Thursday July 7, 2011

Monday July 11, 2011

Tuesday, July 12, 2011

Monday, July 18, 2011

Thursday January 29, 2009

Friday January 30, 2009

Thursday February 5, 2009

"We drove to Luchenza in Thyolo and stopped at the microfinance office where we met with Michael Nampanda, the Project Officer, Feston Mbera, the accountant, the new credit clerk Hardwell  Kapasuka, and Esther Munyawa who also works on the accounts and serves as a credit clerk.

After our meeting at the office, we went to the field to meet with two groups of women.  We met with the first group at a primary school.  I was impressed with this classroom, which had desks, and was attractively decorated with hand-made maps of Malawi, charts about supervision and interviewing techniques.  Maybe a standard (grade) 7 or 8 classroom that prepares children to enter the workforce since so many kids finish school at standard 8 and start work?  The maps and charts and other things in the school room showed a lot of creativity on the part of the teacher because they were made with very simple and mostly recycled materials.  So many classrooms in Malawi don’t even have desks, and you rarely see anything on the walls.

The clubs we met with were Chisomo, Tawomboledwa, Tisaiwale, and Mwanalirjeri clubs. In total, about 30 women came to the meeting representing these clubs.   These are clubs that have paid back their loans on time and qualified for second and third rounds of loans.  We asked the women what had been the impact of the loans:

Katherine: She explained she had taken the loan because of the poverty in which she lives.  Her business is in trading of dried fish which she buys in Mozambique and then sells in markets in Malawi.  She travels to Mozambique by minibus, and conducts her business 2 days per week in the markets in Malawi. When she travels to Mozambique, she can be gone for 2-4 days. Her husband looks after the children when she is gone.  She started trading small fish, but now has moved on to bigger fish.  She has been able to build herself a new house with the profits over the past 8 months, and it is in the last phases of construction, she needs to buy iron sheets for the roof. She paid the builder MK 12,000 ($80) for his work on the house.   She is married with 3 children, ages 9, 4, and 13 months. The two older children are in school, and with her profits she has been able to buy shoes for the children.  She has made MK 30,000 profit from her business (~$180 US).  She is very pleased with the program and plans to take another loan in October, after the house is finished.

Eness: She belongs to the Tawomboledwa club. She is also married with 5 children and she takes care of  2 orphans in addition. Her husband has work, and so her income supplements his.   She also took the loan because of her state of poverty.  She trades in beans, also buying them in Mozambique and selling them in Malawi, using a minibus to get there.  She has paid her children’s secondary school fees with her profits and bought them clothes.  Two of the children have now finished secondary school and are taking their “O Level” exams (like a high school diploma in the US). She said she had really been helped by the loan, and she hopes that GAIA will consider making larger loans to the women, because she feels she can handle the increased amounts and the larger loan would bring her greater profits.  She tries to save at least MK 500  (~$3) each month from the loans to build up her savings.

Rose: She belongs to the Mwanalireji group. She has 8 children, ages 6, 9, 11, 12, 14, 16, 18, 23. All of the school age ones are in school.  She trades fish and new clothes which she sells at the nearby tea plantation, going there 2 days per week.  She uses the profits for school fees.  She feels the loans have benefited her family through the products she is able to get for her family, especially food, soap and clothing.  She has two children in secondary school (high school), forms 1 & 2 (grades 9 & 10). 

Chrissie: This woman was very enterprising.  She grows broilers, makes doughnuts and sells them, and has a hair salon.  She started with 25 chickens and now she has 100.  She uses the chicken manure to fertilize her garden. 

Elina: She is an older woman and a widow. She cares for one granddaughter who is a teenager in form 3 (grade 11).  She trades rice and makes cushion covers. She brought some for us to see. She sells a set of six covers for MK 4000 (~$25).  She does the hand smocking work on them herself, and then hires a tailor to finish the covers and turn them into a finished product. He charges her MK 90 (~50¢) to finish each cushion. She would like to get a larger loan because she could buy more materials and turn a profit more quickly, or buy more rice to sell.

I asked for a show of hands, and all together about half of the women gathered  (15) had spent their profits on secondary school (high school) fees. (High school is not free in Malawi). Seven of the women had established their own bank accounts at the local bank.  Only about 5 of women manufacture a product, the rest are in trading.   Several women requested that loans be increased to MK 50,000 (~$300). All groups noted that they had eliminated members who did not pay repay their loans. 

We asked about what happens when a member dies. There was a lot of murmuring and discussion among the women at this point. It was clear that they were very unhappy with the fact that a group would be required to pay back the loan of someone who died, and especially so if it meant the family had to use condolence money to pay off the loan.

"Driving out to where this clinic operates took quite some time, over an hour. You go through Mulanje BOMA, drive around 20-30 minutes to the trading center at Mwalamulanje (which means the “Rock of Mulanje”). The trading center sits at the foot of a particularly rocky prominence of the mountain.  It was another 40 minutes or so out to the stop for the clinic which was held in a little church. 

I sat with the Clinical Officer and watched as a number of patients came through for treatment:

C.: 8 years old, in Standard 3 at school.  Had fever and was visibly shaking.  She tested positive for Malaria. This was the second time she has had it in 3 months.  She had been treated at GAIA clinic last time.  I asked her mother if she understood how malaria is transmitted. She replied that it came from mosquitoes. I asked if C. slept under a bednet, she said no. The family does have one net, but that is used by the mother and under-five children, who take priority because their malaria is more life-threatening to them.  The mother told me a net costs too much (they sell for around $5-8  in shops), and she cannot afford one.

Girl in a head scarf: this girl looked much younger than she was at 14. She was also positive for malaria.

Boy, 14 years old had impetigo, a skin infection which will be treated with antibiotics.  He came with his cousin.  I asked how far he had walked and it was about 2 km, not so far for him.

Another small boy about 5 had otitis media.  He had a runny nose and was coughing.  The C.O. used and otoscope to look at his eardrum.

Another young preteen boy came in with asthma. He was treated with solumedrol and aminophylline.  I asked Alice to ask him about how food was cooked in his house. It is cooked on an indoor fire, but he said that part of the house had no roof so the smoke can go out.  Still, I wonder if the house gets smoky and aggravates his asthma.  I didn’t ask too many more questions, and as it seemed that he boy, who was on his own, seemed a little scared of me and looked anxious, like maybe I was going to say he couldn’t have the medicine. I thanked him for talking to me.

Another mother and small child (8 or 10 months) came in with fever and vomiting.  The malaria test was negative, but the CO thought he had some kind of sepsis (infection) and prescribed amoxicillin.  I asked the mother if she had been to the clinic and she said that been here last month. She lives close, only 1km away.  I asked her why she uses the clinic. She said because the services are available, medicines are in stock, and she is attended to in time. 

Another woman with a 2 year old child, the child had pneumonia, which is a major killer of children. She had walked 5 km with the child to the clinic. The child was treated with an antibiotic and panadol for the fever. 

Another child with malaria has walked over 5 km for treatment. She tested positive for malaria. She has a bednet, but it has holes. 

A 20 year old mother came with a 4 month old baby who had a fever and coughing. She was negative for malaria, and the CO diagnosed bronchitis. She was treated with antibiotics.  

A young 11 year old girl feverish with malaria had walked in from 2 km away. She was accompanied only by her 4 year old brother, who served as her “guardian”. The child lives with her mother, but the mother was not well and could not escort her. 

A mother with a 10 months old baby with an infection was prescribed Bactrim and paracetomol. She lives in Blantyre but had been visiting with her parents in the village while on holiday. Her child had fallen sick and her parents told her to bring the child to the clinic. 

The last two patients I saw come in before we were left were two boys, L. and F. They were about 11 or 12 and both had Bilharzia (Schistosomiasis). They had walked about 1 1/2 hours to get to the clinic (approximately 8 km).  Biharzia is common among boys in this region because they swim in the rivers more than the girls. 

I asked one mother how many meals a day they eat, and she said 3, but this is unusual.  Alice asked more patients this question, and the general consensus was that they have 2 meals a day, one about 1PM and another later in the evening around 6 PM.  Breakfast is not eaten.  Most school children attend school without eating breakfast. 

GAIA Villages

We went to visit a home based care patient in the original Mulanje A village group.  Mr. M. is a 35 year old man. He has 3 children. When the caregivers came into the village he was still very weak, and unable to do any normal activities at home. They found him coughing with symptoms of TB and he tested positive.  He was treated for this, and tested for HIV and found positive. He started on ARVs (antiretrovirals). The caregivers convinced his wife to be tested as well. Fortunately she was HIV negative and a recent repeat test shows she has stayed that way.  As GAIA prepared to exit this group of villages, he asked to be a beneficiary of the goat program, which is part of the exit strategy.  By then he was strong enough to build a corral for the goats, a requirement to be part of the program. 

He was given 2 female goats, and got to choose them himself from those on offer from local sellers.  The boer goat (male) is now with the females since they are in season. One goat has already been impregnated, and appears to be carrying twins (as is often the case). Once the second female is found pregnant, the boer will be moved to another pair of females to service them.  Once the kids are born, the females are passed on to another beneficiary. The reason for this is that the next beneficiary will check to make sure that the original beneficiary is caring for the goats properly, because he/she has an interest in seeing the females remaining healthy.  The goats can be bred for about 5 cycles.

Next we visited an HBC patient named Mrs. W. She is also 35 with four children, twins age 17, and an 11 and 3 year old. This woman was just brought into the program. She appeared very sick and weak, scared, a little frightened of me and sad. Her guardian was a very frail old woman.  Hopefully, once she has been in the program a while her health will improve and she will come to trust the caregivers. 

"I have described the goat pass on project above, and today I went with GAIA staff to actually purchase the goats and transfer them to beneficiaries. 

We arrived in the village where the goat sellers were gathered. They sell the goats for MK 4000, 4500, or 5000, depending on the size of goat whether small, medium or large.  The beneficiaries have already met with the sellers and agreed which goats they want to buy. Only female goats are exchanged.

One of the exit strategy coordinators sat on chair and each pair of buyers or sellers came to her. They parties agreed on the prices for the goats and the seller was given a voucher to collect the cash.  The beneficiary left with the goats right then.  The sellers entered the church where the Gladys, GAIA’s accountant,was set up with a large bag filled with cash, since all transactions in remote village areas occur in cash. ( The largest bill in Malawi is the 500 Kwatcha note which is only worth about $3, so all transactions of any size involve large wads of bills.)  Two plain clothes police men were hired for the day to guard the Gladys and the cash and stood on either side of her in the church.  A group of sellers from one village entered the church and selected a representative from the group to sign off for the cash received by the group.  Each seller presented his/her voucher and received the cash.  Then the voucher indicating what the group as a whole received was signed off by the chosen representative.  The individual vouchers serve as the detail for this payment.  It all proceeded in a very orderly way and I was impressed with the efficiency of the process.  I got lots of pictures, but I wish I could have captured the sounds of the day. Goats have remarkably human like cries, and it was like being in a big pack of children all day. The beneficiaries were delighted and excited at finally getting the goats.

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Notes on antiretroviral (ART) Training Wednesday July 13, 2011 at Chichiri Lodge Blantyre
I watched a session taught in the morning by a trainer named Musa Mwenechanya who is a Clinical Officer.  He taught back and forth in English and Chichewa which is good. Most of the faculty (tutors) speak English very well, but some are more comfortable in Chichewa, and so reinforcement of concepts in Chichewa is helpful. In the afternoon Lyson from the MoH taught the monitoring and evaluation component and he was excellent. He had a very lively, clear lecturing style and you could see the participants really enjoyed him.

At lunch I spoke with several of the tutors (faculty members) taking the training.  I spoke with one from Kamuzu College of Nursing (KCN), one from St. Luke’s Hospital School of Nursing, one St. Joseph’s, and another from Holy Family in Phalombe.  These are CHAM institutions that train nurse midwife technicians (NMTs)  The one at Holy family explained that government service contract covers all referred patients, but then there have been problems with the contract and the government has not paid enough to support hospital costs.  This has meant they are only taking maternal and child health patients and the other wards are empty except for a few patients who are able to pay the fees. They have to send students for clinical training elsewhere.  Also, because the two years ago the government stopped subsidizing CHAM students for a period of time, their  2nd year class of students is only 17,  while first year is 58 and  the third year is a similar size. 

Later on in the day, another trainer taught about  second  line ART regimens and adherence issues.I was impressed that he talked about the importance of developing rapport between patients and providers.  He commented that the provider needs to discover the reasons for non-adherence and individualize a plan for each patient.  For example, you need to find out when it is that the patient misses doses.  If it is on the weekend, when their regular routine changes, you can help them construct a good way to remind themselves on those days. 

At the trainings, the participants are asked to fill out evaluations.  I looked through the comments and Beth will log the quantitative data which looked like people were very satisfied with the training.  Some comments that were written on the trainings:

“The knowledge gained will assist me to deliver the correct and accurate information to students on PMTCT (prevention of mother-to-child transmission) and ART (antiretroviral therapy)”

“The day was well organized by our facilitators.  Congrats.”

“I do appreciate for the refunds and allowances, never expected it.  Participants should not complain of money, as they are being empowered.” (This was interesting in light of the fact that that some participants had complained they were not getting more in terms of per diems or meal allowance—this is a common problem that NGOs encounter).

"We met with a group of about 40 KCN first and second year students.  I asked them to tell me about the GAIA scholarship and what it had meant to them:

Hilda, a 2nd year student told us that she loves interacting with patients, seeing them go home well, and takes satisfaction in knowing she helped that happen.  She says she feels pain when a patient dies and has to learn to deal with this.  She says a particular challenge is having to deal with inadequate equipment and supplies.

Ruth in her 4th year enjoys working with teenage mothers and helping them with the specific challenges they face.  She also talked about the lack of equipment available in hospitals.  She noted that “the theory is a little different than what we see in the hospitals.  We have to improvise all the time.”  She says what is hard is when a client dies. She wonders what went wrong and sometimes she feels guilty and wonders what she could have done.

Vivian is a second year’s master’s student.  She got her first nursing degree in 1987. She spent 11 years in clinical work at a government hospital and got frustrated that she never got a promotion. She then worked for a private hospital for 10 years.  She has two sons who are in school and she must pay their fees.  She is very grateful for the scholarship, because she said that although the ministry used to sponsors master’s students, they no longer can. She knew she needed a master’s degree to progress on her career path and wondered how she would ever be able to afford to go back to school. She simply couldn’t do it and provide for her family too.  She said the scholarship has made her life so easy, and she is able to work hard on her studies for the program. It has “allowed her to use this chance to the fullest.”

Ellen is a 2nd year student. She travelled 4 days to come to school and start the program. Her parents worried how they could afford school for her and she was worried too about how she would afford it. But when she got the letter to come to KCN, her parents encouraged her to just go and see if somehow it would work out. She applied for the GAIA scholarship and got it. She said “this has made my parents free, they were so worried about how I would be able to do this.”

Mary is a first year masters student and earning her M.S. in midwifery.  She was so happy when she did well with the interviews at KCN, but wondered where she would ever find the money for the fees.  She said “really, the scholarship has shown me that the Lord is good, all the time. Our people need our care.  Knowledge is power, and here we learn that with knowledge you can really perform well as a nurse. I want to thank GAIA for the benefit of being sponsored.”

She is doing her dissertation on prevention of antenatal malaria. She aims to find out what expectant mothers understand about malaria prophylaxis and whether they take the 2 doses of Fansidar as recommended.

Martha is a second year student.  It turns out that she was one of the students that GAIA sponsored at Likuni Girls School.  She graduated and did well on the exams. “Sister Chipungu encouraged me to go to University and to pursue nursing.  I am very grateful to GAIA for helping me. I had no one to support me.” It was just great to see that one of our secondary school students is now in the NSF program.

"I spent today with mobile clinic A. We headed out a dirt road about 30 minutes to a clearing with a building that the community built for home based care classes. This is used as a site for the clinics. It has a large room where the patients wait and are seen by the Clinical Officer (C.O., like a physician's assistant in the US). The under-fives are seen in their mothers' laps and if the C.O. needs privacy with a patient, he moves to the corner behind the screen.

"The mobile clinic nurse sees patients in a separate small room attached to the building where she performs ante-natal checks and does HIV testing. A 55 year old woman came for testing. She has been having chest pains that were not responding to antibiotics and feared she may be HIV positive. She permitted me to watch the test and said I could photograph it being done. I was impressed by the nurse's manner with the patient. She had a very gentle and quiet way and listened closely to all that the patient said. You could see how this built the patient's trust. This time the news was good. The patient tested negative. Her joy at the news was palpable, and I felt touched to witness this good news with a woman so close to my own age. She will continue on the antibiotics for another week and return if her chest pain is not resolved.

"Outside the building was the medication box and a small table for dispensing medications and teaching patients about their treatment. I have described this process in detail in my notes on the clinic we saw the next day. The same process is used by both clinics. The nurse aide assists the nurse with dispensing medications and helps with other general go-fer type duties. They see over 100 patients every day, and some days as many as 150. They can process so many because some women coming with children only need a weight check to assure the child is growing.

"Even the driver gets involved, helping to triage patients so the sickest are seen first.

"The vehicles themselves are used to transport the crew and equipment to the sites and then for transport of severely ill patients to the health center for emergency care. Several times they have had to transport children who are having seizures secondary to cerebral malaria.

"Each of the clinics has five different implementation sites in the catchment areas. The areas were chosen after Alice spent 2 days touring the district with the District Health Officer who pointed out and chose areas with the poorest coverage by the Ministry of Health facilities. For example, the implementation site I visited today is 10.7 km from the nearest health center, 2-3 hour walk. The clinics rotate through the sites, Monday through Friday, so the villagers know that the clinic will be at a particular site, for example, every Monday. Churches and community buildings serve as sites.

"The biggest challenge is responding to the overwhelming number of patients. Originally they thought they would be treating 50 to 60 patients a day, but they often treat three times that number.

"We also visited the Mobile Clinic A office located in a centrally located small town, The district health officer required that each vehicle have an office for security of medication storage. It is a pleasant building with two large rooms and secure storage for medications and supplies. They showed me the drug inventory procedure. They place their order for medications with the GAIA the project officer; the medications are logged in as received at the office and then noted as dispensed to the clinic when they go out each week. The balance remaining is noted on an inventory sheet each month. Some supplies and medications, for example TB sputum cups, are provided by the DHO.

"The office has a computer for data entry, although there is no internet connection. Staff members are learning to use the computer and doing quite well. The project officer collects the reports on her bi-weekly supervision visits using a memory stick. The vehicle itself is parked on the grounds of the nearby Mulanje district hospital at night and on weekends to assure its security.

"In the afternoon, we visited 2 Home-Based Care patients in the GAIA villages. The first patient we visited was 35, painfully thin, and lying on blanket on the little mud porch of his hut. His mother was with him. The patient had been a casual laborer, working in Blantyre, when he collapsed on the job. Earlier, he had been diagnosed with TB and was on treatment at the time of his collapse. He was diagnosed with Cryptococcal meningitis; his neck was frozen and his legs were paralyzed. He was found HIV-positive. His wife left him and kept his two children. He returned to the village where his mother is his main guardian. A friend helps him get to the hospital when he needs treatment. He is also on antiretovirals, and his health is slowly improving. He can now walk but is extremely thin. He said he appreciates the daily visits by the caregivers and the help with household chores, especially getting water.

"Then we visited a young woman aged 25, and her husband, who is 31. The woman had developed swelling in her legs during her second pregnancy which she thought was due to the pregnancy. It didn't go away after she gave birth and she was diagnosed with Kaposi's Sarcoma and found HIV positive. It is likely that her husband is HIV positive as well. Her legs show large black patches and one bulging 4cm tumor. She is on Vincristine for the KS, although Alice said that in her experience it doesn't work very well. She is also on antiretovirals. She has 2 children, ages 5 and 3. She talked about how much she appreciates the faithful daily visits of the caregivers, the likuni phala and the soap.

"A tiny, lively woman is the GAIA caregiver for both of these patients. I asked her how she liked her work as a caregiver. She replied that she enjoys it and is proud of her bank account and is planning to build a house with the stipend she is saving.

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"After reaching Mulanje, we headed on a road to the East and South and climbed 40 minutes up a very rough dirt road, high into the hills opposite Mulanje Mountain. We stopped at a church at the edge of the road, and, stepping over the ditch that edged the road, climbed up to the entrance.

"Inside the Mobile clinic B was set up and over 100 people were waiting on benches inside the church. The clinical officer was at the front of the church on a chair, with another chair opposite him for clients to sit in. He was seeing the under-five patients and was examining a baby as his mother held him. Next to him was a portable table that serves as the prescribing station. All of the bulk bottles of medications were set out on it. A large water container with cups stood nearby, so that patients dosed with medications to be taken right away could take them there. After the C.O. has seen the patient and written in the record, the patient is sent with their health book to the prescription table. Here teaching concerning taking the medication properly is done. The pills were dispensed in small packets marked with the medication and the dose using little icons showing the sun rising, the sun at noon, the setting sun, and a night sky (designed for people who have poor literacy and little access to clocks).

"The nurse aid was manning this table. Under the nurse's direction she counted out tablets and placed them in packets as the nurse gave patients prescriptions. As throughout Malawi, patients keep their own medical records in a small health book, which they are to bring each time they visit a clinic or health center, and the diagnosis and treatment are recorded inside it. This information is also recorded in the Clinic Patient Register from which data is taken and submitted to the DHO. The indicators and data monitored at the GAIA mobile clinics is the same as at all Ministry of Health facilities, so it means the collected data can be merged with that from other health facilities in the district.

"A screen was set up at the front of the church. Behind this was where ante-natal care, family planning, and HIV testing are done. Shortly after I arrived the nurse, left her station at the prescribing table to begin the family planning session. She would come back later in the morning to fill the prescriptions for the patients that the C.O. was seeing.

"Three women were seen for family planning. All are using Depo-Provera injection as the method of family planning. They come every three months to get the injection. Condoms are also distributed by the clinic for family planning, but there is less demand for these, likely because the women cannot control the method, and so it is not reliable for family planning, though, of course, used regularly, they would be of help in reducing transmission of sexually transmitted diseases.

"After finishing with family planning, the nurse began seeing women for antenatal screening. A lovely, bright faced 25 year old came in, looking healthy and pleased. The nurse asked her if the GAIA project officer and I could observe the visit. She agreed. The nurse weighed her, took her blood pressure, which was normal, and then had her lie down on a mattress to examine her belly. The baby was head down, not breach. She listened to the fetal heart. While doing this she chatted with woman, who said this was her third child and she wanted to have four altogether. She is married to a business man. She is the second wife. His first wife lives in the neighboring district. The woman had consented to be tested for HIV, which is now done for all pregnant mothers on an opt-out basis when they come to the clinics. She was also tested for syphilis. The nurse drew the blood by finger stick and ran both tests.

"While they were waiting for the result, the nurse asked her how she would react if the results were positive or if they were negative. I was impressed with the nurse's manner which was kind, and forthright. The woman said that she wanted to be tested and would follow whatever the nurse told her regardless of the results.

"It was time to read the results, whereupon the project officer stopped translating what was being said. The nurse spoke at length with the woman, and then the project officer did too. I suspected that one, or likely, both tests had turned up positive and that the project officer did not want to reveal this to me in front of the patient. In an instant, this lovely young woman's future had changed completely.

"Later the project officer explained to me what happened in the session. Both the syphilis and HIV tests were positive. The woman wanted to be put on antiretovirals right away, but the nurse explained that at the moment she was very healthy, and that after delivery she would be evaluated on a regular basis. She would be put on antiretovirals when the clinical signs warranted it. The woman said she would not reveal to her husband that she was HIV positive as she feared he would abandon her, leaving her without support. She was also afraid of stigma from the community, worried that she would be the talk of the village. The GAIA project officer encouraged her to reveal her status to a trusted family member. Her mother and other relatives live near by. The project officer told me that in general, it is harder for women to reveal their positive status to husbands that vice versa.

"The nurse said that she should tell her husband about the positive syphilis test because he should be tested and treated as well, and the first wife also. The patient was understandably upset by news of the tests and told the nurse and the project officer she needed their support. She was asked to return to the clinic each week for follow-up counseling and monitoring. She was told that in her eighth month she would be given oral Nevirapine to take at the onset of labor to prevent mother-to-child HIV transmission. She was also told that she should deliver in the local health center so the birth will be attended by a skilled person and so that the baby can receive Nevirapine within 72 hours of delivery. Should she end up delivering in the village with a traditional birth attendant (TBA), she should bring the baby to the local health center for a Nevirapine dose within 72 hours. Alice says they are working with the Traditional Birth Attendants to be sure this is done.

"The woman was given a penicillin injection, oral follow up antibiotics, iron tablets, and SP prophylaxis for Malaria. She folded the medications into her chitenje (the wrap-around garment the women wear) and expressed anxiety that the pills would disclose her HIV status. The project officer explained no, these were not antiretovirals but the same medications people take for other kinds of conditions.

"The second woman I saw the nurse examine also tested positive. By then Alice had gone to help at the prescribing table, so I didn't have translation and did not have a chance to chat with the woman before the test. When the nurse told this woman the results of the test, tears came into her eyes. I felt I was intruding on an intensely private moment, so I quietly got up and left the nurse to continue her post-test counseling. Once again, I was impressed by the nurse's caring and kind manner.

"While we were at the clinic the nurse saw six antenatal patients. One was on her second antenatal visit and had already been tested, but the other five were tested for HIV. Four of the five tested positive. The nurse said she usually sees between 12 and 15 antenatal patients on each clinic day, not all of those would be tested, because some would be seen for a repeat visit.

"Then I sat with the C.O. for a while as he examined one person after another, mostly sick children. Many had symptoms of malaria or GI disease. One child had a severe case of otitis media that had perforated the ear drum. The ear was draining with swollen lymph nodes evident around the ear. Other kids had bellies distended with gas, and a history of several days of diarrhea. One of these also had an earache. The C.O. was going to put this child on antibiotics for the otitis, and oral rehydration therapy for the diarrhea, and said the antibiotic also sometimes helps with the diarrhea. The kids were listless, but stared at me. Azungus (white people) are rarely seen in these villages so I think I interested them. With the great number of patients, the C.O. has only a few minutes with each, but his presumptive diagnoses made sense to me. In general, people are treated and told to return the following week if there is no improvement in symptoms.

"It is difficult to convey the power of today's experience. What I witnessed was intense need and people who are very grateful for the help that has come to them. To be with people when they learn they are HIV positive is disturbing. It is, of course devastating for anyone to learn they are HIV positive, but I know how very different this experience is for people who learn they are HIV positive in the developed world. Finely tuned care and many more resources are available to them. I marvel at how much things have changed in the US since I took care of my first HIV patient in 1982.

"What we have to offer in Malawi pales in comparison. It is humbling to witness the courage of those who get tested and to stand with them as they try to take in the news and move forward with the resources we have offered them.

"After we left the mobile clinic, we visited the office for this clinic in an attractive small adobe building in Mulozo. The nurse aide lives at the back of the building in three or four small rooms fitted out as an apartment. Some family members appear to be living with her. This arrangement helps with security and means she is there during weekends when the security guard is not guarding the vehicle.

"Then we visited the District Health Officer (DHO). The GAIA project officer said he has been very helpful with setting up the mobile clinic project, setting up protocols and coordinating all work through the district health office. He is by all accounts hard working and extremely dedicated. He said, "I'll just be straight with you. We could use two more ambulance vehicles to transport people from the health centers to the district hospital." He has only 6 ambulances to serve 600,000 people and it is not enough, especially in the area we are working in where he has 5 health centers that basically have no transport to the district hospital, except for two motorcycle ambulances.

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"We visited the microloan project in Luchenza. I met with all of the staff in the Luchenza office: the project officer, the credit clerks, the bookkeeper, and the office assistant.

"The Project Officer has created an extensive manual for the project detailing all the procedures which has been translated into Chichewa and has been very useful. Another 750 women in about 30 clubs have been added to the project bringing the total number of women served to over 900. Each loan club must come up with 10% of the loan total for the club as a group to be put into savings before they can receive the loan. The savings account can then be used to pay on schedule should a member default.

"Most of the women still are doing trading businesses, chiefly bananas. They buy the bananas in Mulanje, hire a truck together, take the bananas to Lilongwe or sometimes Blantyre and sell them over a period of about 2 weeks. They sleep in the open in the market place while they sell the bananas.

"After meeting with the staff, we headed out a dirt road, riding for about 20 minutes before coming to a school yard where we met with one of the loan groups. About 20 women were gathered. The chairwoman was a very energetic and competent woman and the group appeared to have good cohesion. The women have 20,000MK ($142) in their group saving account and all have been paying on time. A few of the women told me about their businesses. One woman sold bananas; her loan had been for 10,000 Mk ($71) and she had made 5000MK profit after paying her loan (over the 6 month loan period).

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