Tricky Parasites

This is almost too crazy to be true so I’m going to explain it as if it is a hypothetical situation. That way its just part of my imagination rather than reality pissing me off.

Imagine it is the height of malaria season in one of the poorest countries in the world. Most adults who have lived in the area get over this illness without much difficulty because they have built up good immunity after dealing with multiple infections throughout their lives. However, young children and pregnant women regularly die from this disease. These days there are a limited variety of available drugs to treat malaria. Because the country is so poor, with the average person completely unable to pay the market price for these medicines and with the government not even close to being able to generate enough revenue to supply the country’s health centers with an adequate supply of these medicines, it relies upon places like the United States to supply the malaria medications.

Over the past year and beyond, there have been more and more reports about healthcare workers in the country stealing these donated drugs from the hospitals they work at so that they can sell them on the black market for 100% profit. Albeit slowly, the United States has caught on to this nefarious behavior and has decided to crack down hard. All health centers must now record the basic information of each and every individual receiving these medications. This new record keeping is in addition to the typical records for individual patients and pharmacy inventory—both of which are notoriously inaccurate. A new list of those receiving the medicine and where each of them lives must be available so that the cranky Americans can come at anytime and crosscheck this list by going into the community and making sure those who reportedly received the drugs indeed received the drugs. If there are any discrepancies, the supply of these lifesaving medications will be cut off. It turns out that many health centers aren’t organized (or motivated or aware or whatever) enough to even do this new record keeping. There is an entire district that can’t produce these records, and they just lost their entire donated supply of malaria medications.

Adjacent to this district, there is a large mission hospital that has been able to relieve some of this devastation because it is relatively well organized. Although their staff is completely overwhelmed this time of year with spikes in admissions due to severe malaria, they have been keeping good enough records that the Americans haven’t cut off their supply of malaria medications (yet). The people in the district nearby without any medications flock to the mission hospital in search of care. This hospital was already overwhelmed to begin with, and this further influx of patients further stresses its capacity. Furthermore, the patients coming from the district without any medicine are traveling long distances to get there and often arrive after much delay so that their illness is very severe by the time they get to the hospital.

To add to this, there is a parallel story that demonstrates the mission hospital’s difficult predicament: for many years, they have had a service level agreement (SLA) with country’s government. With the SLA in place, they received enough funding to subsidize basically all patient costs at the hospital. The SLA also allowed them to spray insecticides in houses throughout their catchment area of 80,000 people on a yearly basis before each rainy (ie malaria) season. This insecticide spraying is a powerful public health intervention for preventing malaria in endemic areas. While the hospital was doing this spraying over the past few years, they have seen a large decrease in the number of admissions and deaths during the rainy season. (There is an interesting story of natural selection and how the mosquitoes have rapidly gaining resistance to these insecticide sprays, but we'll have to save that for another day.) Unfortunately, due to a variety of reasons (including government officials stealing almost all the money from the treasury while the former president was visiting the USA a few years back) leading to depletion of funding for the program, the country’s government had to break the SLA a few months ago. As a result, the impoverished patients now encounter a fee for service billing structure. Word spread quickly that everyone now has to pay when going to the hospital, and many (not just those traveling from form the neighboring district) are now delaying to go to the hospital until they become very sick. Hospital staff also think that more people are seeking help from traditional healers rather than going to the hospital. Not only do these traditional healers swindle the poor with hoax therapies, but many of these therapies are dangerous. Only a small fraction of the hospital’s catchment area was sprayed prior to the current rainy season, and this is thought to be another big factor in the recent increase in overall malaria cases, death rate, and total death count.

Last week, the medical director of the hospital went to the Ministry of Health to discuss the possibility of reimplementing the SLA. He was armed with lots of facts about how detrimental the dismantling of the SLA has been over the previous months. The meeting never took place because there was no one there to talk to. Just before this meeting was planned, over 60 officials in the Ministry were fired because they mishandled funds from the CDC.

At this point, healthcare in the country is in complete disarray. But it has more or less always been this way so there’s not really any general sense of urgency to improve things in a meaningful way.

Don't Let Your Boy Grow Up to Be a Minibus Conductor

Riding a minibus in Malawi is always an adventure. Crammed in with people that haven’t bathed for a few days, goats and chickens at your feet, baby’s peeing on your shoes, it’s a unique experience. Someday I’ll quit being so stingy and move around more in taxis or rental cars or even my own car. In the meantime, I continue to amuse myself with this immersive cultural experience.

 

My foot falls asleep just looking at this picture

As in most businesses, the more customers you have, the more money you make. More passengers in a minibus means more money. The four main factors that limit the number of passengers in the bus are 1) tolerance of the passengers, 2) road laws, 3) the need for a driver and conductor in the bus, and to a lesser extent, space. Unfortunately, Malawians are generally used to, and accepting of, poor customer service (at least compared to my high, pompous standards). They’re used to getting crammed into a bus like sardines because this is the way it always has been. I’ve heard people complain from time to time, but these seeds of upheaval are quickly put down by a stern scolding from the conductor and driver. Like most laws in Malawi, those regulating the number of passengers in a vehicle are very loosely and erratically enforced. This is due to police officers being underequipped, understaffed, under-motivated, bribed, etc. Probably the most important reason for poor enforcement of road laws is that certain roads rarely have police on them, and on those roads the conductor and driver can pack people in excessively without any fear of consequences. Until the Google car or whatever gets to Malawi, there’s no way around needing a driver. However, the space the conductor takes up is very flexible. To make more room for passengers, the conductor can stand up hunched over (the roof of a minibus is about as high as that of a minivan). He can put his head, torso and arms out the window (I’ve heard of more than one conductor being decapitated here, it’s a dangerous job). I’ve been in buses full with one to many people allowed by law, and while approaching a roadblock with police officers, the driver told the conductor to get out, run up ahead, and we’d simply pick him up beyond the roadblock. Very sly.

Maybe I’ve been in America for too long, but a couple days ago something hilarious happened that I had never seen before. I was getting on the bus to the hospital I’m working at. The bus was filling up quickly. The driver and conductor were confident there wouldn’t be any police along the way so they packed us in. We started off with what seemed to me to be a completely full bus, with the conductor hanging out the window barely keeping his legs inside. I was surprised when we stopped to pick up another passenger about a kilometer down the road. Everyone in the bus groaned. Someone asked the conductor where the hell this new passenger was going to sit. The conductor told everyone not to worry. The passenger got in with the conductor pushing his butt in from behind and quickly slammed the door shut. The conductor was outside and I figured we would just leave him behind and the driver would pick him up later or something. The conductor then jumped up so that one of his feet got onto an open window and he pulled himself up on top of the bus! I started laughing, and then everyone was more amused by me, the big white guy on the bus, being amused by the situation then the situation itself. We all joked that this would be a Malawian-style bus ride and that this would never happen in the States. We then proceeded to Nkhoma with the conductor clinging onto the top of the bus. The road to the hospital is curvy through some low mountains. We could hear him struggling to brace himself up there around a few turns, but I had the impression he’d done this many times before and probably had pretty good core strength for this work requirement.

I’ve said it before: this place never stops amazing me. A friend once said that living in Malawi is like one big acid trip, but I’m going to refrain from confirming or denying that…

I'll Try to Limit the Sad Posts From Now On

So I’ve been in Malawi for two weeks now. This past week was my first of six weeks at Nkhoma Synod Hospital. One can find it on Google Maps. It’s about 50 km northeast from the Chadabwa/Mitundu area I was working in as a Peace Corps Volunteer. I have been and will be working mostly in the pediatric ward at the hospital. We’ve had 80+ patients each day, with a turnover of about 20% each day due to new admissions, discharges, and deaths. This is an absurd number of patients given that the staff is at most three nurses, two clinical officers (somewhat similar to a physician’s assistant in the States), one doctor for only half the day, and me and two other medical student who barely know what the hell were doing. This is the maximum staff we have. Usually, most of these people are either out in the parking lot talking with friends or hiding somewhere thinking about how tired they are. But that’s a rant I’ll go on a different day. Today, by briefly explaining three patients I worked with this past week, I want to give you a picture of how bad the situation is here, especially now as the rainàmosquitoesàmalaria ramps up.

I didn’t really take care of this first child because there was nothing to do by the time she got to the hospital. She was about one to two years old and suddenly developed malaria at home. The story I heard was that the family lives in a very rural area on the outskirts of the hospital catchment area. There’s a very basic health center near to there home, and when the parents took the child there, the staff quickly told them to go to our hospital because her illness was so severe. This is a distance of about 30 km over muddy, washed out, hilly roads. Unfortunately, the health center’s ambulance was broken. Then were told to get the child here on their own. This time of year, most families have miniscule cash reserves. The yearly cycle of cash flow from selling portions of one’s harvest reaches its nadir around this time, and basic things like arranging rapid transportation to the referral hospital become very difficult. The parents managed to scrounge up enough cash to hire a motorbike to bring them to the hospital. This was the only motorbike in the area, and apparently it had some problem so that it could only get up to a maximum speed of 10 km/hr. On the steeper hills it lost power, and the mother with child in hand had to get off and walk. About two thirds of the way to the hospital, the motorbike completely broke down, and the mother had to carry the child the rest of the way. By then, the child was seizing. By the time they reached the gates of the hospital, the child was dead.

There was another child, a cute cubby little 4-year-old boy, who I hadn’t seen until after he had been in the hospital for a few days. He also had malaria, and it was confirmed that the parasite had gotten into his brain (called cerebral malaria) on the second day of admission. Before I saw him, he was seizing on and off for a few days and combative at times when awake. The nurse had asked me to see him because he was acting strange after he seemed to have recovered the previous 24 hours. I went over to his bed and saw him sitting in his mother’s lap with her barely able to hold on to him as he was flailing around and biting her at times. He was laughing at the same time, and at first glance he just looked like your typical problematic toddler. I told the mother that he looked much better and full of energy! She gave an awkward laugh but then shook her head and briefly stated that he was acting very strange. I watched him for a bit and realized that his eyes were darting all over the place. He was calling out the names of people that weren’t there. He was swatting at flies that weren’t there. A couple of the other clinicians and I brainstormed what was wrong: HSV brain infection? Rabies? Psychotic episode? We couldn’t figure anything out that day and couldn’t really settle him down. The next morning one of the doctors saw him, and she immediately proposed the idea that he’d simply lost all his vision. I flashed my penlight over his eyes and he didn’t react at all. We ended up having the ophthalmologist come up and take a good look at the retina of each eye. He confirmed our suspicion. We concluded that he lost his vision due to the malaria infection in his brain. Given that he is young and his brain is still developing, there is a chance some of his vision will return, but most likely he will remain blind the rest of his life. I was choked up as I broke this news to the family.

The saddest story for last: The doctor and I were seeing a new patient. Again, this one had severe malaria (pretty much every patient we admitted in the last week had malaria +/- other stuff) and looked pretty bad. We were asking the mother about what was going on with the child, and I asked her weather anyone else in the family had been sick recently. She offhandedly said her husband died the day before. I’m fairly decent at Chichewa, but I often mishear things, especially when people use words/phrases with double meanings. I was surprised but what she said and thought maybe I was mishearing her so I called over the nurse to make sure we were all on the same page. We were understanding each other, and we quizzed her a bit more about the husbands death to see if might be related at all to the child’s illness (for example, did he have TB that he might have given the child?). It didn’t seem like he had any type of contagious disease so we moved on trying to figure out how we were going to treat this very sick child. Without going through all the details, I’ll skip ahead to the next morning. Most days, the majority of the medical providers at the hospital meet up at 7am for Morning Report. This entails discussion about what happened on each ward overnight and maybe a brief lecture on a certain topic from time to time. The clinical officer that was on the peds ward overnight described how this child had declined quickly and passed away a few hours prior. I can’t imagine how that women felt first loosing her husband and then loosing her last-born child the next day.

At least one baby/child has died in the ward every day I’ve been here. After living in Malawi for over three years and knowing how dysfunctional things can be here, this doesn’t surprise me at all. It only makes my angry.

The guesthouse I'm staying at, just up the hill from the hospital. I don't have any evidence yet, but I still think it's haunted.

Globalization of Butter

On my flight to Addis Ababa, I had the pleasure of spreading Land O Lakes butter (from the great state of Minnesota) on my bun.

On a different note: as part of my grand plan to make this 13 hour flight bearable and begin adjusting to the 7 hour time zone change, at the beginning of the flight I had three glasses of wine, 10 mg of melatonin, and 75 mg of Benadryl. That seemed to do the trick. I was feeling nice and sleepy, put my jacket over my head, and fell into a deep sleep. Later on, I woke up to the hustle and bustle of another meal getting doled out of the noisy cart being pushed down the aisle. At the beginning of the flight, I remembered them announcing that we would get breakfast shortly before our arrival in Addis towards the end of this flight. I woke up, pleased with myself for being able to sleep for the entire flight and up just in time for another complimentary meal from Ethiopian Airlines. I looked at the map of where we were at on the screen on the back of the seat in front of me. I had only slept for two hours! We still had 9 hours to go! As the lady in the seat next to me shifted and knocked my arm off the armrest, my frustration with the situation only made going back to sleep more difficult. At that time we were just getting a snack. With two toddlers frequently running up and down the aisle, stuck in a middle seat with barely enough room for my legs, and wide awake,  I had to wait many hours in my seat before our breakfast came and we soon arrived in Ethiopia.

Back To the Warm Heart of Africa

Yesterday, I arrived back in Malawi. I’ll be here for two months so I thought I’d resurrect this blog. I expect to be pretty busy so I can’t promise too much writing but I’ll do my best.

Some initial observations in the first 12 hours: Nothing’s really changed. People are still very friendly and excited to talk to an American whether they have ulterior motives or not. In a country of now over 16 million people (and rising quickly) everyone still seems to know everyone. The driver in my cab ride from the airport grew up in Mitundu, the community I used to work in. This was surprising because I ran into him in Blantyre (a couple hundred kilometers away from Mitundu), and he knew all the people I worked with. The same family is still running the country. When I left at the end of 2011, Bingu wa Mutharika was president. He passed a few months after that. Depending on who you ask, this was going to be a fresh change for the country. Well, glossing over a lot of the details, four years later his little brother is now in power, and the new boss is the same as the old boss. On sunny days during the rainy season, you can still see forever. Packs of skinny, dirty, adolescent boys in ragged clothes still roam the city streets begging for money, getting especially vocal towards foreigners. It’s still a big seen when I go jogging in the morning. This time of year the weather is still much better than the Upper Midwest.

I’m off to Chikwawa today. A year ago, devastating floods displaced many of the people living there and destroyed much of the local infrastructure. I’m interested to talk to people about the situation one year on. I don’t expect to hear much good news, but maybe I’ll be surprised. This place is full of surprises.

Final Thoughts

So I've kind of lost interest in this whole blogging thing, but I understand that a lot of you are still interested so here's one more for all of my fans out there:

I'm leaving Malawi this Tuesday, closing a chapter this in my life. I have grown a lot as a person during my three plus years here. I'm ready to move on to bigger and better things (hopefully), but I'm also sad to leave. Many people have been asking me over the past few weeks "What will you miss most about Malawi?" The answer is simple: my friends. I have built many strong relationships over the past few years, and I have to admit that saying "goodbye" to everyone hasn't been easy. My time here has been well spent, but I am spent, and I want to go home for a little while. I plan to come back someday, but I've got some business to take care of first.

To end things, here are a few words of wisdom:

In general, poor people are cooler than rich people.

The best way to charm a Malawian woman is to bring her pumpkins from your garden.

"Give me my money!" is not an effective begging strategy.

It's important to have a balanced diet. If most of your calories come from maize and overcooked greens, your wounds will heal slowly and become easily infected, you'll find yourself tired all of the time, and (if you're a growing boy) you'll be more likely to end up six feet under rather than six feet tall by the time you're 18.

Be wary of over-polite strangers; they probably want something from you.

When you teach a man to fish instead of giving him a fish, make sure that you teach his neighbors as well so they don't become jealous and jack his fishing pole.

Life is less complicated when you only have one brand of beer to choose from.

Life is more complicated when you had one too many beers and forgot to put on a condom.

Life is less complicated when you don't have to fill up your car with gas because you don't have a car.

Life is more complicated when you can't fill up your car with gas because of daily fuel shortages and mile long lines at the gas stations.

Life is less complicated when you fall off your bike and into the mud when you're almost home.

Life is more complicated when you fall off your bike and into the mud 20 kilometers from home while wearing your nice clothes.

Life is less complicated when you know that there isn't a chance in hell that a single drop of rain will fall between the months of May and October.

Life is more complicated when it pours rain for three days straight and there's mud everywhere.

Akon was cool the first 1000 times I heard him.

Michael Jackson will always be cool.

It's not fashionable for a grown man to wear children's snow pants as shorts in the middle of summer (or any time of year for that matter).

Washing your hands with soap isn't easy when you can't afford soap.

If you're too cheap to buy TP, then a suitable substitute is unclaimed exams from you're students. (I understand that this point is debatable)

It is much easier to read a magazine while on a toilet instead of while squatting over a hole in the ground.

It is much easier to squat over a hole in the ground rather than squating over a toilet with no seat.

If you're walking through the bus depot looking lost with three half-opened bags in your hands while talking on your IPhone, then you deserve to be robbed.

The best time for a misanthrope to go out in public is Sunday morning.

Having people's undivided attention is good when you have something to say but bad when you want to crawl into a hole.

A kid can't learn to read and write if he has to heard cows all day.

A kid can't learn to speak English if her teacher can't put a full sentence together.

It is not any fun to live in a place where it's necessary to have three guards and a ten-foot fence around your house.

If over half of your students are failing, then it's a lot easier to grade their exams if you have a good buzz going.

If over half of your students are failing even though you work your butt off and can objectively be considered at least an average teacher, then your students probably just aren't very smart.

If you don't understand what a democracy is, then you probably shouldn't try to institute one.

Finally, this place is really, really messed up...and that's why I like it so much.

Nkhuku yanjiru siiswa. Chewa Proverb

[Translation: A jealous chicken will not hatch chicks.]