Sunday Morning~ Blantyre

July 2, 2017

Tsache latsopano limasesa bwino~ A new broom sweeps well.

~Malawian Proverb

Hi Everyone,

When am I ever going to learn to stop looking at Facebook unless I want to get depressed? This is like a bad cops and robbers movie that has gone on way too long. And I am not even looking at the posts I don’t agree with. Yeah, yeah, yeah, I know the argument about getting to know your enemy. I read The Art of War. I embrace the notion that once you truly know and understand the enemy, there will be no war. I try to understand where people are coming from, but this extremism …I don’t know where to go with it. It’s too painful for me to see people I know actually think this way. What does one do when all avenues of reason have been exhausted? Even Nelson Mandela got to the point when he believed armed resistance was the only answer. I pray to God we don’t come to that. Surely in this day and age there can be a more civilized answer. I mean, as adults we know when a child is having a temper tantrum because he can’t have ice cream for supper, we don’t give in. It’s uncomfortable, yes. It’s hard to reason and stand your ground, yes. Is it easier to just give him the fucking ice cream? Of course! Do we want our kid to die of malnutrition if we only feed him ice cream? No! Isn’t ice cream for dessert enough, for God’s sake? When are the uber-rich going to be satisfied? When they have eaten the entire earth? My aunt Ulca’s raspy voice is ringing in my ears, “How many steaks can you eat?!” (That was back in the day when steak was considered a treat.)

So, my state is shut down because of a temper tantrum and avenues of reason are littered with landmines. In grade school, when learning about past wars, I don’t recall learning what led up to them. I feel like we’re heading toward one now and it terrifies me. My recollection is the teacher saying a whole war was started when one guy stepped off a curb at the wrong time. It all seemed like fiction to me. Even though I devoured The Diary of Anne Frank and was horrified by the events, I felt like it was of a time I could, or would, never be part of. That somehow those people weren’t as intelligent as we are now, or something like that. I liked to think I would be brave enough to hide them in my house, never assuming I would be the one persecuted, of course. I always placed myself in the savior role. Best supporting actress. I remember the story of the woman who played a certain song on the piano to warn the Jews to get to their hiding places and be quiet. Her courage thrilled me. It made me want to learn to play the piano. I used to wonder what I would do in that situation? I wondered if I would be that brave? Would I have hidden slaves on the underground railroad? I always thought I would. I thought I would make a quilt to hang on the line to show them the way. But that was all when it was hypothetical. Now I feel like this is really happening, and what will I do?

George left this week for his home leave. The nursing school and the medical school are not coordinated one bit, so his schedule and mine do not jive at all. His classes have been finished for several weeks and start again late August, so he’s back in Maine until then. The nursing school doesn’t really have a break, not for the faculty anyway. Since there are so many students, they have to be staggered, so they go year-round. So I now have a group of fourth year students in clinical in one place, second year students in another, and I found out two weeks ago I was supposed to be co-teaching the community health class for the first year students. I found this out after the class had already started. “Didn’t anyone tell you you were teaching this with me?” Lily kindly asked one afternoon when I was already feeling overwhelmed with case studies. “I am?” I asked, surprised and sure she was mistaken. And then she pulled out a sheet I’d never seen before with my name and hers in the slot for Community Health. She claims it was emailed to us a while ago. I never saw it.  So my little calendar is a mess of scratched out names of health centers I’m supposed to go to. I have to keep rearranging the days of the week to accommodate all the different schedules. It’s confusing and I don’t feel like I’m doing a very good job.

Monday of the past week was a holiday. I found that out on Friday. It was Eid Mubarak celebrating the end of Ramadan, a national holiday not found on any calendar. So that meant I had to rearrange the trip to the health center I’d planned to go to that day, but it gave me a chance to hang out with Jill, our visitor from the states who was leaving that day. She and I spent the morning walking all over Blantyre looking for easily-packable souvenirs for her to take home and getting some exercise while seeing the sights.

Tuesday morning I walked the forty-five minutes to the Zingwangwa clinic to supervise the students there. I’ve found it’s quicker than walking to campus and waiting for a driver to take me. Plus, I get some exercise and have a chance to get mentally prepared to be depressed about the deplorable care women receive. But, I enjoy the walk and I get to watch a slice of life here I find fascinating. The market I walk through is rough and gritty and looks straight out of Dickens. Guys are making hoe blades with a makeshift forge of charcoal on the side of the road, next to another guy pounding tin into watering cans. We’re in the dead of winter and mornings and evenings are cold, in the 50’s. It warms up to the 60’s or low 70’s during the day, but it’s rather brisk now and walking is very pleasant. Zingwangwa is in the foothills of Soche Mountain and it’s even chillier there.

I found the students in their respectful areas but not doing a whole lot. I get frustrated with this, but can’t say it’s their fault. There is no one to guide them. There were a hundred (or more) women waiting for the the antenatal clinic to start. A health worker was doing a health talk and the students were just hanging around. I didn’t interrupt to ask why they weren’t the ones doing the health talk, just went in to see what was happening in labor and delivery. There, I found all three beds occupied with moaning women and the three students standing at one bedside talking to each other. None of them could tell me what was going on, so I got the “chart”, a piece of paper with a labor graph on it which was only partially filled in. There was no staff person to be found anywhere. These are second year nursing students with no obstetrical experience, managing three active labor patients alone. It was cold. I had on a long sleeved shirt and leggings under my uniform and a sweater on and I was still cold. The windows were open and cold air was blowing into the room. The laboring women were lying on wet zithenje covered only with another chithenje, curled up, shivering. Moaning. One woman sounded like she was pushing, so I pointed this out to the students and told them to get a delivery pack ready. They told me they had no delivery supplies; they were all finished. What?! “Well, get something!” I said. I had gloves in my pocket (I never go anywhere without gloves in my pocket) and put them on, and yes, indeed, the baby was coming. The students collected a piece of cotton pulled off a roll that was supposed to be sterile but was lying on a dirty table, two plastic cord clamps, and a syringe with oxytocin in it. They placed these items in an empty glove box. (Note the adjective: empty) I asked how they were expecting to cut the cord? Oh right. We’ve got to cut the cord…. In Chichewa they asked the woman if she’d brought a razor blade? Well, between pushes, she responded, yes she had, it was in the basin with her zithenje. We found the tiny Bic razor and got it out of the basin just before she vomited into it. I used my foot to move, the now full, basin under the bed and she collapsed onto her side. I lifted her leg and said, “Ok, the baby is right here.” One student said, “Madam, she should get onto her back.” I said, “No, she doesn’t have to move. She can stay like this. Watch.” Then did the delivery with her on her side over an intact perineum, placed the squalling baby between her breasts to keep the kid warm, and had to ask for one of them to give me a chithenje to cover him! Jeepers! It was freezing in there! The students were not impressed with me. They seemed put out. As I was telling them to get a dry chithenje to cover this baby with, the woman in the adjacent bed screamed, “A MAI!” and I pushed back the curtain with the back of my bloody glove to see a baby fly out of her vagina like being shot out of a canon, into a pool of water that I was hoping was still body temperature as the cold wind blew in the window above her head. Babies die here because they get cold. They die. I took my gloves off and fumbled for another pair in my pocket and got them on and got the baby onto her chest and covered with one of her chitenje when a staff member came running in and took over. I went back to the first woman and looked at the students and said, “Do you see why I tell you not to leave the women alone? Ever?” They said, “Yes.” and nothing else. “Do you think she got good care?” I asked. No answer to that and I didn’t push it as we still needed to finish with the placenta and everything. I was running out of gloves in my pocket. The mother was smiling and happy, though, so that was something. It’s so hard to teach anything here because it’s always such a mess. I feel like I’m just continually telling the students what they are doing wrong. I shouldn’t have to prod them to cover a cold baby! But they show up at these sites and the staff isn’t there and there is no one to teach them (Though, that is pretty damn basic and they learned it in lecture. The ones that weren’t asleep anyway.) Ugh.

So I finished up in there and went over to the antenatal clinic. The four students there were all in one exam room doing the visits themselves, no staff. I went in, greeted everyone, and asked them to explain to the patient who I was and tell me about her. They explained who I was then… silence. So I started, “How old is she?”  They have to look at her health passport to find the answer. “What number baby is this?” They have to look again. “When is she due?” The answer to this is always, “She doesn’t know.”  So I asked, “Then how do you expect to take care of her if you don’t know any of this?” Silence.

“What is her blood pressure?”

“We didn’t take it.”

“Why not?”

“The blood pressure cuff is low on battery. They told us to only take a blood pressure if she has symptoms.”

At this point I was refraining from banging my head against the wall. I pulled a manual cuff out of my bag and said, “Take it now.”  I taught this group of students in lecture and spent ten hours teaching them the components of an antenatal visit. Then they get to the clinical site and there are no resources and no clinical preceptors and it all goes to hell. It is so depressing. However, I told them that day, “Talk is free! Ask her! At least act like you care! That’s worth something!” But it was eleven a.m. and they hadn’t eaten and they were hungry and couldn’t focus and it’s just so depressing. (Ok, I think I have used that word enough) Most of these students don’t want to do obstetrics and it shows. This is a required rotation. This particular patient had a two year old with her, and I watched the child eat rice from a plastic container while her mother was examined. The child did not spill one grain of rice. Every single morsel made it into her mouth methodically. I couldn’t stop watching her. I thought it was a rather advanced fine motor skill for a two year old. It’s amazing how little gets wasted when there is true need. I thought of all the meals our dog ate off the floor when our two-year olds ate rice.

When I left there I walked an hour to a lovely little restaurant where I met a guy who is here on a Fulbright, teaching architecture at the Polytechnic Institute. He’s interested in helping design this model ward I am desperate to get going. Days like that were a perfect preamble for my argument. I unloaded all my frustrations over a coca cola (a real coke in a glass bottle, with real cane sugar, so delicious). I told him the likelihood of this being a new building with solar power and rain water collection systems is close to zero. As much as that pipe dream would be fabulous, the reality is going to start in a corner of the existing ward. I’m just hoping to have a steady water supply and blood pressure cuffs (some of which have been donated and I’m guarding with my life). But we need a place where students can see what decent care is, and I don’t mean loads of supplies, though, having a way to keep what we do have clean would be nice. Respecting women, showing compassion, allowing them to labor and deliver in whatever position they want, all of this is free. I don’t want to build the Mayo Clinic. So I had a great time with him (his name is Chris) and he is supportive and amenable and eager to do whatever he can. That felt good. And then I walked home where I thought George and I would have a nice dinner and evening for his last night here. Well, that was a bust. He was totally stressed and preoccupied with finishing up loose ends before leaving here for seven weeks. I was exhausted and stupidly laid on the couch looking at Facebook, freaking out about my country. We’ve had better evenings.

Wednesday was the day I had to go with the first year students to the Blantyre Water Board and the Sewerage Treatment Plant as part of their Community Health course. George’s flight was at 3:40 so the taxi was coming at one. I told him I’d be home for lunch to say goodbye. Lily and I and the twenty students loaded the bus for the Water Treatment Plant. The students had prepared questions and we were all in uniform and looking smart. I was looking forward to this! A field trip where all I had to do was learn something! It wasn’t very far, and when we arrived, Lily told the students to wait while we went in and announced ourselves. The receptionist had no idea we were coming and didn’t know where to direct us. Lily gave her the name of the woman she contacted and we were directed to her office. We walked though the office building, down a maze of corridors out to another building where we found Brenda sitting at her empty desk. Well, it wasn’t completely empty. There was a phone and a laptop, but those occupied one  twentieth of the desk. It looked empty. Lily introduced us while Brenda shook her head sadly. “We didn’t know you were coming”, she said. “You were supposed to book ahead.”

Lily said, “Yes, you knew we were coming. I sent a letter and the secretary followed up yesterday with a call.”

“I never got a call. You can’t tour today. You have to book ahead.”

Lily said, “But the students are all on the bus and we did book ahead. I didn’t call myself but I know the secretary said she called yesterday.”

“I never got a call. You need permission from the director and it’s too late for that” said Brenda without having the slightest sympathy. It was like she had a thing against Lily. It was very weird.

I asked if she could call the director and ask because we really did try to book ahead. Sorry for the miscommunication. This seemed to make Lily mad. She said, “No! We did book ahead! They are just showing their muscle! They can take us!” Well, it looked to me like we had to get by Brenda and she wasn’t budging. I didn’t know if Lily’s tactic was going to be effective. I’d never seen Malawians act like this before. I shut my mouth. Then Brenda made a great show of picking up the landline and calling the director. The conversation was all in Chichewa, but she put the receiver down and said definitively, “No sorry. Not today. You have to book ahead.”

Lily said, “But that’s because of how you asked him! You didn’t tell him I sent a letter a week ago!” And with disgust she told me to get up, we were leaving. And we walked out. I asked her what Brenda had said to the director? She said, “She told him she only saw the letter yesterday and we didn’t confirm and we just showed up!” then walked ahead of me to the reception area. I stopped at the desk and asked if we could talk to the director. I turned to Lily, “Maybe we can explain ourselves to him.” The receptionist told us we couldn’t see him, but directed us to a lovely woman in charge of PR and there we described our situation. She was completely sympathetic. “Oh! The students are sitting out there on the bus? Of course you can have a tour! Let me find someone!” But we’d left out the Brenda part. This lovely woman bopped back into the office saying she’d gotten permission and would just go over to Brenda’s office to find someone to take us on the tour. She told us to go ahead and bring the students in. Uh oh. I was kinda hoping we wouldn’t see Brenda again. Lily was impressed, though. She said, “Wow! I would have just given up. I’m glad you persevered.”  I said, “Let’s get the students in quick before she talks to Brenda.”  So we got the kids off the bus and all twenty in the reception area looking at the blackboard with the water quality data. A few minutes later, Lovely and Brenda, both stone faced, marched through the group to another office and closed the door. I said, “I think there’s a disagreement.” They were in there a long time. When they finally emerged, Lily and I were told to come into a different office where Lovely wasn’t so happy with us. Brenda stood behind her like an executioner. Lovely said, “You will be allowed to tour today. But in the future, you are required to book ahead and receive a confirmation before you bring anyone here. There are safety issues.” I said, “Oh, of course. I’m so sorry about the miscommunication. We’ll come in person next time to make sure it is confirmed and not rely on telephone. What time are you here in the mornings?”

“Seven thirty.” No smile.

I said, “Ok! Thank you!” Lily looked furious. Brenda stomped out saying she would go find someone to take us on the tour. I told Lily, “At least the morning isn’t wasted. I’m so used to kissing ass to get things done. It’s just like this at home.” That seemed to soften her mood and we went out to wait for someone, whom I hoped would be nice to us, to show us the plant. We explained to the students that finally someone was coming. This whole thing had taken two hours. Well, it was Brenda. She couldn’t find anyone else, so had to take us herself. I thought, oh this is not going to be good so decided to try to warm her up a bit. I walked next to her and asked questions like: how long she’d worked there?, what was her background?, did she find the work interesting? and it worked. She turned out to be quite chatty and nice and very informative. I’m not sure what the earlier dynamic was, but some kind of power struggle I didn’t understand. We walked out to the reservoir and then through the treatment plant. I was impressed, though the equipment looked beaten up and corroded, it seemed the process worked. On the blackboard it said the fecal coliform bacteria count was zero, so it looked to me like they were doing their job. The tour was cut a little short since we wasted the first two hours, but it was worth it. We thanked her profusely, the student leader did a lovely speech of gratitude, and we left. I made it home to say goodbye.

That afternoon was another field trip to the sewerage treatment plant and Lordy it was disgusting. We wore face masks but the smell was overpowering and when I saw the (untested) water flowing into the river I was nearly gagging. Then we saw kids washing their legs in the sewerage and I did gag. The guys doing the tour would not stop complaining about their jobs. They said they don’t have the money to fix the equipment when it breaks down. They have to sell vegetables at the market to raise money to fix the machinery. I looked toward the river and saw what looked like a gorgeous vegetable garden. I’m sure it was well fertilized. I won’t be buying vegetables at that market.

I came home that evening to an empty house and felt strange. I lived alone for many years and loved having the time and place to myself but it is an adjustment. I’ve become used to having someone around. I’m acclimatizing; I’m not uncomfortable and don’t feel unsafe alone. I thought this would be wind down and finish up loose ends time. I thought I’d get lots of craft time in. But being out at clinical sites three days a week chews up a lot of time and I find myself behind with administrative and grading stuff. I’ve still got case studies to grade and sixteen projects I’m starting to wish I never assigned.

Thursday I was out with the fourth year students and went on two home visits with them for their postnatal project. That was fun. I love community health. I love going to people’s homes. These were long walks from the health center, an hour each way, but as I told the students when they complained, the women have to walk this in labor! They both did a good job and were sensitive and caring and thorough. I was impressed and relieved after Tuesday. Maybe something is getting through. The conditions in the village are pretty shocking, though. It’s incredible to see how people live with next to nothing. They had mosquito nets, but not much else. Still, the babies, both a week old, were warm and thriving. The mothers both complained that they had pelvic and back pain, but were still walking a half mile to the bore hole and carrying heavy water back on their heads. I suggested that maybe they rest for a week and have someone else carry the water. They are asking quite a lot of their bodies. Finding someone else to do it is another thing, however. I asked the students if the village women don’t help each other after childbirth? Can’t they form some kind of coop for getting water when someone is fresh postpartum? Maybe we could introduce that idea. A new idea like a new broom. Sometimes everyone can see that it works well.

Friday, I met Noah, a young Peace Corps volunteer who is going to help with the permagarden at the orphanage. We met for lunch to discuss our plan then took a minibus out to meet Godknows. But he wasn’t there. I called him and he hadn’t realized we were coming, another in a series of miscommunications, so suggested we talk to one of the older kids; he’d catch up with us another time. Noah, having lived here for over a year, was totally nonplussed. We found Sandra, a twenty year old university student who described herself as “one of the kids”. She showed us where they currently grow some vegetables and gave us as much information as she could, but we’ll have to go back another time when Godknows is there. It wasn’t a waste though. We took photos and measured the space and got an idea of what we had to work with. I hadn’t needed to carry the ten pounds of seeds around all day, however. But that will just make me stronger. Noah and I made a follow-up plan, said goodbye, and I walked home the ten kilometers to sink into a Friday evening beer and bed. Wiped out but satisfied.

Whew! That was a lot to tell!

I’ve got another busy week coming up and I can see my final month before home leave will fly. I’m determined to eat what’s left in the house before I go so I can unplug the fridge while we’re away. Just a little personal challenge I like to give myself. I will not however, be able to drink all the beer and gin our friends left! It’ll be something George doesn’t have to shop for during his two solo months.

Ok, now to make turmeric tea with the fresh turmeric a friend just brought and then break my no-work Sunday rule and finish these case studies….

Love to all,

Linda