Traveling in Africa takes a long time. To travel reliably, I’ve been told one has to go through Johannesburg and then onto Malawi. Luckily, the plane from Jo’burg to Lilongwe goes every day. That differed from when I went to Blantyre. That flight only goes on Wednesdays and Saturdays.
In the Johannesburg airport, I rushed to get to the gate. I had left the restricted area in order to mail a letter at the post office in the airport, buy some minutes for my cell phone and then made my way to the gate. It was a maze of people and counters. My ticket said gate 24, but the board said gate 1, located waaaay at one end of the airport, down a long corridor.
So, I made my way to gate 1. There were about 30 people sitting there, chatting, but there were no airline personnel. We waited… and waited. Perhaps we were too patient – we all sat there past the time when we were supposed to board.
Finally someone got up and walked about 500 feet to the nearest board. It now said gate 24 – all the way at the other end of the airport. We all gathered our stuff and started hustling our ways to the other gate – a good 7-10 minute walk (there was one man who relied on a cane and he was having trouble keeping up).
Once at the gate, airline personnel were unperturbed that we’d been sent the wrong way.
Back in Malawi
I finally arrived in Lilongwe in the afternoon, flying in with Dr Mina Hosseinipour, an American infectious disease doctor who trained at UNC-Chapel Hill. She’s been at the UNC Project for 7 years, pretty much since the time she finished residency. She gave me the background on the project.
OK. Perhaps I’d missed this in my previous conversations with people at UNC… Perhaps they’re used to the size of their project. They said it was ‘big,’ and being familiar with international NGO projects, I reckoned that ‘big’ meant several dozen employees.
Boy, was I off-base!!
On the plane, Dr Mina informed me that the project has 320 employees – the vast majority of them Malawians. I had to have her repeat this fact… she drew me an organization chart.
But even with this preparation, I had no idea of the scope and scale of what I’d find. I threw out the plans I’d had for stories and started from scratch.
Custom-made ceramic tiles greet visitors to the Tidziwe Center
Tidziwe (pronounced: tid-ZEE-way) Center is located on the grounds of the Kamuzu Central Hospital (KCH) in the northern part of Lilongwe. In 2003, UNC built a two-storey building to house research facilities that include administrative offices (everyone shares an office, except the director), a state of the art lab, and clinical rooms for patient exams.
If Tidziwe were it, that would be something special, but it’s not. The next building over from Tidziwe is the Lighthouse, a program for patients with HIV/ AIDS. Currently Lighthouse follows some 8000 patients with HIV.
Some of the people are participants in research, all of them receive anti-retroviral medications. There’s no quid pro quo… patients don’t have to participate in research in order to receive drugs. But many do. Lighthouse is one of the two largest programs for patients with HIV/ AIDS in the country, and has become a model for the care of Malawians with HIV, and a center for research into better ways to deliver service to patients who are often very, very sick.
UNC clinicians who do research work at Tidziwe spend at least 20 percent of their time doing patient care at Lighthouse.
Staff employed by the UNC Project also run an clinic for sexually transmitted infections at Kamuzu Central Hospital. This clinic has daily clinical hours, conducts research and does outreach in the community to encourage testing for HIV. Most of the employees are Malawian, the STI clinic is headed up by Gift Kamanga, who was a Fogarty Fellow sponsored by UNC.
As if these activities weren’t enough, the UNC project crew (fewer than ten expatriates, and more than 300 Malawian staff) are involved in research about:
- malaria
- a malaria vaccine trial
- research to determine the right combination of HIV and TB drugs for patients diagnosed with both diseases
- research to determine better ways to notify partners of people diagnosed with HIV
- methods of creating informed consent that work for people who are illiterate and semi-literate
- research to compile data on trauma in Malawi
… and, of course, all kinds of research about HIV/AIDS, from drug research to finding the best combinations of drugs, prevention trials, and on and on and on.
I’ll be filling people in on more details in coming days. Tomorrow morning’s story will look at services aimed at curbing the spread of HIV/ AIDS.
I returned to CO3 – the obstetric emergency ward at the University Teaching Hospital for one last day, hoping to take some photos to illustrate the ward for this travelogue.
In the West, we’ve been exposed to many photos of desperate looking African people waiting for care, or food, or assistance of some sort. But I wonder how often photographers ask permission of the people they see through the lens, and if they did, how often those people would decline being photographed.
I think part of the assumption is that these folks don’t really care as much as we do about privacy. This is a society where entire families live in a single room – privacy’s not an issue, right?
Well… maybe it is something people desire, even when it’s not something they frequently get.
Case in point: I wanted to take a photo of people crowding the waiting room at CO3. I wanted to show an image of how 30-40 women – minimum – cram themselves into a waiting room space that’s about 15’ x 15’. Most sit quietly for hours at a time. Some are doubled over in pain, some lie on the floor or lie with on the wooden benches with their heads in the lap of the woman next to them – frequently a stranger, but united in need. There isn’t a lot of talking. And they can hear moans and screams from within.
To get my photo, I walked out into the room and stood there for a few moments, trying to work out the best way to frame it. Everyone turned to stare at me. No one smiled. I stood for a few minutes, feeling profoundly uncomfortable.
I’ve rarely felt so… foreign… in every sense of the word.
Then, the midwife stepped outside to see if I was done.
“No… I’m… I’m thinking I should ask their permission,” I said.
“Why would you want to do that?”
“I’d just feel more comfortable. I feel …really weird about just taking the picture,” I said.
So, she translated for me.
“Hello, I’m a reporter doing some stories about health care for women in Zambia. I’d like to take a photo of the waiting room to show how crowded it is. Would it be OK if I take the photo? If you don’t want to be in the photo, let me know.”
No one responded, but they let me know all right. As I stood there, many of the women peeled themselves up off the floor and the benches. Two-thirds of the women filed past me, and away from my lens.
Needless to say, I didn’t take my photo.
Witness to suffering
If you found yesterday’s entry was disturbing, you may want to skip what comes next.
Mupeta comes to me and says there’s a 16-year-old girl who’s been brought to UTH by her mother. She’s about nine weeks pregnant. They came to Lusaka from a small city, traveling on a bus six hours to UTH. The daughter had gone to a traditional healer already and had spent the past few days passing blood. Mother and daughter are asking for a legal abortion. Mupeta asks the girl and her mother and they say it’s OK for me to sit in on the procedure.
In the US, many routine medical procedures get performed using anesthesics, that can include local anesthetic, such as Novocaine (for dental procedures) or Lidocaine, which can be injected at the site of an incision. Patients in the US also routinely receive medications to reduce anxiety, such as Valium and Versed. There are also options for opiods, such as Percocet or Vicodin. As a matter of fact, six countries – the US, Canada, France, Germany, Britain and Australia – use 79 percent of the world’s morphine.
The procedure begins . For privacy I sit on a stool behind the patient’s head, so I can only see Mupeta, but not the patient’s genitalia. The midwife, Iness Kabamba, keeps up a steady stream of conversation with the girl, asking her questions to which she mostly gives one word replies. They call it ‘verbal anesthesia.’
Mupeta talks to her and she nods. From what I can see, he examines her, but without that slippery gel that makes vaginal and rectal exams a little more comfortable. The girl whimpers a little. Kabamba talks to her.
Then Mupeta uses a speculum so he can see the cervix. Again, no gel, but this is not terribly different than a woman’s annual pelvic exam. The difference comes when Mupeta inserts a catheter into the girl’s uterus. I can tell this is what’s happened because the girl arches her back and cries out in pain.
Mupeta attaches the manual vacuum aspirator, an instrument that looks like a big syringe. Although it sounds archaic, the difference between this instrument and what women in the villages have inserted into their cervixes is enormous . For one thing, the catheters used with this instrument are blunt-tipped, the MVA’s and catheters are all sterile and the MVA can evacuate the entire contents of the uterus. That last point is important… if products of conception (that’s the medical term for the fetus, placenta, uterine wall lining, etc) remain in the uterus, it causes a life-threatening infection. So, for women who receive unsafe abortions in the village, if the sticks placed into the cervix don’t cause massive infection, the retained products of conception will.
By now, Mupeta is extracting bloody material from the girl’s uterus. She moans, writhes, breathes heavily and at times, howls.
Meanwhile, Kabamba chatters away, looking the girl in the eye in an attempt at distraction – ‘verbal anesthesia.’ As the procedure goes on, Kabamba asks the girl more questions that require answers… several times she calls her name to refocus her on the conversation. Mupeta offers reassurance, sometimes in the local language, sometimes in English, “very good, very good…”
But the girl is writhes in pain. I get up and wander into the hall… indeed, you can hear everything out in the hallway.
Finally, after 7 – 8 minutes, the girl plaintively asks Mupeta if it’s finished… he says yes, and she sighs in relief. She groans as she sits up on the table and starts to cry. Kabamba rubs her back and talks to her reassuringly.
Mupeta looks at me and says, “You’re uncomfortable with this…” I nod. This has been awful to watch.
Mupeta and Kabamba seem unflappable. I suppose they’re used to it, or use that unemotional façade that many health care workers use to keep from upsetting patients. In the past, I had perfected that blank mask. But I’ve let it drop over the years since I’ve stopped practicing nursing.
If it were me, that façade would be protecting me from the frustrations of this situation – the unavailability of contraception, the powerlessness that many women have over their sexual and reproductive lives, the basic lack of knowledge about biology and sex, the lack of options for women who do get pregnant but might want to keep the child, the unnecessary deaths of both women and fetuses, the lack of health care resources. I wonder how health care workers keep from burning out.
Leaving Lusaka
I was pretty shell-shocked by the time I left Zambia, and was glad I’d planned for a few days’ worth of R & R in South Africa.
Now, I’m not a wimp. Really. I worked as a trauma nurse in an inner city ER in DC when it was also the gunshot capitol of the country (‘92-‘94) and saw my share of blood. I worked in a drug treatment program in NYC, where I witnessed how some women were willing to degrade themselves and abandon their children, to get a fix. I later worked in a program where I saw elderly people die alone, abandoned by their families (or they outlived all of them) and listened to the stories of my Holocaust-survivor patients. I worked in a camp for people who ran away from their homes because some other ethnic group was intent on hacking them to death with machetes. I’m not a shrinking violet… yetI was deeply disturbed by what I saw in Lusaka.
Watching what unfolded there, I realized that women will seek out abortions –whether they believe it’s legal or not, whether it’s safe or not, whether it will cause them extreme pain… or not.
Quick update: May 27, 2010 – this story has won multiple awards, including a Gracie for the best investigative feature (American Women in Radio and Television); Best Health Feature (both North Carolina Associated Press and Radio and Television News Directors Assoc – Southeast Regional)
Warning: this entry contains some very graphic and potentially disturbing material
To hear today’s story, you can click here. Or here:
CO3, the “low cost” emergency gynecologic emergency department at the University Teaching Hospital is always busy. Between 60 – 80 women arrive daily to see a handful of nurses and doctors who also cover labor and delivery, surgery and rounding on inpatient wards. It’s this busy, even on weekends. Yet the women come because this is one of the only government run free hospitals.
The atmosphere is chaotic, an impression enhanced by a profound shortage of staff, supplies, medications and private spaces. But it’s not chaotic in the sense of “E.R.” chaotic, it’s chaotic in the sense that no one ever seems to have an idea of what’s happening, and there’s a randomness to when and how patients get seen. Of course, that’s exacerbated for me by my lack of the local language – but even when people are speaking English, there’s a seeming disconnection between how sick some of the folks here are and how urgent anything seems.
This rusty gurney is typical of the patient care equipment in CO3 'low pay' clinic.
Women who can pay come to the ‘high pay’ clinic for services that cost the equivalent of 3-5 dollars. The fact that women continue to come in the face of all these deficiencies is only a small indicator of the extent of the unmet need.
As I sat, I took notes in the little notebook I carry around with me. Here are some excerpts:
8:30 am: I get there, the waiting area is packed.
I wander down the hall and the midwife, Iness Kabamba is leaving the staff toilet, dragging a mop. There’s water on the floor. She tells me it overflowed last night. If you don’t turn off the intake valve for tank, it overflows. Someone forgot. I ask her if there’s housekeeping, she tells me she hasn’t seen any today.
Method used to heat water to clean instruments. This outlet is in the nurses' room, about 30' from the procedure room.
9:00 am: Kabamba’s lugging a bucket for boiling water to clean instruments before they go into the autoclave. There’s no hot running water, so she uses an electric coil that hangs into a five gallon bucket, suspended by a stick. There’s no good electrical outlet in the procedure room, so she heats the water in the nurse’s room and schleps it down the hallway (about 30’). Then she starts washing up.
10:00 am: Apparently a toilet’s overflowing in the ‘high pay’ ward. Three men arrive to take care of it. One carries a plunger, one carries a snake, and the third…?
10:20 am: One of the men leaves, comes back, the three leave. I ask the nurse. She says they can’t fix the toilet today.
10:30 am: Still no doctors. A nurse, Cherisencia Kasiya is taking vital signs at the little table outside the nurses’ room. Blood pressure – uses the old fashioned mercury sphygmomanometer. Reliable.
I watch for a while… has she taken a pulse? I’m not seeing it.
Mercury thermometer too… shaken down and placed under a woman’s armpit. Not as reliable – you have to add a degree or two to get the ‘accurate’ reading. But easy infection control. They don’t have a lot of alcohol to clean it off in between patients. I think of all the plastic disposables we use in the States, and am amazed.
Nurse Cherisencia Kasiya takes a patient's blood pressure in CO3.
Kasiya writes the women’s names and vitals on little slips of paper that look as if they’ve been torn from a notebook. Then they get laid in a little stack on the table. The women carry their own medical ‘files’ about the size of an elementary school exercise book, with a pre-printed cover. Apparently, if they lose their records, there’s no copy at the hospital.
An old box of gloves that’s been torn open is where ‘lab results’ get placed. I file through the pink carbon copy forms. Some are for blood tests done a week, two weeks earlier. I’m utterly confounded how some doctor would ever find results.
11:00 am: The doctors arrive, Doctor Mupeta is followed by the Congolese female doctor with the wild hair. She’s wearing the same clothes as yesterday. Mupeta says he was up half the night with deliveries and a caesarian section. We chat. It’s then I realize he’s not even completed residency yet, and yet, he’s the senior doctor on the ward.
Things get more lively and women start to file into the examination room to be seen.
11:15 pm: A young woman wanders up and down the hallway of the ward . She speaks in the local dialect, so I can’t understand what she’s saying, but she seems unfocused. She comes up and stands at the table where nurses take vital signs. They shoo her away, but she wanders back in a few minutes later, and finally lays down in the waiting room among the crowd of women there. They tell me she has a psychiatric problem and is homeless. She sleeps outside in the campus of the hospital, and wanders through the wards, always complaining of some physical ailment. She comes to CO3 often.
Noon: Needing a break from watching general activity, I wander to the treatment room at the end of the hall. There’s a woman in a bed in one of the six beds in the room – all full. She’s got a bag of blood hanging, slowly dripping into her. It’s about half complete. She has a thick cotton jitenge (one of the colorful cloths women wrap around themselves to use as a skirt) separating her from the rubber mattress. No sheets. The mattress is about 2 inches thick. The gurney she lays on is pockmarked with rust.
I ask her when she came in:
“Last night, about 22 hundred (many people here use a military-style clock for timekeeping).
“How many days were you bleeding?”
“Three”
“Feel better now?”
“Some”
“When was the last time you saw a nurse?”
“Last night when they started the blood.”
“Has anyone taken your temperature?”
“No.”
I’m struck by how passive she seems. Well, to her credit, she’s been bleeding for three days, she probably has the energy of a limp rag. But she’s there alone and there’s no one with her to advocate for her. And no one to advocate to – there are maybe 3 nurses floating around. Kabamba’s in the procedure room with the doctor. Kasiya’s taking vital signs and doing assessments.
It’s been a while since I worked in a hospital and knew the protocols about hanging blood on someone… but I remember it was something you watched like a hawk, monitoring for a reaction. The first sign was always an increased temperature…
A view into the 'high cost' patient ward, in the morning before patients come.
12:15 pm: Lunch break. I’ve brought a little sandwich that I made from breakfast leftovers and a bottle of water. The nurses insist on sharing their lunch with me. They give me nshima – cooked maize pone. Here in North Carolina it would be called grits, maybe polenta. They cook it to a consistency more like polenta. I dip balls of the nshima into a small amount of stew that is mostly oil, spices and some meat (I don’t ask). I have a chocolate bar, so, I reciprocate and share it with them.
Once again I’m blown away by how willing these folks are to share when they have so little – Kabamba says she makes only about a hundred dollars a month. And she’s the lead nurse. The others make much less, but they’re doing ‘well.’
The young woman with the mental illness wanders into the nurses room. She tells them she’s hungry, they give her a plate of the food. She squats in the corner to eat.
A chart showing how to estimate varying amounts of hemorrhaged blood.
Just before 1:00 pm: I take this photo. It’s a picture of a chart on the wall of the nurses’ break room… using a mannequin, it shows how to estimate the amount of blood lost during post-partum hemorrhage (PPH).
1:00 pm: I wander out to the waiting area… Doctor Mupeta has come and gone, done some procedures. I touch the wall separating the procedure room from the hallway across from the area where the women sit. The wall gives to my pressure – it looks like it’s about quarter inch thick plywood. What I know for certain is that the women waiting across from it can hear everything coming from the procedure room – including moaning, screaming, pleading as Mupeta does procedures without analgesia, much less anesthesia. It’s not sadism, it’s just that they don’t have the medications. The best they can do is give women some paracetamol (roughly akin to Tylenol) 20-30 minutes before a procedure that in the US would merit opiates, or full anesthesia.
Kabamba says she uses ‘verbal anesthesia’, essentially, talking to women during their procedure to distract them from the pain.
2:00 pm: Something has prompted a mass movement. At least ten women wander down the hallway to where the nurse usually does assessments. They stand there, waiting. One argues with the nurse.
Kabamba comes out and starts taking vital signs. She places a thermometer under one woman’s arm to take her temp. Then someone comes and calls her away. She’s gone for 20 minutes – I know, because I timed it.
The entire time Kabamba is gone, the woman sits with the thermometer tucked into her armpit. When she returns, the woman is still sitting there. I casually mention the thermometer. Kabamba walks over, removes it, jots down the temperature and dismisses the woman to the waiting room.
3:30 pm: A woman shuffles down the hallway to the assessment table. She’s bent over, wrapped in many brightly colored jitenge that have faded with time and washings. She’s carrying a opaque garbage bag, you can see that there’s something bloody within. It’s only then I realize that the bag’s been leaking, dripping blood-colored fluid onto the floor … drip… drip… drip. I follow the drips back to the entrance of the hospital.
When I get back to CO3, a maintenance man has appeared, he’s mopping up the blood in the hallways all the way back to the entrance. I ask: it’s a fetus that the woman expelled earlier in the day. She had taken a bus to UTH, with the bag, to show the doctors. Now, she’s in the room in the back, waiting to get some blood. I wonder how long the bag’s been leaking.
I wonder how long she’s been bleeding.
That’s when I decide I’ve had enough for one day. I say my goodbyes, arrange to return on Monday and leave. I go back to my hotel. The first thing I do is order a beer and stare into the swimming pool for a long time.
I spent four days hanging around in CO3 – the “low cost” obstetric emergency ward at the University Teaching Hospital – watching procedures and sitting in on consults, trying to be a fly on the wall. The unit is ‘low cost’ because anyone can come and get treated for less than a dollar – but that means sitting cheek-to-jowl in a cramped room, waiting for hours to be seen.
The waiting room is located just outside the main entrance to the ward. Sitting there, you can often hear moans and cries of women within. But few leave – they have no choice.
Unemployment rate: 50 percent
Median age: 16.9 years – that means half the population is younger than 17
Life expectancy at birth: males – 38.5 years, females – 38.7 years
Percentage of adults with HIV or AIDS: 16.5
GDP per capita: ~US$ 1500 (ranks 200 out of 229 countries in the world)
Infant mortality: 101 per 1,000 live births Mortality of all children under 5 : 182 per 1,000 live births Average number of children for a woman: 5.5
Maternal mortality rate: at least 730 per 100,000 (this is the low-end estimate) Chances of a woman dying due to childbirth related issues over her lifetime: ~ 1 in 27
Number of people who live on less than a dollar a day : 64 percent
People who live on less than two dollars a day: 87 percent
In many ways, it was reassuring to see some women walk in with garden variety gynecologic diagnoses: fibroid tumors, pregnancy induced high blood pressure (ecclampsia), spontaneous abortion (aka, miscarriage), suspected uterine cancer, pelvic inflammatory disease. These are issues that affect women in countries wealthy and not.
But so many others arrive with problems emblematic of Zambia. Obstetric fistula often develops in the wake of an obstructed labor (which would be treated with a quick caesarian section in the West). It leaves women with a physiologic passage from the colon to the vagina, causing them to drip feces from their vaginas. It’s really awful. You don’t see obstetric fistula in the US because 1) it doesn’t happen that often and 2) it’s fixable with a 20 minute outpatient surgical procedure if it does occur.
Other women arrived thin and weak, wasted from untreated HIV. They remind me of the hospice patients I cared for in the early 90s, in the days before antiretroviral therapy.
One medical resident is a Congolese woman with LOTS of hair, and going in every direction. Kind of like Einstein, but a lovely dark brown. She sees woman after woman, sitting down at a table to write her assessments as the women stand in front of her. Most of the more serious cases have already been assessed by the nurses.
Midwife Iness Kabamba sits opposite at the little table, prompting her:
“You should ask her about … “
“Yes, of course”
I have to laugh – it’s a lot like the way nurses prompt the residents at teaching hospitals in the states. Later I mention this to Kabamba – I compliment her on her professionalism, her thoroughness in working with both patients and doctors. I mention that in the US, too, nurses do much of the teaching for medical residents.
We both crack up.
Midwife
Midwife Iness Kabamba cleans instruments after a procedure
I was amazed at Iness Kabamba. She was so calm, so professional, in a setting that was so … crazy. It would have had me over the edge in days (you’ll see what I mean after you read tomorrow’s post).
One of her duties is provide “verbal anesthesia.” If you dissect that phrase, you’ve got the concept.
U T H is a government hospital with limited funds… that means few, if any, patients get pain medication. That includes women having procedures that are potentially painful – abortions, biopsies, incisions, etc. Kabamba talks to them as the doctor works.
I sat in on some procedures. Kabamba stayed near the patients, talking to them, chatting with them, asking them questions that required answers just as the procedure was getting painful. It’s basically a form of distraction.
Here’s the comparison – it’s like the dentist’s nurse talking to you as you have a tooth pulled – without Novocain. It’s something I’m not sure we can imagine in the US, as the data shows we are one of the world’s largest consumers of pain medication.
African countries tend to have morphine consumption of less than 0.5 mg per person, per year. In comparison, the US averages more than 35 mg per person, per year.
Post Abortion Care
Kabamba was patient and thorough working with patients. One of her primary responsibilities is post-abortion care. She was trained by Ipas to provide PAC, and went a step further to become a PAC trainer herself.
PAC protocol consists of not just telling a woman how to care for herself after a procedure… but it’s a protocol that’s aimed towards helping women to avoid unplanned pregnancy in the future, i.e. family planning.
Kabamba works with women to find the right method of family planning (condoms… or pills… or injection of DepoProvera… or IUD). The counseling is the same whether the woman has had a spontaneous abortion (miscarriage) or an induced abortion.
She also works with women about how to talk to their husbands or partners about family planning. It’s a challenge because by all accounts, the majority of women are not in a position to negotiate contraception use with their sexual partners – whether that be husbands or boyfriends. Brand new data show that only 5 percent of married couples use condoms, use of pills + injectable methods combined equals25 percent. (For purposes of comparison, 18 percent of all American couples use condoms, 36 percent use pills or injectables.)
That’s why many women use the injectable contraceptive DepoProvera – their partners don’t have to know they’re using contraception. Of course, that doesn’t protect these women from HIV…
I arrived to the University Teaching Hospital in Lusaka early in the morning. I was supposed to meet Dr Stephen Mupeta, one of the lead OB/GYNs at UTH. Mupeta left me waiting for several hours past our appointed time to finally meet up with me. I was angry at first, but over the next few days I learned something important – Mupeta is one of the few OB/GYNs at the entire hospital and he is very, very busy.
University Teaching Hospital has 1800 beds – that’s about twice as many as are at the behemoth UNC hospital. But the footprint is tiny in comparison – why? Because patients are jammed into small wards, sometimes two to a bed. Mupeta does deliveries, caesarian section surgeries, emergencies, consults, procedures, is on call every other weekend and gets followed around by a string of residents. And he’s not even a full doctor – he’s the chief resident, not an attending. During the four days I spent hanging around the CO3 – the gynecologic emergency ward – I never saw an attending physician.
One person Mupeta introduced me to was Iness Kabamba, a nurse-midwife, who counsels women on contraceptive use and assists with MVA procedures. MVA is short for manual vacuum aspirator, a low-tech, but high-impact instrument manufactured and marketed by Chapel Hill based NGO Ipas.
Ipas was created in 1973 to complete research, development and implementation of the MVA when the US government got out of the business of helping countries create access to safe abortion.
Manual Vacuum Aspirator
Ipas has worked in Africa for twenty years, training health care providers on using the MVA properly. One of the strengths of the technology is that the one instrument solves a number of medical problems for places with few resources: the problem of incomplete miscarriage (known by it’s medical term spontaneous abortion) or of resolving an unsafe abortion (known by the medical term incomplete abortion); the need to biopsy the uterine wall; and the need for a safe method of performing abortion.
The organization also trains health care providers on Post Abortion Care, or PAC. PAC is not just basic patient teaching about how to deal with the aftermath of an induced abortion (bleeding, cramping, etc), but how to prevent unwanted pregnancies in the future. During PAC, women are given information about contraceptive choices, instructed on how to talk to partners about safe sex and, when available, given the contraceptive that they think will work best for them.
Ipas has also worked more recently in Zambia helping government officials assess the need for contraceptive services, determine the extent of unsafe abortion and find out how much people know about Zambian laws surrounding safe abortion.
Zambia has one of the most liberal abortion laws in all of Africa. A woman can ask a doctor for an abortion based on five criteria: 1) risk to the life of the woman, 2) risk to the mental or physical health of the woman, 3) another child poses a risk to the mental or physical health of existing children in the family, 4) the unborn child has gross congenital abnormalities. Three doctors need to agree that the abortion is necessary, and then the woman can have the procedure performed in a hospital or clinic setting.
The penalties for unsafe, illegal abortions are steep – the woman receiving the abortion is liable for 14 years in prison, the person who performs the procedure is liable for 7 years in prison. So why do women continue to go to local practitioners when they have an unwanted pregnancy? Because it seems most women in Zambia just don’t know that it’s possible to have an abortion without risking her life.
Malawi Children’s Village is an example of how some determined people are pulling hope out of despair. But my next story takes a measure of the desperation of many African women when they find themselves with an unwanted pregnancy.
This means that over a lifetime of childbearing, a Zambian woman stands about a one in twenty-three chance of dying due to causes related to pregnancy and childbirth. The UN has estimated that about 30 percent of all the death due to maternal causes is as a result of unsafe abortions. (That’s from a report titled: Ministry of Health & Family Health International, Safe Motherhood in Zambia – A Situation Analysis (Lusaka, Zambia: Ministry of Health, 1994). I’m getting an online copy of the report from the authors.)
No one really knows for sure if that mortality estimate is on target. That’s because unsafe abortion is such a hidden phenomenon. Is the pregnant woman who arrives at the hospital bleeding because she’s having a miscarriage, or is it because she went to a traditional practitioner who inserted ground glass into her vagina, or a cassava stick into her cervix? These women who arrive bleeding don’t reliably get counted into those numbers.
What’s unfortunate, though, is that these unsafe, illegal abortions are unnecessary – Zambia has one of the most liberal laws regarding safe, legal abortion in Africa. The law’s been in place since 1972. Safe abortion is ‘legal’ and unsafe abortion ‘illegal.’ But most women don’t know that safe methods of terminating a pregnancy even exist. So they ask neighbors, local healers, their sisters – anyone – who might help them terminate an unwanted pregnancy.
And… every single woman I spoke to in Zambia knew someone who had died from an unsafe abortion.
That’s why I decided to do a story about the work of Ipas. I know abortion’s a difficult topic to write about, fraught with landmines. I also know that women are not going to stop seeking them out, despite what lawmakers put into legislation and despite what many people of good will would like to happen. That much was obvious in a place like Zambia.
In doing this story, I wanted to try to cut through the rhetoric and look at what it’s really like in a place where access to safe abortion isn’t readily accessible.
You can hear today’s story by clicking here, or here:
One of the ways Malawi Children’sVillage has survived is by changing with the changing needs of the population they serve. Director Chakunja Sibale says when he started the project twelve years ago, most of the children were young. But children grow up and need support to become successful adults.
Sibale decided that he needed to train children who were getting older for the world of work. So, he set up a tailoring shop, a woodshop, a dairy and demonstration garden.
Take a look at this short video of the demonstration garden. It provides food for all the children at the infant feeding center, and is a place to teach local people about good agricultural practices.
Sibale also started a secondary school. After a mere three years, the Gracious School is considered the best in the district. There are 218 students… 118 of them are orphans, and all these orphans have a sponsor somewhere in the United States.
If you’ve ever worked in a foreign country, you know the anxiety of wondering if you can trust the people you meet. That anxiety is elevated when you arrive at a place you don’t know at all… so, you take a deep breath. You walk out of the airport building and a group of guys surround you, “Taxi! Taxi!” You look the guys in the eye, hope someone meets your gaze and start to negotiate the fare.
After I landed in Blantyre, I walked out of the airport, and one man sauntered up to me and asked if I needed a taxi. Of course, I did need a taxi to the guest house where I was staying for Saturday night, and someone to drive me to MCV early the next morning, as well. His car had a bumper sticker on his taxi promoting the anti-child abuse campaign. I didn’t know it then, but that was a good sign.
Along the way to the guest house, I gave him the treatment, namely asking all kinds of details about him: whether married, how many children, their ages and how they do in school, how many brothers and sisters, religion, how long he’s been driving a taxi… When I lived in Asia, I got into this habit. If you’ve ever been in Asia, usually whoever you meet extracts this info from you – and more – within five minutes.
He seemed like a good guy and by the time I reached the guest house, I proposed he might be someone to drive to Mangochi… if the guest house proprietor had not arranged that already, of course… and depending on his proposed price.
Well, I struck gold in John Juma. The price was good, the man was honest and not only did he answer about 200 questions – everything from “what does it say on that billboard?” to a discussion of press freedom in Malawi – but he jumped in when we were at the orphan project, handling babies and touring around the facilities with us. It turns out John’s wife runs a day care, and he was great with the children at the infant feeding center at MCV.
I learned a lot from John, including the mechanics of setting up a walking club in one’s neighborhood! It seems that his doctor told him he was too sedentary, and that his blood pressure had increased unacceptably. He told me this on our last day together. He arrived and I asked how he was.
“I’m tired. I’ve walked 11 kilometers already this morning!”
“Really???”
Then he explained how he organized several men from his neighborhood to walk every morning.
It’s an amazing thing to land in a strange country and immediately meet someone you can trust. I am very, very lucky.
Thanks, John.
(Sorry… I never got to take a photo of him, and he gently demurred when I asked to interview him on tape)
Hear the story of Malawi Children’s Village by clicking here or here:
One of the reasons that Malawi Children’s Village works is that its director, Chakunja Sibale, saw that the program needed a presence in the villages where orphans live.
One sad reality is that many orphan children in Malawi end up becoming de facto unpaid servants – close to slaves – even in the households of relatives who take them in. That includes ‘marrying’ off young girls to older men. According to UNICEF, 39 percent of ‘married’ people in Malawi are between the ages of 15 and 18 – many of them are girls.
UNICEF's Stop Child Abuse Campaign is visible throughout the country
The problem is so prevalent that UNICEF started a “Stop Child Abuse” campaign . No matter where you drive around the country, you’ll see dramatic billboards and bumper stickers displaying black handprints on a red background.
That’s why programs like MCV are so important to kids. Sibale knew his culture when he realized he needed to insure that the children under his care actually got what their guardians said they’d give them. So, early on, he recruited several volunteers from each village to monitor the progress of the children. 72 volunteers receive a small stipend – ‘soap money’ – of about 3 dollars per month, a t-shirt identifying them as MCV volunteers and – most important – they are loaned a bicycle to use for commuting back and forth to their villages (they get to use the bicycle in other parts of their lives too, like to bring produce to market). Now THAT’S a big deal, in a country where most people walk and there are few motorcycles.
Sibale says monitoring the children using local people has insured that they get what guardian families have been given to support them.
Outreach worker Florence Mndala gets ready to go out to a village - carrying a scale on her head!
Another part of village outreach consists of two outreach workers – Catherine Shabanie and Florence Mndala. They travel a circuit of all the 36 villages where orphans are living with guardian families, teaching basic health education, monitoring child nutrition and health.
One morning we took a trip to a nearby village to check on orphans there. Check out our trip in this small slide show.
In the past few years, MCV has also initiated a malaria prevention program in the villages. The organization distributed donated malaria bednets to people in villages where orphans live – the families every child under 5 years of age in these villages received bednets.
Tomorrow we’ll find out what happens to older orphans involved with MCV. But here’s a preview… Director Chakunja Sibale says Malawi needs more schools, more education. Take a listen… (or if you have problems hearing the audio, try clicking here)
The person behind Malawi Children’s Village is Chakunja Sibale (pronounced: Si-WALL-eh). Mr. Sibale was trained as a medical officer – not quite a doctor, but in the seventies, it was the closest thing you could train to be as a Malawian. He eventually went to Scotland and earned a degree in public health, later working for relief agencies all over Africa. But unlike other Malawians who received medical training in the West, Sibale actually came home to Malawi.
Apparently for many years, there were more Malawian doctors in Manchester, England than there were in Malawi. This factoid may be apocryphal, I was told this repeatedly, but couldn’t confirm it. But it underscores a point – that for many years, people left Malawi to train as professionals and never returned home.
In the 1990s, Sibale was working for a project in Malawi funded by the US National Institutes of Health. He met families who had taken in three, four, five, even six children of relatives who had died of AIDS. At the time, about one in five adults was infected with HIV.
Sibale got the germ of an idea – what would it take to keep kids with their families? It makes more sense in a culture where – in normal times – orphans are never separated from relatives. But when those families are overwhelmed, the system breaks down.
Sibale wanted to find a way to help people take in these orphans – and succeed.
The needs are simple – families receive basic necessities such as extra seed corn, school fees and uniforms so the children can continue in school, extra blankets for the cool season – simple necessities, but sufficient to make it possible to support another mouth.
Faith Sibale prepares for a day in the MCV Clinic
As time has gone on, Sibale has been able to dangle other incentives for families that take in children – for example, a clinic accessible only for the orphans’ families. Sibale’s wife, Faith, is a registered nurse. She runs the clinic and sees sometimes more than a hundred people a day.
Sibale’s idea was simple, elegant… You can build an orphanage, and you can house a hundred, maybe two hundred children at high cost. But, create an infrastructure for supporting families and you can support hundreds… thousands… of children – at a fraction of the cost.
Take a short video look at MCV’s campus here (if you can’t see anything, click here):
Malawi’s Children’s Village isn’t so much a place as it is a concept. The compound houses workshops, a demonstration garden, an infant feeding center for malnourished children, a clinic, and now, a secondary school. The compound sits in the middle of a region that runs about 20 km along the shore of Lake Malawi, and about 5 km inland, comprising 36 villages. Currently about 2500 orphans are living with relatives, several years ago, at it’s peak, MCV was monitoring the care of close to 4000 children.
Recently, Sibale started a secondary school open to all the children in the area. After a mere three years, the Gracious School is considered the best in the district. There are 218 students… 118 of them are orphans, and all these orphans have a sponsor somewhere in the United States.
This young man, Emmanuel Ntala is an orphan who’s continued on to post-secondary school. He’s getting support from MCV to pay for tuition at a teacher’s college. Take a listen below. (and if you can’t find the audio, click here)
The first place I’m headed to is called Malawi Children’s Village. But first, I had to get there!!! If you think Malawi is far, then try getting to MCV… it’s really, really remote.
Roads in Malawi are mostly two lane kidney-crunchers, filled with potholes and crumbling at the edges, heavily traveled by trucks, goats and bicycles, oh… and people. Turn off the main road and you’re on compacted dirt, sometimes the main road is compacted dirt.
The morning after I arrived in Malawi, I got up at 5 AM (still jet lagged!) to ride three and a half hours to Mangochi, on the southwestern shore of Lake Malawi, a whopping 100 or so miles away. The last 12 miles was a dirt washboard that created clouds of dust as we crawled forward. Everyone I’ve talked to says the rains haven’t come yet. And when they do, everyone tells me this road will be a mud hole. I hope it doesn’t start raining before I leave!
For all the difficulty of travel (25+ hours on planes – Atlanta to Senegal to South Africa to Malawi, then the road trip), Raleigh residents Tom and Eve Vitaglione make this trip almost every year. And they’re in their 60s!
Tom and Eve first came to Malawi as Peace Corps volunteers in the 60s. It’s how they met. They came home to the US, got married, raised kids, had careers and weren’t particularly involved with Malawi until the mid-1990s when they started hearing from old friends about the many orphans being created in the wake of AIDS. To date, close to a million Malawian children have lost one or both their parents – that in a country of about 13 million people.
In case you missed that, 1 in 13 Malawians is an AIDS orphan. Stop reading for a moment and let that sink in.
OK, now back to the narrative…
The Vitagliones got involved with Malawi Children’s Village as they neared retirement. Tom’s a long time children’s health expert who was long-time employee of state government working in public health. Now he works part time as a children’s health advocate. Eve worked as a science educator at the North Carolina Museum of Natural Sciences.
They come to Malawi for close to a month each year. While here, Tom gathers data about the health of the kids and prevention activities, and consults with the director on crafting programs. Eve has helped set up the library and spends time in the infant feeding center. In the US, they raise funds from their friends and from their church, St Marks Episcopal in Raleigh.
Stay tuned, WUNC will run a story about the project – Malawi Children’s Village later this week.
Going to church
This year, Tom and Eve, also brought a present from their church – St Mark’s in Raleigh – for the church they attend here – St. Michael’s and All Angels. It’s a hand sewn banner made by women in North Carolina, and a gift of money raised by people at St Mark’s.
The altar at St. Michael’s and All Angels Church, with the banner made by people in Raleigh on the table.
I was able to attend church with Tom and Eve on the day I got to Mangoche. The minister gave a long sermon in Chichewa that sounded as if it had lots of fire and brimstone. The congregation um hm-ed and amen-ed in response.
I was duly introduced as Tom and Eve’s friend, the radio reporter… this gave me license to roam around the church during services, primarily recording the exuberant singing – filled with tight harmonies, percussion and ululations.
The choir from St. Michael’s and All Angel’s Church.
I tried to be discrete, but it’s hard to hide a strange woman wearing a microphone and headphones. A couple of kids broke into tears when they saw me!! Their parents were less frightened, albeit just as curious!
I hung out after the services as the choir sang me four more hymns that I was able to burn to a CD later that day and present to them before I left (I love flash recorders and computers!) I also had my hand shaken by about 30 people at the end of the service – everyone wanted to meet me!!
Sunday afternoon, I got to swim in a Great Rift Valley Lake – Lake Malawi, several hundred meters from Tom and Eve’s house. It’s Africa’s third largest lake, surrounded by mountains.
Oops. I also learned it’s full of schistosomiasis (bilharziosis), a type of parasite that’s endemic in the area – in other words, everyone has it, and it’s a primary cause of illness in the area. Don’t worry, I’m getting checked…
African kingfishers were plentiful near the lake
Later, sitting with Tom and Eve on the beach, we saw a hippo in the water, about 30 meters offshore… no one told me they hung around the area. Eve didn’t mention until then either that crocodiles are frequently seen there too!!! In addition to big critters there were some great birds – African kingfishers, fish eagles and storks – just hanging around the lake shore.
The possibility of parasites aside, I was glad for the short break – it was the first time I’d stopped moving since leaving North Carolina close to five days earlier.
I got up early on Monday morning and took some photos of the lake before we went off to see MCV.
Sunrise on Lake Malawi, looking east to mountains in Mozambique
Local fishermen return from a night of fishing on the lake. Lake Malawi is known colloquially as the Lake of a Thousand Stars – from the many torch lights used by fishermen at night.
Global Health Connections is part of the North Carolina Voices series present by North Carolina Public Radio® - WUNC. Read more about the North Carolina Voices series here.
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