Homeward Bound

          Even as I made my way home (about thirty-eight hours of air and waiting time) I read about the unrest in South Sudan with fighting erupting in Juba.  This was touted to be a possible coup as a result of a power struggle between President Salva Kiir, a Dinka, and his Nuer ex-deputy Riek Machar. The rivalry sparked a widespread ethnic conflict spreading to five of the ten states with an estimate of 120,000 people being displaced and most are housed in UN camps and about 1,000 killed.  Unity State where I volunteered last spring, a Nuer territory, is now occupied by rebel forces capturing the city of Bentiu.  The peace in South Sudan is very transient and fragile.  My e-mail to Johnson with whom I worked in Unity went unanswered, I hope he is safe.

Nelson Mandela in Parliament Square, London

          I had an eight hour lay-over in Heathrow.  So I took the Underground into Leicester Square and wondered off to Trafalgar Square.  In front of the South African Embassy was a makeshift memorial for Nelson Mandela who just passed away a few days ago.  I revisited a few familiar places in central London for old time’s sake having spent a few months in London University many years ago as an exchange student: Buckingham Palace, St. James’ Park, White Hall, Westminster Abbey, and Parliament Square where a new statue of Nelson Mandela was festooned with flowers.   The man who spent 18 of his 27 years of imprisonment in Robben Island still had a big heart to forgive his enemies, “As I walked out the door toward the gate that would lead to my freedom, I knew if I didn't leave my bitterness and hatred behind, I'd still be in prison.”

          MSF-NY wanted me to fly straight to New York for debriefing but I flew back to Boston instead. Having packed no winter clothes on my way to Malawi, I needed to stop at home for some warm clothing.  There was plenty of snow here, a stark contrast from hot but by now rainy Nsanje. The next day I took the Acela to New York passing bleak but crisp winter scenes of New England.  By the end of the day I was exhausted but was elated to meet my son Charles in Manhattan for dinner and then to Penn Station to catch the train to Boston.  I did not find the transition from Africa to US stressful, having shuttled back and forth between the two continents so many times, but I did recall when I first came back from Africa I thought the pace of life here was fast, people spoke way too rapidly and many of them were extremely large.  However the transition from a temperature of 95 degree F to 15 told me that I needed my winter stuff.

Home

Charles and Me at Penn Station, NY

        As I run in snowy Belmont and Cambridge, I remember the children waiting for me in Nsanje along the dusty road in the morning.  During my last run they all said,”Tionana Mwawa” (see you tomorrow). I never did say good-bye to them.

Running in the Snow in Belmont

         

         All my children are home for Christmas.  It is good to be home.

Santa Came

Stockings Hung with Care

Christmas in Belmont

Farewell to Nsanje, Malawi

         
          Jacaranda has given way to the bright red flame tree flowers, the baobab trees have put on leaves and no longer look bare. The rain which usually falls about now has not come.  The villagers in Nsanje have been hoeing their fields, mainly the women but they have not finished doing it.  Every morning, lines of women with hoes, baskets, and babies on their backs walk to their fields.  In Limbe where there has been some rain, they have already planted their maize seeds and some of them have already sprouted maize seedlings.  I also saw a family working together to plant the seeds, the man hoeing, the daughter placed the seeds and the son covered them with soil using a shoe.

Flame Tree in Bloom

Woman and Baby to the Field

A Family in the Field

          My Mentorship Program will end at the end of this year instead of the first quarter of next year so I have decided after discussion with the Field Coordinator that I would not come back after the holidays.  The last few weeks have been a whirlwind of activities: HIV training for the healthcare facilities, TB/HIV Integration training for Nsanje District, traveling to the East Bank and finishing up reports and rounding in the hospital. Sankhulani still does not have a functional clinic space but my mentor and I managed to find a bucket with a spigot for the HIV Clinic for hand washing. 

Examining a Patient with Malaria

          I have been itching to leave office work for disaster relief work.  While I have been here I have missed being sent to the Philippines for the typhoons, Syrian and the Congo refugees.  After a respite at home with my family for Christmas as everyone will be home for the first time after two years, I will be heading to the Philippines for the typhoon-affected people and I hope to visit my family in Penang, Malaysia on the way.  Perhaps when I return I will plan on going to Lebanon for the Syrian refugees.

 

The Kids Running with Me

The children Waiting for Me during My Morning Run

        Yesterday the national staff organized a farewell party for me and Kuyvina was brought from Shire House to the party as a surprise.  As the party started, rain drops began to fall.  One of my mentors gave a nice farewell speech and it was about my not afraid to speak my mind and be open and honest.  My last morning in Nsanje I went around in the village giving the children some little presents and biscuits as the rain started to fall.

        What I will not miss are the many long tedious meetings which usually do not begin on time and last at least three hours, the numerous reports, monthly, quarterly or whenever reports, the argument about who should have access to the database (I could not care less if I were not given a password, and how does one write a report without access to the database?), the half-hearted or no contribution from the people who work for the Ministry of Health, the perpetual problem of  their demands for allowances, the entitlement to them when they are asked to go for training or to collaborate with MSF, the demand for the rights of traveling in a private car with a personal driver by a public servant  and of course the entire bill is to be paid by MSF in addition to getting a daily allowance for food, lodging, and stipend...I will not miss seeing a string of chickens being strung on bicycle handle bars upside down and goats tied onto bicycles with bended knees in the most uncomfortable position on their way to the market, with the goats bleating in the most piteous way.
 
          I will miss greeting the Malawians in Chichewa which does not fail to bring a broad and ready smile on their faces, my runs in the village when I feel like the Pied Piper of Hamelin with the children running after me, the children whom I have taught to “high-fiving” with me, Malawians’ habits of interchanging “r”with “l” (for example exactry for exactly, and the guard Alan, asking me, “Doctor, you didn’t do you lun (run) this morning?”), the support national people who take great care of us, my mentors whom I have gotten to know very well and have a great deal of fondness, regards, and respects and I wish them well, the birds that chirp various tunes around Shire House, Roger and Volcano our guard dogs and most of all the Shire House cat, Kuyvina Mavuto. 

My Mentors and Me at the East Bank

Roger and Me

Kuyvina and Me

          And so I bid farewell to Nsanje, tsalani bwino!

  

Nsanje Boma, Village and the Children

         
          Nsanje Boma is a very small town center with two tarmac roads running through it and some secondary dirt roads.  Love and Peace Supermarket is their biggest market but almost all the products are displayed on shelves behind bars. One can only view them for afar and point to the products that one wishes to purchase.  There are a few bars and restaurants, Folly Brothers Shop, True Man Executive Barber, Praise God Shop, Chikondi Restaurant, Miss Call Bar... In front of the Nsanje market are women selling beans and rice.  In the market one can find tomatoes, onions, potatoes, pumpkin leaves, peppers, lemons, limes, bananas, sweet apples, green beans, eggplants, fish (dried and fresh), meat, eggs, hardware stores, textiles from Malawi and Tanzania.

 

Nsanje Boma Market

African Doctor

          Near the entrance is a store of an African doctor, Peter.  He sells all sorts of roots, bark, and porcupine and snake skins.  One can either have him brew a concoction right on the spot after the recounting of one’s symptoms or take home some herbs, roots, etc. with instructions on how to prepare a brew. 

Nsanje Boma

 

Along the dirt road vendors sell second-hand clothes, shoes, Chinese made plastic products: buckets, basins, clogs and flip flops.  Wednesday is their market day and the dirt road is completely filled with vendors. We could not wander around in the market without a following of children asking for money.

Within minutes one would have gone through the whole town but we are happy that we could find enough variety of food to sustain us.

This morning I packed some four-day-old rice in a tupperware to feed it to the chickens during my run before Peter, our housekeeper, threw it away.   As I saw chickens rummaging in the dirt and leaves for food, I sprinkled some grains of rice, that quickly attracted a few dogs.  Unbeknownst to me soon my action was observed by several children who chased after me.  I ran faster than them and soon they were left behind.  I hid the rest of my rice in a bush to retrieve it on my way back.  When I returned the children were waiting for me and the oldest of them all said, ”Rice” as he looked at my tupperware.  Then I realized that he wanted my rice.  When I gave him the container he quickly wrapped it against his body with his shirt, there was obvious delight in his eyes.  These were a bunch of very hungry children, I was being insensitive in sprinkling rice at the chickens.  I let the children listen to my ipod and there was amazement in their eyes.

I ran home and packed the rest of the left-over rice in a bag and ran back, left it near an embankment in a village as I waved to the children who would probably find it.  A few days ago I saw a plastic bag of bread rolls in the garbage pail in the kitchen, I was tempted to retrieve them to give to the dogs or birds. Often food is being thrown away unnecessarily in Shire House. Living in a walled-in compound we often forget that outside our artificial world live many people who are perpetually hungry.  Children walk to school probably with hungry stomachs, a few lucky ones suck on a mango when mangoes are in season.  

As I ran with the children, some yelling from the village ”Mzungu” , I started to teach them to chant ”Akuda”(Chichewa for Black People).  The grown-ups sitting outside their huts just laughed and waved. 

Ruminations after Quarter Three District Health Officer Presentation

          This was my first quarterly presentation.  I was given a copy of the power point presentation of quarter 2 as an example of what to be expected for the presentation. No one told me the objectives of this exercise but I gathered that it is a forum for updating the quarterly data but more importantly it should also be a place where constructive action plans should be put forth for the fourth quarter although already one month late since the report was scheduled a month into the fourth quarter.

          Even before the meeting, MSF staff was busy preparing the data for the presentation.  The MSF data persons made several trips to the East Bank to gather the final bits of data.  I worked on my mentorship part with my mentors and learned that in the past MSF prepared the presentation and the Ministry of Health (MOH) staff presented because this was supposed to be a collaborative effort.  Already this was sounding all wrong to me.  The preparation should be a joint effort but that I was told this could never be accomplished because the MOH staff has generally not be able to rely upon to appear to work on a project.  So eventually the following scenario develops: the MSF staff succumbs to time pressure and analyzes the data, makes them into pretty slides, outlines the challenges, the accomplishments and the action plans all without the input of the MOH.  Is this really a collaboration?

For this third quarter, a day or a few days before the presentation after numerous phone-calls, text messages and e-mails, you asked nicely, cajoled, reminded the MOH presenters they needed to go over the slides with you before the day of presentation.  Even after all that the HIV coordinator warned me that he might not be able to come to present, he might have to ask the ART coordinator whether he could kindly do it.  I often wonder why you need a HIV and an ART coordinator, why can’t this position be held by one person?

What are the reasons behind this MOH staff’s inertia? Is it because through experience over the last few years that MOH staff has learned MSF will follow through and not fail to present a finished product even if they themselves (MOH) don’t lift a finger?  Is it because of a lack of commitment? Is it a leadership issue?  Or the universal issue of ALLOWANCES? Would they come and knock on our door to help prepare the presentation if we said we would offer a handsome allowance? In my long discussion with my staff, it is all the above and perhaps some other unknown reasons.

MSF has always taken the leadership role in this supposedly collaborative effort.  My observation of the mentorship program in my first couple of months here gave me the distinct impression that MOH mentors are just as content to let MSF lead and they themselves take the back seats. The mentorship program started in 2011 and I came in at the end of quarter 2, 2013. Initially MSH and MOH were supposed to jointly come up with a monthly work plan but now it has become an MSF originated work plan, waiting for MOH staff to work together to formulate one did not succeed.  They either did not show up or assumed that someone would.  Days, weeks and even months would pass and nothing concrete would come about so by default MSF filled in the GAP. Even now the HIV coordinator has not been able to assemble his mentors and he himself has been known not to show up for meetings that he arranges.  There is a lack of commitment on the parts of the MOH mentors and a lack of leadership on the part of the MOH Mentor of Mentors (MOH MOM), their hearts are not in this program.

When MSF still provided an allowance which ended at the end of September MOH staff clamored at the door of the mentors’ office for a copy of the work plan which they did not work on and so had no clue what MSF mentors’ objectives were for the month.  When allowance ended MSF mentors now in turn have to ask if the mentors are coming with them to the health care centers to mentor and inform them when they are being scheduled.  There are often excuses for not being able to come: too busy, sick and not feeling well today, just back from Blantyre and now in the middle of doing her laundry.  These are all true excuses that we have heard so far.  MSF mentors have even asked point-blank why they are not coming.  One answered, “I’d come when there is money.”

In November, we start a series of training through lecture presentations in the health centers, again the preparation materials were all done by MSF mentors.  MOH mentors are slotted in the training but everyday we have to ask them whether they would come to review the slides with us and whether they would be coming to jointly do the training, the answer is, you guessed it.  So at the training we dutifully remind the health centers personnel that this is an MSF/MOH effort but where is the MOH representation? 

And so I digress.  Back to the third quarter District Health Officer (DHO) presentation, as is often the case the meeting started almost an hour late.  All MSF staff was present and MOH mentors except one whom I later learned that the HIV coordinator forgot to invite her.  He even has trouble remembering all his mentors. The DHO came in to give the opening remarks but did not stay for any of the presentation!  District Nurse Officer (DNO) excused himself around ten am because of a previous engagement in Blantyre and he was quite apologetic.  The (District Medical Officer) DMO did not come until close to the end and asked a few questions and then made the closing remarks.  The main persons from MOH who needed to hear the presentation could not make themselves available.

Was this a useful exercise?  Have we accomplished what we wanted?  What did we want to accomplish anyway? The collaboration here was a good show but not a real one.  We still are trudging along as the bulwark of this mentorship.  The handover for this part of the MOH-collaborated mentorship is at the end of this year, the MOH portion is still taking small tentative baby steps, not ready to walk let alone run on its own.

As we finished lunch at a restaurant, the HIV coordinator said to me, “Next time, don’t arrange for lunch just give me money.”

Happy Birthday Tim!

Tim and the Cookie Monster

Tim and Me in the Garden

         

             Being the oldest has its disadvantages, it means that your parents were likely inexperienced and you would most probably end up being a guinea pig for the sake of your future siblings. In addition your parents were more cautious and stricter with you as well.

            Timothy or Tim as he likes to be called is my first born but despite all the cautious upbringing, he turns out just fine.  I remember looking at all the Montessori schools in Boston and the surrounding areas just to make sure that we found the best one for him when he first started school.  One of the fears that a mother with two boys has is that they may one day want to join the army.  I should have been warned when he asked for a big bucket of soldiers in various poses and spent hours playing with them in his room arranging them in various battle formations. In his last year at the Boston College Law School, Tim announced that he was joining the US Army as a JAG (Judge Advocate General).  He was posted to Fort Bliss in El Paso and was almost deployed to Afghanistan but eventually that was canceled, a big sigh of relief from us but he was greatly disappointed.  Now he is posted to Fort Bragg in North Carolina, much closer to  home. 

Tim in the First Armored Division

          

           Tim is always rooting for his siblings.  When Cara was born he took to her right away, there was no sense of being displaced.  When Cara and Charles ran their first marathon in Vermont, he jumped in the last third of the marathon to run with Cara despite having no previous training in running and coaching her to the finish line.  She would have given up if he was not there encouraging her all the way.  

Tim and His Baby Sister, Cara

          

          The following year in 2007, Tim joined the Legal Eagles Running Club to train for the Boston Marathon.  He and I frequently met for lunch on the weekends and when I learned that he was training for the marathon I was then training to run “the Boston Run to Remember” half marathon. I quickly changed that to a full especially when he said that I could do it if I had run up to 17 miles as one of my long runs in my training while his siblings were more skeptical.  And so we did the 2007 Boston Marathon, our first; he running with the Boston College Law School with the theme of “Running of the Bulls”. Since then Tim has run several marathons despite having a late start comparing to his siblings and he and I ran the New York Marathon in 2009. We share our love for the Boston Redsox and celebrated its becoming the World Series Champion this year.

Tim and Mom Running the Boston Marathon in 2007

          

Tim and Me at the Baseball Game

            He believes in keeping traditions and so our Cape Cod vacation, Thanksgiving and Christmas, that is all family gatherings carry wonderful memories for him.  When he is home for Christmas, there is always a set of things that we all have to do as a family for it to be perfect.

Cara, Tim, Me and Charles at Cape Cod

Christmas at Belmont

Almost a year and half ago, Tim got married to Ju-Lin whom he met in college.  Like me she is also from Malaysia, what are the odds of that happening?  We are all very happy for them and their new adventurous life together.  I am a very happy and lucky mother.

Tim and Ju-Lin

         

My BD Present to Tim from Nsanje

 Happy Birthday Tim!

A Weekend in Limbe and Blantyre

     
          Last weekend I was in Limbe and ventured into BCA village again.  This time I met Ruthie who took me deep into the village through winding narrow dirt paths with haphazardly scattered houses, stagnant pools and stream filled with plastic bags and some garbage, probably ideal homes for mosquitoes.  We were soon tailed by a group of children.  She passed by her mother’s home and finally her own house which consisted of two dark, dingy rooms with only a very small window for the backroom, her bedroom. There was no back door.  The front room was filled with her kitchen utensils, the bedroom had a twin bed with no mattress, and along the wall was stashed piles of clothes.  She lived there with her three children ages three to eight, her husband passed away three months ago at Queen Elizabeth Central Hospital of malaria.  The house had no latrine and she shared her mother’s.  There was no electricity or running water, she had to get her water in a communal pipe.  She pointed to BCA Hill where she cleaned house for a man who paid her 2500 kwacha a week, about $6 US. She took me out of the village via a back route and I shook her rough hand as we parted.

BCA Village

The Children and Me at Ruthie's House

          

Ruthie at Her Bedroom

          Queen Elizabeth Central Hospital in Blantyre has both the paying and non-paying sections, cleanliness, crowding and privacy mark the difference between the two.  Overall it is one of the cleaner hospitals I have seen in Africa.  In the non-paying section, the nursery was packed, mothers sat besides the bassinets where their babies slept. The wards had beds placed close to one another reminiscent of the old Boston City Hospital where I did my Infectious Disease Fellowship.  I chanced upon a neurology ward with six hydrocephalus children; heads so huge that some of them were weighted down by them.  My first hydrocephalus baby I saw was in Cook County Hospital in Chicago when I was a medical student.  The teenage mother did not realize that her baby’s growing big head was abnormal, presuming that it indicated the degree of intelligence of her child.

Queen Elizabeth Central Hospital

Male Ward

Hydrocephalus Child

Me and a Hydrocephalus Child

          I walked across a street to the campus of the University of Malawi, College of Medicine; it looked very clean and new.  Makarere University in Kampala cannot compare with this campus. This is probably all built with donation money.  One wonders when Malawi will get out of the need for donor’s aid.

College of Medicine

That same weekend Erin invited me to spend a long afternoon and evening with a group of fifteen Americans for a Thanksgiving dinner.  I went to Blantyre Market to buy fixings for a salad.  We were from all over the place but at least three of us came from Massachusetts.  There were Peace Corps/Medical people, logisticians, teachers, counselors from different organizations and had stayed in Malawi from a few months to several years.  It was good to feel like being home away from home and among friends.   

Thanksgiving at the East Bank

          A few days ago right outside the gate of Nsanje District Hospital, an old woman, topless with flabby loose breasts, bent down to pick up a mango pit from the ground and promptly delivered it to her mouth to suck it.  A few feet away she spotted a brown banana peel and she picked that up as well.  She was like the many goats milling around there scavenging for discarded edibles.  A frail blind old woman holding a walking stick was guided by a youngster, probably her grandson standing at the door of a store at the filling station hoping to be given something.

This week my team and I are spending our time at the East Bank.  The rain which is expected about now has not come, the farmers are growing anxious.  We stay in Thekarani up in the mountains so the nights are windy and cool. I took a walk our first evening here and lo and behold as my mind was on Thanksgiving I saw three turkeys pecking away by a church yard, the white turkey looked quite ancient. 

Turkeys in Thekerani

          On Thanksgiving morning, children in Thekerani were going to school, many were not in uniform and almost half of the children were barefooted.   Two boys were walking slowly to the market aimlessly obviously they were not going to school.  Another two about fourteen years of age walked with a grown man who carried a sack.  The boys were in shirts filled with holes and shorts that barely clad their skinny bums.  They sat on the curb rather listlessly.  The man reached into the sack and produced two small loaves of bread which he gave to the boys who bit into them slowly.  There was no beverage to wash them down.       

Thanksgiving is a time when we should sit down and count the many blessings bestowed on us: peace in our country, loved ones, family and friends, food, shelter, financial security…I feel particularly blessed when I travel and volunteer in many countries where I witness the daily struggles of the local people for their daily bread, people who are caught up in war and conflict and their lives are turned upside down by them, natural disaster, hunger, famine or people dying because of lack of healthcare.   

            At Great Grand Rounds, we saw a HIV-infected young man who began treatment six months ago came in with signs of meningitis.  He was started on medicines to treat bacterial and cryptococcal meningitis.  He was no longer awake and was drawing on his last breath.  He died shortly after we left him.

            Two people were attacked by crocodiles this past week while fishing in the Shire River.  The man’s arm was injured but he was lucky not to lose it.  However the young lady lost her left arm as the crocodile ripped it off when she reached into the river to catch fish.  A medical assistant estimates that they see about four crocodile attacks a month at the hospital. 

Woman and Crocodile Attack

          As we drove downhill one day from Thekerani to the East Bank, a father frantically flagged us down and asked for a ride to bring his five month pregnant daughter to Thekerani Rural Hospital run by MSF, it meant going back up the mountain from where we just came.  She looked well but he was worried that she was anemic.  She had not had any prenatal care having been hiding her pregnancy from her father as she got pregnant after staying with a friend.  The father was wearing an oversized pinstriped suit, his forehead beading with sweats.  We would bring his daughter and told him MSF restricts us to one accompanying guardian.  Backtracking is not recommended but if we were to go forward she would have to go to Trinity Hospital, a paying hospital.  A few hundred yards later, he yelled out to the driver to stop and apparently another daughter had come from Thekerani to meet them.  She then boarded the cruiser and the father got down, we were under the impression that his home was close by.  Later we learned that father and daughter had walked all the way from Trinity about 15 km to this village to discuss with the man who impregnated his daughter what he planned to do.  As we drove back again we saw him climbing the road towards Thekerani Hospital, still wearing his jacket in the heat.  I felt really bad that we did not realize how far he had walked and he still had a distance to walk to the hospital.  If I had known, I would have broken the rule of one guardian on board.

            Later the same day we took a young woman who was bleeding at her fifth month of pregnancy to Trinity.  Our visit to the East Bank is always filled with surprises.  The bridge that will take us straight to Makhanga in the East Bank within an hour instead of the five hours is still being built and the date of completion has been pushed from November to February.  We drove to see it from the Makhanga side crossing a solid iron railway bridge over the Shire.  This bridge was built years ago and still remains strong. 

The Railway Bridge

The Mtayamoyo Bridge Viewed from the East Bank

          My family is gathering at my son’s place in North Carolina for Thanksgiving.  I was not able to hang out with them on Google video because there is poor intermittent or no internet access in the East Bank.  For a brief moment I was able to skype with them, I was thankful to hear their cheerful voices.    

            This weekend I will gather with Erin and her friends to celebrate a belated Thanksgiving in Blantyre.  Two Thanksgivings ago I was in Dadaab, Kenya where a fellow American volunteer was so lonely for his family that he retired to bed early.  It’s a great blessing to have your family close by and treasure them as much as you can while you have them.

            Happy Thanksgiving!