My Month at Ndirande Health Center

In order to teach nursing in Malawi, I am required by the Malawi Nursing Council to complete a four-week orientation in “general nursing.”  Originally, the council wanted me to complete this experience at Queen Elizabeth Central Hospital, which is the referral hospital for the Southern region of Malawi. To say I was a bit worried about this is an understatement. The acute care setting is not my cup of tea, and I haven’t been in the hospital for over seven years. Thankfully, my counterpart rescued me and arranged for my orientation with the District Health Office at Ndirande Health Center. 

My uniform. All navy indicates I am an educator. The hat is optional.

 Ndirande is essentially a suburb of Blantyre, and probably, the largest one. I remember reading somewhere that the health center serves around 200,000 individuals with approximately 20,000 HIV positive individuals. They also deliver a ton of babies. For my month of orientation, I spent a few days in each of the six clinics that the nurses staff (or should staff). As there is a nursing shortage, some of the clinics are left to the HSAs (basically community health workers) or nursing students. The health center is trying to become a hospital with an operating theater (for C-sections) and adult and pediatric wards. Of course, this costs money and requires physician coverage, which is challenging with an even larger physician shortage. I enjoyed my time at the health center and have been impressed, for the most part, by the nursing care. I have especially been impressed by the charge nurse and matron, who happen to both be KCN graduates.  Here is how my day would typically go:

7:30 AM: Arrive at the health center and wait in the labor ward for morning report

8:00 AM (ish): Receive morning labor report from night duty nurse and possibly short stay (urgent care) report if the Clinical Officer/Medical Assistant is still around and it is Monday, Wednesday or Friday

8:15 AM: Head back to the labor ward to await my assignment for the day. The charge nurse assigns nurses to different clinics everyday except the labor ward, which is a two-week assignment.

8:30 AM: Head to my designated clinic and start the day. Each clinic has its own routine, which I will summarize below.

12:00 PM: Head back to the labor ward after clinic is finished. This could be anywhere from 10:30 AM to 1:30 PM depending on the day of the week and how busy each clinic was.

12:00 PM-1:00 PM: Lunch

1:00 PM- end of day: CPD (continuing professional development) presentation if it is Wednesday; discussions with students from other colleges; or sitting around until it is time to knock off (usually 2:30 PM-3:30 PM)

Postnatal and Family Planning Clinic

Postnatal Clinic (20-30 patients per day)

Postnatal Clinic shares a space with the Family Planning and VIA (cervical cancer screening) Clinics. VIA is done only a few days per week depending on if the nurses that know how to do it are working. I haven’t really figured out the schedule. It is supposed to be 2-3 days per week, but I have only seen it 2 times in the past month. Women and their babies come for postnatal checks at 1 week and 6 weeks. They typically arrive around 7:30 AM to get their place in the queue. All of the clinics run on a first come first served basis, except if a woman comes with her partner. In that case, she goes to the front of the line. I like that this is encouraging women to bring their partners, but it unfortunately doesn’t happen that often. Every morning there is a health talk usually given by the nursing students or nurses. The talk is for all women attending Postnatal and Family Planning Clinics. Prior to the talk, the women sing. I’m guessing the songs they sing are about health, but my Chichewa skills are not sufficient to translate songs yet. The talks are typically 20-30 minutes and are focused on birth control with some other topics depending on the audience. After the health talk, the mothers line up to get their babies weighed. After the babies are weighed, they are brought into one of two exam rooms one-by-one for their assessment. I observed a large variation in assessment skills. For the newborns, some nurses just felt the skin temperature (the primary way to assess for fever here) and looked at the umbilicus. The more educated nurses did a more detailed assessment including conjunctiva, mouth and genitalia, but they were not close to the full assessments to which I am accustomed. The use of stethoscopes is very limited in all of the clinics and is definitely not a part of routine assessments of newborns or their mothers. As far as assessing the mothers, sometimes, the nurses didn’t assess them at all depending on if they reported any problems. Other times, there was an assessment of conjunctiva, breasts, abdomen, and lower extremity (LE) pulses. The genitalia would usually only be assessed if there was a report of a tear and no speculum exams were ever done. Blood pressures were also rarely taken in the postpartum women despite a large incidence of pre-eclampsia/eclampsia in Malawi. In one case, a woman was having significant LE edema (2+ pitting for my medical fans). The nurse did an excellent job educating on how to alleviate dependent edema, but didn’t take a blood pressure. When I suggested taking her blood pressure, the nurse shook her head and said it wasn’t necessary. Because I was there to observe, I didn’t press the issue. I’m hoping after some reflection, the nurse will act differently in the future.

Family Planning (20-60 patients per day)

In Family Planning Clinic, after the aforementioned health talk, the nurse collects the patients’ health passports (book with what should be all of their health information) in the order they are in line. Then, they enter the exam room individually for the family planning consult, which primarily consists of Depo, Depo and more Depo. The clinic does have two types of implants- Implanon and Jadelle (the new Norplant), but only one nurse knows how to insert/remove Jadelle and nobody (except me) knows how to insert Implanon. This leads to patients being told to come back to clinic another day for implant removal/insertion. I removed Jadelle on a woman who had been trying to have it removed for over three weeks and another woman who had gotten pregnant on Jadelle (likely because of interaction with ARVs) and was in for her 6 week post-partum visit. I was able to demonstrate Implanon insertion once to the Matron. She was very enthusiastic about learning the procedure and is interested in having a training (stay tuned for updates on this project). The only other forms of birth control available at the clinic are pills- combined and progestin only. In my three days in Family Planning Clinic, we had no Depo for one entire day. It had been ordered, but had not been delivered by the District Health Office. The shortage of medications and other supplies is a common occurrence in Malawi. The phrase that is used in Malawi when something is not available is, “it is finished.” When Depo “is finished,” women are given the option of using another form of birth control or coming back another day for Depo. Most choose to return another day for Depo. Most of the time when they return, they are now late for their Depo. In the US in this situation, we would just do a pregnancy test and give the Depo if not pregnant. Because the clinic is often out of pregnancy tests, the women would have to pay out of pocket for one, which rarely happens. The alternative is to have the women prove they are menstruating with a cotton ball. Without proof of menstruation or a pregnancy test, women are turned away without an alternative form of birth control. The fertility rate in Malawi is 5.7 (expected number of children per woman). At this rate, the population of Malawi is expected to more than double by 2040 from around 16 million to over 40 million. Already one of the poorest countries in the world, this population growth in Malawi is not sustainable. Family planning is the answer. Thankfully, there is a new family planning initiative in Malawi with the goal of increasing modern contraceptive use. I am hoping the focus will be on IUDs and implants. Chabwino, I will now step off the soapbox…

 

Family Planning exam room

Price list for methods at private clinics (1USD=530K). Methods are free at public clinics. Lupu=IUD

Antenatal Clinic (20-50 patients per day)

This clinic is run by Blantyre City Council, which causes some disconnect between it and the other maternity services. During the three days I was at the clinic, there was only one nurse and approximately 10 nursing students. The nursing students had not done antenatal care previously; therefore, the one nurse had to see the patients and supervise the nursing students (and the mzungu). The clinic starts in the same manner as the aforementioned clinics with singing and a health talk. The health talk is significantly longer, lasting around one hour. After the talk, the patients line up to be weighed (returning patients) or to have their height taken (new patients). The returning patients then move on to blood pressures, while the new patients are weighed. The whole process is much like a dance- everyone moving to the various stations while maintaining their position in line. There are also tetanus immunizations given and HIV tests done somewhere in this process. Then, the nurse and nursing students start to see the patients in one of four exam rooms. I was working with two students in one of the exam rooms. I was impressed that the women are instructed on self-breast exam at each visit. This is the best method of breast cancer screening in Malawi, where resources are limited and cancer screening is low priority. One of the most frustrating aspects of antenatal care in Malawi is the use of McDonald’s Rule to calculate gestational age. In America, fundal height (FH) is about equal to gestational age (GA) after 20 weeks. We use FH to monitor growth, but not to calculate GA. In Malawi, they use FH to calculate GA using the formula: FH x 8/7. This is apparently called McDonald’s Rule. This formula has caused many an issue when it comes to determining if someone is post dates. For example, if a woman has a FH of 31.5 cm, GA will be calculated at 36 weeks based on the rule. Now imagine she is actually 30 weeks pregnant and she presents to the hospital 10 weeks later to deliver at 40 weeks. Based on the last calculation in her health passport, 36 weeks+10 weeks= 46 weeks. Does this make sense? It doesn’t, but a resident told another GHSP volunteer that a woman was 46 weeks pregnant. I understand using FH as an approximation of GA when there is not a reliable LMP and limited access to ultrasound. However, it is often used in place of a pregnancy wheel when there is a reliable LMP. I attempted to teach the students that there are a lot of reasons that someone could be measuring larger than or smaller than expected, and if there is a reliable LMP, use it. I had a fantastic time working with the students. In the future, I hope they will hear me saying, “Does that makes sense?”

Miracle, one of the students in Antenatal Clinic

 I realize that this post is not only overdue, but also verbose. I am breaking it into two parts inspired by Back to the Future Day. Up next on Part II: ART Clinic, Under 5 Clinic, and Labor Ward.

The Dreaded OSCEs

The acronym OSCE triggers a certain reaction in medical and nursing students. I remember hearing about OSCEs from my nurse practitioner students and friends. The mere mention of OSCE would be followed by a heavy sigh and a dramatic story usually with fear as a theme. OSCE stands for objective structured clinical exam. When I was a student, our clinical exams didn’t have this lovely title.

Excited for OSCEs

The OSCEs were one of my first duties as a lecturer at KCN. Amber, a fellow GHSP volunteer, traveled down with KCN Lilongwe to partake in the OSCE fun. For this session of OSCEs, we were grading all 250 of the second year students. This is quite the production with lecturers from both campuses of KCN and several master’s students. 

Amber and I donning our lecturer uniforms (I'm rocking the Hopkins pins!)

 The first day, the students were tested on urinary catheter care and colostomy care. We had 20 stations set-up- 10 for each scenario. The second day, we were testing insulin administration, and thankfully, were able to have all 20 stations dedicated to this task. The students were given a scenario, for example: Mr. Basi is a diabetic who is on 10 units of soluble insulin daily. They were then responsible for demonstrating the procedure to administer insulin to Mr. Basi including proper documentation. As the examiners, we had a checklist in order to grade the student’s performance with two examiners per student. Each student was allotted 10 minutes to complete the procedure. We held the OSCEs at the Kameza campus, which was recently built, but the process of transferring the bachelor’s classes/students to this campus has not been completed. I heard there was an internet issue, but that is probably only part of the story. It is a beautiful campus located approximately 20-30 minutes outside of the center of Blantyre.

Kameza campus of KCN

Here is how the first (and longest) day of OSCEs went:

6:50 AM- Picked-up by KCN Lilongwe bus at my house. Make 2-3 more stops in Blantyre to pick-up other Lilongwe faculty.

7:45 AM- Arrive at Kameza campus and proceed to unload many of the supplies needed for the OSCEs.

7:55 AM- Realize that there is a lot of set-up needed before we can start. Proceed to wander around the campus looking for photo ops with Amber (see below for results).

8:30 AM- Wander back to the OSCE room and arrive just in time for the meeting to discuss the process.

8:45 AM- Divide into groups with two examiners per curtained-off station.

8:55 AM- Meet with everyone grading our scenario- urinary catheter care. Read the scenario and the grading sheet, and discuss proposed changes.

9:00 AM- Head back to our stations and await the first group of students.

9:10 AM- Grade the first set of two students.

9:35 AM- Meet again to discuss how the first set went. Discuss some more about the grading sheet, but make no changes.

9:45 AM- Grade more students.

11:45 AM- Tea time!!!

12:00 PM- Grade more students.

1:30 PM- Lunch

2:00 PM- Grade the rest of the students.

4:45 PM- Tea time.

5:00 PM- Head home.

Here is what would happen during a typical OSCE:

The student waits outside to be told to enter the area. When instructed, the student enters the room and is given 1 minute to read the scenario. A bell rings, which signifies the start of the 9 minutes. The student comes to the bedside of the “patient”, introduces themselves (usually in Chichewa), informs the patient of the procedure, and obtains consent. The next step is to provide privacy. In America, this is implied as our hospital rooms are set-up to already be either private or semi-private. In Malawi, there are sometimes 8 or more patients in a room (if there is a room) and no curtains. This was the one step in the checklist that I found most interesting. The student then continues the procedure describing the process to the “patient” (in English thanks to my fellow examiner). When the students finish (and hopefully after remembering to wash hands again), they document the procedure. Then, the bell rings again signifying for the student to leave and the examiners to finish grading. 

The full lecturer uniform

View from campus

Student dorm

The students did fairly well on their OSCEs. It was interesting that the students later in the day did better than the students in the morning. I was wondering if there were a bit of sharing on the part of the morning students- it is a communal society after all. The most frequent mistake during catheter care was not cleaning from the urethral meatus out. I could hear the voice of one of my nursing professors at Hopkins emphasizing this important point. Also, the students often forgot to assess not only the genitalia, but also the catheter. We have been told that the Malawian nursing students are very good at memorizing, but are challenged by critical thinking. Assessment is one of the most important roles of a nurse. I am determined to impart this on my students. I was overall impressed by the preparation of the students and sympathized with their evident nervousness.  What a way to jump into my role! I am now spending the requisite 4 weeks of orientation at a health center.  My next blog will focus on this experience- stay tuned.

Swearing in and Moving to Blantyre

I realize that I have been out of touch for the past several weeks. I would love to attribute this to lack of substance, but alas, I can only blame my procrastination. Since we last met, my life has transitioned from the living out of a suitcase/very structured life of a trainee to the being settled in my lovely home/more freedom existence of a GHSP volunteer. I am extremely thankful for the training we received- I can have a very short conversation in Chichewa, and have found myself thinking on numerous occasions, “I remember that from orientation.” I will now attempt to summarize the past few weeks into a somewhat manageable blog entry.

 The culminating event of our orientation experience in Lilongwe was our first opportunity to meet and interact with our counterparts. We had several sessions to acclimate us to working with each other (including how to work with very direct Americans) and to delineate expectations.  This was an extremely eye-opening experience as all of our counterparts have multiple roles within our institutions. The faculty shortage in Malawi translates to one individual doing the job of two or more. For example, my counterpart is not only a lecturer at the bachelor’s and master’s level, but also has several administrative roles. I am excited to share in her teaching responsibilities in order to lighten her load. The students are just now at the end of second semester; thus, I will begin teaching with the new school year in the beginning of November. I will likely be teaching first year students in community health, and possibly, master’s students in reproductive health. Kamuzu College of Nursing (KCN) has two campuses- Lilongwe and Blantyre. In Blantyre, we have half of the first year students (approximately 125), all of the second year students (250), and all of the master’s and PhD students. The rest of the students spend their time in Lilongwe. Chabwino (okay), back to the story of the past few weeks…

 After spending the day with our counterparts and a quick wardrobe change, we all ventured to the US Ambassador’s residence for our swearing-in. It was a wonderful ceremony filled with many inspiring speeches including two from my fellow volunteers- one in English and one in Chichewa. As I was reciting the oath, I was recollecting the previous occasion on which I spoke these same words, nearly fourteen years ago, when I swore-in as a volunteer in Samoa. The setting was vastly different, but the emotions and meaning behind the oath are unwavering. Following the ceremony, in true Peace Corps fashion, there was food.

GHSP Malawi 2015-2016 (Photo credit: Corey)

Taking the oath (Photo credit: Steve)

The next day, we packed up our suitcases and bid farewell to our colleagues/friends traveling to Mzuzu and staying in Lilongwe. The process to leave Lilongwe involved a stop at the Peace Corps office to pick up bicycles, PPE, water filters, etc.; a ton of shuffling of both belongings and passengers in order to accommodate all of our stuff, three GHSP volunteers, two counterparts, and two drivers; and a brief hiatus at KCN in Lilongwe to pick-up exams. We departed for Blantyre slightly off schedule, but had a smooth four-hour journey to our new home. The highway between Lilongwe and Blantyre is actually very nice. I have heard stories about the road system in various parts of Africa being somewhat treacherous. This is not the case (for the most part) in Malawi- I have been pleasantly surprised. One of the most interesting points along our trip was near Ntcheu, where the highway serves as the border between Malawi and Mozambique- on one side you can buy Malawian tomatoes and cross the road to the other side to buy Mozambican bananas. No documents needed to cross this border- oh how the US politicians would have a hay day with that.

 As the gate opened at my compound, I was stunned, and honestly felt like I was back in America. I absolutely love my house and could not have asked for a better situation. I guess I was somewhat expecting housing similar to what I had in Samoa, but was relieved to find I have tile floors instead of “carpet” (concrete floors covered with sheets of plastic flooring); a bathroom with a window and without “skylights” (holes in the roof of the ceiling that let in leaves, not light); hot water (I was not looking forward to doing the cold shower dance); and real closets with actual doors. I believe I am much more appreciative of my current accommodations having been a traditional Peace Corps volunteer. Have no fear readers, I am not immune to the realities of living in Malawi- power and water outages, insect visitors/roommates (although they don’t usually survive long thanks to the cat), washing laundry by hand, ironing anything hung outside to dry (thanks to Botflies), and the whole water treatment process- filter, boil, cool, drink.

My lovely house

My bathroom

My bedroom

Chichi, the princess/diva of the house

I spent the rest of the week and weekend settling into my house and exploring Blantyre. The city has a striking landscape as it is flanked by mountains. This translates into a great workout everywhere you travel on foot as there are a ton of hills. So far, I am enjoying Blantyre and thankful that it is more compact than Lilongwe.

Blantyre

I just want to give a shout-out to my dad for teaching me how to use tools. I had a broken closet door when I moved in, and decided that I could totally fix it. After multiple trips to acquire the necessary tools and a new hinge, I successfully removed the old hinge (with stripped screws) and attached the new one. During this process, I realized that whoever installed the doors made a major mistake by cutting into the door frame, which ultimately caused the hinge to break. Therefore, I had to decide between another potential broken hinge or a space between the closet doors. I now have a lovely space in the upper portion of one of my closets. For those of you who know me, you would not be surprised that I was super determined to fix this closet and didn't stop until the door could again be opened regardless of the gap. Such an accomplishment!

My handy work

It was exactly one month from the time I left Minnesota to the time I arrived in Blantyre. It feels good to finally be settled into my home for the next year- Chez Blantyre as we lovingly refer to it. Stay tuned for my next episode in which I jump into work at KCN with OSCEs.

Cultural Experiences- Malawi Style

In the midst of various training sessions, we have been fortunate to get a glimpse into Malawian culture. Our first venture out of our training bubble was to Kumbali Cultural Village. We had our very first Chichewa lesson in which we learned a few simple greetings, and most importantly, the word zikomo (thank you). Zikomo appears to be used in a variety of ways- I am still trying to suss this one out. After a brief and informative introduction to cultural practices in Malawi, we were served a traditional Malawian meal. The staple of the Malawian diet is nsima- a polenta like starchy paste made from maize. Nsima is supposed to be eaten with your hands (I was 50% successful at that feat), and is typically served with a few side dishes. I enjoyed the nsima, and actually prefer it to taro (sorry Samoa). After indulging in the Malawian delicacies, we were charged with the feat of learning a few Malawian dances. That's right, dancing!! I think I was the one in our group who was most excited to participate (not surprising!). After a brief demonstration, we were invited to join our instructors to learn three separate dances. Set to drums and singing, the dances are very rhythmic and involve a lot of hip movements, which is right up my alley. At one point, the main instructor pulled me to the front row with the experienced dancers- apparently, I was doing something right.

Learning the Malawian dances

After our lesson, we were given the privilege of a performance by the dancers who were teaching us. Their body movement is amazing. And, they do it all while singing. It was quite an inspiring experience.

Our instructors performing

At the end of the performance, we were invited to join in on the festivities and display our new skills. I would love to continue to learn the dances of Malawi- would make for a great workshop back in the US (talk about the 3rd goal of Peace Corps).

Showing off our moves

After another week of training including a PEPFAR meeting and a session with the ambassador (amazing!), we set off on our weekend cultural excursion at the beach. On our way to Salima, we visited a health volunteer at Nathenje Health Centre outside of Lilongwe. This was our first glimpse into the healthcare system in Malawi. When we arrived at the health center, there were numerous (probably around 30-40) patients lined up for services, and this was the "slow" day. The Medical Assistant (aka Clinical Officer- equivalent to a PA in the US) is the solo practitioner at the health center- he sees patients all day and is on-call all night and weekend. There are 7 nurses at the health center that rotate between the maternity ward (labor and delivery/postpartum), antenatal clinic, and ART clinic. They did have a lab at the clinic, but are only able to do TB smears (when the microscope works) and rapid malaria tests. It was amazing to see the dedication of the healthcare providers despite limited resources.

We bid farewell to the health volunteer and set off for Salima. The picturesque drive was dotted with rolling hills, smiling faces, selling of produce and products, and honking at goats/cows/people on bikes. In my mind, I was contrasting this with the numerous drives in a wooden bus I experienced in Samoa. Sights, sounds, and smells were easily recalled.

The scenery

Traffic jam

Adorable and smiling faces

Our nearly two hour trip culminated in our arrival at the Sunbird Livingstonia Hotel, and our first glimpse of Lake Malawi. What an amazingly beautiful and calming body of water. Fun facts: Lake Malawi is approximately 360 miles long and 47 miles wide; was formerly called Lake Nyasa, which translates to Lake Lake; and has more species of fish than any other lake.

Lake Malawi

The next day we ventured to Kungoni Centre at Mua Mission. The center celebrates the cultural and artistic traditions of Malawi. The focus of the center is on the three main ethnic groups of Malawi (Chewa, Ngoni, and Yao). Depicted through art and photography, we learned about the major traditions of each of these groups including birth, initiation, marriage, and death.

Mask at Kumbali- used by the Chewa

Before heading back to Lilongwe the next day, we stopped by Kuti Wildlife Reserve to visit an environmental volunteer and see some animals. The volunteer works closely with Kuti and the surrounding villages to educate about conservation. Deforestation and poaching are still issues in Malawi. Our environmental volunteers are paramount in promoting awareness of these issues, and educating their communities on how to use resources sustainably.

Zebras

The volunteer and a Malawian guide accompanied us on our game drive; and thankfully, we had the guide with us or we would have missed most of the animals. The reserve has numerous mammals including multiple varieties of antelope (sable, kudu, waterbuck, reebuck, nyala, bushbuck, impala, oribi, duiker, and grysbok), wildebeast, zebras, primates, and a giraffe. We were fortunate to see several varieties of antelope (even the illusive kudu), the giraffe, the zebras, and a few monkeys. It was an amazing experience and I cannot wait to enjoy more! 
 

Kudu

 

Giraffe

This weekend I was able to check off "seeing a giraffe" on my list of "must sees" in Africa. After such rich cultural experiences, I feel like I've finally scratched the surface of Malawi.

The GHSP Need

As promised, I am writing a Global Health Service Partnership (GHSP) 101/ what I'm doing in Malawi entry. For an extremely eloquent version of this, I recommend watching Vanessa Kerry's TED Talk (see below).

Let me begin with GHSP. If you smartly watched Vanessa's talk, you may skip to the next section (this is a choose your own adventure style blog entry). GHSP is a public-private partnership between Seed Global Health, Peace Corps, and US President’s Emergency Plan for AIDS Relief (PEPFAR) that aims to increase human resources for health (HRH) in Malawi, Tanzania, and Uganda. HRH is the fancy way of saying healthcare workers. In the case of GHSP, this refers specifically to physicians and nurses. You may be wondering why this program is targeting other countries when the US news repeatedly highlights the shortage of nurses and physicians (primarily primary care) in our country. Let's look to the numbers for the answer:

Physicians per 100,000 people

U.S.               240

Malawi            2

Tanzania          1

Uganda           12

Nurses per 100,000 people

U.S.              980

Malawi          28

Tanzania        24

Uganda         131

Some more staggering data: Africa has 24% of the global disease burden and merely 3% of the world's healthcare; Africa has 75% of the global burden of HIV; 1 in every 9 children under the age of 5 will die in Africa, while 1 in every 125 children under the age of 5 will die in the US. These statistics highlight the need for programs like GHSP that focus on increasing HRH. 

We've established a need for more HRH in GHSP countries. So what are we going to do about it? As GHSP volunteers, we plant seeds that will hopefully one day become a forest. In other words, we are teaching the next generation of physicians and nurses that will then become educators and foster the next generation. This is a challenging concept for us because as Americans, we seek immediate gratification. The results of our efforts may not be fully appreciated for years. Therefore, we need to follow the mantra pang'ono pang'ono, which means little by little or slowly in Chichewa. The need is tremendous. We cannot expect to meet this need completely, but as Mother Teresa said, we can make tiny ripples.

Tiwonana Alaska and Minnesota

I have had the best intentions of writing my first post for what feels like months. In true procrastinator fashion, I pen my first entry merely hours before I depart for Malawi. The past month has been a whirlwind of saying tiwonana (see you later in Chichewa) to friends and family in Alaska and Minnesota. I am grateful for the time I was able to spend in Alaska with the family. Rural Alaska prepared me for some of the challenges I will face in Malawi: water shortages, sometimes slow internet, dustiness, and large, potentially dangerous, mammals (hippos are the moose of Africa). However, the sense of community in rural Alaska is akin to what I anticipate finding in Malawi. Leaving Minnesota was definitely harder this go round thanks to an amazing group of individuals I am honored to call friends and family. A special shout-out to my zouk family- I expect you guys to grow our community by the time I get back!

On the river in Alaska

When I arrived in DC over one week ago, my first action was to study the bios of my fellow volunteers and the staff at Peace Corps and Seed Global Health. I am humbled and honored to work with such an extraordinary group of individuals with the shared mission of strengthening the health systems in Malawi, Tanzania, and Uganda through education. It has been an amazing experience getting to know everyone- I look forward to sharing this journey with you.

GHSP 2015-2016 Team

I realize that I am lacking detail on the program and what I will be doing in Malawi. This is something I plan to tackle on my 15 hour flight to Johannesburg. Stay-tuned for my next installment- coming to you from Malawi.