Babycatcher

So I survived the night shift last week, all 15.5 hours! And, by the end of it I had, with my hands, caught 8 babies (6 boys and 2 girls). Nights are definitely busier. There was a point when all 14 beds in the labor room were occupied and two women were laboring on top of their chitengis on the floor. I'm planning another night shift next week. Of course the nurses are appreciative of me just being at Bottom, since they are so understaffed, but I felt I really earned some good points working a night with them. One of the clinical officers recently told me, "I've been watching you and you are the kind of person who can really survive here." Then a nurse added, "Yeah, and she even worked a night." I felt my head swell : ).

Yesterday at Bottom was my day for big babies. The first one (a boy) I caught weighed 10.7lbs. Really! The delivery happened so quickly that the head didn't even have time to mold (usually as the baby's head moves through the pelvis the skull bones ride over one another to allow it to pass through more easily, giving some little ones temporarily a funny shaped head). As it crowned it seemed as though the head of a five year old was being born. Thankfully the baby was born easily and the mother's perineum did not even have a tiny tear, incredible. (This was the mother's fourth delivery.) When I told the mother her baby's weight, she said, "A gift." A couple hours later I caught a girl weighing 9.24lbs also healthy. She was the second child of a very small young woman.

To date I have caught 34 live babies here in Malawi.

8:00 Friday night in Dedza, Dana's husband, Macfarlen, received a call from a friend of his who said that there had been a road accident, that the vehicles were on fire with people burning inside. Macfarlen is not a medical professional (he's an electrical engineer) but he lives nearby and he has a truck. In a world without EMS, without quick responders, and few ambulances, the lives of people involved in MVAs often depend on local good samaritans and those who happen to be passing by.

We hurriedly piled into the truck and drove the 10 minutes to the scene but by the time we arrived, the flames engulfing the three vehicles had already devoured everything carried and were now hungrily licking at metal and rubber. A large solemn crowd encircled the wreckage at a safe radius, passing around fragmented versions of the collision in shocked voices. Macfarlen's friend had come across the scene on a motorcycle just minutes after it had occurred, the fire just beginning to build and screams of trapped people close but unreachable. He called the hospital, the police, and the local law enforcement but when those responses were unsatisfactory he called Macfarlen. We didn't learn much that night other than the fact that several people were rescued including one man who had been pinned under a truck and had his leg hacked off with a hoe in order to attempt to preserve his life. Four vehicles were involved in the wreck, a two ton open bed truck that was carrying people. A three ton truck loaded with potatoes and tobacco, with a couple people perched on top, a pickup, and a sedan. Only the sedan, which was pushed to the opposite side of the road escaped the fire. Recognizing that there was no longer anything to be done, we climbed back into the truck and drove home. In front of the truck, just millimeters above the horizon hovered the most amazingly beautiful and enormous full moon. The vision was somehow both comforting and confusing. The night illuminated by the serene timeless beauty of the full moon juxtaposed with the horrifically tragic end of so many human lives. I imagined our individual lives as short flashes of light over the planet filled with incredible motion and emotion . . . searching for meaning, loving, living, struggling, surviving . . . but why this type of end?

The next day Macfarlen met the man who had driven the pickup and we all got his story. Apparently the large truck was loading potatoes but was parked in the road facing oncoming traffic with its lights on (the night was already thick) and the other side of the road was blocked by minibuses loading passengers. The driver in the sedan saw the impasse and slammed on his breaks, as did the pickup which followed, unfortunately, the open bed truck was unable to stop in time and slammed into the others pushing the sedan across the road and the three remaining vehicles into the ditch. The fire began instantaneously and the driver of the pickup was only able to extract his wife and child from his truck. By the time they were safe all he could do was watch and listen to the screams of those trapped under the burning wreckage.

Certainly accidents happen everywhere. Fatalities from motor vehicle accidents are common everywhere there are motor vehicles, but once again I am reminded of the differences between poverty and wealth. In addition to the obvious difference of the absent 24*7 EMS response, there was an unknown number of people who died in this wreck. Open bed trucks are a common means of transportation here and no one will know how many people died or even the identities of the dead. These people will simply never return home sparking mysteries partially solved over time only by probabilities. Lives in the developing world so often are not counted, they are estimated in, imperfect but easy to work with, round figures. I imagine if this happened in the States, the names and perhaps pictures of the dead would appear in the paper along with interviews with family members and pieces of their personal histories. The fact that these people entered and left the world perhaps without any official recognition does not mean they were loved any less, or that their deaths were any less tragic, but just that their individual beauty and worth is more difficult to convey. I believe that those of us who live in the developed world should be grateful for what we have but never complacent, we must resist the tempting illusion that round figures are merely figures.

Apart from the tragedy, the weekend in Dedza was wonderful. Dana and Macfarlen have a really sweet cozy little home located at the base of Dedza mountain. They own a few hectars of land and have planted gardens with vegetables, flowers, and trees. From their plot the view is spectacular - the pine covered mountain (which is quikcly becoming deforested), other houses nestled in the trees, and more moutains pink and tan in the distance. It was cold but we made a fire every night, we ate well, spent hours and hours talking, visited some near rock paintings that are over 2000 years old (unfortunately they being defaced), and just had fun. Dana took lots of pictures which I will have to post as soon as I get them from her.

Life is settling into distinguishable patterns of color and experience. Landing in a new environment is something like sitting in a snow globe, with no fixed landscape, that someone just shook vigorously. Everything seems to whirl around, you're just taking in a wash of vivid color and sensations, and every day is filled with the unexpected. It's sometimes difficult to know what is stable and what is just part of the transition. Of course the adventures continue, but now there is a least a stable backdrop against which they are occurring.

My three weekly shifts in the hospital continue to exhaust and surprise me, but I am more frequently seeing beyond what initially seemed to be pure chaos. I am able to enjoy moments of beauty, notice what functions, and envision positive changes. I want to share a little analogy that Dr Tarek Meguid recently told me. He said that if a patient has a condition that needs surgery but the surgery has only a 20% chance of success, you absolutely must counsel the patient about the risks so that they understand they only have a 20% chance. But, if they agree to the surgery and you agree to perform it, you (the physician) must believe 100% that that patient is among the 20%. If you don't believe that, wholeheartedly, there is no point of doing the procedure. So you take that philosophy and apply it to life. . . In relation to whatever you are doing, even if the chance you will succeed is small, you must absolutely believe that you will succeed or you should not be there at all. What a wonderful gift to have a boss with that philosophy in this environment!

I will be working my first night shift at the hospital this Wednesday (I'm a bit nervous). The night shift begins at 4:30pm and ends at 8am, simply because after that time it is difficult find public transport and dangerous to travel. I imagine that despite the long hours they will pass quickly, several nights in a row the midwives told me that there were over 40 deliveries (shared between 2 midwives). I'm sure I will have stories after that. At the moment my count is up to 23 (18 boys and 5 girls).

As for my free time, I have been spending less and less time with the expat community but I do have a few close friends. Right next door to the Kamuzu College of Nursing is the College of Health Sciences, which educates clinical officers. Clinical officers are the backbone of the medical system here and Malawi's somewhat ingenious way of dealing with "brain-drain." The program to become a clinical officer is three years plus an internship year, all straight after high school. When they graduate the COs function like general practitioners, even doing surgery, but they only have a diploma, not even a bachelors degree, and their education is not recognized outside of Malawi. Even in Malawi, if they decide to pursue an MD, or even a BS, they must start from scratch, making career changes and emigration less appealing. Anyhow there is always a group doing clinicals at Bottom and early on several of the students took me in, so now I spend a good deal of time with Clement, Fatsani, Mavuto, and friends. I also recently met an American woman around my age who has been here 6 years (4 yrs with Peace Corps) and is married to a Malawian. She is the education coordinator at the nearby refugee camp in Dzowa, and she's great. We spend hours talking, laughing, and catching each other up on a lifetime of stories. She and her husband own a house in Dedza and have invited me for the weekend, it will be my second venture out of Lilongwe, I'm really looking forward to it.


Sadly, while people are starving in the villages, today on the news I heard that the President Bingu wa Mutharika just increased his salary by 350% to 20million kwacha/yr (a little less than $200K/yr). This president has been the hope of the country; a powerful force against corruption. He made many enemies initially when he was elected in 2004 firing and imprisoning those government officials who had been accused of mismanaging public funds but this news is definitely disappointing. He has 4 more years in office we'll see what happens. Unfortunately I have been hearing a lot of grumbling about Democracy. Under "President-for-Life" Kamuzu Banda who ruled for 30+ years people were poor, but crime was low (punishment for even petty crimes was often death), the kwacha was stable, and public offices (including health care) functioned better. From what I hear people in general were motivated by fear but there was greater economic stability. Malawi has always been a peaceful country and no one envisions that changing but something needs to happen to strengthen the country in general and the people's appreciation for democracy.

Today after about 10 visits to immigration and trips to other offices around the city, I finally received the two stamps in my passport giving me permission to live and work here for the next two years. Every accomplishment, even successful bureaucratic hoop jumping, is a success worthy of celebration.

A Snap from Bottom

Friday night when I came home Chimwemwe told me that Mr Aisa's (the gardener at the Kaponda's) sister in-law had given birth that day at Bottom hospital to a little girl. I flipped through my mental images of all the women and babies I had seen that day trying to figure out who she might have been, thinking that if only I had known who she was I would have been at her side as much as possible. Chimwemwe didn't know the birth story but she told me that the mother fainted on Saturday and soon before she was discharged. I imagined that she was one of the women delivered by a different midwife.

As it turns out Mrs Black, the sister-in-law, lives only a few houses down the road so Sunday I went with Chimwemwe and Ekari to visit her and to see how she was doing. Mr Black met us at the gate and led us to the small room where he and his wife live behind the main house. As soon as I saw Mrs Black we both laughed, her birth was the vacuum delivery that I had assisted with and I had actually spent several hours by her bedside on Friday before the delivery. With Chimwemwe's help we talked for a bit, I did a brief exam, held her baby (who I was very happy to see was doing well post-resuscitation), and left. As for the fainting, I remember her telling me during labor that she had not eaten since the previous afternoon and Sunday she said that she was just weak from the birth and lack of food. Thankfully it was nothing more serious than that. On seeing her and the baby again the warmth from my heart flowed up to my cheeks and made me feel a bit heady but I also thought, "I wonder if she liked the care I provided?" It's strange to be so close to someone, to see and care for them only as you would a stranger, and then later learn that you have a fairly close connection. Chimwemwe told me that if anyone asked she would say yes, so we didn't ask.

Monday evening when I got home, Ekari told me that Mrs Black had come by to thank me (I had sent her some Ibuprofen). Then Tuesday a while after I came home, Chimwemwe said to me, "Oh, I almost forgot, Mrs. Black was back and she wants you to name the baby." Chimwemwe is often sarcastic and sometimes it's difficult to know if she's serious or not so I laughed but then both Ekari and Mrs. Chirwa confirmed that the story was true.

At first I felt completely overwhelmed (honored but overwhelmed) . . . how could I pick a name for this child? a name that will be heard, spoken, and written thousands of times over her lifetime? what kind of a name should it be? would the parents like it? No one wanted to help me decide, they all agreed it must come from me. So after worrying over it a bit, I decided I would give her the name that was given to me.

Two weeks or so after arriving in Malawi, the four girls at the house (Chimwemwe, Ekari, Maggie, and Yankho) decided that I needed a Chichewa name. So, one night over dinner they spent about 10 minutes deliberating in Chichewa. I heard some names I recognized flying back and forth followed by sounds of general consent and silence. Yankho said, "Ok, we have decided that your Chichewa name is Tianjane (tea-on-JOHN-ny)." Tianjane means something like "we should be friends" or "we should be together" or "we should get along." I like the name very much and now a small handful of people are calling me Tia.

This morning at 7am Ekari and I went to see Mrs Black and give her the name. As we walked in the door Mrs Black laughed, handed me the baby, and asked Ekari if we had come with a name. I told her, via Ekari, that I had been given the name by people I liked very much and that I also like the meaning of the name, so I would give it to her daughter wishing her the best. Tianjane. Mrs Black smiled, rolled the name over her tongue a few names, and said "Cha bwino" (OK). That was it. She left Ekari and me for a few minutes in the room, while she resumed her morning work, free as long as Tia was in my arms. Tia's eyes were wide open when I first took her from her mother, but slowly as I held and rocked her they closed, and as she was drifting to sleep - becoming still and quiet - this 6 day old little girl smiled a big full smile. And then, just in case I had missed the first smile she smile two more times.

Mrs. Phiri is an instructor at KCN and she's a friend. Mrs Phiri is in her early 40s, she stands maybe five feet tall, wears her hair pulled back a bit severely and a skeptical expression over a half smile. She's often quiet in a group but when she does speak her voice is strong and she doesn't mince words. I met her a few weeks back at the Saving Newborn Lives training and now I see her regularly on the KCN campus. I know that teaching at KCN and raising her daughter consumes much for her time, so I was surprised to learn about her third busy and extremely charitable life.

Mrs Phiri and her husband, together and without any organizational backing, have started a foundation for orphans called the "John C. Thomas Children's Foundation." Right now they have three centers in different regions, which do not house the orphans but provide meals, tutoring, and vocational training. When I asked Mrs Phiri about why she decided to do this she said that she was raised without a father, that her childhood was difficult and she related in a personal way to the lives of orphans here. She said, "I want to make being an orphan something to be proud of, I want to give them opportunities and resources that will make the other children in some way wish that they were also orphans."

Two of the centers are doing well but the newest one in Tengani does not yet have a stable funding source. I gave Mrs Phiri several hundred dollars from the money I received from you (and she sends many thanks and blessings) but I anyone who is interested can also send money directly to her, email me at: joanne_jorissen@yahoo.com or see Mrs Phiri's contact info below.

Here is some information about their organization and their current needs in her words:

The purpose of the organization is to reduce stigma among orphans and other vulnerable children with the goal of improving their quality of life by raising their social, economic, education status.

The Area. Nsanje (pop: >200,000; 60% women) is one of the boarder districts of Malawi bordering the Southern part of Mozambique. The HIV infection rate is higher in women in this area and the overall rate (now at 19%) is steadily increasing resulting in higher mortality rates. In the targeted area of Tengani, 2001 statistics indicated that the area had 11,300 orphans in dire need of care and support. This need is compounded by the facts that (1) most of those dying are young girls who die without leaving behind any substantial property to support their orphaned children (parents of these girls in most cases are severly improvershed themselves and do not have resources to care for grandchildren); and (2) the education level in Nsanje is the lowest in the country.

Discussions with the people of Nsanje, including key leaders, revealed that the people deny the presence of HIV/AIDS in Malawi. They believe that witchcraft not HIV/AIDS is the cause of many deaths. Unfortunately, many cultural practices are very risky as far as HIV/AIDS transmission is concerned. The following provide some examples: (1) Polygamy is common especially among chiefs. (2) At puberty, a young girl is forced to have sexual intercourse with an older man, who is specifically appointed by village elders to perform this duty. (3) When a husband dies, elders in the deceased's family along with village chiefs choose one person (usually a brother or an uncle) to have sexual intercourse with the wife of the deceased. It is strongly believed that if she refuses, the whole village will be under a curse and everyone will die. As such the woman has no choice but to submit to this practice. (4) Girls usually marry at an early age 14-15 years, preventing them from pursuing an education. These belief systems in addition to the general disempowerment of women account for the high prevalence rate of HIV/AIDS in Nsanje district.

Project activities under the John C. Thomas foundation have been designed specifically to address these problems. Present activities include:

• Sensitization meetings with local leaders at Tengani
• Identification of 1000 orphans and vulnerable children in the area
• Formation of committees in Tengani
• Procurement of a garden for the community to cultivate for income generation
• Distributions of items to assist the orphans and vulnerable children
• Training 60 volunteers in orphan care
• Sensitizing the community of HIV/AIDS transmission and voluntary testing and counseling (VCT)
• Establishing youth clubs
• Establishing widow/granny clubs

Desired future activities include:

• Paying tuition for 10 needy and vulnerable children
• Connecting 10 orphans with local artisans for aprenticeships
• Conducting sessions on the journey to life to community leaders
• Establishing and running co-operative shops
• Parental training workshops
• Providing sholastic materials to needy children
• Procuring and distributing 10 fish nets to 10 orphan headed households
• Organizing fundraising activities
• Building a resource center

With regard to sustainability, the communities will be encouraged to support orphans and other vulnerable children through the extended family. It is hoped that this will improve the acceptace of orphans and decrease their stigmatization within the communities. This will be done through sensitization meetings with the leaders. As the communities develop an understanding of the plight of orphans and understand the need for and activities of the project they will support its sustainability. Funds raised from the gardens and co-operative shops will be used to run the center. Skills acquired by orphans will empower them and enable them to become self-sufficient. It is believed this will reduce promiscuity and stigmatization among orphans and vulnerable children in the area. Higher levels of education provided to the children are also central to the empowerment process.

Constraints. Currently the foundation has no donor. The activities carried out so far, have been accomplished through small individual contributions. The lack of funding is the main constraint at present.

Requested items (shown in Malawi Kwacha, MK/US$ = 120/1). Mrs Phiri says she will give an account of how donated funds are spent.

• School uniforms for 100 children 50,000MK
• Bags of maize 200,000MK
• Bails of sugar 120,000MK
• Sewing machines 105,000MK
• Bags of beans 130,000MK
• Maize seeds 70,000MK
• Blankets 720,000MK
• 3 bails of second hand clothes 54,000MK
• Soap 31,000MK
• Water pump engine 120,000MK
• Weilding equipment 80,000MK
• Carpentry equipment 30,000MK
• Fertilizer 200,000MK

Contact jctchildrenfoundation@yahoo.com tel: 011-265-8-375-326 or 011-265-8-509-775

It's official I'm now a Malawian midwife. I successfully jumped through all the necessary hoops and now I have my badge, which I proudly wore to L&D yesterday. Yesterday was quite a day actually slow but not without drama. In the morning a woman came in with a cord prolapse, so severe that you could actually see about a foot of cord dangling between her legs. On arrival her baby was still alive and preparations started for a c-section. In my mind people were moving so slowly, walking to get the IV, walking to get a catheter, talking in normal voices, walking to get a gurney. I tried to breathe and stay calm but it my head I was screaming and pulling out my hair. Somehow the baby was out within 35 minutes. Initially blue and floppy but after a little resuscitation and she picked up and did just fine. Afterwards I was told that usually there are no emergency c-sections. Usually the baby is left to die and the woman delivers vaginally. Everyone was happy with the end result, including myself, and I was reminded that everything is relative, especially expectations.

The second birth of the day that I participated in was a vacuum extraction. The charge nurse did it and I pumped the vacuum (during the procedure someone acutally has to pump in order to maintain the suction which is an incredibly tiring task). She said next week I'll do the vacuum - see one do one. One thing I won't be doing though, is cutting an episiotomy with a razor blade as she did. It was a necessary epis but with a razor?! Although I heard the midwives do this, this was the first one I saw. Your fingers and the baby's head are both less than a centimeter from the razor blade and lots of possibly HIV+ blood. And if the mother jumps?! I know the ALSO group left scissors and this practice really must change. Anyway the vacuum procedure birthed another blue baby so in one day I did two resuscitations. This little one also did fine and left the ward in her mother's arms.

The third birth of the day was another c-section. The mother, who had 4 previous births, was completely dilated but the baby was still floating high in her belly. I went to receive the baby in the OR. It made me pause to realize that I represented what would be an entire pediatric team at a delivery in the US. Thankfully the baby came out screaming so my job was easy this time.