Give Me Money!

This is the resounding request we get from children and even adults all day long as we walk through town. It gets really old quickly. However, you can’t blame the people, considering this is a country with nearly half their national income coming from foreign aid. Malawi is experiencing a serious fuel shortage these past months and the president actually traveling to individual countries begging for fuel buyouts, China bought Malawi out in January; and just recently, the president was in Nigeria asking for the same.

So why is Malawi this way? In honor of the national holiday we experienced while visiting Malawi, Martyr’s Day on March 4, here is a very brief history of Malawi, as I understand it:

In the early 19^th century, Malawi was ripe with the East African Slave Trade. In 1859, British explorer, Dr. David Livingston, reached Lake Malawi. He describes in his writings a body of water so full of skulls and dead bodies that it was straight from hell. He set a mission to abolish the slave trade in Malawi. He died during his cause in 1873, likely from Malaria. Hence, Martyr’s Day is a celebration of Dr. Livingston. His death inspired a legion of British missionaries to come to Africa, bringing with them commerce and Christianity. Thousands of these missionaries died of malaria, young husband and wife and infant child all buried together.

Following the missionaries, European adventurers and trade pioneers began to arrive in Malawi in masses. By the early 1900s, the British had colonial rule over the country, mainly using Malawians as a labor source for their mining and trading in surrounding nations. Although colonial rule brought with it an end to slave trade and intertribal conflicts, as Americans know that colonies pay a price, so soon the struggle for independence began. It is interesting to note that when Malawi finally gained its independence, it was left with none of the benefits of colonial rule that we had in the United States, such as sufficient railroads, roads, or transport system, nor a decent education system.

Malawi gained its independence in 1964 and the leader of the independent movement was made President, Dr. Banda. He declared himself “President for Life” and ruled for 30 years before his downfall and then death 3 years later. In 1993 Malawi became a multi-party system and elected United Democratic Front (UDF) Leader Muluzi in 1994. With Muluzi’s leadership came many positive changes- such as freedom of speech and print. He was re-elected in 1999. In 2002, Muluzi failed to pass a bill t6hat would have given him life presidency and named Mutharika as his successor, who won the election and is the president of Malawi today.

Although Mutharika did great things for the economic growth (like the fertilizer subsidy program) and healthcare (stepped up the fight against AIDS/HIV) it seems that the power may have started to go to his head and political corruption has ensued. For example, the government has a monopoly hold on the lumbar industry in Malawi. Furthermore, a recent email from the Malawian British ambassador back to the UK was (purposefully?) leaked. This email suggested that Mutharika has become more of a dictator than a democratic ruler. Mutharika promptly asked the British ambassador to leave the country, and Britain, who had provided considerable aid to the country since its independence, subsequently withdrew their financial aid in Malawi. As a result of this, several European nations have since done the same-- hence, the “Give me money” desperation of this country.

Malawi has a very difficult time ahead of it. The next election is in 2014 and the press is very openly criticizing the current president. Malawians are very peaceful and religious people. War and major violence has never disrupted the natural beauty of this country or ravaged its culture. Let’s hope it stays that way.

I can show you the world

Major Operating Theatre - used for "larger" procedures, including c-sections, hernia repairs, etc

Adult Male Ward at Ekwendeni Hospital

Weekend trip to Makoya Village with friends.
Top Row: Julie, Claire (midwife student from Northern Ireland)
Bottom Row: Stevie, Carol (physician at Ekwendeni Hospital), Jenny (midwife student from Northern Ireland), Rianna (Dutch teacher working in Ekwendeni)

Bible Study Group
Standing: Colin (physician from Lilongwe), Daniel (host), Julie
Middle Row: Helen, Weston (Malawian med student), Anneke (Dutch physician), Helen (teacher from UK), ??(Daniel's wife), Carol (Scottish physician), Matt (theology student), Rianna
Lower Row: Stevie, Mtendere (Malawian med student), Robin (minister), Emmanuel (Malawian med student),  ??(minister from Ekwendeni)

Chibambo Guest House, where we stayed while working in Ekwendeni

CCAP (Church of Central Africa Presbytarian) in Ekwendeni, located right next to our guest house.

Dinner with Dr. Anneke

In front of Ekwendeni Mission Hospital

View of Senga Bay from the beach outside Cool Runnings guesthouse. Lizard Island is visible in the distance!

Lizard Island - taken on our snorkeling trip on Senga Bay

O-H-I-O with some Malawian children on the beach

Playing with some local kids on the beach at Senga Bay

On safari in South Luangwa National Park in Zambia
Left to Right: Claire (medical student from UK), Leah (German college student), Stevie, Julie

Pediatrics Ward at Ekwendeni Hospital

Feel the Rhythm, Feel the Rhyme

Saturday afternoon and Sunday morning were beautiful and perfect sunny days on the beach at Cool Runnings Lodge in Senga Bay. Now,  I could spend time describing the quaint lodge and its sandy beach, our leisurely swims in the Lake, or even the delicious food we ate (grilled cheese (CHEESE!) with bacon and avocado for lunch, as just an example), but although it is kinda cheesy, I want to try something different for this post:

During meditation and relaxation exercises we are often told to “picture our beach.” Well, I’ve found my beach. I can’t think of a place more intricately breath-taking and relaxing than the scene I experienced this weekend and I want to describe it to you, so maybe, if you need it, you can make it your beach. A picture just wouldn’t do it justice (and I’m not convinced my words do either…)

Imagine a soft, padded, immeasurably comfortable lounge chair. I lay in the cool and breezy shade of a very large tree under a canopy of huge, beautiful, green, feathery leaves. Scattered among the giant leaves are large, brown, banana-like seed pods. Peaking between each feather and seed pod is the bright African sun. Looking forward, passed the shade, across the sandy beach and the clear blue water of Lake Malawi, passed the rocky white and bushy green Lizard Island, you see miles into the distance rolling rounded mountains on the opposite Lake coast lining the horizon. Above these mountains are crazy and intricate white cloud formations silhouetted by the bright blue sky.

Looking down the coast to my right, I see crowds of Malawians bathing and washing clothes at the water’s edge. Women are bent over the washing buckets with half-naked children playing nearby. Way down the coast you can see dark storm clouds forming, with scattered flashes of lightning. Maybe you even hear the faint rumble of far-off thunder. It seems very odd, considering the bright sunny sky above me. Its almost like all of my worries and concerns put far-off, but from a distance, even they look beautiful. The distant storm doesn’t appear ominous or concerning, it just exists and is beautiful.

Down the coast to my left, I can see hundreds of fishing boats, some anchored at various distances, some pulled ashore. The beach itself is cluttered with giant, parachute-like fishing nets, and its edge lined with small thatch huts, bordering the lush forest just beyond the coast. People weave among the fishing boats on the beach and cast lines

Breathe in the beauty! Listen to the laughter of Malawian children splashing in the water and the faint distant thunder. Feel the cool breeze. Maybe a small butterfly flutters by. Breathe out and smile!

No worries. No hurries.

One thing I have always admired about my younger brother is how everything just works out for him with very little planning on his part. I used to contribute this to his lack of decision-making capability, but I think maybe he’s actually on to something. Since Julie and I have been in Malawi, rainstorms, fuel shortages and lack of time orientation have prevented us from planning very far in advance. But somehow, everything just works out. These past few days, our last in Ekwendeni and northern Malawi, are the very example of this…

After blogging during lunch on Wednesday, we returned to the hospital. It was a quiet afternoon so Julie and I roamed the hospital wards. At the very end of the day, we discovered a patient that had been admitted on Tuesday night around 8:30pm and hadn’t been seen by a clinical officer or physician yet- the only note in the chart was by the admitting medical student, did not include a physical exam, and was not signed off by a clinical officer or physician- that’s 21 hours in the hospital without being seen! Furthermore, this was a sick child. The chart described a burn on her arm, but upon actually examining the child, she had second degree burns on her right arm, right chest and abdomen, and right leg, where boiling water had spilled off a table onto her. And now the child had a fever! Julie and I immediately set to work finding the staff nurse, calling the officer on call, and ordering fluids and antibiotics, based on the hospital’s burn protocol. Although there was a miscommunication somewhere regarding the care of this child, she faired well. This is a rare occurrence, but dangerous and concerning to us. Yet another shocking reality of medicine under entirely different circumstances. At home it would have been a major lawsuit!

The rainy season reached a monsoon-status downpour Wednesday evening, which we trekked through to Bible Study. It was a very fun evening- we broke up into small groups of 3 or 4 to discuss various assigned passages, then returned to the large group to first mime the passage for the group to guess, then summarize our discussion on the passage. It was entertaining! Futhermore, when Julie and I announced that this was our last Bible Study night and that we were leaving for Lilongwe on Saturday morning, one of the visiting physicians, Colin, told us he was driving south on Saturday and offered us a ride! This meant avoiding another 9-hour public bus ride back to Lilongwe, so we immediately accepted.

Our last two days in Ekwendeni were a blur. On Thursday, Julie won our coin toss to scrub in with Dr. Anneke for a C-section. We also learned a valuable lesson about delivering bad news in Malawian culture. One of the Malawian nurses was upset because a physician had spoken to a terminally ill dying patient’s family, explain that the patient was dying and there was nothing more we could do to treat her disease, but we could make her more comfortable. Although this is a totally appropriate conversation in Western medicine, people do not speak so openly about death in Malawi. One is supposed to explain to family members that the patient is “very sick”, nothing more. While we might consider this an inaccurate portrayal of reality, the seriousness of the situation is implied in Malawian culture. The family should “just understand”. From their perspective, only God decides who is dying- not the physician. It is not the physician’s role to state this. Definitely not what we learned in CAPS class! This is yet another example of the intimacy between religion and medicine in Malawi.

On Thursday night, Anneke and Martign had us over for dinner and to play with the children. We had a blast and enjoyed some delicious homemade pizza!

Julie and awoke on Friday morning at 4:45am in order to climb Mt. Chinongu for the sunrise. Although the lighting was really beautiful, the clouds and fog made the sunrise look more like an orange-ish blob rising behind the distant mountains. Just like it gets so suddenly dark in Malawi, it gets so suddenly light. And as soon as there is light, the village wakes up and there was noise surrounding us. It was surreal.

After watching a couple more procedures in the theater (an evacuation and an EGD) and doing a little ultrasound scanning, Julie and I finished our work at the hospital. We took the afternoon off to head into Mzuzu to run a few errands- such as shopping for chitenges at the Tanzanian market (the skirt covers that all Malawian women wear every day) and hitting the grocery store for a few local goodies. However, the return trip to Ekwendeni was more difficult. The fuel shortage has made taxis very scarce, and there was an aggressive crowd waiting for only a couple taxis driving back and forth from Mzuzu and Ekwendeni. After almost taking a cigarette to the face, Julie and I managed to wrestle ourselves into a taxi and make it back to Ekwendeni before dark.

Back in Ekwendeni, we met up with our friend, Sweet Man, who wanted to show us his family’s farm before we left. We had been trying to do this all week, but the rain and late work days had prevented this visit. We walked the village road behind the primary school, past maize fields and sweet potato plots to Sweet Man’s farm. We met his family (still not sure which of his extended family he actually lives with) and he showed us his room- it is in a small concrete building, next to a rabbit and pigeon hutch , with two rooms: one for him and one for the family goat. His room barely fit a bed and a coffee table inside. In fact, the door didn’t even open all the way because it would hit the bed. It was amazing to be invited to his farm and witness the actual living conditions of the villagers. Sweet Man was one of our friends throughout our stay in Ekwendeni and we were really honored to be invited to his farm. From the stories he’s told us, his family has really been through a lot. Both his older brother and sister have died, and his mother, who is very ill, does not live with them, leaving his widowed sister-in-law to run the household. But they persist and continue to sustain themselves and live happily. What a place this is!

Finally we ended the evening with dinner at Carol’s house, where she served us homemade mac ‘n’ cheese (CHEESE!). It was really nice to spend time with everyone and wish them well. The hospitality in Ekwendeni has made us feel so welcome and at home during our trip. It was a sad late night packing our bags.

If Julie and I had bought our bus ticket to Lilongwe in advance in order to secure our seats, we would never have experienced the most beautiful and relaxing weekend yet. Early Saturday morning, Colin drove us along the Lake Malawi coastline to a Senga Bay, a town on the Lake just one hour outside of Lilongwe, where we decided to stay for the night. The drive was awe-inspiring. We passed rubber tree farms, maize fields, and sugar cane plantations, interspersed with views of the sparkling Lake Malawi and a distant mountain backdrop on one of the most beautiful days we’ve had yet. We had no idea where we were going to spend the night, but, of course, the first lodge we called had their last dormitory, with 2 single beds, available. And so somehow we ended up with another unplanned weekend at the Lake in the very beautiful, secluded, and hip Cool Runnings Lodge. It was 11:30am and we were at the beach. No worries. No hurries. It all works out. This is Malawi.

Five Things: Oh The Places You'll Go

1)      Falling Into Place

Before we left for Africa, we had a million questions: what to expect at the hospital, what clothes and books to bring, where can we lock up our valuables, which hotels should we stay at, how to book bus tickets ahead of time, etc etc. It was hard to get straight answers to a lot of these questions, and now that we’re here, we understand why. Things just have a way of working themselves out in Africa. For example, last weekend we were planning to take the long bus ride from Mzuzu to Lilongwe, and had been told that it was not necessary to buy bus tickets ahead of time. We were skeptical considering we got stuck on the local bus that made TONS of stops at the beginning of the trip, but decided to wing it. This worked out in the best way possible: Dr. Colin, a missionary doctor based out of Lilongwe who had been working in Ekwendeni last week overheard that we were heading to Lilongwe and offered us a ride in his comfy Nissan Pathfinder… he picked us up at our guesthouse and dropped us off at Cool Runnings – and even stopped at a pharmacy on the way to pick up some antibiotics for my sinus infection! Another example: an American med student and her boyfriend recommended an Italian restaurant called Mamma Mia’s. It was off the beaten path in Lilongwe and we were having trouble finding it, but when we asked the first mzungu we saw (middle-aged guy with 2 daughters our age, not creepy, don’t worry Mom) if he knew where it was, he was heading there himself. Not only that, but when he picked up his take-out and left, he also paid for our ENTIRE DINNER without ever even mentioning it to us. The waiter just said that it had been taken care of… talk about paying it forward, Woody Hayes would be proud!

2)      In A DIFFERENT Bubble, But Still In A Bubble

Med students often get stuck in their own little bubble. I don’t want to speak for everyone, but I myself am usually woefully behind on current events… for example, while studying for Step 1 I Nick and I didn’t know there was an oil spill in the Gulf of Mexico for over a week after it happened… very embarrassing. When Stevie and I came to Africa, we thought it would expand our view of the world. We would see things that shocked and surprised us, and leave as more culturally aware young adults. This expectation got completely turned around a few days ago when a man from South Africa who we met walking down the street to Mamma Mia’s was the first person to tell us that there had been a high school shooting in Ohio. We were surprised and sad to hear it, but he didn’t know many details and thought that it had been in the same city as Ohio State. When I found out in an email from my friend Emmy a few hours later that the shooting had taken place at Chardon High School – ten minutes from my own high school, the place where I substitute taught in my year off after undergrad, and the place where one of my favorite middle school teachers is now the principal – it felt like being punched in the stomach. To be so far removed from our home lives that we would not even know about such a tragedy was really scary. We’re so happy to be here, but the world is a big place and you can’t really be fully present both at home and here simultaneously.

3)      Getting Too Comfortable?

Our first day in Malawi, I tried to buy a postcard at the market and was swarmed by about 10 men trying to shove their postcards in my face….it was terrifying, and I pretty much ran away empty-handed. This week, I returned to the same market to buy postcards as a seasoned haggling veteran, and when they swarmed me I firmly told them to wait their turn and then let them line up and hand them to me one by one…. didn’t phase me a bit. Similarly, a couple weeks ago we were appalled to be sharing a taxi to Nkhata Bay with a live chicken. This weekend, Stevie and I shared a rainy ride in the back of a short-bed pickup truck with 11 other passengers, all of our luggage, 2 bicycles, and several baskets full of bananas… and laughed about it. It’s strange how quickly people can adapt to their surroundings, but it’s also frightening when the same principle applies to sick patients. When we saw our first child who was very sick with cerebral malaria – seizing and with labored breathing - we were thinking of him all day, wondering if he was OK and thinking of the medical interventions that could be made in the United States. However, it became a pattern to us that all of the cerebral malaria patients recovered, and we got used to seeing it that way. When we came back from lunch last week and learned that one of these children had died while we were gone, it was somehow shocking – this wasn’t what we’ve been seeing, and we had already forgotten how scared we were with that first patient. Although we have adapted in small ways to life in Africa, Dr. Colin told us something that rings true… the poverty and sickness that exists here should ALWAYS shock and upset us, no matter how much of it we have seen.

4)      Delivering Bad News

An interesting discussion came up last week at the hospital, when one of the Malawian nurses approached one of the missionary physicians regarding a patient who was terminally ill. The patient’s family had been told that his condition was incurable, and that although the doctors would do everything they could to keep him comfortable, he would not get better. According to the nurse, this had upset the patient’s family tremendously, and she said that in Malawi culture it would be enough to tell the family that “the patient is very sick.” The nurse’s perspective is that the family understands when a doctor uses the term “very sick” that the patient is ultimately dying, but it is up to God whether the patient recovers or not. The physician’s perspective (like ours in America) is that telling a terminally ill patient’s family that he is “very sick” is not enough – lots of people who are “very sick” get better, but terminally ill patients do not and withholding that information is hiding the truth. We found the discussion remarkable, and can see how it can be very difficult for physicians who have been trained a certain way to work in such a different environment. Ultimately, we think that the physician handled the situation flawlessly – holding strong to a personal code of ethics while still being receptive to the nuances of the Malawian culture.

5)      Quality Over Quantity

In previous posts, I’ve touched on how “connected” the town of Ekwendeni is – seeing the same people in church, on the street, at work, etc. This same feeling of personal connection is especially true regarding the relationships Stevie and I have made with our attending physicians at Ekwendeni Hospital. In three weeks, we have come to know these women on a deeper level than almost all of the physicians we have met in our four years of medical school. We have been invited into their homes for dinner, played with their children, gone on weekend excursions, discussed our spiritual beliefs at Bible Study, and learned about the life experiences that have shaped them and brought them to Malawi. We have been blown away by the warm reception we received in the hospital, and have felt that we were truly allowed to carry a little of the workload. It is remarkable how much a work experience can be enriched by learning about the lives of your colleagues, and we’re just grateful that we were able to make such deep connections in such a short time.

Maternal and Child Health Outreach Clinic

Taken at Luhomero Outreach Clinic, where Stevie and I spent the day performing antenatal visits and helping with vaccines. The kids we're with attend a nearby primary school, and ran over to check out the "mzungus" who had showed up!

Boy's Brigade

Boys Brigade (kind of like Boy Scouts, but with more emphasis on Bible Study).

The young boys meet every Sunday afternoon for religious teaching, lunch, and games. This particular day they played futbol on the pitch you see in the background, which is just a clay area between buildings...and they were all barefoot! In the far back right corner is Sweetman, their teacher and our friend, who showed us the path up Mt. Chinongu and took us to his family's farm.

Trauma, Miscarriage, Malaria, HIV, and our Mobile Clinic experience

This post begins with our voyage atop Chinongu Mountain Sunday evening. It is really just a large, bouldery hill, but my super graceful climbing skills (ha) made it much more difficult than necessary- I now have minor battle wounds to show for it. Free souvenirs! Hope you enjoy the view we posted :)

So far this rainy week we've had a very busy time at the hospital:

Hearing about the weekend events at the hospital on Monday morning was quite shocking. We learned that on Saturday there had been a double mini-bus accident on the main road when one mini-bus tried to overtake another right by Chinongu (which isn't surprising considering the driving we've witnessed here!). Sadly, 4 people died in the wreck- one a mother of a 3-mos child. Luckily, the child was unharmed in the accident. Someone also saw a man covered in blood running from the scene of the accident, assumingly the driver of the bus. However, the staff of Ekwendeni Hospital on-call and at home came together and worked very well through the trauma, allowing no deaths in any passengers brought here. Also, we learned that a child died in the ward on Friday evening. This was upsetting because we had rounded on her in the morning and, in fact, her case was not very rememberable because she had no issues at the time and no hint of decompensation. Two tragedies.

Seeing new patients this weekend has been very interesting. On Monday we US scanned a woman 20-weeks pregnant, diagnosed with malaria, who had been having vaginal bleeding and contractions for 2 days. Although we found a fetal heart rate, it was slow. There were no fetal movements and no amniotic fluid, indicating that a miscarriage was inevitable. We just had to wait. However, the heart was still beating (with decelerations) on Tuesday and she had actually stopped having contractions, but when we scanned her again today (Wednesday), there was no longer a fetal heartbeat. It was difficult news to deliver (and to receive, I'm sure). Now labor would be induced to avoid any septic complications.

In the children's ward this week have been some more sad cases. One child with cerebral palsy was diagnosed with malaria and malnutrition- he is 4 years old and weight 8 kg! It has been very difficult to assess his feeding ability both orally and through his NG tube. Its funny- at home we worry about levels of functioning in children with cerebral palsy, but the largest issue here is simple nutrition. We also discovered that another child we have been following for the past week was HIV positive (we simply screened him because there were tests available, not for any reason in particular), as well as his mother. I can't imagine what him and his mother have been going through. Just imagine- bringing your child to hospital because he is deathly ill with sepsis, but watching him improve over the course of the week until he is ready to nearly go home, then discovering that both you and him are HIV positive and that your three-year-old son will need to start antiretroviral therapy now, which he will continue for life, and you may need to start medication soon as well. It breaks our hearts. We actually discovered two HIV positive children through routine screening this week.

On Tuesday there was fuel for the mobile clinic! At 9:15am we were told they would be leaving at any minute, so Julie and I rushed over, ready to go. But typical Africa time, we were FINALLY on the (very bumpy) road to Luhomero village by 11am (after stopping once for a live chicken - lunch! - and once for vegetables and rice at the market). The "clinic" was really an empty building with 4 empty rooms, but was crowded with mothers and their babies waiting to be seen. Children were weighed (by hanging them on a hook with fabric pieces), screened, and received various immunizations. Unfortunately, Julie and I were not extremely helpful talking to the young mothers (in the villages hardly anyone knows English, and we only know how to ask a few questions in Chitambuka which are only helpful with yes or no answers). However, we did perform the antenatal exams on the expecting mothers- weight, blood pressure, gestational age, fundal height, and listened for fetal heart tones- with a hollow hourglass contraption, not Doppler! Its definitely a learned skill, but we are just starting the get the hang of it. We also were able to give a couple vaccinations, so we weren't totally un-useful! It was a great experience and we were very glad there was fuel to go that day!

Now this morning was the most interesting day so far. After rounding in the children's ward with Anneke, a man came into the rounding room and sat down in front of Julie and proceeded to hand her a small package with what looked like teeth in it and then began to take off his pants. Something was wrong with him (drunk? mentally ill?) and we quickly rushed him AWAY from the children and to the outpatient department. Then a man was brought in who had been hit by a taxi as he was walking alongside the road. He was clearly bleeding internally, so we did what we could and sent him to the larger surgery-capable hospital in Mzuzu... by taxi! (The ambulance had left, but no worries, Dr. Jack accompanied him to Mzuzu in the taxi and stayed with him until they took him to the OR for a splenic laceration). Then we US scanned the pregnant woman described earlier, then another pregnant woman for gestational age, although she "guessed" (correctly) she was about 9 months, and then another patient who had been diagnosed with pancreatic cancer and had some operation, but was now experiencing abdominal pain again. Julie and I thought we had been becoming more comfortable with ultrasound throughout this year, but due to the operation and cancer, this gentleman's abdomen was a mess. It was very difficult to identify normal structures and landmarks. It was possible that the cancer had metastisized to the liver and that there was a large cyst near the pancreas- anotehr case in which a CT or PET scan would be more than helpful! Lastly, we returned to Children's ward to check on one child who was quite sick and nearly unconscious during rounds, but she had not improved with fluids, so we started antibiotics and I did an LP to rule out (hopefully) meningitis. There are no more glucose strips available to test her blood sugar, but hopefully the dextrose in her IV fluids will help. Another day where the lack of resources are just so pronounced. But I mention only the interesting cases, which are often the sickest cases. Over just the course of  two and a half weeks, we've seen hundreds of patients get well again. Mickie is not an exception! While we can constantly comment on Malawi health care, one of the poorest of the resource-poor countries, we can also celebrate the healing that occurs in hospitals like this one. Everyone is just doing their job with what they have- and very well!

Oh, and one last disappointing (albeit humorous) comment to leave you with, Julie and I ONCE AGAIN bought "mangoes" at the market only to discover that, yes, they were, in fact, avocadoes. Fool us twice, shame on us. Maybe we are lacking some mental resources here...

Five Things: A World Away

There isn't a real "theme" for this edition... just a random assortment of insights:

1) Sightings from Home

It's amazing how even the smallest glimpse into our lives at home excites us. Stevie has spotted a couple of old Philadelphia Eagles tees/jerseys and jumped into pictures with the person wearing them, and I have been patiently waiting for my moment of Cleveland glory. On Monday, I got my chance when I spotted a retro Cleveland Indians tee on my morning run (and not retro in the brand new, really expensive throwback way... retro in the worn out, this shirt has been worn every day since the 1980's way). Without my camera or Stevie there to verify the sighting, I suppose you could argue that it was just a mirage... but with the way that poor guy looked at me as I was frantically pointing at his shirt and squealing in a foreign language, I'm pretty sure it was real. Oh, and if I see someone in a "retro" Omar Vizquel jersey, I'll probably trade them the shirt off my back.

2) Lunch on the Road

To us in America, this means grabbing a granola bar and a banana... or maybe packing up a PB&J if we're not too rushed on the way out the door. In Malawi, this means loading up a car filled with 11 people and then making two stops on the way to the village clinic: the first to buy a chicken, and the second to buy vegetables and rice at the market. Then we drove 40 minutes to the village clinic and saw patients for 2 hours. Meanwhile, 2 women came with us just to prepare lunch - they built a fire, killed the chicken, and cooked everything over a fire 10 feet from where we were giving children measles and polio vaccines. When we finished seeing patients, we all sat around outside and ate... with our hands. Then we washed dishes, piled back in the car, and drove back to Ekwendeni. The whole process of buying a live animal and transporting it with you to the place where you will kill eat it was a little strange... but on the upside, at least we knew it was fresh!

3) Singing

Everyone sings here. There were at least 5 different choirs in church the first time we went, and probably 3 or 4 this week. Just outside our guesthouse window, there is a building where all of the choir groups practice throughout the week - this makes for lovely background music when we're hanging out in our rooms in the evening! Bible study each week starts with everyone joining together for a few songs, and even the people out jogging are singing as they pass us. When they ask us if we sing, we're honest with them - yes, we sing, but no one likes to listen! They tell us that everyone can sing, and that seems to be true when it comes to Malawians!

4) How to Attract a Crowd

Whether it be doing lunges across an empty soccer field, riding in a minibus, or going for a jog, Stevie and I always seem to have curious followers...usually children. Yesterday we drove past a primary school 100 meters from the outreach clinic we were heading towards, and within 3 minutes of getting out of the car, over 50 children from the school had wandered over to us for a closer look. Last week we were up early doing a workout on an empty netball court, and there were one or two children cutting the grass when we started. (Side note: when I say "cutting the grass", I mean using scythes that cut approximately 10 blades at a time.) By the time we finished our workout, over 20 kids had gathered to help cut the grass... somehow I doubt that they are usually so eager to do chores at 6:30am!

5) Wearing Many Hats

Everyone here seems to have multiple different jobs. The lady who we usually see cleaning the hospital floors was the same woman who came with us to the outreach clinic yesterday and cooked our lunch. People who work in the hospital also hold positions in the church and in village shops. Beyond their usual work, the Malawian people have a real sense of unity and are very willing to take on additional responsibility when others are unable to do so. Both responsibities and rewards are shared among many, which is a refreshing change from our more private Western ways!

Disclaimer

This blog is supposed to document and celebrate our amazing experiences in Malawi. We are sharing our patient stories so that you can follow our incredible hospital encounters in the most accurate light possible, but the real names and details of some of the patients have been changed for their privacy. In addition, no pictures of the hospital wards or patients will be posted without permission from hospital staff or patients.

This being said, every Malawian we have encountered has been thrilled to have their picture taken and their story shared. We hope you've enjoyed reading so far!

We also sincerely apologize for butchering the spelling of the names of many people mentioned in this blog- especially the Dutch!

Dr. Anneke's children - Maria, Thomas, & Ruth

(I know this pic is a little messed up but I will try to fix it later!) Stevie and I were lucky enough to spend Sunday morning after church at Anneke and Martin's house. We played with their 3 beautiful children and munched away on popcorn, brownies, and cookies. Best of all, Anneke told us the next day that they ask their kids every night at bedtime "what was your favorite part about today?" and their response was..... "when the students came to play with us!"

Chimongu Mountain

Our little hike turned into climbing Mt. Chimongu with Sweetman (really its a big rocky hill just on the edge of town). But don't worry, I still found a way to skid a couple feet down a rockface and scrape up my wrist, leg, and ankle. But it was totally worth the view from the top! Behind us you can see the town of Ekwendeni and even some surrounding villages and mountains.

Chibambo Guesthouse

Lot's of people have been asking us about our accomodations. Here's our nice little room in Ekwendeni- complete with mosquito nets (and No, Mom, we did not clean up just for this picture- I've actually been pretty tidy)! Window to the left, door to the hall on the right. On the wall behind me are 2 wardrobes and a door to the bathroom which we share with one other room. We'll spare you the pics of the bathroom floor... lets just say, flip-flops recommended!

Wedding Crashers

Wednesday and Thursday were quiet at the hospital. We tried for several days to go on one of the Mobile Clinics into the local villages, but there have been fuel issues in Malawi lately and there was none to operate. (Mickie is doing great, by the way! Just breastfeeding away every time we check on her!)

Wednesday night was Bible Study at at a Dutch couple's house, Marika and Djerck (pronounced w/ a "Ch" sound, not "J"!). Focused on some Lent-related passages. We sang and prayed and discussed. It was really
nice!

On Thursday we did see a couple interesting patients. One child was extremely malnourished child with severe Kwashiorker's. She had the bloated belly, swollen hands and feet with weeping blisters and some open wounds from blisters that popped, downy hair, and not to mention scabies all over her body. The mother says they have enough food at home, but there is some social situation that we can't get a handle on. 2 of
4 of the child's siblings have died. It was really sad. Dr. Annika even teared up a little after the patient and mother left the room. Even by Malawian standards, this child was SO not healthy and not clean. Such compassion. We also watched a baby being born! Walked into the room just as its head was almost fully out. The midwife student, Claire, only had time to get on one glove! The interesting thing was that the baby was almost born in the amniotic sac- her membranes didn't rupture until nearly the shoulders were out! Very different from our previous OB experiences. The midwives also speak up if the parent wants to name their newborn something funny- they are simply told "Nope, you can't name him/her that!" This is how one midwife students had a baby named after her- might be one of the only Malawian Jennys!
We planned a half day for Friday in order to head to Nkhata Bay, so of course it was the busiest day at the hospital. We spent all morning helping Carol round in the Children's Ward. It seemed like every time we finished one admission, there was ANOTHER child with severe malaria who needed a blood transfusion! Another patient presented to the female ward, which Dr. Summers definitively diagnosed as a stroke based on physical exam and history alone! That's what you have to do with limited resources. No imaging. Could only put her on oxygen, monitor her blood glucose & blood pressure, and maybe slip her some aspirin if she becomes conscious enough to swallow. That's all.

We finally got on the road to Mzuzu, stopped at the bank and post office and our new Mzuzu buddy, Donald the Duck, set us up us a taxi ride to Nkhata Bay. Just otuside Mzuzu a Malawian woman passenger made the taxi stop so she could stop at a small stand where we picked up a couple other passengers, of the poultry variety. Yes, we had an hour car ride with live chickens in a plastic bag squawking away. At one point they did calm down- either they were sleeping or suffocating... Malawian drive-thru dinner! But it was still a really pleasant trip, driving through the mountains, listening to reggae and a Zambian song about Facebook.

Got to Mayoka Village in Nkhata Bay just in time for a quick swim before dark. Feasted at the DELICIOUS BBQ buffet- salad, avacados, Morrocan carrot salad, potato chips, breaded eggplant, veggie
sausages, beef kabob, spinach cooked in peanut flour, potato sald, honey BBQ chicken, and, Julie's favorite, the chilli bites. Spent most of the evening chatting with Nick and Zuflaa, a couple from Sydney who
are on a 4 YEAR trek through Africa which they started at the World Cup in South Africa. They've already backpacked South America and Southeast Asia some years ago. They plan to finish their trip in
Greece in 2014 to get married at Nick's grandfather's castle! Crazy, right? They stay in one place for several months to earn money as they go- Zuflaa works as a bartender and Nick is a chiropracter/
acupuncturist who does free-lance work, even getting room and board in exchange for treatments! We also met Clyde and Anthia, a couple from Derbyshire, England who are here for a wedding. One of the Malawian Mayoka staffers, Benji is marrying an English girl, Eimei (pronounced "Eema"), on Saturday AT Mayoka Village! They actually met 10 years ago when Eimei was volunteering as a secondary school English teacher during her gap year and visited Nkhata Bay one weekend! Things just tend to work out in Africa like they're supposed to. Now she lives here permanently- they actually just built a house just a little
down the bay from Mayoka Village.

Saturday morning was pretty lazy. It had thunderstormed all night and was still raining in the morning, so we didn't get the sunshine we were hoping for. Julie and I were planning on leaving in the afteroon to get back to Ekwendeni Saturday night for church on Sunday, but how could we pass up partaking in a Malawian wedding?! Once again, the decision was easy to stay an extra night.

We read on our lakefront porch then headed to the deck for breakfast where they were already setting up for the wedding. Clyde, Anthia, and Suzie (the bride's mother) recruited us to move tables and twist
fabric for decorations while we waited for our food- suddenly we were practically part of the wedding party! Which paid off later because we had prime seats for the reception). Then the actual wedding party left on a boat, with an army of brightly colored umbrellas, for the ceremony on a private beach. Julie and I took the time to swim across the entire bay and back. It was a great swim and we made it back in time for the reception...which included Benji's entire village, including the chief, crowdingon the Mayoka deck. Thats about 150 people on a deck meant for, hmm, 50, max?

But it was FANTASTIC. Great food, great festivities. The reception started out with speech's by the brides parents and the groom's father (done in both English and Tambuka with the help of the translating
priest). A close friend of Benji (who looked straight of out of Jackson 5 with his fro and plaid get-up) serenaded them with the guitar and another Mayoka regular, Wonder, read them a poem he wrote
(we've heard several of Wonder's poems during our Nkhata Bay visits-he's really good actually. And in case you're wondering, yes I took a picture with him- of Stevie & Wonder).

Then, it traditional Malawi fashion, the crowd threw money at the bride and groom. This consisted of music playing (the Facebook song- twice!) and people dancing their way to the front of the room and tossing
money in a big bowl in front of the newlyweds. It was HILARIOUS. Especially when people asked for change out of the bowl. We were cracking up.

The reception ended around 6 and most of Benji's village headed home- that's when the party really got started. Lot's of music and dancing. Everyone had a great time! We met Benji's great uncle who was the
village elder at the ripe old age of 81. He had a little photbook he carried with him of pictures that had been sent to him from previous traveler's. It was really cool. He also had a picture of his father,
one of the first men in Malawi to practice medicine! Thie highlights of the night include one local, Charles nicknamed MJ for his dance moves, going crazy whenever an American song popped up on the ipod,
another Malawian who danced the night away balancing a beer bottle on his head, and, best of all, a private reggae concert. This guy was real good. The crowd favorite was a song about Lake Malawi itself:

How big is the Lake?
I said the Lake is SO big.
How big is the Lake?
Its SO big! SO big!
How big is Malawi, yeahhh?

We got really into it. One of the verses consisted of him giving the true dimensions of the lake. I tossed in a line about over 600 endemic species, which he, while in song, corrected me to 740 endemic species. I don't usually like being wrong, but it was well done.

All in all, we made the right choice to stay for the wedding festivities. WHAT a day, despite the rain. And we even hitched a taxi early this morning back to Ekwendeni and made it back in time for the English Church service! Then we were invited for coffee at Annika and Martin's house where we got to play with their 3 frickin' adorable children- Thomas (6), Mariah (4), and Ruth (1). The best part? Annika served us brownies, popcorn and... cheese! Its a little rainy and muddy here today, but we are gonna try to go on a hike later this afternoon.

Everyone we've met has said 1 month is too short of a visit Malawi. Now we get it. So much more to do, to see- its hard to accept we are over halfway through this journey. SO big! SO big!

Five (Dumbest) Things We've Done in Africa

To mark the halfway point of our trip, Stevie and I decided that we would like to share with you all the 5 silliest things we've done so far in Africa. Laugh away :)

1) Tipping

For me, figuring out how much to tip people other than waiters/waitresses is always a bit confusing. Do I really need to give the bellhop who carried my bag five feet $3? Do I tip the valet guy when I drop the car off AND pick it up or just when I pick it up? If it's stressful in America, imagine getting off the plane in Lilongwe, exchanging American dollars for Malawi kwacha, and then 10 seconds later having twenty cab drivers swarm you and offer you a ride into town. Another man who was basically an airport bellhop (although he was not actually employed by the airport, just trying to carry bags for some money) took our big bags, walked 20 yards and loaded them in the trunk, then turns to us and says "now you tip me." Scrambling to do conversions in my head, I hand him 40 kwacha. He flat out says "this is too small." Now I'm really caught off guard, so I do some quick math and realize that 40 kwacha is about a quarter. Embarrassed, I take out the only other type of bill I have, which is 500 kwacha. Doing the math in my head, I realize that it was about $3, and didn't think much of it until about a week later when someone told us that 500 kwacha is an average day's wages in Malawi...should have stuck with the 40 kwacha tip! On the flip side, one night Stevie and I were eating a a restaurant where our meals came to 400 kwacha each... we left 80 kwacha each on the table as a tip, figuring that was 20%. As we're walking down the street a couple minutes later, we see the waitress running towards us with the tip money waving in her hands. She gave us the money back and then left. Needless to say, we still have no idea whether we're supposed to tip in this country.

2) How to use a mercury thermometer

This seems self-explanatory to all you adults, but for us children of the digital generation, it's not so obvious. Stevie and I were helping collect vital signs in the pediatric ward one afternoon, and all of the digital thermometers were broken. The nurse handed us 2 mercury thermometers without any further instructions and we proceeded to go child to child checking temps. After about 4 children, I had noticed a strange pattern... all 4 of the kids had temperatures of 39.4 degrees Celsius. I turned to Stevie and asked her if she was having the same problem, and she said "yes, mine are all 38.5." Not sure if the thermometers were broken or if we were doing something wrong, we asked the nurse, who looked at us with an expression somewhere between shock and pity. She then informed us that you have to shake the mercury back down between uses....who would have known?! In retrospect, I have vague memories of my mom flicking her wrist with the thermometer when I was little, and I always just assumed she was waving it dry after cleaning it. What's even funnier is that even now, I always shake my DIGITAL thermometer dry instead of wiping it because that's how my mom always did it... little did I know that the wrist-flicking technique only applies to MERCURY thermometers.

3) Tomato, To-mah-to....Mango, Avocado?

Before we left America, we were told that mangoes would be in season in Malawi during our trip. By the time we arrived, we were craving mangoes, and went to the outdoor market in Ekwendeni to get some for dessert on one of our first nights. We didn't really see anything that looked exactly like the mangoes we buy from Giant Eagle, but we found something that was about the right size and shape and when we said "mango?" and pointed at it, the seller shook his head yes so we bought them. After dinner that night, we were about to cut into them when the night watchman came up to us and asked if we wanted a spoon. Confused, we asked how you eat a mango with a spoon, to which he replied "Those aren't mangoes. They're avocadoes." Turns out he knows his fruit, because those were two of the biggest avocadoes we've ever seen. A few days later, we tried again. We perused the market for awhile until we found someone who spoke English, and they pointed us in the direction of bowls fruit the size and shape of limes, which are actually mangoes. Stevie and I attempt to buy 2 mangoes for 50 kwacha each (30 cents-ish), thinking we're getting a pretty good deal.... and then the lady proceeded to dump two entire BOWLS of mangoes into our bag. Turns out we had gotten a pretty GREAT deal.... and also more mangoes than we knew what to do with.

4) Timing is everything

If tipping is confusing, trying to figure out which events you can be late for and which ones you actually need to show up on time for is a complete mystery. Stevie and I were invited to a Valentine's Day fundraising dinner for HIV/AIDS programs that started at 6 pm. We showed up fashionably late - 6:15 - and were literally the very first 2 people there. Our other mzungu colleagues from the hospital showed up around 6:30, and then the 6 of us stood there for over an hour until any Malawian people arrived. Literally no one came until 7:30. Figuring this was just the way things roll in Malawi, we decided not to show up at Bible Study the next night right at 7:30. We arrived around 8 (after getting lost in the dark and showing up at 2 wrong doors) and were the very last people there... they had already done 2 rounds of passage reading and discussion, and because of us the study leader had to read the entire Bible passage aloud again to get us caught up. Apparently we chose the wrong event to stroll in late.

5) To Pee or Not To Pee?

Stevie told you all in her blog about our visit to Lake Malawi last weekend, and how we decided to swim despite the 99% risk of getting "bilharzia" (aka shistosomiasis aka a gross parasite). We figured there is one easy pill you take 6 weeks after swimming and you're good to go. So after our first leisurely swim, our midwife friend Jenny starts talking about how she saw this show on TV where the parasites swim up your urethra while you're peeing in the lake. Stevie and I get really quiet all of a sudden, prompting Jenny to say "wait, you guys didn't pee in the Lake, right?" HOW DID NO ONE MENTION THIS TO US BEFORE WE WENT SWIMMING?!?! We were in there for like 4 hours! How did this not come up?! Anyway, we were pretty grossed out after that, but it kind of sounded like an old wives tale. As soon as I could get my hands on a textbook, I discovered that the parasites actually penetrate through skin, so no worries... at least Jenny has bilharzia now too ;)

Mayoka Village, our weekend paradise in Nkhata Bay

Picture steep/irregular staircases connecting quaint chalets nestled into the hill. Also featuring beautiful featuring stone showers... and a compost toilet.

Five Things: A Sparkle Of Hope

1) Road transportation

Getting around in Malawi is not always easy. There are lots of minibuses and so-called taxis, but as it said in the guidebook, they are "overcrowded, unreliable, and dangerous." Our trip to Nkhata Bay last weekend, which would take only an hour if you had your own car, took over two hours. The first leg of the trip (to Mzuzu) was in a minibus containing up to 12 people at times. We paid less than $1 for this ride, but since we were the first ones in the van, we had to wait around until it filled up. The second part of the journey (from Mzuzu to Nkhata Bay) was in a station wagon type taxi with 4 friends we've met here and 1 other Malawian man. This trip cost about $5 each. The crazy part about it was that we were pulled over at police checkpoints 3 times during the 1 hour trip and fined several dollars each time for random, minute reasons. Additionally, fuel here is extremely expensive... it comes out to almost $8.50 per gallon!!! Between the stiff fines and cost of
gas, it's actually amazing that any of the local people can afford to drive at all.

2) Simple Solutions

Before we left for Africa, two people gave us cheap international cell phones to use while we're here. However, one of them didn't have a charger, so I assumed that it would be worthless and left it at home. Similarly, we were asked to carry a package from a Malawian man living in Indianapolis to his father here in Ekwendeni. The package weighed about 8 pounds (which is a lot considering a suitcase must be less than 50 pounds!) and was sketchily taped shut, so we decided we had better open so it we would at least know what was in it in case someone from airport security asked. Inside were about 25 cell phones without chargers - we didn't see the point but brought them anyway. Now that we're here, we understand... there are cell phone charging shops called TNM set up all over the place. Because of this system, even people without electricity have cell phones. It's really an ingenious solution, and a good reason to donate old cell phones (even if you've lost the charging cord)!

3) Pancake Day

Yesterday we were invited to Dr. Carol Jack's house for "Pancake Day." At first, we thought she just really liked pancakes (and who doesn't?!), but then she explained that Pancake Day is a tradition in the UK on the Tuesday before Ash Wednesday. The idea is that people use up all the excess eggs/flour/etc that they will not need during Lent. There was also some talk about people doing races where they run and flip the pancakes in the pan... but only one person tried that! We told everyone at the dinner about Fat Tuesday and Mardi Gras in the US (leaving out a few choice details about how beaded necklaces are acquired), and then we each tried the pancakes. Actually, they were more like crepes, and toppings consisted of jams, mangoes, and honey. Although they can't hold a candle to Javorek family pancakes, they were still pretty delish :)

4) Clean water

Residents of Malawian villages spend a good deal of their time obtaining water. There are pumping stations along the side of the road, and women go there in the mornings to fetch water and carry buckets back on top of their heads. Water is often boiled for purification, but yet we've still seen patients in the hospital admitted with dysentery because their water source is a dirty stream. Stevie and I brought chlorine drops and a portable water filter to make sure we'd have clean drinking water, and even that task has become tedious after only 10 days. We jump at the chance to drink a Coke or a Fanta because it means we don't have to filter more water, and have really come to appreciate how easy it is to turn on a faucet back home.


5) How to hold onto the Sparkle

Much of this week, we have been in the pediatric ward focused on a very sick child named Mike. He had a complicated case of cerebral malaria, and had been seizing for over 24 hours when he came in on Monday. Throughout that day, his condition remained grim, and by the end of the day there was little hope that he'd make it through the night. However, Dr. Anneke told us that she still had what she called "a sparkle of hope." We thought about that patient a lot overnight, and were amazed and ecstatic to see that he was alive and improving the next day. Thinking about what Anneke had said the day before, we realized how resilient children can be. Was Anneke's hope stemming from the wisdom of a pediatrician who has seen similarly sick children survive, or is that "sparkle of hope" something that everyone can strive for?

High Highs and Low Lows

Still coming off our buzz of such a great weekend, Monday was one of our toughest days in medicine to date. We basically spent the entire day watching helplessly as a 10-month old little girl struggled not to die.

Mickie came in Monday mornign seizing. Her mother and grandmother reported she had been convulsing since the day before... She was afrebile, but the most likely culprit was cerebral malaria. We've since this before- LP to r/o meningitis, IV Quinine, and you see that patient stop convulsing and start to improve. But Mickie didn't stop convusling. Not after several doses of anti-seizure medication. She was in status epilepticus and we couldn't stop it. |Then she started breathing less and less. There were no other new admissions in the hospital, so we spent the afternoon watching Mickie gasp for each breath (respiratory rate got down to 10), in between episodes of small fasciculations and larger tonic clonic convulsions, all the while contemplating the amoutn of brain damage this girl is going to have, even if she lives. Other than nasal cannula oxygen, there are is no airway support at Ekwendeni Hospital, and Mickie was too unstable to transfer. Back home she would have been intubated long ago. But we literally did EVERYTHING we could for her- Nasal O2, IV fluids, dextrose, anti-malaria drugs, antibiotics, anti-seizure medications (which we had to stop because of her depressed respirations...). Then we just watched her, hopelessly. She remained about the same- episodes of convulsions, respiratory rate of 10 for the rest of the day. There was a sparkle of hope, but both staff and family doubted this little girl would make it through the night. We went home for the usual workout on the footy field with a bunch of the little boys following us, email, dinner of pork & rice, shower, and bed- but Mickie was on our minds entirely.

Call it a miracle, God, or modern medicine, Mickie was alive Tuesday morning. We couldn't say that she had improved, but she was alive. Her respiration rate was up to 16. Her sugar was a little better controlled, as well as her convulsions, but she still remained unconcscious for the most part. She definitely looked strange and hyper-agitated. Its hard to explain, but if an old medicine man confessed to me that there was a child in the hospital filled with evil spirits- I'd pick Mickie out right away. She facial expression and movements were weird and jerky. She's alive, but something doesn't seem exactly right about this child...

But Tuesday brought us more patients- another young boy with seizures that didn't respond right away to anti-seizure medications (but ultimately improved with anti-malarials), an HIV patient in the male ward with possible cryptococcal meningitis. Julie and I joined a medical officer in the operating theater for 2 tubal ligations- done under LOCAL ANESTHESIA. That's right, women who are reading this blog, with just a little lidocaine, the surgeon sliced through the skin and abdomen, dug around until he found the fallopian tubes, tied them off, cut them off, tucked everything nicely back in the small but deep hole he'd created, and sutured the belly back up- all with the same piece of suture. These women must've REALLY wanted the surgery. One woman did end up getting general anesthesia because some adhesions on her uterus complicated the surgery, but the other patient got through the whole shebang with a little lidocaine- while crushing my hand in the process she was squeezing it so hard. But Mickie made it through Tuesday too.

Tuesday evening was very pleasant. I spent quite a while playing games with handful of local girls, about ages 8 through 10. We were playing hand games and they were teaching me some of their clapping songs. This brought me back to my days at Erlton Swim Club, me and Jeannie passing by the miserable minutes of adult swim with "Double Doube This This Double Double That That". If a young African girl comes up to you asking to play Double Double- I'm taking credit for teaching them! We'll see if it catches on... We also joined the Ekwendeni Team Mzungu (bascially all the whites in town plus the Malawian medical students) for Pancake Night at Carol's house- the ever-so-innocent UK holiday similar to Mardi Gras, marking the Tuesday before Lent. They make pancakes in order to use up the flour and sugar and whatnot around the house before Lent. They were tasty pancakes-- much more Ekwendeni-style than earning mardi gras beads in New Orleans (although we've seen our share here, as Julie mentioned about indecent exposure).

This morning, Mickie was still alive- AND NOT CONVULSING! She actually appears to be getting better. Who knows if she will ever be a normal child, but at least she's alive today. Other than that, today was very slow and (dare we say it?) quiet around the hospital. Nice to relax and read on the porch. We'll see tomorrow what Malawi throws our way.

Standard Operating Theatre Attire

Scrub dress, welly boots, reusable cap and mask, and a rubber apron: Very stylish.

In this moment, everything is perfect.

Lake Malawi. Now we get it. What a wonderful place. We were there for approximately 7 minutes before we decided that...
1. We are jumping in the lake immediately.
2. We are coming back next weekend.

We stayed at Mayoka Bay, a backpacker's paradise about 10 minutes outside the main town. For $10 a night, we had a brilliant lake view, ate delicious food, and met some amazing people. If it weren't for the lack of plumbing facilities (1 actual toilet and 1 compost toilet for the whole place), I'd call it a resort.

It took about 2.5 hours to get there- I was proposed to by an old Malawian man on our minibus ride to Mzuzu, then our taxi to Nhkata Bay was stopped at all 3 police checkpoints and fined for some minor detail (no fire extinguisher, 8 people in the car instead of 7, having tanks of gasoline in the trunk...) Malawian police have to make their own wages, so they often stop and fine taxi drivers, or elicit bribes. But we finally got into town, then hiked about 20 minutes uphill to the lodge. As soon as we got our rooms (Rhianna, Jenny, and Carol right on the lake) and Julie and I a little higher up the cliff, we changed into our suits and jumped into the lake, swimming out to a little floating dock anchored off shore. The water is clear green/blue, deep, and the absolute perfect temperature. Totally worth the shisto, which we will definitely have by the end of the trip. Oh well, there's meds for that.

After a short swim before dark, we changed (who needs to shower when there's a lake?), and headed down to the main porch/dining/bar area for a BBQ party (SALAD! guacamole, beans, carrot slaw, veggie sausages, eggplant, chili bites) and some "beverages" of the Carlsberg category. We were all staying in little cabins with porches, but there were also many backpackers there camping out in tents.  Backpackers are some of the most interesting people. Chris a scuba instructor from South Africa, Vionne a flower harvester for perfumes from South Africa, and Scott a tree climber from Seattle (and younger brother of Cross Country skier Olympian Holly Brooks) had previously met each other on other backpacking adventures, but all decided to meet up again, quit their jobs, and take a year to travel from Capetown to Cairo. Dave and Karen were a young couple from east coast Canada who also quit their jobs to travel through Egypt, Tanzania, Malawi, and Mozambique for 10 weeks and we looking to extend their trip a month longer. Brendan was a young structural engineer from Ireland who had spent 5 weeks in Mzuzu setting up water pipes before starting a new job this spring in Cairnes, Australia. Nicole and Amanda are 2 Dutch sisters working at a hospital in Nhkoma, just outside of Lilongwe for a year. We chatted with everyone and shared amazing stories. It was a really fun evening, which ended to eloquently as Julie and I sat on our porch watching it lightening mystically over the Lake. Words fall short, really.

It thunderstormed pretty severely overnight, but we managed to sleep in/ Julie and I grabbed some brunch (the Breakfast Combo- the most delicious toast with homemade lime marmalade, a bowl of tropical fruit (papaya, mango, apples, bananas, guava), french press coffee that is impossible not to spill, and muesli, a cereal-like mixture of oats/grains/craisins). The food alone is enough of a reason to return. Then we hiked a little down the hill to a small row of craft shops to haggle for some souvenirs and postcards, then returned to the lodge just in time for the Lake Boat tour! This was the excursion of the day.

In a small wooden fishing boat sat Jenny, Claire (who arrive earlier this AM), Carol, Rhianna, and the Dutch sisters Amanda and Nicole, Julie, myself, and our captain named Gift, and a couple other Malawians along for the ride. Captain Gift led us out of the bay and along the coast of the lake where we fed eagles! There are two eagles named Tony Blair and Condoleezza Rice. Gift stuck a small fish with a stick, whistled loudly, and tossed the fish into the air where it landed about 20 ft from our boat (after he had jokingly put the dead fish in his own mouth for a minute or so- EW). Tony left his perch on a tree, fly right over us and dove down to swipe the fish out of the water and flew back to the tree to enjoy his snack. We repeated this a couple more times, I got to throw a fish but purposefully tossed it close to the boat, which didn't please Tony. I had to retrieve the fish and toss it a little further out for his liking. Still got some amazing pictures though. We also saw lizards and monkeys scurrying along the coast. Next we found a nice big rock to go "cliff jumping" (which was really only about 5 meters high). Climbing up the rock face itself was a bit of a challenge (my climbing skills would've made Josh proud!) and being the show-off that I am, I started off with a nice front flip of the rock, but (serves me right) over-rotated and hit the water just perfectly to lose my bikini top over my head. Did I mention how clear the water was? Luckily, I was able to pull my top back over my head before surfacing, but it was still a good laugh for everyone. Gift, Carol, Julie, Amanda, and Nicole (with A LOT of persuasion) made the jump. It was actually so deep right off the rock that I was even able to do a few nice swan dives!

After we had our fill of jumping, we swam over to a collection of rocks perfect for snorkling. We saw so many schools of small fish- some neon blue, some black, some dalmation. It was really something. There were also a few small cave tunnels that Julie and I had fun swimming through. Then we swam to shore and met the rest of the boat on the beach where we had a long jump competition with some of the local children. Julie represented Team Mzungu very well- a smashing third place victory earned her the nickname "Serious" dubbed by Captain Gift. As the daylight started to fade, we boated back to Mayoka Bay, fed Tony and Condoleeza a couple more times, then docked for the evening. Julie and I relaxed with some hot coffee (was getting kind of chilly without the bright sunshine) and the most delicious fresh Bruschetta on homemade baquette. We showered then returned to the porch bar to play some pool with Dave & Karen (we won, obviously), partake in the Curry Night buffet (not quite as good as the BBQ, but still yummy), and sat around the table sharing more stories wtih more backpackers. Jasmine, a Dutch girl who just graduated from law school but decided she didn't want to be a lawyer was traveling alone for 9 months with the ambition to visit 3 continents- South America, Africa, and India, had just arrived in Malawi, starting month 5 of her trek. Exhausted from the day's activites and the blazing sun, we hit the sack pretty early Saturday night, but still took soem porch time to enjoy the lightening over the Lake.

Another full night of thunderstorms, but Julie and I awoke early on Sunday and enjoyed another Breakfast Combo each, plus one giant banana pancake. Then we decided to hop in one of the dugout canoes and paddle around the bay ourselves. For those of you who didn't watch the Malawi episode of the Amazing Race in which there was a dugout canoe race, dugout canoes are crazy tipsy, incredibly difficult to balance, and even more difficult to maneuver- but we made it across the bay and back without tipping (although steering was another issue)! It was quite the accomplishment- none of the Mayoke workers thought we could do it! Although, we did stradle the boat with our legs on the outside, instead of the inside, which makes it a wee easier. Next week we aim to successfully complete the Mayoke Challenge- paddle out to the floating dock and back without tipping earns you a free night's stay (legs on the inside, of course)! Then we sunbathed on the floating dock, enjoyed pineapple Fantas, and chatted with a few more backpackers until our cab picked us up at 2pm to take us back to Mzuzu. We were sad to leave.

Backpackers are another kind of people. We LOVED hearing their crazy stories- people that actually QUIT their jobs just to accomplish crazy dreams. Chris put it nicely when he explained to us "I figured I could travel the states and Europe when I'm old, but I had to tough out Africa while I am still young". How can you argue with that? We just listened with awe the things they have done and seen. We want to accomplish these things too! It made me realize that this will certainly not be my last trip to Africa. I'm coming back.  There is certainly a sense of longing when you hear their stories and you start planning your trips for the future. But then again, we're HERE too. Right NOW. We ARE accomplishing these things and seeing amazing sights, even for just one month. In this moment, we are all the same. In this moment, everything is perfect. That's Lake Malawi.

Five Things: How Many Christmases Do You Have?

This weekend (on our fabulous trip to Nkhata Bay... check out Stevie's blog for more details!), a Malawian man asked me my age by saying "How many Christmases do you have?" I laughed at first because it was such a funny way of saying "How old are you?," but later it got us thinking about other simple things that are much different here than they are at home. Each of the five things today have an American version and a Malawian version - here they are:

1) Rainstorms

American version: In Ohio, rainstorms last all day.... or even all week. There is rarely sun within 24 hours of a storm, and when there is, we all make a huge deal about finding a rainbow. In fact, when I was little, my dream occupation was to become a "rainbow watcher"...my career plan was to hunt down rainbows and take pictures of them - that tells you how rare and special they are!

Malawian version: It's "the rainy season" here, so Stevie and I came well-prepared... new raincoats, umbrellas, ponchos... we almost even wasted precious packing space on rain boots. Little did we know that even on days that it rains (which has only been about 1/2 of the days we've been here), it's 80 degrees and sunny the other 23 hours of the day. The clouds roll in very quickly, usually in the afternoon, and it rains for an hour or so. Don't misunderstand, it rains HARD during that time - the gutters at the hospital are the size of waterslides - but then the sun comes out and dries up all the rain... and the spiders here are not so "itsy bitsy"!

2) Contact/droplet isolation

American version: These terms are used to describe patients who currently have infectious diseases that can be transferred to other people in the hospital, and are used to prevent disease transmission. For example, anyone with signs of influenza, tuberculosis, etc would have one of these signs hanging outside their door, and anyone who goes in or out of the hospital room would have to put on a gown, gloves, and a mask. Some of the patients with more serious conditions (tuberculosis) are even placed in rooms with negative pressure air filtration systems, and single-patient stethescopes are used.

Malawian version: Tuberculosis is common here, and there is a specific "TB ward" in Ekwendeni hospital. However, this ward is located at the very back of the property, so there is concern that the sickest TB patients (who usually also have HIV/AIDS) do not receive as much attention as they would if they were closer to all the other patients. Therefore, the sickest TB patients are placed in the regular ward with everyone else... kind of counter-intuitive. They are placed in "private" side rooms on the end, but the windows are left open, and often during rounds the patients are not even in their rooms. When we asked Dr. Anneke where the patients go, she said they often go to the market for lunch.... so basically from now on, Stevie and I will be donning our N-95 masks 24/7, and especially in the market at lunchtime.

3) Indecent exposure

American version: It's tough to really think of anything here, because pretty much anything goes in America.... low-rise jeans, tube tops, itsy-bitsy-teeny-weeny-yellow-polka-dot bikinis. Public displays of affection are also common, and you might see 10 different couples kissing during 1 trip to the mall. However, breast-feeding in public is very rare...malls might have a special stall or couch in the bathroom, but it would be strange to see a breast just out in the open. Look what happened to Janet Jackson after her "wardrobe malfunction."

Malawian version: We haven't seen a female knee since we arrived 10 days ago... but we have seen a lifetime's worth of breastfeeding. Women walking down the street are covered from head to toe in fabric, but yet their chest is exposed and they are breastfeeding while they walk. It is completely socially acceptable, which is great for the babies! The other strange thing is that men and women really don't show any affection in public - no hand holding and definitely no kissing. However, same-sex friends often shake hands and then continue to hold hands throughout their conversation. Two men holding hands and walking down the street is very normal, and means nothing more than friendship.

4. Transferring a patient

American version: The process of transferring a patient from an Intensive Care Unit room to a regular ward room can literally take ALL DAY. It might start after morning rounds with the ICU resident calling the ward resident and explaining the patient's hospital course. Then the ward resident would track down her attending physician and clear the transfer with them. Then the unit clerk would have to call the patient transfer center and check for bed availability. And of course the ICU nurses would have to check out the patient to the regular floor nurses....and then maybe by late afternoon, the transfer team would come and move the patient to a special bed, wheel them to a new room, and then put them in their new bed.

Malawian version:

8:05:10 seconds - Dr. Annika tells ICU nurse that Patient X is ready to transfer out of ICU to regular room

8:05:15 seconds - ICU nurse yells across room to Patient X's mother that she can take patient out of ICU

8:05:25 seconds - Patient X's mother scoops up the baby, all of her belongings, and the patient's IV bag and walks 10 steps out of ICU and into regular pediatric ward room

8:05:40 seconds - Patient X transfer complete

5. Nightlife

American version: Young men and women go out late and stay out late (just ask my little sister Elle!) There is really no social stigma associated with being out late at night, and even restaurants and movie theaters are open past midnight. There is also a huge spectrum of "drinking": having a glass of wine with dinner is not the same as being an alcoholic.

Malawian version: Proper women really just don't go out at night, and definitely not without a male companion. I've already written about how things slow down a lot after dark here, and a few nights ago Stevie and I had an interesting experience when we got stuck at the hospital later than usual. We didn't have any dinner planned at the guesthouse, so we had to go into the town to grab a bite to eat. When we left the restaurant, it was completely dark out, and we really only encountered men and young boys on our walk home. (Also strange was that we were the only people with a flashlight - it seems like everyone around here has night vision!) Perhaps the women are at home busy with the younger children by this time, but it's interesting to see that only men really visit bars. In Malawi, either you DRINK or you don't.