The Beginning of CorpsAfrica in Malawi

Last night I had the pleasure of attending the swearing in ceremony for the first cohort of CorpsAfrica Volunteers in Malawi.

You can find many more details at the organization's website (http://www.corpsafrica.org), but my one sentence summary is that it is like the US Peace Corps but they recruit volunteers from within the country (eg. Malawians serving as volunteers in Malawi) instead of Americans going to developing countries like I did in 2008. It's a one year commitment for these inspired young adults. It was started by a former Peace Corps Volunteer that served in Morocco. She naturally started the program in Morocco, and they are just starting to train their third cohort of volunteers. This year they have expanded to two additional countries, Malawi and Senegal. I was amazed to hear today that all of this, including these new activities in Malawi, are being funded by a  Moroccan mining company.

I had a lump in my throat throughout most of the ceremony. I'm very excited to see how these guys do over the next year.

Taking the oath

See the video of the new volunteers taking their oath

I had the opportunity to visit their training a few weeks ago and talk with some of them. It's very inspiring to hear about their dreams, and some of their life stories will give you goosebumps. The current director of operations here in Malawi, Adam Gaskins, started his Peace Corps service while I was about half way through mine. It's great to see this old friend leading this group and hopefully taking things to the next level over the next few years. One of the new volunteers is a woman I worked with a lot on a variety of projects when I was here before, and I'm very excited that she has this opportunity to advance her skills and career.

In my humble opinion, community-based, human-centered organizations like this are the antidote to inefficient, obese, authoritarian organizations like USAID and Save the Children (just to name a few).

12 new volunteers cramming a years worth of luggage onto this little
bus before they head to their new homes. 

Updates

1. When I lived here before, it took me at least a year, and many bumps on my head, to habitually duck at every doorway. To generalize, Malawians are much shorter than people from places like the USA. Add poverty to that equation and you get tiny doors all over the place. I have the most difficulty with those just shorter than me and above my eyes. I can deal with the slowly progressing bald spot on the top of my head, but right now it’s got a few scabs and bumps on it too. But I’m getting better—only bumped my head once in the past few days. I’ll be ducking through doors for no reason when I get back to the States in a few weeks.

2. If you haven’t already, check out my GoFundMe project: gofund.me/HolySpiritSchool. It’s easier for me to direct you there rather writing about it twice. You could even donate money if you want!

3. [The section has been censored by someone with the new nickname Madame NoFun.]

4. Last week I climbed Nkhoma mountain, which looms over the town and hospital I’m working at. I took a wrong turn and ended up taking a little path the goats use to get to the top, but it was still awesome. This is sort of the view from the top.

5. When I was here before, I went through more than a few bottles of spirits. I’ve never seen AK-47 Vodka (below) until the other day. It’s the cheapest vodka around for good reason.

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.