Sunday Morning ~ Blantyre

Kwa eni uyenda umaweteka ~ At somebody else’s place you walk gently and humbly.

~ Malawian proverb

June 10, 2018

Hi Everyone,

Oh so much has happened. I feel like I’ve been around the whole world––from sweet dance recital in New England to benchmarking visit in East London, South Africa––within a few days. I spent two consecutive nights on airplanes and in airports and returned back to public toilets I have to flush myself. I’ll say it again, I don’t think we were meant to change worlds so quickly, though coming this way it’s a little easier. 

It’s been awhile since I wrote anything about my work in Malawi. I have been so desperately hoping we could get this model ward established in my lifetime.  My time here is getting so short and I am under no illusion that it’s be done in the next three weeks, but I have been hoping for at least a commitment to get it underway.  We are getting closer to that. An MOU by the end of June is a possibility. Several great gifts have fallen upon us that might make it happen. 

In the process of writing the proposal for the project, one of my fellow volunteers forwarded an article she found about a similar ward started in South Africa. As I read it, I was struck by the similarities in our settings. Frere Hospital in East London, South Africa launched a project to create a midwifery-led ward within the tertiary care hospital. The article was an audit of the project a few years after it’s inception. It was a template for us and evidence that it was possible to create this in our region. I wrote to the lead author asking if they would be willing to share their protocols and process of getting the ward implemented, explaining we wanted to do the same thing in Malawi. That email led to a correspondence with the midwife who was instrumental in getting the ward established. She told me initially that since it was an international inquiry, I had to be referred to the department of international affairs at the ministry of health. I figured the whole thing would stop there and I’d never hear from anyone again. But I did hear back that they were very interested in our inquiry and wanted to know if we’d be able to visit there to see the ward for ourselves. This was several months ago and I think I assumed that wasn’t going to happen as I’d never get funding for a trip like that. I considered just going myself and paying for it out of my own money, but this cannot be my project alone to implement and would only be fruitful if my Malawian colleagues could go as well. I had applied for a grant to cover the cost of the initial start-up of the ward and received a little money just to provide tea and refreshments at our meetings. When the idea of visiting the site in South Africa came up I asked SEED if they would consider funding the trip for three of us to go. The timing was poor for that request as the organization was trying to regroup after acknowledging that the partnership between them and Peace Corps was ending. 

A little background into what’s happening there: The PEPFAR (President’s Emergency Plan for AIDS Relief) funding for the GHSP program I’ve been working with is ending. It’s tragic, really, as it was the major funder for the program. PEPFAR was established under George W (to his credit) but now the state department is in such a sad condition it’s relationships with other countries are being destroyed. This was a great program that I completely believed in with long term potential. The partnership with Peace Corps, which was a good marriage, was ending as well. It’s all so discouraging. So the request for the site visit to South Africa wasn’t granted. 

In the meantime, I continued to correspond with the contacts I’d made in South Africa, both the midwife and the representative from the ministry. They were so eager to have us come, that I again thought I’d just go myself on my own dime. Then at our close of service meeting in Salima, just before I left for the states, we all had to do a little presentation about what we’d accomplished this year and someone from the SEED office in Boston was there. I explained the rationale for this ward and how far we’d come to date. I explained about the ward in South Africa and how helpful it would be for us to visit there. Well, after my presentation, Julie, from Boston suggested I put together a quick budget for three of us to do a benchmarking visit and she’d see if she could facilitate making it happen. It was a total whirlwind the day before I was taking a thirty-five hour flight to the states, but the trip got approved! I frantically (with crappy internet) contacted my colleagues in Blantyre to get their shit together and choose two midwives to make the trip which was going to be tacked on to my trip to the states. So instead of flying directly back to Malawi I got off the plane in Johannesburg and took another flight to East London, where our hosts had arranged to collect us and transport us around for the visit. 

I thought the obvious choice for a representative from the college of nursing would be Ursula since she is the one who has been instrumental in pushing this project forward, but she wisely said that she wanted buy-in from everyone, so encouraged someone else to go. So it was decided that Elizabeth Chodzaza, who’d been the head of clinical studies, make the trip. Since we had three slots, one of the matrons (nursing supervisors) from the hospital was chosen as well. This would give representation from the hospital who we really need as a stakeholder. It’s always amazing to me to see how they can pull something together so quickly. They had a week to find coverage and leave for a four day trip to another country. We all met up at the airport in Johannesburg, them arriving from Blantyre, a ninety minute flight, and me from Boston via Dubai, a thirty hour voyage. I was a little tired by the time I met up with them for our one hour flight from Johannesburg to East London, in the Eastern Cape province on the Indian Ocean. 

We walked out of the arrival area to see a man holding a handwritten sign saying, “Malawian Delegation, Frere Hospital” which obviously was our ride! I had been nervous about all the pieces coming together: changing my flight to Blantyre, meeting up with the others, getting transport to a hotel in a strange city, finding the hospital, etc. but every step of the way I just focused on the next step. So, okay, we had a ride to the hotel. The driver dropped us there and told us someone would pick us up in the morning at 7:45 to take us to the hospital. Phew. Ok, next step taken care of. I desperately wanted a shower and sleep, so was happy with that. Then after we booked in we turned around at the reception desk and there was a man introducing himself as the representative from the international affairs office and wanted to welcome us. He introduced us to his colleague accompanying him and they ushered us to a sitting area so we could go over the agenda for the next day. They handed us each a copy of a printed agenda laid out in fifteen minute blocks. I noticed with alarm, that the Malawian group was scheduled to give a presentation outlining their objectives for the visit at 9 a.m. I was rather blown away by this (#1 blown away). I was expecting to show up at the labor and delivery ward, meet the midwives and sit around shooting the shit about how they got the place started. Clearly I had not thought this far ahead. They got up to leave and, after bidding them goodnight, we looked at each other in shock. “Can you believe this?”  “I have never been welcomed like this before!”  “Oh my God they are organized!”  “What are we going to do for a presentation?”  It was now Wednesday evening. I’d been up since Monday morning. Elizabeth said, “Linda, can you put together a power point presentation?” I sighed. I said I’d see what I could do and went to bed. 

I set my alarm for 5:30, got up, and put together the lamest little presentation imaginable, but it was better than nothing. I already knew what we wanted to learn from them, it was basically putting it into a formal format. Not my forte but I’m getting better at it. I work well under pressure.

They collected us right on time and off we went through the city to Frere Hospital, a tertiary care hospital established in 1881. It is affiliated with a university and a nursing school and has about 1,000 beds. The size and university affiliation is something they have in common with our Queen Elizabeth Hospital in Blantyre but that’s about where the similarities ended. Their CEO, Dr Wagner, met us at the entrance to the hospital and escorted us to the room where at least twenty-five people were gathered to spend the day with us. Blown away #2. (Our CEO took six months to meet with us about our proposal and only then after we sat in the waiting room and refused to leave until he did.) The program started with  introductions, which, given the number of people in the room, took some time. Then it was our turn to do our presentation. Until this point, all of our correspondence had been about logistics and none about content, so they were very happy to understand more about what our goals were and what we hoped to learn from them. I started off the presentation then my colleagues described their specialty and perspectives. Our hosts clapped and cheered and acted like we had given them some huge gift. Blown away #3. 

After that the CEO described the hospital services offered at Frere, which, along with their value system, are impressive. She emphasized that no one succeeds unless there is buy in from everyone. If there is success in one arena it is because there were support staff helping to make that possible. No one’s achievements get celebrated alone. (Here here!) Then Dr. Hofmeyer, (the lead author of the article I originally responded to) described the establishment of the Midwifery Birthing Unit (MBU) complete with stats on how it has improved outcomes and care overall. He waxed poetic about respectful care of women and how WHO has new guidelines for that. I wanted to kiss him. After that Thozeka, the midwife with whom I’ve been corresponding, described the services provided in the MBU, holding my hand throughout the entire presentation.  She was praised by everyone in the room, all the administrators and support staff were cheering her for bringing the Malawians to Frere. “You put us on the map!”, they exclaimed. She beamed and gazed at me. Then an overview of the HIV and TB services was given by the director of that program, a Congolese man who’d been in South Africa for nine years. All this transpired before our tea break.  

After tea the entire entourage walked through the intensive care units on our way across the street to the midwifery ward. We spent quite a bit of time there learning how it functions, how it is staffed, and how the record keeping is done. While that was happening the three of us from Malawi got pulled out into the hallway to be interviewed by a reporter from the East London newspaper. This entire tour was led by the CEO, who: greeted every staff person, explained the funding for each unit (including exact amounts received from donors), stopped to give directions to patients, held and soothed a crying baby in the nursery, explained the nuances of their electronic medical records system, and stooped to pick up pieces of trash and deposited them in the nearest waste bin. Blown away #4, 5, and 6. I felt like I was watching a movie! I kept pinching myself. I whispered to Elizabeth, “Is she for real?”  Elizabeth whispered back, “I know. Can you imagine this?”

At one point while touring the pediatric cancer treatment ward, Dr Wagner told a story about an employee who went to the newspaper to report on an incident that wasn’t handled well. Instead of getting angry at him, she said it was a sign that something was systemically wrong and they should address it. She said, “It was upsetting, but in reality I had to acknowledge he was advocating for the patients. I took it as an opportunity to look at what was wrong and try to do better. It would have been better if he’d come to us first, but getting angry wasn’t going to help the situation.”  They then worked together to address the issue. I thought back on all the times we’d tried to address problems in our department at MDI hospital and were scolded for actually bringing it up at a meeting. When I finally wrote about it in my blog they acted like I was a traitor. I kept thinking, “How can we clone this woman? It is possible to have a CEO who is smart, compassionate as well as passionate, reasonable, and a problem solver! Who knew?” I felt like we’d been given a glimpse inside the pearly gates.

I started panicking about the possibility of them coming to Blantyre for a site visit. This is going to be a tough act to follow.

Included in the entourage was the director of the nursing school associated with the hospital. She told us she was hoping to have time with us the following day and since that day (Friday) was left open, we agreed to meet with her in the following morning. As we walked from department to department she fell into step with us asking questions about how we handled students in different situations, how we could collaborate long-term, how possible would it be for them to visit Malawi?

There were several times Dr. Wagner began an introduction with, “Like your hospital…” because on paper they do appear similar. She’d done a good amount of research about our hospital and knew the number of beds, services offered, and population served. However, like I said, that was on paper. The only part of our hospital that comes even close to theirs is our new pediatric surgical unit built with Madonna’s money. The rest, no. Not even close. Dr. Wagner told a story in hushed tones about a terrible incident where they had cockroaches in one of the postnatal wards. She explained that some patients were bringing in food and the result was a cockroach infestation. So they closed the ward and moved all the patients to a temporary ward so they could fumigate the area. Then they took the opportunity to paint it since the ward was empty. Blown away #7. I stood there listening to her tell me this story and made murmurings of acknowledgement of her feelings and efforts. I was contemplating telling her about the rats in our maternity ward and the complaint lodged by a family when the rats had eaten part of their stillborn child who was left lying on a counter in the utility room. And you know what was done about that? Nothing. Nothing was done about it even after it was reported in the newspaper. But I didn’t feel like it was appropriate to one-up the cockroach story, so I praised their efforts in addressing the problem and told her we had a lot to learn from them.

We were ushered to a conference room where lunch was laid out for us, a very simple lunch where platters of samosas, tuna tarts, and meat pies were shared. It was simple but completely wonderful. After we ate, Dr Wagner wanted to go around the table to have everyone share their thoughts about our meeting and what we’d learned from each other. The Malawian contingent was to go last. I have to say, I was overwhelmed by this gesture. Blown away # 8. It was incredible. Several people from different community departments said how grateful they were that we’d come since they’d never toured the hospital before and what a great opportunity it was for them. They kept telling us how much we’d brought to them. The nursing school director told us she felt like our visit was a gift from God. Thozeka, the midwife who started the midwifery ward went on and on about how grateful she was for what we were trying to do for women, then, I swear to God, broke into song like…we are talking Ella Fitzgerald. I have never seen anything like this. Everyone joined in singing, holding hands, swaying, laughing, oh my God. The entire trip was worth that. Blown away #9, 10, 11. I had to take a video, I just had to. I thought no one would believe me.  Then I was thinking…we have to follow that?! Are you kidding me? Our turn was next. 

Elizabeth was the first to go from our group. She started, “I would just like to say that in Malawi people think South Africans are lazy.” I looked up in horror! What was she saying?! She continued, “It’s because a lot of Malawians go to South Africa to find work, so people think that South Africans must not want to work. I realize now that I have visited for the first time, how hard working and wonderful you are. It has been such an honor to be here. I will go back and explain what I have learned.”  The room broke out in cheers. I heaved a huge sigh of relief.  Then there was much discussion about them hiring a bus and traveling to Malawi together. “How far is it? Can we do it in twenty four hours on the bus? We all should go!” 

I am telling you, the only hope we have for world peace is to travel. The only hope.

My own bed tonight. More next week.

Love to all,

Linda