An American in Malawi: Madonna’s First School, Glucose Meters, and Baseball
by james s. hirsch
I am sleeping in a mud hut in an African village, lying beneath a mosquito net on an unforgiving dirt floor, thankful that rest has finally come. But it doesn’t last.
“Arrrghh!” A loud groan comes from the adjacent room, quickly followed by two defiant whacks. Then the voice of my friend, Jim Ziolkowski: “I’ve been bit!”
He grabs his head light and shines it on his assailant: a fat 15-inch rat. It had begun to gnaw on his left ring finger when he awoke and slammed his hand to the ground. Now Jim Z, as he is known, looks right into the bulky rodent’s beady eyes before it waddles off into the dark. Blood smears his wedding band, and the flow doesn’t stop until he stanches it with toilet paper.
It's our first night in the Village of Kankhumbwa, in the Central Region of Malawi, without electricity or running water or even a cot to sleep on. I understand what a soldier feels when he survives a round of fire but his friend next to him is killed – despair over the death but grateful for his own survival. I’m mortified for Jim Z but relieved that I wasn’t bit. I’m not sure I could “survive” an African rat bite; I might have gone home right then. Actually, as we soon discover, we aren’t sure Jim is going to survive either.
I’ve taken many business trips in my life, from Paris and Amsterdam to the Philippines and Bangkok. Because I have type 1 diabetes, I have to take extra care in my planning. Swift changes in diet, schedules, sleeping and activity patterns are enough to throw the most conscientious patient into glycemic turmoil, but I’ve always managed.
Then came Africa. You can go to any country on the continent and find modern accommodations. I’ve heard Americans talk about their “African experience” – going to safaris during the day, to safely gaze at the lions, elephants, and zebras, while staying in comfortable, even luxurious digs at night. That’s not the Africa I experienced, and it’s not the Africa most Africans experience either. I stayed in impoverished rural villages for almost two weeks. Despite my best efforts, I had several diabetes-related mishaps and near-crises, and I learned far more about the country’s primitive health care system than I bargained for. The trip overall was a surreal blend of the pre-industrial age and the digital age, of ancient customs and new opportunities, of haunted mountains, joyous dancing, and the crack of a baseball at twilight.
I am in Malawi to research a book – a collaboration with Jim Z, a global youth advocate, on his memoir. His nonprofit organization, buildOn (www.buildon.org), constructs schools in developing countries while also running programs in the United States in which high school students volunteer for community service. Each year, some of these teens travel abroad to build schools, and 15 such students from the South Bronx were selected for this trek to Malawi.
BuildOn only assists the poorest of the poor countries, and Malawi easily qualifies. A former British colony, it is a small landlocked nation in southeast Africa, with one of the world’s lowest pre-capita incomes – the average Malawian earns less than $1 a day. While its biggest cities have amenities such as electric lights and hot showers, those comforts do not grace the country’s rural areas, where 85 percent of the population lives. There, the men toil in the tobacco or corn fields, the women haul buckets of water on their head while balancing a baby on their back, and the children walk barefoot to school along dirt roads.
I had never been to Africa but tried my best, medically speaking, to prepare. My insulin, for example, would need to be kept cool for two weeks. There would be no refrigerators or cooling blocks in the village, but a friend told me about the FRIO carrying case, which can keep insulin cool and only requires water every two days to activate its cooling properties. I use the wireless OmniPod system, which means I only need a short-acting insulin (Novolog in my case). But the first rule of diabetic travel is that for every supply item, you need a backup. Not only did I bring two vials of Novolog, but in case my pump broke down, I brought a long-lasting, or basal, insulin (Lantus), plus syringes.
I packed my glucagon kit and showed Jim Z how to use it in case I ever passed out from hypoglycemia. I packed my backup batteries for my OmniPod “personal diabetes manager,” or PDM, the machine that both delivers the insulin and tests my blood sugar. I had backup plastic pods, backup glucose strips, backup glucose tabs, even backup granola bars. Medically speaking, what could possibly go wrong?
The most memorable moment is our arrival at the village. We ramble in on an old school bus, along deeply rutted dirt roads that would be impassable in heavy rain. Today is bright, and as we chug along I see children from all different directions streaming toward us from four or five different villages. They’re chasing the bus, hundreds of kids, singing, smiling, dancing – as if this were the opening shot of a movie, a sweeping panoramic across the African fields. The students from the Bronx step down into the unconditional embrace of these nameless, exuberant children. Some of the students dance. Others cry. Many watch in amazement. The children know we are here to help the community build a school, but their love speaks to some deeper connection. No one just happens by this isolated community, and there is no evidence the government pays it much heed. Our arrival signals an important message: you matter.
The new school, which will replace an older, dilapidated one, has another distinction: it is sponsored by Madonna. The pop star has an adopted child from Malawi and a foundation for the country; she recently gave money to buildOn to construct 10 schools here, and this will be her first.
But that means little to the American students, who just want to be accepted in the village. At a lengthy opening ceremony, our trek coordinator, Rosann Jager, gives each of us an African name. I am Kadammanja, which means “black hand.” I appreciate the literary touch but can’t absorb all the syllables. I introduce myself as “Jim.”
The Americans are assigned to a host family, and I room with Jim Z and our translator, Chris, a smart, friendly college student who only speaks when spoken to. It takes 35 minutes to walk to our mud hut, and the skies suddenly open as we trudge along. Some of our clothes will stay damp for the rest of the trip. We reach the hut by nightfall, and I have my first real glimpse of how barren my next two weeks will be. The hut, its thatch roof leaking, has two front rooms in which the three of us are to sleep. But there are no beds, no chairs, no benches, no tables, no shelves, no nightstands, no lights, no mirrors, no nothing.
Check that. The hut has one thing: cockroaches, which crawl brazenly along the wall. Jim Z believes they can fly, but I don’t have the good fortune of seeing one airborne. I decide to sleep in the smaller room, by myself. I lay my thin inflatable mattress on a hard wooden mat, then hang my mosquito net from a rafter. It dangles over and around the body so that when you open your eyes, you are literally enmeshed. The only light comes from a flashlight. Inside the hut or out, the darkness is unremitting.
All of this has repercussions for diabetes. Have you ever changed an infusion set, drawn up insulin, or tested your blood sugar in the dark? It’s not fun. I don’t appreciate until now how many moving parts there are to diabetes care. Here’s one suggestion: ditch the flashlight and use a head lamp, which may look like a goofy coal miner’s tool but frees up both hands. Diabetes management also generates a surprising amount of garbage: test strips, infusion set packages, snack wrappers, used syringes. At home, this is no problem. Pitch ‘em in the trash can. But in my hut, there are no trash cans. I have a large plastic garbage bag, but on my first night I can’t find it in the dark, and it will elude me throughout my stay.
The darkness brings to mind one more peril. What if my blood sugar crashes in the middle of the night? I’ve shown Jim Z how to use the glucagon kit if I’m unable to revive myself. Under ideal circumstances, it would be asking a lot for a neophyte to use it correctly – mixing the powder with the solution and giving the injection. But in the darkness, with no shelf on which to place the kit, he wouldn’t even be able to find it, let alone administer it.
As I fall asleep on that first night, I’m beginning to think this whole trip may have been a mistake. Then I hear Jim Z’s scream. His pain tolerance is probably as high as any person I know, so when he curses the “bastard rat,” I know it’s serious. Jim Z wasn’t using a mosquito net, which may have deterred the rat. The host family later tells us that it knows it has rats, which usually feed on sacks of corn but have bitten their children in the past.
We leave the hut that night and transfer to upscale sleeping quarters – the school headmaster’s new house. It has concrete floors instead of dirt, which probably means fewer rodents. Jim now sleeps with a mosquito net.
The next day, we head into town and find a clinic at a private school. Jim Z needs a vaccine, which is a series of five shots over 28 days. A nurse gives him his first shot. We then talk to a doctor provided by FrontierMEDEX, a travel insurance agency. He tells Jim Z that he needs to also take a second vaccine as well, immune globulin, which would be injected right into the potentially infected finger. He says Jim’s chances of having rabies “are low but not zero.” A rat on its own wouldn’t carry rabies, but if it were bitten by a rabid cat or dog, it would then be infected, and a 15-inch rat would be large enough to survive such a bite.
“If I do get rabies,” Jim Z asks, “what are the symptoms.”
“You die,” the doctor says.
Silence. “Okay, before I die, are there any symptoms?”
“You become irritable.”
Before leaving the clinic, I enter the washroom, desperate to clean my hands. There is hot water, but no soap.
Back at the village, I meet with Frackson Chambalkata H.S.A., or health service assistant. He speaks pretty good English. He explains that three years ago, he came to Kankhumbwa to establish a health clinic, but it consists of nothing more than two trees, where he talks to villagers seeking care. He has no medical supplies and no diagnostic equipment. No wraps, no Band-Aids, no painkillers, no thermometers. He does have one thing: he distributes condoms.
The problem is that the district he services – eight villages and about 1,600 people – is too poor to afford care. Midwives deliver babies in homes, and herbalists brew concoctions to ward off disease. A more substantial clinic, which has refrigerated vaccines, is about four miles away, and a hospital stands about 30 miles away. But no one in the village has a car, so reaching either, by foot or bicycle, is difficult.
The most severe health problems are easily prevented. Malaria, for example, kills about 12 people a year in the district, with children under five the most vulnerable. They would be protected if they had mosquito nets, but most households don’t have them. A net only costs about $5, and several Western aid organizations supply them to developing countries. But Frackson says that the nets that are sent to Malawi never reach his villages. “They are sold on the black market,” he says.
Malnutrition, AIDS, and tuberculosis are the next biggest killers, he says. I ask about diabetes. He says the district has about 15 people with the disease and that some use insulin, some don’t. I ask whether they have type 1 or type 2, but he is unfamiliar with the terms. I then show him my PDM and test my blood sugar – 190 mg/dl. He’s never seen anything like it.
He asks me what the normal “temperature” should be for someone without diabetes.
I explain that the machine doesn’t measure body temperature but determines the amount of glucose, in milligrams per deciliter of blood, and a fasting blood sugar should be no higher than 120.
“Ohhhh,” he says. Frackson is fascinated, and if I teach him how to recognize an elevated blood sugar, then I’ve made a small contribution to Malawian health care.
Three days after receiving his first rabies vaccine, Jim Z needs his second injection. The buildOn staff has no medics, so I am asked to administer the injection. My qualifications? I’ve taken thousands of shots because of my diabetes. The vaccine is assembled in the same way as the glucagon, with two vials, one liquid and one powder. I give the shot without incident – bevel side up for the needle, as I was taught years ago – and realize this is one of the few times in my life that having diabetes is an asset.
Next, we need to take a very long road trip south, to the village where Jim Z built his first school in Africa 19 years ago. But first we stop in the capital city of Lilongwe at the African Bible College, whose private hospital – we are told – has the immune globulin shot. But when Jim Z arrives, the doctor says the hospital has no such shot, and he’s not aware of any other clinic or hospital that might have it.
Jim Z’s window is narrowing. The shot is only effective if taken within seven days of the bite. He has four days left. Before we leave, I go into the washroom – but once again, no soap. It is a luxury that even hospitals cannot afford.
We have a daylong drive ahead of us. In addition to our translator, we ride with three women – a photographer, a videographer, and a producer – who are developing social media campaign for buildOn. They specialize in working for nonprofits for humanitarian causes. They are high-tech, multi-media missionaries, equipped with highly sophisticated digital and video cameras, smart phones, chargers, and laptops, trying to capture the sights and sounds of a land that seems passed over by modernity. We see the beauty of the landscape and the people, but also the primitive conditions: the shacks and shantytowns, the rusting hulks of nothingness, sagging in the mud, selling trinkets and snacks along the road; the conspicuous signs for coffin makers as reminders that death is a booming business; the thinned-out dogs and cats, goats and cows, as hungry as their owners; the many walkers along the highway, without the resources to travel any other way.
I myself feel like a technological oddity, with my Star Wars insulin delivery device, as if I’ve walked back in time to tell the locals what the future of diabetes care will hold.
BuildOn’s country director tells Jim Z there is no immune globulin in Malawi, and the doctors at Medex are urging him to evacuate to South Africa or Kenya for the shot. He should also be seen by an infectious disease doctor. But evacuation would mean he would lose two days from this trip, whose stories and photos will be used for fundraising later in the year. But if he doesn’t get the shot and develops rabies, he’ll probably die. The doctors are vague about what those chances are, but driving along the road, Jim Z tries to calculate the possibility of death: less than 5 percent? Less than 1 percent?
He has always seen life as a series of risks and rewards and, in working and traveling from Haiti and Nicaragua to Senegal and India, has been exposed to far greater risk than this one. Indeed, he almost died from malaria in this very country 19 years ago. His only hesitation now is that he is a husband and father, with two young boys. “I love them so much,” he says. He worries that his wife might not find another husband if he dies. “She’s beautiful but introverted.”
He nixes the evacuation plans, confident that the risks of death are low, and continues on with the trip.
We arrive in the Village of Misomali and see the remarkable legacy from Jim Z’s first school in Africa. There are now five schools – the village received money from the Malawi government as well as the European Union – educating more than 1,000 students, half of whom are girls. Jim Z had planted a dozen eucalyptus saplings, no more than six feet high, and they now tower over a courtyard garden adjacent to the schools. Signs of progress abound. Electric wires have brought power to some of the huts. Telephone polls have been erected. Concrete homes with corrugated roofs have been built for teachers. Satellite dishes dot some of the structures. Bicycles carrying sacks of grain roll over dirt roads. Of the five sub villages, four have female chiefs – unheard of in Africa. A baby girl that Jim Z once held is now a beautiful 19-year-old woman who, thanks to her education, is teaching a new generation of students in Misomali.
Jim Z reunites with three of the men he had worked with on the school, but the reunion is quickly tempered when he is told that three other men from this volunteer crew have died. They were his friends, including the village chief, who courageously worked on the school in the face of politically motivated lies by some in the village. Devastated, Jim Z tries to learn what happened to the chief and hears a disturbing tale that resulted in unfounded corruption charges against him. He was sent to prison and, after his release, died from AIDS.
Night falls as we walk back to our house, and the village suddenly takes a menacing cast. We are next to Mount Mulanje, one of the highest peaks in Africa and beautiful to behold in the day. But the locals believe it is haunted by evil spirits, and they must perform juju, or witchcraft, to fend those demons off. Jim Z recalls his own experience here with malaria – he was lucky to survive, but so many others have perished.
“This place is a death trap,” he tells me.
Moments later, we’re at the house to eat dinner with our team. I test my blood sugar, and it’s 144. Then I press the buttons on my PDM to deliver my bolus . . . but nothing happens. I try again, and the meter reads “error message.” Again, same result. And again. I have plenty of battery power, but the machine won’t work. Finally, I get a message that tells me to call a toll free number for assistance. Both my son, who also has type 1, and I have used these PDMs for about five years, and I can’t recall one ever just dying. But now it has.
I blame the evil spirits.
I don’t panic. I have backups – my Lantus for a basal insulin, and my syringes. Bevel side up. This regimen will require at least four injections a day for the next week, but I can manage. I am outside at the car gathering my supplies when it suddenly dawns on me: my PDM was also my glucose meter, and I didn’t bring a backup meter. I’m now in the middle of Africa with no way of testing my blood sugar.
Okay. Now it’s time to panic.
When I return inside, I tell Jim Z and friends all that’s gone wrong. I’m blessed with an understanding audience. The photographer’s sister-in-law has type 1 diabetes. The producer’s sister also has it. We’ve been joined by Brett McNaught, buildOn’s vice president of International Programs, and his nephew has type 1. That’s one upside to an epidemic: everyone knows someone with diabetes. Brett says I can buy a glucose meter at a pharmacy in Blantyre, which we’ll be passing through tomorrow.
I say I don’t want to slow us down.
Jim Z says if I don’t get a new meter and strips, he’s going to evacuate me to South Africa or Kenya.
I’m practically moved to tears by their support.
I’m still in uncharted waters. I have to make the transition to Lantus, which I haven’t taken in seven years. I receive a basal insulin rate of 0.5 units an hour, or 12 units for every 24 hours. A once-a-day insulin, Lantus is supposed to last 24 hours, so I assume I should give 12 units before I go to bed. I draw up the syringe but am horrified by the huge volume – I can’t recall the last time I gave 12 units of any type of insulin. My pre-meal boluses are usually around 4 units. What if I’ve miscalculated or if I’ve not remembered correctly how Lantus works? I have no one to ask. A mistake could be fatal. I inject the fluid and wonder if I should learn some juju.
Meanwhile, my insulin pod – the one that I was using when the PDM died – starts beeping right before I go to bed. Why it’s alarming, I have no idea, but I know of only two ways to silence it. Stick a paper clip in it, or put the pod in a plastic bag and shove it in the refrigerator. I have neither a paper clip nor a refrigerator, but I can’t allow the pod to cause a racket indefinitely.
So I go outside and heave it into the black African night. It lands deep in a cornfield. In weeks or months or maybe even years, someone will pick it up – still beeping, perhaps – and believe it was dropped from the sky by an alien. Which I am.
It’s a strange feeling. I began testing my blood sugar on a regular basis in 1979 or 1980, so for the first time in more than 30 years, I have no idea where I’m at. I wake up in the morning, and I can’t tell if I’m hungry or hypoglycemic. I eat two granola bars just in case. We leave Misomali and make it to Blantyre for lunch. I stop at the Mudi Pharmacy, ask for a glucose meter, and am handed SD Check Gold, which looks like a Roche product. It costs about $34. The pharmacist speaks English, so I ask him if many diabetic patients in Malawi test their blood sugar.
“No,” he says. “The meters are too expensive. We sell very few.”
“What about insulin?”
He points his thumb straight up. “Oh, yeah, we sell a lot more insulin now. We have generic insulin.”
I had already read reports on the Internet about the rise of diabetes in Sub-Saharan Africa, of which I am now a beneficiary: without a market, there would be no glucose meters.
The new machine works fine, but the box only comes with 10 strips, and the pharmacy doesn’t sell strips individually. So I’m only given a temporary lifeline. Does Malawi sell strips alone? It’s Sunday, and the other pharmacies in Blantyre are closed. After a day of driving, we reach Lilongwe. I visit a pharmacy, but it doesn’t sell strips. The other pharmacies are closed. I could survive on 10 for the rest of the trip, using one a day, but I’d rather not.
Before heading back to our original village, we get gas. But when Jim Z drives out of the station and onto the road, the car inexplicably stops with a loud thump, and tilts downward. Chris jumps out of the back, inspects the scene, and yells to me, “Jim! Get out! Get out!”
I open the door and step down, but there is no ground. Jim Z had driven into a four-foot wide open trench – invisible in the darkness – and now I’m falling into it. I step out and reach over the opening, and Chris pulls me across. With the help of others, we push up the front end of the car, and Jim Z is able to back out.
I’m beginning to realize, that’s Africa at night. You never know when the ground below is going to disappear.
Someone from the village goes into Lilongwe the next day and finds strips for me, which I very much need, because I spend the rest of my time in Africa battling low blood sugars. Specifically, I’m crashing overnight and waking up in the 50s and 60s. I lower my Lantus and by the time I go home five days later, I’ve cut my dose from 12 to 6 – 50 percent! I plow through my granola bars, consuming about 60 for the two weeks. When I return, I speak to my brother, Dr. Irl Hirsch, who’s on the diaTribe advisory board, and he tells me that the conversion from a basal rate to a basal injection is usually not one-to-one. He recommends breaking up the basal injection into two smaller doses per day, which gives you flexibility for overnight. It’s also a good idea to test the basal insulin before you take a trip to see how much of you actually need.
Good advice. Wish I had gotten it before I left.
Building a school, it turns out, is hard work. But everyone pitches in, the Bronx students and the villagers, and the foundation is dug, the cement is mixed, the sand is hauled, and the bricks are carefully laid. Two walls begin to rise.
Besides a new school, I think what this village needs is baseball, so at the end of the work day, I bring a bat and ball to the dirt yard next to the work site. Baseball is played at the universities in Malawi, but it hasn’t reached the rural areas, and this appears to be a first at Kankhumbwa. Brett and I demonstrate the basics of hitting and catching, and the kids from the village immediately line up and want a turn swinging the bat.
Each time, whether they strike the ball or miss, they squeal with laughter. Baseball as it should be – for its pure joy. The kids aren’t big, but they haven’t spent a single minute of their lives watching TV or playing videos. They are lean, strong, and coordinated; soccer is their game, but they swing the bat with gusto and hit the ball hard. One girl in a green skirt – she can’t be 7 years old, but she rolls her top wrist like Henry Aaron and consistently whacks the ball over a tree in left field. (Early scouting report on the Malawians: they’re dead pull hitters.) Another boy whips the ball like a young Roberto Clemente. Another flags ground balls like Ozzie Smith.
On our last night in the village, I give the bat and ball to the girl in the green skirt. She seems confused at first but soon understands that this is a gift. I hope she’ll remember me by it.
Our farewell to the villagers is emotional, as some of the American kids have grown close to their host families, and they to them. The school bus rolls out of the village, with Jim Z, Chris, and I trailing in a Toyota Corolla. Alas, nothing is easy. We end up taking a more difficult route to town, and our car doesn’t have the size to handle the ditches in the road. The car gets stuck, and for the second time in Africa, I’m trying to push a car out of a hole. We succeed, but we’re still in trouble. Our cell phones have no battery, and we’re in the middle of nowhere, so if the car becomes disabled, we’ll have a long walk before we can find anyone for help.
Chris finds a smoother route, and we eventually find our way to town and reconnect with the bus. Jim Z says he wasn’t worried because even if the car broke down, it would have only been a two hour walk. That’s the difference between those who have diabetes and those who don’t: I don’t measure a crisis by, say, the distance needed to walk, but by whether I’d have enough granola bars and glucose tabs to make it. I wouldn’t have.
That’s just the way it is with diabetes. When you travel, you live on the precipice – as I find out one last time in Africa. Jim Z has to get gas on the black market, so he gets it with one of buildOn’s country coordinators. I leave my glucose meter in the car but stay behind. When Jim Z returns, I check the car to make sure my meter is still there. I think I see it. But after we drive off, I double check. The meter’s gone. I assume the country coordinator inadvertently had it in her hand when she left the car. It was my fault for not being more careful, and now I have to buy yet another meter.
My life in Africa: chasing lows, chasing glucose meters.
But those are quibbles. All in all, it was a memorable trip.
Madonna’s first school is being built.
Misomali’s school children are thriving.
Jim Z lived.
And in 20 years, I hope to return to this village and see five schools across every grade level, a clinic that dispenses essential medicine, and a ball field with sturdy bases, an electric scoreboard, and two white foul lines that stretch beyond the cornfields, over the dirt roads, and into the heart of villages unseen.