New reality

When there's so much to say, I like to just barf it all out and see if any kind of order establishes itself, like reading tea leaves... of barf. 

This was the month we really settled into our new reality. "I can't believe we actually moved to Africa," Thea commented yesterday. "I know," I said. "Me either." The other part I can't believe is how much it is exactly as I wanted it to be. I wake to the dissonant calls of roosters all around us, play a few hands of cribbage with Matthew over breakfast (he's beating me eleven games to three!), then jump on a motorbike with Rex for a ride to the district hospital. 

It's 7 AM, and the roads are streaming with pedestrians going to work or school, mothers with small children on their backs, men with bicycles hefting big bags of charcoal, young people giggling in green school uniforms. The morning light is clear; all the hues are bright. When we turn onto the tarmac road, Mount Mulanje towers up on my left, draped in elegant morning fog, with palm trees ringing her base. It's beautiful. Riding a motorcycle is a wonderful way to start the day. I inhale deep and smile the whole way.

Then I arrive at the hospital, which by now feels like an old friend. I was so nervous to start and now have a real affection for the people and the place. It's terrible. It has to be as close to the experience of working in a refugee camp without actually experiencing the horrors of war and displacement. Okay, so nothing like a real refugee camp. It's a calm place. But there are so few supplies - that's the part that's terrible. In a month's time, my last shift was the first time I encountered handsoap. It surprised me so much, I took a picture of it. 

I felt guilty taking a picture of this chair, because it's not representative of all chairs there (mostly there are nice wooden benches) and I thought maybe it had been set in the hallway on its journey to a trash pit. But it's still there a month later, and yes, it gets used. 

But the employees are so warm, kind, welcoming, and humble. I love them. Not having enough sterile instruments to remove a contraceptive implant is a real bummer ("when this happens, we just have to use our fingers"). Kicking a woman in active labor out of her hospital bed so another women in more active labor can give birth first kinda sucks. But it's the way things are. You do what you gotta do and I deeply respect that. Us richies are so used to being in control of everything, but the real measure of a person is how they cope when they aren't in control of almost anything. 

The unfussy practicality displayed by both providers and patients is admirable. The hospital depends on the Malawian government to provide everything they need to provide free healthcare. If they don't send enough soap, you wash your hands with water alone. If they don't send enough beds, you lay on the floor. If the x-ray machine is broken for a month, you do your best to keep patients alive until it's fixed. The results are... variable. But could we do any better under the same circumstances? We're not so remarkable. 

That women at 8 cm dilation stumbling out of her bed - half-naked, dragging herself out of the way into the busy hallway, so the 16-year-old at 10 cm can fall on the bed in her place to push her baby out - didn't say a word of complaint, not a peep. I find that incredible. Like the ultimate anti-Karen. The hospital serves one meal to patients and staff per day, and every day it's nsima and beans. We midwives share it together, eating off the upside-down lid of a bucket. They've eaten the same thing for lunch, seven days a week, for as many years as they've worked there. I contributed some apple slices I brought (imported from South Africa, purchased in Blantyre), and one of them exclaimed, delighted: "Today we get fruit!"

That soap bottle is empty.

I am learning so much about how to practice midwifery in a developing, tropical country, and I am eating it up. There were 78 antenatal patients in a ward designed for 25. They used to have an overflow room (which housed both early labor patients and TB patients together), but it burned down last year from bad electrical wiring. All the women bring their own garbage sacks, cut open so it can lay flat, as a protective barrier (there are no disposable underpads). They lay on it for cervical checks and to give birth and to rest on the floor or a bed if they can nab one. 

If a consent needs to be gotten for an emergency cesarean section, the midwife grabs a blank piece of paper and rips it in half, then writes out the wording by hand. Every time, because the pre-printed consent forms haven't been re-supplied. Same for charting: we draw a line down the length of a page and free-write whatever needs to be said. Every time. If there are staples, they then get stapled onto any previous papers, an ever-thickening collection of handwritten scraps. That's the patient's health record. If it can be found, we refer to it for pertinent history; but mostly we just take each person as they come. I chastise myself five times a day, in disbelief that I didn't shell out a couple grand for some fetal dopplers before I came (one for personal use, the others to donate). I make do, as they do, with an imperfect fetoscope. When even your cups were donated by USAID, all one hundred prenatal patients share the same cup to take their malaria prophylaxis pills. It makes me chuckle to imagine a US hospital trying that and people actually complying without a second thought. 

(Of course, USAID has now been abruptly withdrawn so I hope no one steals the plastic cup.)

Fetoscope.

After an eight hour shift, I am sweaty, hungry, and a little shell-shocked. It's just another workday for my coworkers who will be back tomorrow, while I'm thanking God I only work two days a week. I hail a bicycle taxi, unwinding as the driver slowly strains up the hills to get me back home, my forearms getting sunburned in the afternoon heat. 

Yet I love it - a great mercy, a tremendous gift. 

I've been taking pictures of feet. Look at these plump little toes!

Yes, let's!

The other three days I spend at the mission hospital each week, which seems luxurious now by comparison, working as a nurse educator and helping with outreach clinics. Yesterday I taught the labor staff how to use the single infusion pump we have. We don't have any working fetal dopplers either (or thermometers). Why didn't I bring some?, I keep wondering in disbelief. I was told they used them, but I was not told they only had one and that it was broken.

SOMEONE PLEASE BUY ME 4 FETAL DOPPLERS. I've tried many times to get used, donated ones, to no avail. Fetal dopplers aren't deeply sophisticated medical equipment, they're just a basic battery-operated way to listen to a baby's heartbeat for a period of time to be really sure if they're in distress or not. They help prevent asphyxia and stillbirth. Decent ones cost about $800 each. I want to give one to the district hospital (for being so welcoming to me and helping me get my Malawian license). I want to give one to the mission hospital labor ward, one to the antenatal clinic, and keep the other one for myself. I will name it after you. 

Learning how to set the pump rate. (Taken with permission.)

In an outreach village.

Patients gathered for the non-communicable disease clinic (mostly hypertension and diabetes).

The Under Five outreach clinic, tracking babies' growth.

As I write this, there are a stream of people surreptiously searching through the small field behind our house looking for gleanings or small sticks for firewood. I'm on our patio with a $700 laptop, peering over the top of it as they sneak around right in front of me, because the field technically is ours. The maize from the previous owner was already harvested, but there are bits and pieces of other crops mixed in, and even though I'm sitting right here, they are desperate enough to gather it anyway, nervously glancing over at me from time to time, quietly daring me to confront them. I can see the thought bubble above their bent bodies: "She has a computer. Her noisy children have playing cards. She can spare these sweet potato leaves." Indeed, they are correct. 

This is a desperate time in Malawi. In between feeling jubilant that I am able to do something I've wanted to for so long (i.e., be a midwife in Africa), I also feel crushed. Matthew too. It's not just novel and titillating that women give birth on trash bags, like poverty voyeurism. It's heavy and hard to see people's quiet desperation in the midst of really bad economic times. The number one thing that Malawians want to talk about is how they can get out of Malawi. They are gobsmacked that we came here by choice. "Why?", they ask, heads cocked to the side, wondering if we may be dimwitted. Sure, they agree it is very beautiful. And it's obviously a given that nsima is the most delicious food a person could eat. But other than that... ???

In a supreme example of global injustice, little gentle Malawi (who never hurt anyone) has the second highest fuel prices in the world right now, driven by widespread fuel shortages that damage people's prospects in real ways, affecting their ability to buy & trade, to scrape by. Food prices are commensurately increasing, as shortages pop up unpredictably. You can feel how everyone is just a little on edge, the tension simmering beneath the surface despite these beautiful, sunny days. Their minds are always hyperfocused on one thing: how can we make it? How should I diversify? What can I do to keep sending my kids to school? To have better prospects in life?

I want to illustrate just how thin the margin is for people here. Back in early March, I noticed one of the frail-looking grandmas at the outreach clinic had gained 12 lbs since her last visit and that didn't seem right because how could she have gained that much in a single month? I brought this to the attention of the clinician, speculating that differences in the scale were the issue. He politely agreed that could be the reason - but then gently explained that the real reason is because November, December, and January are the months immediately before harvest and many people go hungry in those months. He questioned the woman in Chichewa: "Blah blah blah?" She nodded, responding, "Yadda yadda yadda." Then he turned and interpreted for me, "She says she only ate one helping of nsima per day for three months, but last month they harvested their field, so now she's coming back to normal."

That was before our country invaded Iran. Now things are even more out of whack. Fuel is still $14 a gallon. When a station has fuel to sell, the lines of cars and motorcycles stretch for more than a mile. 

The sweet 19-year-old nursing student I was teaching at the district hospital the other day (I had the pleasure of helping her remove her first contraceptive implant from a patient) just couldn't wrap her mind around the fact that I take a mototaxi five kilometers to the hospital each morning (rather than walking or bicycling). That ride costs me about $1 (or two, depending on which exchange rate you're using, the official or the black market rate). 

Put another way, it costs 5,000 Malawian kwacha and the government's daily pay for a trained nurse/midwife (who went to school for three years) is about 6,000 kwacha.* It pains me to reveal that we pay our housekeeper 10,000 kwacha a day (again, that's $2) because it sounds like slave labor, but as you can see, it's actually a really decent wage for handwashing our clothes and mopping our floors two days a week. (The rate was very carefully considered and set by the medical director.) You never, ever, ever can talk casually about wages here, or you'll have essential nurses quitting their jobs to be housekeepers for expats like us. When I bought soy sauce in Blantyre, I immediately peeled the price sticker off, so our housekeeper wouldn't see it cost the same as three days' wages for her. I do that constantly, but she's not stupid. She's gotta know. The system is so messed up. 

I loved that this student asked for a selfie together.

I don't know what else to barf out. I haven't said a thing about Matthew and the kids, but they are all doing well enough. It's been a month since I last posted but it seemed important to set the broader context for what things are like here right now. It's a lot to take in. 

In summary: Things feel both heavy and light, hard and good, and maybe that's what you set yourself up for when you move to a new place like this. 

Also - SOMEONE DONATE FETAL DOPPLERS, PLEASE!

This post is over. But I'll leave you with something unrelated but funny, because I could use some light humor after all that. Matthew asked me to start using Google Keep for our grocery list, and when I logged into it, I realized I must have used it briefly when the kids were little to remember things they did or said. 

Here's a few I rediscovered. Thea was 4 years old at the time. 

Thea [examining a fairy dress-up thing we just salvaged from a neighbor's free box]: I wish it had wings.

Me: Yeah, I know you really like wings. You're kinda a "wing girl". 

Thea: What does that mean?

Me: Well, I just mean you have always been interested in wings. Maybe instead of a teacher, or maybe IN ADDITION to being a teacher, you'll also be a pilot!

Thea: What does a pilot do?

Me: A pilot is the person who flies an airplane.

[Thea looking thoughtful, considering this. Me feeling proud of my empowering parenting.]

Thea: Weeeeeeell, actually I think instead of being a pilot, I want to be the person who hands out the snacks on a plane.

Me: [fake brightly] Oh, great!

And this: 

Cutting Thea's fingernails.

Me: Look at that one, how did that one get so long?

Thea: I don't know, maybe its a lion nail.

Me: Oh, like how sometimes I say that you have Tiger Toes? A lion nail? How did you get lion nails? Are you part lion?

Thea: Nooo. You can't turn into a lion.

Me: No, but sometimes you can kinda feel like an animal in your soul. Like me, in my soul I kinda feel like a whale. What do you feel like?

Thea: I don't know. 

Me [sliding her off my lap]: Well, think about it.

Thea: Well, I guess probably like a sock. [Runs off]

And finally, this:

Thea: Look at the word I made! 
Me: What is it?
Thea: Read it. 
Me: [garble garble garble]
Thea crestfallen. 
Me: What was it supposed to say? 
Thea: Mr Potato Head. 

Why does he keep beating me at cribbage? My mojo is off.

* I got this information directly from a locum tenens midwife I was interviewing. In the US, these typically fill short-term staffing gaps, but this particular person has been in that role for three years. He was even chosen as Nurse of the Year for his department. Permanent positions are very hard to come by. I think that folks in permanent jobs may be paid a few thousand kwacha more by the Ministry of Health, but it's not much more. I can't really ask directly.