Blessings Hospital and Malawi's Economic Tsunami

  

Economics, the course I found most difficult to comprehend in my studies at Harding University, is having a devastating impact on Blessings Hospital. But, there are some pretty simple economic truths that did make sense and stick with me until this day, most of which my Daddy taught me before I got to Harding.

1. You can’t spend money you don’t have.
2. Loans cost more than savings earn (bankers have to make a living too).
3. When the government prints more money, it is relatively worth less.

And now, a brief summary of the economic chaos which is Malawi today.  For some years Malawi has been very dependent on outside donors for the normal operations of government, not just special projects.  Forty percent of normal budgetary operating expenses are paid for by outside donors, with England leading the way.  In August or September, while the president was out of the country, a high-ranking budgetary official was shot in the face about midnight one night as he was waiting for the gate to his house to be opened.  Other high-ranking officials were accused of being involved in this attempted murder.  

Shortly after this a series of low and high-ranking officials were found to be in possession of rather large amounts of cash, extravagant houses, or other things far above their means  for which they could not account. Now, after some weeks of international forensic auditing, it has been announced that $34,000,000 either disappeared (half of it) or was grossly misused by government officials in the six months ending in the shooting.  England and the European Union cut off all aid to the country in anticipation of this result, gutting that 40% of the country’s operating budget.  

The value of the Malawian currency, the Kwacha, has plummeted, going from a fixed rate of 150 per dollar to a depth of 430 per dollar in less than 2 years.  The troops in the trenches were pressed as salaries decreased in buying power.  Some non-governmental international aid organizations (NGO’s) were able to make salary adjustments to the extent their income was in dollars, but government no longer had such a luxury.  Even the cost of corn soared as the fuel to transport it and grind it climbed in price. Workers became very restless.  Something had to be done.  So, the government gave all its employees a 50% raise.  

This eased the cries of the proletariat, but . . . where did the money come from?  Within a few months reports began to leak out.  A friend working in a government clinic told me that at their site, the only medicines which are available are contraceptives, malaria medicine, and meds for HIV, all of which are supplied through special projects mostly administered through NGO’s without the government touching the money.  Other departments reported workers sitting in their offices unable to do their usual work due to no tools or ability to take a departmental truck into the field.  The one department that seems to have increased activity is the Malawi Police Force:  I have never seen so many police on the highway handing out fines newly increased from MK 3000 to MK 5000.

The effect on competition for workers with the private sector has been devastating.  Due to chronic shortages, the government and mission hospitals have not quit hiring medical personnel.   Mission hospitals (called CHAM hospitals for their membership in the Christian Health Association of Malawi) have been relatively protected because their clinical personnel are paid mostly by the government.  One large mission provider recently reported that 40% of its income comes from the Malawi government, 40% from donations from outside the country, and 20% is generated from church contributions within the country and from hospital revenues.    

Blessings Hospital is in trouble.  We are running out of nurses, and are unable to hire others at our current salary level.  The administration is working hard to become a CHAM member, but it is estimated that the process will take 2 years.  Most of our operating revenue comes from the care we deliver.  Our census is rising.  The number of people we are helping is going up.  The number of babies born in our facility is increasing.  By the grace of the Sara Walker Foundation we are visiting an increasing number of villages with a mobile clinic, villages that are far from medical care whose only transportation is a bicycle.  The same vehicle makes it possible for us to carry patients who need it to a higher level of care. 

Our biggest acute problem is personnel salaries.  We need to give our workers a generous raise.  We need to hire others.  Desperately.  We are living off per diem nurses who earn less, mostly government workers who are willing to double on their vacation days.  But, the time when most people take vacation is about gone, and our needs are increasing as our nurses leave.  

If you would help us raise a nurse’s salary up to a minimum level, or even explore a partnership like that for one or two years as we process our CHAM papers, please contact me at brucesmithmd@gmail.com  We will be happy to share further details with you and explain how to process your tax-deductible contribution so that it can be used most effectively.  Learn more about Blessings Hospital through her Facebook page, or for a tour of the hospital, click here.

Ox-Cart Medicine

For some time the staff at Blessings Hospital have longed for the security of an ambulance with dedicated driver to provide a means to transfer complicated patients to higher levels of care.  This prayer was answered in January by the Sarah Walker Foundation with the equipping of a used Land-Rover Defender (the famous, nose-down box that never quits) and the hiring of a driver.  This vehicle does many duties, one of which is to carry a clinician to outlying villages within our service area, where local churches offer their building as a clinic site, and then work with the chief and their neighbors to spread the word insuring that patients come.

Yesterday the clinic was at Chimbwala, some 20 km /15 minutes away.  It was afternoon.  The clinic was finished and the driver and clinician were packing up their supplies to return when an ox-cart was noticed  moving unusually slowly toward the church building, but there were no oxen!  Instead people were struggling, 4 pushing the yoke and 6 pushing from behind, to move the cart along.  In the cart was a young man who was seizing.

The patient had complained the day before of body aches and fever, but people had ignored him.  He wasn’t much better when he woke up the following morning, and in the afternoon he stayed home while everyone else went to a soccer game with a rival school.  When his family and friends returned he was unconscious and seizing intermittently.

Lacking IV supplies, the decision was made to hastily move the patient to Blessings.  Not too long later Harold Banda, our administrator (himself a nurse-midwife), and William Banda, our nurse on duty at the time, were chatting on the front veranda when they noticed the ambulance careening around the corner into the hospital grounds, lights on, flashers blinking.  (We don’t yet have a siren or true emergency lights on the ambulance, and they were sorely missed as the driver worked his way down Malawi’s principle artery in the late afternoon traffic which was returning to the capital).

William started back into the hospital thinking it was a ruse, but Harold urged him to wait and see: maybe there really was an emergency.  The staff on board hopped out of  the ambulance almost before stopping and related the essentials.  As they opened the back door to extract the gurney, the patient was seizing.  He had not regained consciousness since they first saw him.  The patient’s wife and friends shared the history, and  malaria, the most common illness in Malawi and one of the major killers, was immediately suspected.

Harold (who doesn’t regularly work clinical shifts) joined William in getting an IV started.  Some blood was sent to the lab for malaria testing, and IV Valium was pushed to stop the seizure.  Ceftriaxone was pushed as per Malawian protocol in case of bacterial meningitis, and then the malaria rapid test result returned:  Positive for malaria antigen.  IV quinine was begun, and the patient later awakened.  

The following morning a man walked into the hospital entrance, and he and Harold recognized each other immediately:  He was Harold’s head teacher in secondary school.  Questioning the occasion, Harold was

The "Man in the Oxcart"
thanking Dr. Harry.

told by the visitor that the malaria patient himself, also a teacher in the village where the clinic was held, was his younger brother.  The patient felt much better that morning, was awake and taking food and oral medicines, and was discharged with his wife and brother to finish a three day course of oral meds for malaria at home.  As is customary here where transportation is often a barrier to care, he was returned to his home in the ambulance.  

Medicine, perhaps especially in Malawi, at times presents occasions of great grief, futility and frustration.  Malaria can be stamped out, as it has in many countries, if the political will exists at national and local levels, and if enough resources are applied to the task.  South of the United States, for example, in two very different countries politically, Costa Rica and Cuba have eliminated the scourge, but they are the only ones.  In spite of the many frustrations here in Malawi, there are thankfully also occasions where all hands, including the neighbors,  do their parts well, everything works like it is supposed to, and potentially tragic or fatal situations are redeemed to life, joy, and ongoing service.  

Funerals--The USA and Malawi

I remember my first funeral well. Some older person in our church had died, but I didn’t know him or her, and the funeral was to be held in Grand Saline, about 50 miles away. My Daddy was the song leader in our little congregation, and he needed a tenor. I was taken out of school, it was about the 7^th grade, and carried to help form the quartet that would comfort family and friends with songs of heaven. It was a good, hands-off, impersonal preparation for my second funeral.

A few weeks later a boy in our small town (about 95 in my graduating class) was killed. He was one grade ahead or behind me; I think his name was George. He had lived, just around a corner or two, but we were not good friends. His single mom tried, but he ended up being one of the boys my mom didn’t want me to play with. That’s why he died. The square dance club met in the City Auditorium, an old frame building out by the rodeo arena. I was in that Auditorium only once or twice in my life. It was just the other side of the railroad tracks from down-town and our houses, mine and George’s, and about a mile down the tracks the other side of Main Street. Drinking was strictly prohibited in the Auditorium by the Baptist members who’d broken into square dancing, but not alcohol. The Methodists conceded, but some folks kept a flask under their front seat to loosen up their turns between dances. And in a small town, nobody locked their car.

The County was dry, and booze hard to get, but George had figured this one out. While the fiddle scrawled and the gentleman called, George was helping himself outside. He was pretty drunk when the dancing ended for the evening, but he made it to the tracks without being discovered. He didn’t make it home. He just laid down on the ties and gravel between the rails to rest a bit. He was drunk enough to sleep in that unlikely bed, but not enough to sleep through the 2:30 train that came through town. He was too low on the track to be seen until he raised his head just before the train reached him. I remember a few things about the funeral: almost everyone from school came; they didn’t open the casket; and it was generally very quiet but for his mother sniffling up front, fighting back the pain.

Malawian funerals are not quiet. No one is fighting back the pain. Men and women who are close to the deceased wail almost continuously, even through the hymns, except when a preacher calls for quiet for prayer or an exhortation. Most of the rest of the time, during visitation (12-36 hours) and the trek to the grave a host of mourners including the close family wail, and contort the body, some walking around outside the house where the body lies and calling on the deceased “mkazi wanga, mkazi wanga” (“my wife, my wife”) or “mlongo anga, mlonga anga” (“my sister, my sister”). My friend Steve Kay, who out of his own profound experience speaks and writes well about grief, especially male grief and its expression, would admire the Malawian men I think, bent at the waist, arms wrapped around their bent heads, weeping and crying, wailing and calling of their loss and for the departed. I am also reminded of the Biblical stories of funerals, where Jesus quieted the mourners before challenging death itself.

The body lies in state in the front room of a small hut, usually for less than 24 hours, but occasionally longer if some family must come from afar. Wailing women fill the small room, surrounding the body, covering the floor, spilling down the hall toward the bedrooms. A thin path through the legs from the door to the head of the deceased, and sometimes out the back door allows others to view the body, or at least the face, where only a small portion is visible, the rest, including the mouth and nose, wrapped in cloth. The closest female members of the family are literally and bodily supported by other family members, propped up where they are sitting on the floor.

Male family members visit the body periodically, joining the wailing on entering the door, and sometimes continuing in the courtyard as they walk off their grief outside. Clusters of men and women sit in their respective, quite separate areas all around the house, sometimes stretching throughout the neighborhood, but in these circles quiet respect reigns. Stores in the close neighborhood are “closed” though discrete sales through a cracked door allow life to continue in this world of many funerals. Some women bring in food (meaning nsima, the boiled corn meal which is the staple of diets throughout this part of Africa), while others stir the flour into pots of boiling water and prepare greens, beans or meat to add “relish” to the center of the meal. I’ve never seen a small funeral or memorial service. Honoring the dead is a core part of African life, and everyone shows up who knew the deceased and knows of the death. All the neighbors are there, and friends and relatives from near and far. Everyone is fed. Contributions are made, and a list of civic leaders who contributed, and how much they gave, is announced at the formal service before the shift to the graveyard. The village chief speaks of the deceased. An obituary is read. Singers sing. A preacher preaches.

When the grave is ready, or some other social marker unknown to me is reached, the body is witnessed by as many as possible as it is being transferred into the coffin. The tapping sound that followed puzzled me until I remembered the two hammer-bearers entering the house. The wailing, which had grown with the transfer of the body, swelled even more as the lid to the simple casket was nailed shut. The casket was moved to the bier, and the trek to the grove of trees marking the graveyard began, women leading if the deceased is female, men if male, but never mixing. Sometimes the grave is near, sometimes far.

At the graveyard there is more singing. More preaching. And more wailing, but now by isolated family members overcome by the grief of the moment. Some are comforted by others. One by one family members may be removed from the scene by friends or other relatives, perhaps because their display of grief is too much for that moment of the service, or perhaps for fear that the depth of their grief might become harmful to them on witnessing the burial. One wailing young man fell flat on the ground and was carried out, apparently unconscious. Later another followed suit but was left to lie. At one point a young woman near the grave stood, turned, gasped deeply, and let out a short but forceful cry which ended with her swoon to the ground, arms and legs flailing. Four women lifted her by her four limbs and carried her out despite the jerking of the appendages. Most sat quietly as the casket was lowered, the dirt returned, and the preacher preached on. A choir sang a few songs.

When thunder and lightning neared, women began to slip away. “Mvula! Rain!” One said to Beth. “You’re going to get wet! Tiyeni. Come with us.” The preacher continued. Men soon followed. The preacher himself soon gave up and the feeding began: nsima and goat. The rain mercifully held off another 30 minutes. Then we were on our way home, hurrying against the approaching darkness to get to the highway and then the city before the multitude of bicyclists and pedestrians scurrying home fade into the obscurity and danger of nightfall on the busy road.

Funerals in southeastern Africa have a major effect on business productivity, not only through the loss of skilled employees in their prime years (Malawi lost 6,500 teachers to death in the last three years) but also due to the massive social participation that is required of the living. Funerals take at least one day, often two, and not uncommonly three days away from work, and each worker attends multiple funerals a year. We attended three last week. Employers are expected to be major benefactors toward the costs of funerals in their role as the primary sustenance of the family. Funeral support is in the budget of every major business as a line item, but in one recent year a major civic unit drained that item long before the year was over. Some control of HIV (50% of those needing treatment in Malawi are getting it) and an increase in the line item budget for funerals have avoided the problem of running out of help in subsequent years, but deaths continue in large numbers.

The west has a short attention span, and the current waning attention to the African HIV problem is evidence of that. The US and Europe are moving on (actually around in a cycle) to attack once again Maternal-Child Health. While some shifts in AIDS budgeting may need to occur, the need for western government to support availability of the expensive medications needed to treat HIV still exists. Write your senators or representatives today. Western Christians need to support widow and orphan care by local agencies and churches in Africa. Just as the effects of previous efforts are beginning to be observed, the West is backing out. This is not the time to back out, but rather the time to press forward, to make treatment available for everyone lest the wailing never stop.

A Needless Death-II

She was about 25. She hadn’t done well in school, so at a young age she had decided to try her hand at something else where she might do better—marriage.

She found a man to marry her and they began their life together. No wedding, just a coming together with an announcement to the community: “We’re married now.” Two children were born. One died of malaria, and the community became suspicious of HIV.

A divorce occurred. Her brother did not know why or what the circumstances were. Now she was a single mom with one surviving child, and HIV.

Her test had been positive, and at some time she had begun on antiretrovirals, life-saving medicines that have normalized the life span of HIV patients who are diagnosed early in the disease’s progression and while they are still young—if they take their meds like their lives depend on it; they do. She was young, but apparently not diagnosed early. The hospital was not very far away, but she was sick a lot, and going even a few kilometers on foot was a problem when sick. She was very poor, and probably ashamed of her status. It was not easy to get a ride. So she missed an appointment and then ran out of meds. She may have stopped and started her meds several times. And then she died.

Primary Cause of Death: Unknown, but some opportunistic infection, possibly tuberculosis, malaria, or cryptococcal (fungal) meningitis.

Secondary Cause of Death: Acquired Immune Deficiency Syndrome—AIDS

Tertiary Cause of Death: Infection with the Human Immunodeficiency Virus--HIV

Contributing Factors: Stigma, Shame, Poverty, Unfaithfulness, Single Motherhood, Social Isolation. All these are things which the church must address in its God-given mission to help the helpless, defend the fatherless and the widow, offer forgiveness to the guilty and hope to the hopeless, to love the apparently unlovely whom Jesus loved enough to associate with, to care for, to speak up for (as his Father and ours has done since the beginning of time), and then to die for that we (yes, we are among them) might live to tell the story to others who need to hear it and to live that ongoing story in relationship with them.

“We are One”

I have been reading psychiatrist F. Scott Peck’s, The Road Less Traveled, which was recommended to me by the late Dr. Henry Farrar, inspiring mentor to many of us, just two weeks before his death in February. Peck talks about the peace he had as his wedding approached, peace that lasted until he arrived at the altar where he was almost overcome by terror: he suddenly realized the magnitude of the commitment he was making, and the implications of that commitment being permanent, and conversely of it being anything but permanent.

A few weeks ago Beth and I began to eat lunch at Mtendere Children’s Village, the home for over 100 orphan children which is located right behind the house where we live. We looked forward to the help for our Chichewa from conversing with the children and staff, as well as the increased time with them. We paid the administrator of the orphanage, Gracian Chisema, for the first couple of meals, a very small sum, probably less than we spend at home to fix lunch. We missed several days after that and then started up again, and talked to Gracian about payment. “Talk to Tiwonge” [his operations manager]. “She’ll take care of it.” We talked to Tiwonge, and she refused to take our money, referring us back to the administrator. When we saw Gracian again, he said, “Yeah, Tiwonge talked with me the other day and said, ‘We all eat down there from time to time, and none of the rest of the staff pay, so why should the Smiths pay. They’re just as much our staff as anyone else.’ So, you’re not going to pay. We are one.”

“We are one.” That’s quite a statement. It’s a sword that cuts two ways. First, it’s a really high compliment. At this stage in our language learning to be told, “You are just as much a part of our staff as anyone else here,” is really an honor. We are not staff. Not for the orphanage, nor for the food processing plant, nor for Feed the Children, nor for Educate the Children, certainly not for the School of Agriculture for Family Initiative [SAFI], nor even for Blessings Hospital. We are students of Chichewa working toward a new HIV project which will be based on campus because we are here. We occasionally chauffer the staff here or there. I hold a devotional with the older boys of Mtendere two or three nights a week. One or two of the guards run with me most mornings. And, we are the only biological family living on campus. But we are not really staff. Something is happening, however, that is bonding us to them--and them to us. This blessed something is also a two way street.

With privilege comes responsibility. Beth and I have been reading a couple of relevant books: African Friends and Money Matters discusses the clashes between American values about money and African values about money, and Leading Cross-culturally points out that many American (and some African) values about money have their roots in the Kingdom of Darkness, the Kingdom of this World, not in the Kingdom of Heaven, the Kingdom of our Lord and Savior Jesus Christ. Africans are much more communal about money. Americans are much more individualistic about it. For Africans, what is mine, or yours, is often ours. For Americans, what’s mine is mine unless I decide to make it yours. And don’t push me! It’s still mine!!! For Africans, whoever has a lot of money is a welcome part of this sharing community, a tremendous potential resource. And though we Smiths may have much less money than we did not too long ago, we still are so, so rich compared to most of our colleagues. We thus qualify: we’re a tremendous resource. I must add here that this is not consciously nor conspiringly considered any more than “It’s mine!” is consciously or calculatingly contemplated. They are, respectively, each in the place where it rules, just part of the unconscious fabric of life.

I’m not sure I want to be “one” with anyone but Beth and the Lord, and at times I have my doubts about them. I want to keep what’s ours. I want us to use it the way we want to. I don’t want anyone considering mine to be his or hers. But (the books also point out) that is not the way of life in the Kingdom of Heaven. (Read the ends of the 2^nd and 4^th chapters of Acts.) And as I exhort some of you to give up some fairly large chunks of “yours” to help us do what we want to do here, I run a great risk of standing condemned on my own appeal. Now don’t get me wrong. In Africa there are ways of saying “No”, ways to save some money, there is wisdom and foolishness with regard to money. But current relationships are more likely to rule than the bank balance or fears for the future. Days are taken more one at a time. I think there’s something about that in a book somewhere too, isn’t there?

And so “We are one.” As we by fits and starts, through hesitation and willingness, stubbornness and submission grow in these new relationships and by so doing learn more of what the Kingdom of Heaven is like, what the guidelines are for really trusting the Provider of us all (and not our own strength, or financial acuity, or business skills or any other aspect of “me” which I’ve been really been given by Him for service to others, which I’ve supposedly entrusted to Him as part of our agreement), as we learn what the guidelines are for living the best kind of life possible, pray that we will receive them, live them, and demonstrate to the world around that we do know the One who is three in one, who invites us to be one with him, and with each other through trust, to his praise and glory, and the growth of this life-giving oneness throughout the world.