Language corner

I'm about to make a comparison between Malawi and the US, which is something that I had vowed not to do in this blog. Of course, travelling from one of the poorest countries in the world to one of the richest is going to be a culture shock, but the differences between the terrains, the lifestyles and the healthcare systems are obvious. An entire blog of 'when you stand in Times Square and think about the powercuts in Malindi...well...yeah...' would get really old, really fast.

There is something I hadn't thought about before though, and that's the differing attitudes to language. In Malawi, there are two 'official languages', English and Chichewa. On top of that, there are several tribal languages - the one we were most exposed to was Yao. As far as I could tell, the diversity of language was treated as part of the fabric of Malawian culture. It wasn't unusual at all to be mutilingual. Very small children were able to speak to us in basic English. Although we had a serious language barrier with a lot of our patients in the village, this seemed to usually be a marker of poor access to basic education. After a while, in fact, I think that everyone found it amusing that it was taking us so long to pick up Chichewa. As far as I could tell, the attitude was 'everyone has a different first language, so if we can all make ourselves understood in a few languages then everyone can communicate.' Of course, I'm over-romanticising it a bit - the necessity for speaking English, along with the coming together of tribal languages is rooted in a difficult colonial history - but it's still a skill and an attitude to language that I very much admire.

To me, this intermingling of different languages is equally apparent in New York City. It's fantastic to wander around and hear people speaking Spanish, Mandarin, Hindi, Polish - diversity is part of what makes this city amazing. Yet, I don't get the impression that there's as much of an imperative to learn other languages as there was in Malawi. For those of us who have English as a first language, we always use the age old excuse 'I know it's lazy, but everyone speaks English.' While that is largely true, I think it goes beyond that. I think, both here and in the UK, that we are far too attached to the idea of a language hierarchy, with English at the top. We're very lucky to have the global language of business as our first language, but but perhaps that's just not enough of an excuse any more.

I'm completely guilty of this too - I love languages, but I've been a bit lazy about learning them. I just think it's time for a bit of a cultural shift. I'd love to hear what you guys think.

Buenas noches amigos (I admit, I had to Google the spelling of that. I'm working on it.)

We'll turn Manhattan into a isle of joy...

New York City had a lot to live up to - I've been excited about coming here for the better part of two years. Somehow, however, everything has surpased my expectations. As you can probably tell from the lack of blog posting up until this point, Dan and I have really been getting the most out of the city. Ironically, the increased availability of electricity and internet access has coincided with a decrease in the amount of time that we have to update the blog, but rest assured - we're having an amazing time!

For the moment, I'm not going to detail everything that we've been doing in our spare time. I'll probably do a detailed description of the delicacy known as Korean fried chicken at some point, but I'm currently resisting the urge. Instead, I'd like to talk about medicine for a bit.

So that everyone is up to speed, I'm in New York doing a placement in paediatric (I still refuse to spell it the American way) endocrinology. If I'm honest, I was expecting to feel a bit smug about the UK way of doing things. Anyone who knows me and my 'liberal agenda' knows how attached I am to the NHS, and I am willing to admit that I came into this placement with a prejudiced view. I was semi expecting to claw my way to work through hoardes of people begging for health care while doctors inside the hospital feed grapes to rich people who are being carried around on sedan chairs.

Although there are significant problems with the US healthcare system (and several things that they do better than the UK), the similarities between the styles of medicine really took me by surprise. Here, in the UK and even in Malawi, the desire to make sick people healthy - as simple as it is - seems to run through at a very fundamental level. The methods are different, the obstacles are almost incomparable, but it appears to me that a lot of people across the world went into the medical profession for similar reasons.Whatever my observations about comparative healthcare and international health, the last five weeks really have cemented my respect for healthcare professionals, and I'm honoured to count myself among them.

In other news - I love people's reaction to my British accent. I know we're meant to find it annoying, but it's quite nice to be complimented on it as if it's some sort of skill. I think I've started milking it a bit, I may well start overdoing it if I'm not careful.

Pip, pip and cheerio chaps.

A sad goodbye

By our last day at Nkope, we felt as though we had been there forever. As we packed and went around the hospital taking endless amounts of photos, it was hard to believe that we were potentially seeing this place for the last time. In the afternoon, as we were saying a final goodbye to some of the kids in the village, we got a call from St Martin’s inviting us to spend an evening at the hospital before we left. This felt like a fitting end to our trip, as we hadn’t been able to see St Martin’s since our first day.

I don’t know what we were expecting when we got to the hospital, but we were genuinely speechless when we arrived to a massive outdoor farewell party. As well as all of the people who had become friends with during our stay, several nurses, administrative assistants and other members of staff had come to wish us well. It was unbelievable. There were several speeches throughout the evening, including a rather unprepared double hander from us. We were also able to formally present the hospital with all of the things that we had brought from the UK – largely an assortment of needles, syringes and gloves, as well as books, toiletries and a laptop. The money that everyone so kindly donated through the Come and Sing Haydn’s Paukenmesse was spent on theatre equipment, which the hospital really appreciated. Unfortunately the equipment hadn’t arrived by the time that we left, but St Martin’s should be receiving a large batch of theatre blankets, aprons and sterile shoes at some point during the week.

 As we drove away from St Martin’s the next morning, both Dan and I were quite emotional. Our time at St Martin’s gave us an incredible insight into a world that we otherwise wouldn’t have been able to imagine, and (more importantly) we made some amazing friends that we’ll never forget. We’re planning to keep sending basic equipment to the hospital at least twice a year, and we’re really hoping to go back in the not too distant future.

Thank you St Martin’s – it’s been amazing.

A jumble of thoughts from the warm heart of Africa...

11^th April 2012

As we’re coming to the end of our placement at St Martin’s hospital, I thought I would give you all a rundown of the things that have happened over the last couple of weeks.

The absolutely wonderful thing is that Dan and I have had a baby named after us! Little Danielle (probably not spelled that way – no one here has worked out how to spell my name yet) was born about a week ago, and was my first delivery at Nkope. Although things were nowhere near as eventful as they were during Dan’s first delivery, we clearly made an impression, as the mother came to our house a couple of days ago to let us know that she has named her daughter after us. I can’t describe how honoured I feel. There are a lot of downsides to working in the medical profession, but moments like this make it all worth it.

We’ve been experiencing frequent power cuts over the past few days, which Dan referred to in one of his last posts. This has led to long periods of quiet introspection, mainly because Dan and I have had to rely on each other’s conversational skill for entertainment (seriously, it’s been a stretch :D). Before we got here, I knew how lucky I was in comparison to most of the world’s population, but the last three weeks have really brought it home. A good example is the reaction of both Dan and myself to the food here. Although it is yummy (genuinely, there is a type of dumpling that has just become addictive), both of us completely took for granted the level of variety available in the UK. In comparison to the rest of the village I imagine that we’re eating really well, but the sight of Cadbury’s in Blantyre actually rendered us speechless for a moment.

 What has amazed me is the way that people in the village just get on with things. For instance, the fact that electricity here is so unreliable means that almost everyone gets up before sunrise to make the most of the daylight, and that there isn’t a siesta culture despite the oppressive heat in the middle of the day. Although everyone is (understandably) angry about the fuel crisis, there seems to have been a general acceptance of the fact that getting in and out of Nkope is difficult. I imagine that once I’m back in the UK I’ll be back to complaining about 8am ward rounds and getting cross when the local supermarket runs out of cinema sweet Butterkist, but I hope that my perspective has changed a bit. Either way, I definitely intend to stay in close contact with St Martin’s, and I hope to return in the near future.

One of the things that I will miss (along with the dumplings, the sound of Lake Malawi, and the odd, safe sensation of sleeping under a mosquito net) is the wonderfully friendly nature of a lot of the people that we have met here. They definitely call Malawi ‘the warm heart of Africa’ for a reason. It feels like everyone in the village has really tried to make us feel welcome, and we really have made some lovely friends.

Danni 

The day that Danni nearly crushed a duckling and other short stories

Friday March 13^th

Leaving Nkope was a pretty sad affair. We were given very little notice, and so we didn’t manage to say goodbye properly to everyone that we wanted to. Clara, the amazing midwife wasn’t in but we left gifts for her with her house-keeper [who didn’t speak a word of English] and some of the kids who we would play with were just nowhere to be seen. James, our legendary cook and his beautiful young son Ishmael, were coming with us to Malindi [where St Martin’s Hospital is based]. Driving through the village for the last time was poignant.  We drove past the market where we would go every day to buy food or essentials [such as deep friend doughnuts, or kilos of kidney beans] and lots of people waved us off.

Arriving at the hospital was so strange. 3 weeks ago we’d been horrified at how basic and crumbling the place was, but with rural village health centre eyes it looked almost modern now! We were thrown a really love leaving party that Danni will talk more about in her blog post, and we had some interesting discussions that really hit home just how different our lives were.

• “In England, do you have villages?” Why yes, yes we do. “So people live in huts made of mud with thatch straw roofing then?” Dear lord, no. To us, rural means surrounded by greenery and not too near a city. There are still tarmac roads, often a train station, constant electricity, usually broadband internet, landline phones, plumbing and usually a village GP. Peoples mouths gaped open in disbelief.

• “So, there are no power cuts?” Well, occasionally one house will lose it’s power due to a fuse problem and once in a blue moon a street will go dark for 20 minutes, and it will make headline news in the local paper. In general, we take electricity for granted – it never cuts out.
• “Here in Africa, many people present to hospital late because they trust traditional healers much more. A child died this morning because they turned up to hospital when it was too late. Do you have spiritual, traditional healers in the UK?” Err….not really. Most people trust doctors and will see a doctor in the first instance. One of the many reasons our health outcomes are so good.
• “So do you ever have shortages of gloves in hospitals?” Oh my gosh, we are SO lucky in the UK. Women at Nkope health centre over the weekend had to give birth without midwives being able to perform vaginal exams because they had so few gloves that they just had to guess how dilated the woman was. Any woman in obstructed labour would have died.
• “So, do houses look like this in the UK?” Well….no. <cue me showing a picture of my house, which is exceptional even by UK standards but it’s the only pictures I had> “Wow. You live in heaven! And there are really only 4 people sharing that entire kitchen? You have more than one bathroom in your house?! You own your own car?”.

I’d felt pretty embarrassed after I’d shown them the pictures, but it really hit me just how far away from home I was.

We then danced the night away, woke up early to catch a minibus [read: rusty sardine can stuffed with too many people] to Lilongwe, the capital – another experience that Danni will fill you in about.

I’m sure you’re wondering why the title of this blog post is “The day that Danni nearly crushed a duckling…”, and now that I’ve grabbed your attention for long enough, I’ll tell you. In our little compound in the village lived a family of ducks. Their ducklings were freakin’ adorable and so we tried [and often failed] to pick them up and stroke them. Danni finally managed just before we left but the little ducky didn’t seem too happy. She tried to put it down, and as she did so she dropped the heavy [!!] bag from her shoulder and missed the little fluffball by several centimetres. That would not have been a nice way to end our village experience. Thankfully the duck was fine to live another day.

Thanks for staying tuned – I’m quite enjoying the blogging lark!

Much love,

Dan

Angry Birds – A Universal Language

Wednesday April 11^th

This is a slightly more light-hearted blog post.

Some of the local kids [including our cook’s son, Ishmael] found my iPhone. It’s a testament to how easy they are to use that within 3 minutes they were sat round playing Angry Birds – and LOVING it. They don’t speak a word of English, as none of them have started school yet. It’s a brilliant testament to the user interface of Apple products that even young children in rural Malawi who have never touched, let alone seen, a computer before can work out how to play games on one of their products in 3 minutes.

Not the most insightful post perhaps, but it’s been fascinating to watch.

Dan

P.S. For those of you who’ve never heard of Angry Birds – shame on you!!

My last day at the Health Centre

Wednesday April 11th

I can’t believe that time has passed so quickly! It’s the morning of our last day.

I have mixed emotions. Whilst I could never live like this for an extended period of time, I will miss it. Listening to the waves of Lake Malawi crash onto the beach 15 feet from our house, being able to leave our door unlocked during the day and having people stop by all the time to say hello. It’s nice.

Life is very hard for people living in rural Africa. They work long hours in awful conditions with little to no chance of being able to leave their village. I’m so glad that I’ve gained some insight into this. It’s easy to read about it in articles [or blog posts!!], but to experience it is something very different. If you ever get the opportunity, you should take it!

I have huge amounts of admiration for all the hospital staff, working in appalling conditions to provide pretty darn good medical care to their patients. I’ve learnt a lot about professionalism and that many [most] of the things I complain about are like the colour of the icing on top of the cake, whereas here in Malawi they don’t even have enough flour to bake at all. [OK, weird analogy – it sounded better in my head].

I hate to use clichés about “life-changing experiences”, because I know that ultimately my cushy life won’t change. Even as a student on no income, I am rich beyond everyone in this village’s wildest dreams and that won’t change. People here will still be the poorest people on this planet, and I will still be one of the richest. What I hope will change is my ability to help. Danni and I want to send twice yearly shipments of basic equipment [gloves, syringes etc.] to the health centre [please make sure we do it!], and I want to get more involved with development charities. To my friends back in the UK, prepare to hear a lot more about poverty and how you can help.

Today will mainly involve taking more pictures of the village and the health centre to show you guys, giving out presents and also saying goodbye. Tomorrow we present the equipment that we have bought and then on Friday we go back to Lilongwe, the capital of Malawi, to prepare for our flight to Cape Town and to buy lots [an unnecessarily stupid amount] of touristy wooden carvings and paintings as presents for people.

My humble thoughts about Development

Tuesday April 10^th

My trip to Malawi is the third trip that I’ve made to Sub-Saharan Africa, and one of several more to the rest of the developing world. Since my first trip to Ghana in 2007, I’ve thought a lot about “International Development”, what the main problems are and how I would tackle them if I were ever fortunate enough to be in a position to do so. I’m obviously no expert, but here are my views:

Roads and Electricity. I believe that the poorer regions of Africa will fail to fully develop until it gets a handle on these two factors. They affect everything.

Every single village and every single person should be easily accessible with good quality, tarmac roads. Many rural villages in different parts of Africa are only accessible via dirt roads, which are susceptible to weather conditions and are often in such a poor state that motorized vehicles can’t gain access. This means no ambulances if people are sick. No exporting vegetables or other resources, to make money for the village. No importing building materials, people or money. A single tarmac road leading to every village in Africa would allow greater access to healthcare, to schools, to towns and to transport. If I were to give money to a development charity it would be one that is determined to lay tarmac roads to villages everywhere.

How can anybody function properly when electricity can cut out at any moment? Everywhere that I’ve been in Africa has had issues with electricity being scant. I’m not an electrician and I do not have a mechanical brain so I cannot understand why this happens but it needs to stop. Imagine if a surgeon was half way through your operation and the power cut out. No lights, no anaesthetic machine, no nothing. You’re dead. Speaking of dead, the president of Malawi died last week. His body had to be flown to South Africa as not a single hospital in Malawi was capable of keeping his body refridgerated. Sad.

We live in a digital age, and with digital technology comes an increased requirement for electricity. If city office workers, internet café owners, supermarkets, health centres etc. can’t run properly because of a lack of electricity – it costs millions of pounds to the economy.

Having had to experience poor roads and numerous electricity cuts, my personal opinion is that if these 2 factors were sorted out, everything else would follow. People would have more of an incentive to keep to time, healthcare outcomes would improve massively, vehicles would be better maintained [and might actually become safe], tourism would flourish and the economy would make these countries so much richer, giving them the freedom to develop.

I’m sure many of you have more sophisticated views than mine. I’d be interested to hear what you think?

Much love,

Dan

The times, they are a changing...

7^th April 2012

We’re currently in Blantyre, having a little city break (of sorts) in the economic and cultural capital of Malawi. As you can imagine, the journey from Nkope was far from easy. We had to get up at 5am on Friday to make sure that we reached Blantyre at anything resembling reasonable o’ clock. While we were waiting for transport from Nkope to Mangochi, we discovered that we weren’t the only ones who had had an unsettled night’s sleep. Everyone had been up listening to the radio, because the news had come through during the wee hours that the president had suffered a cardiac arrest and had been flown from the hospital in Lilongwe to one in South Africa. We later found out that he had died.

I don’t know anyone has been following this in other parts of the world, but the strange thing is that any of you watching the news would have known about the president’s death before a large proportion of the Malawian population. Those of us with access to the international news sources found out fairly quickly, but it wasn’t declared on the local news until yesterday (for reasons that I still don’t fully understand). The political situation here is already a bit delicate. Speaking to people over the last few days, it has become clear that there has been a lot of dissatisfaction with the government, largely due to the destabilisation of the kwacha, which has put the Malawian economy in a precarious position. Among other things this has caused massive fuel crises for the past few months, and people are now queuing for hours at petrol stations. It will be interesting to see what happens with the cabinet over the next few days. Neither Dan nor I have been in a country where the head of state has died before, so it’s a bit strange. Being in a tourist bubble in Blantyre means that not too much has been affected for us. That said, the Easter weekend when the president dies is not a weekend to try sightseeing. A lot of places have been closed, for one reason or another. 

One of the interesting things has been the reflection on the quality of healthcare in Malawi. Apparently it’s quite unusual for the president to ever be treated in Lilongwe (which is the capital city) and the reason that the president’s body was flown to Cape Town was due to a lack of electricity. Although we’re used to conditions like that in Nkope (the maternity unit was repeatedly lit with candles this week) we were sad to discover that things aren’t necessarily that much better at the hospitals in the big urban centres.

In better news, part of the reason that we came to Blantyre was to start sorting out the purchase of supplies for the hospital with the money raised via the ‘Come and Sing Haydn’s Paukenmesse’. We’ll be presenting the equipment to the hospital on Thursday, and we’ll let you all know how it goes!

Hope everyone is having a great Easter weekend,

Danni 

Disability Digest

4^th April 2012

Any OUSU people reading this won’t be surprised that, having covered womens’ health, I’m moving on to disability. It’ll be the Malawi welfare state next.

I was curious about the attitudes to disability here from the moment we landed – as well as the obvious worries about accessibility issues from a personal point of view, I was thinking about the inevitable crossover between medical care and the spectrum of impairment. I’m happy to admit that the way that disability is treated here is completely different from what I was expecting.

Let’s start with accessibility. Trick question – which hospital is more wheelchair accessible; the world class John Radcliffe Hospital, Oxford, or St Martin’s Hospital in rural Malindi?  OK, ok, to be fair to the JR, I assume that St Martin’s Hospital is all on one floor due to lack of resources, rather than through concern for those of us who can’t manage the stairs. That said, I was very surprised by the amount of ramps at both St Martin’s and Nkope and all of the stairs are both wide and shallow, meaning that a wheelchair bound person could probably get around without too many problems. Again, I’m not sure that this is deliberate, but it is quite refreshing. From my point of view, however, the massive downside is that every hard surface is made of smooth concrete. In wet weather (it’s currently rainy season) this makes the whole place an absolute death trap. Oh well, you can’t have everything.

In terms of the attitudes to disability, my first experience was, of course, how people reacted to me. For anyone who doesn’t know, I often use a walking stick, particularly at work. Having already asked one of the nurses about the prevalence of female doctors in Malawi (there aren’t many), I was fairly certain that I would be the first disabled doctor that many people here had encountered, and I’m pretty sure that they don’t watch House. To be honest, people seem to find it about as strange as they do in the UK. The big difference is that everyone is quite direct about it. As Dan mentioned previously, the idea of privacy isn’t such a big thing around here, which means that no one hesitates in asking me why I use a stick. I have to say, I much prefer this approach. It makes things a lot quicker, just for one thing.

Something that I’m still not entirely sure about is the management of mental illness around here. I thought that we might come across an obstetric patient who suffered from psychosis or post-natal depression, or that there may be mental illness in some of the HIV patients, for instance, but so far we haven’t encountered this. It may well be that these sort of illnesses manifest themselves differently due to the cultural differences, or that I’m missing things due to the language barrier. I’m not sure. What we have seen, however, is the management of a patient with a learning disability. A woman came to antenatal clinic, 16 weeks pregnant. She had been complaining of symptoms of pregnancy and movements in her abdomen, but she wasn’t able to understand the fact that she was pregnant. The nurses clearly had a protocol for managing this sort of thing; they had insisted on her being brought by a guardian, who helped explain the whole process to the patient. Dan and I were impressed that the nurses took the time during the busy clinic to make sure that the woman was receiving the required antenatal care, despite the difficulty of the situation. However, the issue of consent loomed in both of our minds – how had a woman with an impairment significant enough to render her incapable of understanding the concept of pregnancy become pregnant in the first place? Concerned, we asked one of the nurses, who explained that she was married. It would appear that the issue of capacity is not one that is necessarily considered around here, and both of us were very uncomfortable with the whole situation. That said, we are relieved that the patient in question appears to be receiving a lot of social and medical support, and hopefully the situation will be managed appropriately.

Danni

Wildlife Update – Thursday 5th April

The praying mantis has died.

A large funeral procession is currently being held on the floor of living room. The ants are doing a very good job at carrying the thing away. Let us all share a moment of silence. Thank you. BLEURGH.

In other news, our electricity cut out this morning. I miss being able to see my way around and then sit in front of the fan. Now both St Martin’s Hospital [the main site] and Nkope Health Centre [the satellite centre that we’re at] have no electricity.

We’re heading to Blantyre tomorrow [Friday] to determine what we are going to buy with the kind donations given to us by everybody who came to our “Come & Sing” event in Oxford. We’ll keep you updated with what we spend the money on. The hospital has a severe shortage of basic equipment [were it not for the fact that we bought a few boxes of gloves, the health centre would be completely without now], so we’ll see.

Hoping to get this week’s blog posts online from Blantyre, and reconnect with people on facebook and my beloved twitter. Since we’ve had no Internet to entertain us in the evenings [or anything else for the matter], Danni and I have been singing our way through every musical we have on Spotify.

I can’t believe we only have one more week left in Malawi – time flies! A week on Sunday we fly to Cape Town, and then to NYC via the UK for a few days to regroup and do some proper washing up!

Stay tuned to further chart our descent into happy madness.

Dan 

My First Malawian Baby aka “The Day I realized I wasn’t hardcore enough for Obstetrics”

Wednesday 4^th April

So, I delivered my first Malawian baby today. It was beautiful, but my gosh it was scary. Here’s why:

So, I think Danni’s kind of explained to you the conditions of the delivery room here. By UK standards, it’s barbaric. No privacy, lying on a plastic bag on a plastic mattress surrounded by insects and very little else. It really is every woman’s nightmare. The midwives do their absolute best and are 1000% professional and they do an amazing job but really – you would NOT want to deliver a baby here.

Mum was a primigravida [i.e. this was her first pregnancy] and she was 17 years old. She was clearly scared and in a lot of pain. Danni did an absolutely sterling job of comforting her, since nobody else seemed to care [Seriously, this girl will never forget the kindness she was shown by Danni this afternoon].  Her contractions were coming in thick and fast, and the midwife determined it was time to push. “Who’s delivering this one then?” she asked. It was my turn so I gowned and gloved up and got ready. The head was delivering slowly but steadily and as it was coming out I could see some umbilical cord. In the heat of the moment I didn’t think much of it, and the midwife was just looking at something else. She turned back 5 seconds later, by which time we could see that the cord was wrapped around the newborn’s neck. Shit. The midwife acted fast and cut the cord whilst it was still basically in the woman’s vagina. I then delivered the shoulders and then rest just kind of plopped out [like it should]. The baby was floppy. I stood back as the midwife tried to get the baby to cry [breathe]. She wasn’t crying [breathing]. What felt like 20 minutes [but was in fact probably 45 seconds], I stood there limp as the midwife initiated neonatal resuscitation procedures given our woefully limited resources. Thankfully, baby eventually started crying. We were out of the woods….or were we?

“Do you want to deliver the placenta?” “I’ll try”. I gave the woman an intramuscular injection of oxytocin [which helps the uterus contract] and then lightly pulled on the umbilical cord [the end still coming out of the woman’s vagina, which is attached to the placenta]. There was some give and then some tension. I [rightly] handed over to the midwife, as I felt out of my depth. Just as I did so, the placenta plopped out like the bag of Jelly that it is. Then the woman started bleeding. PPH, or post-partum haemorrhage is such an important emergency that it was an entire station in my practical obstetrics and gynaecology exam back in Oxford. Behind the woman’s head was a chart on the wall describing how to manage just such an emergency [since my rubbish memory had forgotten most of it]. 1) Rub up contractions – done. Still bleeding. 2) Administer some more oxytocin – done. Still bleeding. 3) Remove clots – done. Still bleeding. 4) Empty bladder – it was empty. Still bleeding. 5) Put up a litre bag of IV fluids – we have no IV fluids. Shit. Back to rubbing up a contraction and looking for tears in the vagina or cervix. The girl lost over a litre of blood before we got it to stop. I’d never been so relieved. Mum and baby are now both fine, thankfully.

In spite of all the scariness, bringing life into the world is a massive privilege. I can’t tell you how much I appreciate the amazing obstetric care we have in the UK. It makes me even angrier that “free birthers” [women who want completely “unmedicalised” pregnancy to the extent that they don’t go for scans and give birth alone or with their partners only] are allowed to do what they do. Women in this part of Malawi don’t have access to scans, or even an obstetrician. Their sad options in labour are often “push” or “die”, especially with the current fuel crisis, meaning ambulances are unable to transport women to bigger centres. When birth is “unmedicalised” only bad things happen. Women and newborns die by the thousands. To any woman I know who will ever get pregnant – please take full advantage of every medical interaction you are lucky enough to have. Women here would.

Hope you’re all enjoying life as much as I am!

Dan

RELIGIOUS TOLERANCE

Tuesday 3^rd April 

For those of you that don’t know, we’re working in a mission hospital. This means that the founders were Christian missionaries, and the institution has a religious character.

As a not-particularly-religious Jew, this had worried me before I arrived. I was told that prayers were held every morning before the start of clinic/ward rounds and that prayer and faith were a large part of the institution. This hasn’t really been the case. All of my concerns were unfounded. Prayer is usually private, and so we pray [aherm] in our house before we come to work and religion is barely mentioned, and certainly doesn’t seem to feature in medical practice. They seemed completely unfazed that I’m a Jew and Danni isn’t “particularly religious” [although for the first 2 days she reflexively told anyone who asked her any question about anything, that she was baptized].

The health centre treats unmarried pregnant women exactly the same as married women and abstinence is not the only preventative measure suggested to the local population against HIV and other sexually transmitted infections [hello, condoms]. After all the horror stories I read in the UK about certain churches withholding funding to mission hospitals in the developing world if they go against Christian teaching [read: condoms are immoral and help increase the spread of HIV, don’t advocate their use], it’s nice to see a more relaxed and realistic attitude to public health here.

The best of all is that there seems to be genuine harmony between different religions here [I can’t say I’ve seen many Jews]. From what I can tell, the population that the health centre serves is roughly 50:50  Muslim: Christian and also our neighbours are about 50:50, too. It seems that the attitude is “as long as you believe in God, it’s all good”. It’s a very refreshing attitude, but I think I’ll keep my atheism to myself.

Hi everyone,
Sorry that we haven't posted until now, internet access in rural Malawi is a bit patchy (unsurprisingly)! We've checked into a hostel in Cape Maclear for the weekend - you'll see why further down.

Rest assured that we're having an amazing time and we're both tanned and happy : ). We've written lots of blog posts over the past week, so have a look, they're all posted below!

More soon,

Danni

Living Room Safari aka “I’m A Doctor, Get Me Out Of Here”

[Friday 30th March]

OK. This is getting ridiculous. I kid you not, but we’ve just battled [unsuccessfully] with a giant BAT [yes, a flying rat] in our living room. It’s like a reality TV show where some sadistic producers release larger animals to see how we contend. To save you having to watch this on ITV78 in a few month’s time, I’ll just tell you.

On Monday it was King giant cockroach – HUGE! We’ve started to get along now though. Danni and I just think he’s a bit lonely and is looking for friends. He’s freakin’ ugly, so I’m not surprised he hasn’t yet found any. We now live in equilibrium. I don’t even scream like a girl [or a boy] any more when he says hello of an evening.

On Tuesday it was the Praying Mantis – HUGE!! OK, this one flies and looks deadly. Now, I don’t <think> these creatures are dangerous but they’re bright green and look weird so I naturally assume that even being within 10 metres will cause certain death. Still not used to him.

On Wednesday we met the mouse [read: RAT, but we’re trying to make ourselves feel better] and his family. At least they don’t fly but my gosh do they scurry, and are big and hairy and OBVIOUSLY full of rabies, hepatitis and malaria etc. I’ve kind of got used to them, Danni hasn’t.

On Thursday it was the giant spiders in my room – I think they’ve been there before but with other worries on my mind [cockroaches, praying mantises and rats] I hadn’t noticed. Thank GOD for mosquito nets. Bleurgh.

Tonight [Friday], as I said -  it’s the bat. We were literally just talking of how many animals we’d met in our abode and we see a bat above our heads. We duck [obvious, natural reaction to a flying rat] and then worry about getting too close to the floor lest we meet the cockroaches or floor rats. Sigh. We realize quickly that we can’t just coax it out the door, so we do what any intelligent people do – we run into Danni’s bedroom and barricade ourselves in. That’s where I’m sat now, writing this. Ugh.

We’re going away for the weekend, but I fully expect a lion and a dragon to be sat on the sofa when we get back.

Wish us luck.

Cross your legs girls...

29^th March 2012

This morning, Dan and I got a call at 7am to say that a woman had gone into labour. Having struggled out of our mosquito nets and thrown on some scrubs, we hurried over to the maternity unit, where the nurse in charge filled us in. The presentation of the baby was ‘footling’, which is a rare type of breech presentation where the baby’s foot is the first thing that is going to come out. This is particularly dangerous situation for both mother and baby. To put it into perspective, in the UK this would be an emergency, requiring a specialist obstetrician and an urgent caesarean. By the time we arrived, the nurses had already called an ambulance to take the woman to a larger hospital, as Mkope doesn’t even have an operating theatre, much less an obstetrician. The response over the phone was that neither ambulance was available due to lack of fuel. We were on our own.

By we, of course, I mean the mother and the nurses. I personally was hiding in the corner, with images of a traumatic labour, forceps, horrible tearing and paediatric resuscitation dancing through my head. Your average five-year-old child would probably have been of more use.

As the woman in labour reached full dilation and began to push, my heart leapt into my mouth, and from the look on Dan’s face he was feeling the same. As the first foot came out, I braced myself for 10 to 15 minutes of utter terrified panic. However, within five seconds, the woman had somehow pushed out the entire bottom half of the baby. Before we knew it, a pair of shoulders appeared, followed by a head, which promptly started crying. Somehow, this woman had managed to give birth to a breech baby with almost no assistance, within the space of about 40 seconds. We were stunned, relieved, and incredibly impressed.

Want to know the particularly incredible thing? This was done with NO PAIN RELIEF. No epidural, no pethidine, no gas and air. While doing her basic observations, I rubbed her shoulder and said ‘well done’, which felt about as appropriate as giving a thumbs up to someone who had just climbed Everest with no oxygen. Particularly as she didn’t seem to speak much English. Marvelling at the miracle that we had just seen, Dan and I nipped out for a quick drink of water.  Within about 15 minutes, the woman who had just given birth walked out of the labour room and into the post natal ward, fully dressed and carrying her suitcase.

Before the end of the morning we had also seen another woman deliver. This woman had come to the hospital saying that she was in labour, and had once again calmly walked onto the ward. Within minutes she was on the floor delivering the baby, as she didn’t have time to get to the bed. She had walked in and spoken to the nurses while literally in the process of giving birth.

Labour and birth are almost unrecognisable here. This is in no way diminishing the achievement of anyone who has given birth in the UK – having seen the process I absolutely take my hat off to all of you.  It’s just hard to do anything but gape in awe at women who sit through hours of contractions without anything more that rubbing their backs and moving around a bit. According to Clara, the aforementioned (amazing) head nurse, only about 20% of the women who deliver at Mkope scream. I witnessed her definition of ‘screaming’ this morning. Trust me, I made more of a fuss about the mosquito bites. When it comes right down to it, I’m just so impressed with the strength and courage of everyone involved today. Every member of staff and every mother seemed like part of a wonderful team that had banded together to ensure that mother and baby were safe and well, regardless of the difficulties that they encountered.

Also, seriously, no pain relief.

Mothers of Mkope, have a standing ovation.

Danni

PUBLIC HEALTH CAMPAIGNS & CONFIDENTIALITY

[Thursday 29th March]


This is going to be a bit of a mixed-bag blog post, but over the past few days there are a few things that have struck me about working here.

The Malawi Ministry of Health clearly knows what its priorities for public health spending are: Malaria treatment, Anti-retroviral drugs for the treatment of HIV and Maternal Health.  Whilst a lot about healthcare here is disorganized, haphazard and a bit of a mystery [seriously, today I saw the clinical attendant in clinic prescribe amoxicillin for “cellulitis” which was almost certainly just a mosquito bite], the three areas I mentioned at the beginning of this paragraph are astonishingly good.

Malaria treatment is provided free of charge to everybody who pitches up at the clinic. The Ministry of Health has provided the hospital with “Rapid Detection Tests” [RDT] for Malaria, which take 30 seconds to give a result and free LA [The first-line anti-malarial treatment] is then available in well-designed, easy to understand packets. A disease that is potentially deadly has been reduced to the level of annoyance of the common cold [and a few hours waiting at a clinic to get some treatment]. Amazing.

As I’m sure you’re all aware, HIV is a huge problem in Sub-Saharan Africa with nearly 1 in 3 people in Malawi being infected. Whilst HIV [and the subsequent development of AIDS] was almost a death sentence 20 years ago, anti-retroviral drugs have turned this disease into a chronic condition. Not only do these drugs stop people from dying, but they also [almost] stop people from being able to infect others as they reduce the amount of virus in the blood to almost nothing. This is a fantastic public health campaign. Each patient is given free anti-retrovirals in clinic. Lots of details for monitoring their condition are taken on official WHO forms at each clinic session. It was nice to see that unlike in the UK, there was no stigma attached to having HIV. Again, amazing!

Just to quickly mention maternal health. Maternal mortality [the number of women who die around childbirth] should be zero. In the UK, There are usually less than 10 maternal deaths per year and each one is the subject of a huge inquiry. Sadly, this is not the case in the developing world, where it’s much more commonplace. The Health Ministry fully funds the maternity unit here at Mkope. Whilst the conditions are very, very [!!] different compared to the UK, the work here is amazing. Women here have 5 antenatal clinic appointments during their pregnancy and each time is an opportunity for some education. Women sit in groups and are taught the importance of lots of different aspects of their pregnancy and symptoms to look out for that could suggest a serious illness at each clinic appointment. We heard about a new campaign by the Ministry of Health encouraging women to keep having sex with their husbands all the way through pregnancy and then afterwards to stop their husbands finding sex elsewhere, thus containing the spread of HIV. It was an amazingly candid campaign, and whilst I imagine many feminists would hate it – I was impressed at the honesty.

A final word about confidentiality – one of the first things I learnt about in medical school. It is all-important for doctors in the UK to ensure that what our patients tell us is kept between doctor and patient. This health clinic doesn’t quite stick to the stringent confidentiality codes that we do. Several patients are often invited into the clinic room at the same time, a woman gave birth on the floor of the maternity room today [having 10 seconds early walked in carrying her own suitcase] with the door wide open and people watching. Best of all was this afternoon when the village priest was in the consulting room printing off some “proof of baptism” certificates [the clinic room has the only printer in the village] whilst patients were sharing intimate details of their sex lives. Awkward.

A feminist interlude...

26^th March 2012

As anyone who has met me will know, I’m really interested in womens’ health. It was great, therefore, to spend my first day in the hospital in the maternity unit. Off the top of my head, I’m not sure of the maternal mortality rate here, but in countries as poor as Malawi it is usually staggering. The government are clearly trying to address this; the maternity unit at Mkope is government funded (unlike the rest of the hospital), and newborns get free treatment for the first week of life. As far as I can tell, Mkope has taken this funding and run with it, something which really seems to make a difference to maternal health. Every pregnant woman is seen 5 times during her pregnancy and given iron supplements, malaria prophylaxis and a free mosquito net. There is also a massive push for maternal education, both through public health campaigns and antenatal classes. I was able to watch one of the midwives give a class on the signs of certain dangerous conditions in pregnancy, something which is particularly important at a hospital in such a rural area. The whole thing was very different to the way things work in the UK. As the entire thing was in Chichewa, I didn’t follow everything, but it seemed much more didactic – in the UK, the paternalistic approach isn’t seen as appropriate any more. Personally, I found the ‘if your ankles are really swollen, come to the hospital’ approach quite effective.  The public health posters are quite similar in style. One that I particularly liked said ‘a good husband takes his wife to the hospital before the 4^th month of her pregnancy’, which I thought was a really important message, pretty much regardless of delivery.

The department, of course, has to deal with unbelievable shortages – women sometimes deliver on mattresses on the floor, due to lack of space. Despite this, several women that I saw in the antenatal clinic were invited to stay as inpatients because they were near term and lived far away. My admiration for the entire department was cemented on hearing that a woman who had presented with eclampsia (intractable seizures related to pregnancy) had been successfully treated and gave birth to a healthy baby girl.

Update on the mosquito bites – Dan now has two, which I’m sad to say makes me feel slightly better. As much as I don’t want either of us to get malaria, I was starting to feel as though this was some sort of plot by the makers of Anthisan to make me start buying it by the litre.

Danni

MY FIRST DAY AT WORK – MKOPE MEDICAL CENTRE

[Monday 26th March]

I was already awake when my alarm went off at 6.30am this morning. My mind was racing all day yesterday worrying about work. Today would be the first day that I’ve seen and treated patients since becoming a “doctor”.

We arrived at 7.20 and decided to sit under the massive “Oral Rehydration Treatment” tree [picture to follow, or to be found on facebook – it is an epic tree], that provided some shade from the already intense sun. Petre, the clinical assistant, met us and showed us round. I was staying in the outpatients department for the day, whilst Danni went off to Maternity.

I was overwhelmed at first watching Petre work, at how he managed to make clinical diagnoses based on a few sentences of history and a scant examination. By the afternoon I realized that his diagnoses actually fell into two categories – “Malaria” and “Infection in the place where the presenting symptom has developed”. Such fun! The only investigations we could order were: Haemaglobin, Malaria test [RDT] and urinalysis – so when I got to diagnose patients by myself, I really was using my own clinical acumen. Well, either that or just copying Petre by saying every patient with a fever had Malaria. I have to say, it did feel weird prescribing drugs all by myself. Now, I know this may seem unethical to some of you [given that I may have passed finals, but I haven’t graduated yet], but really were it not for me then none of my patients would have got their drugs.

Mid-morning we performed a ward round through the male, female and paediatric wards. It was here that I could truly appreciate how under-resourced and poor this centre was. We met a woman who had been having an asthma attack for 2 days. The centre could only afford enough salbutamol for 4 puffs twice a day. There were no prednisolone tablets, no aminophylline, no nothing. I suggested that perhaps the patient may have a secondary pneumothorax and got a blank look back – the nearest place to get a chest x-ray was 50km away. In England, she’d be back to full health by now, having been fully investigated and treated for free. I love the NHS.

Nurses came in and out of our clinic all afternoon complaining of a lack of syringes [there were 2 left at 4.30pm on Monday], IV fluids [there were none] and staff shortages.

Again – I know this all probably sounds like I’m working and living in hell, but I can assure you that I’m not. For all the drawbacks, the health centre provides good quality healthcare where it can [lots of public health campaigns happen here, and it is fantastic to see!]. After work, myself and Danni walked through the village, and amassed about 50 kids following us! That was fun!

I’m quite tired now, so I’m going to stop typing and I’ll hopefully update later in the week, or maybe write something about the public health campaigns that I just mentioned?

Lots of Love, as always!

Dan

OUR HUMBLE [AHERM!!] ABODE

[Sunday 25th March]
So. It’s not exactly the Ritz.

On the plus side – there are walls, there are distinct rooms, it has windows.  Also, it’s right by the hospital AND right on the shores of Lake Malawi. OK, this kind of sounds idyllic, right? WRONG! :P

[I’ve been sat here for 10 minutes trying to find more positives – I think that’s about it].

It’s the insects that get to me the most. I fully understood, expected and remembered that the physical infrastructure can be poor in Africa [especially rural Africa] and so the fact that some windows are a bit broken, that some doors don’t fit into their frames and that there are constant power cuts don’t phase me. The fact that I just had to stop writing this blog post because a cockroach the size of my foot just tried to crawl ONTO my foot, does. BLEURGH!

Danni went to bed with 3 cockroaches and a lizard, and I had none. Sigh. I’m also only marginally offended that the mosquitos don’t seem to like my blood/skin. Danni’s 34 [at the last count, in 24 hours] bites are staring at my like war wounds that I wasn’t cool enough to get. [Just kidding, apparently they itch like hell and they don’t look too pretty – so YAY!].

If I could find an internet connection fast enough, I would upload some pictures. For now though – stop complaining about a bit of mould on the wall [aherm, my house in oxford] and do NOT complain about not having an en-suite bathroom [although I currently do have one here, I wouldn’t wish it on any of you].

I’m having a seriously amazing time here, in spite of [because of] all this. Our first day at work is tomorrow. We’ve been sent to a Satellite clinic for a week [MKOPE MEDICAL CENTRE]. We are the only doctors there [and really, we are only doctors in the MOST literal of ways – we passed some exams]. A lot of women give birth here, but there are no operating theatre facilities [nor any forceps or ventouse] so if a woman needs a C-section we have to send her by ambulance to Mangochi. The only problem is that the only ambulance has no fuel. :-/ It should be interesting.

lots of love to everyone at home.