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.

Day 3, The chicken stew had feet in it

I woke up at 6:45 and stared out through the blue gauze of the mosquito net. The night was chilly, and I slept well.

We met Dr. Mlotha, head of the dental department, at 8:45 to go over our plans for our time in Malawi. Afterwards, she gave us a thorough tour of the grounds and facilities. There are two separate facilities in the hospital, one for those who can pay and one for those who can’t.

The payers (as she referred to them) had the option of a private room, meals, bedding, and other sundries. For the non-payers, they were four to a room. Families camped out on the grounds during the day, and they brought their patients food, clean clothes, etc. As we moved through the open air halls, we were constantly avoiding family traffic. Pots precariously balanced on heads, blankets and rugs were tucked under arms, babies strapped in slings across backs.

We went into the dental clinics after the tour. I went to the diagnosis clinic (which was actually the extraction clinic). I followed around a third-year dental therapist named Innocent. The extraction kit in the diagnosis clinic includes only a syringe and a pair of forceps (pliers for the non-dentist readers). A new staff dentist confided to me that if they couldn’t extract the tooth with that equipment, they then resorted to modified elevators to pick out root pieces. She considered the therapists’ abilities with elevators near-miraculous.

Our patient came in and described his condition. From the patient, Innocent took the patient’s “Health Passport.” This is a government-issued booklet (passport-sized) that acts as a mobile medical record. The provider documents the exam findings, treatments, and prescriptions in the Passport, which the patient carries with him when he needs treatment.

After the usual health histories, etc., Innocent got to work. He immediately performed the necessary anesthetic injections for the extraction of the upper right second molar. After a few minutes, he grasped the crown of the tooth with the forceps and began firmly rocking it back and forth. It didn’t budge.

Standing now, he struck a power-pose, legs wide-spread and slightly crouched. The muscles of his forearms were perfectly defined as he exerted his full strength on the tooth. A crack sounded from the patient’s mouth as Innocent sighed and showed me the forceps’ cargo. He had ripped the top half of the crown off, leaving the gingival crown and all three roots still in the patient’s upper jaw. He requested an elevator, and we waited patiently. When it arrived, I watched him maneuver the tip around the tooth until all three roots plopped wetly onto the pad of gauze.

Lunch for staff is served in a little building adjacent to UNC’s infectious disease folks. Three women operate simultaneous businesses in a 300 square foot room. For 150 kwacha (roughly $1), an enormous plate of rice, stewed vegetables, greens, and beans is yours. Two of the ladies operate nearly identical menus. For another 100 kwacha, you can throw in beef, offal, or chicken stew. Another woman sells cold sodas in vintage-style glass bottles for 50 more. If you go all out, lunch runs about $2. After a thorough perusal of the options, I settled on a plate of white rice and a coke. I’m going to try to buy some groceries to handle my own lunches from here.

We headed into town to get our endorsements from the Medical Council of Malawi. The streets of the city were thick with pedestrians and minibuses. Furniture and coffins appeared to be hot sellers in the numerous stalls lining the streets. $100 each in traveler’s checks gave us the credentials we needed to be able to legally practice in Malawi.

We got back to the guest house exhausted, and we rested until one of our preceptors offered us a ride to the American-style grocery store, the ShopRite. Needless to say, pickings were slim. Like Tolkien’s hobbits, I’ll tighten my belt and think about the good food at home.

Dinner, however, proved delicious. Ms. Joyce roasted a chicken, made a spicy vegetable soup, and cooked some rice. After a few battles of Charles’ card game “Tonk” (please excuse my spelling), I retired to type up today’s blog and get back on schedule.

Day 2, The trouble with life is there’s no danger music.

Tuesday found us fairly early. Our flight to Lilongwe left at 11:20 AM, so we had agreed to meet the minibus driver at 8:45. Requested wake-up calls never came, so it was a bit of a scramble to meet the driver on time.

On the way to the airport, we got to see a bit of Johannesburg in the daytime. It’s a little bit like Atlanta, but there’s a vaguely European vibe around the entire place. I took a picture of this excellent billboard:

As we boarded the plane, there was a general sense of eagerness to get out and see the “real Africa.” The plane ride was uneventful, and we soon got our wish. Things were pretty different when the plane set down in Lilongwe. A dog was visible trotting down one of the runways.

Our extremely gracious hosts from Kamuzu Central Hospital picked us up at the airport in an older minibus. We sped away along the Malawian countryside, dotted periodically with the smoke plumes of trash fires, people resting along the side of the road, and women carrying heavy loads balanced perfectly atop their heads.

Traffic here takes three forms: the dangerously overcrowded minibus, or (despite the wide footprint of the capital city) walking and biking. We’ve been told that no matter where one goes in the distant countryside, there will be people walking roadside.

The accommodations are comfortable and dorm-like. Ms. Joyce runs the UNC Guest House, and she’ll be acting as a surrogate mother while we’re here. A few other UNC folks (a couple of medical students, an IT guy, and a lab guy) are sharing the building with us, and they’ve been very welcoming. The people have been uniformly friendly. After dinner at an Italian restaurant, we headed home in the streetlight-free darkness.

I’m hoping tomorrow will be sunnier and warmer – supposedly there are house geckos that live on the building. Seeing them would be a real treat. We’ll get a tour of the facilities and register with the Medical Council of Malawi, and then on Thursday we set off to the Home of Hope Orphanage.