The small cloud that's been following me around, started to lift a bit yesterday. It was a day that made me feel good once again about myself and about working as a midwife here. First, I happened to be standing in the hall outside the labor ward when one of the cleaners came to tell the family of a laboring woman that she had just pushed a little girl into the world. The cleaner said, "wamkasi" (girl) and small group of women, several with babies on their backs all clapped and hollered in unison, then started laughing and slapping hands. In a place where women, more often than not, get the extremely short end of the proverbial stick, it was wonderful to see and hear such a joyous welcome for a little girl.
Later, towards the end of the day, one of the nursing students who is in the labor ward this week, came to me and said, "The woman in the last bed is pushing and there's a foot coming." I rushed down to the bed and sure enough a foot was dangling from her introitus and with the next contraction legs and bottom quickly followed. Footling breeches (when one or both feet come down first) are more dangerous than frank breeches (when the baby is in a pike position) because the umbilical cord can slip down, become compressed, and cut off the oxygen supply, but thankfully I when I checked the heart tones the little valves were ticking away. I was just focused on the woman but from all the voices coming from behind me seemed that most of the people in the labor ward came to witness and participate in the birth. A nursing student started the delivery, then another midwife helped us with an arm, and I finished by delivering the head. It was so amazingly wonderful to see that sweet pink baby boy and place him screaming on his mom's belly. I turned around to ask for the delivery pack and saw a sea of smiling faces. That was great. Just what I had been missing -support from co-workers, and the opportunity to share the sense of elation that comes from witnessing a beautiful birth.
Tuesday, August 30, 2005
Tuesday, August 23, 2005
Convalescing
This weekend I made another retreat to Dedza, sponsored once again by Mac and Dana. Their home - knitted into the beauty of nearby Dedza Mountain by their flower and vegetable gardens - is most definitely a retreat. I left Lilongwe Friday with the ambition of hiking the Mountain, but instead a small uninvited colony of Giardia kept me running from the bed to the bathroom. The Mountain will wait. 
One benefit of spending the day in bed was that I did have the chance to do a lot of reading. I’m finishing My Traitor’s Heart by Rian Malan. Malan is a white South African journalist who spent years reporting on apartheid and race relations in SA. This non-fiction, which was published in 1985, reflects his personal tortuous process of sorting through horrific imagines and conflicting emotions. He gives voice to victims and perpetrators alike, and convincingly illustrates how virtually all South Africans were complicit in unfathomable atrocities - actions following thoughts, conscious and subconscious, arising from the old putred stew of fear and hatred. It is well written, provocative, and utterly depressing (at least up to now, I’m not quite finished). I recommend the book but it wasn’t the best choice for me following a couple rough weeks filled with frustration and death. I’m feeling better today as I’m sitting here typing but I’ll admit that my path definitely has a few potholes that send me stumbling into a generic existential crisis every now and then.
Sometimes it is so incredibly tiresome to consider life's injustices, the millions of people who dedicate their lives to creating positive change in the world, the millions who do nothing, and how all the roles just seemed to be recycled again and again as we push forward and slide back. At times it seems that both complacency and activism are equally undesirable choices. That’s the line of the very hopeless voice in my head. In more hopefully moments I have to believe that whatever I’m doing is resulting in more good than harm, that I am making a positive impact even if it is only in the lives of a few whom I directly touch. Whatever happens beyond personal interaction is truly in the realm of hope and faith. I found one beautiful and inspiring quote along these lines in Malan’s book. It is taken from a white South African woman who, along with her husband, truly gave everything to understand, share, and ameliorate the suffering of impoverished black South Africans . . . “Any change is so slow as to be imperceptible, and so deep as to be virtually immeasurable.”
One benefit of spending the day in bed was that I did have the chance to do a lot of reading. I’m finishing My Traitor’s Heart by Rian Malan. Malan is a white South African journalist who spent years reporting on apartheid and race relations in SA. This non-fiction, which was published in 1985, reflects his personal tortuous process of sorting through horrific imagines and conflicting emotions. He gives voice to victims and perpetrators alike, and convincingly illustrates how virtually all South Africans were complicit in unfathomable atrocities - actions following thoughts, conscious and subconscious, arising from the old putred stew of fear and hatred. It is well written, provocative, and utterly depressing (at least up to now, I’m not quite finished). I recommend the book but it wasn’t the best choice for me following a couple rough weeks filled with frustration and death. I’m feeling better today as I’m sitting here typing but I’ll admit that my path definitely has a few potholes that send me stumbling into a generic existential crisis every now and then.Sometimes it is so incredibly tiresome to consider life's injustices, the millions of people who dedicate their lives to creating positive change in the world, the millions who do nothing, and how all the roles just seemed to be recycled again and again as we push forward and slide back. At times it seems that both complacency and activism are equally undesirable choices. That’s the line of the very hopeless voice in my head. In more hopefully moments I have to believe that whatever I’m doing is resulting in more good than harm, that I am making a positive impact even if it is only in the lives of a few whom I directly touch. Whatever happens beyond personal interaction is truly in the realm of hope and faith. I found one beautiful and inspiring quote along these lines in Malan’s book. It is taken from a white South African woman who, along with her husband, truly gave everything to understand, share, and ameliorate the suffering of impoverished black South Africans . . . “Any change is so slow as to be imperceptible, and so deep as to be virtually immeasurable.”
Thursday, August 18, 2005
My Little Girl
Wednesday I went to nursery as soon as I arrived at Bottom to see my little girl and found that she had died during the previous night. The nursery nurse and Mrs. Phiri both said that she was looking good on Tuesday, acting like a normal baby. Tuesday afternoon the pediatrician came through and started her on antibiotics but early Wednesday morning she starting gasping and soon died. I imagine that she probably needed a much earlier start on the antibiotics but we missed the window.
The little boy was doing well though, and he was discharged home with his mom early Wednesday afternoon.
The little boy was doing well though, and he was discharged home with his mom early Wednesday afternoon.
Tuesday, August 16, 2005
One True Success
I realize my entries have been splotchy lately and I suppose it's a reflection of my state of mind. I also have not been spending as many hours in front of a computer with internet access as I was previously. Within a single day at the hospital my emotions continue to range from absolute frustration to pure elation. Yesterday was a case in point. I arrived in the Labor Ward to find an intern resuscitating a baby. Apparently the clinical officer was called and told there was fetal distress but no action was taken until sometime later, when the intern appeared. He then delivered the little girl whose only sign of life was a faint heartbeat. When I came in, he was finishing a 24 hour shift and still had another patient to assess, so I volunteered to take over the resuscitation. This is when the frustration began.
At the change of shift in the morning, the ward is full of clinical officers, nurses, physicians, interns, and students. Yesterday morning, many people were busy, but many were just waiting for the rounds to begin. I needed an extra pair of hands, as I was bagging the baby, for a couple minutes, to do simple things like find the larygoscope, turn on the suction machine, plug in the oxygen machine, etc. But, just to get that much assistance at times is a near impossibility. In fact, to do those few things took at least 15 minutes. One person found the larygoscope handle, but left before they found the blade, another found the blade but didn't hand it to me, another got both pieces but wouldn't put them together, and so on. One medical intern asked why I was taking so much time with the baby and recommended that I take the baby to the nursery and just put her on oxygen. (She was not breathing on her own so that would mean certain death!!) Finally, I saw Mrs Phiri and felt such huge relief knowing that she would step in, and of course she did. I spent two and a half hours with the little girl and at the end of that time, she was breathing, sucking, and kicking. I fear that there was significant brain damage due to the unknown period during delivery when her oxygen supply was compromised, but that will only become apparent with time as she develops or misses developmental milestones, as the case may be.
Dealing with emergencies in this setting is one of the great sources of personal frustration. I assume that people's complacency comes from the need to stretch limited human resources, but even so the limited, or lack of response, at times becomes infuriating. Often, if I respond to an emergency no one will be there to offer support. If I call for help and things work out well, people look at me strangely and ask, "what was it that you needed?" To me, if someone is bleeding or seizing or if a baby is being resuscitated that is a serious event that needs the emergent attention of not just one person but several, and it calls for quick steps, and calm, but quick actions.
At the same time that I was resuscitating the little girl another baby was brought in from a c-section that needed resuscitation. I tried not to pay too much attention to his resuscitation, knowing that I already had my hands full. But, after my little baby stabilized, I took over for the nursing student who needed relief (she actually stayed a couple hours doing the resuscitation herself). Unfortunately, in the end the baby didn't make it. Immediately after that death, I found Dr Meguid resuscitating yet another baby who also died. At that point I went to check on an unattended primip (woman with her first delivery) who was screaming at the far end of the ward, and found that the fetal heart tones were also showing signs of distress. The clinical officer, who was in theatre, was called but without assessing her, told us to wait. Instead of waiting I did a vacuum extraction and resuscitated the depressed boy (he was the one true success story of the day). Sometime around 4 I went to lunch and then when I came back was told that there had been a maternal death. A woman, with her 11th pregnancy, came in with a ruptured uterus, a hysterectomy was done, she was stabilized and transferred to high risk postnatal. She was left unattended for 1.5 hours and when the nurse came to check on her, found her dead. That was the fourth maternal death within 5 days.
These events and numbers are unacceptable anywhere, even here in this impoverished environment. I don't understand why so many people seem to preach about the horrors but fail to act or just see them as part of the setting. While it's true that more women and babies will die here because of what we can't do there are many who can live because of what we can do. I try to remind myself that I'm here for the women, that I should fix my eyes on the women and babies that my hands are touching, that I can only do what I can do, but there are days when I can't help but raise my gaze and those days I feel so incredibly lost in and frustrated with the bigger picture.
At the change of shift in the morning, the ward is full of clinical officers, nurses, physicians, interns, and students. Yesterday morning, many people were busy, but many were just waiting for the rounds to begin. I needed an extra pair of hands, as I was bagging the baby, for a couple minutes, to do simple things like find the larygoscope, turn on the suction machine, plug in the oxygen machine, etc. But, just to get that much assistance at times is a near impossibility. In fact, to do those few things took at least 15 minutes. One person found the larygoscope handle, but left before they found the blade, another found the blade but didn't hand it to me, another got both pieces but wouldn't put them together, and so on. One medical intern asked why I was taking so much time with the baby and recommended that I take the baby to the nursery and just put her on oxygen. (She was not breathing on her own so that would mean certain death!!) Finally, I saw Mrs Phiri and felt such huge relief knowing that she would step in, and of course she did. I spent two and a half hours with the little girl and at the end of that time, she was breathing, sucking, and kicking. I fear that there was significant brain damage due to the unknown period during delivery when her oxygen supply was compromised, but that will only become apparent with time as she develops or misses developmental milestones, as the case may be.
Dealing with emergencies in this setting is one of the great sources of personal frustration. I assume that people's complacency comes from the need to stretch limited human resources, but even so the limited, or lack of response, at times becomes infuriating. Often, if I respond to an emergency no one will be there to offer support. If I call for help and things work out well, people look at me strangely and ask, "what was it that you needed?" To me, if someone is bleeding or seizing or if a baby is being resuscitated that is a serious event that needs the emergent attention of not just one person but several, and it calls for quick steps, and calm, but quick actions.
At the same time that I was resuscitating the little girl another baby was brought in from a c-section that needed resuscitation. I tried not to pay too much attention to his resuscitation, knowing that I already had my hands full. But, after my little baby stabilized, I took over for the nursing student who needed relief (she actually stayed a couple hours doing the resuscitation herself). Unfortunately, in the end the baby didn't make it. Immediately after that death, I found Dr Meguid resuscitating yet another baby who also died. At that point I went to check on an unattended primip (woman with her first delivery) who was screaming at the far end of the ward, and found that the fetal heart tones were also showing signs of distress. The clinical officer, who was in theatre, was called but without assessing her, told us to wait. Instead of waiting I did a vacuum extraction and resuscitated the depressed boy (he was the one true success story of the day). Sometime around 4 I went to lunch and then when I came back was told that there had been a maternal death. A woman, with her 11th pregnancy, came in with a ruptured uterus, a hysterectomy was done, she was stabilized and transferred to high risk postnatal. She was left unattended for 1.5 hours and when the nurse came to check on her, found her dead. That was the fourth maternal death within 5 days.
These events and numbers are unacceptable anywhere, even here in this impoverished environment. I don't understand why so many people seem to preach about the horrors but fail to act or just see them as part of the setting. While it's true that more women and babies will die here because of what we can't do there are many who can live because of what we can do. I try to remind myself that I'm here for the women, that I should fix my eyes on the women and babies that my hands are touching, that I can only do what I can do, but there are days when I can't help but raise my gaze and those days I feel so incredibly lost in and frustrated with the bigger picture.
Wednesday, August 10, 2005
Updates
Cromwell, my friend who had the stroke almost three months ago, is much improved although still far from where he was. Without the help of physical therapy, he has progressed from needing help to sit up to walking on his own. He has a significant limp and still cannot move his left arm but he has made dramatic progress, so there is hope. The biggest problem I believe is psychological, I have watched him wade through periods of depression as he struggles to adjust to his new disabilities and well as the reality that friends who were once abundant have now become quite scare. The entire series of events is unbelievable. I have a few pictures of him standing, which I will post later, and he asked me to extend his thanks to everyone who is keeping him in thoughts and prayers.
Mrs. Phiri is a powerhouse. I mentioned that she distributed maize flour to orphans a few weeks ago and she brought me pictures of kids carrying bags of maize on their head with expressions of absolute glee. Really, that just food could bring such happiness!? Recently, she bought bundles of clothes for the orphans with the money I gave her and I'm hoping to go out with her when they are distributed and take some pictures that I'll be able to post. A couple days ago I also learned that her in town she keeps her doors open for teens who want to come and talk and she teaches them about HIV. She's wonderful!!
As for the hospital, last week was a bit rough. Unfortunately I gained intimate knowledge of some institutional politics and experienced a cultural stumble, which just left me feeling a bit down. But, everyday things are getting better and the clinical staff assures me that all is well. At the moment there are nursing students in the ward so I'm having the opportunity of precepting them, which I really enjoy. I've also had a couple beautiful births recently, which always give me a high regardless of my general emotional state.
This past weekend I went to Blantyre again for Clement's cousin's wedding. We didn't actually attend the wedding. It seems like this is common in Malawi. Few people actually witness the religious ceremony but everyone who has ever met or is in anyway connected to the bride or groom shows up at the reception. I was told that you generally send out about 30 invitations and then prepared for hundreds. This weekend the dinner after the wedding on Friday was set up for 600 people. This is impressive in itself but even more so when you realize that there are no caterers or event planners. There is a wedding committee made up of representatives from the bride and grooms families who organize everything.
The bride's family took care the meal, which meant that the men rented the tables and chairs then set up the hall and the women cooked the food. I went to the house where food preparation was happening and helped, but mostly watched, cartoonish quantities of food cooking in pots large enough to accommodate several small children. Clement's mom's family is of Asian descent so there were tubs and tubs of samosas, curried meats and vegetables, and many entrees I had never previously tasted. By 9pm Friday the hall was full and people seemed generally happy with the enormous quantities of spicy food. Afterwards I slept in a car with Clement's sister while the men cleaned the hall and stacked tables and chairs well into the night.
The following evening the wedding reception, organized by the groom's family, brought the crowd together again. I have been to a couple of receptions here, usually they are held in an auditorium, the guests all sit in seats facing a stage where the bridal party sits at a table facing the crowd. As the guests enter the hall, they are given a program with the order and timing of speeches, cake cutting, snack serving, pelekanipelekani (which is when the bride holds a basket and all the guests dance up to her and through money in the basket), and other events. Often receptions last all day - literally 8am to 5pm. I have to admit that in general I much prefer the free flow American style of receptions. Thankfully this reception was just an evening affair. Guests sat at round tables, not in auditorium seating, and although there was a stage, the bride and groom's table was on the floor in the front of the hall. There was no printed program and the planned events lasted less than an hour but the music and dancing went on until 2am. Over all it was really nice. I had a great time dancing at the reception and I met more family members, including two more sisters, who were both welcoming, loving, and beautiful.
Mrs. Phiri is a powerhouse. I mentioned that she distributed maize flour to orphans a few weeks ago and she brought me pictures of kids carrying bags of maize on their head with expressions of absolute glee. Really, that just food could bring such happiness!? Recently, she bought bundles of clothes for the orphans with the money I gave her and I'm hoping to go out with her when they are distributed and take some pictures that I'll be able to post. A couple days ago I also learned that her in town she keeps her doors open for teens who want to come and talk and she teaches them about HIV. She's wonderful!!
As for the hospital, last week was a bit rough. Unfortunately I gained intimate knowledge of some institutional politics and experienced a cultural stumble, which just left me feeling a bit down. But, everyday things are getting better and the clinical staff assures me that all is well. At the moment there are nursing students in the ward so I'm having the opportunity of precepting them, which I really enjoy. I've also had a couple beautiful births recently, which always give me a high regardless of my general emotional state.
This past weekend I went to Blantyre again for Clement's cousin's wedding. We didn't actually attend the wedding. It seems like this is common in Malawi. Few people actually witness the religious ceremony but everyone who has ever met or is in anyway connected to the bride or groom shows up at the reception. I was told that you generally send out about 30 invitations and then prepared for hundreds. This weekend the dinner after the wedding on Friday was set up for 600 people. This is impressive in itself but even more so when you realize that there are no caterers or event planners. There is a wedding committee made up of representatives from the bride and grooms families who organize everything.
The bride's family took care the meal, which meant that the men rented the tables and chairs then set up the hall and the women cooked the food. I went to the house where food preparation was happening and helped, but mostly watched, cartoonish quantities of food cooking in pots large enough to accommodate several small children. Clement's mom's family is of Asian descent so there were tubs and tubs of samosas, curried meats and vegetables, and many entrees I had never previously tasted. By 9pm Friday the hall was full and people seemed generally happy with the enormous quantities of spicy food. Afterwards I slept in a car with Clement's sister while the men cleaned the hall and stacked tables and chairs well into the night.
The following evening the wedding reception, organized by the groom's family, brought the crowd together again. I have been to a couple of receptions here, usually they are held in an auditorium, the guests all sit in seats facing a stage where the bridal party sits at a table facing the crowd. As the guests enter the hall, they are given a program with the order and timing of speeches, cake cutting, snack serving, pelekanipelekani (which is when the bride holds a basket and all the guests dance up to her and through money in the basket), and other events. Often receptions last all day - literally 8am to 5pm. I have to admit that in general I much prefer the free flow American style of receptions. Thankfully this reception was just an evening affair. Guests sat at round tables, not in auditorium seating, and although there was a stage, the bride and groom's table was on the floor in the front of the hall. There was no printed program and the planned events lasted less than an hour but the music and dancing went on until 2am. Over all it was really nice. I had a great time dancing at the reception and I met more family members, including two more sisters, who were both welcoming, loving, and beautiful.
Ernest
“To live in Africa, you must know what it is to die in Africa” I read this quote from Hemmingway yesterday and although I’m not sure of the original context, it makes sense. Life’s fragility and precariousness are clearly apparent here. Life and death move through this country hand and hand, giving and taking equally and unexpectedly. It is feasible that any seemingly insignificant choice (boarding a minibus, crossing the street, waking up, walking a particular path) may transport you instantly and abruptly from the grasp of the former to that of the latter, irrespective of age or health.
Certainly my personal sense of mortality has increased a hundred fold in the past five months. Death is no longer a distant concept to be considered as a dreaded inevitability, years down the line, in the future of my healthy parents. It is here, all around, every day, touching every life intimately. Life expectancy at birth in Malawi is a mere 38 years. HIV and high infant mortality rates are responsible for this low number in part, but not completely. There is not a lot of gray hair here. I haven’t yet moved beyond acknowledging this fact. Mostly it’s just stunning. The situation is stunning here, and really, now looking back at the US, it's stunning that death there is a distant foe rather than an unwelcome but tolerated relative. I’m not planning on dying soon; I’m not taking any excessive risks. I’m protecting myself as best I can from HIV in the labor ward and careening minibuses on the road, but I’m recognizing that each day is a gift not an entitlement. The 80 years on this planet, which I previously perceived to be my birthright, I now see as a hope.
Certainly my personal sense of mortality has increased a hundred fold in the past five months. Death is no longer a distant concept to be considered as a dreaded inevitability, years down the line, in the future of my healthy parents. It is here, all around, every day, touching every life intimately. Life expectancy at birth in Malawi is a mere 38 years. HIV and high infant mortality rates are responsible for this low number in part, but not completely. There is not a lot of gray hair here. I haven’t yet moved beyond acknowledging this fact. Mostly it’s just stunning. The situation is stunning here, and really, now looking back at the US, it's stunning that death there is a distant foe rather than an unwelcome but tolerated relative. I’m not planning on dying soon; I’m not taking any excessive risks. I’m protecting myself as best I can from HIV in the labor ward and careening minibuses on the road, but I’m recognizing that each day is a gift not an entitlement. The 80 years on this planet, which I previously perceived to be my birthright, I now see as a hope.
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