Clinic Day

Mother and child

Child Health Passport

Her First Delivery

Moms waiting for clinic

My favorite picture of the day

Sick Child Clinic







Clinical day
The sun is warm even early in the morning as I am driven to work in the college car by Samuel, one of the more talkative drivers and the one who stops so I can buy a paper in the morning. I had to be picked up very early today because I must meet the students at the hostel at 7:15 AM. When we arrive the students are all outside gathered in small groups with their green coats or aprons and white uniforms. They are chattering away in Chichewa except for the three Dutch students. Some sixty students and I board the bus and the chattering and laughter are unbearably loud. We drive a short way through city streets and then turn into a very rutted dirt road that goes past small houses and shops. As always early in the morning, the streets are full of school children and adults on their way to work, the market, the garden, or school. We make several turns onto increasingly rutted roads and pull up in front of the Kawale Health Center. Thirty students alight laughing and chatting. Some have stethoscopes, others bags with water, and perhaps a thermometer. All have the small Pediatric handbook for Malawi and a larger spiral bound book that contains the protocols for treatment developed by USAID. The bus is quieter as we drive a short way on a dirt road to pick up the main tarmac heading towards City Center and eventually Area 25 which I am told is “way out”.* [A word of explanation- city center is not the center of the city it is the area around the new government buildings that contains mostly banks, embassies and consulates, and a few businesses. This area is about 3 miles from the true city center. All the neighborhoods in Lilongwe are named by Area. Unfortunately there is no rhyme nor reason to the names. Area 3 is next to Area 29 and Area 47 is close by. Everyone asks where do you stay and expects you to name an area – the locals all know where each area is, we mzungu don’t. I go to church in Area 3, Regina goes to church in Area 29 and the churches are a mile apart. We live outside of town so we don’t live in an area we just tell everyone we live near Bunda turnoff]
We drive out in the direction of the airport (to the north of town) on a road that parallels the airport road. We go about 6-7 miles and arrive at the Area 25 health center. The area around the health center is mostly open fields planted with corn and other crops. There are many women with children tied on their backs holding the hands of small children walking toward the clinic. The clinic is a collection of one story flat roofed brick buildings. Off to one side is a roofed over area with a concrete floor but open sides. Inside are a large number of women and children sitting on concrete benches. Other women and children have formed long lines at the doorways of the other buildings. I follow the students to the open building where following a prayer; one of the students gives a short presentation on Family Planning in Chichewa. The student is very engaging and the women participate by smiling and answering questions. Following the presentation the women and the students sing several lively songs that are about family planning. Everyone knows the words and the singing is enthusiastic and melodious. About half way through the singing I notice that  the faculty member responsible for these students has arrived. She stays with the students in the open area as this is the well-baby and immunization clinic. I go off with the other half of the students to the under 5 sick children’s clinic. We enter a large space with the ubiquitous concrete benches in about 15 rows. The building is very dark as the only light comes through a series of openings in the bricks on the far side. The benches are full of women and small children. The students spread out one taking each row and begin to see the children. Using their protocols they ask a series of questions and use the algorhythm in the USAID book to decide what to prescribe. The two students I am working with are careful to do a thorough assessment and are thoughtful about what they decide to do. I am aware however that some other students are less careful skipping assessments and jumping to conclusions. The first child we see is 6 months old and even I can see that the child is very small for age. Each mother and child has a health passport in which immunizations, health visits, and for children ht/wt graphs are kept. Sure enough this child is below the acceptable range for her age. The mother is complaining that the child is not eating but I observe her taking the breast quite vigorously. I wonder if mom – who is very young probably about 15 – has adequate milk and whether the child is getting any additional food – the women here usually feed maize gruel from about 3 months despite the recommendations of health professionals to wait. I suspect that the mother does not get adequate food herself and likely neither does the child. The student focuses on the child’s eating and encourages the mom to give the child maize porridge in addition to the breast milk. The next child is about 9 months old, has a fever, and gunky sounding lungs. According to the protocol she should be treated with co-trimezole for pneumonia and be given panadol for fever, but the health center has no panadol and the parent likely has no funds to buy it. The next child clearly has a cold, as does every other child in the family – he has a fever and could use some panadol but there is none. One problem with the protocol is that if there is fever malaria is to be suspected and a finger stick test to confirm done – however this health center has no test kits today so I think many children who do not have malaria are being treated. The treatment LA ( Lumefantrine Artemether ) is not benign and in my short time here I am aware that a great many people receive treatment for malaria who clearly do not have malaria – unfortunately this drug can be bought OTC so many people self treat. [A nursing faculty member wanted to treat herself for malaria when she felt achy and tired but had no other symptoms]. The next child also had a cold and was sent home with advice and no treatment. Suddenly the room which had been so noisy I could hardly hear the student speaking in my ear was much quieter as the children were seen. The students had no faculty in the clinic with them except me and only the students near me asked for my help. There was a “clinical officer” available whose training is close to but less than a PA. She spent her time sitting at a desk reading the newspaper and answering questions for students but I never saw her ask them questions. I know a lot of kids got antibiotics that day who did not need them and I worry that this country cannot afford the drug resistant bacteria they are breeding.
When the sick kids clinic slowed down I went outside to the immunization clinic and watched what was happening there. Since it was outdoors the light was far better as was the noise level. All children got a quick head to toe, height and weight graphing, and moms got questions about family planning. The immunization schedule is similar to the US and all immunizations are free. Everyone gets BCG (against Tb) at birth along with Hep B. Most of the mothers were very young and the older ones had 3-6 children. Girls “marry” here very young – as young as 13 especially in the villages. Malawi has the highest number of teen pregnancies and the lowest marriage age on the continent and that is saying a lot. I learned about some interesting practices related to fontanels in this clinic. Apparently there is a belief that the soft spot makes the child vulnerable to spiritual assault so the area is covered with a gluey black material to protect the child. I wondered what people used for diapers and I certainly found out in the immunization clinic – EVERYTHING! Towels, pieces of worn chitenges (the wrap skirts worn all over Africa), torn t-shirts, an occasional cloth diaper but much to my delight not a single “disposal diaper” because no one can afford them. Although everyone assured me that students never recapped needles – I saw a lot of recapping in this clinic.
Neither of these clinics had any facilities for handwashing except in the staff bathroom which was far from the clinic buildings, there was no waterless handwash, so they went from child to child without washing. I talked to both Regina and the Principal about this situation and suggested at the least they could provide basins with bleach and some towels.
At the end of the day, the faculty member took me on a tour of the rest of the buildings – a very small overcrowded family planning and antenatal clinic and the labor and delivery and post partum ward. In the Labor and delivery room I found four post registration students (RNs) who are enrolled in the nurse midwifery certificate program. One of them had just delivered her first baby all alone except for the other students and a health care worker – not a midwife. Regina who is a midwife was livid when she heard about this saying “this should not happen”. Nevertheless the mother and baby were healthy and the student was glowing with delight in her accomplishment.
About 1130 the bus arrived and we all piled in for the trip back but we were held up when we got to the airport road because the President’s convoy was due in from the airport and sure enough a large number of big saloon cars, 4WD vehicles and screaming police trucks soon went roaring by. [Some day I will write about the “official vehicles” here and a bit about the politics which are interesting and complicated]
I will be going to the outreach clinic in a village next week as well to the clinics at Kawale so I should have more stories.
Meanwhile just a bit of information to put poverty in perspective. The minimum wage for an urban worker (not a farm worker or a person employed as a servant, maid, houseboy, or gardener) is 129 Kw per day that’s 0.86 cents. Monthly income is $15.00 and yearly income is $289.00. Maids, houseboys, gardeners etc may make $5-10.00 a month but they are often housed at their employer’s expense. People who farm their own small plots in the country may make $300/yr if their tobacco crop sells high, otherwise they just keep from starving by growing their own food and selling a little excess for money for salt and oil. Causal laborers may get $3.00 for 5 days work. Even the smallest hovel costs $10.00/mo and even if all you eat is nsima (maize porridge) you still need at least 10 kw a day per person for one meal. Government employees in professional capacities may make $500 a month. Now consider this – I had my hair cut today and it cost $17.00. The President’s new wife was appointed National Coordinator of Safe Motherhood and Early Childhood Development by her husband the President. Her salary is $7586.00/mo plus two cars and her presidential housing. This job was previously held without salary by the Vice President. The gap between rich and poor here is enormous.

Mushrooms

Dutch Girls and Regina enjoy the spaghetti with the mushrooms

Four short observations/stories

Last Class with Year 3 students
Last Wednesday was the last day of class with the year 3 students in Research. They now go off to have clinical practice in the community or in the hospital. However I am not really done with them as they have a paper due March 18 and I will write a final exam in May. I asked them to write the two things they learned that they will remember and the vast majority said ethics and informed consent, some mentioned literature review the importance of or how to access articles on line, how to write a clear research question and how to critique a research article. I was pleased with their responses and they enjoyed the slide show at the end of class consisting of pictures I took of them. They really get a kick out seeing themselves. Some students came and downloaded the pictures onto a memory stick so they could share them with their peers and put them on their phones. By the last day the students were really interacting with me, asking questions, telling me when they didn’t understand what I said or what I meant, teaching me Chichewa and laughing at my pronunciation. Now when I walk across campus they said “hello Madam, how are you Madam?” – all the lecturers are Madam, as are all the employers of household or garden help. They are inviting me to share Malawi food with them partly to see if I will eat it. I will miss them but I am going to clinical with them later in the week so I should have stories soon.
One thing I found interesting is that they didn’t ask many questions about my students in the US even though I shared pictures from some of my clinical groups. They were much more interested in how I saw them and they were pleased when I said they were every bit as sharp as students in the US –which is absolutely true. They wanted to know what I thought of the hospital and Lord knows I won’t tell them the truth because it is pretty awful in terms of care. I wish I had some more one on one time with them to learn about them and their stories.
Dutch Treat
We have 3 Dutch students from a University in Amsterdam who are doing a global health minor in their nursing program. They are doing clinical with the students here and attending some classes in the context of doing a project or projects for their home university. They are living in the hostel with the Malawi students which is mostly a marvelous experience for them except after a week and a half they were getting tired of nsima, beans, and chicken. So I invited them to come out to Regina’s house on Sunday for some pasta. I made sauce with real ground beef, lovely local mushrooms (see the photo), onions, and peppers and they brought the pasta. I also baked a local squash (they call them pumpkins) and made some garlic bread. The latter two items had to be cooked in the oven and I soon learned what a challenge that was. Regina’s oven doesn’t work right. When I turned it on I got the broiler and after burning the tops of the squash we figured out how to make the oven go on but then we couldn’t control the temperature which was in C anyway and I had no idea where to set even if it was working right. The squash came out ok because I cooked it open side down but when I put the bread in the oven somehow the broiler came back on and scorched the top. Nevertheless everyone really enjoyed the meal. AnneMarie, Charlotte, and Sandy talked about life in the dorm and how they were managing to avoid mosquitoes by slathering themselves with deet before bed and sleeping under nets. They said they were the only students using nets which is not a surprise to me. We had a great meal and good conversation. Regina asked them questions about their experience here and so I didn’t get to learn about their program so I hope I can do that later. They were a bit sunburned from an afternoon at a hotel pool and were happy to be in a warm sunny place.
Getting Malaria
Getting malaria is just something that people expect here. Most people I have talked to have had it multiple times, several students were missing last week because they had malaria. No one gets very excited about it even though it is miserable, some people get very sick, and others die. I think there is a fatalism about it that goes beyond knowledge – all the students know nets protect against malaria and they teach families to use them especially for children under 5 but they don’t use them themselves nor do most of their family members. There is a very deep belief in God or Allah – many vehicles bear bumper stickers saying “God is in control” Perhaps on the other side of having God/Allah in control is not having any personal control. Consequently if God/Allah lets malaria happen then I will get malaria.
Religion in Malawi
Most people here are Catholic or Presbyterian but no matter the denomination all are very conservative – thus the laws criminalizing homosexuality. The Scots brought the Presbyterian Church to Malawi along with a hefty dose of Scottish austerity. (Scotland still provides a huge amount of foreign aid). Every Sunday there are hordes of people walking on the roads in their Sunday best going to church, I often see women who are members of women’s groups in blue skirts, white tops and head wraps (they look like Pilgrims to me) walking to church on Sunday morning and evening as well as sometimes during the week. Church lasts at least an hour and a half even in the Catholic Church and much longer in some other churches. Even the Anglicans stay for almost 2 hours not including tea time. On Friday and on Sat AM the two big mosques are full and the little masjids in the villages are also occupied. Most of the Muslims here are Sunni. There are two mosques in town right across from each other – both are Sunni but seem to disagree about many things. The big mosque on the main road is festooned like a big cake with green and white lights this week. Shaibu my trusty taxi driver says it is to celebrate the birthday of “Mohammed (Peace be upon him)” and there will be a parade tomorrow through town. The other mosque has no lights and Shaibu says that they just don’t think it is right to celebrate the birthday. (He belongs to the mosque that is celebrating).
Superstition is strong here despite the deep religious piety. Most Malawians are afraid of chameleons because they bring bad luck, hearing the call of an owl is a bad omen and seeing one means something very bad will befall you or someone close to you. Cats are associated with witchcraft and one student said that when a cat looks at you he can see through to your insides as well as your naked body. Witchcraft is feared and people who are thought to be witches are feared and sometimes accused of crimes. However, a recent article in the paper indicated that only someone related to you could bewitch you and prayer could reverse bewitchment (although I don’t see much evidence that this is widely believed) and I do see evidence in the many newspaper ads that people believe in the casting of counterspells.
Pictures later

Meeting people in Lilongwe

My new Malawian Sister Sophie
Meeting people in town
When I left the Wildlife center I caught a minibus back to the center of town and then took another bus to Crossroads a shopping center on the northwest side of town. I needed some cash and Crossroads has two banks with ATMs that are never very busy – on Saturday mornings the ones at the banks in the center of the city have lines 30-40 people long. I also thought there was free wireless at the coffee house there but I was wrong – it was just a hot spot for a paid wireless and the store that sold the minutes was closed. I decided to try a burger – bad decision it was awful. There was a white couple sitting across the way from me – the woman smiled at me and we started talking. They are from England but having been living in South Africa for many years. They are moving to Malawi permanently on Tuesday to open a supermarket owned by a large South African company. They said they didn’t know a soul except a few business people and that their experience was similar to mine in approaching other English people in Malawi – they were ignored. I think the store they are opening will be a big asset since they will have a butcher shop with high quality meat and the store will be open 8-8 M-Sun. {Here in Lilongwe all the big stores close at 6 on weekdays and 1 on Sundays. The little mom and pop stores and the open markets like the Caphiri market near me stay open very late but carry mostly produce, dried fish, and goat or pig that has been hanging all day). We exchanged phone numbers and emails so I expect I will be in touch with them again.
I left Crossroad and walked back down the hill to the center of town and stopped to sit in the shade and have a Coke at the?food court?. There I met my new Malawi sister. An older woman dressed in a beautiful red traditional dress and head wrap began talking to me as I sat there. For some reason age came up and I said something about being older but she said she was 67 and then we discovered we were both nurses. Sophie Makwangwala studied nursing in Berlin in 1964 and came back to Malawi as one of the first German trained nurses. She went back to Germany again in the 1980s and got a specialty certificate in dermatology and now works at the dermatology clinic at Kamuzu Central Hospital. She invited me to her house telling me I could walk from my office because it was just down the street behind the hospital. Of course she knew Regina. When I returned home Regina commented, “Oh my, that woman can talk!”
On the way home on the minibus the men were testing my Chichewa and teaching me new words. I think they enjoy laughing at my pronunciation! A young journalism student who lives not far from me kept me company as the driver and his side kick tried to overfill the bus. By the time she and I got off = there were still 14 people on the bus and a number of really large packages. Because this bus goes all the way to Bunda (30km more), they really like to have to have it

Wildlife and Nature Centers

Blue Monkey native to Malawi

One eyed Romanian Lioness

River in the sanctuary

February 5 2011
Wildlife Park and Nature Center
I was supposed to go on a cultural adventure on Sat. but it got cancelled because a large group from South Africa cancelled and the organizer needed a certain number of people to make it happen. I decided I needed to get out. Otherwise I stay home and eat cookies – I’ve already gained some weight from this bad habit. I went down to the Lilongwe Nature Center where I was told there were animals who were not in cages and that you could walk through the forest and look for them. I got there around nine so it was still relatively cool. The Lilongwe Nature Center and the Lilongwe Wildlife center, where the animals are caged, are both part of the same 160 hectare (365.4 acres) reserve in the middle of the city. Both take animals that need rehabilitation or that can no longer live in the wild. The forest in both parts of the reserve is fairly pristine and there are two different rivers running through each center but both dump into the Lilongwe River in the center of town. As I set out with my guide we entered a thick forest with tall acacia trees and I was confronted with the largest Sisal plant I have ever seen, the center spike was at least 10ft high and the spread of the plant about 12 feet in diameter. The guide said this plant was not particularly large! We walked down the forest path towards the river and came across a beautiful blue violet and a large millipede that was chewing on a red fruit that looked something like a cherry (the guide did not know the name of the fruit). Once at the bank of the high muddy brown river we saw a large crocodile basking in the sun. He turned out to be the only animal we saw although the guide assured me there were civets, hyena, duikers, and impala in the park. (I have been told that there a hyenas on Capitol Hill at night scavenging – somehow this seems fitting). We heard a lot of birds including doves and weaver birds who have a beautiful song. The weaver bird is bright yellow but you seldom see more than a flash of yellow as they flit by. As we walked we came upon an enormous granite rock about the size of a foot ball field. The rock was crumbly and fairly flat on top. The guide said he didn’t know where it came from – maybe a volcano- but I rather doubt that. As we headed back to the office we came to a small house where I met three nice young men who were attached to the center as part of their ecology or tourism studies at Mzuzu University. They had been to all the National Parks and they gave me some very helpful information about the parks. One of them was inspecting hotels and lodges for the tourism ministry and he told me about a some nice places to stay.
When I left the Nature Center it was still early so I walked down to the Wildlife Center where I was given a tour. All of the animals here have been rescued from individuals or zoos. Although they are “caged” they are in very large 3-4 acre enclosures that have natural habitat. They do not have many animals. There are two types of baboon, the olive monkey from northeast Africa, the beautiful blue monkey (see photo) native to Malawi, and a large python that is fed one chicken a month. All of these animals were rescued from private owners. The only lion is a rather pitiful one eyed lioness rescued from a zoo in Romania. She lost her eye to an infection and she also had Ricketts but what worried the guide most was that she had been living in a very cold cage. The Center is also home to a leopard whose rear knee cap was destroyed by a cable trap set by poachers in one of the national parks. Although he seems able to leap up onto his platform he can’t live in the wild anymore. He sleeps all day on the platform coming down at 3PM when he and the other animals are fed.
I felt sad. Although Malawi is home to many marvelous and wonderful animals, the animals in this reserve are likely the only ones most Malawians will see. The national parks are far away and are costly to visit although the entry fee is only $1.00 (150Kw/day for Malawians the tours, food and lodging are beyond the means of most people.

Toll bridge and market on the north bank of Lilongwe river

Close up of the bridge "deck"

Women at the market

Aren't they lovely?
Another visit to the market in Lilongwe
So Saturday I decided to visit the big market that is on both sides of the river next the Lilongwe Bridge. This market covers several acres and sells nearly everything you can imagine. I met a nice young man on the minibus into town and since he was going my way he walked with me down into the market and showed me how to cross the toll bridge which cost 10Kw each way (see photo) from one side of the river to the other. He also gave me a quick outline of where to find things in the market. On the north side of the river is the fruit and vegetable market which seems to be divided into several sections. There is the onion section redolent of red onions which seem to be the only kind they grow here. Then there was the bean section which had mostly dried beans and peas and some other items I could not really recognize. After I walked a little way I came across a young man with a box of the biggest mushrooms I have ever seen. Some of them were the size of dinner plates – they are light brown and look fairly meaty. He said they grow in the bush in the southern part of Malawi and it is now mushroom season. I bought two big ones and found them very meaty and tasty especially when fried with butter. (I will get photos next time). I also saw some enormous avocados and bought one of those too. The vegetable market is really a riot of color – red tomatoes, green beet leaves, green beans, okra, purple eggplants, green lemons, orange carrots, and yellow bananas. In my stroll through this section of the market I found 4 lovely older women just sitting and chatting next to one of the stalls. They didn’t speak English and I don’t know much Chichewa but we communicated. I took their pictures, told them they were beautiful and they giggled and pointed at one another. (See the great photo!). The lady in the middle wanted to come to the US to work for me and clean my house and wash my clothes. When I said I did all that myself at home she just laughed and seemed surprised. After a few minutes her granddaughter came over and asked to be in the picture. You can really see the family resemblance. I tried to figure out a way to get the pictures to them. I think I’ll print them and take them with me next time I go to the market.
I crossed back over the rickety bridge to the other side and walked into the used clothing market. There are literally hundreds of stalls. People buy large barrels of used clothing – a lot of it from the US and then they sort the contents and apparently sell off the items they don’t want to other dealers. Stalls seemed to specialize. One had only white shirts for men and women, others had only skirts, or jeans, or pants. Some had sheets, others had curtains, tablecloths, children’s clothes, or women’s dresses. People from other stalls wandered around and if you show any interest in an item in one stall they would say they had something better in theirs and then lead you to it. The first item I picked up was a cotton dress with a tag from Value Village! The price on the tag was $5.99 and the guy wanted to sell it to me for the equivalent of $15.00. Quite a markup! He swore it wasn’t a mzungu price but when I walked away the price suddenly became more reasonable. As I moved further on I came to the shoe market. Every time I cross the bridge I see people down in the river washing shoes. These are the used shoe dealers – they wash the shoes in the river, polish them and sometimes repair them and then sell them. These dealers also seem to specialize in women’s, men’s or children’s shoes although one stall just had black shoes. Further on I came to the electronics area where I found parts for all kinds of electronics as well as stalls where the guys inside would repair your cell phone or if that failed sell you a new used one. Beyond there was what I called the beauty aisles – you could buy cosmetics and beauty supplies or step inside a stall and get your hair braided or your nails done. Beyond this area and closest to the road were a row of “takeaway food” stalls. Some looked mighty sketchy, few had cooking facilities and none had running water so I won’t be trying them. Most were selling – yes you guessed it barbequed CHICKEN! and rice or nsima (maize flour porridge). After passing these shops you reach the street and Highway Bridge where young men are selling religious calendars, phone cards, and pens and the beggars are seeking alms. The beggars seem to have regular “stations” because I always see the same ones in the same place. I also see them in front of the big Catholic cathedral after mass and in front of the mosque all the time. Most of the male beggars are disabled – post polio or are missing a limb. The female beggars usually have small children with them. It is sad to see but if someone gives one something then they all clamor for some too. I don’t want you to get the wrong impression – most of the people in Malawi work extraordinarily hard and the number of beggars is small but they are quite prominent because of their locations.

Friday rush Hour at the Minibus station

Traffic Jam at 5 PM in Malawi

Minibus station but this doesn't do justice to the mayhem and noise!
Friday rush hour at the minibus station
Today Regina left early to go find gas (petrol). We have shortages about once a week and the cars line up into the streets either waiting for petrol deliveries or waiting in line to be served if the petrol has been delivered. The price also went up on Thursday from about 260Kw to 290Kw per liter. (The problem seems to be related to lack of foreign exchange resulting in inability to pay the suppliers in their currency which is usually the USD and work on the bridge over the Zambezi River on the road connecting Malawi to Mozambique).
I got downtown in the college car since it was going that way and then I caught the minibus to the “bus station”. It took a long time to get there even though it is likely only about 1.5 miles. The single bridge over the LIlongwe River was backed up into the rotary that precedes it and the side roads into the rotary were all clogged as well. There also were traffic police stopping vehicles to check for appropriate stickers and insurance. (The traffic police wear caps that look the ones used by yellow cab drivers – they are beige with black and white checks on the hat band). When we finally got to the “station” it was very close to 5PM and there were people and minibuses everywhere. I got herded into a bus going in the right way and once everyone got packed into it we were ready to go. But there wasn’t anywhere to go. The roads in and out of the bus station were clogged with minibuses. After many sweltering minutes we finally reached the main highway and it was smooth sailing from there, except the price had gone up from 100Kw to 150Kw which some of us paid and others did not. I am very grateful I don’t have to commute this way every day.