Return to Malawi

Africa.

A place that calls to me in unusual ways. I have tried to call it my home but also know that its hardships are not the most desired. But here I am again, after only 1.5 years, back to the motherland. I remember my first sight of Africa I was in tears of disbelief that I was finally here. But yesterday was different as a calm fell over my body feeling almost at peace with my arrival back to the land I had dreamed of so often as a child.

As I write the trees are alive with the songs from different birds and the sounds of people speaking chichewa as they walk past. I am in Lilongwe, malawi. The last time I was here was with my father trampling past his memories of the peace corps at a catholic school. It was such a gift to watch him retrace those memories. We walked through old rugby fields, stood on the basketball court that he built, listened to stories of where he created the marching band,and finally walked into the bar that would tie my mother and father together. It was a gift to be there with him.

But today I am here walking another path. I arrived here with Chris buck and Jeff Pierce, both ex-Baylor docs who are here now for new reasons. Kabadula. A forgotten town. A lost hospital. One with one mid level provider caring for over one hundred patients 24/7. No doctors. And only 9 nurses. It was discovered by a few other Baylor docs in 2006 and there was a desire to help. So formed World Altering Medicine, WAM. They have slowly pieced together needs and support and are slowly finding ways to support this forgotten child. I invited myself hoping to find a place but uncertain still what I am quite getting myself into. I know even with my insecure self and feeling of inadequacy that I still would have something to offer, but what is still a mystery.

This morning I looked at my watch as the sweet sounds of singing echoed from the mosque. It was only 4:45am but it sounded so mesmerizing. So calming. So beautiful to me. I was happy to have chosen to come on this journey and for one week to hopefully sort out what it is exactly I want to do with here, and maybe with my life.

FIFA World Cup- A Feelin'

Vuvuzelas-An unforgettable sound that rings through the air reminding you of the energy and excitement that is about to occur. Any other day those horns would grab at your nerves wishing that you could just swiftly remove it from the blower's hands and break it across your knee. But, for some reason, the sound is different when it comes with the fever.

I am sitting here in the heart of WORLD CUP FEVER...living next door to all of it! FEEL IT!

The crowds have been filled with life wearing Bafana Bafana shirts and singing South African songs. I wake up hearing the ring of the horns which reminds me of what is going on.

Yesterday, my heart was running to a different beat waiting for the moment for this all to begin. I was at work with Black Eyed Peas repeating the words "I gotta feeling..that tonight's gonna be a good night!". It was hard to concentrate and I wondered why I was getting so excited for what seems to be such a minute thing- a game- called Football here, soccer at home. Why?

History seems to be a good answer. You look at the fact that this continent has such history, such change, such pain. And through this they are able to bring people together to celebrate with the same focus. They take frustrations, excitement, anger and put it into a team. And all of a sudden there is room to smile, dance, sing. Filled with the colors yellow and green, the room glows. I realize that it's not the game that I am excited about. No. It's the people that surround me to make this event what it is. A community that fighting for the same goal. We may have different teams but we can celebrate together!

Last night I watched South Africa tie Mexico. I almost felt like I was right there, and in a way I am. I am so glad that I can spend it with the Basotho for some, and live for others!

Feel it! You Can....IT IS DEFINITELY HERE!!!

'Til Death Do Us Part...

5 deaths in 24 hours. It's astounding. You sit there watching the tidal wave flow over the hospital as if someone poisoned the formula. And the problem starts when you begin to hope for a miracle. I have really invested my heart and soul to children that come knocking on death's door and wonder why they don't survive. I already know that parents bring in children too late using hospitals, often times, as a place for their child to die. But when I look at a child, and their eyes still open, and they are even able to produce a tiny smile, I start to hope and wonder if they have enough left to fight.

Skin and bones. Sometimes that is all they are left with. When I can visualize the skeleton that makes us human, I know we are nearing the end. So I started slow. I talked with mom. I looked at the child who sat up and I thought...maybe we have a chance. Mother so desperately wanted to feed her child, but the crazy twist is that now "food" may be her enemy. Her system is so sensitive that even the slightest off balance can kill her. So. We started slow. We tried hydration. We even started with slow feeds. I saw her start to perk up. My heart even started to have faith. She stood up with her legs made of bone trying to hold herself. I told the mother to continue this regimen all night and not to change. These children can fool you. And she did. The next day she was dead. Just like that. I knew from the start that the chances were slim, but the hope still comes seeping out from some unknown place.

Gasping. Walking by an unknown bed I see this child. His eyes are opened wide trying to get in any air that he can. I stop to ask what his story is realizing the seriousness of his state. Looking through the notes, I realize that he has received the bare minimum to survive. Luckily there was oxygen. I immediately got an xray and a tested him...both positive for TB and HIV. The poor child had been suffering for weeks...and nothing. I gave him the thumbs up sign and he smiled through his gasps. We started treatment immediately. The next day he sat up in bed trying to breath through all the fluid that was filling his lungs. He looked at me and told me he was tired. I talked to him. An hour later I gave him chest compressions only to pronounce him dead. We were too late. It is so difficult to watch a child drown and have nothing to give them. Nothing.

Fever. Such a common complaint. But a fever to a cancer patient always raises my eyebrow. Laying on the bench, I knew this child was sick. We rushed him to the treatment room and started an IV line. He was so thirsty. We kept giving him water. He was breathing fast and so hot that we gave him antibiotics and sent him for a chest xray. I called his oncologist in South Africa who advised me on the limited drugs we had and to call him if he got worse. My next call was to tell him that he was gone. I had heard the mother wailing and rushed to the bedside. His heart had already let go. I held his hand and tears rolled down. I could not hold it in any longer. He was not supposed to go. He was only 6 years old. I held the mother crying with her. It is not ok.

And this is only one day. 24 hours. I sat just lost. Brain on protective numb mode. I hugged my counselor who has stood by my side through all of this. She has been my back bone. Doing work that others are supposed to do but not willing. Hugging me when she saw the tears drop. Crying with me when we could not seem to understand the day any longer.

As I was walking out a baby caught my eye. She cooed with her eyes fixated on my face. I walked over and picked her up. She fell comfortably in my arms. A smile melted onto her face and she slowly closed her eyes. I stood rocking her for a bit smiling at mother. My backbone side kick still with me at 6:30pm after everyone has left talking to the mother in Sesotho about how well her child was doing. The next day I sent her home from the hospital, with her child in hand.

Maybe there is a reason for all of this. Maybe we do save one out of the many that make it here. But my heart does not seem to fixate on the one I save. It only charges at those that I cannot. Death is inevitable. I know. But when you are 6 months, 6 years, 12 years, I can't seem to think it is right. Not for them. They all have a chance. They all need a fighting chance. And they need someone that will fight for them. Until the end.

I am here. But when I face a day like today...it really strikes my core. What am I doing? Am I even doing it right? Do I have a fighting chance? I am not ready to give up the battle, but I can't seem to do this fight on my own. I need change. A new hospital. A government that cares to supply adequate medicine. A community that understands that hospitals can be ok if we have the two former in place. A staff that cares to work. Enough doctors to care for the children. No. I can't do this fight on my own with all of those stacked behind me.

Today was a hard day....

Soweto Adventure

Our adventure to Soweto was supposed to be simple...go there...run the race...enjoy the surroundings and quietly go home. Unfortunately, we got the full experience.

The Soweto marathon is an amazing run through the township. I did the 10K and noted two people running barefoot. Being a minority, I felt like I was in an olympic race with some of the most fit people around. The race itself was fun and even some had zulu headwear on with one man even sporting a skirt. Of course they wore all of that while completing the marathon in sub-3 hours while talking to their neighbors as if they were taking a stroll. It is here that the adventure began.

The one thing I have learned about Johannesburg is to never drive with Lesotho license plates and to definitely not park next to your friends. It was like a christmas day to any thief as we gifted them three lovely foreign cars to play with. Fortunately they only decided to leave with one but completely rip apart the starters for the others. We were the lucky ones to have the tools they used in our car still but the dangling wire underneath the wheel gave me the idea that we might be a bit stuck. No place to put a key to start the car, the very nice locksmith taught all of us how to hotwire a car. I felt like 101 in J-berg stealing. It was great!! We were able to get our car running again, but the dangling starter and ripped apart dash gave it a whole new look.

We decided to head back, but since our friends were one car short they asked us to pick them up in Johannesburg. Of course, we start to head in the right direction but immediately got lost...even with two atlases in hand. I think we toured the entire Soweto before finally finding M70 and feeling grateful...(even though we had to do a U turn on it to go back towards J-berg.) The map said we could get to the M1 and we really truly believed it, but alas the two girls (one with daddy as the geographer) amazingly got misplaced again only to get pulled over by the cops.

At this point my heart started to feel a bit more excited and I really felt as though I had just stolen this car and got caught...how the hell was I going to explain this crazy story to the corrupted cops who made me step out of the car. I got smelled up by the woman who blamed me for being "heavy on the wine" (unfortunately mistaking my bad breath for alcohol) while Ntate kept singing "wake up...wake UP". As they went back to the car to get the breathilizer I started to feel a bit at a loss....as thought this was just another addition to our already dysfunctional day. And leave it to me to get pulled over by the cops...it happens everywhere I go.

But after I pouted about our robbery and painted the truth with my just finished Soweto MARATHON they handed me back my passport and showed me the proper way to the freeway. At this point we were now an hour late only to receive the infamous phone call that they don't need our services anymore. It is moments like these that produce tears with your laughter from surrealism of the day. Please tell me, what more could go wrong?!

Well, the drive home was less of a story other than getting lost on the 709 only to end up on some foreign dirt road and running into the most amazing lightning storm following by diagonal rain....

What a journey. I do admit, this will be one to remember.

Isolation

A driver. Really?

I step out of what felt like "hell" in the midst of a finished Queen II hospital experience and was introduced to the fact that I will be required to have a driver take me to my outreach site and stay the entire week with me while I am there. Safe- says some of you. Aww yes. Says I . Maybe safe because I have another Sesotho speaking person with me who can help fix a tire or get me out of the mud. But safe for my life? Well, that I can argue is a much different answer.

I was quite irritated to hear that I would lose my wonderful time spent on the mountainous hills, listening to whatever music I felt like, and allowing my brain to sift through whatever material came through its way. Then I felt the loss of independence as I would have to wait for the driver to come pick me up, late, and take me to wherever they day would send me whilst he slept or played games in the car. It actually felt quite silly to me. But the third loss what control. Here I had someone else who was deciding the destiny of my life as we sped around curves and cliffs putting my poor own life to risk. And I say to myself...A driver. Really?

Needless to say, the crankiness dissipated as Mpho and I met at 5:30 in the morning for our daily high altitude run. With the sun just warming up the land and the birds already up for hours, we headed down new foot paths to a long footbridge that went over a beautiful winding river only to have to crawl back up the mountain again saying "dumela" to all the Ntates already up. Then we would take the 1-2 hour journeys to all of the outreach sites meeting with the staff, helping with treatment and initiation of HIV medicines and training.

These unbelievable rides to and from my sites are probably one of my favorite parts of my journey to Africa. Children still run up to the road just to wave you by and sheep still try to figure out what a road is really meant for. The mountain ranges seem to go for miles even though I feel our drives are just that long.

I did feel the pain of any job where you encounter those who are not passionate about life or their job, and you wonder why they even bother since they try to make your life miserable. But you just find that child that makes you smile and it all seems to move on.

But with this job, it seems that with every good bit comes a piece of sadness. I lost a child this week. I was very sad, and in fact had to stop to let my tears flow. Unfortunately, this is one I actually had hope would make it. And, of course, these are the ones that you put hope into and feel like you have "caught" them just in time to only find out they are gone. This child came to me in the hospital. She had short hair and cherry red lips to match her fever of 105. You could just tell that she was uncomfortable. I, for many reasons, was concerned but her mystery diagnosis had me dreaming of her at night. Before I transferred her to South Africa to receive better care, I felt in my heart that she must have cancer and we were going to "save her" by having them diagnosis and treat it.

But, the email that none of us ever want to get gave me the date and time of her death along with all the efforts they did to save her. She did become an "interesting" case to them as well, but her loss became more of my memory than what she had. She would give me her arm so willingly as I would, yet again, try to replace another IV that had stopped working. Or trying to give her water as she so desperately would slurp it down wanting more. My resources were limited and the antibiotics I had seemed so minimal. But the thoughts just poor into your head- did I keep her too long? Could I have given her a treatment earlier that would have saved her? Could I have prevented her death?

Of course, I will never know. We did not have any of the resources they used in South Africa, but there is always the "what ifs". I know that I "did the best I could", but as a doctor it sometimes does not feel good enough. And you are just left to wonder. The guilt I can learn from and I do, or at least I try to. It makes you really sit down and think about that next patient that you don't want to die because of you.

In fact, that held true with a kid that came to me in outreach this week. Her arm dangling after falling with painful tears rolling down her dirty little face. She, in my eyes, had obviously dislocated her elbow anteriorly (not one we deal with as often). With the last child I had, they refused to go to hospital. So I tried my best to relocate it there. For days, that child haunted my thoughts with what the right decision was and I wondered if it ever went back. Fortunately, I just popped the girl and the mother in my car and we drove straight there to confirm the dislocation and provide analgesia to help her.

Emotionally, it has been a good week and month despite the sadness I carry with the loss of that child. I find the isolation from Baylor this month (whether it be Mokhotlong or my 3 week journey in the hospital) to be quite refreshing in moments like these. But it does make you feel isolated from everyone else who has been paralleling their lives at the COE. I am thankful to have people in my life that I can confide in and have put smiles on my face when I felt these moments of hardships hit me the most. It has been uplifting and comforting.

Queen II Hospital- Week 1

I have officially completed one week at Queen II Hospital- the main establishment in Maseru which is the capital of Lesotho.

I say that because as I round in the morning with the medical officers- I often drift off into space and count the cockroaches on the seeping walls wonder if there are more of them or more patients. The place would be condemned in the United States. I see a cockroach scatter across a baby's bed, on their food, in the cracks...they are everywhere. The babies sometimes share a bed, especially when we can't find room for them. The ceiling holds lights by electrical threads and the walls, I think you can see to the outside with the cracks.

HIPAA does not exist. I have tried. But the mother's sit on the bench next to their children and there is no privacy. The nurses may remember to check on a patient through the day or night, but the mother's are responsible to feed, bath, administer medicines to their child. And all the parents have for rest is the ground, or the hard bench next to the crib of their child. It's a mess.

Sanitation is a joke. But you try. I have gloves. That's a start. A mask in the TB ward is not heard of. In fact, you just give the children medicines and open the windows and hope your next PPD is negative still.

I have two patients that seem to stick out in my head and are worth mentioning.

My first is a 14 year old girl. She weighs 44 lb which gives you some inkling of the bones and skin that exist on this child. I have fought with her to take food and she has been a wild mess as to what she wants. I can't say too much more about her since I don't want to violate patient's privacy even though it does not exist here.

The second is baby death. Baby death was born a mere 5 lb. Mother stopped feeding the baby milk and started to use bread flour and water. The baby is 3 months old and weighs less than 4 lb. I think her weight is how much her bones, head, and organs weigh. There is nothing left. She came in grey, gasping, and with a very little heart rate. The only things we have to offer are bagging (thanks to NICU), some dextrose, warmth, and fluid. She decided she liked that, the first time.

After rehydrating her, we started feeds. She didn't like that and went back to dying. After I bagged her back and gave her more glucose she decided to live.

This morning, I walked by her crib and noticed her gasping like a fish out of water. No breaths. No real heart rate. And their sat the mom. Just watching her. I wondered if she just brought her to the hospital to die. She seems not so interested. But maybe that's the culture.

After bagging her back, checking her sugar and giving her more, adding more antibiotics than before and reassessing her bad line, I found a scalp vein and started her fluids once again. it's not like the fluids will save her. She needs food. But with her gut not probably getting the blood flow it needs, it's a tough spot to be in. We have no other way to feed her but the gut. But the fluid is giving her the sugar she needs now.

Well I will tell you how done I was with this child when I came back later and noticed the fluid had run out. Do you know what this means? Losing fluid means you practically lose your vein and access to this child! I had spent and hour finding that darn vein and now it was gone! I looked at the mom wondering if I should put any more effort into her child since she obviously was not. In this world of the hospital you teach the parents everything. I had to teach her about the fluid, the warmer, how to feed her child...etc. With the fluid, the instructions were...if this gets empty get a nurse! Your child needs this.

So for another hour I played with that same scalp vein fishing out clots with a catheter and finally getting it to work. I could not believe it. There the drips flowed from the bag to my baby death. Again- another small success.

With little left in my back pocket to use, I told the mother we are just going to have to start feeding your baby. This child will die if we don't, and maybe she will die if we do. But I can't chance not feeding her anymore.

It has been quite a week and there is the weekend and 2 more of these for me to have my fill on! I have so much respect for the medical officers who are doing it all in addition to running to the c-sections to assist in surgeries! At home, I feel that we have nothing to complain about. These medical officers are run to the ground. No duty hours making them go home at noon post call. And at night, they have to hold down all of the hospital.

That is QEII hospital.

Week 1.

Mokhotlong Revisited

I have secretly fallen for this rather desolate homely piece of the world! Spare me as I repeat the description of this district.

Set against the majestic Drakenburg Mountain Range with the highest peak over 11,000 feet (Thabana Ntlenyana). I drive over the smaller ranges of 10,000 ft to get to the town of Mokhotlong. It really was thought of as the most remote location in Africa, but now a road has been constructed all the way to the center. However, that is it. Even the road here has the occasional large pothole that will take out the bottom of your car, and is impassable in the winter with snow that can leave people without access for weeks.

But as I sit in the Senqu hotel and look out my door, there are layers of mountains that paint the background as the sunset creates various shade of blue. The children are laughing below as you can hear them running after each other trying to kick the ball between the two makeshift goals on the dirt. I watch everyone walking home from work, school, or just walking talking to each other on the goat paths with no fences that separate people's lives here. We lose that at home. The poverty here makes it impossible to find work and people just work hard to survive. The farms are packed against each other as people have to farm their own food in order to eat. There is not much here, and people often feel as though everyone including the government fail to remember that they are here.

The potential of Mokhotlong is here and there is already an amazing group of people already in place, if only people would stay. This area is so remote that they are unable to keep anyone, especially for how low their salaries are for how little it appear people seem to appreciate their work. People, in general, seem to only want out once they are forced in. But there are a few that have remained, mainly because they are from here. Mpho is my partner in crime and who I rely on to help me find information. She is young but with a great sense of humor that keeps me on my toes. She keeps everything going including me and has it all ready by the time I arrive every month. Siti, her sister, is the numbers girl and keeps all the statistics in line. She has been an amazing asset when trying to get a new clinic accreditated for HIV treatment, and the only thing that seems to hold this team back is the ministry. The clinics in the Mokhotlong district are "hole haholo" (Sesotho-far) and are so remote they can't even get Ibuprofen supplied in sufficient amounts. They send request to the ministry but will only see a response months later. It feels as though people are left with little hope but will do anything with what they have.

I can see the potential but this district, this country needs a voice. They need a change. And I feel like it all starts with the Ministry who runs this joint. The funding- is it really not there? There must be. Is it not odd that the government will guarantee HIV treatment suppplies to be readily available to all facilities (thanks to Baylor's voice and push) but they can't treat the daily events of pneumonia, pain, broken bones, etc. It's almost surreal. I met a boy whose arm he held by his side, deformed a bit from kids beating him. I could tell the elbow was out, but could not get him to settle to put it back in. The mother refused to go in because she could not afford the xray. The little I could do may have put it back together, but without painkillers the child refused to have me near him again. It made me realize how little we are trained for general medicine out here, and how much I want to help and find ways of improving this impoverished place.