Sunday Morning~Blantyre

August 28, 2016

Sunday morning in Blantyre

Hi Everyone,

Whew, what a week. I spent my first week in labor and delivery and came home Monday evening in a state of distress unlike any I’d experienced so far. I thought maybe I should write about it right away, but wasn’t even able to do that. I left the hospital that afternoon, staggering past the market, looking at the ground, muttering “Oh my God.” I’m going to have to dig deep here to get through the weeks of orientation. I thought a few days would give me some perspective so wanted to wait until today to write. I slept great last night despite the blaring music from the bottle store down the path, and will try to do a good job of describing my week with a little more perspective than I had that day.

The mornings start at 7:30 with a morning report. The hospital is so big, that the reports are done by departments, so our’s is just maternity. This includes: antepartum, gynecology, postpartum, labor and delivery, obstetrical surgery, and neonatal intensive care nursery. The night midwife gives a report of all that transpired on the ward for the past twenty-four hours. It’s done in English, but when there is a heated discussion, they almost always revert to Chichewa. A few times the matron has reminded them that I’m in the room and please speak in English. I have to concentrate to understand the English; I don’t know how I ever did this in French. The reports consist of the numbers of admissions, discharges, births, deaths, and those that “absconded”. Then there is a description of the problem cases. The incidence of deaths are always described in detail, or what detail they have. Often the case is a bit lacking in detail, like cause of death. The matron is a conscientious, brilliant woman, with a gentle demeanor. I’m so impressed with her investigative questions that are non-threatening, but shows what a deep level of critical thinking she possesses. She doesn’t miss a trick. The nurse-midwives have so much to deal with. The sheer volume of what they do in an ordinary shift is mind boggling to me. I watch them, completely non-plussed, glide through their days, dealing with one problem after another, in a manner that must have evolved from deep survival mechanisms.

After report on Monday I went with the midwife in charge to get oriented. She had no time for this, but she was very polite and showed me around the ward (which I’d seen on my original tour and almost fainted) and gave me a brief description of what happens where. I saw the “Recovery Room” had six broken beds with torn mattresses and a few women were sitting there with their babies. I asked the midwife how long they are kept in this room? She told me they have to wait until there are six women to take them over to postpartum. The volume is so high, they can’t take them one at a time, so they are held in this room until it is full, then they are brought over in a group. So it can vary from ten minutes to eight hours in there.

I was told there were eight midwives on the day shift, which is 7:30 to 4:30, and six on the night shift, 4:30 p.m. to 7:30 a.m. Whew. That’s a long shift. But often they have only five or six during the day and as few as three at night, for 50 to 60 deliveries. The place however, was swarming with people, all looking like care-givers. I learned these were all nursing students, twenty-four of them from three different nursing schools, all working in roles that would be a high-level labor nurse position at home. They looked to me like they were doing all the care. So even though there are twenty-eight bays with a bed and laboring woman at one time, and five or six midwives, there is usually a one-on-one student with the woman. This was heartening. But the students are completely unsupervised. In fact, at the nursing school where I’ll be teaching, there is only one clinical instructor for 250 students in midwifery. I’ll be number two. But many of the students were already nurses and were coming back to school to get certified in midwifery, and they were really good. They were doing all the assessments and the deliveries completely independently. One of them told me it’s the way the government gets free labor.

Ok, I know that the first day is the hardest in an unfamiliar environment. I know that I will adjust, and by Thursday, I wouldn’t call it adjusted, but was more resigned to the conditions. Only a few of the sinks have water. Some of them have clogged drains with standing, bloody water in them. I saw one maintenance person scooping it out with a cup, and gagged. The beds have no sheets. The women put down one of their chithejes, the cloth they use for skirts, luggage, child carrying, sanitary pads, dish cloths, towels, blankets, shawls, EVERYTHING. This cloth is used for everything. There are thousands of colorful patterns and the newborns are often identified by which chithenje they’re wrapped in. The women are asked to bring at least six chithenjes, a plastic basin, and a guardian. The guardian is paramount; they do a lot. It’s always another woman: mother, mother-in-law, aunt, sister, someone. God bless those guardians.

After a woman is assessed in the little room by the door to the ward, she’s given a status according to priority. Those in very active labor go straight into the labor and delivery room with the twenty-seven other women, and others, not so active, sit on a bench and wait. For hours. Sometimes they get sent to one of the clinics if appropriate. The screening process is pretty good from what I observed. There were three students doing the assessments and one midwife supervising. I spent most of the first morning putting my eyeballs back in their sockets.

At one point a maintenance person opened the door and said there’d been a delivery in an ambulance. A woman being transported from an outlying clinic had delivered on the way by another patient in the ambulance. A student ran down to the parking lot and delivered the placenta, which she hand-carried, wrapped in a chithenje (of course) to the red bucket in the ward, designated for “placentas only”. (I saw a ton of other shit in there, though.) It’s a long walk to carry a dripping placenta. This woman got priority seating in the labor room, just in time for her postpartum hemmorhage. Blood everywhere. But it was handled quickly and efficiently and I was impressed. The students and midwife got the bleeding controlled, an IV in, pitocin given, and the blood sopped up, within a matter of minutes. (I know this because I spent so much of my week watching the clock. I can’t count how many times I said to myself, “it’s only been a half hour?!”) I will say, though, the charting is extremely simple. I can see why they have time to take care of so many women. The charting is done on scraps of paper tied together with a piece of gauze. Someone in the admission room punches two holes in the paper and threads a string of gauze which has been cut into a strip, through the holes, a little like our fourth grade book reports. Only our reports had nice construction paper on top. These do not. Anyone walking by can write what they want on the scraps of paper, such as a medical student creating a plan of care for a woman he saw for ten seconds. Then the latest plan gets more or less followed. The plans, as far as I could tell, were not consistent with the current status of the women, but based on some diagnosis previously recorded. (Eyeballs back in.) The part I liked about it though, was, no one was looking at a computer. Or a monitor. There are a few dopplers for fetal heart tones, and they are used appropriately, and shared well among the staff, but no fetal monitor.

At noon that day I came home for lunch, not that I had a big appetite, but I felt like I needed to eat something in order to be able to go back for the afternoon. When I got back over there at 1:30, a few of the midwives were sitting in their break room eating their lunch. There is a table to eat at and a side table with a microwave on it. Next to the microwave is a large hole burned in the table. Under the hole, on the floor, is a blackened electric burner, which, I assumed, caused the hole in the table. Since the midwives can’t leave the hospital at lunchtime, their food is brought to them, either by the hospital kitchen, or a friend. As I was sitting and chatting with the ones that were still eating, a large rat ran out of the adjoining room, through the eating area, out into the hallway, and headed down toward the labor room. I gasped (I did not scream) and came off the chair about two feet into the air. Not one of the other midwives budged. Not one bite of their lunch was disturbed by this sight. The midwife across from me popped a bite of nsima into her mouth and said, “That was a big one.” When I got back into my seat, I said with a hint of alarm, “You have rats in here?” Again, not missing a bite, the midwife in charge said, “Yes. They go for the placentas.” They giggled a bit at my reaction, and kept eating.

It was a disturbing afternoon and the rat was only the smallest part of it. I need to adjust and be patient with this hierarchical system. It disturbs me that the midwives, (and students, for that matter) are completely ignored when the medical students and residents are doing rounds. At about 3 p.m., a herd of twelve white-coated people at various stages of training, went from one bed to another discussing the woman’s case as if she were a mannequin. She is not addressed except to be told to lie down, roll over, spread her legs, or be quiet. She is examined, with unnecessary roughness, or just unnecessarily, for learning purposes. One after the other. It was like watching a gang rape. I looked around to see what the midwives would do about this, and the answer was, nothing. Everyone turns away. I was ill. I was shaking. The woman who’d had the hemorrhage was examined one after the other while screaming and trying to get off the bed. I could not figure one reason why she’d need to be examined. I asked one of the midwives why they were doing this and she just shook her head. I left the ward and staggered home, fighting tears. Poor George had had a good day. He’d started the six week psychiatric module at the medical school and was excited about it. He took one look at my face and realized my day wasn’t so great. He listened as I vented, for which I was grateful. I kept saying, “I’ve got to toughen up. I see now the huge difference between the MSF hospital in Shamwana and this. There, we were the boss. We set the standards. We determined the protocols. I’m a stranger in a strange land here. I have no say.” That said, I do see how teaching students can make a difference down the road. It may be a thousand miles down, but I see how we can eventually make a difference. I do believe in this program. It will take time.

Tuesday was better. At least I wasn’t blindsided by the behavior and I didn’t see any rats. (I also realized we didn’t see those in Shamwana because the people had eaten them all.) On that day I stayed with one particular student from the school where I’ll be teaching. She was great, incredibly knowledgable and professional. She gave me great hope for the future. She will be graduating in October and carried herself as though she’d been a midwife for years. She was taking care of a woman who’d transferred in from a health center for failure to progress. She’d been 8 cm for several hours and it was thought she’d need a c-section. I said before that the c-section rate is very high here and the decision making process is incredibly vague. Women aren’t given more than an hour to push before they declare it CPD (cephalo-pelvic disproportion). This is preposterous! They do repeat c-sections on everyone who has a previous scar. I should reserve judgement about this because they don’t have a way of monitoring women in labor for signs of rupture, but it just seems insane. The babies are very small. I have a hard time believing they won’t fit. The woman we were caring for was having her second baby and had no apparent problems and the first birth was normal. She’d been in labor for more than a day and hadn’t eaten anything. She did progress to fully dilated but had no energy to push, so when the medical students and residents came through and examined her (horribly) they declared it wouldn’t fit and she should get in line for a c-section. The student went and bought her a thick drink made from maize flour and the woman devoured it instantly. I thought, hmmm, our anesthetists would go ape shit over that right before surgery, but at that time I hadn’t realized that she had to wait hours before her surgery. There was a line in front of her. In fact, she had to wait so long, she ended up delivering vaginally. I happened to still be there when she was delivered by a male midwifery student who was wonderful. He did a beautiful delivery. I was so relieved.

Next day a woman was admitted in labor but she’d had a previous c-section and was to have a repeat. She was moved to the front of the line. But the attending was busy with a woman who had acute onset of psychosis and was screaming and had gotten violent. They had her tied hands and feet to the bed. She was seven months pregnant and screaming and writhing so much they couldn’t get a lumbar puncture done, though, God knows, they tried. That was not a pleasant scene. While that was going on in one cubicle, the woman waiting for the c-section started delivering. I was ecstatic! But as the head was crowning, someone decided it wasn’t coming fast enough and she should still have the surgery. I said quietly, “But we can see the head!” Didn’t matter. She was left alone to wait for the OR. I looked in her face and said, “You can do this. Push.” She didn’t speak English so had no idea what I said. I took her hand and let her feel the baby’s head. “Mwana mutu”, I said. (Baby head. I remembered that much from language class.) Her eyes opened wide and she pushed and it really crowned. Then the medical student, who was the only one around at the time, reluctantly opened up the delivery pack, saying she shouldn’t be pushing because she is going for surgery. I held the woman’s head, saying, “You can do this!” She got my drift. By this time a few other students were there as well as a midwife. A resident opened the curtain more, looked and said, “Well, ok. I guess she’s going to deliver.” And threw a few more medical students in to watch. At one point, the patient reached down again to feel the baby’s head and everyone screamed at her not to touch! She pulled her had away like she’d done something terrible. Opps. I guess I wasn’t supposed to have her do that. I looked at her and said, “Opps. Pepani.” (Sorry) She delivered vaginally, though, so I considered that day a success. It had nothing to do with me; I’m not taking credit. She would have delivered while waiting, but it made me feel better to have been there. And later on I walked by her bed and she motioned for me to come closer. She took my hands and said, “Zikomo, zikomo kwambili.” (Thank you, thank you very much.) It was a bright point.

Good god that place is hard.

Thursday, an HIV positive woman with pneumonia delivered at a health center, prematurely, while waiting for an ambulance that had no fuel. They tied the tiny baby to her and she finally made it to our hospital, very sick. I took the baby, who weighed less than 2 pounds, wrapped him, and brought him to the intensive care nursery. I was told to place him in a warmer that had two other babies in it. The nurse came over and asked me if he was labeled. I said, I didn’t know. I was just asked to carry him here.” She wrote the mother’s name on a bandaid and taped it to his arm. “Don’t worry. I did it.”, she said.

Friday I spent the day in the HDU, the high dependency unit, or what we’d call the ICU. It was a lovely day. There were three patients: the one who’d gotten psychotic was there and she was calm and sleeping most of the time. They treated her for malaria and spinal meningitis because they couldn’t tell what was wrong, and she started getting better. Wow. The one with pneumonia was also there. I heard her baby was still alive and her guardian spent the day pumping her breasts for colostrum. She gently did this for hours. I was overwhelmed. The third woman was sectioned for pre-eclampsia at 31 weeks. I was floored that they’d do surgery for a premature baby. When the resident rounded on her I asked if they ever consider an induction instead of going right to surgery? I know that women have seizures here because their blood pressure gets so out of control and they need to deliver, but it seems they’d try an induction first and not condemn her to life-risking surgery again. She told me, yes, they sometimes do inductions, but that was the end of the conversation. I didn’t ask anything else. They are faced with hard decisions every waking minute. The women are really sick and there are so many of them….

Ok, enough of that.

Last Sunday afternoon we went on a fabulous, really hard hike. There are several mountains surrounding Blantyre, and one of our volunteers, Polly, organized this hike with her partner Karl. They’ve done it several times and they are in great shape and half my age. It was brutal. I was drenched in sweat and at one point, thought I wouldn’t make it to the top. I don’t admit easily I can’t make it, so this was serious. I told them to go ahead and I’d go at my own pace. I finally did make it and it was so worth it, but it was steep and hard. Karl said, “The Malawians have twelve different words for “mud”, but none for “switchback”.” It was straight up. On the way down there were a group of three baboons sitting in the trees. They turned their backs to us, but I was a little nervous there. My legs were not able to carry me if I had to run. Then I couldn’t remember if you were supposed to run or not if they came toward you. I think I remember someone saying not to look them in the eye, but I was nearly delirious by then. My legs are still sore from that hike a week later. The baboons ignored us.

The power is going off more and more frequently. We only have it about half the time now and never know when that will be. George got a propane burner so we can cook without power. That’s been very nice. We’ve had to use it several times this week. We also got two big buckets at the market yesterday for storing water. So far we haven’t lost water, but as the dry season goes on, that might happen. I pray the rains are good this year. At the market yesterday I also found a basil plant, a rosemary plant, and a parsley plant. I have high hopes for an herb garden.

We have a gardener, employed by the college of medicine and I asked him if he could make vegetable beds. He readily agreed and made three nice beds out back. He said he could get some seeds if I gave him money, and Thursday I gave him money and a list of the seeds I wanted. That was a mistake. Thursday afternoon he was shit-faced drunk and he hasn’t been back since. I saw him on the road yesterday (appearing sober) and asked him where my seeds were. He said he’ll have them Monday. We’ll see.

I’ll post this and cook while we have power. Then out for a walk. We spent three fabulous hours at mass this morning. Well, maybe two fabulous and one a little tiresome. The music is so fantastic, though. The singing comes straight from the soul. I love it.

Have a good week, all.



Sunday Morning~Blantyre

Well, the party is over. It was a great month of training and I enjoyed almost every minute of it. It was such a treat to have little responsibility besides showing up and listening. We were fed on a two hour schedule, had tea more often than that, had a little spending allowance, and met a steady stream of interesting people. I loved it.

Moving in to our site was a little uncomfortable, yes; we had to go a whole morning without tea. But we persevered and obtained the essentials and have been resourceful with the remainder of our August living allowance until September’s comes. We’ve had simple but filling meals with local produce, a beer here and there, and it’s feeling more like home.

Then culture shock hit us square in the face this week. I find myself comparing my former experience in Malawi to this one. That is very unfair, it was a long time ago I was here. That was then, this is now. Life in the states isn’t the same either so it shouldn’t be surprising that things have changed here. I was in Malawi from January 1979 until March 1981 as a Peace Corps volunteer. Our group did three months of training in Salima in the central region, then I went to Karonga in the far north of the country. It had been a decade since independence and there was a highly revered, president for life with absolute control of the country. We were a group of twelve volunteers in health and agriculture, the first allowed back in Malawi since Peace Corps was expelled in the late 60’s. In the early 60’s Paul Thoreaux was a Peace Corps volunteer here, and he did some writing that the president felt was threatening to his power. That didn’t go over well. I think there were others who were protesting the Vietnam war and there is a strict rule that Peace Corps be apolitical and they were asked to leave. When things simmered down and we were invited back, our group was warned, in no uncertain terms, to be careful about what we said and wrote in letters home. There was no internet or public blogs, but our letters were subject to being opened and read. All media was censored. It was an oppressive dictatorship for sure, but as one local man pointed out to us last month in Lilongwe, “We didn’t know we were oppressed. Things worked well. It was necessary to go from colonialism to independence that way.” I suppose there are arguments to be made about that statement, but from where I sit now, I can see that things did work better in the health care system then and that is saying a lot. But I say that about the health care system at home, too, so judgement should be withheld. But people are allowed to talk freely now and that is progress. They remain extraordinarily polite and respectful people, though protests do occur. That was unheard of back then.

When the ambassador addressed us in Lilongwe, she described Malawi as the poorest country in the world. The per capita annual income is $240 and there are few natural resources here. In 1979 there were five million people here, a country the size of Pennsylvania. There was malnutrition then, but for cultural, educational, and economic reasons; it was possible for the country to produce enough food to feed itself. Now there are almost 17 million people and the prospect of widespread famine after last year’s drought is very real. It’s unlikely that this country can agriculturally feed itself anymore.

One kwacha, the local currency, was worth $1.25 in 1979. Now there are 780 kwacha to the
dollar. The coins that were called tambala don’t even exist anymore, though I saw some earrings made from them in a gift shop.

The health centers and hospitals are greatly understaffed. There is now one nurse per 10,000 people and one doctor per 50,000. I don’t have the stats for what the ratio was in 1979, but it wasn’t that bad. In our small district hospital in Karonga we had twenty midwives. Now in centers that size they have one nurse midwife and two local midwives for hundreds of deliveries per month. When we visited a health center in Kasungu during our training in July, the medical officer there was seeing 300 patients per day, some had walked 20 kilometers to get there.

So that brings me to our first week on the job. The nurses in our group of volunteers have to do four weeks of clinical orientation to get our Malawian nursing licenses. Our weeks have been assigned to us by the board of nursing in Lilongwe and they are specialty dependent. Because I am in maternal and child health, I must spend a week in the antenatal clinic, a week in labor and delivery, a week in postpartum, and a week in the neonatal intensive care. It makes sense that before we start teaching, we have an idea of how the hospital works.

The Kamuzu College of Nursing (KCN), where I’ll be teaching, is situated next to the largest hospital in the country, Queen Elizabeth Central Hospital, or fondly referred to as QECH (pronounced ketch). This is where the students do their clinical training. The college campus is lovely. There are long, one story buildings, starfish-like, fanning out into green grass and tropical plants. The buildings were built in 1964 when the school opened, but are well-maintained and clean, simple, brick and cement structures, airy, open, and nice. Dressed in our new uniforms, Christine, Elizabeth, and I arrived there on Monday to meet our counterparts. Christine will be teaching medical/surgical nursing, and Elizabeth will be teaching research to graduate students; I’ll be teaching midwifery. There were some administrative details to accomplish before the three of us were brought on a walking tour of the hospital.

The hospital is a huge sprawling series of one-story buildings, many in disrepair, with roofs that look like they will not be much use in the rainy season. There are 1,200 beds in the hospital, but often there are 2,000 patients in them. Some are on the floor, others share beds, especially in pediatrics. When we toured the nursery, there were at least two babies in each crib, sometimes three. It’s a tad shocking to see. I feel like I’ve gone soft since my experience in Congo. It’ll take me a bit to toughen up again and get used to the conditions. The place is remarkably clean though. I see people all day long washing the floors. It doesn’t smell bad at all; I’m very grateful for that.

I think what shocked me more than the conditions and overcrowding were the labor and delivery statistics. When I saw them on the board in that unit I nearly fainted. They do over 1,000 deliveries a month here (between 40 and 50 a day) and the c-section rate is terribly high, around 30%. I start tomorrow there for the week, so will have more to write about next Sunday, but it knocked my knees out from under me. They said they have eight midwives staffing the place for that many deliveries. And when I say eight midwives, it means that they are the only people on the ward. There are no other nurses. This is mind boggling. This is the referral hospital, so only the high risk women get sent here from the district hospitals, but still, 30% is high.

When George and I got home the first day we both were in a stunned state. I have never seen that look on his face before and the word “FUN!” suddenly disappeared from his vocabulary. There is only one psychiatrist in the country so he’s doubling the work force here. The clients they see are pretty severely psychotic and they have very few medications to treat them, and half the time those are out of stock. So this isn’t going to be people sitting around talking about how their mother wasn’t nice to them and how that screwed them up. I lost count of the times he said, “Holy Shit!” that night. We spent Monday evening talking ourselves into going back on Tuesday.

The week got better though. It’s really amazing what you can get used to. Already, the scores of people sitting waiting for services, don’t seem intolerable to witness. I spent this week in the antenatal clinic and though I was mostly observing, I found myself exhausted at the end of each day. It looks like chaos to me and it’s tiring trying to learn the system. I’m trying to figure out the flow but it looks like one big free for all. But by the end of the week, at least I wasn’t freaked out, just confused. It’s hard for me to understand how the staff can maintain any type of positive attitude, (and I use that term loosely). Just showing up seems like it would be difficult after years of working in these conditions. They are trying to convince the women to bring their husbands to the clinic with them so they both can be tested for HIV. Those that come as a couple go to the front of the line to encourage this practice. I thought that was clever. But at most, women get very, very basic screening. A blood pressure and weight and not a whole lot more. It’s just impossible with these numbers to do any kind of real screening and care. It’s scary.

On a lighter note, I designed a new uniform and went over to old town to get some navy blue fabric to bring to the tailor. For our original uniforms we had him supply the fabric and it is quite heavy and a little uncomfortable. I wanted a light weight cotton for when it gets hot next month. I drew a sketch of a dress like the old dress-scrubs we used to wear when I was in nursing school. I brought it over to the little hut on Thursday and asked if he could do it by Saturday. He said, “Sure, sure.” and yesterday I went to pick it up and it’s perfect. For the equivalent of $6, I can get custom-made clothing. There are many wonderful things about living here. The nurses at the clinic were impressed with my sketch. They said, “Oh! You can design clothes!” That seemed to make more of an impression than my diagnosis of twins in a woman that measured too large by 10 weeks. Anyway, since I will be in labor and delivery all this week and with 50 deliveries a day, I think I’ll need more than one uniform. Fifty deliveries is what the Bar Harbor hospital does in eight months. Sometimes a year.

After dropping the fabric at the tailor I came home for lunch before heading back to the clinic and it’s a good thing I did! The power was out so I was trying to find something to eat that didn’t require cooking. I heard someone at the back door saying, “Odi!” I went out and a man was there with a huge monkey wrench. He told me he had to shut our water off because the bill had not been paid. I looked across the yard and there was a second man with an equally huge wrench unscrewing some pipe. I said, “Stop! We did pay the bill last week! I’ll show you the receipt!” The first man said, “Ok, but hurry, because we must shut the water off.” So I ran in the house and prayed that George did not still have the receipt in his wallet. (We had a little tug of war at the water company about who would hold the receipt, and he won.) I rummaged around his desk and didn’t see it, then rifled through a bunch of other papers and found an envelope with a bunch of receipts in there, and fortunately the water bill was one of them. I took it and ran outside to show man #1. I said, “See? Right here is the date. We paid for the water on the 12th of August.” He inspected the receipt and had to agree it said 12 August. He called man #2 over to look. They spoke in Chichewa for a bit and I heard twelve August about five times, then he finally looked at me and asked, “So what should we do?” I said, “You should not shut the water off because we paid the bill on 12 August.” He said, “Ok. But you are very lucky!” I said, “I know. Thank you.” And they took their wrenches and left.

The weather is glorious. The sunsets are spectacular behind the mountains surrounding the city. The people are warm and welcoming and grateful. There is so much here that I love.

I’ll have more next week, but want to post this while we have power. We have great reliable internet as long as the power is on, but that is only about half the time and there’s no warning when it will go off. We’ve had long dark evenings and no-tea mornings. Propane tank has been bought but we need the rack to put a pot on it. Hopefully this week. I’m worried about long days on the labor ward without tea. I feel like I can face anything as long as I have my tea.

Love to all,

Sunday Morning~ Blantyre

Hi Everyone,

It’s early, and I’m sitting at the dining room table listening to the wind and watching the sky get lighter over the mountain. Streaks of sunlight are now coming across the porch. It’s chilly; I need to wear a sweater. I have my cup of tea with full milk and am quite content. We’ll leave in awhile to walk to church. I think it will take us about forty minutes, but we’ll allow an hour, just in case.

It’s been a full and busy week!

Last Sunday morning we both woke feeling stiff and sore. George complained that his shoulder hurt and my hip was hurting me. When I rolled over, I thought the springs in the mattress were more prominent than they had been. I like a firm mattress, but this one seemed to be getting harder and harder. I figured we were getting a bit soft from all the sitting and eating during our training, so we got up and walked it off. Later that day, when I was sitting over at the Korean Garden Hotel, a guy named Jack was chatting with us. We were talking about what a pleasant setting it was, though simple, and he said he moved to that hotel from the one we were staying in because the beds had only box springs at our hotel, no mattresses. Then I realized, that was the problem! There was no mattress on the bed! We were sleeping on wood! When we got back to the hotel I checked, and sure enough, no mattress. We’d slept on the box spring. Thinking we’d been doing this all along and sleeping ok until that last night, we went to bed and had a horrible night. Hardly slept at all. At breakfast I mentioned it to a couple of the other volunteers. One woman had twin beds in her room and she said, “Ya, I noticed that one of my beds has the mattress and the other just a box spring. I’m sleeping on the one with the mattress.” Mind you, this is a nice hotel. I know there had been a mattress on that bed before. I went to reception and said, “Excuse me, the mattress seems to be missing from our bed in room 109. Could someone put it back today please?” The two employees at the desk responded as if I had asked for an extra towel. They showed no sign of surprise whatsoever. They assured me they would have a mattress put on the bed. I thanked them, and when I went back to the room on our lunch break, there was a mattress on the bed. We slept much better Monday night. All I had to do was ask for a mattress! For the bed. In a hotel.

Wednesday morning was our swearing-in ceremony. This is a part of all Peace Corps service where we take the same oath of all state department personnel. It was quite lovely, actually. It was held at the ambassador’s residence, the same house occupied by the ambassador when I was here in 1979. It was a morning ceremony with a little reception following. There was a bit of a rushed atmosphere as those of us traveling to Blantyre and Mangochi were leaving that same day (a five hour trip), but we still took time for speeches and some visiting with our Malawian counterparts and a few embassy people. The American ambassador to Malawi is a firecracker. I love her. She is brilliant, funny, involved, and informed. She’s confronted corruption head-on and is a cheerleader for this program. Her insight into the workings of the health department were quite impressive, and since a good bit of money for programs comes from the US, she has a grasp on how it’s accounted for and what needs should be prioritized. She was really a pleasure to talk with and listen to.

After the ceremony we were all herded to the Peace Corps office where we signed for our bicycles, helmets, and tool kits. We were handed our living allowance for the remainder of August in cash, collected our medical supplies, then went to the hotel to collect our luggage for the trip. It turns out the bikes wouldn’t fit on the bus, so they were delivered on Friday.

Eight of us volunteers are in Blantyre and we occupied two vehicles. One huge bus was filled with luggage and supplies and another Land Rover with people. George and I were on the bus. The Land Rover beat us here by over an hour. I had been a little nervous about getting here late in the day, and with a five hour ride, it was sure to be a late arrival. Before we departed, one of the Malawians on our bus asked if we wouldn’t mind praying for a safe trip, so we bowed our heads, and with clasped hands, he said a heartfelt prayer asking God that we arrive safely at our destination. Let it suffice to say that driving here has become very dangerous. Driving at night is out of the question.

I was hoping we’d arrive before dark, but as the sun set quickly well before we got to Blantyre, my stomach sank along with it. We would be arriving to an empty, unoccupied house in unfamiliar territory with no food or living supplies in the pitch dark. We were told someone here would have the keys, but it was a little unclear as to who that someone was. I hoped it would be someone nearby. Well, it turns out that the others got here just before dark and were able to acquire the keys, so they opened up the houses and waited for us. We had all the luggage so no one could move in without us. In the pitch dark, we unloaded and sorted what belonged to whom and dragged it to our respective houses. Three of our houses are close to each other and there’s one other across town. Two of the nurses, Christine and Elizabeth, were going there, but that house was recently vacated by another volunteer and was fully equipped. Our’s were completely empty of everything except basic furniture. It was a bit stark. And we had no food. We had brought some tea and milk and I was thinking at least we’d have tea in the morning, then realized we had no kettle or cups. That was a dark moment. As George and I brought the last suitcase into our house, there appeared a small man beside us telling us he was security and would spend the night with us. I looked at George and asked, “Did anyone tell you we’re supposed to have a security guard here?” He looked away and said, “Nope.” This guy’s English was about as good as our Chichewa, and after a bit of hand-signaling communication, we figured he was legit. He said he was employed by the college of medicine and had a blue uniform on, so we just went with it. We did lock our door though, and heaved an “Oh, God.” as we looked around at the bareness of the place. It all seems so threatening at night in a strange place.

Blantyre is at 3,500 feet and this is the cool season. It’s between 75-80 degrees during the day, but the nights are quite chilly, in the 40-50 degree range. We were pretty well exhausted when we got everything into the house, trying not to fall into openings in the pavement, so didn’t even try to hang the mosquito net. We just put sheets on the bed with the polar fleece blanket I’d brought from home, and crashed. We were lucky I’d brought that blanket. The others were shivering, wrapped up in towels that night. Having omitted supper, I was desperate for tea in the morning, but that wasn’t happening. It was a puzzle finding keys to all the doors and figuring out who the strange people were in our driveway. Turns out it was changing of the guards.

Our daytime guard is named Catharine. As soon as she laid eyes on me she came to greet me and introduce herself. She welcomed us to Malawi and wanted to be sure I knew that she was good at cleaning and has four children to support. I was doing my best to understand her while taking in the morning view and get a daylight grasp on our new home for the year.

It’s quite nice! The house, while very simple, is quite large. We have three bedrooms and three bathrooms, so plenty of space for visitors! (If you’ve been craving an African adventure, now’s the time!) There is a huge living room with a fireplace, two couches, and a coffee table. There is room for at least four more chairs, so it looks a bit empty with the bare walls, but we’ll decorate once we get the essentials. The living room opens into a good sized dining room with a nice table and four comfortable chairs. Both of these rooms have doors and windows that open onto a large, covered porch. The kitchen has a double sink, a fridge, very small stove, lots of empty cabinets, and a huge empty pantry. The kitchen door goes out into a courtyard where there is a clothesline and connects with what appears to be, servants quarters. It’s another separate house back there. Empty (we think).

The yard is fairly large, surrounded by a chain-link fence with grass woven into the links, so it’s a bit of privacy. On one side of the fence is a dirt path to the hospital, and the other side is Anneka and Idil’s house. (They are both physicians in our group. Idil is an internal medicine doc and Anneka is a pediatrician. They’ve both just finished residency and are adorable and fun.) We have a huge avocado tree in the yard as well as a guava tree. This is winter, so they aren’t producing at the moment, but I’ve got high hopes. We’ve got a few poinsettia trees, a rose, a frangipani, and several others I can’t identify. We’ve got a view of the mountains surrounding the city, and I couldn’t be more pleased.

The first thing I had to do Thursday was get to a tailor to have my uniform made. I start working tomorrow and can’t do it without my uniform. Polly, one of the nurses in our group, has been living here since January and knew a tailor, so we traipse into his little hut on a dirt path in a cornfield. This mud-brick room is all of six feet by seven feet and has a little table with his foot powered machine, and a notebook and pen where he recorded our measurements. We explained that we’d be lecturers at the nursing school, which means we need navy blue uniforms with white piping. Yes, yes, he assured us he knows exactly what we need. He could go and buy the fabric for us even! Such service! “Come back on Saturday and they will be all ready.” So George and I bade goodbye to our friends and we went to find a tea kettle, two cups, a blanket, and some cleaning supplies, which made the next night oh so much more comfortable. Hot tea in the morning! Yes! But when I went to make a second cup, the electricity wouldn’t work. We spent some time trying to figure out what to do, wondering if the bill hadn’t been paid. So, only one-cupped, we set off again to find the electric company and pay the bill, as Catharine elbowed her way in to clean the entire kitchen. Unsure if we should let her do that if she already had a job as guard, we were a little confused, but I loved the idea of that kitchen being clean, so we just left her to it. We learned along the way to the electric company that the whole city was out of power. Since the drought they ration electricity and have rolling blackouts. We just need to be prepared for them as they aren’t on any kind of schedule. So, having gotten electricity and water all sorted, we came home to a sparkling clean kitchen. I can feel myself settling in to this very nicely. Friday we bought a few more essentials like plates, pillows, a spatula, and internet service. Saturday, I got my uniform which fits like a glove, picked up our bikes, and finished unpacking. It’s all coming together.

We’ll go to mass today, and tomorrow I start my four weeks of orientation. It’s a short walk to the School of Nursing and I’ll meet up with my counterpart, Estnath, who has offered to take me around to meet everyone. I have no idea what I’m supposed to do. None whatsoever. But at least they speak English. I’m just going to get up, put on my blue uniform, drink my tea, eat a few bananas, and walk over there with a smile. Hopefully I’ll figure it out.

Catharine, greeted me at the kitchen window this morning as I was making tea. She’s got a forceful personality. She had Saturday off, and the guard we had yesterday was quite demure and gave us a little space and privacy, but I think Catharine is intent on becoming part of the family. She stood at the window until I unlocked the door, (which, takes a bit of effort) then presented me with a gift. With a smile bigger than life, she handed me a glass jar filled with water. In this water are: stones, approximately eighty tiny fish swimming mightily, a piece of white ribbon stuck in the stones, and a fake red rose. The metal cap has holes nailed in it for oxygen. I thanked her profusely for the new aquarium and it sits beside me at the table. I have no idea where she got the fish or what to feed them. Catharine doesn’t speak much English. I don’t know if they grow big and we’re supposed to eat them? Do people here have little aquariums? It’s in an old mayonnaise jar, it’s not like there’s a filter or anything. What if they all die? It somehow seems a big responsibility.

Oh well, I’ll let you know how that goes.

Off to church as the city wakes up.

Love to all,


Sunday~ Lilongwe

Hi Everyone,

It’s mid-afternoon and there is no power in the city. It went out shortly after we ordered our lunch, which, didn’t seem to affect the service or the food. I left the hotel and walked up to another smaller hotel on a quieter side street where there is an enclosed garden and bar. I think our hotel is owned by Hindus and is alcohol-free. So here I sit, with a full tummy and a beer, pool-side, at the Korea Garden, writing between conversations with stoppers-by. I clearly was not the only one with this idea. Three more days in this city before we go to our site, and I’m just starting to get to know my way around. This laptop is about half charged and I guess I won’t be able to juice it up, so let’s see how far I get. Then we’ll see if I can connect to internet anytime today. Doesn’t appear hopeful at the moment. Funny it’s more unreliable here than it was in Shamwana.

It’s a very pleasant temperature; I suppose it would be considered warm for a summer’s day in Maine, but we walked for miles this morning in the sun and it wasn’t unpleasant. It’s winter here. Come October, that won’t be possible without dying of heat stroke.

Yesterday was our last day of language instruction. We had the assignment of performing skits that depicted what we consider strange Malawian behavior, since they did that for us at the beginning of our training. Since we aren’t as animated or good at acting, it didn’t come easy. Fortunately we are a group of self-starters, so just bit the bullet and got it over with. I wasn’t looking forward to it, but it turned out kinda fun. I thought it would have been better for an evening activity after a few beers, but it was an 8 a.m. assignment. Harsh. We came up with four skits and had a few minutes to run through them before our audience of trainers came in to view the final exam.

The first skit involved a sick person lying miserably on a make-shift bed, which, was two chairs put together. As she was lying, trying to rest, we all filed in greeting her over and over and over and she had to rouse herself to be polite. We kept coming asking her if she needed anything and fawning over her. That was it. Our MC explained at the end of it that we, as Americans, find it strange that Malawians don’t leave someone alone to rest when they don’t feel good. The ill have to endure a steady stream of guests. We find this strange. There was hilarity all around, and though I don’t find the subject very funny, we did a good job of hamming it up.

The next skit had to do with public display of affection. We lined up in groups outside the conference room door and walked in as if we were strolling down the street. George and I were holding hands. Carlos sees us and recoils in shock and breaks us apart and takes George over to Darren and puts their hands together, and George and Darren walk off together. We were laughing more than our instructors, I think. Christine explained that in America we often see men and women holding hands and that is very much acceptable but we don’t often see men holding hands. In Malawi, it is very common for heterosexual male friends to walk along holding hands. (We could have gotten into the fact that this is changing and becoming more acceptable, but we needed a skit and just wanted to get it done. And let’s face it, the majority of Americans don’t live in San Francisco.) Good enough.

The third skit had a group of us having a meal with a Malawian family and they ask to see photos of our family. Carlos shows them a photo and they look and exclaim with happiness and pride, “Oh, they are so fat!” That was the end. They consider calling your family fat a compliment. Calling anyone fat is a compliment. We explained that Americans wouldn’t consider that polite. It would be an insult, not a compliment.

And the last one had to do with our difficulty differentiating some Malawian words that are very similar, but have very different meanings. “Chambo” means fish, “Chambe” is tea, and “Chamba” is marijuana. George has mixed up these words in sentences over the past two weeks, which sends the language instructors into convulsive fits of laughter. So the skit had George as a language instructor teaching these three words which really didn’t have a lot to do with what we consider strange customs, but it filled up some time and seemed to amuse them, and then we were done.

Theirs were better than ours, but we are medical professionals, and a little stiff, so we thought we did exceedingly well, considering.

There are now five people sitting at this table with me. It’s getting a little difficult to concentrate.

We’re all getting a little tired of sitting still during the week. We try to get out for the last hour of daylight and walk, but it hasn’t been much exercise. We have had another week of lectures, which are all very interesting, but they are long days of sitting in one chair in a dark room. We’ve had a couple of field trips, however, and it was good to see how the health facilities have evolved since 1980. We spent an afternoon at Kamuzu Central Hospital, the hospital where Matt was born. It’s quadrupled in size since then, had a fresh coat of paint, and some major bat-elimination. I did not detect even the faintest hint of bat shit smell this week, and that was my predominant memory of the place. I was bracing myself for it, but not a whiff. The facility was impressive, really. The wards were clean and there was good air circulation. The major problem is staffing. The patient/nurse ratio is approximately 60:1. That would be 60 patients to one nurse. It was a little scary. I’ve heard it’s worse in Blantyre. There are seven midwives to cover labor and delivery, where they average eight deliveries a day. The midwives do everything there: all the nursing care as well as deliveries and they have to cover twenty four hours, seven days a week, so seven midwives is not very many. I don’t know how they do it. Guess I’ll find out. I was amazed at how resilient they were as they showed us around. They were honest about the problems but have a lot of pride in the fact that they carry on despite the difficulties.

We’ve had this weekend free; the first free days we’ve had since arriving. Well, that was after we finished the skits yesterday, so let’s say a free day and a half. We spent most of it walking. Lilongwe has a great melange of people on the streets and after two weeks here we are getting accustomed to the frenzy. It’s dusty and dirty and trash is everywhere, and that makes me sad. In the old days we never saw a scrap of paper or string on the ground. If a scrap ever landed there, some child would scoop it up to make a ball out of it. Plastic bags didn’t exist here back then. We shopped with a woven basket. Now they are everywhere. But the humanity! The attire in the city ranges from sequenced evening gowns with stiletto heels, to rags. The cars, from brand new SUVs to ancient scrap heaps held together with chicken wire. And there are thousands of them. Thousands and thousands and thousands of cars. At church this morning they had two policemen directing traffic and two more to assist with parking. There were close to a thousand people at church today (literally) and probably four hundred cars. Yesterday, the pedestrians we passed included: tuxedoed wedding parties, women in business pant-suits and heels, a barefoot man carrying ten live chickens in each hand (got a photo of that), and a one-legged woman with hand-made crutches walking with a bundle of wood on her head. I stopped and watched as she maneuvered the curb and avoided cars at an intersection while walking with crude crutches with a bundle of wood balanced on her head (no photo out of respect for her, but wanted one). No athlete at the current olympic games could impress me more than she did. And there was everyone you could imagine in between these extremes. In the few moments we’re not avoiding being struck by an oncoming car, the people-watching is superb. Yesterday, as we walked along the very busy main road to the wildlife preserve, a pick-up truck sped by with a photographer standing in the bed, facing backward. I couldn’t believe he could stand like that without falling. The truck had to be traveling at least 40 mph. Following, was a honking car with an open sun-roof, where the upper torso of a bride and groom were exposed waving to the camera in the pick-up, veil blowing in the wind. It’s non-stop entertainment on the streets around here!

I’m ready to get to our site, get into our own house and have a little privacy. Tomorrow and Tuesday we have more lectures and wrap up, then Wednesday is swearing in at the ambassador’s house in the morning, then we head to Blantyre in the afternoon. We’ll have four days to settle in to our place before I start four weeks of orientation in the wards to get my Malawian nursing license. I need to get my uniforms made (navy blue with white piping, I’ve learned) and get our house set up and equipped. Then we’ll find a language tutor and we are going to hire help in the house as well. We figured why not support the local economy?

The power is back on and it looks like I’ve got a tiny window with internet, so I’m going to post this while I’ve got a chance. I’ll leave it unedited. Hopefully we’ll have something reliable set up by next week and I can organize my thoughts better!

Love to all,