more likely to perform the abortion if he believes the mother’s health is as risk. The staff at St. Gabriel’s Hospital is catching on to this pattern, and is seeking a safer way to address the situation.

This issue of unwanted pregnancy is only the beginning of the pregnancy-related concern at the hospital. Even more complicated is the discussion of how to facilitate safe pregnancies and births. It’s becoming abundantly clear that this will take immense cooperation with these TBAs. Although it’s free for mothers to deliver at the hospital (they are given government-subsidized stamps as an encouragement to deliver at the hospital), mothers are still choosing to deliver at their village’s TBA for 1000 MK. This happens for a lot of reasons. First, TBAs are typically very well known members of the community – grandmothers, aunties, and experienced mothers themselves. Second, it takes a lot of courage for a mother to deviate from the birthing methods that her community has been using for hundreds of years and to travel to a hospital instead. Third, TBAs offer privacy, intimacy, and comfort – TBAs are often females, while a hospital clinician will almost definitely be a male. Finally, and perhaps most importantly, village chiefs encourage delivery by TBAs, as they receive a portion of the profit that is made by the 1000 MK deliveries.

After almost an hour of frustration about how to approach this complicated dynamic between the community and the hospital, Dr. Kiromera paused:

“The structure of the local community, the relationships between people – this is the driving force. If we cannot take this away, maybe it’s time we start working with them.”

He made a suggestion that resonated well with the work that the 20 Global Health Technology seniors have been doing for the past year. He suggested that the hospital equip these TBAs with whatever they need to provide a safe pregnancy term. The point, after all, is to save lives. This would involve four things, he suggested – tools, training, evaluation of knowledge, and supervision. They must teach them to monitor pregnancy, and to refer at-risk mothers to the hospital for care. He suggested that the hospital reimburse them for the 1000 MK delivery cost for referred pregnancies, to keep them from losing their business.

Ah ha! Solution: Pregnancy Care Pack. I held my tongue for the moment, at least until the Pregnancy Care Pack arrives with Danielle tomorrow, and we have a chance to properly present the project to the clinical staff next Wednesday. Perhaps they will find that this project is a step towards a solution to this complicated and frustrating issue of needless maternal and neonatal deaths. I would like to introduce you to the Pregnancy Care Pack, a backpack full of tools designed for both emergency and routine care of both the mother and the child through the entire term of pregnancy and up to one month following birth:

Between my broken Chichewa and their broken English, in five years we haven’t exchanged more than a few words. Still, these four kids have brought me through more than they will ever know.

“Grace, Malifa, Roderick, Alec. Grace, Malifa, Roderick, Alec. Grace, Malifa, Roderick, Alec. Grace, Malifa, Roderick, Alec.”

I’ve whispered their names to myself over and over through the years. On the start line before soccer fitness tests, in the waiting room before the MCAT, before endless medical school interviews, in the 26^th mile of marathons, at my grandfather’s side. Their names are strength. Their names are humility. Their names are grace.

I wonder if these kids know how many lives they’ve changed, just by being who they are. Grace will never know that millions of Americans saw her smile on Good Morning America this past year. The twins will never know that their smiling faces have had an audience with the directors of global health institutes across the United States. Their family will never know what enormous strength they have shared with my family.

These kids are a reminder of why I ever began this crazy pursuit of a medical degree. It’s easy to lose sight. Their names bring be back to where I started. Grace, Malifa, Roderick, Alec. With those kids by my side, I can do anything.

“One voice can change a room; and if a voice can change a room, it can change a city; and if it can change a city it can change a state; and if change a state, it can change a nation; and if it can change a nation, it can change the world.” (courtesy of Daniel Nesbit)

*More on global health technologies next week.

We decided to make a trip to the Baylor Pediatric Clinic in Lilongwe. One of the PAC Doctors, Dr. Chris Buck, has been extraordinarily helpful to both Rice University and St. Gabriel’s Hospital, so we decided to stop by for a visit. We “chatted” for a while – discussing the challenges Baylor is facing with their outreach budget, the shift to start newborns with infections on ARVs during their first few months of life, and the bravery with which the women of Malawi face AIDS.

Soon after, we met with Dr. Mwansambo, the neonatal pediatrician at Kamuzu Central Hospital, located right next door to the Baylor Clinic. Dr. Mwansambo is a wonderful, dedicated, enthusiastic physician. We soon discovered that he is not just a pediatrician. By night, he is a DJ (no, not Dr. Mwansambo MD JD … Dr. Mwansambo MD DJ). He is one of a kind.

Almost before we started talking, he agreed to test the bililights, and was busily chatting with Yiwen about the physics of the LED lights. The bilirubin lights will be incredibly helpful in the new neonatal ward that will open by the end of the year. Currently, 1000 mothers a month (30 a day) are giving birth at a maternity hospital down the road. By the end of the year, at least half of those mothers will be channeled to the Kamuzu Central Hospital maternity ward to deliver.

Both Dr. Buck and Dr. Mwansambo were enthusiastic about the other projects going on at Rice. They just received funding for several oxygen concentrators, but have to hire someone to come test them every 3-6 months, and have no way to determine how much oxygen is actually reaching the patient. Perhaps, Dr. Richards Kortum and Dr. Oden will be able to bring them more bililights, an oxygen sensor, and a pediatric pulse oximeter in October.

Our last few weeks have been filled with adventure. We travelled from Namitete, to Lilongwe, to Zomba, to Blantyre, back to Lilongwe, and finally to Namitete. We were fortunate enough to have the opportunity to join Dr. Richards-Kortum and Dr. Oden on one of their “investigations”, and met with many of Malawi’s most important health care providers. Here are some of the things we did along the way:

1) Our professors arrived in Namitete on Sunday night, “fired up and ready to go”. We took a quick walk to the dam, where we were greeted by playful kids and a smiling sunset. We spent the evening together, as an assembly line, putting bilirubin lights together to bring to Blantyre. Dr. Richards-Kortum and I agreed that our childhood experiences Lite-Bright gave us a strong advantage when it came to inserting the LEDs. After a wonderful traditional Malawian dinner together, we settled down for the night and prepared for the next adventure.

2) The next morning, we met with Matron Kamera, Dr. Heim, and Dr. Mbeya. Dr. Rickards-Kortum and Dr. Oden gave a flawless presentation of the technologies they brought along, and gave us an opportunity to present the lab-in-a-backpack, CHW screening kit, and bili lights. Some of the other technologies that they brought along included an oxygen concentration sensor, that tests the flow rate and oxygen output of an oxygen concentrator, and can be built for <$100, and a pediatric pulse oximeter, with a hinge adjusted to allow for a baby’s entire hand to be placed in the sensor. St. Gabriel’s Hospital was enthusiastic about testing both of these technologies. Since our meeting, Dr. Heim has come up for a different thing to be put “-in-a-backpack” every day. We are undoubtedly thankful for his support and enthusiasm.

3) After a quick visit to the Furniture Factory, and a few tests with the incubator, we began our journey to Lilongwe. There were seven of us in the car, including all of our bags plus seven bili lights, a CHW backpack, and a lab-in-a-backpack. We were quite a Malawian sight, so say the least. In Lilongwe, we met with a PEPFAR representative, and a CDC representative. We discovered that Malawi was not previously a focus country for PEPFAR1, but will be receiving more money now. Here, we discussed the same desperate need for affordable, accessible, and simple point of care diagnostics. The usual issues were discussed – the need for a mobile, cheep CD4 test, early infant diagnosis, viral load, TB and malaria microscopy – along with several other suggestions, including a point of care lactate test, a test for D4T toxicity, and a CD4 machine that uses micro fluidics.

We discovered that Malawi has just started using liquid baby Triomune, and is transitioning to nevirapine throughout all of breastfeeding. Perhaps, with this shift to liquid ARVs, the adherence monitoring system developed by a design team at Rice could be useful. Finally, we discussed some possible focuses for the CHW backpack, now presented as the “Community Outreach Backpack”. The PEPFAR representative suggested that the backpack focus on those who test positive staying linked to care. He suggested an integration of HIV/AIDS care and family planning, and encouraged the integrations of Health Surveillance Assistants (HSA) in the use of the kit.

4) After a wonderful Indian dinner with one of our professors’ friends, we prepared for an early start the next day. Luckily, we left for Zomba before the sun came up. If we hadn’t, we would have missed the sun rising over the majestic Malawian mountains. We arrived at the Baylor Children’s Center in Zomba by mid-day, and sat down with one of the Baylor Clinic’s PAC Doctors, Dr. Kevin Clarke.

Dr. Clarke has been using the lab-in-a-backpack for the past year, and provided us with wonderful feedback about both the backpack, and our current projects. The items that Dr. Clarke are using most often are the glucometer, the urinalysis strips, the pulse oximeter, the sharps container, the basic supplies, and the syringes. Ideally, he would like to include an IV set and a scale in the backpack. Currently, they are using adult scales to weigh infants and children, and have no pediatrician on site. “When you’re dosing an infant that has a 2 kg window, this is sub-optimal.” He expressed his concerns with both the microscope and the centrifuge. While he often doesn’t have time to use these tools, he still likes the idea of the centrifuge. He is only occasionally able to fins urinalysis strips, and hasn’t used the solar panel to charge the backpack yet. Finally, he would prefer a larger bottle for “methylated spirits” as opposed to alcohol swabs.

Dr. Clarke gave us some wonderful ideas about our new “HIV/AIDS and Family Planning Backpack” idea. He suggested that the backpack include space for tests and reagents, a visual aid for what positive and negative test results mean, a chart of family planning methods, space for medicine, syringes, pregnancy tests, visual aids for the disclosure of a child’s status, lancets, gloves, a sharps container, and a DBS collection method (including a method for tight storage of the required humidity cards). He advised us not to develop a rapid drying method, but instead to develop a way to transport the cards to allow for the required six hours of drying time.

Dr. Clarke, like several other doctors in Swaziland and Malawi, discussed the hospital’s need for a drip monitor, “This will reduce deaths, clearly.” Several Rice engineering teams have worked on drip monitor over the past few years. I think this will become a focus for BTB over the next few semesters.

5) Next, we traveled with Dr. Clarke to the government hospital in Zomba. There, we discovered a plethora of technology needs. A few of the ideas that were discovered include: a water bag for handwashing, a DBS kit, a portable x-ray light box, a pill-breaking method, recitation equipment, a nebulizer, a traditional birth attendant backpack, a method for controlling the amount of milk that goes in a nasal gastric tube, a vitals monitor, a device to measure bilirubin load, and a thermometer that can be applied to the skin. One of the German pediatricians working at the hospital made a wonderful suggestion, “A little pill that goes through the entire body, and tells me everything – oh, and doesn’t cost anything.” We’ll be sure to get right on that.

6) Our final stop was the government hospital in Blantyre. We were thrilled to see two babies under the Rice-designed bililights, along with 20+ incubators. After dropping off six second-generation bililights, and presenting several of our current projects, one of the pediatricians sighed and asked (half-seriously, half-jokingly), “Well then… What else’ve you got in a backpack?!”

As the mountains of Blantyre slowly began to disappear, we made our way back to Lilongwe. During the seven hour drive home, I couldn’t help but think – often times, we set out on a path to help people make their way, and they end up helping us along our way. Maybe that’s what it’s all about. Helping each other along the way.

What began as an endeavor to provide Community Health Workers with a screening kit has become a wonderful tool for Home Based Care nurses at St. Gabriel’s. The backpack is not practical for use by CHWs for several reasons. First, CHWs are trained heavily in patient counseling and follow-up, but are not trained to use medical equipment such as blood-pressure cuffs and glucometers. Second, Community Health Worker has a different meaning in almost every region of the world. Often times, like at St. Gabriel’s Hospital, CHWs are involved in specific programs (HIV/AIDS, TB, PMTCT, HBPC) that might or might not involve utilization of the tools in the screening kit. Their responsibilities vary widely, making it difficult to create a uniform screening kit for all CHWs.

I have discovered that almost all of the outreach at St. Gabriel’s Hospital is done by the HBPC team. Twice a week, two Home Based Care nurses (Alex and Matilda) spend the day travelling to communities in the catchment area, providing basic treatment, monitoring vital signs, and doing simple tests (such as checking glucose and hemoglobin levels).

I have been able to travel with both Alex and Matilda over the past few weeks. We travel by motorbike from one community to the next, sometimes spending an hour with a patient. So far, we have used the kit to provide every single patient with some form of care. Some of my favorite cases include:

1. The second patient to benefit from the kit was a 62 year old man who had just lost four of the toes on his left foot to an infection. We used the kit to sterilize the amputation and dress the wound.

2. Soon after, we used the kit to monitor the vital signs and glucose levels of a 100+ year old grandmother. The family said they had stopped keeping track of her age at 100, several years ago. This woman was alive before the benefits of penicillin were known, before we monitored glucose levels, and long before St. Gabriel’s Hospital was in existence. Needless to say, I can’t imagine that, even in her wildest dreams, she ever thought that she would benefit from the use of this screening kit.

3. I was lucky enough to spend the day at the Antenatal and Under Five outreach clinic. We used the hanging scale from the kit to weigh 30+ babies in less than five minutes. The mothers were eager to place their newborns fearlessly in the trust of the cloth sling, laughing as their babies screamed and wiggled.

4. The kit has several compartments that can be used to bring drugs along. Alex and I were proud to provide ibuprofen and multivitamins to a patient who had been incarcerated for seven years after illegally selling 500g of tobacco.

5. Matilda and I visited a textbook end-stage cervical cancer patient, dehydrated with a severe protein deficiency. We sat with her and her ten guardians in her hut as the HBC CHW explained to them how to prepare Oral Rehydration Solution, using the cards from the CHW screening kit.

After presenting the backpack to the matron of the hospital, we discovered that St. Gabriel’s has been given funding to pay for ten more outreach nurses to join Alex and Matilda for, at least, the next three years. Hopefully, we will be able to provide them each with an “Outreach Kit”. With feedback from Alex and Matilda on the first three months of the pilot, we will be able to scale the project up, and provide the hospital with tailor-made outreach packs, designed specifically for their outreach needs.

When we arrived at St. Gabriel’s Hospital late Monday night, we were greeted by old friends. Grace (6) came running into my arms, wearing the blue dress we gave her last year, and a gigantic grin on her face. Roderick (10) followed closely behind, wearing my RFC shorts and Bradock Road Impact t-shirt. Alec (8) and Malifa (12) came next – Alec in my Loudoun Valley Viking basketball shorts, and Malifa in the red skirt I left her last year. All the kids were safe and healthy – only a few inches taller. By Tuesday, they were yelling into our window at 5pm sharp, “Eliza! Eliza! Futbol! Eliza!” They have continued this patter relentlessly ever since.

My mom, Casey, and little brother, Daniel, are staying at St. Gabriel’s Hospital as well, and my older brother, Josh, is in Neno. We all planned our summers separately, but ended up in the same country during the exact same time. Home is where your family is. My mom is a physical therapist, certified to practice in both the States and Malawi. She has had her hands full this summer, working on a rehabilitation program with Dr. Heim, a surgeon from Germany who will be at St. Gabriel’s for the next five years. On top of seeing patients every day, she is training two hospital workers to carry on her work after she leaves in August. Daniel is busy helping her create rehabilitation DVDs to leave behind for these workers.

St. Gabriel’s provides a perfect example of “task shifting”. With a new HIV ward opening this year, a renovated malnutrition unit, and a growing pediatric ward, the staff is spread thin. Cleaners are being trained to provide community health care, hospital workers are being trained to help nurses and physicians, nurses are being trained to help clinical officers, and clinical officers are handling almost all of the OPD (Outpatient Department) patients, leaving the doctors to round in the wards (Male, Female, Labor, Postnatal, Private, and Pediatric). Still, St. Gabriel’s is improving every year. By next year, all HIV care will be moved from “Room 16” (practically, a closet), to a new, spacious, enormous HIV ward at the back of the hospital. When I first came to St. Gabriel’s, the malnutrition ward was a collection of five mats outside the pediatric ward, where mothers sat together and cooked nsima over a fire. Now, the malnutrition ward includes its own building, with four trashcan-size metal cooking pots for mass production of nsima.

There is much to be done at the hospital. So far, I have spent my time helping in the pharmacy every day, helping at the ART clinic three afternoons a week, updating the pharmacy stock system, helping my mom with her physical therapy endeavors, attending training sessions for Community Health Workers, building an incubator, and testing the Community Health Worker Screening Kit in the communities.

While our weeks have been full of hard work and soccer games, our weekends have been adventures. We spent our first weekend in Malawi in Lilongwe, navigating our way from the center of town, to the market, to every bank in the city – including “the black market” – looking for someone to exchange Swazi currency. The craft market in Lilongwe was excited to see us. “Azungus” (white people) provide a perfect opportunity for the craftsmen to manipulate their prices. We weren’t going to be fooled. Not this time. Although every craft shop was “the discount shop”, and the craftsmen were intent upon being flexible with their pricing, we made it clear that we were just looking. Luckily, every craftsman kindly told us that, “looking is for free”. Good thing.

On Sunday, we visited the Malawian Carmelite Sister’s convent. Twelve Malawian nuns live together in a convent next to the hospital. Five of them work at the hospital (as chaplains, in the pharmacy, or in the communities), two of them work at the maize mill, and the others work in the convent, maintaining the garden and grounds. The convent is a wonderful place – overflowing with peace, grace, and patience. Sister Justice and Sister Honest gave us a tour of the garden, a wonderfully huge eden of papaya trees, tomatoes, corn, onions, lettuce, and orange trees – every fruit and vegetable you could possibly imagine (and several that I have never in my wildest dreams imagined). They raise cows, chickens, and rabbits for meat, and kindly offered us nsima and pinky-sized fish for lunch. The Sisters can only be described as gentle souls. I am lucky to know them.

St. Gabriel’s Hospital can be found 60 kilometers from Lilongwe, the capital of Malawi, and serves over a quarter of a million people. With a catchment area of 100 miles, communication is critical for health care delivery at this rural. Patients have to travel miles by foot, bicycle, or even oxcart to reach the hospital, and, Community Health Workers (CHWs) must travel under parallel conditions simply to report patient adherence, seek medical advice, or check a drug dosage.

The target populations for implementation of the Community Health Worker Screening Kit are clinics that utilize CHWs in order to provide healthcare to communities. According to WHO, “among 57 countries, mostly in the developing world, there is a critical shortfall in healthcare workers, representing a total deficit of 2.4 million healthcare workers worldwide.” The 2008 UN report on progress toward the Millennium Development Goals indicates dire need in many public health areas including infant mortality, HIV, and other communicable diseases.

With roughly 2.5 billion individuals around the world living on less than $2.00 a day, the CHW Screening Kit could help bridge the gap between the millions of health care providers in the developing world and these billions of people living in poverty (World Bank 2007). According to the most recent WHO census from 2006, these 2.5 billion people living on less than $2.00 a day are under the care of approximately 22.9 million health care workers (World Health Report 2006). Of these 22.9 million health care workers, only 4.4 million are physicians, and 7.0 million are nurses. Because of human resource constraints, the bulk of health care providers are CHWs, the primary health care providers in rural communities of developing countries and the end-users of the CHW Screening Kit.

The CHW Screening Kit includes several basic diagnostic tools, as well as a glorified first aid kit. The basic diagnostic tools include: a glucometer, pediatric and adult blood pressure cuffs, a thermometer, uranalysis strips, pregnancy tests, a stethoscope, a scale, a tape measure, and a MUAC band. The first aid kit includes: matches, face masks, cotton balls, band-aids, sterile gauze, hand sanitizer, bandage scissors, medical tape, iodine, gauze rolls, alcohol-prep pads, tweezers, and antibiotic ointment. Other tools include: a biohazard bag, a teaspoon, ORS, a swiss army knife, gloves, extra batteries, a notebook, a backpack cover, and a flashlight.

St. Gabriel’s Hospital has three tiers of Community Health Workers. The first, and most highly trained group of CHWs are the hospital nurses. Twice a week, two nurses take a motorbike to outlying communities, in order to continue to establish a relationship between the hospital and the communities. They bring a brown cardboard box of supplies with them. Their supplies include gauze, medical tape, vitamins, Panadol, and several other basic treatment items. The second tier of CHWs includes hospital workers that are not trained in a medical profession. These CHWs include cleaners, nuns, and village role models, all diligently and eagerly edging their way into the medical community. The final tier of CHWs includes all other CHWs – role models in communities, expert patients, mothers, fathers, volunteers. For now, the backpack will be used by Alex – a nurse, the chief HBPC officer, the director of the ART clinic, and the nurse that does most of the hospital’s outreach trips. He will be able to assess which tools are appropriate for CHWs, and which require a stronger medical background. He is excited to begin using it on Friday, and we are excited to begin to get feedback on the pilot of this project.

In the meantime, the Namitete Furniture Factory has begun (and almost completed) work on an incubator prototype. After spending a day gathering wood, and another day building the frame, we will be ready to put all of the pieces of the crib together tomorrow morning. Eric, the carpenter who has been helping us build the incubator, is a kind, gentle man. Perhaps gentle is the best way to describe Malawians. Greeting Malawians reminds me of Paul the Apostle’s subtle insinuation, “Do not forget to entertain strangers, for by so doing some people have entertained angels without knowing it.” (Hebrews 13:2)

Eric whistles while he works, is constantly smiling, will be married next month, and speaks softly to his elderly assistant, who hurries around diligently with his worn-down fisherman’s hat and missing teeth. Places like the Namitete Furniture Factory make you want to pick up a vocational skill.