A Lesson in Humility: Cobue, Mozambique

This week, we decided to organize a short day-trip to the nearby city of Cobué, Mozambique. Our motivation came from all of the Mozambican traffic in the hospital lately. Each day, in both the lab where I have been working and the maternity ward where Katherine has been working, we receive patient after patient from Mozambique. Some have come the previous day or that morning for the sole purpose of being treated in St. Peter’s hospital. As we have reported before regarding the 50% of Mozambican patients the hospital serves, we will refer you to the previous post. But here, I will describe the journey to and sites in Cobué.

After collecting 15 liters of fuel and 500 ml of oil, we walked to the shore where our boat was “docked.” The small, wooden fishing boat had a few planks across it for seating and a small 15 hp Mercury motor on the back. We quickly realized that there were a few leaks, and so I ended up using a plastic milk container to bail us out more than once. After the collection of some oars for the case of emergency, our driver and our housekeeper Charles who was coming with us hauled the boat in from its anchor and we hopped in.

Our first stop, we learned, was to stop at another part of the island to collect a Malawian border pass for our boat. This would not have been a problem, except for the fact that we had spent about 2 hours earlier that morning getting our own Malawian boarder passes and dealing with immigration officials. Why we did not also pick up papers for the boat at that time, no one will ever understand. (Katherine and I always say that when things seem strange, it is because nothing in Africa is ever as it seems!)

Finally we set off for the Mozambican mainland, but with four more passengers than expected. When we stopped for the boat papers, two young women and their little sisters approached us asking if we would give them a ride to Cobué. They had missed the earlier boat, and decided that they would just sit on the beach and wait for someone else going there to hitch a ride. We think it was worth it, though, because they saved about 12,000 Kwacha ($24).

The ride across the Eastern side of Lake Malawi felt heavenly, though the rumbling of the motor did seem a bit concerning. With a strong breeze and the fresh scent of the outdoors, we arrived at Cobué about 40 minutes after setting out. We noticed when we arrived that the Mozambican government is currently working to build a dock for the Chambo boat that services Mozambique, Likoma Island, and mainland Malawi. Everyone is confident that the huge slabs of steel that are being put out into the Lake will provide much easier access to the boat for all its passengers and cargo.

As we got out of the boat, our driver hoisted it onto a deserted patch of sand and tied it to a branch he had stuck in the ground. You may laugh, but we definitely imagined we were the hopeless accomplices of Malawian conquistadors taking over Mozambique! We needed to self-report to Mozambican immigration, so Charles led us to the office where we had to wait for an official to show up! Each of the Malawians received a free entry stamp on their border pass, while Katherine and I received a Mozambican visa in our US passports for $30 USD each, along with a “docking fee” for the boat, around $14 USD. YIKES! Our friends told us we got the “Mzungu” price (white foreigner price).

At that point, it was 1:30pm and everyone hoped for lunch. A quick examination of our surroundings, however, told us that lunch would be nearly impossible. So, we set off to tour the village. Cobué was very small compared to Likoma Island and had little of Likoma’s constant foot traffic and small business enterprises. We did see several signs though of a greater and more deep seated poverty there than we had on Likoma or in Mzuzu. Our first clue was the lack of any electrical lines in sight, and the second was the prevalence of bore-hole hand water pumps every so often.

After passing the secondary school and several beautiful stretches of beach, we climbed some crags and hills and reached the health center of Cobué. What we found, to our great dismay, immediately confirmed for us the necessity of Mozambicans travelling to St. Peter’s Hospital. There was one delivery bed and two recovery beds in the maternity ward, which had few supplies. In a separate building, the only hospital employee working at that hour, an aide, showed us the 4 beds in the general ward, all covered in dirt and with half-used bags of solution waiting for future patients. Finally, we talked about the only nurse in the area while standing in a decrepit room with two dirty beds, one for cleaning wounds and one for examining patients. All together, we noticed only two drugs in the health center and two liters of fluids. Someone mentioned to us that the people become angry with the nurse because she often turns her phone off and is nowhere to be found. Katherine mentioned that she must be overworked and feel so guilty for not being able to work 24/7 for her community. At the same time, we agree that she is making a decision necessary to preserve her own health and usefulness.

We walked a little further and happened upon the boarding area of the secondary school we had previously encountered. We met the caretaker of the children and he showed us the one shelf of books that made up the library, the kitchen, the study area, and the rooms of the students. He explained that secondary education in Mozambique is conducted in Portuguese, even though many of the students speak only Chichewa, due to the proximity of Cobué to Likoma and Malawi. The student’s caretaker showed us into Cobué’s Catholic Church, the only building in the village that one can see from Likoma. All of brick and wood with beautiful stained glass the church stood as an incredible picture of the Portuguese heritage Mozambique holds.

Soon we realized that there was nothing else to see. It was only 3pm. Thus, we walked to the market in Cobué, a pitiful place compared to Likoma, let alone compared to Mzuzu. We stopped there for some bread and coca cola, fuel for our ride back to Likoma. Before we left though, a woman approached us. She was a friend of Charles’ from Malawi who is currently living in Mozambique. She moved there several years prior to pursue her passion for teaching nursery students. After beginning a small school, and educating several of Cobué’s youth, she began to realize that she was being taken advantage of by the community. Unfortunately, nothing she could do could convince the community, especially her students’ parents, that she needed help financially and materially to make the school a success. She was forced to close to maintain her own life and sanity, and now is selling vegetables at the market while she figures out what to do. When she showed Katherine and I where her school had been, under a wooden shelter near a mango tree, tears glistened in her eyes and hope filled her voice. It was a humbling meeting.

During the ride back, Katherine and I remained quite quiet as we contemplated our day and how, if at all, it would affect our work. Indeed, we think it will help us to better relate to our patients at St. Peter’s and to better understand just how lucky the Malawians living on Likoma are compared to the Western Mozambicans. We know the tone of this post may be a little more somber than previous ones. By it, we do not mean any disrespect to the people of Cobué. In fact, just the opposite, we hope to show that just spending a short time in their environment has given us a new and lasting perspective.

The boat we rode to Mozambique (which you can see in the distance).

Cobue, Mozambique

Pumping water for the village is often the task of women and children. The secondary school is in the background.

Mozambique is on the Eastern side of the Great Rift Valley.

Labor bed in Cobue's health center.

This is the general ward in Cobue's health center.

Cobue's Catholic Mission

Our new friend and her incredible school turned vegetable patch.

"Downtown" Cobue

On our way back to Likoma, we passed by the Ilala, an old passenger/cargo ship that traverses Lake Malawi daily.

21 July 2015: Likoma Island Update

(Katherine)

Many days have passed since our last post, and Derek and I are doing well on Likoma Island. Both of us are acclimated to our island home and we really enjoy the service we are doing alongside of many new, local friends.

For my part, I have finished teaching at the secondary school as classes there have ended and exams have begun. Thus, I am now full time at the hospital in the maternity ward. Although I enjoyed meeting the students, I am glad to have more time to be in the hospital environment with patients. But, perhaps it is important to mention that on top of working days, I am also on call for labor and delivery every night! Usually, I do not receive calls to come to the hospital, but there has been more than once when I have been roused to attend a delivery and help with cleaning the baby after birth. I really enjoy doing that, so having the privilege has been excellent. In total, I have been present at 14 deliveries since arriving here on the island!

That being said, my duties at the hospital have come to include more than labor and delivery. As the nurses have been short staffed this month, I have been trained in discharging healthy maternity patients each morning based on orders given by the clinical officers and nurses. Usually one of the patient attendants translates for me and monitors my work. If a woman and baby are healthy after a vaginal delivery, Malawian standard of care is to send them home within 24 hours of delivery. Women who deliver by Cesarean section are usually discharged after 7 days. When I discharge women, I have to record in the health passport whatever has taken place at the hospital, why they have been discharged, their vital signs upon discharge, and what medications they have been given. If a woman has had a baby, I have to weigh the child and take the temperature. For all new mothers, we also give counsel regarding exclusive breastfeeding, family planning, and immunizations.

This brings up an issue of the nationality of the woman and child. If the new baby is Malawian, I must also issue a Malawian health passport and birth certificate. But, many of the women served by St. Peter’s hospital are western Mozambican. If the new baby is Mozambican, I only give the mother instructions to obtain a health passport and birth certificate from the health center when she returns home. On top of that, Mozambican discharges are ideally written in Portuguese because the health care workers at the small health centers in western Mozambique do not read Chichewa or English. Because of this, my Brazilian Portuguese has proved invaluable! Each time I write a discharge in Portuguese I am grateful to my Brazilian teachers and all of their encouragement in learning.

You may wonder why Mozambicans would travel across Lake Malawi to Likoma Island to receive health care from a remote hospital. The very fact that they do can tell us why: there is no other option. In western Mozambique, the government in the central capital of Maputo has neglected developing health care resources for many of its people and instead relies on Malawi’s island. Government health care there is comprised of solely small health care clinics. This lack may be for several reasons. Firstly, Mozambique’s civil war ending around 1992 stunted both public and private development throughout the country. Insurgency has again become active since 2013 and now is preventing further recovery. Secondly, western Mozambique has many hills in which gold is mined. Rather than making the area wealthy, gold mining competition has caused unrest in many western villages which has also prevented developmental efforts. Thirdly, Malawi, as we have truly experienced, prides itself on maintaining an open door, even considering itself “the warm heart of Africa.” Certainly, Malawian border police (there are about 5 stationed on the whole of Likoma, not to mention the staffed army barracks that are also located on the island) could turn Mozambicans seeking care back to their own country. Instead, Malawi has accepted any Mozambican in need, sparing them even the need for a border pass. Thus, Mozambique feels little pressure to spend precious resources developing health care in its western villages.

As we are counting down our last days here, I will continue working at St. Peter’s. But, I hope that my new friends also fill my days so that we can spend as much time together as possible! So far so good: my godchild and his mother, Eliza, came over for dinner tonight, and the Diocesan secretary Bernard will be arriving on the island for a visit later this evening.

(Derek)

The last couple of weeks since our last post have been filled with countless new experiences, new people and hours of personal reflection. My teaching responsibilities have come to a close with the end of this school year. However, this week and last are exams for the students, so I have been assisting with supervising those. Outside of that, I have found new work at the hospital! I have been assisting Richard, the lab technician, with a whole host of tests, including malaria tests, TB tests, HIV tests, blood counts, pregnancy tests and more. Usually it is just him working in the lab, and with so many tests needing to be performed and recorded, it is pretty overwhelming! So, I have been recording all of the results from the tests in the national registry books, and in the patients' health passport (chart that they keep and take with them). Under Richard's supervision, I have also performed countless mRDT tests, or malaria rapid diagnostic tests. Essentially we just prick a person's finger, get a drop of blood, put it in the disposable test strip, add the reagent and wait. On a normal day, the lab will process upwards of 70 of these mRDT tests, and dozens of other tests. It is a busy place!

We have been welcomed by so many people into their lives and into their homes, providing us with many new cultural experiences. We have also explored many places on the island, which has several villages. Yesterday, the Dean of the cathedral accompanied Katherine and I to Fudwe Museum, located about a 2km walk from our house. It contained many historical African artifacts and traditional African musical instruments, cooking utensils, hunting/fishing equipment, etc. It was a very interesting place, and the view was absolutely beautiful from the hill. We could see a good deal of Likoma Island, the lake and nearby Mozambique. The Dean explained so many interesting things about the island's history, some of which we knew a little about, some of which we had no idea. The island was first explored by missionaries from the UMCA expedition, which stands for the Universities' Mission to Central Africa. This society of Anglican clergy was started and supported by Oxford University, along with Cambridge University, with the goal of exploring this region of Africa, starting in 1857. These people also supported the construction and cost of building this magnificent cathedral on the island, which rivals many Western cathedrals. I can assure you that normal churches here do not look like the cathedral! Many of these men died on the expedition from malaria. The Dean also explained some of the history of the Anglican Church governing this island. There was a time when the Dean of the cathedral also acted as the British governor in this region, simply for lack of an actual governor being stationed in these parts. As such, the Dean was the highest ranking British official, and as such held a seat in the British parliament. The Dean would also sign off on important legal matters, act as a judge, etc.

Additionally, the Dean explained to us how the traditional system of governance remains within the new context of a "modern government" as we might think of it in the West, with democracy, elections, presidents, parliaments, etc. When the British regime was ousted in 1964, and after a period of transition a democratic regime was put in place by 1966, the traditional way of governance was firmly kept intact. The system of village "headmen," and the chiefs that rule over them, are actually preserved by Malawian law. It is the best of both worlds for everyone involved, since these "TAs," or traditional authorities, must all be on good terms with the Malawian government. They are the way the government communicates directly with the people, and the people with the government. Still, elected members of parliament represent all citizens as well, but in the more impersonal way that we are so used to in the West. The village headmen, on the other hand, are responsible for all the goings on in a village. If anyone is out of line, having difficulties in their marriage, is a drunkard, etc., it is their responsibility to take care of these issues. They even act as a judge in petty civil matters. The chiefs that are over the village headmen have the authority to remove the headmen if they have lost the respect of the people or the government, meaning that the headmen must be very careful in how they go about things. All of these TAs are paid a small, token salary by the government in recognition of the important work that they do, on behalf of their people, but certainly in service of the country as a whole. The thinking is (and it is a desire of many political theorists, such as myself I might add, that this thinking would expand into Western thinking...) that if everything in the the family structure is functioning correctly, and if everything in the community is functioning correctly, would could possible be wrong with society as a whole? But if we rely on such people as police or elected, distant officials to regulate society and keep it in balance, the thinking goes here, the results will not be good. Not to mention that the traditional way of doing things would be upended in the hurly burly of democracy and capitalism, something that does not sit well with many Malawians.

Indeed, our night watch, Joseph, is a village headman in a nearby village. Our housekeeper, Edith, is married to a village headman on the other side of the island. And the chief of this island always sits near us in the front of the cathedral. In fact, all of the chiefs and headmen have their own respective seats in the cathedral, just like the clergy, owing to the close historical relationship between the Anglican Church and the traditional structure in Malawi. During the colonial days, the Church was even in some cases responsible for appointing new headmen, at the request of the TAs, whenever their missionary work settled a new area. Needless to say, it was quite the education learning about all of this from the Dean!!

Last evening, around 9pm, we made our way down to the beach to watch a ship come into the harbor. Onboard was the Diocesan secretary, Bernard, who was coming to the island to deal with some issues at the hospital. The harbor here is too shallow for most ships to make their way to the shore, so they have to drop anchor out in the lake and ferry people in on canoes. So, in the blackness of the night, the ship pierced the sky with its lights, signaling all of the canoe men onshore to get in their canoes to help offload the hundred+ passengers from the ship, and to make some money in the process. Each passenger was charged K150 (about 25 cents USD) to ride the canoe up to the island. It was quite a site to see, especially in the darkness of the night. Even the small canoes cannot make it all the way to shore due to the water depth, so people have to get out in a few inches of water and walk into shore with all of their belongings. The ship also has its own raft that is deployed using a crane onboard the ship to lower it into the water. It certainly was quite the operation! Fortunately, the boat we rode to the island and will ride back to the mainland next week is able to beach itself on the shore, and using a ramp offload its cargo and passengers. I believe I posted a picture of this shortly after we arrived.

I will again commend the following website to your viewing. It does a great job describing many of the things going on at the hospital, the importance of the hospital, and all of the difficulties in operating a hospital in such a location. I think before we left the U.S., I posted a video from this website, but I highly recommend that anyone interested check out the website in its entirety to get a better idea of what we are doing and where we are now both working. http://www.africansteps.org.uk

Until next time, enjoy this blog post and pictures! Next week we should have more frequent updates as we will be back on the mainland, doing different activities everyday. We also have a trip planned to a wildlife preserve near the Zambian border, where we are promised to see elephants, hippos, warthogs, hopefully some lions, and a whole host of other African wildlife. Then, of course, the week after we will return to the U.S., leaving behind the place we have called home for the last several weeks.

Derek with another teacher and two students who have received soccer balls that we brought for them. They will use them starting in September, when the next term starts. All students here are required to participate in the schools soccer (boys) or netball (girls) teams, which play against other schools on the island, and sometime even travel to nearby Chizumulu Island for competitions.

Katherine with a newborn, delivered by C-section.

Someone is getting their first bath!

Derek doing some of his "work."

Learning how to cook on a "local stove," which is what they call these little tin stoves in which charcoal is burned for cooking.

Fr. Jones, the hospital chaplain, celebrating a mass at the hospital.

Derek holding a baby after his first delivery ever! Now he has seen several, including a C-section.

Betha (Katherine's friend from the hospital) and her family invited us for lunch one day in nearby Yofu village

Near the lake in Yofu village

Still in Yofu village

Hiking with Fred, a nurse from the hospital. We climbed all the way to the top of the tallest hill on the island, where the cellular tower is that let's us have Internet! It really has been working well! 

Derek and Fred at Mango Drift, a beautiful lodge on the beach. They are trying to play a traditional African game.

Local kids in a nearby village where we went for lunch with Katherine's God-son and his mother.

Receiving family planning advice/medications from the St. Peter's Hospital.

A woman preparing to give birth in the delivery ward.

Derek being silly at Mango Drift Lodge, "paddling" the kayak with his hands!

Another newborn baby!

These ladies tirelessly do the laundry by hand in this bathtub. The hospital owns a few nice washing machines, but they are not working. Nobody on the island knows how to repair them, so we wait. The same goes with the ambulance boat, who's engine is not working, hence no ambulance boat to take the seriously ill patients to the mainland. And also the x-ray machine, which is new to the hospital, but is also not working. And our refrigerator, the Dean's refrigerator, and the hospital administrator's refrigerator. There is nobody who works here permanently as any sort of a repairman. Only occasionally do men come over from the mainland with their tools and equipment and spend a few days on the island repairing things. Any blog readers want to come repair all of this stuff??

Some local kids holding a baby.