FEB-C-7
SUNDAY AT EMBANGWENI—
A
DAY OF REST AND CHURCH SERVICES,
AND
ROUNDING THROUGH THE HOSPITAL’S LESS ACUTE UNITS TO SEE THE RESULTS OF THE
ADMISSIONS SO FAR IN OUR STAY AND THE PREPARATION FOR OPERATIONS TO COME
Feb. 24, 2002
Sunday is always a big day for the gatherings at a mission station, and this one would have been the same, but for the anticlimax it may have represented after the large gathering in celebrating of the Kennedy’s service on the prior day. We had been told that there was a necessity to go to the church service for Poehlmans since this is the last Sunday we would be on station. Elizabeth is leaving with the Kennedys on Saturday on the same flight through Heathrow, and we have the idea that she might be able to leave her stuff with me, and take all the action packers she can according to the stricter 40 pound limit against the four year stock of stuff the Kennedys have accumulated and would not be able to carry back. They doubled their allowance for weight just yesterday at the gift ceremony, and I thought I should offer to buy some of the redundant surplus stuff were it not the idea that they represented gifts from friends, but they would have to leave behind quite a lot. This way, at least they can use up all of Elizabeth’s allowance also, and I can then carry Elizabeth’s stuff back to DC, since I have very little that is not making a one-way trip here to stay. If Elizabeth can pick me up at Dulles, she can reclaim her luggage at the same time.
. But, for John Sutter and for me, the one encouraging promise is that we may try to make the trip to the game preserve on the coming weekend, the first and only one in which we will be “off call” before we will be leaving, me first, then john and then the Poehlmans. So, for those reasons we are going to the 8:00 AM English language service for the staff, (there is a 10:00 AM Tumbuku service in the same church as well as a service in the hospital chapel for the patients in Tumbuku, and then John, Elizabeth and Betty Poehlman were keen to walk down the road and hear the Catholic service, which allegedly took place with a lot of drums. The last reason for going to the 8:00 AM service is that it was going to be Neil Kennedy’s farewell service, and he was preaching one last time as a medical missionary, displaying his additional several months in Bible School after he had determined to become a missionary in service in Malawi.
What this meant was that I cannot run, since I had hoped to make a long run and return in time for the breakfast and still get to the Sunday service on Wazunga time—i. e. not an hour and a half late. I had done the long run on Saturday morning and had come back from the run passing the church, which had a burnt tile roof on its lower level, but a pan roof at the second level for the vault. There had been a steeple with a belfry on top of the church, but this structure is now sitting next to the church in a grassy field. There is a story associated with this phenomenon, as well as with a bricked up door that are uniquely African.
AND
THE AFRICAN VIEW OF DISTURBANCE OF THE
BALANCE
IN THE NATURAL ELEMENTS
The church was a very tall structure, as a very big building by African standards, and the prominent centerpiece of the mission station when it was built in 1902. By standards of time lines—this was just after the end of the Boer War in South Africa, and my father was already 3 years old, in church, praying for such far away undertakings, often the single “window on the world” my families would have of what was happening in the outside world other than outbreaks of large scale international wars. The 1902 church here was a magnificent structure with Romanesque arches and pillars and a good chancel with choirs on either side of the nave—a European model of the best of the English countryside parish churches. But the people were worried about the tall steeple on top. Would not that arrogant structure irritate the sky and clouds above it? Would not the sky be “pricked” by the steeple perched on top of the highest roof around here?
Their worst fears were confirmed one day when a big storm came over and the church and the station were pounded by a storm in which the sky opened up. The church and its burnt tile roof held up just fine, thank you, but that was too much for the people here, so they took down the steeple and re-erected it next to the church so that it did not extend up past a respectful first floor structure. It still held the belfry, and the bells could still be used to summon the faithful as well as be the proverbial housing for bats. They also stripped the tiles off the higher level of the church—these were locally made, like the fired bricks of the native clay—and replaced it with the corrugated pan roof—which must be the source of quite a chorus of its own in the rainy season.
OF
THE CHURCH,
AND
IT’S BRICKING UP AT THE END OF THE LAST EPIDEMIC
OF
FEAR, AND, NOW THE NEW EPIDEMIC
AND
IT’S SIGNIFICANCE AT THE CHURCH
AND
IN THE EMBANGWENI MISSION
Then, there is the matter of the bricked-up door. In the front of the church (the main entrance is a large one in the rear, and one enters the back of the chancel and processes forward down the aisle) is a small side door, under a Romanesque arch. It is the “Leper Door.” Through this door of the church, the lepers might enter and sit apart from the rest of the “clean” congregation. It continued in use, until someone figured out that it was a rather unbiblical distortion to treat the lepers as “Unclean” particularly; given the fact that they were coming for therapy at the hospital that would presumably render them non-contagious, so—only relatively recently—the door was bricked up, a rather symbolic act.
When I did my long run on Saturday morning, I came by the leper door and posed in front of it, figuring at that point at the conclusion of my run, I was rather more “Unclean” at that point in my run than any of the lepers probably were at the time they entered their designated door.
This relates to me and my passage around the “Leper Door” of the church with the detached steeple and belfry tower. What about the attitudes of the people in the church, not only given their accommodation of the prior epidemic and their fear of it—but now a new wave of fear?
The Leper Door might have been unbricked and opened up now to grudgingly accommodate the new epidemic of far more “unclean” contagion bearers. At first the people in the church were reluctant to accept the people with AIDS when they were a small minority, and when they had some stigmata that identified them—the most publicly visible one of these would be the “K. S.” –Kaposi’s Sarcoma. Should the church exclude those people who are a threat to it in the sense that they are the harbingers as well as carriers of death? This was not an insignificant question at the time the AIDS epidemic had first descended on this community. In fact, the church itself had a conference, in which all the indigenous leadership pf the Synod of Livingstonia convened here to have a three day conference and workshop to come to terms with AIDS and its effect upon them and their mission. It is to be noted to there credit that they came out in compassion and charity to the victims of the plague, more immediately than the earlier lepers were granted, and the church itself endorsed a three-fold mission of prevention in its social outreach program. First, was abstinence, second, was single partner, and third—it will have to be said over some resistance, but probably less than was experienced in the USA at the same stage of the AIDS awareness—condom use.
So, the leper door has remained “bricked up” and the communion of the Embangweni Mission Station is open to all, with or without the disadvantages and contagions. The rate of acceptance within the African community probably outstripped that which evolved more slowly with hardly less fear in the European populations of the developed world.
AND
HOSPITAL NUTIRTION CENTERS
So, when the bell rang, I was not out running, but gathered with our group of Europeans to go to the large church in the center of the mission, around the lowered steeple and passing the bricked up leper door. The church is a large and airy structure, with benches with backrests toward the front, where both the hymnbooks are present. Ads the pews get further back, both backrests and hymnbooks become scarcer, but that is the penalty paid for late arrival—when most people start mobilizing to come in until there is a nearly full quorum of “church attendees” who would be present about ten minutes from the end. We were seated at about the third row of pews with a few guests and dignitaries who were visiting, some still left from the Kennedy farewell, and others being local church visitors from other parishes bringing with them their “certificates of disjunctions” as the presider had pointed out.
This is the service in the English language, as contrasted with the 10:00 AM service in Tumbuku. That means most of the people here are the educated secondary school graduates at least, but comfortable singing and talking in English—or showing off that they can do so. Most of the hospital personnel are present among this group, and as it is a formal event, with our presence (I in a clean open necked shirt) and Neil Kennedy’s final appearance and valedictory address, all the officers wore coats and ties and full facsimile of proper English dress.
Except for Neil Kennedy. He wore a gaudy African robe with a large portrait of the continent on it and in his sermon, exercising the few months he had spent in Bible School after he had decided to come to Africa, he pointed out that he had to decide “What is a missionary?” And he pointed out to the group that they were all missionaries, and should do so in the most African way they knew. Pointing out that he should need some help in learning how to dance, and that the Africans were very much better at it—witness the rocking good performance from each of the choirs—he suggested that they give a witness of their faith in a very African way. He decried the fact that the Africans were sometime taught to sing hymns in English about mountains an d snow---snow!---while wearing coats and ties as thought they had to become English gentlemen first. He encouraged them to carry on the work as he was leaving and to do so in their most indigenous and original way and not to feel they had to mimic the Europeans through whom they may have first have heard the Word. This was a great message of empowerment to the people here—even if it did have to be delivered in English—and is the direct contrary of the issues I had described in leaving the Philippines after having read two missionary autobiographies—by David Thompson of Gabon and Lincoln Nelson of Mindanao—as I had often heard from others: only the rote repetition of the same culturally loaded unoriginal phrases from a given sponsoring church’s strict and isolated background constitute grounds for any proof of your having been saved and worthy of the mission effort invested in “leading lives to the Lord.”.
The most touching part of the service was the deaf school students who were sitting off to the left in the “choir” of the nave. This group had to sit during the singing and wait until their dynamic teacher would stand up and in vigorous universal sign language, would sign to them the readings and the sermon text. But, the best part was when they came to their part in their service. Each had a color-coded bell, and would follow the director’s pointing to the music written on cloths suspended above them, which she would point to with a stick. The choir would then play a “change ringing” bell choir chorus—which I taped.
There was also the “Survival Choir,” their name coming from a favorite song of theirs, which now is accompanied by a Yamaha keyboard, to which they can swing out. They get into a fair number of overtones in harmonics, and could also show off with the choreography that I have seen throughout Africa, a shuffling swing dance in time to the music.
WHERE
TWO NUNS CONDUCT A NON-MASS
AS
I GO TO MAKE ROUNDS AND ALSO TOUR THE NUTRITION CENTER
Betty Poehlman and the two students went for a walk down to the Catholic Church, since they heard that it was a quite African service with a lot of drums and music. It turned out to be a little more different than that since they had two nuns, no priest, and therefore no sacrament. I had gone on with George Poehlman to make quick rounds on a day when none were scheduled nor expected. While there, we saw a woman come in with a five day old near dead infant born at home five days ago, and not eating. We thought it was not breathing either, but there were a few agonal breaths of this little scrawny skinned rabbit with an old necrotic cord hanging from its umbilicus. We could not measure its temperature, but it was off scale to start, so we put it under the warmer and got its temperature up to 36*. Ironically, it is a source of concern in Africa that hypothermia may set in among the newborn. All those little stocking caps that have been knit by the good-hearted souls in the Midwest sewing circles have saved innumerable lives here, since these little bald nude kids wrapped in whatever rags they have available would be subject to an intensive NICU stay in the US but are left to fend for themselves under their little US-knit bonnets. Similarly, George and I remarked about how our mothers were tearing long strips of fabric and rolling them into gauze dressings in roller bandages, at which time we figured that this was a hobby for the consciences of the first-worlders, of no particular use in the third, never figuring that we would graduate to being practitioners who would be on the other end of the receipt of such beneficence, and that it would make such a critical life-saving difference somewhere else in the world. Ironically, I had a bunch of laparotomy pads that I thought were excessive, but I considered them good padding to put around highly valuable items like the pulse oximeter—which was true. But, almost as valuable were these big formal and official lap pads that were more necessary than anything I had brought except a couple of the specific drug stocks that I had brought. Little things mean a lot.
On the subject of a rather unusual drug need, I saw the demented fellow being held down by his attentive family, and saw that he had not only meningitis, but also most probably AIDS viral cerebritis which would limit his life expectancy, not counting his basic inevitable HIV + status. I took photos of both the fellow with cryptococcal meningitis and the small baby who was hanging on to life with a thread—literally—since we replaced the necrotic umbilical cord with a nice thread of the kind that the “TBS’s” (Traditional Birth Attendants) that Mama Chima trains would have used in this home (or “hut”) delivery. I thought ironically, that the two patients I had photographed last were the two women patients in adjoining beds—each of whom were treated with Kodacolor as the last earthly thing that happened to them. I may be the walking pathologist, since I have taken photographs when I have thought the issue illustrated was of interest, and never postpone until later what you think might be worth recording, since—in these case especially—later did not take more than minutes. My photos of the small baby being fed by expressed breast milk that was then pushed through a nasogastric tube and the man with cryptococcosis as his pathognomonic sign of AIDS (called EDZI here) were the last views anyone would have of them.
There is a superb manual made here in Malawi on the subject of “Syndromic Management” called MSTG –98 version—the “Malawi Standard Treatment Guidelines” which allow the medical officers –or, in most cases, the nurses—to treat desperate conditions on the basis of what is most likely to be fixable given the presenting complaint. More lives are saved by this method than by importing tissue culture labs and CT scanners. We saw this in practical terms when we examined a new male ward admission with a very hard scrotal mass that was tender, and the orchitis was treated exactly correctly by the clinical symptoms the male nurse saw by following the “Book.” The other revered book her is the Maurice King text on “Primary Surgery” Both I: Non-Trauma and II: Trauma. The last Medical Director is a pediatrician who literally has called to have his wife carry the book into theatre to follow the step by step instructions for getting out of something he had never seen, and the others who are all GP’s or at best OJT surgeons are still forced to take call to do whatever it is that comes through he door—and quite horrendous things frequently do!
We saw a few more patients for what is called “VCT”—the “Voluntary Counseling and Testing” who had atypical presentations of rather ordinary problems, since all the rules are rewritten for AIDS in Africa (or EDZI in Malawian Tumbuku.) There are further training programs that are useful: Ishmael had completed the entire course on something called HBC= “Home Based Care” for which a meting is coming next tomorrow afternoon. But, sometimes, the training programs get placed without any rationale. For example, there is a certificate proudly placed on the wall of the Male Ward which announces: “Congratulations to the personnel of the Male Ward for completing sixteen hours of continuing education on breast feeding training!”
For reasons no one who could be reading this narrative would be able to figure out, I have gone around and taken photos of the abundant numbers of twins that are born here. It is incredible to look down at about three pounds of wet and scrawny wiggling protoplasm, and concede that this is viable life, not only, but duplicated. There are about three sets of newborn male twins, of which the mothers are enormously proud, and actually push themselves in front of me to beam for the camera. I think I understand something about twin boys that would make them very proud, and turnaround is fair play, so I showed them what twin boys look like in another part of the world as recently as December 19!
But, not all kids are so lucky. There are 45 pediatric inpatients not including those in the feeding and NRU. There are kids with severe kwashiorkor and the protein calorie malnutrition also known as marasmus. These kids are very common at this time of year, since the crops are all in at late rainy season, but almost none of them have “any food at home.” This is a standard litany—“no food at home” since there are not even any seed corns available. An interesting thesis is that people who have nothing have never learned to save. Why should they have learned? If you have nothing, it is hard to put away anything from your day-to-day bare subsistence to save for a future that could not get any worse than it is today. I have saved up every day of my life, and have probably never ever consumed everything that I have in a sudden binge. But here, the standard statement is that “ALWAYS EAT GREEN MANGOES.” Why? Because they are green, they are still here. Even the fructivore bats that come out at night to eat ripe fruit have not attacked them, and they are definitely still here because they are considered inedible. When ripe, they are obviously a high priority edible item, so that we will not have them anymore, so eat them before they are ripe when everyone else who is after them will already have consumed them. This is not a risk averse society—every day is a very high-risk situation and they have very little to lose by almost any gamble toward making a better chance. This is also a fundamental factor in AIDS control—how can you count on a future against an uncertain present?
I saw a bunch of starving kids. The kids may look like babies that are almost normal, compared to the way babies here look. But they may also be moths to years old as they look like babies, and are apathetic, and are silent victims to a number of assaults, among them the anopheles mosquito. A baby below 1,6 kg gets a nasogastric tube, and still holding to principle, is gavage fed the breast milk that can be expressed from mother or almost any lactating woman anywhere nearby. If the milk is mixed with formula, cow’s milk, or any other kind, it seems there is an injury to the barrier of the GI tract, which is why there is such a big push for breast-feeding exclusively for at least six months in this area. This may be why Jodie McGill goes through the charade a breast-feeding an adopted infant. I saw here master’s thesis in nursing for the Emory University School of Nursing and Public health on the subject “Cultural Practices of the Tumbuku People of Northern Malawi as they Relate to the Sexual Transmission of HIV.” It would not do for a woman who is promoting breast-feeding to be seen carrying around a black baby attached to a bottle of formula—so she does her “pseudonursing.”
It is interesting that she had to do this research according to the “Institutional Research Board of the Emory University” which approved this essentially non-interventive, observation only study. I had learned that the study in Nigeria in comparing the use of Trovan vs ceftriaxone in a double blind random study in which every other patient with meningitis got the alternate drug was performed in a study in which the top of the line care was given free to patients who entered the study for the best possible results (in which no difference was found in survival success)—but the authors were sued, since an American lawyer came over on a plane to say they had not signed fully informed consents to the study—he saw big bucks in a class action in which the “wronged patients” were all recipients of superb care. To be “wronged”, as I understand it, one has to prove damages, negligence, that the damages were directly caused by the negligence, and that there are lasting harms from this nexus. But the absence of an informed consent was good enough in this case, and it was worth lawyers’ trips. So, in a reverse of the usual complaints, Africa has been infected by the west in this exchange!
There is a way to get to the seat olf any patient’s problem here—look for the “Simbo.” These are two little parallel cuts with a tattoo of some burnt herb rubbed into them, overlying the source of their complaint. When we pointed out the tiny parallel cuts and brown pigmented detritus rubbed into them at several points on the tiny 1.4 kg limp near-lifeless body of the near-dead infant brought to us, it was apparent that she had been seen by these consultants before us. When we asked Mama Chimba about it, this diminutive fireplug answered “Sure! Simbo!” Sometimes it works!” And she raised her sleeve to show tow sets of parallel cuts with brown herb paste that had been rubbed in long ago to leave a tattoo, each on the inside of her elbow. She had what she thought was an abnormality, and increased “carrying angle” at each elbow, and she went to the practitioner who had “fixed” this with the scarification. She had them also on her neck for a spasm, which it did not relieve—you win some and lose some. I told her that the angle of valgus at her elbows would make her a dynamite switch pitcher in American baseball.
As part of our tour of the NRU we met someone who seemed quite knowledgeable and bursting with pride in showing us his piece of the action, and we looked over the Hgt/wgt growth charting skewed to a lower curve for the stunted Malawian infants. We saw the bags of bleached Nsima, the mealie maize, and soy powder from Germany as foreign aid in protein to supplement the macro calories and protein need in the protein/calorie malnutrition. I asked if they supplemented with micronutrients, most specifically Vitamin A and iodine, and the answer was “not yet.” But then I learned the official title of the boot-wearing uniform-sporting fellow who had shown us around. He is the Embangweni goatherd! He takes care of a flock of kids and goats which are milked to supplement the maize and soy which were being mixed in a big vat over a fire by a colorful group of women in African attire and big grins through the acrid smoke when I pulled out the camera. So, I have met everyone from the Nkosa (paramount chief of the whole district) to the goatherd of Embangweni—the latter more personable.
AS WE RETURN UNDER
A CANOPY OF BATS IN OUR BELFRY
Our big Sunday off duty but on call ended in a unique experience. We “went out” to eat, in the “Trade Center” downtown. This is the place we had walked to with a refrigerated bag on Saturday before all the festivities here at the farewell celebration, dropping off our liquid requirements that would go along with our very native dinner of Nsima, cabbage casserole and a few other condiments. We had to carry our own knives forks and spoons, not standard eating equipment here where the nsima is usually rolled up in the fingers and used to scoop up the Din-din—some from of greens or gravy. The menu, chalked on the board was Nsima Inhaku (chicken) Nsima Nyama—I thought this name was very close to the term “Myama” in ki-swahili on which i have written-- (mystery meat) Nsima Mazire (eggs) and Nsima Mbuzi (goat). We ate cheerfully, going native, with only one of us feeling very bad after-effects, and that was the most nearly native one of us John Poehlman who took the next couple of days off.
Nsima is as tasteless and non-nutritious but filling as cassava, and has only one advantage—it is not a goiterogen, that I know of. We washed down the native concoctions with our own Carlsberg beer—the only brewery n Malawi, as I had remembered from the border crossings with Mozambique. We had also brought our own water. John wanted to pose under a sign that had a baby on the back of a strong looking Malawian woman with the caption, “Respect Your Mother!”—a sign to carry home with him.
We walked back in the dark, I being guided by my new little Petzel headlamp, and as we went under the palm trees, a rustle of activity preceded the bursting out of a dozen fruit bats—as had happened to me once before in Assa, when I was walking home from the funeral celebration of one of the village’s elder women who announced that she was “tired of living” and would be going now, and after saying farewell to each of her family, died the same day. As I walked back in Assa as the rains rained out the full celebration I had passed under a large royal palm tree, as my companion had said “The rainy season is not the best time for ‘Manifestations.’” A big burst of bats came out overhead and I had pondered, “Assa can be a very mysterious place at times.” Now, I can say the same: as I come back from the “restaurant” in the “downtown” dusty road of the desperately poor village’s Trade Center, and head back under the bursting canopy of bats with two foot wingspans, whirling out of their palm tree roosts. I am between the venues of the chibuku parlors and the half-drunken citizenry who have escaped despair for a few hours and the hospital where we will stop before turning in, where three more lives will be lost to AIDS during this same night.