FEB-C-3
THE ARRIVAL IN MALAWI,
AND INTRODUCTION TO EMBANGWENI MISSION HOSPITAL:
A
CELEBRATION IN HONOR OF THE VISITORS’ ARRIVAL
AND
THE MEDICAL DIRECTOR’S DEPARTURE,
AND
A FLAVOR OF THE HOSPITAL PATIENTS
ON A LATE TOUR OF THE WARDS
Feb. 20, 2002
Arrival in “destination travel”—the Warm Heart of Africa!”
I ended the Feb-B-2 with a few of the frightening statistics of the Malawi demographics and the impact AIDS has had on this particular country in Africa—a “poster child” for African AIDS devastation. And now, I am “into it.”
I turned around the Lilongwe, “new capital” built here in the middle of the country by the “Beloved Mzuzu” President for Life Banda, a London-based Seville Row General Practitioner who wanted to be a good friend of the Europeans, and ruled his country with an iron hand and a sclerotic mind. He wore a British tailored three piece suit every hot day in this African nation—12 degrees south of the Equator, and, as out of touch as he was with his own population, he forbad any Malawian to ever look askance at a British tourist, whose money he hoped would float his inflated plans for a modern new European style capital in a new city he named Lilongwe, moving it out of the colonial power of economic and political dominance in the south of the country around Blantyre, and also forbid any speculation about the Beloved Mzuzu’s age or health on pain of a long prison term. Since he came from a northern village of Kasungu, he had had a very large mansion built for him on the hillside—still air conditioned and guarded, but never occupied—the place we turn to go on to Embangweni, a poor village in the outskirts of the nation along the Zambian border.
The Presbyterian Church put a church here as far back as 1902, with the hospital and manse (the only two story building built within 200 miles of here) built by a Dr. Fraser in 1905. This Presbyterian mission effort is a follow on to the fine British/Scottish physician/ surgeon missionary abolitionists David Livingston and his wandering through this area of the world on which British claims to colonial sphere of influence rested. Livingston’s wife died in the transit along the Zambezi River near what is Berea now, and he himself continued on, sick with fever, trying to reach the large lakes of the Rift Valley in going north through totally unknown territory then that would be Zambia today (after being Northern Zimbabwe in between). He had been pursued and discovered by the intrepid New York Herald reporter and early African explorer Henry Stanley—with the famous “I Presume” quote.
He got as far as the area of the Kifue Flood Plains, which I had explored in 1998, and while kneeling in prayer under a mobolo tree, he fell over dead. As he had requested, his heart was buried in Africa under that Mobolo tree (which in the most characteristic action of the Africans was later chopped and burned) and his body, mummified in the trees by his faithful attendants, was carried to Mombassa on the coast, where a British steamer took it back to London. Recognized by the compound humerus fracture he had sustained when mauled by a lion, Livingston’s’ body was authenticated, and the great Scottish medical missionary was interred with royal honors in the crypt of Westminster Abbey, where I saw his last resting place along the way of my collecting many more of his life’s transit points. I have a rather complete photo collection of the points along much of his route, including the “discovery” of Moise a Tunya—the “Smoke that Thunders”, the mighty waterfall of the Zambezi that he named for his Queen—Victoria.
So, enough of my rhapsodizing about what brought me along this trek and the way I got myself here to Malawi. I now am going to get introduced to the Embangweni Mission Hospital I had heard of from several friends over time, and now am coming to work, supervise two of my own students and record what I see in this new “Diary of this Plague Year.”
AND INTRODUCTION TO MALAWI
ENROUTE TO EMBANGWENI
I landed at LLWM with just enough time to mark the GPS coordinates. LLWM at 13* 47.19 S, 033* 46.26E, when I popped out of the Kenya Air plane and came running to the transit bus. In that interval, the party greeting me did not see me from their observation deck, but when I popped out of the bus on the run toward the terminal, I waved when I saw both Elizabeth Yellen and John Sutter up on the balcony obviously relieved. When they had not seen me deplane, George Poehlman had turned to John and said “I hope you have brushed up on your surgical reading, since there are a lot of patients who have been promised that a surgeon is coming and will be expecting an operation!”
I came through the immigration and customs, where I saw both my wounded Samsonite bag coming off its last airplane flight, along with the box of supplies for surgical cases. I got them through without trouble although the Customs officers wanted to talk to me primarily for their own interest about where I was going and had heard of Embangweni Mission Hospital and were eager to help. Besides, nothing very valuable can be fitted into such poor boy’s baggage. I exchanged fifty US dollars at 72.05 Kwachas per $1.00 US, and immediately paid 22 K for each postage stamp card and 66 K for the two letters I had written on the plane to be sent back at the time of my arrival.
George and John Poehlman and Elizabeth Yellen and John Sutter met me and commiserated about how long it had been since I began this epic journey across the globe and off we went down the newly paved “M-1” road—now a virtual highway. This is not necessarily all good to have a high speed road, George explained as we got into the Embangweni Hospital’s ambulance to make the trip to our destination A team of 83 schoolboys had been loaded into a lorrie to go to some soccer match, and the lorrie, not used to this higher speed road over their usual mired down rainy season passage on the muddy roads, rolled, killing 23 of the boys on Saturday. Even the two-term President Muzuli (trying to succeed himself for a third term by changing the constitution—just like his only other predecessor in the history of Malawian presidents, Beloved Mzuzu Banda)—even visited this area to express consolation—the closest he has ever ventured from the capital in this direction of Embangweni.
John and Elizabeth had arrived on Sunday and were housed in the Rodehavers’ mission guesthouse as they toured around the Lilongwe Hospitals’ children’s’ wards. So, we would all see Embangweni primarily for the first time for each of us. John Poehlman and his father George had come up for a meeting in Lilongwe the day before, and we were all going back together, they sitting on cartons of the medical supplies, along with the two boxes I had transferred to Elizabeth to be driven to Boston for me to intercept on my way to Nepal just after the fateful September 11 change in all air plans. I had said when she had driven them back to DC to carry them along to Malawi, and a better pharmacopoeia from heaven could not have been designed for the acute care problems of this population just now.
We drove into Kasunga, where we loaded up with diesel (at about US prices) and got a coke (“do not worry about dropping the can, it will surely be recycled if it is left in any village!”) and I talked with George as we went down the road into the Green Heart of Africa. It felt good to be back “Into Africa.” It has been too long for me. It is a beautiful country just now, since I had seen it each time in the dry season when things are rather desolate. In the dry season, I remember, kids would rush to the road to show off skewers of mice and rats roasted as they were skewered on a stick. This “Mick on a Stick” was the fast food luxury of the bush, often captured by setting fires to the dry season bush and clubbing the rodents as they came out and then using the same fire to roast whole the skewered rodents as a cash crop delicacy—although I would have to be rather hungry.
The rainy season with all its growth is rather deceptive. This is an odd time of year despite its verdant appearance. Malnutrition has not been higher than it is right now since there is no harvestable crop. A lot of the land is put into the hand cultivation of a cash crop—tobacco—sent largely to the Eastern Europe that could not care about the quality of the tobacco they receive—it could never selling America. The burley is one product and the smaller leaves are the higher quality, harder to grow and cure here. It all goes out as raw product with no processing done to it in this country. But the corn is up, but a long way from harvesting. There are tomatoes and sugar cane and a few other crops, but the poor people on subsistence are running low on their stores and cannot even eat the seed corn, which is hybrid and imported for cash as well, making them all into obligate eternal borrowers, without a hope of repaying. So, western world debt forgiveness is suggested—anything but a disincentive to borrow higher faster and sooner than before—so all of the nation’s GNP is less than the debt service. Over 40% of the country’s health care (as measured in beds) is given by missions and 90% of the quality heath care, such as hospitalization or operations is a gift of missions. Almost all of the government’s expenditiures are directly given from NGO’ s and other foreign aid.
We turned off the M-1 after Kasungu, the home district power base of Banda, and entered the road to Embangweni—an “end artery” as a mired road bed in the rainy season in many spots washed out deep enough to swallow the vehicle. The town is “Jana” and if we had turned around the gate left rather than right, we would have been in Zambia. We drove along in the warm sunlight of the afternoon, which was helpful in drying up all but the biggest puddles or ravines, and drove along to the hospital. When we reached it, I plugged in EMBA 128 07.49 S, 033* 28.47 E, which is BETH 6,942 miles @ 88* or HOME 7,841 @ 313*, or, LLWM 116 miles @ 175*
The compound is well laid out and has a good design as a pavilion style tropical hospital with the walkways covered with rain roofs and the courts between buildings filled with flowers and cisterns and waiting family who cook and care for the patients as their guardians when admitted. We got settled in the very adequate guest quarters, with each room having twin beds with pyremethamine soaked mosquito bed nets over them. The cost of a shared room is 250 Kwacha a day and 300 K for one person, so since there were more than enough, John and I elected to have each our own room—big spenders that we are.
John Poehlman and his wife Mary Bennet arrived here in December, to begin work on his anthropology thesis work, which involves behavior and group counseling for HIV programs. I will have to learn how he has used his interviews in such a way as to get good data without taking up all the daylight during which time, the people have to be out tilling their gardens and trying to make a living out of the marginal grounds they are tilling
We arrived at an interesting time of transition. Neil Kennedy and his wife Sarah (from East of Belfast in Northern Ireland, but trained in Manchester as a pediatrician) and two children have been here as Medical Director for three years and are going home this next weekend March 3rd. He will be replaced by Alex, an overwhelmed GP from Perth Scotland where he could care for most things over the last ten years, and if there was a question, he could send them over to the hospital three minutes away. George Poehlman has arrived from North Carolina for this transition period, as well as his son being here to work on the anthropology thesis (I had reviewed his Fulbright application) and later this next week, Hayden and, later, Margeaux, will be here to help set up the hospital’s bookkeeping, both here and in another mission station for the Presbyterian missions.
I had time just to find my room number 5 and take the first shower of the last several days in transit, when we went over to the primary school’s program for the departure of the Kennedys and the welcome to us, with a cup of tea and speeches by the local “TA’s” (Traditional Authorities)—but, best of all, dances, singing and the traditional chanting with a foresinger and the harmonics of the schools’ teachers. I taped and photographed these traditional cultural activities all within a very short time of seeing and hearing, again, the Tboli dances, and then also photographing the mythology of the Malaybalay tribes in coming together under the Mount Kitanglad in central Mindanao.
I also met the equivalent of the “TLDF” “Tribal leaders Development Foundation” of Southern Mindanao. The surname “Jeri” denotes a hereditary tribal leader intact from the days of Shaka Zulu, who run this area—since the national government really has little role here in the rural periphery. The “Nkosa” (tribal chief”) is a Mister Jeri, and above him is the paramount chief, the NkomaNkhosa. I saw each of them, dressed in threadbare suits and wearing ties, at the Kennedy farewell, while I watched the young schoolchildren perform their dances and frenzied rhythms or their slow shuffling gait I remember well from the Suswati speaking Nguni tribes further south in Swaziland. I recognize everything from the Nguni cattle to some terms—I, for example, am NgoNgo—Grandfather, from my visits to Swaziland. All of these are tied up with the history of the Shaka Zulu over running of the areas along with the British chasing around on the basis of the credibility of David Livingston in his earlier passage.
We met Betty standing in a corn field being tilled by the “NgoNgos” grandmothers, in this case, of the “Orphans’ fields”. There are many orphans of course in a nation with a high early death rate with “tuck shops” along the road advertising coffins—side by side, and all of them needing services so much as to not being in competition but referring to each other to avid a potentials balking of overwork from undersupply. Apparently the technique I saw in Zimbabawe of a cloth bottomed coffin has not caught on here with the reusable upper wooden part after the body is dropped into the grave. But here, they make a good looking wooden casket, and then wrap it with plastic which makes it look cheap—presumably all in the name of permanence. There is little accounting for the burial practices of us as a semi-rational species, but the practices of the wrapped blanket come a lot closer in Africa to an appropriate reverence for the departed soul.
I also learned that funerals are a great opportunity for a shakedown of the guests, whose names and sum of their contribution is sung out to applause—an example being that “One Kwacha and 65 taboles from Mister Chona” –about two cents—and “900 Kwachas from Mister Tembo of the Embangweni Hospital” reflecting that nearly all the wealth of this area comes from mission donations. Since the haul was quite successful, therefore, the hat will be passed again, this time around to the hospital people first, since they are the ones who contributed most heavily the first time. Then some one will stand up and make a lost and found announcement, such as “I cannot find my bicycle, and would someone who has it please return it.” Then there will be a variety of public service announcements, and then a little exhortation—such as to the bereaved spouse—“You will never be welcome back in this village again!”
I will know a lot more about funerals before this time in this part of Africa is over, since they are one of the most common opportunities for people to come together. Unlike “Three Weddings and a Funeral” the ratio of happy times to sad bereavement is quite reversed.
At the dance and singing of the antiphonal chanting on the part of the schoolchildren and the school teachers in honor of the departing Kennedys, I saw the women all dressed in the colorful wrap that was like the campaign cloths given out by Chisano in Mozambique. A number of these candidates’ pictures on the women’s bustling bottoms were the defeated candidates, and it never seemed to dawn on anyone that the dress code was a political statement. The one dress cloth I liked most was a print that looked floral until I got closer to see that it featured---cell phones! Everything is up to date in Embangweni!
There are special drum beating ceremonies that happen at night just around and a t the outside of the hospital and mission compounds that are called Mbuzas—frowned upon by some of the less culturally attuned of the mission staff since they are “spirit worship.” However, we may stop over to investigate these performances as an anthropologic inquest.
AFTER DINNER WHICH FOLLOWED OUR ARRIVAL
AND SETTLING IN THE COMPOUND
We had dinner and asked the myriad questions that compare and contrast this site to the last (Mindanao) and the other African sites (Swaziland, Mozambique and the Central African areas such as the Congo) and, as drowsy as I was having come as far as I had, when George said we could make a quick round to get acquainted with the hospital and a few of the patients within it, we trundled off to see what we could see.
It is a picture of an African plague—and out dropping into this beautiful, gentle poor and desperate country and its people at the point of apathetic resignation. Whatever else I know about Africa and diseases of the tropics, the rules are rewritten against the almost ubiquitous story of AIDS and HIV positivity everywhere. In the women’s ward, there was only one woman, and she was young, with an unrelated problem, that was not know to be HIV positive—and that is only since she was not tested. There is a very standardized process called “Counseling and Consent to be Tested” every one of the patients has to go through before study of HIV status. The course to be certified to do this takes sic weeks for the nurse or health care worker. It is not really necessary for the majority of patients—since “Slim” and CNS AIDS with lethargy coma and seizures (the good old Briticism “fits”) are rather tell tale signs of AIDS. And of all the TB cases flooding the hospital, most (78% in numbers that are less than round, but fit nearly perfectly the four women who were sputum positive in another Female Ward) are HIV positive.
I am going to be writing the “Diary of the Plague year” in Malawi in the next few weeks, I can tell, with TB, malnutrition, and pus somewhere as the common denominator of a few things each of which are variations on the theme of this base line. I will tell you more as we make more thorough rounds and get involved in the clinical dare of the patients who are going to be our beneficiaries in the next weeks—but get to know the epidemic of this millennium, to contrast with the epidemic that reduced Europe by one third in the prior millennium, since it will be very much with us, and in a from far more pitiable and less exotic than the similar disease, caused by a different virus and in a vastly different population in the developed world. Welcome to African AIDS!