roughin it...

OK, not really. Today Kate, Miriam, Chris, Emily and I took a day-trip to Livingstonia Beach, on the lake about an hour and a half away. The beach is actually owned by the Sunbird Livingstonia Hotel - Sunbird is the (only) chain of fancy hotels in Malawi. But they let other folks come to the beach, sit under their little cabanas, and enjoy the lake!

They even have a cool band that sets up and plays Malawian music. It was really lovely...check out the nifty upright bass/drum...it has a drum head, with the strings attached, and the bassist hits the strings with a drumstick and alters the pitch with his left hand on the neck. And the guy on the drum set...is also playing bottlecaps strung along a coathanger...people here are very resourceful.

fisherman a little ways off shore.

Emily and Chris and I climbed some rocks a ways away...and then some missionaries from missouri showed up, and took our picture :)

Its so nice to have this gorgeous lake - really more like an un-salty ocean, because it has sand and waves and shells - so close-by. But its also really striking to go from the grim atmosphere of Kamuzu Central Hospital one day, to a place like this the next, frequented by ex-pats, vacationers, and wealthy Malawians. There's really no "in the middle" in Malawi.

timefoskoo!

I think I mentioned this before, but this week I spent most days in the back of the epi/biostats class that Dr. Miller teaches, every year for 2 weeks, to a class of Malawian MPH students. While a lot of it was over my head, I did get a nice review of statistics on Monday...if anyone could make stats tolerable, it would be Bill, who is so friendly, a great teacher, and really knows his stuff. But stats still kinda makes my skin crawl.

Action shot, complete with hand gestures.

We were very sad to leave the lovely Kim Porter, but she'll be joining us next weekend! I'm glad I got to see Blantyre, but I was definitely ready to get "home" to Lilongwe! We took a charter bus back, an interesting 5-hour trip including too much drammamine, awful Kenyan soap operas blaring on the bus's TV, a beautiful sunset, and lots of snacks which did not but could have included roasted mice on a stick. Tasty.

As far as my work is concerned, I've mostly finished designing/refining the new data entry form for the community department to use on their tracing visits, and will hopefully start piloting the form this week. I'm also learning a lot about database design and management, and Bill is going to be helping me a lot as I get the new tracing database up and running.

I started out a little frustrated about my project logistics, and bummed that it wouldn't be something I can easily translate into a scientific paper. But I'm starting to take a lot of pride in it! Drs. Hosseinipour and Miller are really supportive and receptive to my ideas, and very respectful of my input considering it's coming from a first-year med student with little to no experience in epidemiology, study design, or data analysis. I've certainly gotten a crash course in all these things! And it’s great to have a working understanding of the UNC Project studies, what a HUGE operation it is, and to feel like my work will really help things work better here - even if I won't be making it into JAMA anytime soon :)

bones joints muscles!

On Tuesday I got to spend a busy day at CURE International Hospital, which specializes in orthopedic surgery. 80% of CURE patients are disabled children, who receive free evaluation, surgical care, and rehabilitation, along with three meals a day and housing for themselves and a guardian. The remaining 20% are paying adult patients, mostly wealthier Malawians, who help subsidize the childrens' care with elective surgeries like hip and knee replacements.

During the morning, I worked with the two U.K. med students, Daisy and Sian, doing a physical therapy/play group for the kids, both pre- and post- surgical. Our first session was for children 1-6 - most of these children have congenital deformities like club-feet, cleft palates, or hip dysplasia, or have missing or extra limbs/fingers/toes. A photo of our second session, with the older kids, is shown here. Many of them are disabled due to trauma, osteomyelitis, polio, or spinal TB. During the therapy sessions we tried to get the kids engaged in songs with lots of motions, games with balls and streamers, and even finger painting! (Always a good time, in any country!)

The children's ward at CURE is a large room with 60 beds, partitioned into the ICU (shown here), main ward, and infectious ward, for children with osteomyelitis and spinal TB. Two British surgeons, Dr. Harrison and Dr. Cashman, perform most of the operations - each day one is in the surgical theater, while the other rounds on patients and sees new patients in the clinic. I followed Dr. Harrison on ward rounds after lunch, and spent the afternoon with another physician in the clinic.

Because patients and their parents often have to travel very long distances to get treatment, many children's conditions worsen for years before they make it to CURE. So I saw some really tough things I'd probably never see in the States. It was so painful to watch the clinic physician diagnose a 6-year-old girl with muscular dystrophy, and explain to the father (who had come from Mozambique) that the disease would probably progress rapidly and there was nothing the hospital could do. But I also saw hopeful things - a three-year-old with disfiguring burns regaining the ability to hold a crayon; a ten-year-old's x-ray showing hazy wisps of calcification where bones should be - both his femurs re-growing after surgery removed the long shafts.

Long bones re-grow! I did not know this. Amazing.

“So, how was the food?

I’m thinking about food a lot lately. That probably wouldn’t surprise most of you, because I love to cook and definitely love to eat. But I’ve also just finished two great “foodie” books that were laying around the guesthouse – Anthony Bourdain’s Kitchen Confidential and Bill Buford’s Heat – both highly recommended. And I’m just getting ready for bed after my best Malawian meal yet, hands down. So I thought this might be a good time to get down some thoughts, in preparation for the question I most often ask people when they return from international travel – So, how was the food?

I’ll start by telling you about this meal in particular. Dr. Miller and I were invited to dinner at Dr. Kalilani-Phiri’s house, just a few steps away from our College of Medicine guesthouse in Blantyre. Dr. Kalilani is a young female epidemiology professor, born and raised in Blantyre, who did her PhD in epi at UNC-Chapel Hill under Dr. Miller. She splits her time now between teaching and HIV research in Malawi, and her husband and home in Cary, NC.

We arrived at her lovely house to see a large round table, in the middle a huge wooden lazy-susan covered with enough dishes to feed 10! The starch staple in Malawi is called nsima, its made from corn. Imagine white grits, but ground very finely, and cooked into a dense paste not unlike very very thick mashed potatoes. You then pick up a spoonful of the nsima with your fingers, roll it into a little ball, smush the little ball into a patty, and use it to “pick up” whatever meat/sauce/vegetable you’re eating. Try picking up a chunk of beef stew using only a handful of mashed potatoes, and you’ll see it doesn’t work all that well. Honestly I ended up making such a mess I had to go back to the trusty fork and knife. Its funny, when you’re a little kid, your parents try to make you use utensils and all you want to do is pick up the food with your hands. Tonight I was so relieved to get a fork!

Along with the nsima, we had a sort of beef stew, white rice (yay carbs!), sauteed pumpkin greens, red beans cooked with tomato and onion, another Malawian green that we don’t have in the U.S., itty bitty whole fish cooked in a yellow curry-type sauce, and roasted chicken. For only three people! Dr. Kalilani swore otherwise, but she must have been in the kitchen all afternoon. A word on Malawian chicken – its fantastic. Every preparation I’ve had has been delicious, and I’m discovering its not because of any brilliant combination of spices, because I’ve been asking. The chickens themselves are small and scrawny and a million different colors, and they run crazy on the streets, darting in front of cars like squirrels do back home. But I guess because they’re not bred to death and force-fed to be huge, they’re naturally flavorful. Really, they don’t taste like any chicken I’ve ever had back home. OK, enough words on Malawian chicken.

As is the case anywhere, your best bet for buying good produce in Malawi is to buy whats in season. For right now, the winter/dry season, that means avocados the size of footballs, greens, apples, cabbage, tomatoes, some eggplant, tangerines, bananas, and pineapple. Summer season (U.S. winter) brings mangoes, which apparently you can buy by the bushel for about 25 cents. I also buy staples like wheat bread, jam, peanut butter, and eggs. Milk is ultra-high-temp pasteurized and comes in itty bitty 500-mL cardboard containers, which lasts me about forty-five minutes. Things like cereal and oatmeal are extremely expensive, as are most packaged goods, most of which come from South Africa.

What do I love about the food here? I’m actually a pretty big fan of nsima, and all the tasty sauces you eat it with, but I try not to have it too often. I love that you can get 20 huge avocados here for the price of one dinky little Hass at Harris Teeter. I love that mid-morning and mid-afternoon tea has stuck with the Malawians as a tradition long after the British ceased to run the show, and the native “official” tea, Chombe, is really tasty. And I love Cadbury Mint Crisp bars and Pineapple Fanta – which you can actually get in the States…but I don’t think they’d be as good. I think what I like most of all is knowing where my food is coming from – whether they’re greens and zucchini from the market or eggs from the guy around the corner who sells eggs, or the goat from our front yard. Haha OK, Mr. Delicious hasn’t met his end yet…but all the UNC ID big-wigs are coming into town for a meeting and barbecue so I think his number may be up soon.

I guess I’ll be pretty embarrassed if this is my longest post so far, although I’m not surprised. But I think you can learn a lot about a culture from observing what people are eating and how they eat it!

OK, time to rest and digest :)

meg

Climbing Mt. Mchinji!

Yesterday (Sunday) I was really feeling in need of some exercise...and boy, did I get it. I went along with Kim (Porter, Bill's epi grad student and TA for the Malawian's class) and two of her roommates from her guest house (both med students in the UK) on a hike up Mt. Mchinji, one of the "three peaks of Blantyre." Unfortunately its not exactly Blantyre's backyard...so we started walking at 6am, for about an hour and a half through town...to the nature preserve...and then it was another two hours or so to the top...and then back down...and back to town...the long way...

Sian and I taking a break, trying to spot leopards...(no dice.)

The landscape here is hard to describe, hard to compare to anything I've seen really. On the mountain, its very rocky, with low scrubby grasses and groves of young fern-type trees.

Can you see the white dots far off? Yeah...thats town. I think we walked close to 20 miles yesterday! Thank goodness for Ibuprofen.

The sunrise en-route to Blantyre. This isn't even in the top 10 of most beautiful views we saw of it...but most of those were whipping around cliffs, maybe not the best time to ask Bryce to stop so I could take pictures...

Downtown Blantyre. Not all that happenin...although this was a Sunday.

Photos from Bwaila Hospital

This should give you an idea of about how many doctors there usually are here.

Room where pregnant or antenatal women enrolled in the BAN (breastfeeding/antivirals/nutrition) study come for education about infant nutrition, preventing HIV transmission to their babies, or taking care of infants who are HIV+.

Change of scenery...

Hello all! I'm writing you now from that paragon of metropolitan living...Malawi's biggest city, Blantyre. Ok, so Blantyre probably isn't the mecca of anything, except maybe Chibuku shake-shake. I'm here for a week to work on my project with Dr. Bill Miller. He's an epi professor (and also an infectious disease doc) from UNC who comes to Malawi for a couple weeks every summer to teach a class of Malawian MPH students.

I was able to catch a ride here from Lilongwe with a new friend, Bryce, who works for Feed The Children. Good - I didn't have to ride a scary bus and instead rode shotgun in his swanky Land Rover. Not so good - he had to make a 9am meeting in Blantyre...4-5 hours away from Lilongwe...so we left around 4am. Unfortunately the sky was a bit overcast, but it was still a BEAUTIFUL drive through the Rift Valley, and we watched the most gorgeous sunrise that I've ever seen. I finally got a couple of decent shots with my little camera...but they're such a joke compared to what we actually saw, I'm ashamed to even post them, it would be an insult to the sun.

We also drove through several little villages - shacks built up right alongside the road, mostly. It was interesting to see these places and the people in them slowly waking up, lighting fires, women carrying huge galvanized tin buckets of water on their heads. We saw children walking along in uniform, to schools which we remembered seeing MILES back. Peddlers strapping massive bags of charcoal or rice to rickety bicycles and pedaling or pushing them alongside the road. Vendors sitting in the dirt alongside the road, arranging precarious piles of tangerines or tomatoes in pyramids. Lots of walkers and bicyclists carrying all manner of things and people - I wouldn't have thought it possible to fill a bicycle with live chickens, until I saw it...

In general, very few Malawians actually drive or have cars to drive, especially in rural villages. So there are pretty much people all over the road...and even if you come along behind them in a vehicle very slowly and blow your horn, they're most likely to turn around and look at you like you're crazy, obviously the road is for walking, you impolite azungu, you.

Here in Blantyre I'm staying at the College of Medicine guest house (UNC project guesthouse roomies - it doesn't even COMPARE.) Its comfortable enough, and my bathroom is en-suite, although the water in the shower is barely a trickle. Theres nobody here besides me, Bill, and a student in Bill's class from Tanzania - who just informed us that he has malaria and is going home. Long story short - lonely week of databasing. There's no internet at the guesthouse so pretty much the highlight of my day is getting here to the College (about a 15 minute walk) to check email and feel connected.

Oh, on Wednesday I had written a long long post with pictures about the day Emily and I spent in Bwaila Hospital (another hospital in Lilongwe). The internet then went out and I lost it. So I'll rewrite the short version here.

Bryce (from Feed the Children) let us know he was bringing in 84 kids from all over Malawi - kids with orthopedic and cleft palate disabilities - for surgical consults. So we high-tailed it over to the hospital where the British orthopedic surgeon (probably the only one in Malawi) got those kids in and out like an assembly line. We saw some amazing cases - kids with club feet, congenital hip dysplasia, fused limbs after crush or burn injuries, a kid who had complete breaks of both femurs after a fall, a baby girl with TAR (thrombocytopenia-absent-radius syndrome...crazy). It was a bit overwhelming, not only these kids but the many others with neurological impairments, fulminantly infected wounds. The kids who the doc deemed to be surgical get brought to Blantyre, operated on, cared for, and 3 wks of rehabilitation, free of charge.

I'll try to attach photos soon! I'm feeling very far away, right now, but trying to keep busy.

Yendani bwino,
mj

Weekend in Senga Bay

This weekend, fully rehydrated and almost completely back to my normal self, I joined about 18 ex-pats (Americans, Canadians, South Africans, Brits, Irish, Dutch, and Norwegian) on a weekend trip to Senga Bay. We stayed in The Wheel House, a huge hulking thing built in the 1800's for some colonialist. The architect humbly put his initials, CS, into every piece of ironwork...as shown here in the window of my room. But I guess it was quite a feat, building this thing right into the rocks atop a cliff...The house itself is pretty shabby and parts fallen into disrepair...which I think just adds to the charm for everyone.

I didn't take a picture of this, but Sunday morning I was drinking my coffee on the round sunroom that looks off the front of the house, and as I set my coffee on the side table I noticed that the pedestal holding the table up was an elephant foot. It was a very Edgar Allan Poe moment and I subsequently lost my appetite for breakfast.

Senga Bay Sunset.

Vervet monkey waiting in the mango tree for us to leave food on the beach...eventually he got tired of waiting and started rifling through some other couple's picnic basket that they had left on a table. I know the monkeys are pests here, kind of like squirrels at home...but they're still cute. Most of the ex-pats who have been coming to this spot a lot have ceased to be enamored with them though...at 5am they start running across the wheelhouse's big tin roof like a herd of schoolkids on the playground.

Senga Bay, Lake Malawi. I don't think the photo is quite exposed enough to see it, but you can barely make out the opposite coast of Mozambique in the haze...

"don't drink the water, there seems to be somethin ailin' everyone..."

Some nuts and bolts...

OK, so theres been a request from my dad for some more info about "people, patients, and your work." i.e., less about puppies and fun weekend trips. Which is fair, and I've been thinking about what to write...its just hard to explain. So I'll start with a few bullet points:

• Where I am - Lilongwe, pop. approximately 300,000. The capital of Malawi.
• Currency - 140 Malawian Kwacha (MK) = $1 USD. Things are really priced about the same, or a bit more expensive. Some things are really a lot more expensive - 8$ for a box of cereal?
• The UNC Guesthouse - is really pretty nice. Hot water, power, and internet...about 75% of the time.
  

My work is coming along slowly - I just finished going through a preliminary copy of the tracing database and sent along a draft of a new tracing form I created to my bosses. I also went on several tracing visits with a couple of the community health workers - this is when they go out and try to track down patients who have been missing study visits, or patients who aren't doing well on their meds and need to have their ART regimens changed. What I didn't realize is that I wouldn't even be allowed out of the car - the stigma around HIV is so bad here, that even the health workers have to dress in indigenous clothes and leave the vehicle far from the patient's home, to avoid neighbors' targeting that person as having HIV. But even just sitting in the vehicle I attracted a lot of attention - practically every kid in the village would show up and start cavorting around the truck and posing for pictures. I'll upload some of those, they're cute kids.

Its so difficult to understand how in a country where as many as 30% of the population may be HIV positive, stigma is still such an issue. There are all kinds of issues, I'm finding, that keep people - particularly women - from getting care. I'm finding it disturbingly common in the database records that women are lost to study or refuse further participation because their husbands beat them or threaten to beat or divorce them if they participate in studies. Partly thats just a poor understanding of what the study drugs and procedures involve, and sometimes the community health workers can talk to the husbands and explain things. But mostly its just a real control issue. The gender-power inequality here is frustrating, its easy to see how it contributes hugely to the AIDS crisis.

Anyway...so what else? The people who work at the Tidziwe Center (research study HQ, and clinical care center) are almost all Malawians, they're very nice but also very busy and I've had a bit of a time figuring my way around and whos who. There are Americans coming and going from UNC all the time so I guess its really no one's job to give me a grand tour. There's also not a lot of space for temporary researchers and students, so I do a lot of my work at home at the guest house.

And I've been spending a lot of time this week at home...but not because I've been working, I've been sick this week. I'll spare you the gory details, suffice it to say that it necessitated first-hand experience of the health care system from the patient's perspective, and now I'm feeling much better. Thanks a lot, Shigella.

Think I'll sign off for now! dinner time.

Nkhata Bay - totally worth getting schisto.

I was able to get away this weekend to Nkhata Bay, which is the most beautiful spot on Lake Malawi! We made the 6-hour trip in Ann and Jason's fabulous land cruiser, which was thankfully up to the challenge of some very difficult roads.

Our lodge was built right into the cliffs on the lake - lots of stairs. Here we are at dinner Friday night: Me, my housemate Megan Parker, Vera (Dutch, working at the hospital), Jason and Ann (Americans, working at a nearby refugee camp), Mike (Duke MBA student, doing research on fortified peanut butter manufacturing for malnourished kids). Not pictured are Garry and Owen (Irishmen, UNAIDS and UNICEF ambassadors.)

The view from the front porch of our cabin in the morning, it took my breath away. Mozambique is on the other side of the lake, but you can't see it. Mayoka Lodge was built by an azungu (foreigner) who spent years living and working in Nkhata Bay. The land was practically given to him because it was so rocky and seemingly unusable - but over a number of years he and his wife built this amazing series of chalets, cabins, and stairs right into the rocks. Mayoka Lodge is now a non-profit that employs lots of people and the profits support families and schools in Nkhata Bay Town.

Lake Malawi is the third largest lake in Africa, and one of the deepest lakes in the world. The water is clear and blue - before it drops off (to over 700 meters!) you can see all the way down to the rocks. Its famous for being home to over 300 species of brightly colored tropical fish, called cichlids. 90% of them are found nowhere else! I wish I had an underwater feature on my camera, the fish were amazing!

On Saturday afternoon we watched a dance performance by women and children from Nkhata Bay town (photo above). It was a fundraiser for the nursery school the town is trying to build. I wish I could attach more photos but the internet is so slow here! At any rate, it was a fantastic weekend of sun, swimming, reading...chill time. I'd love to bring the rest of my UNC Project housemates back - but its such a long, tough drive, I hope we can work it out!Hope everyone is doing well.

Back to work for me, so bye for now!-meg

awww julep.

Today was a glorious day. We got a puppy. She was dirty so Megan Parker and I washed her...and she was still dirty.

apparently dogs everywhere know you're supposed to roll in the grass after a bath.

Our pet goat, Mr. Delicious, is a bit miffed about the whole situation.
But don't feel too bad, he's still the healthiest goat in the whole country.

We named her Julep.