mateo's malawi

a year in Africa….


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the daily news

There has been an unexpected, but welcomed, change in my assignment. I have been working in the PEDS A/E (accident and emergency) department supervising some of the 68 students assigned to Queen Elizabeth Central Hospital in Blantyre for the remaining 6 weeks of their pediatric clinical rotation. It’s been a great experience and I have enjoyed (am enjoying) my time in the South of Malawi.

From here, I can sense time moving. Reaching ¾ of the way through my Peace Corps service has taken my mind, body and spirit to various shallows and depths of experiences and exposures with people, travel, organizations, communication, health care delivery, education, culture, relationships, disease, adventure, poverty, emotions, food, wildlife, politics, systems and the human spirit. Some are twists of the familiar…others are completely unfamiliar…etching new pathways to ponder, problem solve and place. Testing mental strength, resiliency, self-confidence, trust, knowledge, vulnerability, common sense and self-assurance. Each one seemingly posing a challenge or a lesson along the way, sometimes without clear understanding, meaning or purpose…or maybe there is no intention of any challenge or lesson, but rather, simply, its just life showing itself in the world around me.

Some days my frustration cloud thickens more than desired…other times its thinner than expected. Regardless I manage at some point to find a way through or around it…depending upon my perception on any given day.

Like when:

…The rains fall and I find myself standing a vulnerable victim to mother nature – at times a very serious mother nature – when the “road” upon I am walking becomes a rapid river in literally minutes…and I go from happy and dry to defeated and severely drenched (most times, neither the umbrella nor the raincoat can provide shelter against the rains of Malawi Mother Nature).

…I walk the path to my house…and a 1 meter black mamba slithers quickly away in front of me…luckily away from my footsteps and toward the vast cornfields that now surround my house.

…I decide to travel within this beautiful country that is Malawi…and wait upwards of 1-1.5 hours for the minibus to fill up with 10 too many people/chickens/rice sacks/logs of wood/(insert: anything else) so the journey to my destination (which is approximately 1 hour) can begin. Within 5 minutes of departing from the bus depot, the minibus runs out of petrol…and is now blocking a quarter of the road as the driver jumps out of his seat, grabs his jerry can for petrol and scrambles to the nearest petrol station. Upon his return he puts some, not all, of the petrol into the tank…and then drives to the petrol station to put in just enough petrol to make it to the next stop (usually none of the gauges work on the dashboard anyway – just one of many deteriorating and dilapidated features of the minibus) leaving the rest of the petrol in the jerry can which is kept in the back of the minibus (note: filling the petrol tank on the minibus to full is bad practice…for fear that someone might siphon gas – which is expensive – equaling money lost). For them, it’s figuring out how to get through each day and make it to the next. I get it. For me, waiting longer to depart the bus depot than it actually takes to arrive to my destination – taking into consideration the many potential delays of multiple stops, flat tires and fallen off door blunders along the way – has just become part of the escapade. I roll with however it plays itself out – arriving safely without incident is the goal. The phrase “time is money” has very little meaning here.

…I have the pleasure of the “Malawian non-service, customer service” experiences. The concept of customer service…well, is basically non-existent. The best examples are during my outings to Airtel (the store to purchase “Airtel money” so that I can pay my electric bill, put internet time onto a dongle plugged into the USB port on my Mac or put airtime onto my 1990 Nokia mobile phone with T9 for text messaging – jealous yet?). Literally, I stand in line and wait appropriately for my turn, as Malawians will cut the line for a more strategic placement then when they first arrived – without question. Once I make it to be “next” in line (because I will still follow my ingrained American culture habit of actually respecting one’s place in a line – waiting patiently and fairly – for my turn)…the Airtel representative may…or may not acknowledge my presence as actually being the next “customer” to assist. S/he may blatantly tend to other business with other customers (who are not in any line per se) or play leisurely on his/her cell phone or use the time to take a personal phone call or just chat it up with a co-worker for a hang out sesh at work…all the while I am standing there staring them down for their attention…until they are good and ready to assist me (yes me, the one who is actually the next “customer” in line). It’s a glorious experience…said no American ever.

…A visit to the ATM machine…turns into a half-day’s event…if you can hold out that long (depends on how badly you need funds – which is ultimately the driving force of your now “mission accepted”). When the ATM machine here on the KCN campus (super convenient…right? – well in theory) is working, it’s great! However, more often than not it is destined to be out of cash or temporarily not available or only allowing for single bill transactions (literally it will only give you one 1000 MK bill per transaction). From here, I am then left with the option to walk the 25-30 minutes to the next nearest ATM…and hope for an oasis of change. My reality undoubtedly slaps me square in the face to remind me…son, the first world this is not. Once I arrive, I will be greeted with a line of Malawians hoping to accomplish the same task of retrieving money for the day. Regardless if there are few or many in line, strategy has no place here, and this is why: what appears to be just one person in front of me…may actually be 6 (say what?!). Ahhh yes, – this is because they, in addition to their own ATM transaction, are also unselfishly handling transactions for a parent, a sibling, a spouse, a friend AND (not or) a neighbor. So the 1 person is now 6. Multiply this possibility by just 3-5 people in front of you…unlucky. Multiply this possibility by 10-15 people in front of you…sheer madness. Patience is tested. Outwait. Outlast. Outstay.

…“Yes” means no…and “Yes” means well…yes. This continues to be my experience…some days I can work within its cultural structure…and other days I’m less amused. Last week working with 8 of my students during clinical I was reviewing formulas and equations – testing their knowledge and math skills with conditions, medication and fluid treatments for things like malaria, hypoglycemia and burns in pediatric patients. This scenario is much better heard from my mouth than I could ever do it justice typing, but here it goes. Regardless of what question I ask – do you know the clinical signs of malaria? Do you know the dose of quinine? Do you know the formula for dextrose 10% and how to make it? Can you tell me the fluid resuscitation volume for a burn patient? Inevitably, the answer is always “Yes”. When asked specifically to list some of the clinical signs of malaria? Or tell me the dose of quinine for a 10 kg child? Or show me the volume in mls of dextrose 10% for an 8 kg child? Or explain to me how you administer the fluid resuscitation volume to a burn patient in pediatrics? Often, more times than not, I will get a blank stare…radio silence. In the past, I would point out the inconsistency of their original answer “Yes”, but now I just try to reword the question (when possible). Truthfully, they say, “Yes” because they do not know the answer and the fear of disappointing you is too great. Which is THE LAST thing a Malawian would want to do. So they say, “Yes” because they know that is the answer you would want them to say (it doesn’t matter if its actually true or not). I struggle with this aspect, morally. My culture teaches me to value truth and honesty with integrity. My culture also respects, mostly without judgment, to answer, “I don’t know” when truly I don’t know. This concept is especially important in nursing and medicine while in clinical practice. A patient’s life could be dependent on my honesty about a medication administration, a procedure or my knowledge to use specific equipment (dramatically worded, yet potentially true). I remind my students that it is ok to tell me, “I don’t know” but they must follow it up with, “but I know where to look to find the answer” and actually go to find the answer to share with me. Even still, the phrase “I don’t know” is very difficult for a Malawian to verbalize. This cultural norm transcends many questions of any nature. In examples nonspecific to the above, I often walk away from conversations not actually knowing what may…or may not have been said.

…The communication and information highway here…is less highway and more of an abyss. Based loosely on a “need to know” now…or never basis. Typically, when I receive messages from one of the faculty members at KCN informing me about a department meeting, a presentation, a lecture, a workshop, an exam vetting, an exam grading session or a (insert anything here). The information delivery usually presents in either one of two forms of communication – both very last minute in nature (my favorite part). The first is if they happen to see me on campus walking to my office, I will discover that at that very moment they are speaking with me is when they are deciding now to inform me about any said event from above. Seems logical, because it is happening now (thanks for the heads up guys). The second delivery method is via SMS (text), which will typically inform me of a said event from above that it is happening in 5 to 15 minutes from now. I refer to this information jokingly as “hot off the press”… but in all seriousness to a Malawian it is standard operating procedure. Truthfully, I find it exceptionally disconcerting because I will be in the middle of supervising students or have had other things planned for that day (which by the way is my fault…planning is a loose term here – something that is meant to be flexible and rarely followed through). As an example, at one point on a Monday morning in mid-JANUARY, I was setting off from the office to the hospital to supervise my third year students in their pediatric clinicals and I happened upon a fellow colleague who informed me the medical-surgical department (my entire department) was in the conference room grading exams…for the week! Ok seriously guys, you couldn’t have told me about this any sooner than TODAY? So instead of supervising students at the hospital that week and holding our 2 skills lab sessions for both the first and third year students…the entire department was on lock down for 4 days as we graded exams, by hand, with each exam reviewed twice by two separate lecturers –including essays, for 150 first year students, 177 third year students and 100 ish fourth year students from their theory classes in NOVEMBER. It turns out; efficiency is another loose term applied here.

…The start of my day is performing chest compressions on a 5-month-old twin who has most likely been suffering from too many days of vomiting and diarrhea complicated by malaria…or the potential electrolyte imbalance from too many days of dehydration.

…Attending mortality rounds each Friday morning to find that in certain circumstances emergency equipment was faulty, non-existent, misplaced or gone unnoticed by staff to suction a child or provide oxygen.

…Witnessing the volume of children admitted to Queen Elizabeth Central Hospital in Blantyre (or KCH in Lilongwe) who are placed shared in a bed as they battle their diagnosis of malaria, pneumonia, sepsis, meningitis, anemia, malnutrition, hydrocephalus, trauma, HIV or cancer…and wondering if true infection prevention and control will ever find its place in Malawi.

…Wrapping my brain around the concept of capacity building…and wondering about the likely possibility of effectively training an intake of next year’s projected nursing class of over 300 students…when I feel the quality of education and clinical competency of the existing 177-250 students in each class is being compromised.

So I am left wondering…

How does a developing country meet the demands of their own broken health care system? How does a misguided government purpose to effectively prepare to graduate the gross number of nursing students per year that is being suggested by the Ministry of Health? How can an overwhelmed university provide a quality education while maintaining accountability for the competency of their students who will graduate to clinical practice? How do overworked and under resourced lecturers, clinical instructors and nursing staff work together to produce knowledgeable and competent students who will practice and care for the children of Malawi in their own health care centers, district and central hospitals?

Are the solutions being presented reasonable? Can a country move forward with goals that appear unrealistic for even the most ambitious of people? I teach my students about making the goals of their nursing diagnosis and interventions to be SMART (specific, measurable, attainable, realistic, timely). Are their own government, their own ministry of health, and their own university doing the same for them for their education and training?

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pang’ono pang’ono

I am reminded of a quote once stated by infamous musician Frank Zappa,

“Without deviation from the norm, progress is not possible.”

If I am being optimistic and using his words as encouragement, I couldn’t think of a better statement to apply to my past 5 months living in Malawi.  I couldn’t feel more deviated from the norm than now, but progress feels slow, barely noticeable.  I am reminded of a drop in the bucket theory…the ripple effect…pang’ono pang’ono (slowly slowly)…

After experiencing a near rock bottom month in October…where my mental psyche, at moments, dipped well below my usual points of self-recovery, November appeared and gave me hope.  The university resolved its strike with government and the students returned to campus to start the school year.  I joined the medical-surgical faculty in their “team teaching” approach preparing and delivering a mid-term exam and 5 lectures on emergency triage assessment and treatment, trauma, pain assessment and neurological alterations in child health to approximately 170 third year nursing students during their 5-week course module.  My nerves were definitely sky high for the first lecture but immediately calmed as I began to share my knowledge of each topic with the students.  I honestly wasn’t sure what to expect, but my lectures were met with engaging students who gave me respect and their undivided attention through each 2-hour lecture series (well…with a few dozing off here and there).

As most of you know, I am not an academic professor, and if I am being honest I couldn’t verbalize to you what “educational teaching theories” or “educational strategies” I was implementing. In the simplest of terms, preparation was probably my best strategy.  My M.O. (modus operandi) is typically to go with the flow unless determined otherwise. I can tell you that I tried to keep classes dynamic involving students as often as possible to hold their interest and keep them on their toes for my random “shout out question sessions” and occasional “review knowledge by doing sessions”.  I can tell you that the class wasn’t afraid to challenge me with their own questions, ask me to clarify or speak slower English at any given point (which I welcomed and encouraged…regularly) or laugh if my American pronunciation of a word did not meet their learned ear. I can tell you that, yes, I did feel somewhat accomplished at the end of each class.  I can tell you that, yes, I actually did enjoy teaching. I can tell you that, yes, two hours is a LONG time to lecture.  Overall, it was fun, but it felt like it was over before it even began.  I was ready for more.  A faint taste of progress maybe…maybe not.

Adding in a fun-filled weekend of Thanksgiving celebrations with my fellow GHSP crew and newly found friends down in Blantyre…followed by a weeklong IST (interim service training) here in Lilongwe with Peace Corps Post, PC HQ DC and Seed Global Health from Boston and ending with a KILLER 3-day safari at South Luangwa National Park in Zambia, November quickly became December…all helping to push time a little faster here in Africa…definitely progress!

This past week the students have been assigned to their respective central, district and community health facilities for 12 weeks of pediatric clinical practice.  I have been assigned as one of the clinical instructors working at Kamuzu Central Hospital with 35+ students who are constantly rotating through the different children’s wards every 2-4 weeks. Once again, I have come face to face with new challenges to ponder and problem solve.  As you’ve heard me say before…in comparison, life here isn’t always easy…and no other place is this more apparent than working in health care at a large central hospital in the capital city of Malawi.

In prior blog entries I’ve discussed the burdens and challenges of working in a severe limited resource setting.  After 5 months, I struggle less with it working on my own, but now charged with teaching other students in a system that is for the most part broken or completely under resourced and ill managed, has the potential to be perceived as a beast to conquer…at least initially.  Imagine trying to teach in a system that you yourself do not completely understand.  Standard operating procedures and protocols for nursing practice are undiscoverable in the day to day.  Organization is just a noun without any real implementation.  Survival is the priority…the rest gets lost in the details.  The students themselves become a dichotomy in this system.  They are an added burden to the already understaffed nurses.  There are just too many patients and not enough equipment and resources, which contribute to an equation of missed teaching opportunities for students.  At the same time, the students are an added bonus.  They are expected to immediately join in and work as if they are staff…reducing some of the workload.  Trial by fire in its truest form. Learning becomes doing with negligible preparation, instruction or even supervision. Not exactly an ideal model for knowledge and skill building.  This is simply the expectation.  This is their education system for learning.  This is their health care environment.  This is their reality.  Of course they recognize the difference but there are few other options.  Throughout all of this, the students carry on as willing and active participants…with very little, if any, complaint.  They remain thirsty for any blip of an opportunity for supervised learning along the way.

The role of clinical instructor is to help offset this burden for staff while providing support and supervision for the students.  This becomes a near impossible task when the reality is that one clinical instructor is left available to supervise all 35+ students simultaneously. You’ll be confused to know that three other clinical instructors have also been assigned to work with the students at KCH along with me, however, in actuality these three other instructors will rarely, if at all, show up to supervise the students.  I am learning that this is sometimes less about the clinical instructor choosing not to show up and more a result from a combination of other duties placed upon them by the university.  Others cite a lack of transportation and funding to get them to the students.  The system is overstretched…by a long shot.

I am discovering that my vision for my role as clinical instructor might have to be reformatted. Over the past week I have been brainstorming and organizing ideas to facilitate the learning needs of the students in addition to their “clinical practice”.  Maybe I am doing it more for me. Maybe they are completely content to move forward as per usual.  My feeling is that if I can show up everyday to supervise, supplement and coordinate their learning above what is expected from their existing learning module – deviate them a bit from “their normal”…maybe then I can feel and see progress…then again, maybe not.

“The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.” ― Franklin D. Roosevelt


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the new normal

If I take a moment to stop…and think about the world happening around me, I notice there is a new normal taking place.  The life I may…or may not have taken for granted previous…is now in flux.  The lens in which I view the world is now skewed a bit.  Some parts are subtle while others are a complete overhaul.  Observing, experiencing, processing, understanding, tolerating, accepting and evolving all take their turns entering my mind.

I believe the saying goes “Change is good: You go first!”

Gone are the days with washing and drying machines; dishwashers; “safe” drinking water from the faucet; hot water on demand; stand up showers; tile, wood or even carpeted flooring; proper waste management.  I now live where every other day I hand wash laundry and then hang it up to dry.  I sweep the cement floors several times a week to clean up the persistent dust and grit, cockroach and spider carcasses, gecko and lizard scat collected everywhere throughout the house.  Daily, I fill my British Berkefeld world-class ceramic filter for safe and clean drinking water.  In the morning I turn on the switch for the geyser so that in 30 min (ish), I can have warm/hot water to clean myself (but not first without removing from the tub the gathering of ants, spiders, cockroaches, gecko scat and other random droppings from the ceiling above).  Recycle? Trash pick up? It doesn’t exist.  I burn my own trash (and hope to start composting soon).  These things all take extra time…luckily I’m living on African time now…my new normal.

Gone are the days of transportation conveniences.  I no longer have access to my Jeep to drive myself…well anywhere at anytime on any given day or night of the week.  Gone are the days of stable, dependable, state-of-the-art modes of public transportation.  I now rely heavily on my own two legs and feet, my TREK mountain bike or cram myself into a dilapidated minibus that should only comfortably fit 12 – but no worries we can easily manage 20+ (including chickens, fish, timber, and whatever else) to get from point A to point B.  This is most challenging when trying to buy food and items at the market…I can only buy what I can carry…and this all has to be done before night falls at 6 pm.  After nightfall, the atmosphere here changes; safety becomes a concern…and my window of opportunity to leave my house or place of work narrows.  Of course there are “cabs” to call at night to travel out to meet up for dinner, a drink, a game, a movie or some other expatriate event, but from a Peace Corps Volunteer perspective, cabs are expensive (a round trip from my house to town is 4000MK – or approximately $10-12 USD depending on the exchange rate of the day) – nearly my daily living allowance – my new normal.

Gone are the days of paying monthly bills online or making deposits at ATM machines.  I now bike to the gas station each month to pay for an electricity credit…then I have to bike back home and enter a code into the unit on my kitchen wall to maintain power.  The same goes for Internet.  I bike to the Airtel store each month to purchase Internet credit on my dongle (the concept of WiFi is a luxury to only a small percentage of the upper class residents or institutions) so, when the Internet decides to function, I can feel connected to the outside world.  I walk to any number of roadside stands to purchase “airtime” on a scratch off card to enter into my mobile phone for communication here in Malawi for texting and calls.  The ATM machine can irregularly have insufficient funds denying a money withdrawal attempt or it limits your withdrawal to 1000MK (approx. $2.50-3 USD) per transaction.  Visiting a bank…forget about it.  There can be upwards of 100 people waiting in line – I choose no.  It’s all an adjustment – but it’s my new normal.

Living in my studio loft in downtown Denver, of course there were interruptions that could challenge a peaceful sleep.  Malawi has its own versions of sounds.  Here, I fall asleep at night to the impressively loud, constant hum of crickets and frogs or a village of serenading barking dogs or a car engine being worked on by the neighbor or music jamming from the students’ dorms…all while killing 5-10 mosquitos before I get under my mosquito net for the night…my new normal.

Similarly, on any given morning I can be awakened as early as 4:08am by a call to prayer from a nearby Mosque or a few car horns aimed at the guards to open the gate or people walking by my window talking or again the same car engine being worked on by the neighbor or birds landing on the tin roof clamoring around or the neighbor children playing and laughing…my new normal.

There are also random things I am finding that I am becoming desensitized to…like walking alongside open foul smelling sewage drains or looking at a menu but realizing only 50% of what is listed is actually an option to choose or having my 13-inch laptop screen suffice for viewing shared movies/tv programs that have been transferred onto my external hard drive from fellow volunteers… or people simply dead staring at me or kids yelling “mzungu” or “give me money” or someone openly urinating by a tree or building along the road  – all done without shame…or a woman carrying items two times her body weight on her head or seeing buildings being constructed without the use of one piece of modern machinery…or remembering to appropriately greet someone before I initiate my intended conversation with them or negotiating prices at market for food or art or clothing or participating in Malawians’ inclusive teatime breaks (of at least twice a day) or carrying my headlamp everywhere I go – just in case the electricity goes out…  These are all pieces of my new normal.

Some of the new normal is refreshing…some of it not so much. Each of it has a place where it impacts my thoughts, my attitudes, my ideas, my opinions, my perspective and my relationship with Malawi.  All of it contributes to my experience here.  I am reminded that life is dynamic…where my version of normal is relative only to what I know, to what I have been privileged to experience.

Experience has been and is my best teacher. It is because of experience that I have learned – newer, is not necessarily always better.  It is because of experience that I have learned that distance from a place, a person or a situation; allows for comparative perspective.  And it is from experience, that I have learned change can be the real challenge in all of this – because change, if accepted, allows us to grow – the new normal.


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¼ Way

This week rounds out the third month of my Peace Corps service as a GHSP Volunteer… ¼ of the way completed! However, at times, I don’t quite feel a ¼ of the way accomplished.

There are many reasons…most outside my realm of control. 

As one example, the University of Malawi support staff has decided to strike (on account the government had promised them a near 21% salary increase – effective July 2013 – which has yet to be reflected in their paychecks)…and today (07Oct2013) was meant to be the first day of the new academic calendar for the arriving new first through third year nursing students.  I arrived to Malawi in July expecting (and ready) to teach…and now it is October.  This new delay is…TBD.

Expectations.  It is a powerful word with many affects – some good, some not so good.  Setting expectations truly seems part of human nature.  It’s just what we do.  There are varying levels of expectations set from different perspectives and applied to various scenarios.  It happens every day to every one of us.  It’s affects surprise, disappoint, motivate, affirm, frustrate, relieve, dominate, challenge, elate, confirm and elicit feelings and emotions within us – a psychological roller coaster.  Past experiences working in the third world have taught me to set expectations within a special, sort of sliding scale.  Comprising a system of evaluation, setting and resetting, as required.  A practice I carry into my first world life.  A practice I pride myself on mastering.  I have learned that “for my own good” expectations should be diminished…if even created at all.  So, shame on me for allowing this word to sneak its way back into the forefront of my mind to formulate a vision of the work I expected to be doing here. 

To function in Malawi…is to learn to navigate through a complicated series of formalities…and informalities.  Negotiating communication…the meaning and unmeaning of words.  Experiencing conversations that can often run in circles where in the end, you feel more confused than from the start.  Reading instructions that may indicate one thing to the recipient but can hold another entirely different meaning from the messenger.  Being provided answers that sound concrete in their delivery…yet are vague in their truth.  Discussing plans in meticulous detail…that may or may not have intention to reach fruition.  To function in Malawi…is not easy.  

Organization in Malawi continues to mystify me.  Consistency here is dearth…at best.  Things appear to be in the right place, set in the right order, working together to achieve a set of common timelines and goals…but once intimately involved, you become more familiar and aware of the complexities, the intricacies, the challenges, the uncertainties, the unknowns…and the confusion in the whole process of the operation.  I am often amazed that things can be actualized. 

As this strike gets sorted, there are rays of light along my path.  I am trying to follow them.  Leading me away from a myriad of emotions…to a perspective I can grasp…and hold onto once again.   I continue to work some mornings in Emergency CWA (Children’s Ward A) as part of the pediatric team at KCH – each day with its own set of challenges and burdens.  I continue to round at the University for meetings and to assist faculty with various tasks related to special projects, module development, evaluation of case presentations, exam review…and both lecture and clinical coordination and preparation for the awaiting arrival of the new students (all sound super great on paper but in reality some days I feel helpful…other days less so). 

The current third and fourth year nursing students (who remain on the old academic calendar of Jan-Dec) are on campus where its business as usual for them – and another ray of light. I am teaming up with another visiting faculty member to hold review sessions to benefit these students in areas of academic deficiency.  We are also working to gain access to the skills laboratory to provide drop in sessions for these students to practice and perfect their nursing skills and techniques.  The goal being to provide them with additional support and avenues to better learning that they would normally not have available to them.

I arrived to Malawi as a volunteer to be a resource, to teach, to mentor, to advise…and to offer my knowledge, skills, expertise and support in any capacity needed.  I may not be teaching lectures or providing clinical instruction to the new third year nursing students in child health as I originally expected – at least not yet…but I am finding small ways to contribute to being effective.  I am remembering to evaluate…set…and reset my expectations.


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KCH

The Malawi Nursing and Midwife Council requires a mandatory “orientation” for all expatriate nurses wishing to function in a clinical role while in Malawi. This process can be from 4-6 weeks, at the Council’s discretion. The Council recommended my orientation to be 4 weeks.

Kamuzu Central Hospital (KCH) is the tertiary referral center for the central region of Malawi, a catchment area of about 5 million people. Rough estimates of the hospital’s size expand a range from 600 to 1000 beds (the actual occupancy almost always exceeds the intended or optimal occupancy). The hospital is centrally located in Malawi’s capital “city” of Lilongwe and has five floors, four operating theatres (potentially), an adult emergency department, one adult and one pediatric ICU, three large pediatric wards (including pediatric emergency), a maternal center, a neonatal nursery, a laboratory (unsure if there is a fulltime pathologist and often results are delayed) and a radiology department (ability for plain films and ultrasound and I think the CT scanner is working now but no MRI that I know of and on a good day you might even find a trained radiologist).

My placement was spent in pediatrics (including neonatal). I alternated my time between the two pediatric wards, the nursery, and spent the majority of clinical in pediatric ward “A” which included the nutrition rehabilitation unit, the high dependency unit (or ICU), the U5 clinic (urgent care/triage), and the “emergency” area of pediatrics (where I naturally gravitated). These past 4 weeks proved to be eye opening as I was able to experience first hand how healthcare is managed in Malawi. I would find that many of the things I would want to do clinically to care for patients – well…just were not always an option.  At current staff, there are only 4 pediatricians available (2 Malawians and 2 Expatriates – 1 is a fellow GHSP Volunteer, Dr. Margot Anderson, who works her New Orleans tail feathers off at KCH) to manage the sometimes 300+ pediatric patients, some whom are extremely sick. Nursing is stretched as well. Nurse: patient ratios can range from 1:10-30 to 1:60-80 depending on staffing availability for any given day or night (the one exception is the ICU nurse: patient ratio of 1:3 or 1:6 – which easily doubles with bed sharing).

In week one, I had my first experience with death, a burden I would learn in the coming days, weeks and months to be almost too unreasonable to bear for any human, but such is life in Africa. I had just arrived to the emergency section of Pediatric Ward “A” and noticed staff gathering to the bedside of a 6 month old in acute respiratory distress. After multiple attempts, including EJ (external jugular – which is done here without sterile procedure – and they are quite skilled in it), we couldn’t obtain patent IV access…and no IO was available (inter-osseous – which proves to be a lifesaving and quick procedure during a resuscitation – the hospital was waiting for more supply). There were no working monitors to trend vital signs. We were able to provide oxygen via nasal cannula CPAP (continuous positive airway pressure, a treatment that uses mild air pressure to keep the airways open)…but ultimately the patient coded (as evidenced by posturing, limp and breathless without palpable pulses or audible heart tones)… none of the present nursing staff were reacting to the deteriorating clinical situation (or at least not how I would have anticipated)…so I stepped in along side the pediatrician to palpate for a femoral pulse and auscultate for heart tones while looking at the pediatrician and saying “she has no pulse…. I am going to start CPR…ok?”.

Working in the pediatric emergency department in Colorado, this delayed response by the nursing staff to initiate CPR would have been viewed as a gross hesitation (a lack of good clinical judgment) and asking for permission to begin CPR, unheard of – but here in Malawi I am learning to wage my actions differently. I am finding my way in Malawian healthcare. I have learned it would have been more inappropriate for me to initiate CPR on my own. I am learning that sometimes doing nothing…is better than doing something (a concept that remains a challenge for me).

However, given the circumstances at hand, standing at the bedside and waiting for action was not an acceptable resolution in my Western trained emergency mind (at that time)…. so I negotiated my actions by first asking for permission before initiating CPR. I had to navigate what my emergency nursing training was telling me to do…while being culturally sensitive to the environment I was working within. Without IV/IO/ET access to give critical medicines like epinephrine, etc….no EKG or other monitoring devises…no AED or usable defibrillator…. and no appropriate blade sizes to intubate…I felt compelled to react, as trained. Another nurse searched for an ambu bag (a self-inflating bag to assist in breathing)…eventually an appropriate sized mask was located… and at the direction of the pediatrician, she and I continued 2 person CPR…in a room with about 70 other sick patients and their caregivers watching us, including another infant sharing the same bed as the patient we were trying to resuscitate back to life. The moments here can sometimes feel surreal.

Here in Malawi, I (…or we) will be trying to function clinically within an already severely overworked, understaffed and otherwise seemingly broken system…handicapped within a resource limited setting. There can be scarcity with drug supply, critical antibiotics and analgesics needed for treatments, procedures and comfort. There are no mosquito nets covering the beds to protect patients from the impending malaria diagnosis. The lack of appropriate supplies for personal protective equipment wage risk for exposure to TB and blood borne pathogens. Management of immunocompromised patients becomes that much more difficult. Supplies for simple procedures like laceration repairs, lumbar punctures, intravenous access and rehydration fluids may be limiting in the options you can choose. What would otherwise be simple management of dehydration becomes life or death.

Orthopedic patients may sit for weeks in traction to reset bones (procedures that would be corrected within hours in pediatric emergency departments in the US). Babies born and who soon will die from “birth asphyxias” and other conditions requiring surgical interventions that are just simply not possible here. Wound care, burn care, infection control…often trying to find a sink with soap and running water is a challenge – need I say more.

Oxygen. Without it, life is lost. Oxygen is taken for granted in the US healthcare system as always being readily available for any patient at any time. For healthcare in Malawi, this isn’t the case. Access to oxygen is in short supply for the number of patients who could actually benefit immensely from it’s use…and triaging to decide which patients emergently versus urgently need oxygen over others is mind boggling. To add to the complexity of limited resources, there are limited working ventilators (a machine that supports breathing) here for patients…so mothers, grandmothers, fathers, siblings, family members are the one’s burdened with bagging their intubated child all day and through the night securing their best chances for survival. A picture truly is worth a thousand words.

And while the mortality rates for children under age five in Malawi remain unacceptably high (about 1 child out of every 8 dies), it is remarkable, given the circumstances, that some children do, in fact, survive. Some children do, in fact, grow and develop into adults. Resiliency – doesn’t seem like a strong enough word to use to describe life here… or maybe rather…Africa is its best version of a definition.

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rhythm

There is a rhythm here….a beat….a buzz…its palpable.  There is an organized rhythm to match the chaos of the day to day.  Malawians know the rhythm.  They are the rhythm.  They live the rhythm.  They set the rhythm.  As expected, they seem to function quite well within it.  Me….well I’m learning…

It is felt in the sounds that I hear.  The songs sung by children playing, women gathering or sadly, as I walk to the hospital every morning, families expressing through traditional ceremonial song the untimely death of a child, a parent or a friend.  It’s both beautiful and heartfelt to witness. Their words I may not understand but their sounds relay a universal tone of understanding. 

Noise.  Horns from speeding cars passing by you within inches or the minibus taxi driver desperately attempting to get your attention to ride in the already overcrowded cab to your next destination.  Words from a passerby on the street simply sharing a hello, a beggar asking you to “give me money”, a child yelling “mzungu” and laughing, multiple street and market “entrepreneurs” calling out “hey boss….brother – over here is good deal” because they need your sale for survival.  Music.  The radio blares at unnecessary decibels from cell phones, from within cars and buses, from the streets and less frequently, from homes.  It can seem random and to my ears the loudness alone makes the music seem unbearable, but not to the Malawians.  It is part of their rhythm.  It is how they must like to hear it.

Cell phones ringing.  It’s interesting.  Most cell phones have dual SIM card capability in the likely event that when one phone network is not working the other one might be -allowing for uninterrupted (in theory) communication.  Regardless of what one is doing when that cell phone rings, there is a >99% predictability that the ring will be answered immediately.  It’s an interesting observation, especially considering that in my culture this would be considered extremely rude, inappropriate and unprofessional in some circumstances, but not here, not in Malawi.  It’s their rhythm.

Here, you often hear the phrase TIA (This Is Africa).  I think from my perspective it helps to explain the unexplainable….the African rhythm.  It’s often used when there is no other solution, no other explanation, and no other words to make sense of the situation at hand.  Psychologically it helps you to disengage from the things you cannot change or the things you cannot wrap your brain around to understand the hows and the whys (which eventually you learn to stop asking)….while allowing you to accept what is…shake your head….have a laugh…and move on – the way forward.  TIA. How does that serenity prayer go again…

So there is a rhythm among the chaos.  A rhythm the Malawians have perfected…and I am just learning the first steps…

 

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house 8/D

Saturday was the official move in day for the 11 GHSP Volunteers in Malawi.  Seven were transported to their new homes in infamous Blantyre, two were escorted up north to the beauty of Mzuzu, and I was dropped off at my house here in Lilongwe along with another GHSP Volunteer (Crystal, a Midwife from Tennessee).

There are a total of 4 identical houses in our “complex” here on the grounds of the University of Malawi’s Kamuzu College of Nursing campus and just down the way from Kamuzu Central Hospital.  My third neighbor is Natalie, an Australian VSO Volunteer, (who is proving to be a wealth of knowledge for us over the next hours, days and weeks while we are getting our feet wet).  Lastly, nestled comfortably across the way is a Malawian family in house number 4.  I had the privilege of meeting 3 of the kids (Sarah, Tondo and Junior) as they welcomed me to my new home and “the neighborhood” on the very first day.

Without dwelling on many of the details, lets just agree that the house may not have been “move in ready” upon my arrival (it had been over a year since someone had lived here…and after taking my first steps into my new African home that fact remained self-evident).  Wasting no time, I headed to market with Crystal to purchase some necessary supplies for cleaning, eating and bathing (back to basics)…and got to the business of making this house a home.

Some highlights over the past 2 days and nights have included the loud random music playing into the nighttime sleeping hours including 3 and 4 and 5 am megaphone wattage delivered religious prayers; getting acquainted with geckos, ants, cockroaches and spiders on the walls, counters, ceilings and toilet; learning to appreciate the art of bucket bathing (and good news: hot water was hooked up today!); hanging the mosquito net from the ceiling to create a malaria free zone around my bed while I sleep at night; boiling/filtering water for safe drinking; enjoying peanut butter sandwiches, dried fruit and left over turkey jerky, starbursts and granola bars (still waiting for the kitchen to be put together and the cooker to be hooked up by a “certified electrician”); taking in my new surroundings while cruising to town on my new Trek (thanks Peace Corps…and yes I have my helmet – rules are rules).

Connection finally made to the States with my 2 sisters over Skype last night to laugh and help lift my spirits to reset my mind for the adventure ahead.

Before I sign off for the night, there is one thing I am certain.  The hospitality in Malawi is comforting.  It is an innate part of the culture here.  “You are most welcome” is echoed often by everyone.  My trials to greet perfect strangers in Chichewa on the streets, on the campus grounds, in the hospital, or at the market yield some of the biggest smiles this side of the Atlantic.  It warms my heart.

house 8/D

house 8/D’s compound

This is home...for now

This is home…for now