Sweckling: Swedish Heckling

I wrote up some notes while in Malawi over the summer about things I wanted to write about and finally have a bit of time to catch up.

The road trip back to Nkhata Bay for our extended weekend can be summed up in one word: sweckling. Swedish Heckling.

I'm not great at this, but thankfully, T$ and Lebekah gracefully befriended large numbers of random, interesting and fun people while traveling. So, we had a little travel family at Mayoka for the long weekend. Four Swedes, five-ish Americans and a Canadian. Games were played, conversations meandered and everyone was sweckled. As it turns out, Swedes are terrible hecklers. They just don't do it well. We learned that a Swedish version of Jerry Springer wouldn't last. If you assume that the insults, drama and passionate yelling are the primary drivers of the show and consider the sweckling it all makes sense. The Swedish version would consist of people saying things like "Oh...that was not a very nice thing to do to her" or "You are not the nicest of people" or "Please remove your hands from my husband, you pretty adulterer."

The weekend was full of celebrating and honorary citizenship to honor the US and Malawian Independence days. It was amazing how alike we all felt for that short time. The trip offered a much needed break from reality.

Fried mice or dirt piles?

Road trip! This past weekend was a long weekend for us. We were allowed to take Monday (July 5th) off in observance of the 4th of July and Tuesday July 6th is Malawian Independence day so that was a free day as well. We headed back up to Nkhata Bay for a relaxing weekend.

I love driving and road trips. The scenery, the unknown, getting lost, but mainly because you end up twisting through all sorts of topics that don't come up everyday. Generally when you move through life you don't have time to let your mind properly toss around stuff. Though it was hard to decide, I think my favorite was the conversation about whether it would be better to eat dirt piles or fried mice on a stick. Lebekah thought mice on a stick were more appropriate since we were in "mice on a stick land." We agreed on fried mice on a stick. Although, it's either better, or it's worse.

Azungu! Azungu!

I've been running a bit while in Malawi this summer. Mostly, I run loops from the guest house in Lilongwe--a few redundant, uninteresting loops on the main roads. On the rare occasion that I'm able to run with a group, 1-2 times per week, we can get a little more adventurous...especially if I run with people who know the areas well. I've been on a few such runs here. It's provided the best opportunity to happen upon village life and day-to-day tasks.

One run took us through a beautiful, open field on a hill, which was timed perfectly to watch the sunset and then finish up before it was too dark. Monday we had an urban adventure that took us through the best shiggy on trail that I've seen. After running through a developing part of the city, we ran through a part of town where small huts or stone houses seemed out of place compared to the rising McMansions. After turning away from the development, toward the older huts and some fields, we found ourselves following someone (who knew the area well) through cane fields and then onto a precarious looking bridge, based with bags of sugar and maize, then topped with stalks from the field. It wove precariously through the dense cane crop, but only knocked a few of us off the bridge and tumbling into the cane stalks. This was also at sunset.

Saturday was a great running day, although it did require me to wake up at 5:30am in order to arrive and get running by 6:30. By no definition am I a morning person, but the run was definitely worth an early rise. We started out at the extravagant house of our host and ran through the school of agriculture, in between fields that were (unusually) plowed with a machine. The rest of the run took us up and around rolling hills, around hand-tilled fields, through tropical forests, disrupting small villages and clearing a path in the bush. So much variety in a 13k run!

In the fields, we scared and perplexed the farmers. One guy I know said that he asked a Malawian friend of his what he would think if a bunch of azungu (white foreigners) ran through his fields. He said if this happened to him, of course it would mean that he was bewitched. Great. That's exactly what I was going for. (sarcasm) Exercise seems to be a foreign concept to the majority of Malawians, although kids and some adults do play soccer and other games. But running for fun, that's just crazy.

On the same run, while running on the single track path in the forest, we encountered a large vertical group of reeds. As we ran past, the reeds tilted sideways and were turned horizontal as they began to levitate--completely unexpected behavior for plantlife! It scared the shit out of us. A (VERY SMALL) Malawian woman, maybe 4 feet 10 inches, was lifting the bundle onto her head for transport. No big deal. It was at least 7feet tall and 2 feet in diameter!

There were four or five villages that we ran through that day. While it only takes a few minutes to pass through a village, I like to think I can get a feel for the personality of a village using a few indicators. The women. Women will either stop and stare, run away, start laughing or yell out "Hello sister!" and wave. Sometimes these things happen in combination. The men. Men tend to completely ignore us and not make eye contact, stare/glare at us, laugh while clearly mocking us, laugh in disbelief or attempt friendly communication.

The children. Kids are the best. I think kids' the reactions to azungu is so telling; maybe equivalent to taking the pulse of a village. It can provide a lot of insight into the resources, confidence, unity and trust that a village may have. If the kids run in fear or stop what they're doing, go stiff and stare, that village may be hurting. They tend to be the ones with huts in disrepair, the people look skinnier and laughter is an infrequent visitor. We've only scared the piss out of children once (see post from Nkhata Bay and Red Cross rescue!). Some kids think we're the funniest thing they've ever seen. They may run after us until they tire out. Some try to race us! My personal favorite is when little kids bounce up and down, running in place, while laughing their little heads off. Others point, laugh, ridicule, mock and have a great time. Usually, they're yelling "azungu, azungu, azungu!" ...over and over again. They never tire of it. If we're lucky, they'll start singing and dancing to their azungu chants. Villages with kids like these are generally better off. They have time and ability find joy in something simple. They aren't distracted with hunger. They aren't taking a break from working in the fields. Usually, we've just interrupted their play. Usually the reaction is somewhere in between these two extremes.

Proud to be an American?

This weekend was full of unexpected encounters with Americans in Malawi. On Friday, I met Bill Clinton. Yup. Just like that. After a great day, I learned that the hospital would be closing early. All cars were to be cleared at 4p. We initially thought it was World Cup related since it's been a big deal around here and most people arrive and then knock-off early to watch. Not quite. Word spread quickly that Bill Clinton would be on campus to visit the new maternity ward at KCH; the Clinton Foundation funded it and he was in the area...for the world cup in South African and other business...so he arrived in Lilongwe to tour the facility.

A productive meeting with my mentors offered a few good leads for me--ditch the project you don't like and try to be a Clinton groupie. Done and done.



Rita, a former Peace Corps worker in Malawi, is married to Rob, the head of the UNC lab here in Malawi. Rob found out about the visit, let Rita know and she made a sign. Her dad went to boy's state with Clinton. That did the trick. She secured a photo with the former president and graciously allowed us to crash the picture party.

The following day was the US vs Ghana world cup game. At this point, Ghana was the only remaining African country remaining in the World Cup; South Africa was hosting and they did a great job making it about Africa hosting the world cup, rather than only South Africa. From what I can tell, most people in Malawi and other places in Africa were cheering for Ghana. It was a really exciting event for us from the US to watch this game in Africa. If the US won, great. If Ghana won, great. It was a big win either way. Ghana won and everyone in the bar made a lot of noise.

One guy wandered around the bar blowing a horn. He came over to where the Americans (us included) were watching the game and started blowing the horn "at" all of us. It was fine, but after a few minutes, a bit annoying. One American guy in another group pushed the Malawian. The Malawian kept blowing the horn. The guy from the US pushed the celebrating Malawian again...and then again...and then a punch. He was very aggressive--more than was warranted for an annoying horn blower. We cleared out and they fought for a bit until it was broken up. After a "win, win" game, it wasn't the reaction we anticipated. It was a severe contrast from the excitement of meeting the former president the day before and what was expected after the game today. The aggressive American guy's behavior made me embarrassed to be from the US.

Fathers

Sunday was father's day. In Malawi, the role of fathers isn't particularly clear to me. From what I can tell, it differs based on jobs, finances, education, etc...as you would expect.

Walking along the roads or through villages, it's common to see women walking with something big on their head, a female child or two trailing behind (sometimes with something on her head as well), and a baby strapped onto the back of either the mother or child with a chitenje (brightly colored African fabric). The men rarely have babies tied on by chitenje. I've only seen it twice here and it gave me a goofy grin that lasted a good part of the day. Sometimes dads will just carry their kids on the shoulders. This is also rare, but more common than chitenje carrying.

Because I'm interested in working with pregnant women and sexually transmitted infections, father's day got me thinking about the role of father's in STI prevention, prenatal care and child care. A NYTimes article talks about the paternal bonds with children in the wild. Apparently it's rare and it made me wonder where on the spectrum of involvement fathers from the US and Malawi were.

In Malawi, polygamy is still common. It's not always the case, but it appears (based only on non-representative, anecdotal evidence) that it's much more common and/or socially acceptable to have a kudzu-shaped family tree. In Malawi, a study assessing the demographics of guardians (family members who accompany patients to the hospital to ensure their patient gets care in the face of a shocking shortage of clinical staff) found that most were women--including for labor and delivery patients. I'm not sure why. Perhaps it was because the men were the primary bread winners or had moved on or were less in tune with how to care for sick children family members or perhaps for some reason I can't possibly comprehend.

I've heard news of a few successful outreach programs here in Malawi that involve men in the family planning process, although a search for references left me with nothing to confirm this. And there is growing urgency to include men in the perinatal activities since the outcomes of successful outreach programs have been impressive. While I can't authoritatively say that Malawian men are less involved in childcare and prenatal activities than US men, it seems that mens involvement can be increased and can result in a significant shift in cultural expectations if done correctly.

As for men in the US, involvement in child-related and family planning activities can span the whole length of the spectrum. Since the US dads range from deadbeat dad to superdad, and have for several decades, I wonder if there is as much opportunity for change or improvement as a result of their involvement with the perinatal process.

To clarify, I'm not saying that I think US dads don't have any interest in improving or that Malawian dads have a long way to go. It seems the US spectrum has shaken out and there will continue to be men at either end and all points in between. What I'm trying (unsuccessfully) to think through is that Malawi is in a unique place right now. It's open in so many ways to change. I think there's a lot that can be done that will make a big difference in the health of many people here and this research that shows the willingness and effectiveness of men being involved may be a critical leverage point. I'm curious if Malawians can rally behind this idea and make it work. One thing I am sure of...if it happens, it will be slow by slow (pan'gono pan'gono).

Nkhata Bay and Red Cross Rescue

I finally made it to Lake Malawi. For my first trip, I went to Nkhata Bay, which also made this my first trip to the Northern region of Malawi. It was a half day journey from Lilongwe, so we took a long weekend.

The lake is big deal in Malawi. Similar to people who live in states or countries near a body of water, Malawians are dependent on its resources and proud of the joy it brings people. Yeah, yeah...it's a lake. Great. It's a great lake. But this lake is more than just another big lake. It's hard to explain. First of all, it's huge. Wiki says it's the third largest, second deepest lake in Africa and the eighth largest lake in the world. It's also reported to have more fish species than any other body of water. And, it's beautiful. At least in the north, where there are green hills, mountains and cliffs surrounding it. There's something that's peaceful, productive, dirty, yet pure about it...all at the same time. But still, I can't really do it justice.

So we arrive at the lake. The huts we stay in are right on the water. The weather isn't too warm, but we swim and relax anyway. On the first full day, we hope to catch a boat ride in the afternoon, but a friend and I decide to go for a run first. We looked at the map of trails and the description of each path and decide to try the Bulungu Hill path. It's described as a 12k hike that requires water, food, a guide and an early start. Of course, we're running not hiking so we figure it might take us 1.5 hours...two at most. No problem. Well, we got lost. We got lost good.

After about 45 minutes, we stopped running straight uphill and then intermittently ran every so often when we had energy, through villages, planted fields...until we realized we should probably try to start conserving our energy. As it happens, Bulungu Hill might be a bit misleading as a name. I would call it Mount Bulungu or Bulungu Big Tall Ridgelined Hike or something more accurate like that. We were told that the view is beautiful--a 360 degree lookout of the lake and surrounding mountainous areas...if we could find it. We never found it. What we did was walk along the ridgeline...all the way to the other side of the range in search of it. We also were told about an easier way down the mountain back to Nkhata Bay from the top. So we decided to try to look for it. Also never found it. We did find the longer way back to town. The ridgeline took us through a bit of a jungle, down a ravine, along some fields and finally, to a village. As we rounded the bend to the village, we heard voices (the first in ~2 hours) and were excited, relieved, etc. The voices belonged to children playing in a stream. They were not as excited to see us. In fact, I'm pretty sure they probably wet themselves with fear.

Our encounter went kind of like this: We round the bend, saw the kids and wave. They froze. Then they stared at us for 30-45 seconds. Their faces turn from frozen surprise to fear. Then the wailing started. So much wailing. I had no idea two little kids (maybe 3 and 4 years old) could conjure so much noise! We waited and let them find their parents and safety. We debated what we should do next...we certainly couldn't turn and head back the other way to avoid meeting up with the parents of these kids since we had been wandering for a total of 3.5 hours at this point. So we had to follow them through their village and face the wrath of an angry mother.

We were first properly greeted.

Woman: "Hello, how are you".
Us: "Fine thank you. How are you?"
Woman: "I'm fine, thank you".

Us, to each other: "Maybe we'll be ok. Hopefully she's not too mad".
Us, to the woman: "We are sorry. We were walking and were lost. We are so sorry we frightened your children."
Woman: "Azungu! What! AZUNGU! You make the baby cry SO much! Why you make the baby cry so much! Give me money."

It went something like that. We managed to escape, make our apologies, see the children calm down and learn which direction we should take to Nkhata Bay ("that way, but very far"). Once we finally found a dirt road, we were very excited. From the dirt fire road, we were able to see that we made it to the other side of the "Hill" and there was no sign of the lake. That killed our excitement, until at about hour 4, a Red Cross truck with a truck-bed full of teenage boys came cruising on by. They stopped and asked us where we were going--not the same place as us, but they offered us a ride back after they dropped off the boys in the back of the truck. Hooray! Great.

Our excitement returned...and it grew! The Red Cross truck was on a community outreach visit. The teenage boys in the back of the truck were HIV peer counselors who had just done an educational intervention in some villages that day! It gets better. The nurse that we spoke to in the cab of the truck, upon hearing we were from the US, announced that he wanted to go to the US to study Epidemiology! It was the perfect rescue. We exchanged contact info and while I may not be able to do much for him, will try to help him through the application process.

We missed the boat ride from Nkhata Bay, but had a great time that night and the next moring before leaving. We failed, spectacularly, to complete the Mayoka Challenenge (2 people rowing a dug-out canoe from the patio around the floating dock, without falling in). Both of us were only in the canoe simultaneously for about 30 seconds!

Ntchisi

On Sunday, we all piled in the Toyota Ipsum for our "church van"-like trip to Ntchisi rainforest in central Malawi.

Since driving in Malawi is equally as safe if you drive with your eyes open or closed, I drove slowly so we took a leisurely 2.5 hours to get there and back. For me, driving through the villages was just as fascinating as the hike. Once we escaped Lilongwe city limits and turned off the paved roads, the views were beautiful...shades of green and brown grass blowing in the wind. There were villages nestled in valleys and on hilltops and people walking back and forth transporting water, crops, chibuku shake shakes and coca-cola on top of their heads and by bike.

I was driving, so didn't get a chance to take a picture of a village with the most beautiful water pump; it had a view from here to forever. It was surrounded by lush bushes with lively yellow flowers. The children took a break from their washing to wave to the eight Azungu women driving past in a badass minivan. I guess I don't need a photo, the image will last.


Once we finally reached our destination, we stopped at the Ntchisi Forest Lodge to check in with the owners, find out what they offer and borrow a map to guide us through our hike. After a great picnic that Amy organized, we headed into the rainforest; it was beautiful. Mo led the crew through some twisted ficus trees, funky moldy clumps and by the largest banana tree any of us had seen.

Timica and I stop to celebrate the view after our successful ascent! When we emerged from the rainforest and cleared the ants from our pants, we headed back to Ntchisi Forest Lodge for some refreshing drinks. The current owners bought the place about three years ago and have been tirelessly fixing it up. It's a gleaming white structure with a beautiful layout, wind and solar powered facilities and views of Lake Malawi and the Mountains across the lake in Mozambique! This picture doesn't do it justice.

Indirect Effects

Before I decided to do a PhD in Epidemiology, I struggled between a clinical or public health degree. Being an epidemiologist might not be the best way for most people to feel like they're making a meaningful contribution, but I knew I wasn't cut out for day to day patient care, mainly when I realized it was frowned upon to invite every patient home to personally oversee their improvement. I also tried lab science and healthcare policy and found them to be more removed than I wanted to be.

Why epidemiology? Yes, it's mainly a methods based discipline which can be as far removed from direct patient care as you want it to be. On the other hand, it seems to be a field where non-clinicians can learn about clinical care and help patients, or at least help clinicians to help patients. It also appeals to my desire to collect, organize and interpret information. And, (don't judge) I like coding.

As a non-clinician, non-native working in Malawi, it's tough to know what's important. What can I do that will a) be useful; b) help; and c) not offend anyone.

The pace. In addition to not knowing where to start, once you make a decision to proceed in one direction, it takes awhile. You have to talk to a lot of people, set up lots of meetings, go through the motions and try to (clearly) explain what you think you want to do. Not a terribly easy task.

No matter what you do, you end up wishing you could do more.

Afri-CAN Cafe

http://theafricancafe.org/

I’m sitting at a café, typing away, enjoying some coffee on a beautiful day under an awning in Malawi. AfriCan Café is a non-profit, cooperative coffee shop made. They’re new to Lilongwe. Right now, they are only in Lilongwe, Malawi and opening soon in Blantyre, Malawi. Soon they will be found in different cities throughout Africa. It’s a little surreal.

The hospital is surrounded by gates and guards, with many sick people floating around the gates and others being treated inside and at other buildings around the hospital area. I can’t imagine many people come for coffee and pull out a computer to sit and write. It feels wrong--out of place. I wouldn’t have done it, but I managed to get what I needed done much earlier than expected (which is incredibly unusual) and now I have time to kill before my next meeting…in an hour. So, I’ll work until my computer battery dies.

The new maternity ward seems out of place too. It’s very nice, but there are buildings in disrepair and out of use surrounding the new building. Given the amount of people who are poor and in desperate situations nearby, I was initially unsure how a western-sty cafe would go over among locals, but as far as I can tell, the idea of a cafe has caught on pretty quickly. Customers are mostly hospital workers not patients and not the average Malawian. I feel a little guilty, but it is a treat.

Bottom hospital

I arrived at Bwaila (bottom) hospital in a giant truck. It seemed out of place. As my colleague opened the door on her way to work, I heard singing. Many, strong, voices singing in unison in the call and response format that defines the African oral tradition. It's beautiful. I asked the driver who was singing and for what. The women sing every day, he says. They learn how to take care of their babies. They learn about labor, delivery, nutrition, family planning, etc. And then they sing about it. Every morning. Half seven.

And then they wait. Lots of waiting.

Malawi has one of the world's lowest physician-to-patient ratio. The numbers aren't clear, ranging from 1:50,000 to 1:10,000 depending on how "physician" is defined; Malawi uses trained nurses, clinical and medical officers to provide the majority of care. It lacks the capacity to offer medical residency training to prepare new physicians. Many positions are unfilled and other still are underfunded. So the women and all the other patients will continue waiting. Waiting in line, waiting for an answer, waiting for care.

Diagnosing my perspective

As I sit here in Malawi reading this article in the NYtimes, I feel lucky to have no other health, financial or family issues. I'm lucky enough to leisurely read about the urgency of an objective test to evaluate ADHD.

Most mainstream researchers consider A.D.H.D. to be an authentic neurological deficit that, left untreated, can ruin not only school report cards, but lives. Nonetheless the quest for objective evidence has gained new urgency in recent years.

Many critics say the disorder is being rampantly overdiagnosed by pill-pushing doctors in league with the drug industry, abetted by a culture of overanxious parents and compliant educators."

Having just wandered through the wards at KCH and Bwaila for the first time, which were teeming with broken, ill and tired people...waiting for hours, the language used in this article appeared to be unnecessarily sensational at first. How can they be concerned about over-diagnosing ADHD in the US when there are so many people in need HERE!

Then I thought about it a bit more. It's a big issue in the US. As far as troubles go for what we're used to dealing with in a developing world, it's something that needs to be examined and made right. Who am I to assign worth to a condition that affects many people in the US and is a complicating factor for education and health resources. It's a burden to our healthcare system and that makes it important.

In fact, the underlying problem--establishing an objective diagnostic method for a difficult to diagnose disease to avoid over treatment--is a major issue in resource-limited settings as well.

In the US, over-medicating kids for ADHD is an imprecise solution to a difficult to characterize problem. In Malawi and other resource-limited countries, TB is difficult to define and diagnose so presumptive treatment is often the solution. Even with an accepted threshold of CD4 counts precisely measuring values is difficult here, which in turn makes the decision to initiate HIV treatment fuzzy.

Since healthcare provision is lacking in different ways in both countries, it's easy to compare and get frustrated with the US prioritization of resources. The diseases are more severe in Malawi, the life expectancy much shorter and the remedies are known and proven in other places (provided resources are available). It's frustrating and really easy to question the ridiculous diagnostics ordered to resolve noncritical health problems in the US. But, I have to keep it in perspective.

While the target may be different, the problem is similar.

If old then happy?

After reading a review of the results from the National Academy of Sciences, also from NYT, I immediately had to look up the findings to identify the comparison group. The population, objective and results from the study weren't clear.

The title of the Times article is "Happiness May Come with Age, Study Says". Did this study compare results from the same people from several years ago with current results? Did they only ask the question once of people of all different ages and find a generational difference in happiness? Could the NYT have presented a misleading picture of the results?

The times reports that "...by almost any measure, people get happier as they get older...". The problem is HOW this study was presented. From this description, I'm led to believe I'll become happier when I age, but first it will get worse until I reach age 50:

On the global measure, people start out at age 18 feeling pretty good about themselves, and then, apparently, life begins to throw curve balls. They feel worse and worse until they hit 50. At that point, there is a sharp reversal, and people keep getting happier as they age. By the time they are 85, they are even more satisfied with themselves than they were at 18.

In measuring immediate well-being — yesterday’s emotional state — the researchers found that stress declines from age 22 onward, reaching its lowest point at 85. Worry stays fairly steady until 50, then sharply drops off. Anger decreases steadily from 18 on, and sadness rises to a peak at 50, declines to 73, then rises slightly again to 85. Enjoyment and happiness have similar curves: they both decrease gradually until we hit 50, rise steadily for the next 25 years, and then decline very slightly at the end, but they never again reach the low point of our early 50s.

Maybe I'm reading it wrong, but the way I read it, it sounds like they followed people over time and evaluated their happiness from age 18 to 85.

But...these aren't the same people. What if the difference in happiness is generational, rather than a generalizable age-based trend. The ones who are satisfied with themselves at 85 may have not have scored the same when they were 18; it would have been 1941. If this same Gallup pole were done in 1941, we may have seen a very different picture.

Also, 2008 was the height of our recent economic crisis. Maybe people at either end of the age spectrum, who answered the phone for the Gallup pole, were less affected by the economic crisis and less stressed about it than those in their 40's.

For selfish reasons, I can't get too mad. When the details of the study design are ignored and results presented in a way that implies an impossible study design, I'm prompted to read things that I generally wouldn't get around to reading. And, I end up reading papers more carefully as a consequence.

For unselfish reasons, I wish the media was able to properly represent study results and entertain their audience.

OK, so I'm sure you get my point by now. Yes, there are flaws to this study (as with any study), but I like the idea. So. Let's just say people get happier with age. I'm hoping there's something to look forward to. What I want to know is...how?

Based on a systematic evaluation of no information at all, I FEEL like they get happier by moving in one of two directions: a) they find a routine, settle down and putz about in the comfort and familiarity of their daily doings; or b) they get more relaxed and adventurous--letting down their guard and escaping the worry of keeping up with the day to day. Both directions result in happiness. Not a bad deal.

For me it's interesting to see what happiness or stress is to each person--how the same experience might be are stressful to some, but adventurous or fun to others.

Mis-information dissemination

Lilongwe has a new parliament building. Last week I asked someone what she thought of the new parliament building. And then someone else told me something else. And then, it became a thing to ask. I never expected what followed. The parliament building was built by chinese prisoners? It was a gift from the Chinese in exchange for uranium? Malawi had the building built to attract business and foreigners and is now indebted to the Chinese three times over. And the list goes on....

Everyone seems to have a different idea. Some say they used some Malawian workers, but some say they didn't. It's surprising to think that in a poor city in a poor country the Malawian government would introduce a new population strictly to build an elaborate new government building. Is there a lack of skilled workers in Malawi? Are the Chinese more in need of work? Are they more trusted to complete the job than local workers? It could be anything. I just don't understand.

A brief google search revealed the following: In support of the UN One China policy in 2007, Malawi changed its alliance from Taiwan to China (apparently there used to be a large Taiwanese population in Malawi that was suddenly replaced with a large Chinese population). Building the parliament building cost 40 million USD. The People's Republic of China funded the endeavor along with a road, future five star hotel, future national stadium and future science and technology institute. The parliament building was completed in 13 months--five months ahead of schedule. The cited motivation behind the parliament building seems a little dubious--it was explained as a gesture by China to support Malawi for their allegiance.

With such conflicting information circulating about one of the biggest, most imposing, well-known structures in Lilongwe, it becomes more clear why information dissemination is so difficult for more nuanced topics.

Fresh Start

Today was a good day. Went to my first Malawian market and made it out with my ass being grabbed only once! I'll write that off as a success. I love the markets here. It's easy to be overwhelmed by the activity and swarms of people, but there's so much color, smell and life!

I was able to get some of my work started, although much less efficiently than usual (which isn't saying much!). One of the others here is leaving in five days, so she cooked a grand feast for some of her friends and co-workers that she's met here. The food was fabulous! It was also nice for me since I was able to meet a few locals and get to know the other people who have been living here a bit more.

Inaugural visit to the UK

Inaugural visit to the UK--15 hours. Thanks to Ian and Carole, I now have a fiercely favorable impression of the UK! It all began when I told Alan that I'll have a ~15 hour layover at LHR; he informed me that his brother and wife (who didn't know me) would be happy to retrieve me from the airport and show me around. And they did.

We started with toast and coffee. I went for a nice run through Sunbury park and around the neighborhood then back along the Thames. After a refreshing shower in a closet cleverly designed by Ian, we headed to Kingston (where Ian and Alan grew up) for coffee...along the Thames an a boat! Although the day started out a bit overcast, windy and cool, the sun came out around noon and it warmed up to ~70F.

From Kingston, we backtracked to Hampton Court.

There we saw the beautiful gardens; wandered around the castle; got reprimanded by a security guard, who seemed happy to have a reason to interact with people; and admired the world's largest vine (which had already begun to fruit!) that was apparently growing when the infamous Henry VIII occupied the place.

Jeannie (their boat) provided a lovely setting for Ian and Carole's tour de la Thames...past narrow canal boats, extravagant house boats, tiny island cottages and beautiful gardens!

Common Threads: After our boat ride, Carole had me in stitches as she gave me the long and short of how random community members were united to create an embroidery display to represent their town for the year 2000. As she filled me in, it became clear that this project provided a great introduction to their tight knit community. All sorts of people, who would never normally find themselves embroidering, were engaged in this project...including a former General Secretary of the Trade Union Congress (also a member of embroidery gang); he entertained us with a story as we had tea at the Walled Garden.

Seeing Carole's embroidery project and her subsequent encounters with sundry Sudburians got me thinking about community. People in the community with very different skills collaborated on this project and once it was completed, continued give back and make their community a better place to live! How great is that? While they've chosen embroidery to sew the seeds of community, it really could be done in any medium. Anywhere.

It begged the question: why do I want to go all the way to Malawi to "do good things" when a simple, well-integrated, community based initiative could achieve the same desired effect--helping people to make a difference in their own community.

This is probably something I'll struggle with regularly during my time in Malawi, or at least I hope I will; it might look something like this (though surely not as graceful as this horse statue at the Walled Garden).

What are the benefits and limitations of public health efforts at different levels--global, community, policy, lab and individual? How do you identify the "right" level for intervention for desired outcomes? Well, maybe there isn't a "right" level. Or a "right" anything. I'd settle for figuring out which levels require intervening for each issue and which interventions are effective. For personal gratification, I clearly don't have to go further than my own community. Now...if only I could convince everyone else, in every other community to do the same!

I should have packed less

I should have packed less.

That's right. I'm going away for the summer and I have too much stuff. And of course, as my travel plans go awry all I can think about is how much crap I have to lug around and what have (temporarily) lost.

Ridiculous extras include:

1. Food: I'm bringing along a lot more food than I ought to. It sounded like a great idea once upon a time. I'll let you know if it was worth it. So far, it's saved my acidic, dehydrated stomach from getting too angry with me after sleeping through two meals on the plane.

3. Books. I'm taking a lot of books as I expect to have time to read at night when I'm too tired to work. I haven't been a good reader for awhile so one of my goals is to make this weight worth carrying.

4. An extra computer. I'm sure this is ridiculous to most of you, but in order to be productive, I'll probably need to have something to entice me into working...like watching shows while managing data. That's the theory at least. I hope it pays off!

5. A little bit of crazy--this is really weighting me down (see #2...).

Assumptions

Do you know what happens when you assume? I do. But, I'll do it anyway. Assumptions are an integral part of an epidemiologist's tool kit. As I won't strictly write about epidemiology, I'll start this blog thinking about the major assumption I made when I decided to create it...that someone will read it.

I decided to start writing because: 1) I love to write and I'm getting bad at it; 2) for my first international work experience, I'm going to Malawi and people wanted updates; 3) I'd like to be more in touch with my favorite people; and 4) I have a lot of opinions and need an outlet.

Writing for an invisible online audience requires making quite a big assumption. It feels a little indulgent too...might I actually have something to say? Will people want to read it? Will they care? I'll spare you the anticipation. Ultimately, no. There will be nothing of consequence written here...well, not on purpose! But...as all bloggers do, I'll make the assumption and proceed.