Who needs power when you've got Batman shoes?

The kids go to an afternoon "camp" run out of the home of a woman we know through Beer'n'Babies (more on this in another post), every Wednesday afternoon, 1:30-5pm. They have sensory play, go outside and run around, and bake things at the end. This last part is a genius ploy to help keep kids coming, as the parents become incontrovertibly addicted to the yummy baked goods. Last week it was molasses cookies; this week, cinnamon buns. Yum!

Those cinnamon buns saved us from dying of hunger after we got stuck in Atlanta-worthy traffic on the way back from one of these camp sessions. It has rained twice in the last 3 days--an unheard of thing during the dry season here--and the resultant traffic was horrific. Not having moved more than 4 feet in 30 minutes, we decided instead on plan B: dinner at a local restaurant. Fueled by cinnamon buns, this plan seemed like a brilliant idea. That is until we had ordered, and the power went out.

Things to know about Lilongwe: cash is king. Credit cards work more than they used to, but mostly only at Chipiku, our fab grocery store

and at some restaurants. We went to Buchanan's, https://www.tripadvisor.co.uk/Restaurant_Review-g293811-d1214832-Reviews-Buchannan_s_Grill-Lilongwe_Central_Region.html

Advantages: chicken nuggets, wonderful gardens, frogs at night, and--you can pay with a credit card!
But when the power went out, I immediately thought: oh boy. Does the credit card machine work when the power is out? We had no cash, because we hadn't been planning on going to this impromptu dinner. Would we have to wash the dishes to make back all the imaginary Kwacha we had spent on this meal?

I asked the waiter, but he did the typical Malawian politeness thing of "nod and smile if you have no idea what someone says and say 'yes, Madam'" so I wasn't sure that he had understood me. Then the generator kicked in and the computer started to work before I could go further down the kwacha-less credit card anxiety hole.

The kids had to go to the bathroom. The generator powered the bar, the restaurant and the kitchen stove (thank goodness), but not the bathroom lights. It gets dark around 5:30 in Lilongwe, and there aren't many street lights, so it was hard to see anything in the bathroom. The glow from the hallway lit the area of interest just enough to enable successful completion of the task for two out of the three interested parties. Agnieszka freaked out and refused to go in; that's when Stas realized that his shoes still do light up, in spite of how beat up they are, and that they are in fact a perfect solution to a power-less restaurant bathroom. He proceeded to dance like a madman, stomping his feet, and light the way for his sister's toilet experience. We all laughed hysterically all the way back to the table. And then the power came back on, we had a wonderful dinner (my request for white wine interpreted as a glass of red notwithstanding), and drove back home in zero congestion.  No cinnamon buns survived the trip.

Being a kid in Malawi is almost as good as being a kid in Pittsburgh

Pure happiness

This post is for the grand- and great-grandparents. You're welcome :)

At Kumbali pretending to be horses

Agnieszka recently confessed that she thinks Malawi is the second best place she's ever been, behind only Pittsburgh. This after a week spent in Paris. Sigh.

Saltcrax...delicious!

Documenting. Serious business.

I'm beyond thankful that the kids have adjusted so quickly to being here. There are subtle differences. Their play now involves pretending to stop each other at police checkpoints, and Stas goes around singing a song that consists of repeating "Mefloquine, Mefloquine, Mefloquine" over and over again. School hasn't started yet, which will be a big adjustment, but overall it's taken a huge load off my anxious parental brain to see them thriving and just being kids here.

Micah also gets to play. Here you see him riding two scooters down the hallway of our house. What you don't see is Stas in running behind, and Agnieszka in front. A regular occurrence, right before bedtime, of course.  

More Kumbali

This is not how they sleep at night...

...this is how he sleeps in the afternoon....

...and in the morning....just not at night ....

Kids contemplating one of the world's best sunsets (according to TripAdvisor, so it must be true!)

Stas getting launched into happiness, and hopefully not into too much schistosomiasis

He is mad that is not Fanta Passion in the water bottle

Looking for monkeys at Cape Maclear

 Stas all alone getting ready to sail off into the sunset :)

Janek with our housekeeper, Aggie. 5 seconds before falling asleep, of course

In praise of skin

This is another work post; apologies if it's too graphic. I want to tell you about dressing change days, and about skin.

Mondays, Wednesdays and Fridays bring dressing changes in the burn unit. This means that every patient—as many as 42, plus the many others who come in from home just to get their dressings changed--line up at the end of the hallway and wait their turn, while 3-4 intrepid nurses unwind and wind miles of bandages, slather ointments, and squirt morphine into their mouths. Except when there is no morphine. Then it’s diclofenac, which is, I imagine, the equivalent of getting a swig of ibuprofen right before you get scalped alive.

Walk with me. From the outside, down a dark hallway filled with people, toward the light at the back and up the stairs, three flights. The staircase is open to the outside and on each flight there's a big window with a view of the city--today it's hazy and hot, so the buildings are distant under a screen of red dirt and smog--but it's not airy or breezy. The stairs are worn from countless people walking up and down it for years, and on the second flight a woman wearing yellow wellington boots is mopping, with a broom that's seen better days and concrete-colored water. On the third floor we briefly bump along behind two policemen, big guns swinging freely, talking exuberantly and walking oh-so-slooooooowly—and finally we arrive on the third floor, and walk down the hallway to 3B, the burn unit.

Before you open the door, take a little deeper of a breath, for you're about to experience that smell. On a good day you manage to take 3 steps inside before it hits--the odor of maize meal cooked into grits-like porridge, or a paste, or a hard cake (nsima); of bodies, urine and boiled cabbage, dirty wounds, feet, doughnuts, and fear--and then you see the mother carrying her five year old daughter wrapped up like a mummy with an IV tube sticking out of her neck--and you feel ashamed for even noticing the smell.

There are six rooms, 4 beds each, lining the hallway to your right.  Linking them is the open breezeway down which you’re walking, which opens onto a shared courtyard where people dry their laundry and family members cook their meals. On the other side of the rooms is another hallway, the khonde, or “outside,” which becomes another long communal room during the months when there are more patients in the unit than there are beds. During the cold season—June, July, August—the khonde is full.

Two boys, aged four and six, one with a bulky bandage around his leg and the other with a belly dressing, are playing with a glove balloon, and you toss it back and forth with them for a little while, their smiles lighting up the day. 

Are you procrastinating? We have to keep walking down the hallway, to the room at the end, where all those people are queued up, since that’s where all the action takes place. Each mother dons a protective plastic gown and gloves and takes the child—the median age here is 3—on her lap. The mothers hold the children down. The first trial begins, that of forcing the morphine into the children's mouths. Most take it willingly, especially ones who have been here a while, but sometimes they purse their lips, or cry, or swat with their arms. It doesn't matter if the morphine trickles inside or outside of their mouths--there is no refill and the dressing change happens with or without it. 

Next, the nurses soak the bandages in saline to help with removal. Since there are 42 patients and 3 nurses, waiting for a complete soak would take way too long. Some of the kids start screaming in the hallway; some when the mothers take them on their laps; some with the morphine; but all of them are screaming by this point. These kids are burned over 10-40% of their bodies, on average; over all possible body parts; in two main ways: they scald themselves or catch themselves on fire. It's the cold season in Malawi, no one has heat at home, and very few people have stoves; cooking happens over open fires, outdoors, and accidents happen frequently. Malawi is burnin', y'all: 

 

Skin gets so much criticism. We stare at our pimples as teenagers and wish them away; at our wrinkling faces as adults, and hate their testament of the passage of time. We scrutinize moles and massage cellulite; we want elasticity and spend millions on creams and lotions that promise to keep us looking young. Even as we enjoy skin's gift of touch, in embraces, caresses, and kisses, we resent and focus on its fragility, its ability to hurt, and too often, its color. We don't appreciate scars. Skin should be blemish-less and baby-soft. Not at all like the skin I see in front of me--discolored, twisted, partially healed, in some cases with the tell-tale cheesecloth appearance of a healed skin graft. This is beautiful skin because it works in its intended way: not as pretty packaging but as a barrier to infection and pain, as the selectively permeable wrapper that allows the rest of the body’s functions to proceed uninterrupted and unthreatened, with just enough openings to allow a regulated exchange with our environment.

It's the absence of skin that exposes its absolute necessity. This six year old girl being unwrapped now has full thickness burns (what we used to call third degree) over 55% of her body: anterior and posterior thorax, both legs, both arms, a bit of face and neck, buttocks. Her big, deep brown eyes look at me with tears trickling down her cheeks as her mother’s helper raises the IV bag above her head and arranges it so the tubing is not kinked. This is a bad burn: flame generally causes deeper burns than hot water, and in this case, it looks like her clothes were on for some time, and the contact did a lot of damage. Like countless others, she was playing with her friends and tripped into a fire, where her clothes caught the flame. She cries, but not much: a bad sign. Although we teach that full thickness burns are insensate, since by definition the heat has destroyed the skin's sensory apparatus, not everything burns to the same depth, and partial thickness areas surround most full thickness burns—and those do feel pain. Her name is Chisomo, meaning Grace. She will die in 3 days. 

I think about the ones we can’t save, back home, and here. I hold on to them for motivation to keep studying, keep waking up, keep leaving my family, and keep trying—and to honor their memory, although I see them usually only in a dehumanized form, although I know them usually only as bodies wrapped in dressings and not as children chasing goats, eating mangoes or diving into the lake. Knowing what makes a patient human makes me a better doctor but it also hurts more—and many times I don’t want to admit they are people because doing so makes me transiently incapable of returning to work. It’s like this in the States and it’s definitely like this here. The constant blur of activity insulates you from processing both the good and the bad, but both stay with you, and sometimes when you get a breather it all comes out, and it’s very hard to figure out what to do with all of it—so I try to just notice it and not cry, and carry on, because in the end, there are more of the ones who get to be human again than the ones who don’t, and so you keep going. As shown by the parents and patients in this burn unit, every day, with their smiles, their high fives, and their endurance, despair is a luxury. Ain’t nobody got time for that.

Pure tourist post this time!

We went to Cape Maclear this weekend with Ted Farwell, one of our former PACRA teammates and Micah's pair partner. The cape was "discovered" by Livingston in 1859 and it's now the busiest place to visit on Lake Malawi. We saw a total of maybe 20 tourists.

There are teams of kids on the beach who serenade tourists using homemade band instruments, such as drums made out of empty plastic containers. One of them sang us "Who let the dogs out" and "In the jungle," while two of the leaders performed interpretive dances.  We passed on another band's offer to "do Shakira."

On Thumbi Island 

The lake and shore around the Cape are declared a World Heritage Site by UNESCO because of the variety of bird and fish species found there and nowhere else on earth. We rented a boat to get to Thumbi Island, where our guides fed fish by hand and we saw toucans, eagles and crabs, along with many different colorful cichlids. There are more freshwater species of fish in Lake Malawi than anywhere else in the world.

Happy girl! Stas as the photographer

Two o say it was beautiful won't do the place justice, so I'll just post some pictures and bask in the memories.

Thinking hard about which beer to drink next...will it be Carlsberg? Or perhaps...Carlsberg?

It's always a good vacation when you can find many trees to climb

We have a family photo! 

This is where we stayed--Thumbi view lodge, cute and comfortable with awesome beach chairs and cheap drinks :)

Agnieszka takes good pictures too

Cows crossing!

Math is relative

It's 3 am. Perfect time to blog, right? With the baby sleeping through the night, I can't sleep anyway.

I want to write about work, probably not for the last time. Kamuzu Central Hospital, one of the country's 4 central hospitals conceived of as tertiary care referral centers, is a half hour's walk or 5-30 minute drive from our house, depending on traffic. This, from the hospital website, is what you see entering the visitor parking lot:

According to dictionary.com, a "hospital" is "an institution in which sick or injured persons are given medical or surgical treatment." But that's the factual definition; the cultural load of a word is where stories lie, and where misunderstandings arise. For example, if I free-associate on the word "hospital" for 2 seconds, I come up with: "white, clean, nurse, love, drugs, pain, death, friends, disinfectant, recovery, fear, babies, surgery, pager, large building, cockroach, elevator, work, hope, despair, emergency room" etc. Your list will be different. The list of a patient will be different from that of a doctor; the list of a woman who delivered a healthy baby different from a son who's just put his mother in palliative care, the list of a Malawian patient different from that of a Malawian doctor, of a Polish patient from an American one, etc, etc, etc. Language operates on an agreement about the factual underpinnings of itself (that is, word definitions), or else all speech would be a subjective hodgepodge of un-translateable experience and we couldn't communicate at all. One of the things I love about traveling is that it forces you to reinterpret and question those factual underpinnings of words and concepts which we take for granted in our own culture.

Hospitals are frequently described in terms of the number of beds and operating rooms they contain. Those numbers help to illustrate a hospital's volume of patients, its importance and function. And they should be easy enough to get, right? Count the beds per unit, add up the units, and voila. Ditto for ORs. But KCH is variously described as having anywhere from 700-1200 beds, depending on the source. How can that be? Math, after all, is supposedly universal. Does 1 bed magically become 2 beds, or half a bed, depending on who's doing the counting? Can Malawians not count? Are they so bad at keeping records that they don't even know how many beds one of their flagship hospitals contains?

The answer, of course, isn't that simple. For starters, the definition of a "functional" bed may include the one placed in the outdoor hallway that connects the rooms, which aren't technically part of the hospital census but which are routinely used to increase the treatment space of a hospital that was built for a much smaller population. Like this, from the Malawi Project website:

Next, "functional" beds aren't, when they're in a unit that's under construction. For example, all the main operating rooms at KCH are currently closed for renovation. If you need your leg pinned with orthopedics, it will happen in the dental operating room; if your baby needs a stoma because of her imperforate anus, she will receive it in the burn OR because the main ORs are just, simply, closed until further notice. So I can't really tell you how many ORs there are at KCH at this time, nor when the main ones will be available again.

Finally, I bet that in your free association on the word "hospital" you did not picture a bed containing more than the patient, and neither did I. At KCH, they do. In the privileged wards, like the burn unit, it's because the whole family might sleep in the same bed with the patient. In the most overcrowded wards--the pediatric ones, for example--it's because there are multiple patients per bed. So depending on how you count, one bed does become two, or three, or maybe even 4.

The thing is, you don't need your own bed to heal. We expect it, because that's our cultural and socioeconomic norm, but your healing isn't contingent on private sleeping quarters. OK, maybe if the patient next to you has tuberculosis or leprosy, that may not be too conducive to health, but in general, a single bed occupancy could be thought of as a luxury; especially when you consider all the other things we take for granted. Like a trained surgeon, or morphine for dressing changes, hot water, air conditioning, blankets, food. But more on those in another post. I do have to get up in 3 hours.

Malaria, Dreamland, and over-ripe mozzarella, or why modern medicine kicks butt

Drove today, no police checkpoints, no traffic stops. So far, second week is looking much better than first week!

I need to write about the burn unit, but I've been working on what I want to say for the past 5 days and it's still not done. So instead I'll write about other stuff. 

First, malaria. Our housekeeper (I'll call her A) didn't come in on Friday because her adopted daughter was sick with a fever of up to 45 degrees Celsius--about 113 Fahrenheit--and sure enough, it was malaria. So first of all, our housekeeper is 27, and has been raising two girl orphans by herself. She also walks 1.5 hours to work each way every day, pays for the girls to get extra tutoring, will go back to school part-time in the fall for nursing, and always has a smile on her face. She's crystal-honest and incredibly giving, and found the time today to bring in some sweet potatoes for the kids because they mentioned how much they loved them when she cooked them for herself last week. So yeah, she rocks. 

I texted her throughout the weekend to make sure she had everything for her daughters and didn't need help. On Sunday she said her daughter was doing much better and would be going in to take her exams today. These are Malawian end of the year exams that determine whether kids get to move on to the next grade. This kid is 9. So she gets diagnosed with malaria on Friday and sits for an exam that determines her next year on Monday. I asked our housekeeper if she could get an excuse and A said that she could, but that she herself (the kid) was insisting on taking the tests. Throughout my academic career I've run into kids and then adults for whom a hang nail represented a good excuse to skip school, and here's this kid who's 9 and legitimately sick who insists on going to school and taking the most important exam of the year! Amazing what some antimalarials and a fighting spirit can do. 

This weekend passed under the sign of sickness. After our trip to the lake, Micah on Saturday afternoon began complaining of feeling achy and tired. He improved a bit on Sunday, so we went to Dreamland with the kids--more on that later. But then Sunday night he made many, many trips to the bathroom and ran a high fever, so I gave him a snack of azithromycin and made him drink ORS (Oral Rehydration Salts, aka gatorade without the flavor), and today he's much better. But no Fourth of July cupcakes for him--which if you know Micah, you know signifies how rotten he must have felt! We have traced the culprit to a block of local mozzarella cheese, as it was the only thing we ate that the kids did not (I feel a bit off, but nothing like his version). Antibiotics--it's what's for dinner!

OK, finally for the fun part/pictures. We took the kids to Dreamland on Sunday. For MK2500 per person, or about $3.33(excluding Janek), you could ride all day, entering and leaving as many times as you wanted to. Dreamland consists of a collection of discarded, probably not-up-to-code carnival rides that some enterprising individual imported from god knows where and plopped in the middle of a dusty red field, enclosed it inside a brick wall, attached a restaurant that serves Bloody Marys on a terrace overlooking the rides, and thus made it into a hungover parent's paradise. You can bring your pride and joys here and let them run free because they can't go anywhere that you can't see from said terrace, and you can blissfully sit and get drunk-or eat pizza (not great) or kebobs (smell awesome) or hummus, which was edible. It's a really brilliant invention that would never fly in the States, and we're definitely going to come back.

Look ma, no seatbelt!

Stas' outfit cracks me up

The kids have now ridden carousels on 3 continents

Finally, for the Fourth, we had vegetarian burgers (cause it was easier on our bellies than beef and cause we don't yet own a grill); and found cupcake mix from South Africa at the local Chipiku (the grocery store that has everything in moderation, except for maple syrup). So we made vanilla cupcakes. Happy 4th, everyone!

Sprinkles are serious business!

First Saturday, it's time for a road trip!

After a late start (Janek isn't sleeping too well so our nights still take a toll on us) we drove the 2 hours to the closest point on Lake Malawi, Salima/Senga bay:

 "The" guide to Malawi (of which we have 4 separate copies at the house, in various stages of use and editions) states that the only thing this place has going for it is its proximity to Lilongwe. That sounds really jaded to me, when you consider it looks like this:

 In addition to swimming in clear water and enjoying the beautiful views, I drove through FOUR police checkpoints and did not get pulled over even once. So, overall, winning! We passed by countless stands selling ripe tomatoes and bought some--Micah didn't bargain, even though it's expected here, because really, these people have nothing and 10 tomatoes were $1.60--and local crafts. There are handmade baskets galore, in all shapes and sizes, and handmade rugs woven from the same rushes or grasses from which the baskets are made. I wanted to buy them all but we didn't have space in the car so I'll have to plan better next time. If I worked for 10,000 Villages I'd be all over this stuff!

I'm sure I'll be writing many other posts about the lake, because it's close enough for a quick trip and big enough that we won't be able to explore all of it. Janek liked it!