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.