Sunday Morning~Blantyre

October 2, 2016

Strangers come with a sharp knife~ Malawian Proverb

Hi Everyone,

Life has gotten so much better since orientation is over. I’m settling in at the college and learning my way around. I’m getting more familiar with faculty roles and expectations. It’s so much more comfortable not being in the way, feeling like a useless ornament.

I spent three days this week in rural areas supervising fourth-year midwifery students at their community-midwifery rotation sites. I can’t begin to express how much more fun this is than my four weeks of orientation. I’m in such a good mood I’m not even going to complain about the unflattering uniform I’m required to wear. I went to five different sites with three different faculty and saw the students in action and I am impressed. These students are graduating in a few weeks, are in their last rotation of their four year baccalaureate program, and are quite skilled in maternity care. The midwives in the rural areas are isolated. Some have only a medical assistant with them, so emergency resources aren’t readily available. They can transfer women to a district hospital if she needs surgery, but transport is usually a problem. I’ve seen reports of babies or mothers dying because the ambulance at the hospital had no petrol. The community-midwifery rotation is for experience in very low resource settings, because once they graduate, students don’t have a choice about where they work. The government will assign them a site where there is an opening, so getting rural experience is part of the program. Once a week a faculty member visits each of the ten sites to supervise and advise them.

We found the students sparkling in their white uniforms. Some of these places were miles down dusty dirt roads. I have no idea how they keep those uniforms so white, but there they’d be, working in the antenatal clinic or teaching in the postpartum ward or waiting for someone to deliver in the labor room, clad in a snow-white uniform. This impresses me, since I can’t seem to keep anything white for longer than ten minutes. In the first site it seemed like the students showed up and the staff took the month off. They were running the show with hardly a complaint. I was with Esnath, and when the morning work was finished, we sat with the students for a little conference. They are required to identify a problem at their community site and make a plan to address it. They told us the biggest complaint women had was the staff at the health center wasn’t always available and the maids are doing the deliveries.  Also, the men in the village are not consenting to their wives getting contraception. There has been a boatload of resources poured into population control here and there is a family-planning program at every health center. When I was here in the 1970’s, contraception was illegal. We couldn’t even mention it. The country then had five million people and though there were hushed requests for contraception, there was a public policy against providing it. Now? It is everywhere. There are vasectomy clinics, condoms, and every method of female contraception known to exist. Everyone has access to it. The population is now almost eighteen million and it is very clear that this country can not feed itself. Population control is front and center. The only barriers are cultural.

Esnath asked the students what ideas they had to address these problems. They told us they had organized a meeting with the village health committee and were going there to talk with them about it. They asked if our vehicle could give them a lift? So off we went together, through maize fields and narrow walking paths in our nice SUV to the village headman, who turned out to be a woman. Some of the tribes in Malawi are matriarchal. We greeted her respectfully and sat on the porch of her mud brick house to wait for the committee to gather. That took about 45 minutes, during which time I spent daydreaming in the nice breeze. Everyone else, including the village head woman, were looking at their phones. I kid you not. The incongruity was mind boggling.

The committee consisted of twelve people, a mix of men and women, young and old. Some women had babies on their backs and some of the men appeared to be late teens. The elders were there as well. The students blew me away. We started with a prayer, and then they each got up and spoke at length about the problems and wanted to hear from the committee about possible solutions. I just loved it. Everyone had a chance to speak; everyone was respectful to each other, even when the topic of men’s resistance to contraception came up and it got a little testy. This was all in Chichewa, so I wasn’t contributing anything, but at one point Esnath spoke up about population control. She was good. I am in awe of their oratory skills. She pointed to me and told them I am from America and my state is bigger than Malawi and has only one million people! Think of that! One million people in a country bigger than this! (I didn’t correct her that it was a state not a country; she was making a point) She said, “Look at the fields ready to plant! What if the rains don’t come? What if we have a drought like last year? The trees are disappearing! We must think of the future! If we have only two children then we can afford to send them to school! Otherwise the children sit all day in the dust and have no chance of a good future!”  She hammered the climate change in a few more pegs and appealed to the men to consider this. She did this all respectfully, but with incredible passion. She is the picture of grace, and to see her use her skills and knowledge like this was a sight to behold. I had to restrain myself from cheering. A plan was formulated to have the village health committee meet with the health center committee to discuss the problems and find some solutions. It’s not like this was going to be solved overnight, but it was great to watch community organization at it’s purist. Cultural changes take time but I see the course accelerating.

On Wednesday, I went to a different site with a different faculty member named Martha. Whoa man, she was tough. She has a take-no-prisoners attitude and I have a bit to learn from her. A few of the students were sitting around looking at their phones when we arrived. That did not go over well. Most of the staff were doing the same thing, which is probably why the students think it’s ok, but when they all gathered for our meeting, she came down hard. “There were women waiting to be seen! I don’t care that you were not assigned to the antenatal! If you had nothing to do you could have helped here! You could spend time with these women! You will be graduating soon! You have to learn to crack your heads and think of ways to make the health center better!” The students all murmured things like, “Sorry madam. We understand.” There wasn’t a lot of blaming going on, which frankly, impressed me. It was noted that there was no blood pressure cuff in the maternity center. I was aghast. “None? Not one?” The students all shook their heads. They told us that no women get their blood pressures checked. I immediately started thinking that I have two of them. Maybe I should bring one out there. But Martha, didn’t miss a beat. “Ok, so you have no blood pressure cuff. What are you going to do about it? Where can you find one? Is it fine to let women go without checking their blood pressure? No! So what will you do? I have asked if there is one at the OPD (Out Patient Department) and one is there! You could go there early to borrow it! Think! Crack your heads!” One of the students started speaking in Chichewa and Martha stopped him, “Linda does not speak Chichewa, please speak in English.” Man, I wouldn’t mess with her if I were them. But she wasn’t inappropriate or a hard ass. She complimented them and was kind, just tough. She has high standards and she told me, “We won’t be helping them if we accept this. We need to show them they can do better and make this health system better!” She asked them what problems they identified in the community. They said, “The distance from the village to the health center is very far and women can’t walk at night in labor, many deliver on the way. Also, the villagers are worried that so many women are having c-sections now.” I sat and listened to this with my mouth agape. First of all, I was so impressed with how professionally these students present these things. Next, I was thrilled that someone else is recognizing that all these c-sections are not necessary!!! Some are, but not 34%!!  Come ON! If a woman gets transferred to the referral hospital, which is Queens, her chance of having that baby by c-section is very high. The volume at Queens is so high that there isn’t anyone to properly observe and monitor women, so the solution is just to get the baby out by surgery, (plus the medical students and interns need their numbers). The sequelae from that (infection, hemorrhage, hysterectomy, death) doesn’t seem to be taken into account. The important thing is the baby got out. Then it seems they get thrown away. But I was thinking at least someone else is complaining about it!! But if the villagers are scared to go to the health center for fear of having surgery, then they will stay home and have the baby unattended, which, is not ideal either. So this needs to be addressed. One student suggested that the village might pool their money and buy a bike to transport the women in labor, someone else said they might look for an NGO to donate a vehicle, one student (who I loved) said they could do some health education about coming to the health center earlier in labor. They had organized a meeting with the village health committee for Friday. They said they were a little nervous about bringing suggestions to them because, strangers come with a sharp knife. The students know that the villagers don’t want to be told what to do. Martha said, “Do you go to the village and say, ‘We are from KCN and we know what to do!’ No! You do not say that! You ask them what they want; what they think a solution could be, and there is discussion. The solutions must come from them!”

She could take that show on the NGO road.

On Thursday I was with Alice. The students we visited that day identified a different problem. The youth in their area were complaining that they can’t go to the health center for contraception because everyone will see them and there is no privacy. I wanted to ask where on earth they go to have sex without everyone seeing them, but didn’t. The students at this place were fantastic. They said that 68% of the deliveries were teenage mothers but only 11% of the women at the family planning clinic were teens. I was thinking, these students get better and better! They organized a youth group to discuss some solutions. Everyone goes to the health center in the morning and it’s usually empty in the afternoon, so they asked the midwife at the health center to have a “Youth Friendly” afternoon clinic once a month that would be only for teens. We went to the village with them to meet with the youth group, the young midwife from the health center in tow. The youth gathered in a circle and we started with a prayer. The students spoke about  their concerns and the solution they came up with. They pointed to the midwife and said, “See? She is also a youth!” then the midwife got up and spoke at length about how they would work to make sure the “Youth Friendly” afternoon was confidential and they could feel safe. Applause! Cheering! I was so proud of these kids. Just blown away.

I couldn’t stop gushing about it on the way back to Blantyre. Alice said, “It’s so nice to hear you talk so much! We didn’t think you were going to say anything!” I told her I was just observing at the meeting last week to see how everything worked. I’m really not very shy. She said, “Oh, that’s good. We were a little worried you wouldn’t talk.” I assured her, that’s not a problem once I get warmed up.

The Peace Corps Director, Carrie Hessler-Radelet is here visiting Malawi. She’s the big director, the one at the very top, the presidential appointee. It’s a big deal. This year marks the 20th anniversary of the Peace Corps Response program and Malawi is on the celebration route. She arrived in Blantyre yesterday and we had a program set for her at the hospital so she could see how Maternal/Child Health is working here. I had arranged for two of the midwifery students to teach a class to expectant mothers for her and entourage to observe, and the students hit it out of the park. They were fabulous. Esnath and I did a demo of teaching at the bedside and again, the students were just great. They explained everything they were doing, showed the utmost respect and skill, and I was overflowing with gratitude to them. They were going over the importance of exclusive breastfeeding with the mother and her baby, and Carrie commented on what a beautiful baby it was and what a miracle babies are. Isabel, the student, said, “Oh, yes, and this baby’s name is Miracle!” and she held up the little health passport to show her the name. Ah! laughing and cheering all around! We couldn’t have staged that any better.

When we were done there (several hours later) a Peace Corps vehicle picked us up and we were treated to dinner together at a nice restaurant downtown. It was a really pleasant evening and there was great relief that the afternoon and come off so well. Carrie was a Peace Corps volunteer in Western Samoa in the early 80’s, and though my time in Samoa wasn’t as a Peace Corps volunteer, we had a bit to talk about. I do love this organization.

It’s getting hotter and the day ahead has the prospect of being a lazy one. I might even set the hammock up under the avocado tree for a nap.

Quickly now, while we have power!

Love to all,