Day 10, Children of ash and dust

We met at the dental clinic at 8 AM to take the bus to the Dzleka Refugee Camp. The bus ride to the camp gives me a chance to mention how road construction works in Malawi.

Any road under construction has a “diversion” dirt road running alongside of it. This dirt road often switches, apparently at random, which side of the inactive road it is on. This forces the driver to slalom back and forth over the main road, spending time battling through clouds of red dust from preceding motorists, ox-carts, and herds of goats. It makes for an interesting ride.

While we were making our way to the camp, I imagined we’d pass through a barbed wire fence with needy faces peering at us with hollow eyes. Instead, we arrived at a small health center about an hour from Lilongwe. The four rooms were like American walk-in closets, and there was a waiting room with three walls. The clinic was originally intended for children, but once the word was out, anyone and everyone showed up. Evidently, the camp was just over the hill and housed many people.

I asked our preceptors what nationalities were represented at the camp. Among those countries mentioned were Ethiopia, Somalia, Rwanda, Botswana, and the Democratic Republic of Congo. Language had been a barrier for our whole trip. In this instance, with all of the languages in a given African country, it almost proved insurmountable. I was reduced to a very rudimentary pantomime.

My first rotation was in ART (atraumatic restorative therapy). Due to a lack of facilities and space, I straddled the end of a bench. A Rwandan woman laid down on the bench with her head in my lap, and I began scraping out the decayed parts of her upper right first molar. After cleaning the cavity the best I could, I filled the hole with a glass ionomer filling material.

I then switched over to diagnosis. When I opened the door from the ART closet, I found the entire hallway literally clogged with refugees waiting in line. I bodysurfed/forced through the crowd, which was not the first time on this trip I found myself lamenting my enormous gut. Once through and into the waiting area, I saw the extensive collection of people waiting to get treatment.

After collecting names, tooth counts, and disease states, I transferred to scaling. Dedicated readers will be familiar with my stories of calculus, but again the bar was raised. When I walked in to relieve Anina, she smiled both gratefully and sarcastically while handing me a scaler. “Good luck – I’ve done the facial side of the anterior sextant.” When I sat down and got to work, I saw what she meant. An hour into my continued scaling of the patient, I had to call over the preceptor. I thought I’d broken a decayed tooth in half with the instrument. He assured me that I had simply knocked free a calculus deposit so large that it appeared to be an additional cusp. After it was removed, the gum was over a millimeter away from the tooth – the calculus had pushed it so far away. Needless to say, there was ferocious bleeding. He took it well, though, and said “God bless you, sir.”

I spent the rest of the day scaling. It was grueling, bloody work.

The ride home was again along the red-dust-diversion-laced roads. Malawians seem to set lots of fires, so the air is always flavored with the sweet tang of woodsmoke. The sun was setting, and occasionally, it would strike perfect silhouettes of the folk we passed between the road dust and the smoke. A cyclist hauling a load of sugarcane was enshrined in amber light as we crested a hill. Some boys playing soccer were perfectly framed in red and black as the setting sun set the colors of the dust on fire. If Malawians could market their sunsets, they’d be able to afford more dentists.

When we got home, I found that our housemates had purchased a pair of goats to celebrate the end of our collective time in Malawi tomorrow. I’m hoping I won’t be around when they’re prepared. It’s like stepping up to grad school in terms of the animal slaughter, and I’m content with my BA in chicken chopping. Hopefully the goats won’t eat my laundry before we eat them tomorrow.

Our last working day in Malawi is tomorrow. We’re going to see an HIV/AIDS support group in Salima, a town next to Lake Malawi. With any luck, we’re going to stop by the beach before coming back to Lilongwe.

Day 9, Happy sick kids, sad well Kev

We started by heading over to Baylor University’s pediatric HIV/AIDS clinic. The Baylor clinic looks particularly out of place compared to the other buildings on the Kamuzu Central Hospital campus. It’s new and clean, and it looks as if someone picked it up in suburban America, gently carried it over the ocean, and set it down next to the hospital.

The doors open at 8 AM, and we were told to arrive at 8:30. The waiting room was PACKED with children and their parents. Most of the children were frolicking like children do, not demonstrating any effects of the sleeping infections they carried.

The room where we were supposed to meet our preceptor for the day was in use, so we waited in the administrative waiting area. A coffee table book entitled “The Art of Texas Children’s Hospital” caught my eye. I found myself tearing up as I flipped through the pages.

When I was five years old, we moved to Houston. Shortly thereafter, I woke one morning unable to move my neck. My mother is a nurse, and she became alarmed. I went to the doctor, and I soon found myself admitted into Texas Children’s Hospital. I had an infection - that much was clear. Beyond that, the doctors were fairly stumped. For two weeks I was an inpatient of steadily declining status. Despite my current girth, I was a skinny kid to begin with, but I quickly began losing weight. I was subjected to a battery of tests, including a spinal tap, and my infection continued to grow. Two weeks into the process, a young doctor noticed that I cried when he touched one of my teeth. The tooth was pulled, and I recovered completely.

The book included a photograph of a mother lying in a hospital bed with her child. It hit home that my parents must have felt completely helpless as they watched their youngest son begin to waste away. My mother stayed with me all the time, and my father would come and spend the evenings with me after getting off work. Occasionally, he’d smuggle in a little Kentucky Fried Chicken to my delight. During the entire process, I never saw my parents upset. I can’t imagine the burden they were carrying, and the strength they showed by never letting me see them strain under the weight.

I put the book down, and I looked down over the balcony. Below were dozens of parents of children afflicted with a horrible virus, and the children who for the most part waddled around completely oblivious to their status. I felt a certain kindred spirit with all of them. I knew there was no tooth we could pull to let them go home and get on with their previous lives.

Our preceptor arrived, and brought us into the board room for a brief review of the oral manifestations of HIV/AIDS. We’d all taken oral pathology, but the review was a useful primer. Most of the conditions mentioned are seen comparatively rarely in the US due to widespread and consistent use of anti-retroviral drug cocktails. In Africa, some of these complications are more commonplace. After he did a quick check with the unit’s pediatricians, we headed over to the wards in the hospital to meet two patients.

The first child was a two-year old boy afflicted with noma. Noma is a horrid, disfiguring condition associated with a particular combination of HIV/AIDS, malnutrition, and other factors. If you’d like to see it, I’ll let you google it with the warning that it is truly horrible. Our patient had already had surgery, so we were seeing it after some improvements had been made. In noma, an infection can bore holes in the patients face, sometimes eating away flesh to leave gaping wounds. Our patient had a hole just below his chin opening into his mouth. The surgeons had removed all the infected tissue and placed him on antibiotics to remove the bacteria responsible. The child, once he realized we weren’t going to hurt him, didn’t even cry when we surrounded his bed to take a close look. He’s expected to recover from the noma, but he’ll still need to battle HIV/AIDS for the rest of his life.

Our second patient was a one-year old with Kaposi’s sarcoma. Kaposi’s sarcoma are purplish tumors associated with later stage HIV/AIDS infections. They can be found on the skin, in organs, or in the mouth. Our patient had one on the side of the cheek, with a white spot where he’d been chewing on it. Again, this is a child who cannot be cured from his infection by any magic that science possesses.

After the morning, we decided that we needed a break from the hospital for lunch, so we drove out to a nice restaurant. We took our time (as everyone does in Malawi) and savored the break from the rigors of our day’s experiences.

When we returned, we went to the hospital dental clinic, but found that there were no patients for the afternoon. The dentists were scheduled to be in the operating theater all day, and the dental therapy students were taking exams. We returned to the guest house.

Jiayin’s room occupied by a newcomer, a nursing student named Amber. Following the lead of those who were at the guest house when we arrived, I took her on a brief tour of the campus while my teammates took yet another trip to the curio market. Amber is UNC’s first nursing student to come to Malawi, and she was very friendly.

After the tour, I went with Trevor (med student) and John (surgeon) to the ABC Christian Center gymnasium to demonstrate my legendary basketball skills. We found a ragtag collection of professors and pastors engaged in a shootout, and we joined them for a game of 4-on-4. I shot 0 for 175 in the first game, and 1 for 5345 in the second. Just my presence in the room lowered the shooting percentages of the poor fools who were doomed to be playing alongside me. To those who were ruined, I am sorry, but I was totally open.

We got home just in time for Joyce’s delicious spicy chicken stew. After a few games of Tonk with Amber and the others, I went to look for Julie online. Luckily, I was able to find her.

A few extra pics are here. There are the white-breasted crows that correspond to the traditional all-black American models, a tiny gecko living in Trevor’s room, and some incredible Malawi sunsets.

Day 8, The surreal life

We gathered at 9 AM with the head of the dental department to head over to KCH’s pediatric oncology ward. She’s a dentist who is pursuing public health training through a school in South Africa, and as part of her research she’s performing work with Burkitt’s lymphoma patients. Burkitt’s lymphoma is a cancer associated with the combination of Epstein-Barr virus (the virus associated with mono) and malaria (amongst other things). It affects the oral and abdominal cavities in particular. You can see what it looks like with a quick google search, but I’ll warn you that it’s not pretty.

The cancer ward itself is probably a lot like you’d expect. Eight beds are in each “ward” of a four-ward open air room. The rooms are painted hospital green, and the only privacy available is a two-panel portable screen. A playground in the adjacent quad is painted with images of African animals, many of which are extinct in Malawi due to deforestation. A school is present for those who have extended stays. Many have been referred to KCH from distant locations, and some will stay at KCH during the months and weeks treatment is provided.

We began rounding with Dr. Mlotha, who was checking up on some previous patients and screening some new ones. We started with a little boy of no more than five years, who had a recurrent lesion on the skin below his jaw. After we left, he played with his infant sister, who his mother held in her arms. It was all downhill from there. A two year old with liver cancer. A seven year old with lymphoma spread to the eye socket and lymph nodes of the neck. Another liver. I won’t go on and on about it, but it was a challenging experience.

After making the rounds, we returned to the regular hospital dental clinic, where we set up shop in the extraction area. I did a few anesthetizations, extracted a few teeth, and got to talk with the dentists in the operatories. We broke for lunch, and then returned and did a few more rounds in the clinic. The pace in the hospital clinic in the afternoon is less hectic, but we got to see some more interesting cases in the surgery clinic: a child with trauma to the front teeth, complete with broken jaw; a man with a mandible broken vertically down the ramus; a woman who would be seen for an excisional biopsy of a probable fibroma. The variations seen in the surgery clinic are really remarkable.

The hours that followed will remain, I hope, the most surreal since my arrival in Africa. The former manager of the guest house, who I’ll call Steve for the sake of anonymity, is a currently serving member of the Malawi Parliament. He took us to dinner at a private club in town. I simply can’t recant the particulars here, but the next time you see me ask me to describe it for you. Steve was very nice to take us out, and I’ll leave it at that.

Tomorrow’s day will be spent at Baylor University’s HIV/AIDS clinic, so I’m sure I’ll have more to write about tomorrow.

PS – No pictures today, as I can’t get my SD card to read on my computer. Tomorrow I’ll borrow a cable and get them in, and edit the blog. The sunset tonight was particularly spectacular, as was the tiny gecko which lives in one of the rooms of the guest house.

Day 7, Deep breath before a plunge

Sunday is a day of rest, even in Malawi. The morning was spent playing a few more rounds of tonk followed by saying goodbye to Jiayin, who left today to return to Chapel Hill.

I sat on the front porch, sipped on bottled water, and finished my first book of the trip, The Great Gatsby. I really enjoyed it. I’m pretty sure I attended school with at least half a dozen Tom Buchanans in my various phases of studenthood (present company at the UNC SoD excepted, of course).

After some cold chicken, I took a walk around the overgrown areas behind some of the hospital buildings. Having done some pre-reading on Malawi’s herpetofauna, I wasn’t in my usual mode of log-flipping and rock-lifting. I was, however, hoping to catch a glimpse of some animals.

The efforts paid off nearly immediately. At first, I thought it was a squirrel, before I remembered that I was in Africa. A small, slender mammal quickly hustled into a pile of debris, but after flipping through some field guides I feel confident in identifying it as a mongoose. Exciting, but now my “Well, here’s where Kev dies of cobra bite” radar was going off the charts.

The only other animal I found, apart from several pretty and too-fast-to-photograph birds, was a small gecko of a different variety than the ones living on the side of the house. This one was dark and speckled, but the enormous genetic diversity of geckos combined with his quick escape will prevent definitive identification.

I found no snakes, and it’s probably just as well. Today had fewer interesting pictures, but here're an unidentified fruit tree and some cool leaking sap.

For those expecting stories of my dominance on the Ultimate field, a scheduling conflict made it impossible to attend. Instead, we had been invited as a group to an early dinner.

The Baylor School of Medicine also runs an HIV/AIDS clinic adjacent to the central hospital, and at 3 PM we were driven to the director’s house. Again, the grilled goat and chicken were the prize winners, along with some delicious rice and potatoes. For the first time, I tasted the traditional dish of nsima, which is a mix of maize flour and water prepared to a consistently not unlike Play-Doh. It’s completely flavorless and eaten with your hands. The texture wasn’t particularly appealing, but the company was excellent.

We were fortunate to have eating with us several participants from the International AIDS Society’s July meeting. It was fascinating to hear the problems of sub-Saharan Africa straight from those at the forefront of confronting them. In addition, we were treated to the company of some of the few Malawian dentists in existence. Their efforts to bring health care to such an underserved population deserve particular recognition.

We then went home to get to an early bedtime. At 9:00 AM, we’re rotating through the pediatric oncology department at KCH, followed by work in the dental clinic in the afternoon.

Day 6, I need money for transport

Today began a little later. I planned on sleeping in, but the guards right outside my window began talking soon after the sun came up. Only my suitemates, Jiayin and Mike, were awake. I did a load of laundry (the chicken blood stains laughed at my meager Tide), hung them on the line to dry, and waited for the rest of my crew to awake.

Evidently, it had been a long night for my teammates. One of our team had managed to chip a tooth of another of our housemates, and no one had gotten home until very late. Bryan emerged around 11:00 AM and announced Silas was coming over to take us to get some more Kwacha (Malawian currency).

On the way home, we stopped by a fried chicken place. I went ahead and ordered a nine-piece box for myself. I’ll have breakfast for at least two days. In the world of Malawian fried chicken, you might say that the secret ingredient is salt.

After a leisurely lunch and a few thrown Frisbees, we decided to take a trip to the local curio market. Mike drove us in, and we met with another researcher who was skilled at negotiating with the local craftsmen. Dozens of vendors had their wares laid out across a parking lot. Wooden animals of all description, painted scenes of fishermen on Lake Malawi, folding wooden chief’s chairs, and all sorts of clever jewelry were available for negotiation.

As soon as we got out of the car, we were swarmed with vendors introducing themselves. “Hello, friend. My name is Charles. I have something to show you. Remember, it costs nothing to look.” Each one insisted that business had been terrible that day, and in order to secure money to pay for travel home, he was willing to give us a truly low price. I picked up a few small carved wooden pieces to bring back home.

We went to Mina’s house for a housewarming party. Mina’s an infectious disease specialist who runs the medical school’s Malawi Project. Her house was incredible, set in a neighborhood of huge, individually walled-off estates. There were fruit trees in the gardens, cokes and cold beers in the cooler, and goat on the grill. It was utterly delicious.

Keeping up my pattern of near-continual exhaustion, I opted out of going clubbing tonight. No pictures today – sorry. Tomorrow I’m planning on playing ultimate with some of the UNC folks for a few hours. We’ll see how the weight that I’ve lost on this trip, my comparatively well-skilled throws, and my inability to run for more than three minutes will balance out into a gametime performance.

Day 5, A day of firsts

We woke up early and headed 60 km south of Lilongwe to the Nkhoma Mission Hospital to run a free dental clinic. The road south was very different from the road we’d taken the preceding day. For the most part, the same crew as the preceding day piled into the minibus and sputtered along through the surreal landscape.

The road wound through several small villages, and in these locations the minibus had to contend with lots of pedestrian, goat, chicken, dog, and ox-cart traffic. We crept through dirt road detours and avoided bicyclists carrying impossible loads.

The landscape is remarkable for its general flatness. Subtly rolling hills are the norm, but they only allow you to have a slightly improved view and don’t give a sense of going up and down hills. Jutting up from these plains are enormous mountains of granite, sticking out like gorgeous sore thumbs. These became more common as we headed south, and eventually became continuous enough to be called a “range.”

Once in the mountains proper, we took the winding road to Nkhoma Mission Hospital. We were introduced to the patients as having “flown in on a big plane across a very big lake,” and they applauded us as we said our names. Like yesterday, we had multiple stations running simultaneously. One group diagnosed disease and referred to the three other groups for treatment: scaling, non-traumatic restoration, and extraction. Each of the UNC folks rotated through these departments. The group wasted no time in jumping into action, since they were lining up immediately, and as word spread to surrounding areas, the lines got longer still.

Many patients hadn’t heard English before. The area was decidedly rural. Women unabashedly breastfed their babies as they listened to the oral hygiene instruction that was given before the clinic opened. Older children played with bottle caps on the benches, or climbed over one another in the dust.

I found myself in the extraction room first. The doctor I was working with anesthetized the first patient and sent him back into the hall while we waited for it to take effect. I watched his technique as he explained his methods. When the next patient came in and sat down, he prepared the syringe and handed it to me. I smiled uncomfortably and said “I’ve never done this.” He responded with “Well, this will be the first time, then.” With his guidance, I successfully anesthetized the poor guy. Within the first half hour, I’d given two injections and extracted six teeth from children and adults. First injections, first extractions.

I’ll briefly mention the scaling again. Today was much worse than yesterday. In my scaling rotation, I worked on a single patient the entire time. Each tooth was coated in at least one solid millimeter of rock-hard calcified plaque. Working on a patient like that, with the wrong tools and an ergonomically untenable chair-operator arrangement, was a challenge for my back and my patience. We’ve got tomorrow off, so hopefully sleeping late will help.

We came home to a Joyce-prepared dinner of chambo (a tilapia-like fish from the area), rice, and vegetables. Our housemates, however, had decided that tonight was the night for a chicken barbeque. As we exited the bus, we saw four live chickens sitting with their legs bound on the front lawn.

At home, I get pre-butchered chicken from anonymous chicken factories. In Malawi, you do the dirty work yourself.

I decided that tonight was a good time to determine how comfortable I am with my omnivore status. I thought that if I was willing to eat chicken, I should also be comfortable slaughtering chicken. When it came time, I volunteered to slaughter one of the birds.

I’ll spare the details, but it’s not a particularly horrifying experience. In order to spare the chicken undue suffering, I decapitated it quickly. As a side effect of not letting it bleed slowly to death, my shoes and scrubs suffered some collateral damage (take a close look at the picture). We gave the innards and feet to Joyce. We didn’t ask what she used them for.

The chicken, which was as free-range as you can get, was grilled over illegally-made and illegally-purchased charcoal sold by men carrying enormous loads of it on their bikes. Real free-range chicken is tasty, but tough and chewy. A long night of card games followed, and when my housemates decided to go clubbing with a preceptor or two, I decided to call it a night. Who knows what’ll be here tomorrow? I have no agenda.

Day 4, Getting out and working

This morning, we crowded into our minibus with people from KCH’s dental clinic and folks from the government dental program and headed to Mchinji, specifically the Home of Hope Orphanage. Chances are you’ve heard of the place. It’s where Madonna adopted two children. I saw no sign of her intervention on the behalf of the rest of the children.

We stopped on the way out of town at a 7-Eleven to pick up whatever we wanted to bring along to eat along the way. I settled on a croissant from the bakery counter, a Nestle Crunch, and an orange Fanta. I wanted to set a good example.

It takes about an hour to drive there, and along the road we passed dozens of tiny gatherings of huts built of homemade mud bricks and thatched roofs. Apparently, brickmaking is an important job, as there were rows of fresh bricks drying beside every such hamlet. The more “urban” areas brought back my foggy memories of Mexican border towns. I think it’s just what poverty really looks like. I spent most of the time talking to one of our preceptors, Dr. Silas Bere from Zimbabwe. Trying to explain American politics in three or four sentences is difficult.

The roads go from paved, to dirt, to one-lane dirt as we arrived at the orphanage. Like any property here, it’s surrounded by a brick wall, although this one was set with jagged sections of broken glass across its crown. The gate was operated by one of the older orphans.

When the minibus had finished meandering through the dirt path that ran between the buildings, we exited beside a playground that consisted of a rusted metal set of monkey bars and a merry-go-round. Only one boy, I’d guess 7 or 8 years old, approached us and then climbed the monkey bars. He was nibbling on the end of a toy tobacco pipe made of a spring and a bowl.

While the staff from the hospital assessed our facilities, I played with the children. Thankfully, the ticklishness of feet is not specific to North America. They started suspicious, and then simply cool, and then began to play back. They were particularly excited about the camera, and they loved looking at the pictures as soon as they were taken.

In groups, the kids were lined up and run through the diagnosis room. After an assessment that included age, number of teeth, number of grossly decayed teeth, and status of calculus (tartar for you non-dental kids), they were referred to oral hygiene instruction, scaling, or extractions. Each of us UNC folks rotated through diagnosis, scaling, and extractions. We gave away all the toothbrushes and a significant amount of the toothpaste that we had carried across the ocean.

When I’m doing scaling at the UNC clinic in Chapel Hill, I have access to a bevy of specialized tools for getting to specific surfaces on specific teeth. At the orphanage, I had one randomly assigned scaler and no mirror. We worked with the dental therapists on everything: diagnosis, scaling (I’ll just leave it at this - I saw calculus deposits I had only seen in textbooks in Chapel Hill); and extractions (two of the UNC folks pulled their first teeth today, and I get first dibs tomorrow).

The children were heartbreakingly beautiful and instantly endearing. That’s all I can say about it.

We piled into the bus after all had been treated, and we began the journey back towards Lilongwe. Per the requests of our local passengers, we stopped several times and bought food from vendors lined up along the road. I ate an ear of roasted maize, which was like no corn I’d ever had in the States. Other purchases included enormous bags of peanuts, sweet potatoes, and whole stalks of sugarcane. When I say enormous, I mean it. I mean 40-50 pound bags for $2. I’d never seen anything like it.

The sun set behind us as the bus finally pulled back to the UNC guest house to drop us off. I was exhausted and eager to share the day with you fine folks. Tomorrow, we head to the other hospital in town. If we finish up early, we’re going to run by the curio market to see what’s going on in the world of incredible hand-carved woodcraft.