Of course there are many days when one feels like quitting, getting back to a place where things work, where women are not beaten up in the market near our house for wearing slacks, where one does not have hurled rocks ricocheting off his car.

Today was not one of those days.

First to see me was an 18 year-old HIV-negative woman who had developed a month of headache and severe vomiting. One of her eyes could not move outward because of nerve paralysis. A new CT scanner at another mission hospital showed a diffuse brain infection. After much debate, we treated her for TB meningitis. Today the eye was nearly back to normal, the headache and vomiting gone. She cried when I told her she would need another month of injections (standard TB meningitis therapy here)--she wanted to go back to school and can't because there is no clinic nearby.

The next client also had TB meningitis, initially diagnosed 2 months ago. She is HIV-infected, and was so ill and confused we had to hold her down, insert a tube through her nose and into her stomach, push in the medicines, and take out the tube--repeatedly. She improved, but was extremely stiff when she left the hospital (from brain damage), and I thought she may never work again. Today she completed her own registration paperwork at the clinic, and walked normally.

Another man I met two and half years ago when visiting patients in the nearby slum with one of our nurses. He does not have HIV. She had found his situation so pathetic that she was trying her best to alleviate his suffering. For six years, uncontrollable itching and a terrible rash had dealt him a miserable existence. We got him into the clinic, sent a biopsy to UCLA with a visiting dermatologist, and put him on the appropriate immunosuppressive therapy. He almost died from severe pneumonia, and was one of the very first people admitted to the new ward after it opened. Now he is fine, with just minor itching. He is poor, and pays nothing, but he brought me fresh fish once.

In the afternoon came a West African man who had grown up in the US.  His wife works for an international organization, and he runs a business across several countries in the region.  After a 17-hour car ride two months ago, he felt a sharp pain in his chest, and then could no longer undertake his daily run, could not even make it twenty yards. Another expatriate doctor referred him to me. We immediately started blood thinners for a presumed pulmonary embolism, and the next day he got on a plane to South Africa--where tests confirmed the diagnosis. After returning to Malawi, and feeling much better, he told me the doctors in South Africa couldn't understand how I had made the diagnosis and started potentially dangerous treatment without technology. It comes from long practice in Africa: When faced with a very sick person, you either act to save a life and take the risk of being wrong, or else matters most certainly will not end well.

Yes, there are many days I would rather not be in Malawi. Today was not one of them.

Yours in struggle,