Beginnings and Endings; February 26, 2007

In a few hours I will be taking off, heading south towards Johannesburg, and then, soon enough, back to where I came from.

Even on the final approach into Dulles International Airport I will have already begun to re-adjust – the landscape, the neatly structured neighborhoods, the strip malls and network of highways will appear familiar to me. Billboards and signs and recognizable company logos in front of buildings will stir dormant, but very alive, reflexes. I may begin to yearn for a gourmet coffee or burger or licorice or maybe all of the above. And quite easily, I will be able to have it all.

I have seen the likes of Eric and many others work in very challenging and daunting conditions with the concerted goal of saving and improving the lives of AIDS-afflicted children in Malawi.
I have talked to so many adorable kids and seen an art-gallery-worthy sunset on Lake Malawi and so much more.
I have learned that buying my flight to Malawi was the most difficult step to getting involved.

How will the time I spent in Malawi affect me?
Has it changed me?
Did my interpretations of what I observed get influenced by the knowledge that I would only be here for a few weeks?
Would I have acted/felt differently had I committed to a longer stint in Malawi?
Will I be inspired to tackle something else? Where would I go? What would I do? What will I do? Is it a beginning or an end?
Only time will tell.

Mountain Biking; February 25, 2007

An afternoon of mountain biking near E’s neighborhood. And then I ask myself why we didn’t think of this earlier – most roads here, most good roads here, resemble a challenging mountain bike trail anywhere else.

We head out mid-afternoon, first navigating through the paved neighborhood. But soon enough, sooner than one would expect, the pavement ends, and the dance to avoid, or perhaps in this case, locate, the largest puddles, commences.

It’s a left turn, then a right, and we’re plowing through high, above-helmet height, reeds, on our path. And the stinky mud flies. Some puddles (ponds?) even require us to turn around to gain more momentum before attempting to cross. None of us get stuck, none of us remain clean.

On occasion we’ll pass locals – who struggle even more than we do heading up some rocky inclines. Of course, they have one-gear bicycles and are often carrying all kinds of things on the bike...
These people, vying to get from point A to B, are probably wondering why we would go out of our way to soil our clothes and find the longer trail home.
It’s tiresome – but fun. And the questioning Malawians we encounter are always cocked and ready with a smiling “Hello, how are you?”

At some point it ends up being Kebba and Eric and me and we explore some really challenging trails. On some we fly down the run only to find a dead end – and have to bike all the way back up. The ever-present maize, the babbling river, something scurries away from us among the low-lying bushes as well. In some spot in the denser wooded areas I hear voices too. Probably not in my head?

Around here, you turn off any paved road and the potential for a great mountain bike run exists. What better way to completely immerse oneself in a country (and country’s mud) and get out there and see and speak with the people?

3 Hours in Zambia; February 24, 2007

Change of plans. We are not heading south to the Malawian town of Zomba for a hiking weekend. Instead, D and I are tasked with coming up with a plan B. And we do.

D and I are going to try to get into Zambia, the neighboring country to the west – all inspired by the Check Game, something that my five close German School pals and I have concocted and furiously compete at.

The Check Game

The aims of the game are quite simple, really. The individual that manages to visit the most countries in the world, wins. You get a point for each country visited, no matter the size or location. And you can only earn a point for a country once – repeat visits do not increase your point tally. Did I mention things can get quite competitive?

At the moment, our leader board has two of the six competitors somewhere in the neighborhood of 50+ countries visited.

Now, in recent times, this heated, yet fair competition has brought up valid and impassioned discussions among the six of us, for example:
- Should countries that do not exist anymore (e.g. USSR, East Germany) be counted?
- What constitutes ‘visiting’ a country? Should a flight connection in a country count?

Employing the Olympic spirit, keeping fairness and equality in mind, we decided that:
- ‘Historic’ countries should be counted like any existing country
- ‘Visiting’ a country equates to traveling in and/or conducting some sort of tourist/business within that country – quite often and if possible, this should involve a local beverage and/or beer. It’s really a matter of establishing oneself temporarily in that country – thus, a flight connection, even if a beer is consumed in the airport, should not and will not be counted towards an individual’s point total.

So it’s a quick call to Jeff, another doc, and it’s a three-party venture. I’m driving E’s truck today, D to my left and Jeff in the back. We’re headed west towards Mchinji, the Malawian border town right on the border with Zambia. It’s a fun drive, it’s fun driving.
And all those people walking on the roads. The towns we pass through have a lot of activity – it seems it is market day. It rains a bit, but we don’t stop, other than at the friendly patrol stops, until we reach the Malawian immigration post.

We park the car, eagerly step up to the passport control, and start filling out our exit documentation. Then we hit a speed bump: we are told that the visa fee to enter Zambia will run us US$100 each, which is much higher than the US$25 that our (respected) guide book quoted. D keeping the spirit of the Check Game in mind, decides to selflessly venture towards the border. He steps through an old chain-link fence and disappears. Jeff and I stay on the Malawian side and wait, hoping that our 120 km trip has not been in vain.

Check!
Eureka! D returns and has managed to ‘negotiate’ the terms of our entry – we will have to pay US$100 for the three of us. The necessary forms are completed in Malawi, passports are stamped and we cross. James, our resourceful, entrepreneurial Zambian immigration official, happily takes our five Andrew Jacksons and assures us he will be present when we return later today. Let’s hope so!

We’re really only halfway there, though. We need a meal/beverage to get the point. That means we need to get to Chipata, the closest town in Zambia and in order to do that we need to hire a taxi. And in order to do that we need Zambian currency – the Zambian Kwacha (ZK).
We exit the immigration post and the vultures descend upon us. These ‘businessmen’ all want our attention. And in this makeshift, open-air stock exchange, we manage to change twenty bucks each and make out with ZK80,000 each.

So a deal is negotiated with Friday (“it’s a good day, it's a cool name”), our driver, for ZK50,000, one-way to Chipata. A considerable discount from the ZK90,000 that was originally thrown at us. His light blue, four-door something drives well, in spite of the huge cracks in the front windshield. His pal, Godfrey, has magically appeared and is also getting a ride into town. We manage to get a restaurant recommendation too and get dropped off in front of the place after the 15 minute drive, having agreed on a time and location for the pick up and return trip.

The vegetarian meal is adequate, the conversation is great, and after a stroll through the local market and walk through the supermarket, Friday picks us up and takes us back towards the border.

Back inside Malawi, with James’ Zambian exit stamps in our passports, we see many bikers carrying an inordinate amount of items on their racks. Some of them are carrying huge stacks of wood – how they balance that, I have no idea. We also stop at a local soccer match between two schools and watch for a while.

I wonder whether I have moved up in the rankings. 35 and counting.

Home Visits; February 23, 2007

E and D drop me off at KASO for probably my last day with the gang. It's another sunny start to the day. Rose, Blackson and Lizinisi are already there and Jonathan and Maureen soon arrive on bikes too. There will be no day care today, instead, we will be conducting 'home-visits' for families that have been affected by AIDS.

Maureen and I depart KASO and head off towards her house to pick up another bike - my means of transportation for the day. We arrive at a neighbor's house and walk through a front yard, also known as a maize plot split by a path in the middle. The two women, Maureen's friends, are both very friendly and sparkly-eyed and converse in basic English with me since my Chichewa is even more basic.

And we're off! I follow Maureen, as she seems to be able to out-maneuver the potentially dangerous potholes and divots in the road better than I. Along the way I get more 'thumbs ups' than I can count, and even more friendly smiles and yells and 'hellos' as we bike through what I think is still Area 25. And even though I have not biked for a good long while, I manage to wave (with one hand off of the handlebars) to some of the kids. As E said earlier in the day, this will probably be as close to being a celebrity that I will ever feel.

Our first stop is at a bike repair stand. It consists of four large branches propping up a cardboard roof with a bench below it. A few bikes are lined up around the area, and this is where Blackson, Rose and son Peter, Lizinisi are already stationed. The repair guy flips Rose's bike and gets to work - and I soon scurry to the shade to join the other volunteers - it is getting very hot today.

I watch the world, this world, go by. Across the way there's a truck depot, presumably a spot used for picking up laborers for the day's jobs. These archaic trucks pull onto the dirt road when loaded with guys my age (probably younger), belching light blue smoke out of their underbellys. Even these guys wave and yell at me. Celebrity.

With Rose's bike seemingly fixed and sun blazing and getting stronger, we continue our trek. Rose wraps Peter onto her back, and we are soon a well-oiled procession of KASO bikers heading to 'I do not know where or how far'.
I enjoy the ride. I am deep in the heart of Africa. I like this feeling. Open air, few vehicles, I hear the maize, high grass rustling in the breeze. We pass tiny villages, miniscule, and kids run alongside my bike, smiling.
I wave, they wave back.

Maureen and her bike

The bikes splash over small brooks that intersect with our path, luckily we've all got mudguards over the tires. I can see really far here and the savannah stretches for tens of miles. It's picturesque and green - thanks to the plentiful rain that has been falling.

We stop at a village called Yepa - no sign, no km markers. Looks like you just have to know you're there, wherever 'there' is. It's a left turn, now we're walking our bikes, and I see the KASO logo on a house/shed. We head around back and a local volunteer opens the door to the buillding. They're housing some 150 young chickens in here - which will ultimately be shared with the local people. That's a lot of drumsticks.

We lean our bikes on the back wall of the house and walk another 500 meters, following a path that's leads us through the ubiquitous maize. I meander, it's getting hot now, past tobacco drying under thatch-roofed huts, and chickens, roosters and goats roam the compound, searching for something to chew on. Alas, the woman we were actually here to visit is at the Area 25 market! Guess she took the expressway, we didn't see her on our way here...

We nevertheless seat ourselves in the shade and chat - the family members are curious to hear where I am from and information about my family. And then there's the 'side-Chichewa' that gets exchanged too - I wonder what they discuss amongst one another after I speak. I get asked to "take us all to your country" with smiles.

The KASO gang, Blackson, Lizinisi, Rose & Peter, Jonathan, Maureen and I walk back towards the 'henhouse'. I am told that the local volunteers and the KASO team need to have a discussion, so we head into the building. And soon enough we have 7 locals, 12 total people in the room. So I listen. It's starts off with a prayer, the only word I comprehend is 'amen'. I get offered a metal bucket to sit on, and I take advantage. It's comfortable, actually, and with my back against the cool wall I almost fall asleep - I'm right by the door, and the hypnotic breeze and the sun nearly do their trick. From this angle I can see the landscape and the banana trees rustling in the wind.

The discussion gets quite heated, but still it seems everyone gets heard and is allowed to speak and in the end a resolution is found. I never do ask what they argued about.

At this point it has gotten really hot outside. We get back on our bikes and start heading out of Yepa. But not before stopping at a shady spot underneath some trees – Blackson needs his front bike tire pumped up. Jonathan, who did not come to Yepa with a bike, communicates to me that he will be stationed on the back of my bike, on the rack. Sure, I’ve tooled around, in my youth, with other people on my bike – but it’s been a while.

I manage, without falling down, to start the bike rolling and get up to that critical speed that allows me to maintain my balance and the bike upright. The first part of the procession runs back the same way we arrived. We soon veer off on another trail and need to hop off the bikes (this proves a bit more difficult with two people on board). Through the maize, we pass some remote-looking huts – an older gentleman gives me a double take – I wonder the last time he saw a muzungu pass through.

At the crest of the hill we make it to another small village. Kids are working a large water pump, filling buckets and now look at the group of volunteers that has arrived. A duck utilizes the water that is being pumped out of the well and tries as best he can to stay cool too. I greet a few of the curious kids. Jonathan then jumps on the back of the bike and the gang and the rest of the group heads down a wider, flat dirt road. I do my best and concentrate not to fall off the bike - successfully. Women, walking with items propped up on their head are passed, bikers cruise in the opposite direction, people are moving: "Hello? How are you?" And always that smile.

The volunteer team and I visit two houses once we make it back to Area 25. Rose and Lizinisi enter first and make sure the rest of the group is welcome too. It's a three 'room' house - no carpet, electricity, just firm dirt under our feet and ambient light. I meet and greet the family - the father has died of AIDS, mother is ill and is surrounded by her three sons, aged 7 to 13.

Nobody's similing in here, understandably so. Maureen explains and translates, I tell the family about the efforts in the Baylor Clinic and encourage them to take advantage of the facilities and help there. We share aspirin that we've brought. I ask her if she is in pain - she says no. Is she lying?

Her oldest son accompanies us to the next house. I recognize some of the kids at the other house we visit - they participated in the Picturing Hope program last week. Three younger children are playing outside, and one cuddles me as I hold her hand, as if she's known me all of her short life. A man, a woman, and four kids are in the house. The father looks dejected and tired, the mother speaks. She agrees to take the kids to the clinic that E and all of the other docs work at. This is good.

The day nears its end and pictures are snapped with Maureen's camera. It's my final walk through the neighborhood - kids follow us, people look. We make it to Rose’s place – goodbyes, addresses and phone numbers are exchanged – I am sad. Then Maureen’s house, goodbyes to Lizinisi and Blackson too. I promise to share photos once I get home. Jonathan walks me through the neighbohood's ‘alleys’ to a minibus stop I would not have found.
And for now, my time with KASO has come to an end. I’ll miss these people.

Images; February 22, 2007

KASO playhouse

Message on poster in KASO


Sunset on Lake Malawi


A president's plea


On the road to Lake Malawi


Kids at play at KASO

KASO; February 21, 2007

I'm headed to the day care center again today. We get to the clinic, I say my goodbyes to the doctors and make my way through the pediatric and adult wards – and both areas are as busy as ever.

It's a bright, sunny morning, in sharp contrast to the monsoon-like conditions that blew through the area the night before. The sun-after-the-rain makes everything seem clean and fresh. I catch sight of a few large branches that are teetering and will soon fall off of the trees that they were once a part of.

I exit through the main entrance gates of the hospital and spot a minibus – one of the few that are not white colored – and approach the three gentlemen that are chatting next to the vehicle. The trunk is open and one of the men is sitting in the back seat, speaking with the other two who are standing outside.
Inquiring about minibuses to Area 25 initially makes the conversation turn towards a 1000 kwacha taxi fee – way above the 60 kwacha fare that the minibuses charge. I laugh off the attempt of extortion and let them know I will try my chances on Kenyatta Road. They seem to agree and think my decision is a prudent one. Perhaps they thought their offer was a bit obscene?

Just as I turn and begin to walk, I hear one of the men shout and point - an approaching minibus appears with the numbers '25' etched on a wood board that lies on the dashboard of the car. I wave it down, climb in the front seat and enjoy once again one of the more popular forms of transportation in Malawi.
But this guy's horn is not working.
A wounded predator, this outfit's ability to notify potential customers of their presence is severly hampered, and thus does not manage to attract as much prey as he would like. And so, the minibus remains quite empty the first half of the drive. To the driver's good fortune, however, his colleague, the fare collector seated in the rear of the minibus, climbs into the front and manages to reconnect part of the steering wheel, miraculously repairing the horn.

They drop me off in the center of Area 25, right smack dab in the middle of the market. The walk to the day care center is pleasant, neighborhoods are different here - no pavement, no lawns to mow, no manhole covers to drop rocks down to hear the echo. Instead, streets are composed of dirt and mud, as are the yards (if not covered with planted maize). I catch sight of a satellite dish in one of the front yards - it looks out of place to me.

Lunchtime at KASO
And finally it's a left through a garden, a right turn at the brick wall and I am at KASO once again. The kids are already there, as are the volunteers. Most of the 50+ kids (there are a lot of them here today!) are in the playhouse - singing and dancing. My appearance makes them, most of whom now recognize me, jump, shrill voices echoing in the playhouse.

The hand-holding is something so universal - some of the kids tussle and vie to hold one of my hands; some are tolerant enough to share my hand even if it is already engaged - others would prefer to have it just to themselves.

For the first time since arriving in Malawi I catch sight of a plane - a small, private jet-sized one - flying overhead.

The Vital Volunteers
We head outside and play chase, and in the hot sun, many of the kids faces are soon covered in beads of sweat. The volunteers suggest a break in the shade, and I use this time to chat about numbers and parts of the face with the children in English. There's something nice about 17 kids, sitting down, looking up at you with big, beady eyes, repeating numbers and words you are teaching them.

Day care ends, and the migrations towards the paths in the maize fields commence. There's always a mad dash to cross the two lane street. Understandably, the stress level of the volunteers is heightened, the kids feel it too. But they all make their way across the street safely, walking in one direction with their heads pointed in the other in order to wave their goodbyes to the volunteers and me.

I make my way back through the neighborhood and flag down an Area 25 minibus. Front seat. The windshield is cracked so my view is slightly inpaired. No matter, all windows are open (or perhaps cannot be closed) and thus provide ample angles for views during the drive. The minibus backs into the waiting area and lurches just a bit as it hits some modestly sized potholes filled with muddy water.

The Area 25 central market is buzzing - palettes of eggs are on sale, irons and potatoes, calm, caged chickens unaware of their ultimate fate. Small stands hawk phone calls (via old land line telephones) and shoes and shoe repair - I find this curious: for all of the shoe stands I have seen, many of the people walking are often not wearing any shoes. Whose feet are all these shoes going on?

Beer and Money; February 20, 2007

In Belize, it's Belikin. In Barbados, it's Banks. And in Malawi, if you're not having a Malawi Gin mixed with tonic, then you're drinking a Carlsberg 'Green' (the color of the label) or a Kuche Kuche beer - which means 'all night long' in Chichewa.

I do enjoy sampling the 'local' beers of the country I am visiting, even if larger conglomerates may have swooped in and taken control.
Inevitably the beers taste better when you're in the country of origin. Buying a six-pack of the imported stuff outside of the country somehow doesn't taste the same. And that's how it should be. Maybe it's the water. Maybe it's in my head.

The Kwacha: that's the currency of Malawi. I'd bet MK500 (that's about US$3.7) that most of you reading this did not know that. I didn't either. There are 100 tambala to the kwacha and the currency is printed in denominations of 500, 200, 100, 50, 20, 10 and 5 kwacha bills.

And things come pretty cheap here - most definitely if you are coming from abroad.
Soda will run you about MK30 and is a distinct luxury and you can eat well for MK400 or even cheaper if you do your research.
I'm not a huge fan of nsima, the pounded maize meal that is boiled in water and salt, but it is the most common food here, and is part of most meals.

Adult Ward; February 19, 2007

I'm on the second floor of the adult ward with D again today and I'm recognizing patients that we saw on Friday, 2 days ago.

Some appear better than they did last week. Some that to me seemed very sick two days ago have disappeared and are not in their beds anymore. Others do not seem to have moved at all.


It's the first day of the next rotation for the clinical officers, so a number of these white-lab-coat-wearing individuals are clustered around their leaders for orientation. D and I head to the first room at the end of the hallway and start looking at subjects. It becomes apparent that some of these people, patients that D evaluated last week, have not had various procedures done over the course of the weekend. Procedures that D requested in order to clarify their conditions.

I can only try to imagine how dull these patients' last 48 hours have been - waiting - standing in line - then being sent back to their beds because the water required in the pipes within the hospital for the x-ray is not available or because specific reagents/supplies have run out. So it's more waiting. At the moment, it seems, this is an ordinary day in the hospital.

D grabs the clinical officers responsible for the particular rooms and works through the patients, teaching them while assessing each patient separately. There's even a little banter and friendly joking going on. And progress is made and 7-8 patients are discharged from the hospital this morning.
------------------

I go for a run with E in his neighborhood in the late afternoon. We only see one other jogger during our 1/2 hour tour - another expatriate. At the midpoint of our run we pass a bunch of kids. Three of them - 2 girls and a younger boy, siblings perhaps, decide to join us for a couple of blocks. In spite of my huffing and puffing I notice that they are wearing flip flops and are carrying umbrellas - and are not even breaking a sweat. At the next corner they break off, smile, wave, say their good byes and E and I are left to continue to try to finish our run.

Lake Malawi; February 17 & 18, 2007

A change of pace. A chance to see more of the country. 9 doctors and I, divided equally between a SUV and a truck, are headed to the southern tip of Lake Malawi.

9 doctors - count 'em - and me. I've never felt safer in my life.

I'm in Eric's truck, along with Devang, Anjalee (E's housemate) and Jeff. We meet Saeed, Maria, Amy, Nader and Ellie in a gas station outside of the city and we're off. Once you get out of the capital and start passing through other towns, blink, and you might miss a village or two.

The 200 km drive is really pretty. We encounter more ambulators and bikers in- and outside of towns. E's altruistic tapping of the horn when nearing bikers leads to a increased rate of 'bike wobble' and often makes passing these mediocre-at-best pedalers, problematic. But we manage - and do not sideswipe any.

Oh, the roads. The roads in Malawi have varying classes of quality. And this variation can change in an instant. Sure, one needs to periodically contend with the occasional pothole (of differing magnitude), but we traverse lengths of really crappy terrain - I wonder whether these things can still be called 'roads'. The first half of the journey is primarily on pavement. Then the road conditions worsen - fast.

The 'road' is wide, and this is a good thing. But across the 3-4 car-wide area, E must perform a ritualistic up- and downshifting slalom, searching for the best 'run' that I thought only downhill skiers were capable of. And we see bikers with overladen racks, we drive through detours, we view the scenery. Some areas look like landscape that should contain herds of elephants and giraffes - none appear.

We make it to Norman Carr Cottage (http://www.normancarrcottage.com/). And it's paradise.

A little bit of paradise...
Taffy and Jenny, the proprietors, receive their 10 children with open arms and make us feel at home. Beers, gin & tonics, Cokes are pressed into our hands and the lunch, served in the shaded dining area right on the beach, is stupendous. How many weeks are we going to stay here?

Taffy takes us on a mid-afternoon boat ride, we drop anchor and swim, snorkel and jump off rocks. Jenny stays home - presumably to ensure that our return to shore will be a comfortable one. Libations are always at arms length. We see and hear a handful of majestic sea eagles. The landscape is picturesque - lush, green mountains with bare rocks jetting out of certain areas. The weather is phenomenal. How many weeks are we going to stay here?

Back on shore, I partake in soccer games and rock skipping with the adorable local kids. I don't know who is enjoying it more - me or them. They are so cute. Their smiles are real.

The rock-skippers/soccer players and me
The team of 9 docs and I all fit and sit at the long table, and manage to mostly sit at the same spots at each meal. And after watching the sun set in Taffy's boat, a big meal and even bigger laughs, we all head off towards blissful sleep.

Much of the same the next day - and staying here for an extended period of time would make the days blend into one another - just as I would like it. Get up, eat, read in the shade, go swimming, make lunch and maybe some plans, take a nap, go swimming, have a beer, or maybe two, think about stuff, have some fruit, eat dinner, relax and then sleep.

The Mitsubishi Strada crew, aka E's passengers, i.e. Anjalee, Jeff, Devang, Lukas, take a different route back - via the Dedza pass - and other than a brief scare about running out of diesel fuel, we manage to thoroughly enjoy the sights and views of this beautiful country. What a nice weekend.

Deep Thoughts on Malawi by Dr. Devang Patel

View from atop the Dedza Pass
The roads in Malawi are surprisingly good although narrow.
Malawians are not afraid of trucks barreling down the road at 100 km an hour. Malawians should be afraid of trucks barreling down the road at 100 km an hour as they saunter across the road on foot.
Malawians are the worst bike riders in the world but will haul anything including barn animals on their bicycles while cars are barreling past them at 100 km an hour.

Everyone should drive through the Dedza pass as they descend the mountains to Lake Malawi. The view is stunning.

The bugs are really big here. No seriously. They’re really big. Some of these things should have license plates on them. The bigger the insects grow, the more likely they are to be eaten by the locals. In fact, you can buy dinosaur-sized grasshoppers on a stick at the side of the road. Mmm, mmm, goodness.

If you have a breast fetish (and you know who you are), Malawi will fix that. Malawian children often breastfeed until the age of 2 and boy do they love it. The women certainly have no hang ups about this. I have seen 18 month olds twist these milk spigots at angles that no part of the human body should have to ever endure.

Adult Malawians will allow you to stick a needle into any part of their person without so much as a grimace even in the absence of anesthetic. Americans are such wimps.

I’m not a big fan of people trying to convert others to their religion but many Malawians living way out in the bush only get medical care due to the presence of missionary hospitals. Whatever the motive may have been, they have done more good for the health of Malawians than I have. Just something to think about.

It rains a lot during rainy season. Africa in the summertime is really hot. Eric is bald. Lukas is old (it’s his birthday today). Indians who don’t wear sunscreen can get sunburned on Lake Malawi during the summer when it’s hot.

The children of Malawi are beautiful. I understand why that crazy woman from the US came and took one of them away with her.

White people are called Mazungu in Kenya and Uganda. The same is true in Malawi. It must be some sort of universal African thing. Malawians must be colorblind because they keep calling me Mazungu.

A child’s eyes tell you everything and sometimes it can be heart wrenchingly sad.

Lukas thinks we have schistosomiasis. And TB. And malaria. And worms. It might be true but it’s totally been worth it.

Cheers from Malawi!!!

Africa, Take II by Dr. Devang Patel

Two Docs in Lake Malawi
Patel is back.

I last stepped onto African soil 4 years ago with Eric in Uganda. And now Patel has returned to Africa to work with his med school buddy in Malawi.

Eric has been working with Pediatric AIDS Corps (PAC) since graduating from residency last summer and I’ve wanted to meet up with him ever since. As medical students in Uganda we were more observers than practioners. Now we actually have the training to do some good in this country. Malawi is one of the poorest countries in the world. There is one pediatrician employed by the government in the entire nation of Malawi. In contrast the Baylor PAC program employs 13 pediatricians in Malawi to provide HIV care. It’s a sobering thought to be sure. One of the physicians here described to me the breakdown of each medical school class in Malawi. The class starts with 30-36 students. 4-6 of them die of AIDS before completion of school. Another 4-6 are lost to poor academics. Half of the remainder will end up going abroad to complete their training and most do not return. That leaves only a handful of Malawian doctors in the country each year. This dearth of physicians is readily apparent in Kumuzu Central Hospital (KCH).

Children's Ward A

How do I describe hospital conditions at KCH in Lilongwe? Remember that this is the tertiary care referral center in the capital city of Malawi. As you walk from the Baylor clinic to the gates of the hospital, you catch a pungent odor that just may induce vomiting. Walking further you enter Ward C. 150-200 malnourished children along with their caretakers occupy this dingy, musty, dark room separated into bays. You smell sweat, feces, urine, vomit, and rotting food that cooks inside this concrete oven during the afternoon heat. And this may actually be an improvement to the adult ward where at least half the patients are laying in an outdoor corridor that runs the length of the building. There are obviously no private rooms here. 6-10 children die every day on the peds wards and the numbers are even worse on the adult wards. X-rays are often not performed because the hospital runs out of water at least 1-2 days per week. For the past 2-3 weeks, no CBCs have been performed because the lab does not have the necessary supplies. These are the conditions under which medicine is practiced KCH. On one particularly busy morning I discovered that I was the only physician caring for about 70 patients on the adult ward. Who would have seen those patients had I not shown up?

Dr. Eric McCollum + Translator in the C Ward
The physicians working for PAC in Malawi should be commended for the work they do here. They have all given up at least one year of their professional lives in the United States to come and tend to the children of Malawi. Eric, Saeed, Maria, Anjalee, Kebba, John, Jean, Amy, Nader, Ellie and all the rest serve as an example for the rest of us. They make a difference in the lives of countless children everyday. My brief experience here has shown me that the work can be tiring, frustrating, angering, and saddening but you always want to return the next day because you know you’ve made a difference.

Adult Ward; February 16, 2007

I shadow D, who for the last few days has been working in the adult ward in the main hospital of Malawi, Kumuzu Central Hospital. I thought things were overcrowded in the pediatric ward where E spends most of his days. It's just as bad or even worse in the adult section.

We're on the second floor of a 4-floor building, dimly lit, mainly by ambient sunlight. The hallways have a faded, light blue color - perhaps a slightly improved hue when compared to the children's ward, but still nothing to rave about. Why someone chose these colors I do not know.

It seems it's just a matter of jumping right in - no forms needed to be signed, no people we need to talk to, just enter a room and start looking at the paperwork, forms and health passports that were also prevalent in the children's ward, and dig in.

The adults are not afforded any real privacy. Each room houses, or 'fits snugly', around only 6 or 7 patients, if they're lucky. Some people appear sicker than others. None really speak much, some are talking quietly with family members that are sitting and waiting with them. The patients lie on basic cots, and their wares, whatever they have lugged with themselves to the hospital, are placed on a ledge or near a small dresser next to their bed. Many sheets of linen look like they could use a washing. I'm sure most of the people would welcome a shower too. Certain rooms, sections, smell worse than others. Still that light blue color. And the waiting.

D first heads to the High Dependency Unit - this is a room where patients requiring more attention get placed. Yet it seems as though there's not enough help to go around. Once we've worked through what he can there, D leads me to through one of the rooms to the outside balcony - which one would assume is a place for patients can grab a fresh breath of air.

Now, while this area may indeed allow patients to alter their air quality for the fleetest of moments, this space also serves as a run-off section for patients that did not have a bed/room to get placed when they were admitted into the hospital. And it's heaving:

We start looking at a sick patient's record - I notice the handcuff on the metal railing next to the guy - and he is coughing a lot. Welcome to the 'tuberculosis area', complete with a small, cordoned off 'Coughing Room'.

This guy has been admitted from jail - and I don't want to imagine what sort of conditions he came from. D recommends to the clinical officers present that this guy get his left side tapped - that means, I learn, that they intend to attempt to drain this patient's incapacitated left lung. And it's off to the next patient.
Some people, even with my non-medically trained eyes, look like they're in the late stages of AIDS affliction. And they are. D provides counsel to a healthy looking brother who is sitting next to his supine sibling who has been wasted away by HIV. I don't see any resemblance between the two brothers.

Dr. Devang Patel perfoming a thoracentesis
We head to a narrow room, no windows, to pick up with the prisoner where we left off. The clinical officers bring in the equipment for the procedure.

Equipment. Many things are not available, so you need to be imaginative and creative with the supplies that are available.
I'm not liking the size of that needle - it looks too big to me.
The gaunt fellow, barefoot and wearing only shorts, sits slumped on a stretcher. And then the needle arrives and goes into the middle of the left side of his back - pop! - no anaesthesia.
And soon enough, dark red stuff starts flowing through the transparent tubing, ultimately ending up in a medical plastic bag.
And when all is said and done, this guy has deposited 2.5 to 3 liters of reddish liquid out of his left lung.

I notice a solitary potted plant growing in the the center open area. It appears strange to me and out of place, so I snap a photo.

Satellite Clinic; February 15, 2007

Our early morning drive to the clinic takes us past the machete-wielding 'human lawnmowers'. You do really see them alongside most streets, probably also because it's the rainy season causing all plants to grow so quickly.

These flailing machete-waving individuals can be seen trimming the roadside flora at a surprisingly efficient pace. There's 'job security' there too - surely, when they reach the end of a street, the grass and shrubs they only recently cut will have grown enough to where they can once again commence their onslaught on the greenery.

Parts of the US are getting hit by crazy snow storms and weather this week - we are so far removed from that right now.

I accompany E & D to a satellite clinic, some 45 km outside of Lilongwe in the afternoon. We fill up with diesel and then head west, soon passing through a checkpoint on our way out of Lilongwe.
The car races through areas that seem really remote and rural - and then I realize, there really aren't many places in the world more remote than this. Come to think of it, I've not seen or heard one airplane since setting foot on Malawian soil - how often does that happen?

We shoot through 'towns' that have a 'Wild West, main street' feel to it, minus the cowboys and indians. There are a lot of locals around, one group is playing cards under a tree at a table, tobacco hangs in another store, kids are sitting on the curb, goats are running around.
Outside of these towns, we manage to see the vast countryside of Malawi - visibility is pretty good today, and distant mountains, probably in Zambia, Malawi's neighbor to the west, can be seen too.


The turnoff to the clinic actually has a sign posted on the main street! We rejoice and take the dirt road, some 4 km to our final destination, passing a large lake - which probably houses just a few mosquitos...
D & E's meeting with Dr. K goes well - it seems that things are going well in this clinic.

KASO & Picturing Hope; February 14, 2007

I return to KASO, and once again, the familiar face, Jonathan, is already there. Better prepared, I’ve worn my still-to-be-broken-in hiking shoes to the muddy environment this time around. The same group of individuals arrives shortly after 8am. Jennifer is one who I have not yet met and her English is pretty good. Jonathan shows me his new bike, a gift from UNICEF.

Jonathan & another Volunteer
As the kids begin to materialize from the corn fields, so does the rain.
Today’s program does not seem as structured and the kids are allowed to race around at free will – or maybe the volunteers are simply tired. Richard and some of the group drive off to retrieve the next 6-month supply of the meals they provide the kids - corn meal, salt and oil. The corn meal is packed in big burlap-like bags which prove considerably challenging to haul into the shed. I carry a few on my own, although my back would prefer otherwise. The bags of salt are smaller and can be carried one in each hand, while the cooking oil is supplied in yellow plastic drums, also easier to lug.

Today I ‘speak’ more with the group and find myself sitting on the porch chatting and listening to the animated Chichewa discussions. I also get asked for money by some passing adults who are carrying buckets of water on their head – they also inquire about my shoes, as most of them are bare foot.

Maureen invites me to accompany her on her walk back to her house to pick up some supplies she forgot. We depart, wave to the kids, assuring them we’ll be back later.
Peter & Konani
The curious stares do not cease. People gaze, obviously so, yet not in an aggressive manner. I contend Malawians tend to have super-vision - they can pick out the muzungu 100 meters away. Maureen and I cross a paved road, then a downward slant towards the start of an extremely muddy road, with puddles the size of fishing holes. We circumnavigate, and almost slip into, a few of them, but escape with only muddier shoes. A right turn, then up hill, past a community water pump – I wonder if the water is totally potable.
I don’t see any mailboxes – do they get mail? Do they write letters?

We pass some half constructed brick houses, I assume these have been abandoned and are left to fall apart since the grass has grown to the height of the brick walls. A flatbed truck, having seen better days, sits dismayed in front of a house with nowhere to go. Passing children greet me with warm, inquisitive hellos and waves.

And finally we make it to Maureen’s place. It’s a one bedroom place – no, really, it’s the size of one small bedroom. No electricity or plumbing, the place is divided into two, with her ‘demi-bedroom’ separated from the rest of the place by a wall with an entrance shrouded by a curtain. Her ‘living room’ is lined by a reed mat and has four benches and a small table. She’s got a few buckets of water along the wall too. The barred window (although I would consider breaking out rather than in) allows for some light to shine in, which combats the darkness of the room.
Maureen has decorated the living room side of the inner wall with pictures from her youth, her son, other people from her life. Many of them are faded – I assume these to be from a time ago. I feel sad. Last year’s calendar hangs alongside 2007’s, probably since two colorful calendars add more tint to the wall than just one.
I share with Maureen the small banana I have packed for the day and once she has gathered her things we exit, lock the door, and start to head back to KASO.
I don’t really remember much about the walk back - I’m a bit hazy in the head with all this – I’m floored by the painfully contrasting lives that we’re leading: I snap my fingers and can have a nonfat mocha on my way home from the gym in an air-conditioned car. Here, people have other worries. Circumstance is a real bitch.

KASO is eerily silent – save the occasional yelps coming from the playhouse – it is meal time. I throw a glance into the window of the largest room and almost incite an uproar – 35 strong, the kids seem to be happy to have me back; or maybe the porridge doesn’t taste that great.
The volunteers are also eating here – fish (probably usipa, the most widely available fish eaten here, which is sun-dried after being caught), nsima (pounded maize meal boiled in water) and salad. My stomach is empty, but I don’t eat. I don’t have an appetite. The kids soon depart after the meal, their time of fun has come to another end.

Richard and an assistant arrive in a larger car. We load three boxes of supplies into the vehicle and Maureen and I jump in. We’re headed to the Mvunguti School in Area 25. It’s the first day of a 4-day course for the “Picturing Hope” program (http://www.picturinghope.org/).
This time around, 30 kids, AIDS-afflicted, have signed up.

We arrive at the school through some gates at some recess time. The place is heaving with kids. Our arrival does nothing to calm the kids down, don't think my presence helps either. We set up the 40 cameras, batteries, rolls of film, pens, notepads, etc. onto the front three tables in the rented classroom. Jonathan arrives with two cases of soda. And at 2pm the kids roll in. All windows and the doorway are populated with curious faces gazing in, all wanting to see what is going on in the room. They stare and wave, some give me the thumbs up sign. But only 30, those that signed up, are allowed in.

I sit myself in the front row on the left side of the room, the kids, aged between 7 and 12, strike the balance between listening to Richard and Maureen speak and watching me. I introduce myself too, with translation, and relay where I am from, etc.

Class in Malawi is conducted with solemn respect for the teacher. The kids seem intimidated by Richard, and only speak when called on. It’s interactive though too, as he often asks them a yes or no question, which the class answers with a joint ‘eh’. Other times they applaud in unison, a collective sign of praise, when a fellow student gives a good answer.

Maureen & Richard leading the class
They are eager and really want to get their hands on the cameras – which they will only get after the second training session. I speak about who I am and where I am from. This elicits applause too.
Pictures are handed out, groups are asked to describe what they see, why they think they see what they see. Many of the concepts they share are related to ‘being alone’, sadness and family. Similarities and differences among different cultures are discussed too.

We take a break. Each kid gets a bottle of soda, Orange Fanta, Coca-Cola, Pineapple Fanta, luxuries for sure, and loaves of white bread are shared among three kids each.

Discussions continue after the break. At the close of the meeting, notebooks and pens are handed out and the students are tasked with answering questions for the next day. These include, What is love? What do you want to take a picture of and why?

Once the travel monies are distributed to each kid, Richard and his team help locate the right minibus for my trip back to the clinic to meet D & E, so I manage to provide entertainment for the passengers in Minibus 25 that late afternoon too.

Crisis Nursery; February 13, 2007

Another rainy start to the day. I meet Sarah, one of the doctor's wives, in the clinic at 8am and she drops me off at the Children's Crisis Nursery in Area 47. It's a gated house that has been converted into a center to take care of kids aged 1 to 3. These kids have parents, if alive, that cannot take care of them. Most of the families are affected by AIDS, some have lost family members.

I meet a number of the caretakers, all women, and a few of them show me around. The kids are separated into 4 bedrooms, and each room houses around 7 or 8 kids. Kids of the similar age group share the same room and lie in cribs or plastic 'newborn baby shells'. Each child has got their name, caretaker and date of birth on a label, there are too many names.
I enter the room to the back left and notice Eduardo is crying while sucking his thumb. It's amazing how quickly personalities and differences among personalities become apparent - while Eduardo sobs, his neighbor, lying face down and playing with a ring of rattles, simply watches it all. While some wake up from the sounds, others just sleep through Eduardo's ordeal.

The work begins - or better yet - it never ends. It's shift work - I speak with one woman who works 4 days straight - nights too - and then will head home to tend to her 7 kids. It is still unclear to me how these women can look at a child and know when to:

a) Change the diaper
b) Burp the child
c) Feed the kid
d) Hold the child
e) All of the above
f) None of the above

It's because of this lack of comprehension I do what I only can do - that is, hold the kids, play and talk to them. I've not perfected the "grab another kid while holding one with the other arm approach" and limit myself to cuddling one at a time. The kids and workers seem mildly amused. Some of the kids take advantage of me and cry when I lay them down - they know how to work the system. Chimwemwe is a particularly antimated kid - and loves to high five.

KASO; February 12, 2007

It’s an early, rainy start. The beginning of the workweek. Do the Malawians lament the end of the weekend too?

Before heading to the clinic, E & D give me a ride to Area 25; this is where the Kanengo AIDS Support Organization (KASO) day care/orphanage is located. After one wrong turn we find the place surrounded by corn fields. It’s an unassuming place – dirt/mud covers the area, two pairs of archaic swings and a slide, grassy playing area, a thatch roof hut for the kids, two shed-sized houses.

I see one guy sitting under the awning of one of the small buildings as E & D drive away. Jonathan, upper 20s, wiry, from the local area, Arsenal hat. We chat, in English, and more volunteers start rolling in. Most of them are women, some of them have kids wrapped on their backs in those now recognizable colorful shrouds. I meet Richard Yohane, the director of the organization. Maureen is one of the leaders of the effort too – she has a son, Konani. She gives me the tour:

Neither building has electricity or plumbing, one of which is utilized for the kids activities. The walls are pockmarked, dull and faded yellow, sickly almost, and have chalk graffiti scribbled on it in various places. There’s the ‘Imagination Room’, ‘Maths Room’, ‘Music Room’, ‘Rest Room’ (for sleep) and the ‘Art Room’. And into each of these rooms items are brought in by the volunteers – reed mats to cover the dark brown, dusty concrete floors, chalkboards, a two-string guitar, a bongo and two sleeping mats. We’re set up and not soon enough – 35 kids, ranging from 3-6 years old, appear from the cornfields within a 5-minute interval. And that’s when things get lively.


In one playground, add the following ingredients, and you’ve got yourself an amusingly explosive mix:

- Place one bongo and one semi-functioning, un-tuned guitar into a room
- Mix in 35 eager-to-play kids
- Sprinkle in a couple of dolls and two soccer balls
- Add 3 large muddy puddles and one muzungu

I fetch water and wood for the maize meal that will be cooked with water, hold a lot of hands and do my best impression of the new guy in town. I soon end up in the ‘Imagination Room’ with my group of around 8, and we manage to share different words in Chichewa and English with one another. They’ve all got mini-chairs too, so it’s a veritable round table discussion:

Tired of sitting in the building, most of the kids go outside. Different circles of children form and the happy kids hop into songs (I could not follow) that I try to keep up with – even 3-year olds find my attempts amusing and watch bewildered. Most kids here have an innate rhythm that I could only dream of having.

Lunchtime! The gaggle of kids storm back into the largest room in their building and sit down – the huge pot of bubbling maize is carried over to that building and colorful plastic plates and red spoons are divvied up to the kids.
Faces quickly become covered with porridge, as it seems not all manage to aim all of the food straight into their mouths – I have the same problem too, sometimes. Most of them, well-mannered and/or well-taught, take their plates to the back of the other building and place them into the pot for cleanup.

And then, just as quickly as they arrived, the procession departs around noontime. I follow the entourage to the street, walk with the group up to the turnoff at the cornfield, wave some 5 minutes to the kids and then watch them disappear along the narrow paths in the corn. It’s time for me to go too.

Jonathan leads me through the local neighborhood streets – dirt-paved roads, houses separated by single rows of corn, brick walls, reeds, dirt piles. These roads are bad, muddy and have considerably sized potholes. Small, makeshift ‘stores’ are visible from time to time, a tailor’s window is boarded up, closed for now, a faded painted Coca-Cola sign lines another wall as we turn a corner. Kids strolling home from school, people walk by and stare. I wonder how many muzungus they’ve seen today. We both see my trip out of Area 25 – a minibus - appear around the corner. My first adventure in one of those things.

The sliding door opens and the gaggle of people stare and smile and let me in. I'm in the second row in the back, knees in my chest, my legs are too long. We depart, driver honking the horn incessantly, 'asking' people on the street if they require transportation. There are no bus stops - the bus stops anywhere there are people, i.e. potential passengers.

We pass through a market, maneuver around and sometimes through the potholes, as the tide of passengers ebbs and flows within the cramped cabin. The attendant straddles the sliding side door, he's also the guy that takes the fee, 60 Kwacha, the currency of Malawi, for the ride.

At one 'stop' I'm asked to hop into the front - I think the driver wants to chat in English. I climb into the front. Radio is on, I hear a bit of international news, something is relayed about conditions in Iraq. The driver wants to visit my country, he says, between the honks.
The minibus gets more full, and another passenger jumps into the front next to me - I have to shift into the middle and staddle the manual gear lever and the makesift boom-box that has replaced the missing car radio.

The ritualistic dance between minibuses driving on the same route is a thing of beauty - the gentle waltzing around each other and past people as they each vie to acquire as many passengers as possible - as quickly as possible. Hand gestures are made, obscene gestures traded, and when their routes diverge there is still a wave good-bye until the next dance.