Sunday, September 26, 2010

A Needless Death

She was 40. Her oldest child was 20, her youngest 7. Her second child, like thousands of other children across Malawi, is waiting the results of standardized testing at the end of “Form 2”, his sophomore year in high school. These results will determine whether he enters Form 3 or repeats the first two years.

Her husband died about four years ago, and she tested positive for HIV. She steadfastly refused everyone’s efforts to get her to take anti-retroviral medication. When she came down with active tuberculosis she also refused treatment falsely stating that she had several small children at home whom she could not leave for the intense initiation of treatment at the District Hospital. Instead, she returned home to the little house she occupied with all her children. Finally they convinced her to go to the hospital and begin treatment, where she died shortly after admission.

There really is no reason for anyone to die early of HIV. A recent study, admittedly in the west, found that people who started treatment for HIV early in the course of the disease and who were younger (I believe that was not yet 60) at the time of initiation of treatment were as likely to live to an old age as their peers who were not infected with HIV. While the medication that has been available in Malawi until recently (the protocols are undergoing revision) are not the regimens that are currently recommended for initiation of therapy in the U.S., they served my patients extremely well in the opening days of multi-drug treatment, leading to prolonged suppression of the virus for those who took them as if their lives depended on it. As it turned out, their lives did depend on taking them exactly as indicated, always. Some people had been on the medications for 10 years or more with no evidence of the virus in their blood since starting them.

Medications are not as readily available for many Malawians as they need to be. Some people have to walk many miles to get to a center that offers the life-saving drugs. That may have been part of the problem for this woman. Yet, that does not seem to have been the case. She was in contact with people who could treat her, and her family could have cared for her children intermittently. Her brother, a friend of mine and the source of this information, is a medical professional who tried to persuade her. Why did she not submit to treatment?

The reasons for this sister’s actions will probably never be known. She may not have held any hope for the medications. She may have heard how “horrible” they were, and difficult to take, full of side-effects, and thus refused, not wanting to add insult to injury. Often, however, stigma is the problem. People are afraid to take the medications because then people will know that they are HIV positive. “And we know good people shouldn’t be HIV positive.” Sometimes, however, the stigma is so deep that people stigmatize themselves. The worst kind of racism is that in which people hate themselves or others of their own kind because they belong to the group. This is also probably the worst kind of stigma around HIV. “Because I am HIV-positive I am a no-good, worthless person. I deserve to die.”

I have had a few other patients who had such an attitude. One never took medications for HIV and she died of her disease eventually, after being pulled “out of the fire” on several occasions for opportunistic infections. She was a deeply religious woman, Roman Catholic, and she made statements to the effect that she deserved to suffer, that her suffering might somehow save her. For another similar case, see my blog at this site, “Shame, HIV, and the Body of Christ”, February, 2010. I wonder if something like this was not working in the sister who died today.

At any rate, I am deeply saddened and very angry on the occasion of this needless death. Needless! All of us must die, but this woman need not have died leaving a seven year old and a son anxious over his grades, and others. She need not have died leaving her children with neither parent. The death of her husband should have been a wake-up call that saved her. But she refused to look to the help that was there. Why do we continue to accept death from the evil one when we could take life from the Father of us all? Pray that as we increase in linguistic skills and embark on this ministry we will be able to join the Lord in offering life, to compellingly offer the resources of the Kingdom of God for life, convincing the wounded and afflicted to reject the Evil One’s seductively compelling offers of death.

Thursday, September 23, 2010

It's a Snake!

We have a den of squirrels in the attic, and tonight a mouse ran across the living room floor several times, so it shouldn’t surprise us that our rodent zoo would be visited by a slithery friend. Last night, headed down the long hall to our bedroom, what should we see but a small snake moving right along with us.

Beth had passed into the bedroom when from the left of the hall it wiggled onto one of the steep down-hills and half slid down the slope. The brightly enameled smooth concrete floor didn’t offer much traction for crawling as the snake tried to reverse direction, so we had plenty of time for Beth to toss me a shoe (in this circumstance I have more confidence in a loafer in my hand than the identical shoe on my foot) and for me in turn to give it a few licks with the heel which eventually hit strategic places, and it lay still. I thought it was probably not poisonous, but this was our first encounter and I have yet to find a reasonable guide with illustrations of the snakes of Malawi.

We cut off the head for good measure, lest it recover from a traumatic swoon and seek to join us in bed (I’m not too up on vital signs in long, thin reptiles), and left it in the hall for a closer examination in the morning.

When asking locals, there are only two or three kinds of snakes in Africa, the cobras, the mambas, and the puff adders, all highly poisonous, some proving fatal within fifteen minutes. But the book on the flora and fauna of a neighboring section of Malawi that I saw in the bookstore on Saturday mentioned seven or eight classes, only two of which could present a direct health risk for humans, the cobra and the mamba. Alas, there were no pictures!

Everyone on campus who saw the snake said, “It’s a cobra!” In response to my query, “What about this snake leads you to that conclusion?” I was rewarded with, “If this snake bites you on the leg, your leg will swell up very much and you may die.” “Yes, but what do you see about this particular snake, this one right here, when you look at it that tells you it is one of those snakes?” The reply was, “It is black and the tail gets smaller and smaller to the final point.” Now, this may well define the African cobra adequately (I know that it doesn’t have a hood like its Indian cousin), but I’ve seen lots of round, black snakes with smooth, sleek heads back in east Texas, and they weren’t poisonous. But again, that was East Texas and this is Southeast Africa, and I think the diamond head of the pit viper of the southern U.S. is not characteristic of Africa’s potentially dangerous snakes.

Our snake measured about 8.25 inches long. It had a total of 167 body plates from just below the rear portion of the jaw attachment to the anal plate (I read something about number of plates in that book on Saturday) and I found no fangs of any kind while probing its mouth gently with my pocket knife. I must admit never having seen the “rear fangs” of one of Malawi’s poisonous snakes, however, so I may have missed them.

The snake probably entered via a garden door that opens into the hall and will not seal, though it has a double locking system. This week we’re going to the hardware store to buy rat and mouse traps. Somehow I think if we can get the mouse to take the bait, we won’t have him around baiting the snakes. In the meantime if there’s an amateur herpetologist among my readers, tell us what you think, and what I should look for to know if there’s really a threat. And if anyone knows what to do with the squirrels, please pass that along, too.

(A week later on our morning run we came across what looked like a large rattle snake without rattlers who’d lost a fight with something, probably a car. We finished our run and returned in the Mtendere truck. This one had a diamond head and fangs, and is probably a puff adder as it looked like the one my son killed in Mozambique in 2005. And they are colored just like a dried corn field. Add that one to the list and keep watch in the corn.)

Saturday, September 11, 2010

Driving as Culture Shock

Living in another place requires adjustment which doesn’t come without the experience of stress. High-speed driving in the U.S. is usually associated with the Interstate. In contrast, we live on the principal Malawian Highway, M-1. M-1 has two lanes, and usually narrow, considerably variable shoulders, with nothing but a very faded, dashed line “separating” you from the oncoming traffic. I drive M-1—on the left side of the road, with the steering wheel on the right of the car and shifting gears with my left hand—and I occasionally run or walk along it, so I’ve gotten a closer look than I want at times.

The shoulder along M-1 is defined with a yellow stripe, also quite faded. The shoulder may be as wide as a meter, or erosion may actually eat past the yellow stripe into the road-bed proper. The asphalt shoulder gives way to portions of gravelly clay undersurface which in turn transitions to the grass growing in the similar red clay of the surrounding soil. At times the transition from asphalt is very smooth, but even at entrances of dirt roads, it may present a four to six inch drop; at times it is up to 18 inches. At some points the deep indentations look like chunks of road bed have been taken by a giant “cookie monster”. This makes it difficult for pedestrians to walk beside the road or get off when the traffic is thick.

While M-1 is full of cars and trucks of all kinds, sizes and shapes, including double trailers with six axles on each, the motor-powered vehicle is not the principle means of Malawian transportation. There are many more pedestrians and bicycles than motorized vehicles on most sections of M-1. Pedestrians are usually aware, even wary, of the vehicular traffic, but occasionally they stumble home drunk as one young man I saw this evening. Some times children run toward the road, but I’ve never seen one actually on the surface who wasn’t carefully crossing and of an age to do so.

Bicycles present a bigger challenge with occasional cargo of grass bundles three meters long, one meter presenting on the highway side, or the man I saw today carrying about a dozen five gallon pails fashioned out of tin on the back of his bike; at least he was walking, using his bike as a cart. Mattresses, bamboo, goats and pigs, as well as people, get a lift on bikes, and these combinations present challenges coming down the edge of the highway. Today I saw a bike strapped crosswise on the luggage rack of another bike: a bicycle wrecker!

The most common means of long-distance transportation is the incredibly polyglot fleet of “mini-buses” that run the roads of Malawi. These 7 or 8 passenger vans which have been modified to optimally hold 12, but not uncommonly have 16-20 passengers, ply the roads, stopping suddenly to pick up or drop off passengers, re-entering the road with little warning, racing one another while fully loaded and occasionally resorting to blows to settle disputes with other drivers or passengers (they usually stop for this). Minibuses are crewed by a driver and a “conductor” who collects the fares and buys cans of gasoline while the driver recruits other passengers on the road side by the station.

Stress jumps a notch at 6:30 in the evening when it is already quite dark and many people are still working their way home, bright and errant lights shine in your face, and the ability to see and adjust for pedestrians or bicycles on the road is limited, and you struggle to time your approach to reach them when there is not an oncoming car preventing your “swinging wide”. The worst-case scenario finds bicycles on opposite sides of the road passing pedestrians while you meet a tobacco truck whose cargo is hanging over by about a meter on each side, and behind him is a mini-bus driver hanging over the center stripe looking for his opportunity to pass. At least the truck is driving slow, where a car wouldn’t be, so that either can make the heart race and surely raise the blood pressure as well. It really gets wild when the approaching driver has his high beams on, you reach down to flash your own lights, and find you’ve sprayed washer fluid all over your windshield!

Most modern autos on M-1 like to travel at 110 to 120 Km/hour. (70-75 mph), though the speed limit is 50 to a max of 80 (31-50 mph). The big trucks usually are well under limits by necessity, but that generates tremendous impatience in the lighter traffic and motivates risk-taking. Then there are the aged and decrepit. Saturday night as we returned home late, we saw a faint light in the distance rounding corners, going our way. As we quickly overtook it, a pick-up with no tail lights (we finally saw reflectors as we approached) putted along, its engine trying to keep up with its electrical system. The one front light was on the left and pointed toward the ditch; when on dim almost nothing of the road could be seen; when on bright you knew a car was there.

We drive no more than we have to (not having our own vehicle is a blessing in this) and we particularly avoid the hours just after dark. We absolutely refuse to be hurried on the road, and we take preventive measures to avoid the flying flak should others have accidents while taking risks around us. The most common cause of death for expatriates living in Africa is an auto accident, and we take care to not become a part of the numerator in those data sets. Pray that we may avoid the foolish and the temptation to become too condemning or bothered by others’ behavior on the road, that we may have eyes to see the obscure (go carrots!), and that we’ll never be perturbed by others’ impatience with us or their insistence that we get somewhere now. And as you enjoy your next drive down the interstate, send up a prayer for our safety on the road along with your own of thanksgiving.

Tuesday, September 7, 2010

The Breathing “K”

What’s the difference between a guinea fowl and the possessive “my”? It’s the “h” that comes right after the “k”. Spoken language not uncommonly includes sounds that are not indicated in the written form. The “h” after the “k” is one such sound in English. Put the back of your hand right up close to your open mouth and say the word “Coke”. Feel the puff of air against your hand after the “c”? That’s the “h” (unwritten in English) that follows the “k” sound. “K” sounds in English when followed by a vowel, whether represented in writing with a “k” or a “c”, have that “h” behind them. We learn it as a part of the “k” sound without ever being told it’s there. So it doesn’t have to be written. “K” sounds at the end of words, however, such as the “k” in “coke” may or may not have the “h” after them! (Bruce doesn’t, Beth does. How about you?) And we learn that (whichever way we do it) without being told either.

For Chichewa, however, the national language of Malawi which we are learning to speak, there about as many “k’s” without the “h” as there are with it, even in the middle of words, and all are followed by vowels. So when a “k” appears you have to indicate whether you want the “h” with it, or not, (and, of course, say it) and the difference can be crucial. For example, the word for guinea fowl, nkhanga, has the “h” after the “k”, but an almost identical word without the “h” is one of the eight different ways you can say “my” or “mine” in Chichewa. (Yes, eight different ways, each with its own particular place! But that’s another story.) If you’re not getting the “h” right, though, there always the “n” before the “k” in nkhanga to distinguish “yours” from the fowl. But that’s another story too.

So try saying both “k” sounds in “coke” (or “cake”) without creating the puff of air which follows. I call it “swallowing” the “k”. You simply put the middle of your tongue up against your palate and pull it off just before making the vowel. It’s almost a quieter form of the cuckle or click you do when you pull the front of your tongue sharply away from your palate, and just one of a wide number of new sounds we’re learning to make. Instant regression to one year old! But also a reminder of the terrible frustration that must come to little ones when their sounds are not understood. It probably won’t take us 2-3 years to be saying sentences, understanding and being understood, or will it? Please pray that it won’t.