The first year in Malawi I was full of enthusiasm; the second year I started to get tired; the third year I was on my knees, and the fourth year I could hardly put one foot in front of the other. You didn’t have to be a prophet to have predicted this – the clues were there right from the start. On my first weekend in Nkhotakota, I went for a little walk to get my bearings. I found myself around the back of the little missionary church, in a graveyard. It was poorly tended, with gravestones sticking through the long grass just enough to be able to make out the names on them:
Lillian Smith RIP 1900–1930
Poor Lillian! Thirty years old, two years younger than me. I wondered what had happened to her.
Then I looked at the gravestone next to her:
Paul Whetstone RIP 1911–1935
Twenty-four years old. With a sense of mounting panic, I started scanning the rest of the headstones. I found several names of early missionaries, and not one living beyond the age of 35. There were no clues as to how they had died, but it didn’t look good.
I walked over to Lake Malawi; it stretched over the horizon like a sea – a long thin strip of water over 350 miles long, the ninth-largest lake in the world. Nk’otakota was one of the 60 towns and villages that had grown up along its banks, and I could see in the distance the mud huts of the next village. The water twinkled blue in the early morning sunshine and there were men fishing in small boats.
I remembered reading in an encyclopedia borrowed from the library in the Mother House that Lake Malawi had more species of fish than any other freshwater lake in the world. Steamboats went backwards and forwards, some probably off to Mozambique on the other side. They reminded me of the film The African Queen, which I had seen as a teenager. Then, Africa seemed impossibly exotic and remote. Yet here I was like some 1970s Katharine Hepburn. No sign of a Humphrey Bogart to corrupt my missionary work, though, I chuckled to myself.
Down near the beach an impromptu bazaar had appeared. Large pieces of driftwood had been used to set up stalls of fruit and colourful materials. Children were playing while women haggled. The smell of Africa – damp, rich earth mixed with tropical flowers like hibiscus and frangipani – overpowered me.
How could somewhere so close to Paradise hide such mortal sickness?
The answer was there in front of me – diarrhoea, vomiting and malaria were rife among the people. As I looked at the tiny waves whipped up by the gentle breeze, I remembered why none of the children were actually in the water. Beneath the pretty blue lurked bilharzia, parasitic worms that, while rarely fatal, result in lifelong illness and all sorts of damage to your internal organs. There was danger in paradise, as if the more beautiful the landscape, the more deadly it could be. In a way that was exactly the reason why God had sent us here, but at what cost? It seemed that others who had come before us, doing His work, had paid the ultimate price.
Despite this nagging fear lurking at the back of my consciousness, it was amazing how quickly I left smoggy, cold London behind and became acclimatised to my hot, exotic new home.
It had started on the boat over. Sister Rachel had made us some new habits that were more appropriate for tropical Africa. And gosh, how ridiculously exciting that was – a new outfit for the first time in years! We were allowed to have a say in the design and we decided on pale blue habits with short sleeves and skirts ending just below the knee, and shorter, lighter white headdresses. (Of course our crosses of St John and girdles were eternal.)
As we sailed over the equator and the weather heated up, we abandoned heavy old home clothes and put on our new habits. One day, as we sat outside on stripy deckchairs, becalmed and sweltering in the South Atlantic Ocean, Sister Marie-Louise exclaimed, ‘Lord preserve us! Would it really matter if we took off the undercap?’
Sister Belinda and I looked at each other.
‘No, no, I don’t think it would – not if we all do it. Shall we?’ I asked.
‘I’m game,’ Sister Belinda said. So we retreated to our rooms and emerged like butterflies from a chrysalis, lighter and transformed, never to put them on again.
The transformation continued once we got off the ship at Cape Town and started our ten-day train journey north across Africa to Malawi. I gazed out of the window at landscapes that seemed to have come straight out of a picture book – an idea that wasn’t helped by reading the whole of The Lord of the Rings. It had just come out and looked reassuringly thick, the kind of book that you might be able to read several times, which considering I was a bit like a guest on Desert Island Discs who can only take one book besides the Bible and the complete works of Shakespeare (books would be few and far between in Malawi and I didn’t have much room in my suitcase), Tolkien it was. And although it’s not supposed to be religious, it is about good versus evil, and I could see Christ in there, so it proved to be a good choice. But which seemed more unreal, the book or the view from the window? I wasn’t sure.
When we arrived in Malawi, the jolly Bishop put us up in his colonial house for a few days while we recovered from the journey, and then we set off on a long jeep ride deep into the centre of the country, to our final destination – the small clusters of settlements known as Nkhotakota.
Our little patch in Nkhotakota was like an African version of the square back in Poplar. The hub of the community was a large quadrangle, with an enormous tree at its centre. On the one side was the missionary church, with the graveyard behind; at right-angles to it was a primary school and opposite this was the hospital. Down a dirt track was another square with more buildings – houses for the various volunteers and missionaries, and our new home, which we would rename St John’s House. Again, in the middle was a large tree that had apparently been planted by David Livingstone in 1859, when he stayed there resting on his journey to find the source of the River Nile. Everywhere there were flowers and mango trees. At first glance it really was quite beautiful.
However, on closer inspection it became clear what we were up against. The new St John’s House had only the most basic furniture. Luckily, we had been warned and we came with trunks full of linen and cutlery. The roof was made of corrugated iron and leaked. One night there was a terrific downpour and I dreamt I was being rained upon. I woke to find a trickle of drips pouring onto my forehead. Marie-Louise was sleeping in a little bed on the other side of the room and seemed to be dry, so I pushed my bed across the room next to hers. But as the rain continued, we both started to get splashed.
‘Botheration! This is no good,’ I said. ‘Let’s go and see if we can slip in with Sister Belinda.’
So we scurried down the corridor and opened the door to Sister Belinda’s room, only to find her sitting bolt upright in bed, holding an umbrella over her head! Luckily, there was an easy solution which involved offering a small amount of pocket money to some of the local lads, who were only too happy to spend a day on our roof.
The hospital itself was a greater worry: the wards were made up of tiny beds or mats placed tightly next to each other on the floor, so that there was barely any room for us to get between them. It had space for 60 patients, but there were always more than 100 women needing treatment. During the day it was so hot (generally over 100°F) that the verandah was full of heavily pregnant women sitting or lying, all trying desperately to keep cool.
There was only one labour ward, which consisted of four walls and two iron beds with rubber mats. There were some bowls and disinfectant in a kidney dish, a pair of forceps and some scissors and clamps; the only light was a Tilley lamp. It had to be held in the right position, otherwise we would have had to deliver babies in the middle of the night in total darkness (and the African night could be very dark). This meant that there always needed to be two of us up, one to cross-match the blood and the other to be down at the business end.
It has to be said that this was not necessarily a bad thing; generally the mothers who arrived at the hospital were those who needed emergency care. No matter how experienced, I always found it helpful to have a second opinion and support if things went wrong. And they did go wrong. To my horror we did lose mothers and babies from the start, women and children who would not have died in the East End of London, because we just didn’t have the equipment or the expertise to deal with some of the extreme emergencies we faced.
The most obvious problem was that we didn’t have an operating theatre. If an emergency Caesarean was needed, the mother would have to be transported at great risk to the main hospital, which was a ten-minute drive. But we only had one method of getting them there, which was the old Land Rover, and if that was already off at the hospital, or on an errand, or even acting as a mobile clinic going round the local villages, we would face an agonising wait.
We had two men helping us in the house – Anton, who cleaned and drove the Land Rover, and Henry, who cooked. Jobs were scarce in Malawi, so we were encouraged to employ local men with families who badly needed a steady income. Anton and Henry were both devout Christians, with lots of mouths depending on them to be fed, so they were immensely grateful for the full-time, secure jobs we gave them. Nothing was ever too much trouble.
Henry was smaller, more inscrutable and intense. Anton, on the other hand, was tall, lanky and funny. He became my right-hand man. Driving me from emergency to emergency, singing hymns (sometimes changing the words), giving a running commentary and gently teasing me (he insisted on calling me ‘Reverend Mama’). Meanwhile in the hospital we had the help of a Dutch doctor who regularly visited and a rich American volunteer called Eloise. Two years before she had come out for a short eight-week placement, but ended up staying for eight months, then went home and then came back indefinitely with her baby grand piano. Every evening she used to play it with the french windows open and sometimes we would go and sit on the grass in the quad and listen. I used to watch Sister Belinda (the former concert pianist) listening impassively and wonder if it was torture for her. One day, I said to her, ‘Go on, why don’t you ask Eloise if you can have a go? I’m sure she’d be delighted.’
I regretted it immediately. Sister Belinda looked hurt and vigorously shook her head.
‘That was my old life. It has no place with me now.’
I wanted to argue with her. Why on earth not? Just because we have started a new life, does that mean we have to reject everything of the old, even the most creative, positive bits? But I sensed at that moment it was more important to respect Sister Belinda’s approach to her vocation, so I remained silent.
On my first day I was bewildered by the sheer mass of people and weight of things that needed to be done. There was an extraordinary line of women and young children winding all the way out of the hospital and up the road, with more coming and joining from all directions. They didn’t seem to be pregnant. I asked one of the nurses what was going on.
‘Oh, that’s the vaccination clinic,’ she said.
‘Vaccinations? But these children are quite old, some of them look about five.’
‘Well, we’re a maternity hospital.’
‘Yes, exactly. What are these people doing here, they don’t look pregnant?’
‘Well, part of the job of the maternity hospital is to look after the health of the babies until they are five.’
‘Hang on, in England a baby is a baby until about the age of one year and then they become a child! And anyway, a baby is only the responsibility of the maternity hospital until they are six weeks old and then they are handed into the care of the health visitor.’
The nurse shrugged.
‘In Malawi, maternity hospitals look after the child until they are five.’
That was a bit of a shock. It meant we were responsible for the health of all the children in the area until the age of five – a huge job for any unit, but especially in an area where so many children were vulnerable to disease and malnutrition. ‘I will not be scared, I will not be scared,’ I repeated over and over to myself, and I made a mental note to send off as soon as possible for a book on basic paediatrics from the London School of Hygiene & Tropical Medicine.
The responsibility of being in charge of all this was feeling a bit overwhelming. But I decided the best place to start was to make an inventory of the equipment in the hospital, if only to see what was missing. I found myself weeping as I examined the medieval-looking forceps; I was filled with the admiration for the missionaries we had replaced, having to work under such conditions. As I was wiping away my tears, a woman came running in and tugged on my sleeve.
‘Uko.’
‘Uko?’ I repeated.
She nodded and said again in Chichewa, ‘Uko.’
I turned to our volunteer, Eloise.
‘What does she mean?’
‘Uko, over there.’
‘Over there?’
‘Yes, it’s what they say when someone is trying to get here and has collapsed. We call it the “Failed to walk” phenomenon.’
‘Dear God!’
‘Well, they end up having to walk miles. There aren’t any cars out in the villages, you know.’
‘Well, of course, but what am I supposed to do about it?’
‘You send someone out in the Land Rover to find them and bring them in.’
‘OK.’
I turned to the woman and said: ‘Uko, where?’
She nodded and pointed in the general direction of the hospital door. Eloise laughed.
‘That’s the best you’re going to get, Sister! They don’t do things like maps or directions.’
‘Dear God!’ I exclaimed again, ‘How on earth does anyone ever survive here?’
‘Well, they do, Sister, they generally do. You’re just going to have to relax, go into Malawi gear and up your praying.’
I studied Eloise carefully and decided I liked the cut of her jib.
‘OK. Eloise, would you be kind enough to take this lady and go and find Anton – I think he’s in the house. See if he can drive around with her and locate her friend and bring her in.’
‘Righty-ho, Sister.’
Half an hour later Anton returned with a labouring, but grinning lady in bright clothes. And that’s what struck me going round the wards – the stoicism of the women. They were calm and uncomplaining despite the heat and lack of facilities, always terribly respectful and grateful. During the day I witnessed five babies being born, and rarely had I been present at such quiet births. Were they experiencing less pain? It’s impossible to know, but my hunch is that, having grown up without a pot of painkillers ready to hand, they were just better at dealing with it.
I also felt there might be something psychologically deeper going on. They were deeply religious, with a depth of faith that would put most of our woolly Anglican churchgoers to shame. It was humbling. But also during our first month, the other Sisters and I were taken to see a traditional ceremony for a first time mother-to-be. I suppose it was the Malawi equivalent of an antenatal class that extended into the labour itself. It took place in a secret location outside the village. The only people allowed to be present were women who already had children (they made an exception for us on the grounds that we were ‘medical staff ’).
The women sat in a circle with the new mother at the end of her pregnancy, freshly washed, in the middle. Her mother then came and danced for her, wearing a corn on a cob tied around her middle. The corn represented the baby. She sang a song, which she had composed herself, where she went through every stage of childbirth in great detail so the new mother would know exactly what to expect. It was very moving. It was then explained to me that she would be taken back into the hut where she would give birth, surrounded by the mothers of the village. The men would wait outside, and when the baby had been born it would be washed and the mother washed and dressed, and brought out and presented to the village. There would then be great rejoicing, with the traditional noise made with fingers waggling in their mouths. Somehow it seemed to me that the Malawi women were as well prepared by this ritual as British women are by their antenatal classes.
I was still struggling with the enormity of the responsibility until I had a bit of an epiphany in my second week. One afternoon the local Mothers Union came to sing and dance for us. They stood under the big tree in the centre of the quad, while the patients shuffled or even crawled on to the verandah, and started to sing low gospel songs, swaying, clapping and laughing. Everyone who could joined in. Before I knew it, I found myself shifting my weight from one foot to the other and clapping.
Sister Marie-Louise stuck her head out of a window and raised her eyebrows at me. I didn’t care – I was the boss now. This was a thought that hadn’t struck me before, and I suddenly felt terribly liberated. Yes, I had huge new responsibilities but with them came a new freedom. My life as a nurse and a midwife, and as a Sister, had been extremely ordered. I had been in institutions for a long time, and I’d had a place in a strict hierarchy (usually somewhere towards the bottom). The standards of procedure, order and cleanliness demanded by both my profession and my calling back in England were very ingrained. They were the canvas and foundation upon which I had worked, and had seemed an absolute prerequisite for any sort of success. Now I realised these standards would have to be left back in England and I would need to learn a new flexibility and resourcefulness.
After supper I took a long walk outside. The clarity of the sky was overwhelming. The stars were so bright and close I felt like impersonating Henny Penny and running for cover to stop them dropping on my head. Fireflies danced around me. I couldn’t help but fancy them little Tinker Bell fairies – ‘Sprinkle your dust on me and take me to Peter,’ I said – then I remembered myself and said a much more serious prayer: ‘Dear Lord, thank you for bringing me here and letting me witness such a different, amazing piece of Your creation.’
And as I spoke, in the distance there were flashes of forked lightning, igniting the sky. I wondered where all my resistance to this adventure had gone; I seemed to have left it behind at Southampton docks. I felt terribly liberated and energised. Eloise’s words about getting into Malawi gear came to mind. My head was racing with plans for the hospital. The scale of the task might be overwhelming but if I approached it with the attitude that I could never make it into a mini London Lying-In Hospital, but instead every little improvement I made was a step in the right direction, that would justify my presence here, and I would have done my job.
I was drawn towards the lake and walked along the shore. I could see the twinkling lanterns of the fishing boats. When David Livingstone had been here he had called it the Lake of Stars because of these twinkling lanterns. A hundred years later, so little had changed. Then I went back and sat on the little bench under the big tree in the middle of the quad as the lightning flashed around me, and the old familiar prayer of St Francis of Assisi came to mind:
God grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
Then I got a little notebook out of my pocket and started to make a list of all the things I wanted to do.
The next day I grabbed Marie-Louise and Anton, and we took a trip into the nearest town. We bought every pot of paint and paintbrush we could lay our hands on and then, with bribes of pennies, we hired some of the local young men and emptied the hospital, room by room. We took out the beds, ward by ward, and laid them out in the sun to air while we swept the floors thoroughly. Our patients lay under the big tree while the children repainted the rooms in cheery colours – red, yellow, green and blue. (And Anton singing ‘Red and yellow and pink and green’, or ‘Dear Lord and Father of mankind, Forgive our Foolish Green, repaint us all in purer mind, in purer lives thy service find’, or ‘Paint then wherever you may be, I am the Lord of the Paint said He’, or any ridiculous variation he could think of.) We then put health charts on the walls. Not that we needed them, but just to give the place the feeling of being professional.
Right from the start I knew that my most important task was to set up the midwifery school. Once I had installed a proper training programme, there would be a constant stream of qualified professionals who could then go out and spread their expertise across Malawi. First of all we had to build classrooms, a library and accommodation. We were asked to take 20 students on a two-year course. During that time they would have lessons with Marie-Louise, Belinda and me, and have practical experience working with us out on the ward (which was probably the most useful bit).
For reasons I never quite understood, the Dutch government had given the money for the new buildings before we came, so we were able to start work straight away. For our first six months in Nkhotakota, the quad was a building site. I didn’t know anything about building to begin with, but by the end I thought if ever I was defrocked, I could get a job working on a construction site. Men were forever running into the hospital, asking, ‘Excuse me, Mama, sorry Mama, shall we dig the trench now?’
I didn’t know, but actually most of the enquiries just seemed to be a matter of common sense, so I guessed the answers and the buildings got built. Of course we did have a Master of Works, but he was often busy off-site. And indeed he had been busy. One day he and a young English lady volunteer walked into the kitchen, hand in hand, and announced their engagement.
We had a wonderful wedding in the church; I loved being in there. The priest’s vestments and the altar furnishings were ancient and elaborately embroidered. They must have been brought over 100 years ago by the original missionaries, and for me they were a tangible link with our missionary past. The Malawians were so exuberant, the most wonderful uninhibited singers, making up beautiful harmonies as they went along, usually singing our traditional hymns in their own Chichewa language. Especially for the wedding, someone found an old pedal organ and the church was filled with all the locals who crowded in to see what a traditional Western wedding would look like. I did shed a tear – it was a wonderful day. But as I watched them pack up and the young volunteer and her Master of Works disappear up the dirt track to start a new life elsewhere, suddenly I felt a bit left behind.
However, this didn’t last for long, although it took an unexpected accident to set me back on the path. First, I must point out that food played a very important part in the religious life. When so many avenues are closed to you, a bit like being a prisoner or a patient in hospital, food is eagerly anticipated and relished.
It’s not difficult to fulfill the Grace, ‘For what we are about to receive, May the Lord make us truly thankful’. We generally were; except in Malawi. My goodness, the food was monotonous! With transport links practically non-existent, we were totally reliant on what the local earth could provide. So, breakfast every day was fruit, often the kind of fruit you can’t get in many supermarkets even today – pawpaws, guavas, passion fruit and granadillas. Lunch would be maize flour with groundnuts and dinner was fish straight from the lake. It sounds appealing but I hated it. Boiled, steamed, baked or fried, cooked every which way, but always fish. I longed for meat.
Once a month we would take turns to get into the Land Rover with Anton and drive the 75 miles to Lilongwe with a shopping list. This meant when we got back there would be a few days of fresh meat for everyone. It was an eagerly anticipated event.
A couple of months after the wedding I went off with Anton to do the shopping, but on the way back, on a dusty windy road in the searing heat, the car broke down. We spent five hours trying to start it. I began to feel a bit panicky but Anton made me laugh, ‘Don’t worry, Reverend Mama. It’ll be OK – the Lord will save us.’
Then he started to sing loudly in his rich, low voice,
She who would valiant be ’gainst all disaster,
Let her in constancy follow the Master.
There’s no discouragement shall make her once relent
Her first avowed intent, to be a pilgrim.
Now when I find myself in a tricky situation, I start singing Anton’s feminist version of the old crusading hymn.
Well, as he had predicted, help did eventually come in the form of a lorry. The driver got out a rope and started towing us along the road. But we hadn’t gone very far when there was an almighty explosion. The Land Rover’s tyre burst, sending us spinning off the road and down a slope, saved only by the rope holding us to the lorry. Somehow we managed to get ourselves out and then tow the car back onto the road, change the wheel and get home. But more drama followed when I realised I had left all the food by the side of the road. I was devastated. We did often long for our usual Western food, and that food parcel with its fresh meat was so important to the spirits of the Community, so I felt as if I had let them all down. However, the next day a huge food parcel arrived from home, and then someone left ten eggs on our doorstep, and then someone else gave us the gift of a chicken for the safe delivery of his daughter. Actually, in the end we didn’t lack for anything and I was put in mind of a passage from the scriptures:
Consider the lilies how they grow; they toil not, they spin not; and yet I say unto you, that Solomon in all his glory was not arrayed like one of these.
‘Don’t worry, the Lord will provide,’ I told myself. But I wondered whether He was doing more than that when a few days later we finally got the Land Rover to a garage. The mechanic turned the key in the ignition and the car started straight away. He could find nothing wrong with it.
‘Lord be praised!’ Anton said. ‘If the car hadn’t broken down, then we would have been driving when the tyre burst, and we would have spun off the road, down the slope and could have been killed. It’s a miracle. Thank you, gracious Lord.’
The mechanic nodded and crossed himself. I wasn’t entirely convinced – the car might not have spun completely off the road, we might not have been on the edge of a slope at the time, and we might not have been killed. But then again, here I was alive, and for what purpose? It did feel like a message.
And this feeling grew as I became more confident in my midwifery work at the hospital. Before we came out, Sisters Belinda and Marie-Louise and I discussed that we would probably have to do procedures that only doctors were allowed to do in England. As soon as I arrived, I realised I would have to perform ventouse deliveries. This is where a vacuum device is placed on the head of the baby to assist birth when the mother is having difficulty pushing the baby out herself. We did sometimes have a doctor visit the hospital but he was more often than not somewhere else. Very soon I was facing a situation when I had to deliver a baby myself with the ventouse. I was nervous but as I told myself, I had witnessed this procedure many times before and I was very clear what had to be done, and if a doctor could do it, then why shouldn’t I be able to do so?
A young mother was in the hospital with her second baby. I could feel that the birth canal was adequate and the baby was importantly in the correct position, but she had been labouring for a long time and was exhausted, and the baby was not progressing. So I placed the suction cap on the head of the baby and as she had a contraction, I gently pulled. Within several contractions the baby was delivered. It was a wonderful feeling (and a huge relief) that I could do it. After that I regularly used the ventouse. Sometimes it only took a few minutes, sometimes up to half an hour (particularly if it was a first baby), but it usually worked.
Very occasionally the birth canal was just too small to allow a normal delivery and a small cut had to be made through the back of the symphysis pubis (the joint that unites the public bones), at the front of the pelvis to enlarge the birth canal. Delivery could often then take place with a ventouse. This procedure is never done now in developed countries, you would just perform a Caesarean section. But in developing countries like Malawi, where the option to have a Caesarean isn’t necessarily there, they still sometimes have to be performed. Afterwards the mother’s pelvis would be a bit wobbly, so I had a very useful leather case strap, which I used to place round, her pelvis to hold it up securely while she healed.
And then I faced a situation that was always going to happen – a mother who had a fully obstructed labour and needed a Caesarean to save her life. We diagnosed that she was obstructed, we knew she needed a Caesarean section and we also knew that the doctor was stuck behind flood water, some 80 miles away. I watched her for hours, labouring in great pain, and it was obvious that unless something was done her uterus was liable to rupture and she would likely die.
‘She’s going to die, Dear God, tell me what to do,’ I prayed.
I watched and prayed in agony as the woman’s contractions grew more desperate and she got weaker. There was nothing I could do – or was there? Unbeknown to me the staff had already started preparing one of the rooms as an operating theatre. Suddenly I knew: this woman was going to die, for sure. But I had a choice – I should try to help her myself and if she died, well at least I had tried; it had got to the point where I felt there was nothing to lose. I asked for a room to be prepared, and then they told they’d already done it.
I’ve never seen a woman moved into theatre so quickly but even as we got her onto the table, her uterus ruptured. However, it was possible to remove the baby, who had already died, and the placenta then sew her up and repair the rupture. To my utter amazement she did indeed survive. When the doctor eventually arrived he said, ‘I don’t suppose you sterilised her at the same time, did you?’
‘No, I jolly well didn’t!’ I said, probably a bit abruptly.
That night I thanked God for giving me the courage to act. A baby had died, but a woman lived to be able to return to her village and her family. It didn’t take long working in the hospital to feel that I was doing something really important, and I no longer felt left behind by the departure of the Master of Works and the volunteer, but blessed.
Towards the end of our first year in Malawi, this feeling was reinforced when I hosted the grand opening of the new Midwifery Training School. The Dutch Ambassador was coming especially to see where their government’s money had been spent and I had to make a speech. I was determined to make some of it in Chichewa, as well as in English, so everyone could understand.
We decided to get the Ambassador to plant a tree to commemorate the occasion. The building work had mainly been done with the help of non-violent prisoners, who came in trucks every day from the local jail. On the morning of the ceremony I asked one of them to dig a hole outside the Midwifery School to plant the tree in. Rather inconveniently, the labour ward suddenly got very busy, so I was otherwise engaged when one of the student midwives came running in: ‘Mama, you come. Man, dig big hole up to shoulders.’
I went running out to find the prisoner had dug a hole big enough to bury himself in standing up. Seeing as the tree was only a tiny sapling it seemed a bit like overkill.
The opening ceremony was a joyful occasion. I made a short speech to the accompanying dignitaries in Chichewa. By then we had recruited 20 student midwives. They were mainly qualified nurses who wanted to continue their training to get midwifery skills as well, and I have to say I generally found these nurses the best to work with because they had a basic foundation on which to build. I decided that we should alternate days between working in English and then working in Chichewa, so there was a feeling of equality in the hospital and we all learned from each other.
Our teaching facilities were terribly basic – a blackboard and a piece of chalk and one textbook – Margaret Myles’ old standard text on midwifery. It helped a bit – it did have pictures – but the level of English was above most of the students’ capabilities and it was too technical. We also didn’t have the equipment that was in the book, so it wasn’t appropriate for the students to rely on. But still, the students were generally very dedicated. We gave them beautiful blue uniforms made by Sister Belinda, which they loved and kept immaculate. They had different coloured belts according to what stage they were at.
It was a great opportunity for the students: at the end of their course they would sit national exams, which would give them a qualification they could take to other places, and they were proud to be with us. I was particularly fond of Molly, who arrived as a trained nurse and stayed with us after she qualified, working her way up to become a staff midwife. She was a lovely, happy, reliable girl and it gave me great pleasure to see her grow in confidence and rely increasingly on her own judgement.
During my time in Malawi a phrase of my mother’s kept coming to mind – ‘necessity is the mother of invention’. For example, when a mother died and the baby lived (as unfortunately still occasionally happened), the student midwives would have to look after the child until the baby’s family was located in the surrounding countryside and they had made a decision which of the extended family members would take responsibility for the baby. Sometimes this would take a long time. One little girl stayed with us for six months. Her family seemed in no hurry to come down to the hospital and claim her. It proved no problem, she lived permanently strapped to whichever student midwife was most free on the day, and was a very useful addition in our baby skills classes. She got a lot of nappy changes and baths. Occasionally she slept in my room when she was ill, but as I was usually up each night delivering babies, I didn’t get to know her that well. When she was finally collected, there was much weeping from the students.
As it turned out I was right to have been intimidated by our responsibility for the care of the under-fives. Between 800 and 1,000 children had to be seen every year as part of the government’s health and vaccination programme. Generally, about seven in every ten children who arrived at the clinic were malnourished. The most severe cases had to go into the hospital, but for the others we converted a house where they could stay and have supervised feeding. I set the student midwives to work growing vegetables and caring for chickens, so we could offer them some decent food. Meanwhile, Sister Belinda gave their mothers basic lessons in cooking nutritious meals. A great favourite was her rice pudding. Rice was part of the staple Malawian diet, but they never put milk in it. The mothers watched in great amazement as Sister Belinda added milk and sugar to iron-fortified rice, thereby transforming a pretty nutrition-free meal for growing children. As far as I know, milky rice pudding has gone down in the region’s history!
As our first Christmas approached we wanted to give the student midwives a small gift, but we were rather stuck on what to choose. We didn’t know how they would receive a present, whether they would then feel obliged to give us something back in return, or what the custom was. It seemed quite a delicate issue, but we really did want to give them just a little something each. As we sat at the dinner table one night, Sister Belinda had a brainwave.
‘I know, why don’t we give them an umbrella each?’
‘Oh yes, well, there’s an idea,’ Sister Marie-Louise said.
The students hated getting their beloved uniforms wet in the tropical downpours as they rushed from their house to the hospital. I loved the way they took such great care of them, keeping them totally spotless (which was difficult because Malawi was so dusty) and pressed (unlike some of their British counterparts!). So we ordered 20 big, sturdy umbrellas, in a range of the brightest primary colours. On Christmas Eve we wrapped each one and labelled them, and left them on the beds of each of the student midwives.
That night as the time approached for Midnight Mass, we could hear a rising sound of singing coming from all directions. We looked out of the window and could see tiny pinpricks of swinging lights in the dark night as the people came down from their villages to church, all singing their own carols. It was a beautiful start to Christmas, to be surrounded by such uninhibited, joyful devotion; it was, I think, the most meaningful Midnight Mass I have ever experienced.
By breakfast time on Christmas Day, however, we still had heard nothing about our umbrellas.
‘Gosh, I hope they haven’t taken offence!’ Sister Belinda said.
‘I hope they know what they are,’ I added.
‘Oh, look!’ Sister Marie-Louise exclaimed, pointing out of the window.
The students were coming out of their accommodation in a long line, each holding their umbrella and singing as they came up the path. We followed behind them, intrigued and a little anxious as to what they were going to do next.
They walked into the main quad up to the big tree where we had a crib displayed and made a circle around it. The little student at the front stepped forward to face the crib, bowed and showed her big green umbrella. Then her face broke into a grin and she said, ‘Look, Jesus! Look at my umbrella. It is good. Thank you, Jesus!’
Then she put it back down and walked back to the circle, and the next student stepped forward and did the same with her big red umbrella, ‘Jesus, this is my umbrella. See how it works. Thank you, Jesus, thank you for my beautiful umbrella!’
And so it went on until every one of the 20 students had presented their umbrellas to baby Jesus. The umbrellas went on to be treasured by their new owners.
Gradually the items on the list I had written on my first night were getting crossed off – I had set up the midwifery training school, the Land Rover was increasingly used as a mobile clinic to give antenatal and post-natal services to the remote villages, the hospital facilities were gradually being upgraded (we had addressed the ‘failure to walk’ problem by clearing one of the outbuildings and opening it to heavily pregnant women to come and live in simply, in the one or two weeks before their babies were due), and plans were well underway to build a proper operating theatre.
Because there was no such thing as a national health service in Malawi, everyone had to pay to use the hospital. Obviously, most people didn’t have any money. To help, we introduced a scheme where every time they came to the antenatal clinic, the money they paid for their visit was offset against the actual delivery. This meant there was a great incentive for mothers to come in for their checks and we avoided quite a few medical problems later, and most people did not have to pay for the birth of their babies.
But one thing that I felt was still desperately needed was a special baby-care unit for the babies who needed intensive care because they were either born very prematurely or were acutely vulnerable. Our resources were very limited. In the hospitals I’d worked in, back in England, the neonatal units had proper incubators, monitors and breathing and resuscitation equipment. Here, all we could manage was a higher staff-to-baby ratio, hot-water bottles for the night, a fan for the day and specially made tiny clothes. Really, it was about keeping a closer eye on them, their feeding and weight, and guarding them more carefully against infection. However, we felt that this was better than nothing and lives would still be saved, so we got the room set up. We had room for ten babies and it seemed to be helping.
But in newborn babies, particularly those who have been born prematurely, the greatest threat they face is infection. Of course in Malawi we were surrounded by so many more dangerous diseases than at home. I didn’t really know how we could protect these vulnerable babies except by strictly limiting those who could come into the room to the mothers only, and forbidding anyone who had the slightest cough, sneeze, sore throat or – the biggest threat in Malawi, diarrhoea and vomiting – to come in. So I always had someone on the door with a checklist of questions.
‘Which baby are you coming to see?’
‘What relation are you to the baby?’
‘In the last 24 hours, have you had a sore throat?’
‘Have you had a cough?’
‘Have you got catarrh?’
‘Have you had a temperature?’
‘Have you had diarrhoea or vomiting?’
And lastly, ‘Have you washed your hands?’
These questions were a constant hum in the background of the special-care unit like a kind of backing track, and I always had an ear open for them, to make sure they were being asked. One day, I was in there and I was vaguely aware of the reassuring sound of the usual checks taking place, when suddenly one of the mothers shouted, ‘She was sick this morning. She lied! I saw her.’
She was pointing at one of the other mothers, who was stroking her baby lying in her cot. My heart sank.
I went over.
‘Is this true?’
She nodded.
‘You have put your baby in grave danger. You must leave straight away,’ I said.
She left the unit but it was too late. Within a short time her baby started to get sick and within 48 hours, she was dead. One by one, all the babies started to get ill. We worked so hard. All the nurses and Sister Marie-Louise came in to help, but it was no good. Within a few days many of the babies were dead.
Soon the hospital was filled with the most terrible wailing. The Malawian people had their ways of expressing grief, which were loud and dramatic. Sister Marie-Louise and I were quiet, in a state of shock. We didn’t know what to do or where to put ourselves. The staff didn’t know what to do with us either. In the end they took our hands and led us out to the big tree in the centre of the quad, where we usually met for prayer. They sat us down and stood facing us, and started to quietly sing hymns for us. They sang until the sun went down and the moon rose. Thoughts of my father and his resilience came into my head. In the end I stood up and said a prayer for the women who had lost their babies, and then said:
Bless us God, Keep us safe in your encircling arms, with the bright moon that is above us, and the warm earth beneath our feet. Hold us and protect us through the friends who surround us and in our knowledge of you living in our hearts. Amen.
And I went into the house and went to bed, exhausted, in the hope of a better day.
Going to Malawi was the most amazing experience. I grew and I changed; I found an energy and resourcefulness that I didn’t know I had. But it came at a price. By the start of my fourth year I was exhausted and sleepdeprived. The work was relentless; we could only handle a fraction of the mothers who came to us. The sheer scale of the help that was needed was frightening and I began to become overwhelmed with the feeling that whatever we did, we could only scratch the surface. The money, resources and manpower were not there. And most of all, I began to get ill. I had suffered from diarrhoea from the moment I arrived, but I got sicker and sicker, my guts were rotting. I felt I could not stay much longer in Malawi, but I also could not imagine myself back in England, or even back in the Community after being so free. So at the beginning of my fourth year I wrote to Mother Sarah Grace:
Dear Mother,
I am writing to tell you I can no longer continue with my work at St Anne’s Hospital. I am exhausted and I am ill. I am also concerned that I am going to find it very difficult to return to life in the Community after four years away, and I am not sure how to go on living the religious life.
A week later, we received a wire saying that Mother Sarah Grace was on her way over to see us. I felt terribly guilty: it wasn’t a short trip. But when she arrived, a few weeks later, it was not with the reaction I expected. I think she did not know what to say to me or how to handle the situation; I felt as if I had become a stranger to her. For a start she didn’t seem to want to speak to me. Mother Sarah Grace spent most of her time in St John’s House with Sister Belinda. Of course I was terribly busy in the hospital so unless she came down to find me, our paths wouldn’t cross. When I finally did have a meeting with her, it seemed terribly formal. I longed to hear some loving concern and care in her voice. Instead she sat opposite me impassively as I explained that I was exhausted and ill.
‘Well, you have just got to get on with it,’ she said.
‘I don’t think I can carry on, Mother.’
‘In which case you will have to come home.’
‘But I’m not sure I want or even can come home now. As I said in my letter to you, I don’t know how I can return to Community life or perhaps even stay in the religious life. Being here has changed me absolutely.’
‘Sister Catherine Mary, you made formal vows to God. You cannot seriously consider breaking them. No, I can see, you need to come home straight away.’
And that was it. Before I knew it, I was packing my bags and Sister Sarah Jane was on her way out from England to replace me. It was heartbreaking. Anton was in tears: ‘Goodbye, Mama,’ he said, bowing and then he broke my heart by bursting into the first verse of one of my favourite hymns,
Abide with me, fast falls the eventide;
the darkness deepens; Lord, with me abide:
when other helpers fail, and comforts flee,
help of the helpless, O abide with me.
I’m not sure what I had been looking for from Mother Sarah Grace. Maybe some understanding, some recognition of what I had been through, that I had tried my hardest and yes, maybe some praise. I think I definitely needed to feel someone cared, that I was cherished in some way and concern could be felt for me. Sometimes I had felt these things from our Reverend Mother and indeed the rest of the Community, but on this occasion I didn’t. I was left feeling like I had failed.
A year later, when we had completed our five years, the Sisters packed up, handed over the hospital to the diocese and national midwives, and came home.