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,