[We’re in Lilongwe with MK & Sam! In honor of the internet connection being relatively amazing here, I’m going to cover a topic to which I’ve been looking forward for a while: toys and games. Legos, K’nex, and trains were the toys that made me want to be an engineer as a kid, but they’re not really available here. Instead, the kids have figured out their own ways to play.]

Liz and I have also been occasionally playing in the nurses’ evening pickup netball games, but we neither of us has wanted to take time away from the action to take pictures. Netball here is played on a weedy dirt court and what are essentially two small basketball hoops with no backboards, with a carefully-kept children’s soccer ball that Comfort stores at home. The movement of the ball follows rules much like ultimate frisbee, but only two people can shoot and there are 7 players for each team on the pitch at a time. We’re not very good, but it’s fun!

You know how when you’re in a pool in the middle of the summertime and it’s just about to start pouring, you can tell because you can see the drops making circles in the water? I used to love those minutes in between when the rain would start and the lifeguards would blow their whistles for us to leave the pool because if you swam to the bottom and looked up, the sky looked like a dalmatian.

Every day at about 5:00, we see those spots on the water by our cottage. After the first few days, though, we realized that it wasn’t drizzling– the spots were bugs hitting the water. Today in the late afternoon, we went out in canoes on the dam and I realized just how thick the air really is with bugs at that time of day. No one here seems to think twice about it, though, even in the dry season.*

Malaria, HIV/AIDS, and Yellow Fever are so common here that most people laugh to see how afraid we are of them. Every bed at the hospital has a malaria net, but they’re commonly misused because malaria is seen as such a minor issue. In the village, malaria nets are more useful as a makeshift garden fence to keep the animals out, because a full course of malaria medication is only 150 kwacha ($0.44) at Jey Jey, right behind the register next to the razors and super glue.

Millions of dollars a year go to distributing those malaria nets; technically, it’s punishable by Malawian law to misuse them. Yet people who have them often don’t use them because they know that malaria causes minimal damage if it’s treated early, and that they can easily obtain the treatment. That attitude unfortunately leaves children at risk, because for them it’s more dangerous and less easy to diagnose early. Reportedly, during the wet season the pediatric wards are full to the hallways of malaria patients. Overall, though, the attitude we see is that people who live here can recognize and self-treat malaria more efficiently than nets or prophylaxis can stop it.

On the other hand, we see Oral Rehydration Therapy (ORT) integrated into the local culture as something mothers standardly buy for their children when they’re sick, even though we tried some and it tastes absolutely awful. Advertisements on buildings show the packets and they’re available cheaply at the local market.

Giving people things doesn’t seem to work nearly as seamlessly as making it an option for them. Without end-user adoption, we can throw all the money in the world at getting people to use malaria nets and young people with HIV to use condoms and still not do much good. If the people here don’t think it’s an issue, aid-givers in the proverbial there can’t do much to solve things. Either we all, local institutions and global ones, have to intelligently enough educate the people on the benefits of a technology to change their attitudes, or we have to adapt the technology together to better fit the environment.

The mosquitos are swarming, but at the end of the day Malawians don’t need more malaria nets. They need people to listen to them.

*Disclaimer: while we were on the water we were wearing a heavy perfume of bug spray and we’re faithfully taking our prophylaxis every day before we go to sleep under our appropriately-used untorn mosquito nets.

We asked Comfort. She said that a fatal road accident had come in; the singers were the members of the deceased patient’s church, singing hymns with the family until the funeral. They weren’t Catholic, she thought, probably Presbyterian. Religion is very important here. Most of the population is Catholic, Presbyterian (CCAP), or Muslim. Parochial schools dot the road between Namitete and Lilongwe. We see Hallal butcheries, bakeries, and restaurants in trading centers. Mostly, though, as you might have imagined given that we’re at a hospital called St. Gabriel’s, we interact with Catholic institutions.

The hospital was founded by a Carmelite sisterhood of nuns from Luxembourg, and it’s currently run by a group of those sisters who work with Malawian sisters living on the hospital grounds. Both groups of sisters feel a sense of ownership of and responsibility for the hospital. They set the tone of hospital pride that we’ve seen in the clinicians, nurses, and staff here.

Our first Sunday here, we went to the Malawian sisters’ mass in Namitondo. The service was from 7:30-10:00 (scheduled until 9:30, but naturally ran long) and it was conducted in Chichewa. The choir at the front all wore white shirts and sang with a rotation of upbeat backing tracks. Because the service was in Chichewa (includings the bible readings), I didn’t understand most of it. Even Liz was surprised, though, near the end when a long line of women and couples came in carrying 50kg sacks of maize to be blessed. Men sat on the left and women on the right. By the time the service let out, the church was full of worshippers in their Sunday finest.

Sister Justa is our friend, mentor, confidante, and guide. She and the Malawian nuns sold us fruits, vegetables, and a chicken, then took us to Namitete to get everything else we needed. (The bottom picture is mostly for the benefit of everyone who’s asked me if I’m eating enough here. Hi, mom!)

This past Sunday, I trekked to the Luxembourg sisters’ mass at 6:30. It was in English, but I honestly still didn’t understand most of it. It was just me, Sister Justina, two other sisters, and Father Williams, and they were very gracious hosts. The things I did understand this time, though, were the sermon and readings: fish and loaves and a selection on Abraham’s generosity.

It made me realize how strongly many of the people here draw their sense of purpose from religious teaching. Many of the expats here give a lot of thought to the nature and effectiveness of charity, and the sisters in particular have given their lives to serving this population.

In morning report, the nurses often read bible passages focusing on Jesus’ administrations to the poor, though they tend to be less explicitly about charity. Tertiary education, especially here in the rural areas, is exceedingly rare; healthcare workers in Malawi take on a very difficult career path for less compensation than they could get with comparable degrees despite the great cultural honor given them. The majority of medical students in Malawi come from the city and doesn’t truly encounter village poverty until the immersive public health unit in medical school. I wonder how they see the parallels between their work and biblical narratives.

In our interactions with patients, I’ve seen that the religiousity here gives them a deep sense of identity. “Traditional” village medicine, muti, is often posed at odds with biomedicine at home. Here, though, many patients’ care regimen includes both. “Traditional” religion, for many patients, isn’t something apart from global religious structures and biomedical ideas. Rather, they simply coexist naturally in the patients’ minds.

During the next two weeks we’ll be travelling the north part of the country helping with bCPAP data collection. We’re excited to get to see more hospitals and spend time in Blantyre!

Almost five years ago, a bunch of Rice students did something pretty incredible. They’d designed a simple, easy-to-use and rugged clip that caregivers could use to dose liquid ARV’s for children. Misdosing can be dangerous for any patients and any drug, but inaccurate dosing of ARV’s can lead to fatal drug resistance.

The part that awes me, though, two weeks into our eight here in Malawi, isn’t the elegance of the design. It’s what happened next. After demonstrating the technology for the Swaziland Ministry of Health in summer 2010, by 2011 BTB had turned around and engineered a coalition of the Clinton Health Access Initiative (CHAI), the Swaziland Ministry of Health, and manufacturer 3rd Stone Design to get the clips made and included in a nationwide Prevention of Mother to Child Transmission (PMTCT) of HIV/AIDS program. Now, over 213,000 of the clips the Rice team designed are being used by almost 12,000 people in Swaziland.

It’s an almost fairytale success story– elegant design, appropriate national scale up, the right architecture and smart enough donors to allow the technology to make a difference. Unfortunately, though, outside the scale of a major national scale up device-specific technologies can be tricky to make universally useful.

Last year, BTB sent St. Gabriel’s prototypes of similar clips and matching bottles rescaled for morphine dosing. They’re designed so that you fill the bottle with liquid morphine, screw on the syringe, insert the clip, invert the bottle, and draw the correct amount of morphine.

Yet last week I posted a picture of a patient taking home morphine in a water bottle, and this week we were a bit chagrined to note that when we asked to see the Doseright™ clips, they had to dig them out of a box at the bottom of an old supply closet.

A big barrier to developing detailed dosing technologies in the developing world is supply inconsistency. When Tara, Teresa, and Kamal brought the clips last year the hospital was using syringes that worked with the bottle caps and access to patient bottles wasn’t a major issue. Because funding sources have shifted slightly, though, now the hospital uses a different kind of syringe and many patients bring home their medication in plastic water bottles with imprecise dosing caps that came with bottles of an antibiotic that the hospital recently got in stock.

To effectively implement this kind of dosing technology, we need a design plan more than a single device: something that is adaptable and integrable enough to be truly sustainable, rather than a clip that is suitable for only one size or brand of syringe. The hospital seems to have a consistent supply of 25mL syringes with the slip-tip tops in this picture, and Comfort assured us that if we had a sustainable, functional prototype that they could distribute to all their patients, it would be a better option than the current cups.

Dr.Richards-Kortum, Dr.Oden, and MK visited us at St.Gabriel’s this week, and we brainstormed some ideas for water bottle cap/syringe innovations that could just slightly modify what the hospital has to make the dosing clip concept work here. The store-bought water bottles work well because the hospital can reliably get them and they’re easy for the patients to transport on bicycle, so anything BTB would bring to the table needs to be similarly integrated. We’re planning to play around with some ideas for on-site punching slip-tip sized holes in the water bottle caps so they can be inverted, maybe with secondary caps attached by the bottle neck for easy transport. We’ll also be bringing home a syringe for future GLHT classes to try their hand.

DoseRight™ has, by all accounts, been a pretty incredible success thus far as a device. The next step is to adapt the concept to make it even more integrable and sustainable as a design.

Yesterday evening the power was out for longer than usual, so we watched an episode of the American television show “My Super Sweet Sixteen” on a laptop. Among other things, it made me reflect on a conversation we’d had with Sister Justa over lunch.

Storm warnings, voting information, and disease outbreak protocols are all critical pieces of our health and civic system at home. At home, I can access any of them through what right now seems like an unlimited number of communication mechanisms.

I can see that this kind of information does get disseminated here, but it’s hard for me to discern how. How does someone 100 miles away know that they are within the catchment area for St. Gabriel’s? How do they know who is running in the upcoming elections and how to vote? How do new outpatients know what days of the week the HIV clinic accepts new patients? How does everyone know who Barack Obama is?

Most people who work at the hospital get their national and global news from television. The hospital has one receiver that plays in multiple locations on the grounds, so they see BBC news when it’s on at the hospital. Some people have televisions and receivers at their homes, and if they understand the languages they can watch the African news before the Malawian news. Malawian news focuses mostly on the government and President Banda. Very few people have dongles or laptops to access the Internet.

St. Gabriel’s, with its huge catchment area, does a remarkable job keeping its furthest reaches in touch. A big element of that is the volunteers, who, despite recent cutbacks, keep the clinicians here in touch with patient needs and act as deputized representatives of the hospital where they can. There aren’t always enough supplies to go around, but at minimum they can give their information and expertise.

Another big element of communications is tradition and word of mouth. A worker from the hospital, Gift, showed us his home and introduced us to his family yesterday (Check Liz’ blog for pictures!) While we walked, we asked him the same question that confused us before: how did he know so much about President Obama? He didn’t really have an answer for us—only that everyone knew. While that was the starkest example of a bit of information that’s simply known around here, it seems that direct resource communication accounts for many of the linkages that make things run around here.

Direct communication increasingly relies on cell phones. It’s an oft-cited statistic that more people in Africa have cell phones than toilets, and Namitete seems to be no exception. In fact, SMS Frontline, an SMS-based health reporting service, was developed by Josh Nesbit at St. Gabriel’s. Alex, who coordinates the volunteer program, communicates with everyone by SMS. Most people here have a cell phone, even though many have never left Lilongwe District.

Here at St. Gabriel’s, morning report seems almost exactly parallel to rounds at home. Outside the hospital gates, though, patients communicate in a world of ways I don’t yet know about or understand.  People like Alex and Josh Nesbit are doing really innovative work bridging the two systems to improve health care—I’m humbled to get to see it in action.

Madzuka bwanji (good morning, how are you) from Namitondo!

Our first week, thus far, has been about observing; we’re mostly focusing on palliative care right now because much of Rice’s collaboration (DataPall and the CHW Backpacks) with St. Gabriel’s has been with the HBPC (Home Based Palliative Care) team.

The majority of the hospital’s palliative care work is done with outpatients and in the community. There are 16 (6 M, 6 F, 4 Peds) beds in the inpatient ward, but St. Gabriel’s is the hospital for approximately 250,000 people in this area. After we talked to Sister Justa and Nurse Comfort (Kamal, Teresa, and Tara: they say mulibwanji!), who work most directly with DataPall, we helped Comfort sort pills during the outpatient clinic. While we were there, we met many of the patients who were getting treatment.

Most of the patients’ primary health issue is cancer, cardiovascular disease, or HIV, but sometimes the ward sees sickle cell patients. The patients come in once a month to pick up medicines and get a checkup; if necessary they are admitted to the inpatient ward. Morphine is a very important resource here. For many patients, Comfort measured 1mg/mL “weak” liquid morphine into a plastic jug which they took home for the month. Everyone was very interested to talk with us, and we’re hoping that they find our limited Chichewa endearing.

”]We’ve only begun looking at the problems that Justa and Comfort had been having with DataPall, but from our conversations with them DataPall has been especially useful for two things: tracking individual patient data and generating reports for internal use, for government use, and for NGOs from whom St. Gabriel’s gets funding. The reporting needs to be fixed a bit, which is one of the places where we’re starting work.

The database is built to track patient profiles, appointment information, and prescribed drugs. They use the patient tracking element, however, in a very neat way that I hadn’t anticipated: every month, they check back over their patients and see who has missed appointments, and if they see a pattern or concern they ask a community health worker to stop by the patient’s home and find out what’s happening.

The plan for the rest of the week is to keep working on DataPall and bring the newly-arrived CHW Backpacks to Alex. We’re also looking forward to market day in Namitondo today. Comments, questions, updates and emails of any kind are most welcome at ha9@rice.edu