We are a tiny tender green shoot that sprung up gracefully although unexpectedly.
Joanne Jorissen Chiwaula moved to Malawi in March of 2005 to volunteer as a midwife in the public hospital. When her stories of the women, their babies, and Bwaila hospital reached friends, family, and strangers back home, a stream of emotional and financial support began flowing. Joanne used the money donated to buy formula for the surviving infants of women who died during childbirth and to support women who were critically ill after delivery. As the number of women and babies in need increased Joanne founded African Mothers Health Initiative and Chimwemwe mu’bereki to carry out the work.
The true inspiration for this organization came from Joanne’s experience with one small orphan. Here is the story in its entirety, as Joanne wrote it in 2006 . . .
Tuesday, January 10th 2006, I held a three-day-old baby while his grandmother, supported by the arms of strangers, watched as the maids loaded the body of her 17-year-old daughter into the ambulance. These things are not supposed to happen. I wasn’t in the labor ward when she died. I was in the theatre. When I came back Chipeta, the charge nurse, told me the story. The woman delivered with a traditional birth attendant on the 8th but was experiencing a lot of pain and bleeding and so on the 10th she went to the health center near her home. The health center transferred her to Kamuzu Central Hospital, (KCH has the only ICU in the Central Region of Malawi, but does not have a public maternity ward). Clinicians at KCH for some reason decided to send her to Bottom but as soon as she arrived, before she could even be assessed, she began gasping and then collapsed. The resuscitation attempt was unsuccessful. The clinicians speculated that she had an undiagnosed ruptured uterus, which lead to sepsis and eventually to her death. As she told me the story, Chipeta gestured to an older woman sitting on the bench at the entrance to the labor ward unsuccessfully trying to console a screaming baby. When I asked Chipeta what would happen to the baby she said simply, “He will return to the village with his grandmother, and probably die within the week.”
Monday night one of my friends had given me a large can of formula to donate to the nursery. When I was shown the woman holding the crying baby, I took her to the nursery, retrieved the donated formula, and prepared a small cup of formula while the nurses gave the woman instructions. Once she was done feeding the baby and the baby’s eyes were dry and bright. Another nurse came to tell us that the ambulance was ready to take her and the body to the mortuary at KCH. I carried the formula in one hand, the grandmother held the baby, my other hand lightly rested on her back. I could feel the bones of her ribs and her shoulder and her hips beneath the layers of tattered cloth. I noticed her bare feet with their thick soles. I considered the can of formula, at a cost of approximately ten dollars. I knew the newborn would not continue to eat this food without significant help. Before we even made it to the door of the hospital, tears began running down her wizened cheeks and her steps faltered. Several women, waiting in the halls for their own daughters, approached her, removed the baby from her arms to relieve the weight, and listened to her story as it came through her tears. I took the baby from one woman and she moved to support the grandmother who appeared close to collapse. She kept repeating, “I am alone, I am alone.” I considered the baby who was crying in my arms simply because he was a baby and wet. He had no concept of how his life was changing nor would he carry any memory of the day forward.
I had the nurses write down the village of the grandmother and tell her that I would meet her at the nearby health center on Tuesday with more formula. The 17-year-old mother died under our noses and now I’m trying to provide hope and help by giving cans of formula. One word – inadequate.
January 17th 2006. I went and delivered formula to the baby of the 17-year-old who died in labor ward. I found my way to the rural health center and when I arrived at the health center the grandmother was waiting for me with the baby and her other daughter. I drove them back to their home in the “nearby” village, which was a good five miles away, with the grandmother giving directions in Chichewa and gestures. The terrain was mostly four-wheel drive worthy roads but my little Toyota Sedan did a great job. When we did reach a muddy impasse, I stopped the car and we walked the rest of the way to the house through the stares of all the neighbors. Finally we arrived at a neat brick and mud home with mud floors and a tin roof. Inside there was one small room with a couple goats and one bare large room, with a large straw mat and one chair. The grandmother offered me the chair and the mat quickly filled with women. I felt honored, content, and uncomfortable. After a few minutes she escorted me back to my car and I promised to return again with more formula.
February 4th 2006. I returned to Mbewe village to deliver formula to the orphaned baby of the 17-year-old. My friend Deb came along with me this time and I was incredibly grateful for her company. I was planning a quick visit – seeing the grandmother briefly and handing over several large tubs of formula – but, that is not the way it happened. I found the house again without a problem and the baby’s aunt welcomed me with a warm smile. Apparently she had been caring for the baby but when I arrived the baby was somewhere else with another woman. The aunt ushered us into the house and instructed us to sit on the mat while she went to retrieve the baby.
My heart sunk the moment she placed him in my hands. He was wrapped in two wet cloths, he was still, and, even though he was a month old on Feb 3rd, he weighed no more than a newborn. I unwrapped him to examine him in a thin ray of light that filtered though the slats in the wall, and saw greenish pus crusted over his eyes and a light pink rash sprinkled over his body. I could see his ribs with each of the infrequent breaths he took and touched his sunken fontanells (a sign of dehydration). He was slightly febrile and when I wiped and parted his eyelids all I could see was red. I asked the aunt how long he had been like this. She said his eyes had had pus for three days but he had not had diarrhea. I asked her to prepare some formula which she did immediately (she said the other cans had finished so I’m not sure who was feeding him or what he was being fed). With obvious difficulty he managed to swallow and suck a bit. After he took about an ounce, he wiggled slightly and then unloaded a lot of diarrhea. I told the aunt we needed to take him immediately to the health center. She looked distressed and I have no idea if it was because I was taking her away from other chores and children, or if it was a lack of money, or if she resented this extra-mouth. I can only say that it broke my heart to find this baby so close to death in the village.
As we loaded into the car, the grandmother appeared with bright eyes and a big smile, took the baby in her arms, and also got in. At the health center the nurse told us we would have to take the baby to the hospital in Lilongwe. She weighed the baby, he was only 2.7kgs (5.9lbs). She told me that the prognosis wasn’t good. The aunt seemed hesitant about accepting the news of a trip to Lilongwe, but the grandmother said she was ready and I heard the nurse telling the aunt something about being grateful for having care and transport and that the baby was dying. We returned to the house for the cans of formula, the aunt decided to come along, and the four of us set out to Lilongwe.
When we reached the hospital we were able to find a clinical officer to attend to the baby right away (right away after asking a handful of nurses). He wrote out a treatment plan for neonatal sepsis and dehydration, and told us the baby would be admitted to the nursery. Just as a note, there is no clear linear flow or direction given on how to move from being examined to admitted to the treatment rooms to the nursery. There are many benches along the hall outside the ward rooms and by the nursing station and Deb and I just had to keep asking everyone we saw for directions (which were incorrectly given multiple times) and for assistance, which was also reluctantly and slowly given. I am certain that if we had left before the admission process was complete, the family would have remained waiting on the benches for hours before anything happened. With our insistence we were able to insert a nasogastric feeding tube and took the baby to the malnutrition ward – Children’s Ward C – for a feeding.
As we rounded the corner to Ward C, low lights flickered on and off while the screams and cries of many children echoed off cement floors, walls, and ceiling. Thankfully, in Ward C we met a very nice accommodating nurse (Beatrice Namaleu) who immediately helped up prepare formula with boiled water. Our little boy finally had a much needed meal and as the formula went down his tube I turned to my neighbor on the bench and saw a father holding his 3 to 5-year-old child (very difficult to determine the age). The child was only a skeleton and the eyes were sunk deeply into the skull. It’s an image I’m sure most of us have seen on the television, but it is entirely different to sit next to a child dying of starvation and know that a meal awaits you and that you rarely even experience hunger pains. Of course problems on many levels contribute to and finally culminate in the death of a child from starvation, but to know how little a child requires to preserve life and see (really see) that the world has failed to meet that very humble need is devastating.
From there, and with Clement’s help (who joined us along the way), we found the nursery and recruited a nurse’s aid to choose which child our little boy would share a crib with. The nursery was full and babies are sometimes placed two and three to a bed; their mothers or guardians sleep on the cement floor next to them. Knowing that they were settled, we left the floor.
Thursday, February 9th, Clement called me to tell me that the baby had been discharged and that the two guardians were waiting for me to take them back to the village. I met them at the hospital and the little boy looked a bit better but he is still way too tiny and way too weak, at least his eyes were clear. I dropped them off and promised to return Saturday.
This morning, February 11th, I found the aunt with the little one wrapped to her back, just a tiny head peaking over the cloth. He is so frail. I fantasize about watching him transform into a chubby little boy who will run and jump and scream just for the fun of it. Now, looking at him I hope he will hang on to life. I stayed in the village for about an hour – long enough to get teary-eyed a few times and long enough to feed him a small amount of formula. He is still too weak even to suck, I just pour a bit in his mouth and wait until he swallows and try not to let him choke. His poor little mouth is covered with sores caused by yeast and the aunt is treating him with an antifungal but I’m not sure if it is improving. I imagine his little immune system is completely overworked, trying to keep down so many small insults without the help of a mother’s antibodies from breastmilk.
Wednesday, February 15th, I called Lisa (an Australian pediatrician working at the hospital) and asked her if she would come out to the village with me to see the baby. My initial thought was to go early in the day, to make sure the baby was still alive and then, if it was, to bring Lisa in the evening but Lisa made herself immediately available, saying she had not yet been to a village and the three of us -. Deb, Lisa, and I – headed out to Mbewe. When we arrived we found the grandmother, baby, aunt, and a gaggle of children in the yard. We exchanged greetings and then Lisa unwrapped the little boy carefully looking him over, head to toe. She said that his prominent overriding sutures signified brain atrophy. His eyes were clear but she noted that they did not track movement. She said the thrush sores in his mouth would not improve despite the anti-fungal medicine until his general condition improved. She said his lungs and heart sounded good but that their rhythms portended a bad outcome. (She said his heart should have been beating at a minimal rate of 160 beats per minute but it hovered between 100 and 110bpm). She turned him over and what should have been a chubby brown little bum was bony, pink, and raw.
She said he was wasted and stunted, that his diagnosis was “Failure To Thrive (FTT),” and that he would not survive in the village. He was more active than he was the day I first took him to the hospital, but his movements were lethargic and although at times he grimaced, he never cried. Lisa said either way his prognosis was not very good. She asked if the grandmother would go to the hospital immediately but she said she wasn’t ready. We agreed that I would return early the next morning to take them back to KCH and Lisa would meet me at KCH to ensure that they were quickly and definitely admitted to Ward C, the malnutrition ward. Lisa said she wasn’t sure if the baby would survive the night. Even so, I felt hopeful. I was so grateful that she agreed to come along. I learned a lot from her quick assessment and I felt that life inside this baby was fighting to continue and now at least we could give it a fair chance.
Lisa is great. She’s one of those people who confronts desperate situations with determination, a smile, and a sense of humor. She had Deb and I cracking up all the way back to Lilongwe. She told us the story of an infant she had been seeing. The first time Lisa saw her, the girl was incredibly sick and weak and unable to eat. She gave her treatment and scheduled the mother to return for a follow-up visit. When the mom came back, she was eager to show Lisa how much the child had improved. Lisa asked, “Can she eat?” The mother enthusiastically replied, “Oh, yes! She can eat porridge!” Lisa, then asked, “Is she eating?” And the mother, still enthusiastic said, “Oh, no. There is no food,” quickly adding with a proud smile, “but if there were food, she would be eating!” There are countless small horrifying incidents, and if your proclivity is to cry, the stream of tears will be endless. It’s good to remember that laughter is an alternative.
I returned Thursday morning, arriving in the village at 7am. We were supposed to meet Lisa at 7:30 but in my planning I forgot to account for the village concept of time (or rather the absence of a concept of time) and so by 8am we were just getting in the car to return to Lilongwe. Lisa of course was there to meet us and helped expedite the admission process. The baby weighed 2.4kg (0.5kg less than a week and a half before). She said the trick would be to hope that he wasn’t wasted and stunted to such a degree that his weight for length actually appeared normal, in which case he’d be denied admission. We crossed our fingers and the admitting nurse calculated that his weight was less than 60% of what it should have been for his length – he was in! Lisa said she would also help with formula and that she would be checking in on the baby regularly. I gave the grandmother a little money for food and told her I would be back soon.
Friday I quickly peeked in on the baby and then went again today. He is looking better. His sutures are still prominent but his face appeared slightly fuller and, to his grandmother’s delight, he met and held my gaze as I spoon-fed him formula. Unfortunately his little bum looks worse, he now has a small ulcer forming. Lisa gave them some Vaseline to act as a barrier and the grandmother is using it but, with the constant flow of diarrhea, it’s hard to keep him dry. The grandmother was happy to show me how much he improved and was eager to know when she could return to the village. What she doesn’t know is that the baby will not be discharged until his weight is over 80% of the norm for his height, which could take weeks. I’m not sure if she sees my involvement with their family as a blessing or a curse. (If she knew she might be there for weeks, I imagine she’d see me as a curse.)
Although the baby is improving, the gain is tenuous and it would certainly regress if she returned. I do feel bad for her though, and slightly (just slightly) guilty about knowing that her stay may be a long one. She sleeps on the cement floor, under the crib her grandson shares with another child, side-by-side with about ten to fifteen other guardians. She has no mat or even a single change of clothes. The ward is divided into various sections by chest high cement walls, which help control the traffic flow, but do nothing to dampen the deafening acoustics of a couple hundred children crying. I imagine she doesn’t sleep much.
March 9th 2006. Gabriel. I don’t think I mentioned that his name was Gabriel. The second time I went to the village to collect him along with grandma, Anije (who actually turned out to be his great-aunt), I asked her his name. She just shook her head. Thirty minutes later when the admitting nurse at the hospital asked her she said, “Gabriel.” And so, just like that he became someone. From the time of my last entry until this Monday grandma and Gabriel were regulars on the malnutrition ward. I stopped by every few days to check-in on the two of them, and usually found grandma roaming around with peanut strapped to her back. He was so tiny, sometimes you had to consciously look at the form of her chitenge to see his small bulge.
On the ward his health improved significantly; his little bum healed, the thrush sores in his mouth healed, his little cheeks started filling out a bit, and my fantasies of seeing him as a chubby little kid took flight. The stay was clearly doing much good for Gabriel but it was a strain on Anije. Everytime grandma saw me or Clement or Lisa, the pediatrician, she always asked brightly when they could leave. About two weeks ago I called a social worker Friday evening to see if I could get the baby placed at a nursery in town. The nursery, “Crisis Nursery” is run out of a home, and staffed by a mix of paid Malawians and many volunteers. It’s clean and the babies get plenty of attention and good care. The social worker met me at the hospital Saturday morning and interviewed Anije, me, and the nurse after which she decided that the baby would not survive in the village until it was at least six months old. She made a deal with grandma – they would stay in the ward until the baby weighed 3.2kgs (at that time he weighed 2.9kg) and then we would take him to the nursery and I would pick grandma regularly from the village to come and visit until he was 6 months to 1 year old. The social worker called the nursery and the director said she would come and visit baby and granny the next day. I was so thrilled and impressed by the speed of the.
From that point, the program continued . . . my visits, grandma clearly loving but eager to leave, and the little one, improving but failing to gain weight. He hovered around 2.9 for at least a week, reaching 3 on some heavy days but always returning to 2.9. Monday night Clement told me that grandma left without being discharged. She sought him out so he could convey the message to me that her son-in-law was very sick at a hospital in Likuni and she had to go see him and her daughter, and that I should find her there to take little Gabriel. I had to laugh when I realized that she was probably stashing away the money I was giving her for food to fund her escape – without that I was her only way out.
Yesterday, I called the director of Crisis Nursery and she said she had come to meet them previously but couldn’t find them. She found another abandoned baby instead who she gathered up and took with her to the nursery. She said she would meet me Thursday to go to Likuni together and collect Gabriel. I wanted to make sure they were at the hospital so yesterday afternoon I went to Likuni and combed every corner of the grounds with the help of a few nurses and maid but did not find them. I thought about going to the village but thought again and decided to go this morning.
Today was not a good day. On my way out of town I dented my car at a gas station (they have these big cement blocks that are low to the ground, too low to be seen, but high enough to do damage) and that was the beginning.
About a kilometer from the turn off of the main road towards the village I met grandma walking with a group of women with no little bulge on her back. I stopped and she told me so many things with incredible emotion but I only picked out that Gabriel died Wednesday. Thankfully her daughter-in-law who was present, spoke English and filled in the details. Apparently she went to see her son-in-law at Likuni but he died shortly thereafter and so she returned to the village to help with preparations for the funeral. The seven women were on their way to Lilongwe for the funeral when I met them. Wednesday, Gabriel began coughing and as they were heading back to the hospital, he died. Anije said we should go together to the house to see the body and then I could give them a lift back to Lilongwe.
As soon as I heard he died tears starting spilling on to my cheeks. We drove the 600 meters back towards the house, parked the car and then walked the last 500. There were so many women the whole way, lining the path to the house, silent, watching. Anije led us, moaning and crying with each step, her daughter-in-law took my hand in hers and we cried together silently. When we approached the house an older woman I didn’t know took my other hand and the two of them led me inside behind Anije. The small dark room was filled with women and in the middle on a single thatch mat was the little wrapped body. A path opened for me, someone pulled the cloth down to reveal his face, and instantly the room filled with wailing and sobbing. . The scene was heartbreaking but I also felt so much love and support in that small room, in a way I have never previously experienced.
I just sobbed, loudly, messily; the women around me, touching my arms, crying with such love and pain. What really broke me was when one by one, all the women got up, came to me, looked me in the eyes, and silently shook my hand. Their immense gratitude surprised and overwhelmed me. I felt I had failed them and failed Gabriel, but at that moment I also felt, that I would do everything possible to help babies like Gabriel. I will give them anything. I will give myself. We stayed only thirty minutes or so before we headed back to the car. Along the way Anije’s husband and Gabriel’s grandfather intercepted us. They each shook my hand and said thank you and sorry. Gabriel’s grandfather said, “He has died, but he has really been loved. Don’t worry.”