Mumbo Island

Hello! The past month or so since I last wrote has been pretty hectic. The power has been going out almost everyday but at least its cooler at night. The GeneXpert arrived so the TB and malnutrition project started. This study is insane. Right now I'm mostly helping to enroll kids for the 2.5 days per week I work on the study. This entails finding possible participants, giving the study spiel, having the interpretor consent the parents, scouring the illegible passbooks and charts to take a history, and interviewing the parents. As an aside, we recently had one family that immigrated from the DRC and I attempted (and sort  succeeded) to conduct the whole process in French.

Most parents are very willing to have their kids join the study (I think 99% of the Nutritional Rehabilitation Unit - NRU - have our green sheets stapled to their charts). At first, parents were reluctant because of the tube we stick down the child's nose to suck out the sputum but we've since reworked how we talk about the induced sputum process. Many people associate NG tubes (the ones you stick down the nose usually to feed a kid who won't eat) with death since those who have them are really really sick, and our sputum sucker was sort of like that. We enroll kids who have severe malnutrition characterized by one or more of the following: weight for height < 3 standard deviations per WHO guidelines, a MUAC < 11.5 cm, and/or bilateral edema (swelling of the feet, legs, and/or head). There are 3 types of kids we see - those with marasmus (wasting), kwashiorkor (swelling), or both. The malnourished kids are really sick and a good chunk of the ones enrolled in the study have died while in the hospital.

In general, the pediatric wards are incredibly crazy right now. The wards that we recruit from are jam packed with kids and their parents. Most of the children admitted seem to be under 5 yrs.  Then there is the treatment room and it's pretty clear that if a kid spends some quality time there it's not a good sign. The wards smell and I swear every time I leave to come home, I have a layer of grime on my skin. I really enjoy the excitement of the wards, but I also find it pretty stressful and I'm very happy spending half of my week in the outpatient (and air conditioned!) Baylor clinic.

We stayed in these permanent tent structures (this one is mine).

One good thing about the rains are the "green season specials." A lot of different lodges and destinations in Malawi and elsewhere are having discounted packages since the rains are unpredictable (or predictably everyday) and occupancy is down. This past weekend, I went with 3 of my housemates to Mumbo Island, about a 30 minute boat ride from Cape Maclear. This place was AWESOME. The island is within the national park, so the beach, sand, and water were totally pristine. The food was also great and we were the only ones on the island the night we stayed there. I snorkeled some, checked out the cichlids, and got to test out my underwater camera case.

cichlids!

more cichlids.

View of the Lake from my tent

Come to Malawi!!

Happy New Year!

After spending a 3 week vacation over the holidays in the States, I am now back at work. Not much has changed in Malawi while I was gone except for the wards and it seems like there are a lot more expats at the Shack that I don't recognize. Pediatric Ward A (the acute ward) has drastically changed. I took one step in that place and the (even worse) stench, hot humid air, and sounds of crying babies was so overwhelming that I had to take a quick break in the hallway before checking the place out. It smelled. bad. After taking a breather, I went in and assessed the differences. Malawi is now in the "green season" and with the rains come malaria, malnutrition, and other sicknesses. Instead of there being 2 babies to a bed (plus mom), there are 3 babies per bed and more beds in the ward, it's pretty crowded and a lot of the kids do not look good. It's only the beginning, so I can't imagine what the ward will look like in the coming weeks and how crazy the study I'm working on will be.

In other news, I went to the high risk nursery today with Amy to echo conjoined twins. They were born the night before and were connected by the front of the chest. They each had a set of arms (so it looked like they were hugging each other), but only had one set of legs. It was almost as if the bottom half forgot to split. Pretty crazy!

I am also now working on 2 different projects, both pediatric. One is on HIV and cardiac function based in the Baylor HIV clinic, so more of an outpatient setting. The other is on TB and malnutrition among inpatient kids on Ward A and should be pretty hectic. Should be an exciting next 5 months!

what you could be listening to

In preparation for my homecoming (and because I was badgered to post), below are a few popular songs played here that I will be forcing all of you to listen to when I'm States-side next week. These songs are multi-purpose playing everywhere from wedding and engagement ceremonies to the clubs. It's interesting to note that none of the artists are Malawian... they are all Nigerian and sometimes South African or Sean Paul or Wiz Khalifa or Enrique. (I haven't actually been able to watch these particular videos due to bandwidth issues, so I hope they are the right ones and not totally inappropriate. Apologizing in advance). 

Naeto C - 10 over 10

(One of my favorite songs. I actually saw this guy "play" aka lipsync at a local club, Zanzi Bar. What was supposed to be an awesome night ended with my US phone being stolen along with my Angry Birds account). 

Ice Prince - Oleku 
(you should also check out Superstar)

DJ Flavour - Ashawo 

(otherwise known as 'the sawa sawa song' or 'that song they always play at weddings')

Happy World AIDS Day

Happy World AIDS Day! 

With global economic crises, funding for HIV and other health-related programs has been frozen. I have been in Malawi now for almost 5 months where the implications of HIV are incredibly apparent, at least compared to the States. It is painfully clear how important this funding is to keep HIV at bay, prevent new infections, reduce poverty, improve quality of life - anything, you name it. Funding really should be increased - with ART, many people are living longer (and are otherwise healthy!), particularly children. This is great! But it also means that medications and treatment need to continue to be available and needs to be more accessible otherwise the virus will come roaring back on individual and population levels. Additionally, despite very effective PMTCT options, mother-to-child transmission still occurs. Many of the exposed infants we saw in the last study I worked on either did not receive PMTCT or their moms didn't for whatever reasons. Access to PMTCT needs to improve - many moms don't go to hospitals to give birth or can't make it, don't know their status, are newly infected, etc and so there is a much higher risk of vertically passing HIV to their babies. Malawi recently implemented Option B+ - HIV-infected pregnant or breastfeeding women will be initiated on drugs and on them for life - which theoretically should drastically reduce vertical transmission rates (ART -> less virus -> less chance infant will become infected). This, however, requires money. I realize the effects of aid and donor money can be debated endlessly and that all (or almost all) governments and people are tight on cash, but I believe this is a matter of human rights and dignity. HIV might not be curable right now, but it certainly can be managed. The tools exist, but they need to be more available and accessible.

Here are some facts about HIV in Malawi:

• About 12% of the population is infected with HIV - that is around 930,000 people 
• An estimated 84,000 new infections occur annually
• ~35% of HIV-infected people are on ART
• Only 55% of those who need ART receive it
• 63% of new adult TB patients have HIV
• 91,000 kids are HIV-+ (as of 2007) 
• More than 500,000 children have been orphaned by AIDS

(http://www.usaid.gov/our_work/global_health/aids/Countries/africa/malawi_profile.pdf)

Thanksgiving in Malawi

Last night we celebrated Thanksgiving. We didn't have the actual day off so we put off the cooking until the weekend. Probably a good thing since about 40 something people showed up. I said I would make mashed sweet potatoes, one of my favorite tgiving dishes. Unfortunately sweet potatoes recently went out of season. I heard that they might be at the central market so we went to check it out. After scouring the market, I took a chance and bought some yams that people said were sweet. They weren't. They were African yams (not the sweet potato kind, just like regular potatoes). I attempted to mash them and though they were good, they looked really weird.

Sonali setting up the buffet

Since I said that Thanksgiving is my all time favorite holiday, I somehow ended up responsible for cooking the turkey (frozen and from North Carolina!). With some instruction and help from friends, the turkey came out pretty good!! That in addition to the mashed potatoes, stuffing, cranberry sauce ($10/can!?), casseroles, veggies, rolls, pecan pie, pumpkin pie, apple pie, wine, mojitos, and good company made for a fantastic Thanksgiving celebration.

the turkey i made! a little singed on top but was really good

now on to the next thing

Today I officially finished my work on the early infant HIV diagnosis study, otherwise known as the PDHIV study. After 4 months of database tinkering, data entry, data supervision, and data merging/cleaning (aka way too much data), I am excited to take a breather from looking at numbers and Microsoft access. Although I know for sure that data management is not what I am looking to do in my future career, I guess you have to start somewhere and I have definitely learned a lot from the process. For example, a well-structured and functioning database is crucial for easy but accurate entry and therefore solid data sets and good analysis. This somewhat boring data stuff, however, was not all that I was doing (thank god). I also got loads of clinical experience - I can do induced sputums, gastric aspirates, set up and change IVs (not put them in), order labs, take sats among other measurements, and be mistaken for a doctor by people in the hospital including expats (I find this incredibly entertaining). I (re)learned that I liked being in the hospital (I guess taking the MCAT wasn't for nothing), and that working in resource-limited settings and in broken systems can be frustrating for everyone - patients, guardians, nurses, clinicians, Malawian or not - yet incredibly rewarding.

tuckaways

view from the chalet

To celebrate the culmination of the past 4 months of this work, I went to Cape Maclear for the weekend with some friends who work at Baylor (the peds HIV clinic). After spending several hours there a couple weekends ago, I was itching to get back but for longer. Friday night, I hung out at Leah and Jared's house (2 of the friends) eating Indian food, playing Mario Kart, and watching Freaks and Geeks (I fell asleep 1.5 episodes in at about 9 with their cat sleeping on top of me). We woke up bright and early Saturday morning, literally at the crack of dawn, picked up the other friend Ally, and arrived at our lodging mid-morning. We stayed at this place called Tuckaways, a group of 5 reed chalets right on the beach with shared bathrooms/showers. It's beautiful, clean, and totally affordable at a whopping $32/person/night. AND you could pay with a Visa! A weird thing when living in a cash-based economy. The day we got there, Saturday, we just chilled on the beach, went swimming, dove off moored rowboats, and generally enjoyed escaping from Lilongwe, the heat, and the petrol shortage. The resorts at Cape Maclear are situated right in the town/village along the coast so there are plenty of cute (obviously targeted at the tourists) restaurants, bars, and socially places to go with great food and drinks beyond the [insert alcohol+soda] combos, beer and wine. Plus, they had tonic.

yum! fish!

On Sunday we woke up early for breakfast. I had a veggie omelette with CHEESE! cheese is an expensive commodity. We then hired a boat to take us out to Thumbi island. When we arrived, we immediately jumped in and went snorkeling with the cichlids (those colorful, aquarium fish). You could get them to swarm and eat out of your hands by throwing/holding pieces of bread, providing endless entertainment. While we were swimming around, our boat guy, Harry, was making us lunch. He cooked us up some fresh lake fish, rice, and tomato/potato sauce. After eating, we hung out on the rocks for a couple hours and I finally got in some solid reading time. We then headed back to the shore, had some drinks and dinner, and later went night swimming. It was nice to enjoy the water without fear of rip tides, sharks, crabs, or sepsis like I do in the Atlantic and Chesapeake Bay. At 3:45 Monday morning, we woke up, packed up, and headed back to LLW just in time for work. I'm still recovering from that early morning and my sunburn that I got despite multiple applications of sunscreen. Parents, you should be proud - for some reason I really want to go sailing. I haven't found a boat to rent out yet, but it's going to happen at some point.

kids fishing with mosquito nets. guess things i learned in class do happen

Now, I'm back in Lilongwe in between projects and refreshed. I've been working on my PMTCT secondary analysis and figuring out Stata, which I had put off for a solid 2 months. I crunched some numbers and now need to figure out the statistical tests and find some GIS data. As for the next project(s)? I will be a study coordinator for a reproductive health study at Lighthouse (the adult HIV clinic) that is looking at sexual behavior, practices and beliefs of HIV+ men and women and will compare those who are on vs off ART. I'm excited to put my culanth major to work and to have a little more responsibility on a project, though reticent to be waking up a full hour earlier for morning meetings. I'm not sure when this study will be starting, which is why I may also do some more clinical stuff on two pediatric studies (run by my housemates): one looking at TB prevalence among inpatient malnourished kids using a geneXpert (a machine, not a person), and the other looking at cardiac function of HIV+ children with a fancy echo machine and 6-minute walk tests.

For now, I'm just really really excited for my all time favorite holiday - Thanksgiving. Although I'm bummed I won't be home (just 5 more weeks?!), I suppose skype will suffice, and my attempts at cooking and finding necessary items should be pretty funny.

despite its issues, gotta love malawi

The current state of Malawi

Below is an article that briefly describes what is going on in this place right now.  In short: no aid money and poor exports means no dollars which leads to no fuel, failing businesses, increasing prices, power outages, water shut offs, and most importantly, no tonic or minerals. Malawi is on the verge of paralysis (UNC transports fuel supply apparently dried up!). The fuel shortage doesn't just affect those with cars - it affects public transportation and transport of goods (no more tomatoes at the market?), for example. There are a variety of ways to get fuel: 1) Wait for hours at the petrol station (imagine sitting in the heat of the day for 6 hours to be told the fuel dried up). 2) pay someone to take your car or jerrycan and wait in line (however, it takes gas to find gas). 3) Forget the hassle and buy fuel on the black market sold at twice the price and you don't know what's in it.  Gas is already expensive at the pump (290MK/L = $7/gallon) so on the black market it is about $14/gallon!! And yes, the black market is actually a place - its a bunch of guys sketchily standing in the Game parking lot (they pay off the police) and they give a much better rate for the kwacha (220/$ vs 165/$, thats 5,500 more kwacha per $100).

Many of my friends have had their water shut off for 1 or more days at a time and no power. With it being the hot season, that's not good. It's still in the 80s-ish at night - without a fan it's difficult to sleep. I've started sleeping with a wet chitenje (cloth) draped over me to keep cool. I've also gained an appreciation for why people hate to use mosquito nets - its like sleeping in a un-airconditioned attic crawl space with no air circulation - I swear it increases the temperature by about 10 degrees.

The situation is probably not going to improve for another month+ since the president went on vacation to Australia (on Malawi's dime, according to the Nyasa times he requested or got $500,000?!). This isn't very promising for getting countries and banks to give aid money, which comprises about or more than 50% of the annual budget. I wouldn't be surprised if more demonstrations occurred.

Well, thank god my friend found some petrol... off to the lake this weekend it is! Hopefully we find gas to get back... or not, I wouldn't mind being stuck in Mangochi.

World Bank tells Malawi: Address concerns to get aid

The aid freeze started earlier this year with a diplomatic spat with Britain, Malawi’s biggest donor, caused by a leaked diplomatic cable that labelled Mutharika “autocratic and intolerant of criticism”.

Washington joined in after the July violence, suspending a $350m project to upgrade the impoverished, land-locked state’s decrepit electricity grid.

Combined with a collapse in revenues from tobacco, Malawi’s main foreign exchange earner, the aid embargo has triggered an acute dollar shortage, putting pressure on the kwacha currency and hitting imports of basics such as food and fuel.

Petrol stations are frequently dry, and when they do have fuel, motorists are forced to queue for hours to fill up.

The hardship in evidence on the streets is in stark contrast to the official statistics, which suggest which suggest that Malawi has been among the world’s fastest-growing economies in the last six years.

Much of that performance has been based on a fertiliser subsidy scheme for farmers, although the aid freeze has also thrown that programme into doubt.