shake the dust

Awhile back, my brother sent me the link to Anis Mojgani's performance of his poem, "Shake the Dust" which is amazing to watch if you haven't seen it.

The poem ends:
"Make sure you live, shaking the dust
So when the world knocks at your front door
Clutch the knob tightly and open on up
And run forward and far into its widespread, greeting arms
With your hands outstretched before you
Fingertips trembling, though they may be"

I have been thinking about this poem a lot this week. Trying to focus on the positive when there have been so many negatives. When dust is being showered on some of the most vulnerable, marginalized members of our society.  I thought about what it means if the dust is too thick.  If the dust is beyond dust and more like clouds of black flies, toxic and alive.  I think at that point we can't try and shake the dust from ourselves alone. We need to shake it from each other.  And right now there is a lot of shaking to be done.  

I have focused a lot on the negatives of being here so the past couple weeks I tried to take note of the positives.  I had a good couple of weeks.  I went home a few days bursting with pride in the interns and clinical officer students.  We did resuscitation teaching for several them a couple weeks ago and they were eager to learn more and practice their skills on the dummies that we have, asking tons of questions about what equipment to use and how to perform procedures properly, concerned about being able to treat children in the most effective and safe way possible.  Some of them care so much. One of the clinical officer students told me, "We are always eager for more teaching."

We spent some time going over fluid management in the emergency room with our crew of dudes who have been rotating through there the past 2 weeks.  We somehow managed to have an all male group of med students, interns, and clinical officer students.  It was both endearing and hilarious to see them all huddle together and concentrate when we asked them to calculate fluids for some example cases.  

Post-call the other morning, we needed to do a lumbar puncture on a patient, and our wonderful intern (after spending a night in the hospital) was already done with her morning rounds and did the procedure with plenty of time to spare before we signed out.  Our awesome pediatric clinical officer did a paracentesis and ultrasound with me during a busy afternoon and did a perfect job, teaching me a lot along the way (as he stuck a giant needle into a child's abdomen I was mostly excited I gave IV sedation and the right medication to keep the kid from barfing during the procedure). 

It has been nice not to have to round on 30+ patients each morning and actually have time to teach and work directly with trainees in their initial assessment and management of sick patients.  Though I've been on call a lot this month because we were short-handed, I've felt less drained and burned out because I've had time to think and teach, which has been my favorite part about being here.  

Last week I also went up to Mount Mulanje, which is a really beautiful and peaceful place.  I have also been watercoloring (I will spare you any pictures of my terrible art, but the therapeutic value is incredible) and reading a lot of poems which has helped me de-stress and come back to things my introverted self used to enjoy before medicine ate my soul (ok, ok, a little dramatic, I still have part of a soul left).  Here are some pictures of stuff.


panorama at the top (I learned I am terrible at taking these)



views looking down

our little mountain hut


so green.

Christmas present from my lil sis = Spongebob makes it to Malawi

corn fields and mt michuru on this weekend's bike ride

the edge of the earth

You probably think I fell off of it given my lack of any updates for the past few weeks.  It has been awhile. Part of this is because I was sick and in generally feeling low on energy and lazy. I also worked over Christmas week.  I also was having a hard time writing what I wanted to say.

About a month ago, I had a headache and felt exhausted. A few days later I got the most disgusting sore throat of my life, swollen lymph nodes, the works. Thinking this was strep and that I in no way wanted this to turn into rheumatic heart disease (which we see all the time here as a sequelae of the strain of strep bacteria) I took amoxicillin.  Six days later, I looked like a lobster woman.  My face was swollen, I had an itchy, red rash everywhere, and my skin was inflamed and swollen.  I figured this was the amoxicillin.  Turns out, nope. About 2 weeks later it was still going on. I asked everyone to help diagnose me.  The peace corps medics, my colleagues, random people on the street, telemedicine consults home. Everyone asked if I changed laundry detergent, which is a question that when we ask our patients with gross rashes back home, I am always thinking, “For reals? Like detergent can cause this crazy rash?!?!?!” Well, actually, it can. And its name is Toss.  Little did I know, our lovely lady who cleans for us bought a different laundry detergent.   According to the bottle, it is for babies and sensitive skin. But it smells like someone took every perfume in the sale bin at TJ Maxx, dried it, and mixed it with baby powder. 

Don't be misled, definitely not gentle

Shortly after this discovery, I went to Cape Town for a vacation.  The city is beautiful.  It is not intimidatingly huge, but has everything you need.  Good food, great yoga studios, beautiful geography and scenery, generally friendly people (if you are white).  I shopped more than I should have, took a million pictures, and soaked it in. I didn't realize how much I miss being in a big city and being able to walk all over.  One of the days I walked 10 miles just around the various neighborhoods, wandering in and out of places. 

Bo Kap

district six museum

top of lions head

woodstock street art

The culture in Cape Town is super interesting to me.  The history is insane. Not knowing much about apartheid in advance, I decided to learn as much as I could while I was there.  I was lucky to travel with a friend who is much more outgoing than I am and engaged a lot of the locals, starting conversations and asking questions. You can tell there is still a serious racial divide (unfortunately, all too reminiscent of our own race issues in the U.S.).  Because we were travelling, we interacted a lot with people working for the service industry. In South Africa, this means Zimbabweans, Malawians, black South Africans, Congolese, and the list goes on.  It is a melting pot of Sub-Saharan African culture.  Everyone we met was so kind and hospitable, despite the fact that they work extremely hard, are treated like shit, and are fleeing difficult conditions in their home countries where many of them still have family.  It is still crazy to me why we treat people the way we do because they are different.  I do it too.  But why is this something that seems to come naturally to humans?  It is hard to wrap my mind around apartheid being so recent. Even the Civil Rights Movement in the U.S.  How did we do this to each other?

blender lamp in a tiny township house

my fave color township house

I still wonder a little bit about my year so far in Malawi and how it could have been different if I had done something else. When I was looking for jobs/volunteer positions abroad, I considered a 2-year position in Columbia working with community health workers. I ultimately decided this was too remote and too clinic-based for me (loving the emergency room and acutely ill patients).  After the past six months, I question this a little bit.  I think there is something to be said about working directly with locals.  This is what I have enjoyed most about my prior global health experiences.  It is extremely uncomfortable at first as you find your feet in a culture and language that is not your own, but then as you are forced to put yourself out there, the rewards are indescribable.  Here, because there is a decent ex-pat population, I interact much more consistently with foreigners than I do with locals.  I wish I could have more of a connection with my patients.  The same social structures (and conflict) we see in the U.S. when groups of strong-willed people are put together are just as prominent here.  My favorite part about prior experiences abroad was this lack of drama, something that we as Americans (myself included) are obsessed with on every level.  The medicine has been the easy part for me to deal with emotionally. It is the politics and drama that are tough. 

I don't regret being here, but the challenges have not been what I expected.  Some days my heart is so full it could burst; other days I am completely disappointed in myself and the entire human race.  Today I helped a little girl in heart failure sit up to make her more comfortable. As I touched her, I wanted to cry. I wanted so badly to see her and the people of Malawi sit up and say, "It's ok. I can do it myself." Because everyday I ask myself when that will happen. When a country with no economy, so devastated by everything (those who came and went, those who came and stayed, the climate, the infectious diseases, corruption...) will be able to be self sufficient without foreign aid. If I, and everyone else here, is actually doing more damage than good.  Really lighthearted things to think about on a daily basis. On that note, here are some elephants and stuff.   

Liwonde

Creepy baby croc party

all the mango things: strawberry mango jam, vodka, even more vodka disguised as gin

Thanks for reading! It is nice to have this link to everyone back home :)

women in malawi

You balance it on your head

A heavy bucket

Full of water from the pump

Standing straight and tall

Walking with your head held high 

Some, they don't see this crown

They think you are not fit 

To be a queen

You are not worthy

Of learning, of reading, of owning, of being

They send the boys to school

As they run past you on the dusty road

Laughing

Not recognizing 

You are the backbone

Who wears a crown

With no jewels or gold

But worth kingdoms

Not realizing 

You carry their weight on your shoulders

And the future on your back

I wrote this months ago during our stay in the village, but the longer I'm here, the longer it resonates with me as I see what it means to be female in Malawi.

Peace Corps (per the United Nations) is in the middle of 16 days against gender violence.  I wish I could say I haven't seen any gender violence here, but unfortunately I have.  On my on call shifts I have to medically examine girls who come in for "defilement" or sexual abuse.  I have heard their testimonies, interpreted for me by our registrars, many of them who are young females, so I'm sure it's not easy for them to hear firsthand these accounts of terrible events. Groups of boys jumping and sexually assaulting a girl on her way home from school, a neighbor who raped a developmentally delayed girl, among others.  It is frustrating to say the least.  I am so happy to work in a hospital that has a One Stop Center, UNICEF-created clinics where victims of rape can go for healthcare, exams, and counseling.  Police reports are filed, though I have no idea what happens from there.

I have been amazed here at everything women do.  From a young age, girls do everything.  During our stay in the village, I saw the women of the community run the house.  And by women I mean any female over the age of about 5-6 years old.  They are outside by dawn, sweeping the floor, washing dishes from the night before, fetching water, starting the cooking for the morning.  Girls do go to school, but during their time off, they are busy.  And they can balance almost anything on their head.

When we were at the lake last weekend, we were constantly swarmed by young boys whenever we got in the water.  Laughing, swimming around us, trying to see who could swim the farthest.  The girls were on the shore doing laundry, occasionally getting in the water to fill buckets, but they did not stay long.  The boys can run and play and waste time. The girls work.  

During these 16 days, I have learned more facts about girls and women in Malawi.  Half of girls in here are married before they are 18.  Young women 18-24 also make up 58% of Malawi's HIV infections.  Most girls do not complete their schooling and only 67% of women are literate.  

There are two bills currently being proposed in Malawi's government that are being protested.  One is the right for a woman to terminate pregnancy, the other is to make homosexuality legal. I read an article the other day from an extremely conservative newspaper here discussing how abortion is the gateway to "widespread euthanasia" and other "forms of murder and brutality" (Termination of pregnancy bill). This is happening in a country where contraceptive rates are 46% and the average number of children per woman is over 5.  

The BBC published an article about ritual sex practices in Malawi if you haven't seen it: The man hired to have sex with children.  Recently it was updated that he was sentenced to 2 years in jail and hard labor.

Despite how awful most of this sounds, I am happy to be part of an organization that works hard to empower girls and improve the status of women around the world.  I also work alongside Malawian female physicians who stand up for the mothers and children we see everyday.  They are role models for our patients and girls all over Malawi.  There is still so much work to be done.

Thanks for reading and supporting me while I'm here. I'll post pictures some other time, they didn't seem to fit with the theme of this post. Or follow my instagram (bananneka). I post things there from time to time :)

we are more

sometimes the drumming is so loud it becomes your heartbeat
it becomes everyone's heartbeat
there is no you or me or them
only Us
and We are loud
We are so loud
if you want a wall
We will give it to you
a wall of sound
of voices
of music
of love
dynamic but unbreakable
We will pound eardrums
We will shake souls
We will dance into the night
the moon our only light
We will join hands
We will embrace
We take up space
so much space
We will move this earth
We will shatter history
a force so strong
you'll feel us in your bones
deep to the core
you thought you could quiet us
but We are Us
We are more


drums on drums on drums

I had a post started for about a week now and hadn't been able to bring myself to finish it.  Then a couple of awesome doctors here had a celebration with lots of music, theater, art, tons of talent, and that poem just came out.  It had been a long two weeks. I was on call last weekend so I worked 12 days straight.  At the end of the party, I found myself dancing in the middle of a group of people of all backgrounds.  A local hip hop artist trying to teach us some steps, a painter looking just as nerdy as I was trying to bust a move, doctors throwing up their hands with reckless abandon.  It was exactly what I needed.

I've been frustrated.  Before all of the election drama, I was already getting frustrated with the politics of my department and of the medical education system here.  Coming into this position, I knew I wanted to be somewhere that I was doing both clinical work and teaching. But lately I have had the increasing feeling that I am up against a wall here.  I run around trying to staff 30-40 patients per day (unable to actually communicate with them myself) and see the same things over and over.  Babies infected with HIV who are supposed to be screened and followed up but aren't (even though HIV is probably the most well-funded disease here), children dying of TB with a known contact who aren't picked up for exposure, just an endless circle of terrible outcomes and preventable diseases.

So not hard to see why I often leave the hospital completely defeated.  Plus the point of being here and Seed's mission and all that is to strengthen medical education.  And I feel like I don't even have time to think let alone fit in teaching.  I started feeling a bit more optimistic after working with the students last week.  The students here in general are great to work with, but we had a particularly good group on the unit.  After a couple of great days precepting cases with them, I was less cranky.  Then started thinking about the health system here and how there is no money and they are in a hiring freeze so all of these fantastic students we are training will never get jobs here.  They are forced to look for work in South Africa, Swaziland, Lesotho. If they are lucky they might find a job in a private clinic, or with an NGO, or on a foreign-sponsored research project. Despite this, they work incredibly hard.  They are the ones spending the time to explain how to use an inhaler to a family, counseling mothers when their child dies unexpectedly, and chasing down lab results.  So it is not easy knowing that the future for them is very uncertain.  I question almost daily if I should be here, or if it would be more beneficial to just pay one of the many qualified Malawian doctors who would love a job in their home country.

I considered making some comments about the election, but I'm not really sure what to say.  Although I'm still in shock that this man can be president,  I am mostly depressed by the number of intolerant and angry people it has revealed, especially in the aftermath. I think I knew our country still had a lot of this, but maybe wasn't sure of the extent. I at first thought I am sheltered from it, living in California.  But the truth is, I'm really not.  It exists in my own family, on my street, all over my hometown.  And I have made excuses because I know these people will not change their beliefs based on what I say, so I gave up arguing.  But I could have done more to let them know that this is not ok, and I want to start doing that now.  How I am going to have the courage to do this, I'm not sure. Something to think about.


Some less dismal things recently:

my malawi welcome from our gardener


and from my malawi fam


views of blantyre from mt soche


soche!


Malawi hallowatermelons

home

I am sitting in SFO right now waiting for my delayed flight. A flight that starts the long journey back to Malawi.  I thought about writing while I was home, but it was hard. Both hard to fit in and difficult to know what to say.  I didn't realize how much I missed home until I got here. I felt a little guilty about it.

I loved every minute of being home.  Even flying around to 7 cities in 3 weeks and living out of a suitcase.  I saw some of my favorite people (don't worry those of you I couldn't squeeze in, you are still my favorites too) and was overwhelmed with the love and support you gave me for what I am doing. Plus interviewing for something I love to do and meeting others who are just as pumped about it was pretty awesome. It is not easy to leave this and go back to somewhere that I am so far away from all of that.


Examples of support: interview words of wisdom from my mom

I also missed my Malawi family a lot and felt really disconnected from life there.  I was thankful for the texts and pictures from everyone so I still felt a little in the loop.  And the requests for all the goods I am trafficking home :)  It was just starting to feel more like home when I left, so I am hoping it will feel that way when I get back.  It is hard going back knowing that from here I won't be home again for another 9 months. Knowing I'll miss Thanksgiving and Christmas (for the 3rd year in a row) is pretty awful.  But I knew that when I signed up for this and I know the Malawi crew has some fun holiday plans.

Some highlights from my U.S. tour:

residency buddies and skyline views in philly





















Walls of pez in our Air bnb in portland



being cool at portland shows and catching up with an old friend






BFF, beer, and amazing views in portland




























hiking and matching cargo shorts in reno.  Plus tons of dogs including murphy and her fave vodka-themed toy :)





beach views, old and new friends in SD

Plus many many more awesome people and friends and stuff and things that I couldn't capture.  I am eternally grateful to those of you who opened up your homes, offered advice, met up with me to catch up on such short notice. It meant so much to me that I'm traveling back to Malawi with a full heart.  Overflowing.  I know Malawi is where I need to be right now, despite how hard it is to say goodbye again.  I'll miss you all and there is an open room for any of you waiting in Blantyre if you ever want to visit.  

coping

Things have been a little less dismal since my last post.  I have continued in the special care ward.  It seems Wednesdays are the worst. I assume because people finally make it to the small Gateway health centers by Monday, then get referred to us, and finally make it two days later when they are not in good condition.   We were short a resident this week so it was pretty busy. I am trying to get used to 5 hours of standing rounding and pre-rounding to see the 40-plus patients we are responsible for.  

There are some things I am starting to just accept.  Mainly that nothing happens quickly.  Labs constantly need to be followed up to actually get a result.  Trying to get a consultant to see a patient can take days.  Figuring out where to even send certain tests can also take forever.  I was talking to someone from home and getting frustrated for really no reason when I realized underlying all of this was the fact that I had a child this week die because they had a brain tumor (pineal gland diagnosed on outside CT) that was likely operable, but the neurosurgery team took days to see her and then wouldn't take her on their unit because she was starting to seize.  They sent her back with plans to biopsy sometime this week but given she already had signs of increased pressure in her brain and nothing had been done, she died over the weekend. Some cases I am not happy with but figure there probably wasn't much that could be done in the first place, but this one made me more upset.  This was a lot of political drama between peds and neurosurgery (as they are supposed to be trained to manage seizures as it is a NEUROSURGICAL unit and they have their own HDU) and the more senior pediatric consultants were all appropriately angry and went to discuss this with the neurosurgeons.  There have been some problems recently with patients getting transferred for neurosurgery who then are not seen for days, which is really difficult for everyone.  I got the contact info now for pretty much every consultant in the hospital so that I can now go up the chain of command quicker.  I'm not sure if this will help but at least I can feel like I've done as much as I can short of becoming a brain surgeon.


The HDU where I spend a million hours rounding per day.  
There are about 5-7 of these little box beds per side, each with 1-2 patients in them.
There are tiny cockroaches all over the walls (not pictured haha)


The left wall of the HDU where CPAP happens. Usually has 3 babies in that one bed. 

It goes back to the serenity prayer I suppose. God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.  Our first few months here are all about finding that wisdom.  In any health facility there are places for improvement, it is just figuring out what will actually be helpful and create lasting change.



Jacaranda tree on the hospital grounds seen from where we do sign out each morning. They are all blooming now and are sooo beautiful. 

To keep myself sane, I have been trying to accept the inevitable (e.g. if you are a 1 kg baby born here, you probably won't survive no matter what we do) and not think about the hospital too much when I am outside the hospital.  I also routinely vent to the rest of the GHSP peds team, my fellow consultants here, and residency friends back home about difficult cases, probably to an annoying extent, but the support has been tremendous.  It helps to have people corroborate what I'm thinking or suggest things that I wasn't even starting to think about.  My counterpart here is awesome and is always available to look at difficult cases (not just for me but is consulted by everyone which makes me feel a little bit better haha) and then just picks up an xray or looks at the patient and in 2 seconds goes, "This is TB." Or, "This is KS (Kaposi Sarcoma)." Such confidence.  

Besides traveling around the area, I've found some close by activities to keep me sane.  I played basketball this weekend which was crazy but fun. Lots of elbows and more netball style than I am used to, and I am definitely a little rusty, but had a good time.  I tripped and ate it doing my first lay up in warm ups because the hoop has 2 metal poles directly underneath (like right on the baseline) that I for sure was not used to.  So that was an embarrassing start. It is a little scary they aren't padded or anything so I'm hoping that was the worst of the iron pole encounters.

Some dudes ballin' it up in the game before ours (which started 2 hours late unsurprisingly). The bottom of the offending pole can be seen at the far left.  

 I've also continued my grandmotherly activities like yogurt- and bread-making, cooking mass quantities of food, shopping for fabric... My next goals are jam making/canning (seriously), cross stitch (not as seriously), and mass consumption of cottage cheese with canned peaches.  I am also honing my skills as a cockroach assassin and in-air mosquito killer (currently working on the one-handed mid-air grab, the cockroach technique is just gallons of Raid which is already pretty advanced I think). 

Last weekend we didn't take any shortcuts and went Lilongwe (ahahaha gets me every time) to see the rest of our crew and pick up my passport.  There were 4 volunteers who just came last week (who had other commitments at home so couldn't start when we did). So we welcomed them and then reunited with the some of the other girls from our crew.  Lilongwe is definitely an experience in how the other half lives.  There are tons of rich ex-pats there because of all the government officials and embassies around. Everything is soooo spread out and suburbic (I just made up that word) and I have no idea how people know where stuff is.  We went to a lovely outdoor garden restaurant called "Brunch" that is next door to a salon that does pedicures, so enough said.  We had a great time, did some hard core chitenje shopping, ate tons of good (but expensive food), and talked about non-hospital things (plus some hospital things like comparing numbers/sizes of things like beds, nursing staff and cockroaches in our units).  

Lilongwe chitenje market finds. A couple will prob be used for house decor (like the little people one) but the rest I need to figure out what article of clothing they should be made into...

My new fave! Found this one at the fabric store here. Was on a mission to find it after I saw a lady at the hospital with it.  I am not sure what the random little clocks are but I love the bikes. I think it's going to be a dress in the near future.  

Otherwise, mostly have been thrilled to have pretty consistent electricity for the past few days (right when I started fighting for Peace Corps to buy us gas stoves). Probably thanks to this:Malawi: Minister Msaka announces new electricity company.  

High fives for this week:
- Asking for help on a malnutrition lecture to a visiting expert and having him offer happily to just give a lecture he already has prepared on the topic (which, for the students is a huge win given I am prob the least qualified for this topic).

- Letting this chronically ill kid that we can't figure out what is going wrong with him use my phone to take selfies.  He was smiling ear to ear (I'd post it but I didn't ask permission).  We also discussed him in rounds and basically no one knows what is going on with him but at least he got to take some happy selfies using my stethoscope.

- Going to the 1 grocery store that has amazing, amazing things like curry paste, sesame oil, cheap coconut oil, and (gasp!) chocolate chips. 

- Buying keys to the peds department so I don't get locked out again (no one told me we needed to get a key and doors lock at 5:30 pm)

- Meeting pretty much every ex-pat in Blantyre at the Fri night hang out spot this weekend and staying up past midnight (I know, I know, goes against my grandmotherly aspirations).

- Electricity!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 

This week is going to be busy with some ultrasound training, a lecture (that I actually have to give and couldn't find someone to pawn it off on hahaha), and then the visit by the Peace Corps director, ahhhhhhhhh! Then I fly back to the states next Sunday! So exciting.  I might try and post something when I'm home but it probably won't be as exciting (if you consider roach killing and yogurt-making exciting, then my blog is pretty thrilling).   

Thanks for reading!!

No mother

This week was long and tiring.  I was in the HDU (high dependency unit) all week. Picture an ICU but then take out all the monitors and equipment and that is our HDU.  So often we know that there will not be much we can do for a patient.  Even with that expectation, it is still really hard to see a child die.  Even when you know it is coming.  One of the Malawian pediatricians said it best I think when she was referring to TB and saying, "We get used to it. We think it is normal for children to die. It is not normal. These are treatable diseases. We cannot accept that children are dying."

It made me think and this was the best I could do to put it into words. A somewhat rambling poem I think.  

No mother should ever have to see her child die
No mother should ever have to wonder if this fever will be the last
If she has enough money to get to the hospital
If she will make it in time walking with a baby on her back
No mother should question whether she should even go
Because she has heard that the hospital is where children go to die
No mother should have to see her child getting CPR
Then wrap its body in a colorful cloth
Wailing as they are wheeled outside surrounded by women who feel her pain 
Because they too have lost sons, daughters, nieces, neighbors
No mother should have to call her family and speak through sobs over a bad connection
Then carry what was once her baby on her back
Now a husk where there used to be soul
As she waits for a mini bus back to a village
That will mourn its own
No mother should call a name into the silence
Where there once were shrieks of laughter
First words
And tiny steps into outstretched arms
No mother should have to place flowers 
Over newly turned earth
And say goodbye
Because no mother's child
Should die

It is difficult because I think we are all aware of the diseases that kill children in these environments. Malaria, TB, HIV, diarrhea, pneumonia, etc. etc.  And we pour money into this.  And it helps. But it is still happening.  So I am trying not to become complacent while I am here. Trying not to get to where I accept this.  And trying to figure out where we can make changes. Because the reality is providing care in the hospital is the easy part. It is the awareness in the community, the getting to the hospital, the using a bed net, the knowing when a child is too sick to stay home, when they are too sick to use traditional medicine... all of those things that make a huge difference.  And that I don't know how to fix.  Despite this being depressing, I am hopeful.  There are still things we can do, information we can learn, problems we can fix. I just am impatient, but I am trying.