clinic

Ramsey's upshift as we turn off the tarmak before Zomba stirs me from my morning auto twilight zone. Going on an hour and a half in the car since 5:30 and even my new thermos of instant coffee can't keep me from dozing off as the Craig David cassette plays in the background--over and over and over again. But there will be no sleeping from here on out as we enter roll-bar, white-knuckle malawi. Tarmak gives way to dirt, rock, and the occasional boulder exposed by years of trucks and rainfall run-off. This is the infamous short-cut to Mayaka, rumored to save us a half hour on our travel time, but surely promising to cost us in suspension repair and general joint health. Hang on tight as we race over washboards, roll through washed out riverbeds, and pass through narrow markets. My door is shaking vigorously and making a wierd noise. I think its going fall off.

Mayaka trading center opens today, site #14 for us. Some general specs...
Catchment area population: 57,000
Catchment villages: 111
Health facilities: 1 Catholic mission health center, 14 health outposts
Health Surveillance Assistants: 51
Previous malnutrition therapy: none

I understand this information probably doesn't mean much, so let me provide a context. The HSA number best reflects the population size of a catchment, and I'd guestimate our average HSA number lies somewhere between 15-20. So at 51 HSAs this is a absolutely massive site. As HSAs help us run clinic at the various sites, we always have an initial training which took place at Mayaka last week. I'll be sure to write more on HSAs later, but suffice to say that each HSA represents somewhere between 2-3 villages, where they are responsible for that area's health. As a general rule throughout all clinic site, our patient load results almost solely from HSAs returning to their villages as the only trained health worker and refering potentially malnourished children to chiponde clinic. So when asked last week how many children they thought would come to chiponde clinic if all the HSAs were referring, they answered "13,000," which is quite humurous as we can screen absolutely no more than probably 500-1000 in a day. Mayaka is big.

We've come to Mayaka out of need, referred there by the public nutrition coordinator for the Zomba district for which Mayaka is a part of. I remember vividly the smile on the sister's face upon our first site visit a month ago when informing about our potential for treating malnutrition. But 13,000 is a bit much for our abilities, and we are coming to Mayaka today under the pretense that we should start first with patients from mayaka trading center proper, the so-to-speak capital of the catchment. I'm anxious to see who turns out, and in what numbers...

The children run alongside the car, anxious to find what foreigners this white nissan carries and to what objective they aspire to. News spreads quickly that 'chiponde clinic' has come to Mayaka, and the rumor that a truck full of peanut butter medicine has arrived causes quite the stir in this impoverished area. We have intentionally paired chiponde clinic with Mayaka's general under-5 clinic, and thus its 7:30 and the HSAs have already begun to assemble. 'Matzuka bwanji's' copiously ensue as we fall out of the car, anxious to stretch our legs and open this new site. 15 handshakes of the HSAs and nurses and we're off to the sanctuary, where it turns out we will host clinic in a side classroom. Entering say I, "We'll need a table, a couple of chairs and two benches," to the Senior HSA. "The chairs and benches I can get for you, but the tables are all tied up in the health center I'm afraid," he replies. We'll have to commission a table to be made by a local carpenter after clinic--note to self in ink on the forearm.

I exit the dark room to quite a sight--at least two hundred mothers have now in 10 minutes assembled outside the room on the dirt in front of the cathedral. Dressed brightly in their beautifully print-patterned chitengis of purples, blues, reds, greens, they have come from near and far--for some as much as 4 hours walk starting from the darkness of the early morning. They come with their babies wrapped in cloth and tied neatly and tightly to their backs, legs poking out either side of amai, head above the frameless, logo-less backpack resting on mom's warm back. They've come for screening and now our nurses are assembling in front, about to give their daily morning program that precedes chiponde clinic.

"Azmaya, Azmaya, matzuka bwanji" they begin and the attention now turns to the newcomers, and the limits of my Chichewa are quickly reached as introductions ensue. Lydia then Chrissy then Ramsey, and they are looking at me now expectedly with a smile. Its my cue to force out "Dzeeena laaanga dee-na Jay" with a wave of the hand. Some confusion for a couple of seconds, and one of the nurses explains that my name is Jay and what they heard was supposedly Chichewa. Laughs around and then just like that with a couple of spotty claps this 200 strong female chorus bursts into song, so strong, so loud, so beautiful like for ten minutes the music had held its breath till it no longer could and burst in what seemed so natural. We are new here but though the site changes the songs do not, and I recognize the tune of this one. With the sun low but bright, the harmonies are immensely calming to me in anticipation of the madness of clinic that will soon ensue.

What begins now is one of the neatest parts of clinic. Some of the nurses have been working within the project for several years now, and during this time they have developed wonderful ways to teach mothers about malnutrition, one of which involves song. What they have done is changed the words of traditional Malawian songs to lyrics that are instructive regarding chiponde clinic. I've noticed in my small time here that music is truly pervading, from the choruses ringing from buses in the streets of blantyre to the 24 hours of music that resonates from the bar below us. So the mothers return home not only with Chiponde, but also with songs such as this...

Chiponde, Chiponde (Peanut Butter, Peanut Butter)
Chiponde ndi mankhwala (Peanut Butter is medicine)

Mwana akutupa (The child swells)
Tiyetse chiponde (Feed Chiponde)

Scalo ika tsika (The child loses weight)
Tiyetse chiponde (Feed Chiponde)

Following the music and before the clinic screening begins, there is a time of general health advising by the nurses, ranging from family planning to HIV to nutrition education. For some mothers, many of whom remain illiterate, this may be one of the few opportunities to instruct them on these pressing health issues as clinics are distant and the literature from HSA is useless.

Following this session, chaos begins. The mothers rise one by one from the dirt and begin jockeying for position in the line that leads to the beginning of screening at the scale. As the 'managers' of families as large as 10, these women have much to do each day from retrieving water, visiting the market, cooking, and therefore their time is precious. The sooner they can return home, the better. They swarm towards clinic, but luckily today we are working inside, which allows some control of the flow at the door. A HSA lets mothers in by groups of ten, and they move from the scale to the MUAC station to the height board, where I am stationed. The height measurement fills out the data, and a quick check of edema and weight-height status will end the screening process. "Mwana ali bwino"'s (the child is well) are exhaustive today as over 300 come through the screening process. I give two colored kinds of cards: green for the moderately malnourished, and orange for severely malnourished. 20 oranges and 5 greens are gone from my pile by noon, on world record pace. In another hour we find several more, ending finally with a grand total of 25 orange and 10 green. So about one in ten children are malnourished in our screening today here in Mayaka, many of the mothers having seen the crowd on the way to the market and having stopped through to have their fat healthy babies screened. Yet 25 is the new record for me here at clinic, and this is only the first day. Friday's will be long days indeed.

If a mother is given a green or orange card, they are taken to the nurses where they are advised on the particulars of chiponde--its ingredients, its dosing, the next scheduled appointment time, ect. This part takes some time to explain that dad is not supposed to eat chiponde, that chiponde should not be used as a tasty sweetner in porridge, that the oil should not be poured off and used for cooking... The nurses are wonderful at establishing the project's wonderful track record of adherence.

Subconsciously the quiet causes me to glance over my left shoulder, and I am pleased to see the last mother and child. My back is stiff, my mouth parched from lifting so many children onto the height board over the course of 5 hours. My ears are ringing from little ones screaming, afraid of the azungu health man and what he's gonna do when he puts me on the table ('Mugona mwana' we say, telling the child to sleep, which may or may not add to the sense of terror). My clothes are damp still from the little one whose fear materialized though the excretion system. I rise with my height board compadre and we smile, shake hands, and exit the room. And its always a beautiful site to see Ramsey distributing the Chiponde by the truck, Chrissy and Lydia feeding the malnourished children their first chiponde (the last step before the mothers leave). They are checking to make sure that the child indeed is eating, aware that if the appetite is poor, it is better to make our way to the hospital. But today they are all eating praise god, evident from the mess of peanut butter which for this one in front of me somehow made it into the lightly colored, sparse, and easily pluckable hair of this kwashiorkor child. Next week his edema should be gone if he is fed appropriately, and by all indications his appetite could consume the 12 bottles of chiponde in the next two hours. Mom takes the bottle and tightens the lid, child reaching for chiponde and here it comes, the first sobs of anger that chiponde time is over. I think he likes it.

What a day. If it wasn't friday I'd say pack it up and lets do it again tomorrow. But its been a long week of this, and we've got another two hour drive back to blantyre. There's a peace core guy trying to hitch a ride. Dropping him in Zomba on our way, we stop for a couple of cold cokes, and I return to my auto twilight zone as the sun falls slowly. What a day.