OBSERVATION

When an old, emaciated man, dressed in tattered American donations and leaning heavily on a wooden cane for support, approaches you with a solemn story of diseased dependents and no job, what do you do? What about a widowed mother of six, requesting money for food? Or an orphan, living with her blind grandmother, appealing for primary school funds? Even a first year nursing student understands the futility of placing a band aid on a gangrenous wound with the expectation of a cure. So do you give money, and propagate the expectation of a rich foreign savior with Schwarzenegger on speed dial? How about to the next 500 equally sorrowful eyes and tormenting tales?

Think about a community with no restaurants, malls, shops, taxi cabs, banks or movie theaters. Aside from the few lucky teachers, nurses or fisherman, there are no jobs to be had. Prostitution at $6/visit is undoubtably an appealing career option. It is a village in a century-late unsuccessful transition from agrarianism to capitalism. With a late-starting rainy season and a complete petrol shortage, even the crop production is scarce, leaving an old woman roadside, with a paltry pyramid of 9 tomatoes, in a space built for a feast.

Malawi is Malarious: Under 5's Clinic

Collapsing off my bicycle, we have reached the weekly rotating under 5's clinic. Approaching, there are approximately 100 women with their children receiving a lecture in family planning. Lecture is followed by a beautiful harmonious song, intermittently lead by different mothers under the shade of the banana tree. I ask Fletcher, the local health officer and leader of the clinics, the meaning behind the lyrics, and he states that the women are singing about family planning, the dangers of childbirth, and overpopulation. Now, making that sound good, takes talent! Over the next three hours we weigh, measure, and vaccinate over 100 children. The scale is designed to hang from a tree, and each mother undresses her child, wraps them in a sarong, and precariously balances them from the scale. The older children think that they are flying and the younger ones flail and scream as they attempt to determine what wrong they have done to deserve this torture. Every detail gets recorded in the child's health book and trended on a growth chart. In Malawi, each person at birth is given a health book or "passport" which will be a dynamic written record of vaccinations, illness, assessments, diagnosis, lab results and medications. Those determined to be underweight will be referred to the malnutrition program.

Sitting in red dirt, surrounded by man-eating ants, spiders and wasps, I am the recipient of all 100+ passports, pages falling out, and as I attempt surgical resuscitation, I can't help but notice that every third child has the same surname. And then I recall, that each man is allowed multiple wives (and girlfriends), therefore may be the proud father of an entire football team. In fact, if the girlfriend dies, one of the wives is expected to, and does, take in the child as her own, without any Jerry Springer drama.

Children are screaming, crying, playing, pushing and peeing everywhere, and it is a blessing when we finally finish. I stand and fight the first ominous signs of my own dehydration. As the blackness clears from my periphery, I see that about two dozen women have remained. Fletcher approaches me and informs me that these are the women with sick children who wish to be be seen by me- nooooooo! With resignation I grab my stethoscope, thermometer, and the first passport waving closest to my face. With minimal pediatric experience (emphasis on minimal, not experience), I have aggressively tried to absorb the "sick child" chapter in my tropical medicine book, and can only recall that a child is NOT just a small adult (ugh, news to me!). Being taught that white people are in fact ghosts who will eat the child if they misbehave, listening to lung sounds translates to protecting my ears from severe eardrum damage. It is the screaming children that made me happy, the worrisome ones are the listless children that allow limb manipulation, hydration assessment and temperature-taking, without protest. As I assess and dictate, I "diagnosis" multiple cases of malaria, a couple upper respiratory infections, a severe case of kwashiorkor, and a possible strangulated hernia vs. intussusception vs. belly full of worms?!?! At my disposal I had Oral Rehydration Salts (ORS), Tylenol, malaria mediation, and one type of antibiotic. Per protocol, any child with increased respirations gets five days of antibiotics plus three days of Tylenol; fever= Tylenol; fever + diarrhea= Tylenol, ORS, and malaria medication. Of course all we have are adult dosing, and the mothers are instructed to break the Tylenol tablets in quarters. Unfortunately, a common requested fall-back medication, when I refuse to give Tylenol to one mother whose child is completely healthy, a scene is created. I question the medical ethics- liver damage for cultural sensitivity? Two I refer to the district hospital, and seriously contemplate a self-referral as I consider my 10K bicycle ride back, in the blazing African afternoon sun.

No meds, No doc, No problem

My drug-induced sleep prior to my first day at Chintechi Rural Hospital, is laced with dreams of emaciated children and my glaring inadequacies in caring for them. For once, my 5:30AM alarm is a pleasant reprieve. With trepidation I arrive, toting gloves, a stethoscope, a pen, hand sanitizer and a thermometer- a modern day Florence Nightingale? As I pass the dreaded pediatric ward, my breakfast of tea and peanut butter (that's right), threatens a re-visit. I am greeted by the medical officer, who tells me- "I am a Practitioner, you are a Nurse, today you will be with them." Never has such arrogance sounded so musical to my ears! With relief, I follow one of the nurses to triage- an environment that finally instills more comfort than terror. The nurses, all fully trained as midwives, with no reliance of doctors (closest one is over 40km away), are the image of poise and self-sufficiency. Among others, within two hours, we have seen, referred, drawn blood and medicated multiple malaria cases, a child with marasmus, two post-partum women with retained products, a dramatic case of cellulitis, a child with a fractured arm, and a man with a human bite to the chest wall (further details unclear). A second nurse soon beckons me, advising me that a woman is currently in labor, and questioning whether I was ready for delivery. Was this a joke? I hoped so!
Side note: Child birth in Malawi is simple, quick, and quiet. To scream is an embarrassment. The woman checks herself in when she feels contractions. She arrives alone, and is received in the L&D ward, which houses three steel cots separated by makeshift curtains, and an ancient infant-warming contraption. She brings her own sheets and materials for laboring and baby clothes. A female family member may come in and bring her food at any part of the birthing process. The nurse midwife assesses position and station of the fetus. First time breech delivery gets referred to the district hospital, an hour away. Multi-para breech gets delivered here, more often than not, successfully. The woman delivers naked, on her back, hands grabbing the bed railing behind her head. No medication aside from a post-partum intramuscular shot of pitocin to induce uterine contraction to help stop bleeding. No blood pressure monitoring available secondary to supply shortage. No mandatory antenatal rapid HIV screening available secondary to supply shortage.
But back to me! The midwife asks me to preform the “V” test. I'm sorry, what? Ah- insert your fingers into the vagina, spread them to a V, and estimate how dilated the cervix is. Ahhhh! Ummmm, ok. I tell her I feel something hard, and she states, “that is the baby's head, she is ready.” OMG! She is ready, but I am not! The midwife teaches me how to listen for the baby's heart rate and how to feel for contractions, sans technical assistance. I scream “PUSH” every times I feel her contracting, most likely NOT negating the stereotype of the loud American. I start pacing, doning the role of the absent father. After about 20 min, a head emerges. For the next several minutes, an eternity to me, the body fails to follow. I am panicky, and perhaps more diaphoretic than the mother at this point. I am staring at the bodiless head, believing that the baby, who has failed to take a breath yet, must be rapidly approaching brain death. OMG- why am I the only one panicking?! As my mental fog clears, I realize that until the cord is clamped, the baby is still receiving oxygen from the mother. PHEW! Within seconds the body follows, and I place him directly on his mom's chest. No crying. OMG! Has he swallowed meconium? What his APGAR score? Who has a watch? Should I initiate resuscitation?! PANIC! The midwife rubs down the infant, who then produces the worlds most beautiful cry (the baby, not the midwife)! With bloody gusto, the mother delivers the placenta (which will be protected and later burned out back with all the others of the day), and breast feeding is immediately encouraged. Still bubbling with adrenaline, I peel off my gloves, carefully avoiding the gaze of the young woman in the adjacent bed, who has just suffered a late-term miscarriage, and is awaiting manual, bedside evacuation.

Going Batty

Every morning I awake to a pile of insect wings in a heap on the wooden floor. No bodies- just wings of various sizes and colors. Malawian Santa or tooth fairy, I think you have it wrong…As it turns out, as the sun sets, another nocturnal friend has been out and feasting- on the bodies of insects, discarding the unwanted fibrous waste. Which, by the way, in some tribes, is collected nightly in a bowl of water to be fried and enjoyed the next day (souvenirs- done!). Like an old man fixed in his ways, once a location has been chosen, a bat tends to feed in the same spot nightly. Lucky me! It also explains the terrifying flapping noise I hear, as I lay wrapped up and sweating in layers of sheets and blankets, pretending that my mosquito net is impenetrable shield.

Burns and Bravery

Wednesday afternoons, following Mphatso, we visit a girl named Naomi. Two months prior, Naomi suffered from an epileptic seizure while holding her infant, and rolled into an open fire. Her infant was spared- her arm was not. A skin graft was attempted to repair the third degree burns covering her left arm, but has left both her thigh and arm open, raw and vulnerable. Kneeling in dirt, swatting chickens, I attempt to make a sterile field with an old ziplock bag and clean gloves. The smell of cassava soaking in the sun is a pleasant odor of vomit mixed with gangrene, and I briefly wonder if it could be marketed as a potent weight-loss scheme back in the states? Back to Naomi! Today is my first time providing wound care alone, and as I unwrap her dressings, I brace myself. Her left arm is completely blackened, with areas of peeling skin and oozing flesh. She screams as I attempt to clean her open wounds with soap and water, and I am forced to have her brother and mother hold her down. My apologizes sound weak, and it is with urgency that I attempt to redress her arm without trapping one of the carnivorous flies beneath.
It is 5:30, and hour before darkness, before I make it back to the tarmac where I might catch transportation back to the roadblock. From the roadblock, I still have a 35 minute walk down to Mwaya Beach, where I stay. As if a lifelong fear of the dark is not enough to send me into a fit of tachycardia, it is also much more difficult to see (avoid) snakes, past nightfall. For 30 minutes I walk, and wait, yet not a SINGLE vehicle drives past. With the petrol shortage, and the increasing black market prices, I am not surprised. Still 10.5 kilometers from my destination, I start to panic, and flag down the first vehicle to pass me- a 16 wheeler truck. As I sheepishly ask them for a ride, the driver jumps out and hoists me up, from with point I have to climb across the labs of the six men who are occupying the cabin. As they grin at me and offer me Chakula, a white substance in a white carton (milk?), it is with increasing panic that I realize that not only does the passenger door have no handle, I have no local cell phone and dusk is falling. I quickly plan my escape, and wonder if I could survive the 10ft jump out of the window of a moving vehicle, if I aimed for patches of grass lining the road, with obvious care to avoid the crocodile-laden river. Can I fight off 7 men who are currently and actively being fortified with milk? As we reach the police roadblock of Matete I breath a sigh of relief, and thank the driver, who proceeds to tell me that he can not let me out yet, for fear of fine, and must past the bend, out of the site of the police, before I disembark. I feel yet another flutter of panic, my new close acquaintance, and envision a life of sex slavery in Lilongwe. I shout out that the police are my friend (I did meet them earlier that morning), and that they would have no cause the fine them (which is when I realized that the “milk” is really a disguised form of distilled beer), and that they are expecting my immediate and punctual arrival! With that, I climbed back across the men, paid double the expected fare, and vigorously waved to the police officers (who had changed their shift since morning), who peered at my dirt-encrusted body, and flushed face, with mild consternation.