47.

Its been almost a month. A lot has occurred. We're moving houses, clinics are growing larger, different project people are coming and going. And as each day passes in Malawi I'm slowly learning of life here, internalizing what grips my senses. I should preface to say that the topic is heavy today--but you should know that by no means does it reflect the true nature of my days here, which by and large are filled with smiles, laughs, and good heartedness... but I should write about these thoughts now before I become dulled to it, copingly desensitizing myself to its sting...

Do you know what the life expectancy is in Malawi?

For starters, we should ground ourselves in our own experience: 74 for men and 77 for women in the United States. 1 doctor for 350 people and some argue this is not enough. Hospitals within 10 miles and reliable ambulance services on paved roads (for the most part). A couple of days ago I found the Malawi Ministry of Health website online, complete with a listing of doctors nationwide--a wopping 123 MDs here in the public sector for a population of 13 million Malawians. For those of you burgeoning health professionals, imagine an annual patient load of 35,000. Thats about 100 patients a day, 10 an hour for long days without lunch--and no vacation days. Patient history and physical exam what?

Its absurd the accessibility of health care here in Malawi. Just yesterday on the roadside I came across a sick child, underweight with multiple infections. The sister informed that the child and his mother were both HIV positive. But the clinic for ARVs (anti-retroviral therapy) was 17 km away and ARVs are only given out once a month. This is a four hour walk one way, quite a distance for an already ailing individual. Transport is by bike taxi for 1000 kwacha, exactly one third of a months income. Medical care is not accessible.

So back to the original question: Just how low is the life expectancy here in Malawi?

47.

And those are the government figures--Jeffrey Sachs puts it at less than 40. Shockingly low. Staggeringly low, so low its like a Hollywood movie on the ranks of Hotel Rwanda, or Blood Diamond. Shocking and indigestable as a world so horrible it becomes fictional, leaving us no choice but to resign it only to the ability of the big screen. Surely there is no place where 'over the hill' occurs by the end of high school. There can't possibly exist communities where the 'elders' are you older brothers and sisters. Or is there really a place where people really don't expect to live to see their grandchildren?

In the travelers circuit the 'Lonely Planet' series reigns supreme, and it is here on page 1 that Africa is describe as being so full of vibrant life--the colors here are magnificent from the reds, oranges, greens of clothing to the flowers of the jack o'lantern tree which have just this week bloomed a magnificent bright purple unlike any I have seen before. And its true: when you are out and about through Malawi the youngsters so full of energy are everywhere, giving the entire place a feeling of youth.

Yet, as you may imagine there is more to Africa than the passing safari of a couple week visit. Each coin has two sides, each year a balance of seasons, and I must write now of my glimpse of this other side of life here in Malawi as it occurred three weeks ago....


"Jay, she is waiting for you," the nurse informed me. What for I couldn't imagine as I had just finished giving my condolensces and was struggling to return to the height board myself. The child had died a week earlier of dehydration secondary to copious diarrhea (probably rotavirus--the number one cause of child mortality worldwide for which we have a vaccine but pharm companies have decided its not profitable enough to make it), the first in well over a thousand children treated in my clinics. "Its customary to give whatever small thing you are able" said the nurse and so I reached in my pocket and away went mom with Kwacha at the death of one of her firstborn twins. She left, her chest empty of the weight of the deceased little one, brother on back void of sister, and the notion of a material value of a life sent shivers down my spine. I marked 'death' in its appropriate column.

We load the car and drive away, Roger asking for "Tikondane," or "Love each other" before we even hit the road, and I obey, never missing an opportunity to listen to the sweetness of reggae. The slow pretty part fills the car, windows down and the sun beating, but before rasta man can drop his beat Roger reaches in a flash and shuts it off. In the same instant the green branches of the pear tree spread perpendicular across the rutted out road greets my eyes, and its clear that we are entering into a funeral zone. Just 50 yards ahead of the beginning lies the end's matching branch signals, but until then we idle ever so slowly in silence. Through the trees to left we catch glimpses of a large crowd in excess of 200. They surround the house of the deceased, paying their last respects, some choosing a final viewing. And then "Love each other, people of Africa, poor and rich..." returns as quickly as it disappears. "Funeral!" I foolishly yell 10 minutes later for what turns out to be a downed tree as we approach closer--we laugh as I jumped the gun, but hey, we really do pass at least two a day.

I'm happy to be back on the tarmack to home for there is much to do before dinner. By my best estimates we should arrive back in a decent time today which is pleasing for two reasons--Linda can catch her minibus and I can catch the day shift nurses at the hospital before they leave. Linda is off to Mulanje for the funeral of her aunt whose sudden passing yesterday has left a sullen atmosphere amongst the team today. The highly treatable "high-five" has robbed yet another of unknown years, and I'm speechless for in only two months time here the reality of this great global tragedy hits really close to home--again. The story goes that the husband has been quite sick for some time, his condition known and being treated accordingly. After contracting the wife's condition became known but she remained healthy for quite some time. However, in only one month's time her condition degraded precipitously, too fast for the overstretched and primitive health system here to catch her invisible CD4 descent. Therefore, by the time she was started on ARVs it was already too late. The toll that this disease continues to take on married women is appalling...

Almost four weeks ago a one year old child was brought to Chiponde clinic at Chickweo with grade 2 hydrocephaly. When questioned the mother related that she had not sought medical advice and, having never been to school and unable to read or write, in fact was surprised to learn of the potentially fatal consequences of the abnormality. After some coercion they relented to take the long trip to Blantyre--a place she had never been before--to seek help at Queen's Hospital. So back in Blantyre now I'm off to check on them again, curious as to their care and progress on the shunting schedule.

I've been to Queens many times in the last couple months, and at first I thought the ceremonious singing was part of some religious function at the hospital. Choruses echo through the walls of the place and beautiful, peaceful to the ears. But today as I walk towards the pediatrics wards I realize I'm now squarely behind the mysterious voices, and this 50-strong procession of gospel trails a sheet-pulled stretcher. I learn of this tradition at queens, where the entire temporary ward family assembles together to raise up the family of the newly deceased in their time of great suffering. The procession moves through the halls, offering soft melodic expressions of condolence. Tradition happened twice more over the next hour.

Sure--people die in hospitals, but hospitals should not be places that people go to die. What happens all too often at Queens is that by the time someone makes it to Queens, the condition is beyond recoverable. Early intervention makes all the difference in the big 4--malaria, HIV, tuberculosis, and malnutrition--but early diagnosis and transport are difficult. Here in Malawi hospitals aren't the last beacon of hope we so often conceputalize at home. In fact, they have historically been a place of dread and despair, as we meet mothers who only by persuasion allow us to transport them to the hospital for their child's dangerously high fever or unresponsiveness.

Its all a lot to take in after two years in medical school in the United States learning about all the amazing remedies we have available to treat these horrible diseases. Of all of the big 4 mentioned before, every single one of them is highly treatable. But what we as a global society struggle with is providing the access needed within the structures constructed. And there are places and the people within that suffer the consequences. We are on the front lines here in western power carved-up Africa, in this landlocked, economy-less Malawi, where--as I experienced last week--a child perished as the local health center had run out of Malaria medication.

On the way home the phone rings and its Victor from the Chiponde team. He has just received word that his sister has died in Zimbabwe. The details are sketchy, but she had been sick for some time previously. He's requesting some time away from work to travel back to Mozambique to be with his family. For the third time I offer my condolences in one day, feeling now more than ever the weight of the inequalities in this world. "Pitani Bwino," go well my friend.

The sun is setting on this long day, and as their are no landfills here in Blantyre, the smoke from trash fires turns the evening sky a deep red. Traffic is worst now as minibus vans transport working people from the city center to the ring of communities outside. They stop anywhere and everywhere, their competition having driven the public bus system out of service. With its elimination, the transport price has risen again drastically, the competition eliminated and replaced by giant minibus unions. I'm stuck behind one now, careful to keep my distance at the distinct possibility of no brake lights. We're cruising through the streets of Blantyre, and tonight I can't help but notice the plethora of the furniture/coffin shops that line the streets. "Alipo Coffin makers," "God's trust furniture and coffin maker," "hallelujah coffin shop" pass by. At the beckoning of the west, Malawi has been thrown into a game of global economies--a game it knew nothing about. Supply and demand rule the day, and coffins are no exception. Here is a sector of true competition in Malawi, everyone wanting a piece of the economic prize in this sector. Fortunately, in the midst of this life and death reality I have tried to describe, I experience everyday the hope that can be given from a concerned few. Project Peanut Butter is doing amazing things here for child health as I watch every day the weight increases in starving children, the disappearance of edema in nutrient deficient children, and its striking how together we can work towards solutions, that all may have the ability to enjoy the true fullness and beauty of life.