Tiwonanana ku Malawi!

(See you later, Malawi!)

Well, its Sunday evening, and I can't believe it...but tomorrow I'll start my 30-hour journey home to NC. I've got Rusted Root's "Send me on my way" on the iTunes, I'm packing and cleaning, and thinking.

I hope I've been pretty honest on this blog, about both the fun and the tough times here, about the incredible beauty of this country and its people, and painful ugliness of the conditions some of them are forced to live in. In any case, I'm definitely feeling nostalgic, and a little apprehensive about going back to the high-speed United States and MS2 year. Emily was on-point when she said starting classes is going to feel like jumping on a treadmill...one thats already set to 8.0 mph.

But I feel so grateful to be bringing back many new perspectives, great memories, and hopefully a few new skills. I remember back in the winter, working on grant applications with Irving Hoffman - my boss in the ID department back home, and writing a phrase like "to gain experience of how a large Infectious Disease clinical research facility operates in a resource-poor setting." I guess I didn't think much of it when I wrote that - I didn't see why research in Malawi would necessarily be conducted differently than in a resource-rich setting. Maybe not as many hand sanitizers on the wall or computerized medical records software, right?

What I didn't fully realize is that "resources" are way more than computer technology and medical supplies. Resources are employees, and the training that enables them to stay current in the field. Space is a resource, office space, clinic space, parking space. Vehicles are a resource. Phone cards are a resource. Electrical power and clean water, obviously, are resources that we take for granted at home. Government support is a resource. I think about how much less research and clinical care would get done at UNC-CH if any one of these things were lacking, and then I think twice before expressing my frustration about the realities of research at the UNC Project Malawi. The clinical staff and research staff are all doing a phenomenal job and I feel very privileged to have had the opportunity to contribute in a small way and learn in a BIG way.

Speaking of my itty-bitty contribution, a few things have been accomplished that I'm excited about/proud of:

1. The Community Department is now using exclusively the form I designed to collect patient information when they go on tracing visits. The new form will tell the Project much more about patient demographics, and about why patients are missing study visits.
   
2. The Data Department is transitioning to the new tracing database, which will simplify the work of the CD, reduce data entry error, and facilitate quick and useful analysis of trends in patient retention. (I owe Bill Miller about a million cappuccinos for his help in designing this!)

I'm now working on a real paper (!) which will be a comparative analysis of patterns in patient retention in one of the large HIV treatment trials with retention in another of the Project's HIV prevention studies. Hypothesis: they'll be different. (Another thing I've learned about clinical research this summer: baby steps.)

I'd like to think I'll be coming back to Malawi - its a great place to be for both infectious disease medicine and research, of course, but also a genuinely friendly, beautiful, and relatively safe country. Not speaking Chichewa is the biggest road-block for me, and post-colonial tensions notwithstanding, I don't think I'd be comfortable long-term without more of the language just because its what my co-workers use to converse. What I notice is not so much a lack of literal understanding, but the dearth of that emotional understanding that comes when people speak the same language.

A long rambly post with no pictures...but maybe this entry is more for me than you :)

My flight tomorrow leaves Lilongwe (God willing) at 2:45 pm, and my looooong flight leaves Jo'burg, SA at 7:10 pm. After 18 hours I hope to arrive at JFK Int'l at 7 am EST, where I shall make a beeline for a venti Starbucks iced coffee and a vapid magazine. Old habits die hard. Plus I've got 5 hours to kill before my flight to RDU.

(You may or may not appreciate the Megan-ness of the moment last Friday, when I suddenly realized I had scheduled this last leg of the flight for June 29, and not July 29. Obviously I missed that flight, a month ago. Whereupon I called my parents in a panic, forgetting that a) it was 4am their time, and b) getting a flight from JFK-->RDU was not going to be very hard. Thanks mom and dad :)

I can't wait to see everyone back home, thanks for all the emails and comments, and again, thanks for reading.

Basi. Ndapita.
("Thats it. I'm outta here!")

South Luangwa National Park, Zambia - Its safari time!!!

This weekend, with the soundtrack of The Lion King playing in our heads throughout, my guesthouse-mate Miriam and I went to Zambia! The journey to Mfuwe, Zambia was a pretty exhausting 8-hour trip from Lilongwe, complete with border-crossing frustration and ineptitude (some things are the same in EVERY COUNTRY) and incredibly bumpy roads. Fortunately our bus did not shake apart and we made it to the lodge late in the evening, only to discover all of Zambia had been without power all day. Which made things a little trixy, as our lodge is located right on the edge of the (fenceless) park and the animals were well-known to hang out there at night.

I can't fully describe (or imitate) the sounds hippos make, its something like a roar. But I wish I had a soundtrack of the sounds we went to sleep and woke up to in the morning - hippos splashing, strange bird calls, elephants trumpeting, monkeys wreaking havoc...pretty incredible. This was mine and Miriam's little chalet - very safari chic!

We woke up at 5:30 am and were in our safari vehicle, headed to the park entrance, by 6am! There were ten others in our group - two just-graduated university students from England, three Dutch medical students, and five other Dutch students. It was nice to have a young group, pretty much up for anything, and I learned to count to ten in Dutch.

Sunrise over the Luangwa River, which divides the National Park (left bank) from the Game Management Area (where we stayed, to the right.) The park is almost 10,000 square km in area - and no, after almost 9 weeks here kilometers still mean nothing to me. But that's a big park.

South Luangwa is not as well known as some other parks in Tanzania or Kenya, or Krueger in South Africa, but the game is more or less the same, minus rhinos. This meant the park simply wasn't as crowded; although we would see several other safari vehicles each day, in some of the more famous parks there are literally lines of vehicles trolling through, which I imagine would be a bit of a distraction.

I'm pretty sure the animals are conspiring on this point - they don't want to show you too much, too fast. So for a while, all we saw were impala - which are these gorgeous little dip-dyed creatures a little smaller than American deer. And they're so graceful to watch, I never got tired of seeing them.
Lily-pad laden lagoon complete with crocodile sunning himself and hippos in the background. As I've mentioned, its the dry season here, so the landscape of the park was really pretty desolate. We still saw an incredible amount of wildlife for things being so barren and dusty!

Yellow baboons doing what baboons do.

We saw LOTS of elephants, several too close for comfort.

Hyenas are really kinda creepy.

Finally, a giraffe! (Or "und heeraff!" as the charming Dutch liked to say.) This big guy was standing in the middle of the road when we happened upon him -he moved off to the side to chomp some trees and pose for photographs.

Speaking of posing - I think zebras are really quite vain animals that love being photographed. I took about a thousand zebra photos, in all of which the zebra seems to be saying, "Oh yes, i'm SOOOO pretty, just look at all my STRIPES!"

I don't think I'd ever seen a zebra before in real life, actually. They don't survive well in captivity, their hooves turn inward and they go lame, so there are very few zebras in zoos. They're about the size I would have expected, a little bit smaller than horses and pretty stocky. Some of them were downright fat. And they all have the coolest mohawks!

Mother and child hippo crossing the Luangwa River at dusk.

Our eagle-eyed Dutch compatriot Yelnik (totally incorrect spelling.) spotted this leopard on the morning of our second safari day. We're pretty sure he/she had his eye on the small herd of impala grazing nearby - unfortunately after we stared at him for half an hour, eventually he decided he'd just lie down and wait us out.


We had a very lucky safari in terms of seeing the big cats. Our guide told us at the outset that the likelihood of seeing lions and leopards was around 50% - and during our two days in the park we saw three leopards and 15 lions, including males, females, and cubs. I hope that means the animals are thriving in the park.

I didn't get any pictures of our two night safaris, for obvious reasons. Our first night drive was less than enjoyable - just us driving around in the dark with a guy panning a floodlight back and forth, back and forth, for two hours. We didn't see anything new except civet cats (picture a creepy combination of a cat and a raccoon.) And it was unnerving just to catch the same animals in the dark that we'd seen in the day - hippos and elephants and impala mostly, all settling into sleep or nighttime grazing. It felt very intrusive - I couldn't help thinking how I'd feel if the monkeys outside my chalet insisted on shining bright lights in my face while I was brushing my teeth, putting on my pajamas, etc.

But I have to say the second night drive was truly spectacular - while driving along the riverbank we happened on a pride of lions - a male, several females and three small cubs. A hippo had been killed nearby, although we didn't see it. Hyenas had been trying to get at the meat, tearing off small chunks, and we watched as the male lion let out this big roar and chased several of them down. There's nothing like hearing that sound in real life, 20 feet away.

The safari was fantastic - although I couldn't ever really shake the feeling of "we're-really-not-supposed-to-be-here." It was nice, though, to see the occasional vehicle full of Zambians or Malawians, and not just white tourists - if touring the park helps people who live here appreciate their natural spaces, maybe they'll be less likely to cut/burn it all down for the more immediate gains of lumber and agriculture profit.

Home in six days! I've got my work cut out for me here, better get to it!

Thanks for reading.

The children of Dzama village

Today I went with Chimwemwe, a woman I work with in the Community Department, to the village of Dzama, about 20 minutes outside Lilongwe. The UNC Project has "adopted" Dzama, so to speak - in 2005 it financed the building of a water-pump and in 2006 a school for the very young kids in the village. When Dr. Cohen, the head of the ID department at UNC, was visiting a few weeks ago, he told me about Dzama and about the dire need for a primary school there. He hoped that as co-president of my med school class, I could get our class excited about the project, organize/fundraise, and he pledged that the ID department would match our funds, to the $15,000 needed to build the school.

So today I went to check things out - and became truly convinced of both the feasibility of this project and the great impact it would have on the children in this community.

Dzama is a village of around 400-500, no one could give me a good estimate, but there were 50 children between the ages of 3-6 in this classroom today, I just judged from that and the size of the village area. People with land grow corn and tobacco - but nothing is growing now, because its winter, the dry season.

These kids were the most orderly bunch of five-year-olds I've ever seen - sitting politely in their desks and greeting my halting Chichewa with "Good Morning!" They were sharing one box of crayons and a pad of paper torn into strips. OK, it was a 96-pack box...but still.

The schoolhouse is lit by four lightbulbs which hang from the ceiling and are powered by a single solar panel on the roof. The village has no electricity or plumbing, except in the school outhouse (also built by UNC Project.)

During the dry season in particular, food is very hard to come by. The fact that the young kids have this school means that even with its lack of books and supplies, they will get at least one noontime meal of porridge every day. When the children get to be 7-8, they're old enough to walk to the government primary school, 7 miles away. But the school is crowded and often without teachers.

So...here's the pile of bricks! Just a few short steps away from being a school, right? Unfortunately, the bricks have been there for a while, and the slightly-older boys (like the one in this photo) have discovered it's REALLY FUN to climb up the pile and throw bricks off the top. I tried to explain to them that if they want to break all the bricks, I can't help build them a school. Not sure how well that translated...in fact I'm pretty sure this kid climbed back up there after I walked away.

These are three of the teachers and one of the community leaders I met to discuss ideas and needs for the secondary school. They didn't speak too much English, so Chimwemwe helped me a lot with interpreting. She said they do try to teach the children English words - but its hard to get teachers who are fluent in English, and for children who may never get far from Dzama, it might not be the most important thing. Wouldn't it be exciting if a couple of UNC students could come over every summer to teach some English classes? Hmmm...

The school is in dire need of supplies - pens, paper, crayons, books in English of any description, preferably children's books, soccer balls (I've been impressed in every country I've ever visited, just what people will improvise as soccer balls.)
UNC Project (with the help of Dr. Gilligan, everyone's favorite microbe man!) also recently started a sustainable livestock program for the community - i.e., they bought the village 30 goats and built a stable for them. Ideally, the goats will breed and have baby goats, some of which can be sold to generate income for the school, and some of which may be used for meat for the children, who don't normally get much protein at all. (Its a sad irony of Malawi that they use only the nutritionally-lacking part of the corn to make nsima, and grind up the nutritive hulls and husks for sawdust, but thats the way things have been done forever.)

The goats seem happy to be sustainable. At least for now, before the dark intentions of the project reveal themselves to them...bwahahaha. OK its late, I may be getting a little punchy.

Right before I left, I took what may be the first-ever Dzama School Portrait. I'm going to print it out big and send it back with someone coming to Malawi from UNC soon, so they'll have it to hang in their classroom!

Long story short - I'm inspired. Hopefully my classmates will be too - if any of you are reading this and have ideas let me know! And if anyone wants to help me get these kids some books and soccer balls...they would very much appreciate it :)

Tomorrow I'm going to Zambia for safari! I'll (fingers crossed) have lots of pictures of lions and impala and buffalo and elephants and giraffes and zebras when I get back Tuesday!

Thanks for reading.

Nkhata Bay 2! Choose your own adventure...

This past weekend Cameron, Miriam, Kate, Emily, and I went back to Nkhata Bay - the gorgeous lakeside village where I spent my first weekend in Malawi, 7 weeks ago! Since the roads getting there are pretty rough, and we were without a car - we decided to take the AXA Commuter Bus from Lilongwe. We should have known we were in for it when the ticket ladies laughed in our faces when we bought our tickets...

For the narration portion of the Nkhata Bay adventure, I'm going to refer you, good reader, to my lovely roommate (and MS2 classmate) Emily's blog, roemerinmalawi.blogspot.com. She wrote a great entry with lots of good pictures. I'll put a few more pictures of the weekend up here.

All I have to add is that we spent 56 hours on this trip...17 of them in some sort of vehicle. We all agreed that at home, we'd think it was absolutely crazy to drive 8 hours each way to get ANYWHERE for a weekend...but Nkhata Bay was worth it.

Neat quotes painted on the walls of the Mayoka Lodge restaurant

Mayoka Lodge

Acrobats performing a charity show Friday night.
Our afternoon boat ride included a stop at a secluded beach nearby, where these kids got a kick out of looking at pictures of themselves...and we got a kick out of taking them :)


This sweet girl inspired us to try and tie our chitenges like hers :)
5pm, hippie boatsmen singing, sun setting.

Kamuzu Central Hospital

Last week I spent Tuesday and Wednesday in the Pediatrics ward of Kamuzu Central Hospital. The hospital is right next door to the UNC Project guesthouse and the Tidziwe Center, but because Tidziwe is where the HIV research goes on, I hadn't seen much of the hospital until today!

Malawi does have a national health program that provides free care to children under 16 - to the extent that care is available. Every baby born is issued a "Health Passport" - which is a passport-sized notebook that both adult and pediatric patients are expected to bring to any doctor's visit. The HP contains all their immunization documentation, the patient's medical history and all doctors' notes, including HIV testing and results, and all prescriptions. Its not EMR - but I think the HP is pretty ingenious - its a great way to flip through and get a detailed picture of the patient's health throughout life. If you can read the handwriting, that is.

Unfortunately this really isn't the place to ask to take pictures of people...so I had to snap these when no one was around.

This one's for you, Dad...notice lack of red Radiation trefoil logo...
but at least they're welcoming!

I started my day at 8am, sitting in on the weekend hand-off meeting between the weekend staff and attending pediatricians. The clinical officers and a couple of newlY-minted Malawian pediatricians (very sleepy ones) each gave a run-down of what happened in the ward each day of the weekend - admissions, transfers, complications, and deaths. For each day they would pick a couple of the most complicated or interesting cases, and discuss that patient's course of treatment. The chair of the pediatrics department, "Dr. M" ran this meeting, and was grilling these students and young doctors pretty hard, interrogating them about why they made the treatment choices they did, and telling them what could have been done better. Gotta love that Socratic method.

After the meeting I followed Dr. Portia Kanthunzi on rounds. We started with a 12-year-old girl with bacterial meningitis in the High Dependency Unit (a.k.a. Peds ICU), saw a baby with malaria and a 5-year-old with diabetes - a particularly rough diagnosis in a country where the staple food is finely-milled cornmeal. A visiting physician from China, Dr. Chen, was observing for the week: he LOVED to ask me questions and his English was only somewhat better than my Chichewa. So the three of us saw patients pretty slowly - with Dr. Kanthunzi paraphrasing into English what the kids' parents would say in Chichewa, and me translating Malawian-accented English into American English for Dr. Chen's very tiny Chinese interpreter, and she translating into Chinese.

I was pretty relieved to get to spend the rest of the morning with Dr. Patty - a HUGE Congolese internist who came to KCH through UNICEF. We spent most of our time working up A 7-year-old girl who appeared to have acute kidney failure, possibly hemolytic uremic syndrome, secondary to malaria. Around lunchtime he sent me with the poor girl's urine and blood samples in hand, to take them to the UNC lab at Tidziwe. Although designed for the HIV clinical trials and research studies, the UNC Project gets a lot of use from KCH and they're so grateful to have it. Without it, they couldn't do liver function tests or really anything other than a full blood count.

I think I mentioned this before, but most Malawian hospitals don't provide food our laundry service for the patients. So all kids admitted to the hospital come with a guardian, usually a mother or grandmother (who usually has one or more other children to take care of, so they come too.) The guardians prepare meals and wash linens for their children, and mostly just live and wait outside the hospital. This is a shot I took from the Peds hallway, of one of the yards right outside.

A day in the life...

As my summer here is winding down, I thought I'd put together some miscellaneous pictures into a composite of what an average, workin, weekday is like for us here. Its really not all hiking and gorgeous beaches and exotic animals, I promise.

6:30 AM - Morning run through cornfields, push-ups. Emily is my push-up guru.

7:30 AM - leisurely breakfast and working at the guesthouse.

9:00 AM - Today we went to the bank, because 20,000 kwacha just doesn't get you too far...

9:30 AM: Picking out fabrics and fresh vegetables at Devil Street Market.

12:30 PM: We've now officially crossed over from "mwadzuka bwanji" time to "mwaswera bwanji" time. Time for nsima lunch with the staff at Tidziwe.

1:30 - More work in the guest office at Tidziwe.

4:30 - Playtime in the front yard. These boys are Joyce's sons and some friends.

4:23 PM - Emily juggles potatoes for the adoring crowd.

7:00 - Guesthouse dinner! It's an ever-changing crowd, and odds are good we're eating a curry.

8:00 - E! is the only channel our satellite dish reliably gets...fortunately Julep loves watching Denise Richards' new reality show and reading Us magazine.