Lulwe

          Today marks exactly one month after I left home.  Since I have some much briefings and materials thrown at me, I feel I am still learning and with fourteen health facilities to cover, I have not visited them all. Some of the expats seem to work all the time, in the evenings and on weekends. It is a little disheartening for me for I feel I cannot disturb them. There is nothing much to do in Nsanje so I took a long walk alone along the Shire River into the farms this past Saturday afternoon, bringing a folded umbrella with me just in case I chanced upon a crocodile.  A few words of greetings in Chichewa seemed to bring up smiles from the locals and enthusiastic response. Many women were doing their laundry the hard way on the banks and drying them on the rocks. Water hyacinths glided swiftly with the currents.

          Lulwe Health Center is to the south-west part of the tip of Nsanje and is situated high up on the mountains, also called “a difficult to reach area”. The cruiser had to climb steeply at some spots over rocky terrain. Lulwe belongs to one of the Christian Mission centers and charges a fee at the clinic.  As with centers that charge a fee, it is clean and better maintained.  A mid-wife at Makhanga at the East Bank, the health center that smelled of bat guano, wished that his center could also charge a small fee so they could use the funds for maintenance.  However he knew that none of the politicians would agree lest they were voted out of office.  

Lulwe Health Center

          A woman who gave birth to her ninth baby three days ago at Nsanje District Hospital, her last because she had her tubes tied, hitched a ride with us.  Some of her older children were already married.  She was sitting on the ground at the hospital gate and when she learned she could ride with us, she gathered her belongings tied up in a bundle, her basin and her swaddling baby and ran with such energy you would not think she just had a baby.  One wondered how she was going to make her way home up the mountains in Lulwe 40 km away.

Lulwe nestles on the slope of the hills with more mountains in the distance and Nsanje sits in the hazy, flat, hot valley.  Mozambique is just a stone’s throw away.  This is a small center with few patients, a very civilized pace.  It has the necessary maternity unit with a woman who just gave birth this morning.  Being up in the mountains and cooler in temperature, all the babies here wear a warm knitted hat.

A thirty-year-old man started taking HIV medications a year ago and his weight went from 42 kg to 70 kg in a matter of months.  However recently, he developed a cough and his weight has slowly decreased to 56 kg., the health center treated him with some antibiotics but there was no improvement. He had a sputum sample that did not show TB, a second sputum had not been obtained, the next facility is Nsanje District Hospital, far away from here at least on foot.  That is where he could get a chest x-ray.  I asked the HIV/TB integration service person to look into his case; I was told that the national guideline frowns upon empiric treatment.

An eight-year-old boy with wide-open eyes could not let his gaze off me; evidently he had not seen a foreigner before.  He was sick a few months ago with fever and diarrhea and his mother brought him to Mozambique to see “an African doctor” or a traditional healer.  Apparently he was cut in the arms with a razor blade by the healer but continued to do poorly.  At Nsanje District Hospital he was tested positive for HIV but his mother was negative.  He started on HIV medications after his diagnosis. Today they retested him and again he was positive.

         In the afternoon we left the remote but temperate Lulwe heading to the hot valley of Nsanje. 

The Mountains from Lulwe

       

Phokera

Phokera Health Center

          We traveled to Tengani again today to observe their ART Clinic but it turned out it was not an ART day so we traveled further north to Phokera, a relatively new health center built in October 2006 by “Press” donor.  It has the usual OPD, ANC, ART and Maternity Ward.  The beds in the maternity ward look comfortable with cranks that make the beds adjustable.  Already there are signs of poor maintenance; termites have begun to build their nests on the wooden beams.

            The OPD consultation room is spacious across from it is the exam room.  I asked permission to look at it, it was locked; a bad sign, it could only mean one thing: physical exam is not done routinely to warrant it being free and open.  When the medical officer finally found the key to open it, the exam table was squeezed in a corner obviously not used very often and there were two tables keeping it company, boxes and papers were piled on top of these; the exam room is slowly turning into a storage or clutter room.

            Outside the ART room is a narrow corridor also acting as the waiting room for the patients, dark, dingy and congested.  The ART room itself was crammed with furniture: a humongous desk took up center space where the medical assistant presided with papers and bottles of ARVs on the table top.  The table took up so much space that the exam table given by MSF sat in the ANC room next door.  Like many health centers we visited, the medical assistant had two patients sitting in front of him to be seen at the same time, again without regard to privacy and confidentiality which is the first requirement of the dictum of the Ministry of Health of Malawi for HIV care.  The chair prevented the door from closing so the patients waiting right outside were within earshot of what was being discussed.  Our suggestion was to use a smaller desk and rearrange furniture to accommodate the exam table.  With him sitting behind such a big desk it was a great deterrent for him to even reach over to look at his patients.

           

Some other donor has built a new building next door which will be used as a laboratory, the hope is to build additional buildings to make Phokera a hospital for this area, I was told.  I can’t help but compare the healthcare facilities from what little I saw in South Sudan, Malawi has a lot of help from many donors and they have many health centers (with maternity unit, a must for a nation that tops the fertility rate of Africa) which are solidly built and but poorly maintained. South Sudan on the other hand, at least in the places I went, does not enjoy health facilities that are close to the inhabitants, hence the mobile clinics that we ran.  They are far behind Malawi in that respect.  It would be a tremendous loss if Malawi does not keep these places up to continue providing reasonable care within reasonable distance for their citizens.  The so-called “Difficult-to-reach-area of East Bank” is difficult for us to reach because of the washed-away bridge but the inhabitants could still reach their health center except in severe floods.  The Makhanga health center with its bat-infested and damaged ceilings, hollowed beams will soon cease to exist and sealing the fate of the villagers to travel a long way to the next health center.

The Cholera Tent

Trinity: The Problem with Allowances

Trinity Hospital in Muona

         The reputation of Trinity as a well-kept place precedes my visit.  It is a Catholic hospital and a paying one. Because of that there are fewer patients.  In fact the Female Ward is closed and the Male Ward is being used as both a Female and Male Ward. The place is clean and the Pediatric Ward is less depressing of all the pediatric wards I have seen in Africa.  There is also a TB Isolation Ward and a nursing school. The ART Clinic is in a new building and the waiting room was full that day, it is the only clinic that is free with the exception of having to pay for the lab test for CD4 counts, the enumeration of the immune cells.

The ART Clinic in Trinity

       

          The consultation rooms are very spacious but there is the absence of an exam bed.  The Medical Assistant had two patients in his room at one time with absolutely no regard to privacy and patient confidentiality.

When there was a lull he asked my team, “When is the next ART training?

            “Didn’t you already have one?” My team member asked.

            “But I’m looking for one that will pay me a higher allowance.”

            “Why do you go for training?” I asked.

            “To get training and allowance.”

“Fair enough. “I thought to myself

I asked,” What if there is no allowance, would you still go?”

He thought for a moment,” If food were provided, I’d go. But if there were no food and allowance, I would not go.” He added,” I’m poor.”

I am not very clear on the history of allowances.  It was said that years ago, IMF stipulates that in order for a developing country to get aids from IMF in the health sector, the government needs to maintain a low wage for the healthcare workers.  Allowances are given to them for training as a form of supplement to their meager earnings.  As a result there is an unhealthy culture of expectation of being paid allowances to be educated so much so that looking for training courses becomes synonymous with getting paid at a higher level.  Allowance becomes a bargaining chip even when a meeting is called, the mentality of “what would I get in return for showing up” permeates the whole system.  A meeting called close to lunch hour conjures up “a free lunch”.  It could also be used as a form of blackmail; if I were not to be given an allowance, I’d not show up.  Years ago when I was in rural Tanzania, a senior person was away so much on various different training programs in Dar es Salaam, she was never around to do her real work to the extent that an expat was doing all her work and reports for her.

Allowances aside, this medical officer we mentored this morning was so slip-shod with his patients that he hardly spoke to them, burying his face to fill out the forms, the so-called master cards, handing the form back to the patients with their medication refills and mentioning the next appointment date. There was a woman complaining of a lump in her right groin, he probed verbally but never once asked to see her swelling. He failed to listen to the lungs of a man with a persistent cough for a month. It was as though he was afraid to touch his patients.  Seeing patients seemed a very tedious and mundane job for him; somewhere along the way he had lost his passion for them.  My team member was somewhat gentle with him in his final critique but I did not mince my words and told him exactly what I thought.  To be fair, there are many medical assistants and nurses who are really good and kind to their patients and often reach out to them in personal and humanistic ways.

            Yesterday there was a black-out.  The women sat on the dirt patiently outside the mill with their bags and buckets of corn waiting for the electricity to come back.  When it became dark and the electricity failed to turn on, they marched back 

home in droves, singing. This morning they marched back, they no longer pound their corn like they used to. There was a scuffle at the entrance of the mill; it had become more urgent to get their corn milled after all the waiting, they had lost their patience.

We traveled to Mesengere to pick up another member of our team. There the nurse mid-wife immediately came to me to ask for a ride for a primigravida with cephalopelvic disproportion to Trinity.  Having sent their ambulance to fetch fuel at Nsanje, three to four hours away, they did not think of transferring her earlier to Trinity which was half an hour away.  We emptied our cruiser and folded up the seats, placed a mattress in it and back-tracked to Trinity for her emergency C-section. Our driver said we could only transport patients towards where we would be traveling and not back-tracking but I made the decision to do just that, I refused to have a potential loss of life on my conscience, even if this delayed our departure from the East Bank. 

It was dark when we reached Nsanje. Over the Shire River the red ball of an almost full moon hung watchfully.

Makhanga, East Bank: Bat Guano, Give Us Some Mops

          In the morning I ran up the steep hill behind the lodge until I reached the top of a ridge, running into villagers young and old carrying heavy loads downhill to sell at the market.  After my run the rain came in torrents, the roof of the lodge leaked directly where I sat for breakfast, dripping water on my head.  Just as quickly it started, the rain stopped but the road had already become muddy.

Makhanga Health Center

          I thought nothing could top the appalling conditions that I have seen in the health centers that I visited so far.  I was dead wrong.  Makhanga does not even have a sign to indicate that it is a health center.  As soon as we walked into the first room which looked like an ante-room to the pharmacy, we were confronted with huge gaping holes in the ceilings which were moldy and brown with water damage and an overpowering smell of bat guano permeating the air.  Water puddled on the floor from the rain.  The nurse mid-wife showed me the cause of the ceiling damage.  A tree had fallen on the roof a year ago, bent metal roofing with a gaping hole was the result.  The district is aware of it but this could not be fixed because of a lack of funding.  In fact the district health team comes quarterly, takes notes of all the deficiencies and at the end informs the health center that there is no money for repair. 

The Damaged Roof

The Moldy Damaged Ceiling

          Someone stuffed a roll of paper through a hole in the ceiling while another taped a square piece of board in a gallant attempt to pluck the hole while in other areas the staff just gave up and stripped the ceiling altogether.  In the maternity ward the sterilizer was just a container sitting atop an old hotplate with wires sticking into the plug. Like Tengani, this place has a donated sterilizer which has a plug that does not fit the wall socket. 

The Sterilizer

       

            In the Labor and Delivery Room, a woman was groaning in labor, cervix dilated ready to give birth to her fifth baby and she did deliver a 3.4 kg baby boy.  Because there was no light bulb in the post-natal ward, she would be spending two nights in the dark unless her family brought in some candles.

            Like all the other centers, the consultation rooms were always littered with trash, papers, and stacks of frayed registration books not put in any orderly fashion, empty boxes and bottles spilled on the floor.  No one bothered to clean up and there was always an excuse as who was the last person responsible for creating the disorder.

            Perhaps it was the full moon or the bat guano, I just lost my patience today and decided to talk to the person in charge and asked him who was responsible for tidying up the mess after an ART session.  He indicated the clerks were and that I should talk to them myself.  But then I said, “Aren’t you the one in charge?”

           

He had seven cleaners for this health center and yet the place did not seem to be dusted or emptied of trash. 

The In-charge said, “We have no mops! Just give us some mops and we’ll clean”

I replied, “But you don’t need a mop for the general cleaning up.”

There had been a eight-month discussion of swapping the bigger HIV testing room with ART room.  The HIV testing counselor was reluctant and the issue went as high up as the District Medical officer with no resolution.  The exam table donated by MSF sat in the HIV testing room because the ART room was too small for it. The HIV testing room was also filled with trash and cluttered with unusable furniture or horded items that someone thought would be needed in the future. I asked to speak with the testing person and the “In charge”. When we finally sat down together, the In-charge began first by complaining to the counselor regarding the trash in his room.  The counselor quickly placed the blame on the volunteers who helped with HIV testing.  When I asked if he would be willing to swap room with the ART Clinic, he replied, “We could discuss again with the District Medical Officer.”

I said, “Isn't this an internal issue that could be resolved between the two of you without involving the higher-ups?” As I said that a chunk of termite nest fell from the ceiling behind where I sat, narrowly missing me.

Miraculously, he amicably agreed with the stipulations that MSF moved the shelves from the ART room, fixed the broken lock and the non-working sink.  As we walked out, he pointed out the ambulance which had not worked for a year and needed “a very small part” for its engine. I nodded but did not promise anything.  As I looked up the ceiling there were at least three supporting beams which were either broken or were just hollow shells, the inside had been completely eaten by termites.

            Just before we left, a cleaner appeared with a bucket and a mop cleaning the floor of the HIV testing room.

            In the afternoon I went hiking the hills to clear my mind of the clutter of the day and to get rid of the smell of bat guano in my sinuses.  John the driver was talking to a villager and told me he would follow me soon.  On the way the villagers asked me where I was going in Chichewa, I pointed to the top of the hills. One could almost imagine the fall foliage of New England with the clumps of orange and green trees on the hills. After I hiked for almost three quarters of an hour the route sloped downwards and cognizant of waning sunlight I began to head back running downhill and spotted John who gave up on catching up with me and had turned around heading home.  The villagers had pointed to him where I was hiking. Far below us we could see the Shire Valley.

The Shire Valley

Young Girls Carrying Water

East Bank: The Difficult to Reach Area

          On my run this morning a big black mommy pig grunted twice as she crossed my path followed very quickly by ten black cute piglets.  I am not sure whether this meant good luck or bad one.

          This morning my team headed for the East Bank of the Shire River.  The Shire River divides Nsanje District into a smaller northern section and it is around the East Bank which is flood prone.  Despite the yearly flooding the inhabitants are reluctant to move away from this region because of the fertile soil where they could grow even though the rest of Nsanje only enjoys a growing season from November or December to April during the rain, the rest of the year the ground is fallow and dry with very little farming.  An added bonus for the villagers was when the flooding comes there is an abundant supply of fish.

          To reach this area we have to head west to the next district of Chikwawa to a bridge that crosses the Shire towards Blantyre.  There was a shorter and more direct route to the East Bank but the bridge had been washed away near Bangula and so the detour.  After the bridge, we looped back to the East Bank, the tarmac ended abruptly. 
           At the turn my team members tried to scare me by telling me, “Dr. Kwan Kew, now here is the real beginning of our journey to the East Bank, about three hours of long of bumpy, non-tarmac road.”

In fact it was a little less than that, not realizing that I had traveled through the remote areas of South Sudan with perhaps similar or worse toads than here.  The East Bank is a poor and God-forsaken place but the South Sudan I was in was even more remote and isolated.  Here I saw an abandoned Baptist Church, the missionaries had come and gone and the building is crumbling, life still goes on in the village.  We crossed many of the tributaries of the Shire River where children romped in the water while their mothers did the washing.

A Respite from the Heat 

I stayed in Zuwere Forest Lodge up the slope of a hill; the room had large windows which let in the moonlight.  The moon was almost full. It was a particularly windy night, large dark clouds racing across the night sky obscuring the moon.  A tabby cat meowed loudly peering through the windows trying to get in. Electricity was available from six to nine in the evening.  I took a cold trickling shower not knowing that one could ask for hot water, the smoky water which smelled of wood fire.  

Nyala Park: Under the Fever Trees

          This being Saturday, I had time to do a long run and so I ran to Chididi.  The locals have been slashing and burning their land preparing for the growing season.  Ashes covered our porches and in the morning the smog hid the mountains and one could smell the smoky air.  Two nights ago we could see fire in the mountains.  This reminded me of my overnight train ride from Bangkok to Chieng Mai to spend some time near the mountains there last year, only to be disappointed in the morning by heavy smog obscuring the mountains from the farmers’ slash and burn method of farming.  For about a mile the route to Chididi was all uphill with the last stretch being quite steep.  Here I found a group of seven girls waiting at the top cheering me on.  They probably climbed this hill everyday carrying a heavy load and knew how hard it was to scale it.  I only had to carry myself. 
           A few weeks ago it was announced to the entire staff that we would have a team building activity this weekend day at the Nyala Park.  The staff would be provided with transportation and entrance fees but lunch would be pot-luck.  At first this was met with enthusiasm but apparently as the days went on there was a movement to boycott the event because someone thought that lunch should be provided as well.  None of us expats knew about the displeasure among the other staff and the event was canceled the last minute.

          Five of us including the driver decided that we would make this our private trip and paid for it ourselves .  It was a two hour drive over bumpy road, passing a few towns which were having their market days.  Kaunjika or second-hand clothes seemed to dominate the scene.  Illovo Sugar Cane Plantation spans acres and acres of land next to the Shire River and this private company has an elaborate system of irrigation, housing, schools healthcare centers, sport clubs in well-kept gardens; a tiny self-sufficient kingdom within Malawi providing many people with gainful employment.

Kaunjika

           Nyala Park is very small and one could go through it in an hour and there were no Big Five.  Two of the three buffaloes ran away during the flooding season leaving one in the park which was difficult to spot. There were nyalas, impalas, kudus, wildebeests, zebras, vervet monkeys and my favorite animals, the giraffes; the two mothers just had their babies ten days ago.  The babies stared at us for a long time.  We spotted a zebra following a giraffe as it was loping away as though the giraffe was its mommy.
 

Giraffe Mom and Baby

          We spread our mat and had a picnic under a forest of fever trees-- a perfect and lovely spot.  Fever trees are a kind of acacia trees with yellow trunks.  Early European explorers mistook them for the cause of malaria fever because the skin of people afflicted with malaria turned yellow.  Ruyard Kipling’s in his “The Elephant’s Child”, a short story in his collection of “Just So Stories” mentioned the fever trees: “ Then Kolokolo Bird said, with a mournful cry, 'Go to the banks of the great grey-green, greasy Limpopo River, all set about with fever-trees, and find out.', when the Elephant’s child wanted to know what a crocodile ate for dinner. I had been to the banks of the great grey-green, greasy Limpopo River in South Africa but I was high up on the platform, safe from the crocodiles.  However I did not spot any crocodiles but indeed there was an abundance of fever trees.

 

The Fever Trees

Mbenje

We traveled south today to Mbenji Health Center.  Like all the other health centers I have visited, it is basically an H-shaped structure with two rows of clinic rooms connected by a corridor.  One row has the OPD, ANC clinic and the maternity ward and the other row the ART or HIV Clinic and the Nutrition Education Unit with the two big cooking grills and hoods which are no longer in use.  The local women set up their traditional three stoned stoves next to the perfectly good grills to cook dried fish for a woman who just gave birth. They were more comfortable with their cooking method than the large modern grills.

          Mbenje suffers the same fate with other health centers regarding light fixtures, rusty beds many of which have no mattresses, clutter and poor maintenance.  It had no water for several months and the water just came on a couple of weeks ago.  The whole building seems sound structurally, however.

          The waiting room of the ART Clinic was packed with mostly women and children, I saw only two men.  Like most HIV Clinic, men seem to be in the minority.  For this clinic most of the women are widowed, some are divorced which just means that the husband left his wife to take a second wife.  There is no legal proceeding.  It is said that a man cannot have sex with his wife from when she is seven months pregnant till perhaps six to nine months post-partum.  It is too long a period of abstinence so many men just take up with another woman leaving their wives to fend for themselves.  A distraught twenty-five year-old woman with her two-year-old girl is in just such a situation, she survives by selling what she grows which seems to be common here.  Women sit or lie by the roadside with a few heads of cabbages, a cluster of tomatoes or potatoes, a stack of wood, a small container of beans trying to sell them to get a few kwacha. Almost all the women who come to the clinic wear no shoes which I was told are too expensive for them.

          As I walked out a little boy caught sight of me and ran away crying.  He was terrified of me, probably his first time seeing a light-skinned person.  Finally in the safe embrace of his grandmother I reached out with my hand which he took and was surprised to find that nothing untoward happened to him after all.  

Nyamithuthu: The Issue is Maintenance

Nyamithuthtu Health Center

          Nyamithuthu is about 30 km north of Nsanje, 5 to 7 km from Tengani.  It sits on the side of a dirt road after we turned off from the tarmac.  Because it is close to Mozambique, like Ndamera, it was probably built by UNHCR for the Mozambican refugees as a result of decades of civil war, first the FRELIMO against the Portuguese and then the anti-FRELIMO movement, the RENAMO when millions of people were killed or displaced.  The buildings were solidly built of red bricks but because of the lack of maintenance the wooden beams holding the roof are rotten in many places, eaten away by the termites.  Before long this will not be a safe place for anyone. 




         

The first section of the building is used by the outpatient department (OPD) which is closed today.  It has a consultation room, an exam/dressing room and a pharmacy in addition to the open waiting area, and a public health room.  The second building houses the HIV testing room, ART room where HIV patients are seen, an open waiting room and the Antenatal Clinic which is also the Antenatal/Labor and Delivery/Postnatal Ward with a total of three beds.  Like Tengani, the light fixtures are mostly gone except that each room runs on one florescent lamp, the last one for each room.  The sinks all have a problem, no faucet or drain pipe, a bucket is used to hold the waste water.  Outside a tap is leaking very severely, clean water is all wasted.  All windows have broken screens and some are missing window panes. The walls and doors of the latrines are also broken and no longer in use.

          The Maternity Ward is being fixed and that is why the ANC Clinic is used for maternity at the moment.  The roof and the beam supports of the Maternity Ward were rotten and infested with snakes and now it has a new roof. Unfortunately work on the ward has been halted and the ANC Clinic is filled with beds for all maternity care.
           The nurse was the sole healthcare provider for ANC, OPD and ART when we arrived.  The Medical Assistant was out for some kind of training.  Because this was a follow-up visit day for the pregnant women, she was able to quickly see them all.  She then had to run to the OPD to see the patients leaving the ART patients waiting.  My mentors began to see patients at the ART Clinic so they would not have to wait for her.  It was not ideal but we were able to have her back for mentoring after she finished with her OPD Clinic.
           The large tent funded by UNICEF was used for cholera outbreak two years ago.  It still has remnants of the makeshift beds with a hole in the center and instructions for fluid resuscitation.  Outside the health center, there was a leaking faucet, precious water streaming out of it at a furious pace forming a large stream overflowing the drain spilling over to the ground. 

Cholera Tent

Chart of Fluid Resuscitation

         Again my companion national commented as we were leaving Nyamithuthu,” Maintenance is always the big problem and MSF can’t fix everything.” 

         

Tengani: Keep the Last Florescent Light Burning

          My team went to Tengani, about half an hour north of here. We passed through grasslands with scattered tall trees fortunate enough to escape being chopped down for firewood, the rest were tiny bushes which suffered periodic chopping and never were able to grow any bigger.  The mango trees fared better since they bore fruits that could bring in some cash although they too suffered some amount of slashing. The baobab trees with their thick trunks challenged anyone to put an axe to chop them down.  They were attacked only when the hollow ones fell during a storm and the locals had a slow burn of the trunks to make charcoal for sale.  

          About a hundred meters from the tarmac road ran the defunct railway track.  This track started from Lilongwe, the capital all the way south to Mozambique.  The driver said trains used to travel from Limbe to Nsanje but two years ago it stopped because the Shire River flooded and destroyed the track.  Over a dry riverbed part of the track floated in the air with all its trestles washed away.  A vandalized train station with no roof and broken and mildewed walls stood forlornly by the track.  It looked as though it must have been more than two years since the train stopped running.  The driver assured me that “they” were ready to fix the tracks soon...I took this in with a large grain of salt.

          In the hot sun some villagers sat or stood by the road sides selling small amounts of produce; a few papayas, a cluster of tomatoes; on the opposite side of the road, someone just left a small basin of beans with a scooper for sale to passing buyers.  Vehicles were few and far between, one wondered how many kwachas were they able to collect selling such small quantities of goods.
           At the sign of Tengani we turned off from the tarmac to a dirt road and soon passed a cluster of buildings marked Nsanje District, Agriculture Office, Resource Center.  The windows and doors were broken, some windows were just literally ripped off the buildings; it was obvious that no one worked there anymore.  In the afternoon when we passed by again, a truck had just delivered forty to fifty sacks of something stacked neatly on the veranda of one of the buildings.

          Tengani Health Center was in an enclosed compound. One huge chunk of the eaves was missing and another hanging precariously from the roof, it was only prevented from falling off by a vertical drainpipe and another hanging precariously from the roof.  There were two rows of buildings.  One housed the Men and Women Wards which were no longer working as wards, outpatient Department (OPD), the antenatal clinic and then the Maternity Ward which was divided into the Antenatal, Labor and Delivery and the Postnatal Wards.   A broken roof beam in the OPD was splinted together with metal bars from parts of a wheelchair and dangled dangerously over where the patients sat. 

Tengani Health Center

           The six rusty beds in the Antenatal Ward were without mattresses, the mid-wife told us they no longer used it.   On the floor was a sterilizer looking somewhat abandoned but it was actually used for sterilizing instruments.  There were six pairs of florescent light fixtures but only one lamp left, some fixtures had wires hanging out.  When the lamp from the other wards burned out, the lamps from the Antenatal Ward were systematically stripped leaving it with its last lamp.  The counter of the two sinks in the Labor and Delivery room was cluttered with a baby scale, rags, basins, and used instruments.  It had two beds and it did not look like it was ready for the next birth.  On the wall of one of the cabinets was a hand-written note on “How to Deliver a Baby”, there was a notation about providing a clean, warm and well-lit space for the newborn…The postnatal Ward had four beds with mattresses and bed nets.  The floor was sparklingly clean and there was no bad odor.

The Antenatal Ward

          The mid-wife in the antenatal clinic dragged out the one-year-old brand-new unused sterilizer from the storage room which was dark as there was no light bulb in there.  The sterilizer had a plug that did not fit the wall socket and so it was put back in the box and stored.  Already the hands on the temperature gauge were broken.

          Her crowded exam room had a florescent light which did not work.  She used a water tank with a spigot for hand washing.  When I asked her whether things had improved or deteriorated for the three years she had been there, she paused and said, “Things have been changing.”

            “Are they changing for the better or for the worse?”

            “It’s better.”

            “In what ways?”

            She paused again and answered, “We didn’t used to have mattresses on the beds.  A local politician bought mattresses for the Postnatal Ward and the Labor and Delivery Room.  The women are more comfortable now.”

            “But you don’t have mattresses for the Antenatal Ward.”

            “We don’t use it.”

           Apparently a request had been made for more florescent lights but this had been on hold because of a plan to eventually switch to energy saving light bulbs.

           I asked, “What happened when your last light went out?”

            “We ask the patient’s guardian to bring candles.”

            “You deliver by candle light then?”

            She laughed.  I peered at this patient, long-suffering nurse who worked under such distressed condition and yet survived each day on the last leg of a florescent lamp.

          A national commented, “Maintenance is a big problem.”  This is not unique to Malawi, it is a common and chronic problem in Africa. He continued,” It will drain the whole budget of the district if funds are given to maintain this place.”

          We observed the mid-wife taking meticulous care of each and every one of her pregnant woman, unhurried even way past the lunch hour.  Mozambique is to the east of Tengani, Mozambicans cross the Shire River in dugout canoes and walk about 5 km to the health center. Here the Sena people live in Malawi and Mozambique and they speak a mixture of Chichewa and Sena. The boundary between the two countries blurs.

            

Outside the mid-wife’s room her patients sat on a bench, on the floor or lay on chitenjes (wraps) waiting patiently for their turns to see her.  Every single one of them had been tested for HIV. In any country patients would be up in arms to have to wait so long to see a doctor.  Here in Africa waiting for a long time is the norm.