lessons learned

When I was looking for jobs working abroad last year, I had a lot of ideas in my head about what this year could be.  I had worked in places before for a month or two, and always felt like I needed more time. I pictured a year as this perfect time period to have enough time to learn the ropes and then jump in and go full force, teaching, seeing patients, making a difference.

What I learned is that a year is not long enough at all.  A year is just scratching the surface.  It takes a long time to find your role, to determine what is important to the locals, to find where you can enable and not overpower and turn things into your own agenda.  It takes a lot of work to place people in a position that is only 1 year long and provide the communication and tools they need so that they can be effective and integrated into the system.

When I came to Malawi, I did not expect the department I would be working in to be primarily foreigners.  That I would sit in a meeting with the heads of department and look around the room to see only white people.  This is not to say those people are not making a difference or that their hearts are not in the right place.  But I find it hard to believe we are advancing healthcare in Malawi when I add yet another non-Malawian to the table.  Do I have the answers as to how we help transition a country that is so dependent on foreign aid away from this? No.  Do I think that what I was doing here is pointless? Also, no.  But do I think this is the place in Malawi where I could be of the most use, educationally or clinically? Probably another no.

Advice from previous volunteers, other people I knew who have worked abroad, and during our orientation seemed to reiterate that there is a pattern to your emotional stability and adjustment.  You will start the first 3 months a lost soul, finding your bearings culturally, geographically, emotionally, clinically.  You should observe. Be present. Slowly take it in.  By 6 months you should be functional.  Maybe not an efficient machine, but not useless.  Then by around 9 months, you've got it down.

Was this my pattern?  Some of it, yes. I definitely now feel more comfortable clinically.  Sadly, I have seen so much HIV and TB I can diagnose (or at least add it to my differential) automatically.  PSHD (presumed severe HIV disease) is not an acronym I thought I'd ever use during my training but here I write it daily. There are still tons of scenarios where I feel like I have no idea what is going on with a patient, still can't figure it out because there aren't any more tests we can do, still turn to my Malawian registrar or clinical officer and ask for validation because they've seen a diagnosis 75,000 more times than I have (and are a million times better at any procedure than I am). Geographically, I mostly know where I'm going.  I no longer turn down the complete wrong hallway trying to go from the inpatient unit to the emergency room. Still don't know where a lot of the secret stashes are (potassium supplements on oncology ward, heparin in one of the adult wards).  Culturally I think I could be here 10 years and still not know all the nuances.  But I can tell jokes now and get a smile from people rounding with me (who maybe have just become culturally acclimated to me and smile to get me to shut up).  Emotionally, I don't know. I think there are less days where I come home feeling completely drained.  But it still happens.  I still come home some days after seeing hoards of kids with PREVENTABLE and TREATABLE illnesses and want to punch someone (Donald Trump? I don't know who exactly) in the face.  I still feel defeated and tired and useless some days.  The main difference now I'd say, is that I have just had more time, more of a chance, to see the slivers of hope that come through when you least expect them.

Some days I feel like I should stay forever given that I finally have some things going on and have made enough connections to get a few things going.  Other days, I feel like am ok. That maybe I was mainly here to provide some of the spark, that when combined with the extremely capable locals in our department, will light a fire that they can keep burning long after I'm gone.  And maybe one day they will look around the table and see that every head of department is a Malawian.

I have another list of things I will miss and some travel recommendations, but I'll save that for another day.

the simple things

Whew, it has been awhile.  I did a lot of traveling the last month and it was hard to just sit down and write.  I will probably post a few things over the next couple weeks though as my time here comes to an end. I want to post about traveling in Malawi and also some of the things I've learned here.

I don't know if it is a product of growing up in the U.S. or in western society in general that has given me the habit of being cynical with an underlying distrust for anyone asking for help/aid/money.  We learn that people work the system and take advantage of us.  I have seen Malawians help people out however they can, and this help is often not monetary.  Most people don't have much, but they will give you what little they have if it will make your life easier.  They will push your car out of a ditch, change a flat tire, or give you the string from their hoodie to make an impromptu dog leash (this actually happened), without thinking twice.  Driving is like having AAA, because you know if you breakdown along the way someone will be there to help you.

I hope this is something I can take home with me.  As Americans (or at least as me), we value our time and get impatient and angry when people waste it.  We forget people are people first.  In Malawi, you are greeted as a person first, regardless of what you came to do.  Everyone from the janitorial staff to the vice principal of the medical school gets asked, "How are you?" before anything can proceed.  You are acknowledged as a person before you go on to provide your services.  There is less suspicion that people are just out to get you.

I have spent some periods of my life in the past where I became obsessed with buying stuff. These were times when looking back, I was feeling alone and empty. So I tried to make up for it with material things.  When I work abroad, I realize this obsession is gone. I don't think about clothes (ok, I think less about clothes, its no secret I have a chitenje obsession over here), or shoes, or phones, or cars.  I am happy with simply having things that function well.  I am happy with what I need, and not thinking about everything I want, or could have.  I would rather buy a nice gift for someone and see how happy it makes them than buy myself something I don't really need (which is definitely not typical for me).   Not saying I am perfect and never buy anything or want anything, but it is different here. It isn't something that I think about on a daily basis of keeping up with everyone and the consumerism that is a part of our culture.  Hopefully a little bit of this will follow me when I come home.

I won't generalize, or pretend I understand everything about Malawian culture and its people, but I do think more value is placed on relationships and our ability to be happy with what we have.  Maybe I am not that important. Maybe my time isn't any more valuable than anyone else's.  Maybe I can't even change a tire on my own.

This week, I was lucky to meet some of the pediatric clinical officers (like physician assistants who have done extra training to specialize in pediatrics).  They are working out in the districts seeing sometimes over 100 kids on their wards, alone, as the sole pediatric clinician.  Despite this, their energy and enthusiasm is contagious.  Their questions ranged from what to do to with difficult diagnoses, to "How do I convince the government to fix our ward because the infrastructure is crumbling?"  Their brainstorming of how to solve huge problems they are faced with everyday (yet some how still keep smiling) was amazing.  At the end of the meeting, one of them added, "Oh and can someone here just steal me one box of urine dipsticks? No, seriously. We've been out of these for months now in our district."  Followed by laughter and everyone chiming in all the supplies they've been out of forever that they've given up on ever seeing again.

From this interaction, I wish I could have worked with people like this all year.  Not that the staff, trainees, and specialists in the tertiary hospital where I work don't care, but this is not where the need is greatest.  Support is needed out in the districts.  Out where being able to test a urine sample for infection is considered a luxury. Where one clinical officer has to juggle seeing patients, referring patients, calling specialists, working oftentimes with no electricity, no water, but still wanting to learn more so that they can help their patients as much as possible.  I honestly don't know how they don't get burned out and quit.  One of them asked if we could have training on how to advocate for children who they can tell are being abused or neglected when the parents lie and deny this as child protection laws (and their enforcement) aren't very strong nor clear nor enforced.  They are faced with some heavy shit on a daily basis.  I am hoping now that the central hospitals have been strengthened, more focus will be on supporting those out in the communities.  I wish I would have found ways of supporting them sooner.

Again, some photos of beautiful Malawian scenery:

mountain hut at mulanje

some cloud mist and wildflowers up on the mountain

The most fake-looking real picture ever taken

3 zebras staring me down

the zebra family that visited our campsite at Nyika

shake the dust

Awhile back, my brother sent me the link to Anis Mojgani's performance of his poem, "Shake the Dust" which is amazing to watch if you haven't seen it.

The poem ends:
"Make sure you live, shaking the dust
So when the world knocks at your front door
Clutch the knob tightly and open on up
And run forward and far into its widespread, greeting arms
With your hands outstretched before you
Fingertips trembling, though they may be"

I have been thinking about this poem a lot this week. Trying to focus on the positive when there have been so many negatives. When dust is being showered on some of the most vulnerable, marginalized members of our society.  I thought about what it means if the dust is too thick.  If the dust is beyond dust and more like clouds of black flies, toxic and alive.  I think at that point we can't try and shake the dust from ourselves alone. We need to shake it from each other.  And right now there is a lot of shaking to be done.  

I have focused a lot on the negatives of being here so the past couple weeks I tried to take note of the positives.  I had a good couple of weeks.  I went home a few days bursting with pride in the interns and clinical officer students.  We did resuscitation teaching for several them a couple weeks ago and they were eager to learn more and practice their skills on the dummies that we have, asking tons of questions about what equipment to use and how to perform procedures properly, concerned about being able to treat children in the most effective and safe way possible.  Some of them care so much. One of the clinical officer students told me, "We are always eager for more teaching."

We spent some time going over fluid management in the emergency room with our crew of dudes who have been rotating through there the past 2 weeks.  We somehow managed to have an all male group of med students, interns, and clinical officer students.  It was both endearing and hilarious to see them all huddle together and concentrate when we asked them to calculate fluids for some example cases.  

Post-call the other morning, we needed to do a lumbar puncture on a patient, and our wonderful intern (after spending a night in the hospital) was already done with her morning rounds and did the procedure with plenty of time to spare before we signed out.  Our awesome pediatric clinical officer did a paracentesis and ultrasound with me during a busy afternoon and did a perfect job, teaching me a lot along the way (as he stuck a giant needle into a child's abdomen I was mostly excited I gave IV sedation and the right medication to keep the kid from barfing during the procedure). 

It has been nice not to have to round on 30+ patients each morning and actually have time to teach and work directly with trainees in their initial assessment and management of sick patients.  Though I've been on call a lot this month because we were short-handed, I've felt less drained and burned out because I've had time to think and teach, which has been my favorite part about being here.  

Last week I also went up to Mount Mulanje, which is a really beautiful and peaceful place.  I have also been watercoloring (I will spare you any pictures of my terrible art, but the therapeutic value is incredible) and reading a lot of poems which has helped me de-stress and come back to things my introverted self used to enjoy before medicine ate my soul (ok, ok, a little dramatic, I still have part of a soul left).  Here are some pictures of stuff.


panorama at the top (I learned I am terrible at taking these)



views looking down

our little mountain hut


so green.

Christmas present from my lil sis = Spongebob makes it to Malawi

corn fields and mt michuru on this weekend's bike ride

the edge of the earth

You probably think I fell off of it given my lack of any updates for the past few weeks.  It has been awhile. Part of this is because I was sick and in generally feeling low on energy and lazy. I also worked over Christmas week.  I also was having a hard time writing what I wanted to say.

About a month ago, I had a headache and felt exhausted. A few days later I got the most disgusting sore throat of my life, swollen lymph nodes, the works. Thinking this was strep and that I in no way wanted this to turn into rheumatic heart disease (which we see all the time here as a sequelae of the strain of strep bacteria) I took amoxicillin.  Six days later, I looked like a lobster woman.  My face was swollen, I had an itchy, red rash everywhere, and my skin was inflamed and swollen.  I figured this was the amoxicillin.  Turns out, nope. About 2 weeks later it was still going on. I asked everyone to help diagnose me.  The peace corps medics, my colleagues, random people on the street, telemedicine consults home. Everyone asked if I changed laundry detergent, which is a question that when we ask our patients with gross rashes back home, I am always thinking, “For reals? Like detergent can cause this crazy rash?!?!?!” Well, actually, it can. And its name is Toss.  Little did I know, our lovely lady who cleans for us bought a different laundry detergent.   According to the bottle, it is for babies and sensitive skin. But it smells like someone took every perfume in the sale bin at TJ Maxx, dried it, and mixed it with baby powder. 

Don't be misled, definitely not gentle

Shortly after this discovery, I went to Cape Town for a vacation.  The city is beautiful.  It is not intimidatingly huge, but has everything you need.  Good food, great yoga studios, beautiful geography and scenery, generally friendly people (if you are white).  I shopped more than I should have, took a million pictures, and soaked it in. I didn't realize how much I miss being in a big city and being able to walk all over.  One of the days I walked 10 miles just around the various neighborhoods, wandering in and out of places. 

Bo Kap

district six museum

top of lions head

woodstock street art

The culture in Cape Town is super interesting to me.  The history is insane. Not knowing much about apartheid in advance, I decided to learn as much as I could while I was there.  I was lucky to travel with a friend who is much more outgoing than I am and engaged a lot of the locals, starting conversations and asking questions. You can tell there is still a serious racial divide (unfortunately, all too reminiscent of our own race issues in the U.S.).  Because we were travelling, we interacted a lot with people working for the service industry. In South Africa, this means Zimbabweans, Malawians, black South Africans, Congolese, and the list goes on.  It is a melting pot of Sub-Saharan African culture.  Everyone we met was so kind and hospitable, despite the fact that they work extremely hard, are treated like shit, and are fleeing difficult conditions in their home countries where many of them still have family.  It is still crazy to me why we treat people the way we do because they are different.  I do it too.  But why is this something that seems to come naturally to humans?  It is hard to wrap my mind around apartheid being so recent. Even the Civil Rights Movement in the U.S.  How did we do this to each other?

blender lamp in a tiny township house

my fave color township house

I still wonder a little bit about my year so far in Malawi and how it could have been different if I had done something else. When I was looking for jobs/volunteer positions abroad, I considered a 2-year position in Columbia working with community health workers. I ultimately decided this was too remote and too clinic-based for me (loving the emergency room and acutely ill patients).  After the past six months, I question this a little bit.  I think there is something to be said about working directly with locals.  This is what I have enjoyed most about my prior global health experiences.  It is extremely uncomfortable at first as you find your feet in a culture and language that is not your own, but then as you are forced to put yourself out there, the rewards are indescribable.  Here, because there is a decent ex-pat population, I interact much more consistently with foreigners than I do with locals.  I wish I could have more of a connection with my patients.  The same social structures (and conflict) we see in the U.S. when groups of strong-willed people are put together are just as prominent here.  My favorite part about prior experiences abroad was this lack of drama, something that we as Americans (myself included) are obsessed with on every level.  The medicine has been the easy part for me to deal with emotionally. It is the politics and drama that are tough. 

I don't regret being here, but the challenges have not been what I expected.  Some days my heart is so full it could burst; other days I am completely disappointed in myself and the entire human race.  Today I helped a little girl in heart failure sit up to make her more comfortable. As I touched her, I wanted to cry. I wanted so badly to see her and the people of Malawi sit up and say, "It's ok. I can do it myself." Because everyday I ask myself when that will happen. When a country with no economy, so devastated by everything (those who came and went, those who came and stayed, the climate, the infectious diseases, corruption...) will be able to be self sufficient without foreign aid. If I, and everyone else here, is actually doing more damage than good.  Really lighthearted things to think about on a daily basis. On that note, here are some elephants and stuff.   

Liwonde

Creepy baby croc party

all the mango things: strawberry mango jam, vodka, even more vodka disguised as gin

Thanks for reading! It is nice to have this link to everyone back home :)

women in malawi

You balance it on your head

A heavy bucket

Full of water from the pump

Standing straight and tall

Walking with your head held high 

Some, they don't see this crown

They think you are not fit 

To be a queen

You are not worthy

Of learning, of reading, of owning, of being

They send the boys to school

As they run past you on the dusty road

Laughing

Not recognizing 

You are the backbone

Who wears a crown

With no jewels or gold

But worth kingdoms

Not realizing 

You carry their weight on your shoulders

And the future on your back

I wrote this months ago during our stay in the village, but the longer I'm here, the longer it resonates with me as I see what it means to be female in Malawi.

Peace Corps (per the United Nations) is in the middle of 16 days against gender violence.  I wish I could say I haven't seen any gender violence here, but unfortunately I have.  On my on call shifts I have to medically examine girls who come in for "defilement" or sexual abuse.  I have heard their testimonies, interpreted for me by our registrars, many of them who are young females, so I'm sure it's not easy for them to hear firsthand these accounts of terrible events. Groups of boys jumping and sexually assaulting a girl on her way home from school, a neighbor who raped a developmentally delayed girl, among others.  It is frustrating to say the least.  I am so happy to work in a hospital that has a One Stop Center, UNICEF-created clinics where victims of rape can go for healthcare, exams, and counseling.  Police reports are filed, though I have no idea what happens from there.

I have been amazed here at everything women do.  From a young age, girls do everything.  During our stay in the village, I saw the women of the community run the house.  And by women I mean any female over the age of about 5-6 years old.  They are outside by dawn, sweeping the floor, washing dishes from the night before, fetching water, starting the cooking for the morning.  Girls do go to school, but during their time off, they are busy.  And they can balance almost anything on their head.

When we were at the lake last weekend, we were constantly swarmed by young boys whenever we got in the water.  Laughing, swimming around us, trying to see who could swim the farthest.  The girls were on the shore doing laundry, occasionally getting in the water to fill buckets, but they did not stay long.  The boys can run and play and waste time. The girls work.  

During these 16 days, I have learned more facts about girls and women in Malawi.  Half of girls in here are married before they are 18.  Young women 18-24 also make up 58% of Malawi's HIV infections.  Most girls do not complete their schooling and only 67% of women are literate.  

There are two bills currently being proposed in Malawi's government that are being protested.  One is the right for a woman to terminate pregnancy, the other is to make homosexuality legal. I read an article the other day from an extremely conservative newspaper here discussing how abortion is the gateway to "widespread euthanasia" and other "forms of murder and brutality" (Termination of pregnancy bill). This is happening in a country where contraceptive rates are 46% and the average number of children per woman is over 5.  

The BBC published an article about ritual sex practices in Malawi if you haven't seen it: The man hired to have sex with children.  Recently it was updated that he was sentenced to 2 years in jail and hard labor.

Despite how awful most of this sounds, I am happy to be part of an organization that works hard to empower girls and improve the status of women around the world.  I also work alongside Malawian female physicians who stand up for the mothers and children we see everyday.  They are role models for our patients and girls all over Malawi.  There is still so much work to be done.

Thanks for reading and supporting me while I'm here. I'll post pictures some other time, they didn't seem to fit with the theme of this post. Or follow my instagram (bananneka). I post things there from time to time :)

we are more

sometimes the drumming is so loud it becomes your heartbeat
it becomes everyone's heartbeat
there is no you or me or them
only Us
and We are loud
We are so loud
if you want a wall
We will give it to you
a wall of sound
of voices
of music
of love
dynamic but unbreakable
We will pound eardrums
We will shake souls
We will dance into the night
the moon our only light
We will join hands
We will embrace
We take up space
so much space
We will move this earth
We will shatter history
a force so strong
you'll feel us in your bones
deep to the core
you thought you could quiet us
but We are Us
We are more


drums on drums on drums

I had a post started for about a week now and hadn't been able to bring myself to finish it.  Then a couple of awesome doctors here had a celebration with lots of music, theater, art, tons of talent, and that poem just came out.  It had been a long two weeks. I was on call last weekend so I worked 12 days straight.  At the end of the party, I found myself dancing in the middle of a group of people of all backgrounds.  A local hip hop artist trying to teach us some steps, a painter looking just as nerdy as I was trying to bust a move, doctors throwing up their hands with reckless abandon.  It was exactly what I needed.

I've been frustrated.  Before all of the election drama, I was already getting frustrated with the politics of my department and of the medical education system here.  Coming into this position, I knew I wanted to be somewhere that I was doing both clinical work and teaching. But lately I have had the increasing feeling that I am up against a wall here.  I run around trying to staff 30-40 patients per day (unable to actually communicate with them myself) and see the same things over and over.  Babies infected with HIV who are supposed to be screened and followed up but aren't (even though HIV is probably the most well-funded disease here), children dying of TB with a known contact who aren't picked up for exposure, just an endless circle of terrible outcomes and preventable diseases.

So not hard to see why I often leave the hospital completely defeated.  Plus the point of being here and Seed's mission and all that is to strengthen medical education.  And I feel like I don't even have time to think let alone fit in teaching.  I started feeling a bit more optimistic after working with the students last week.  The students here in general are great to work with, but we had a particularly good group on the unit.  After a couple of great days precepting cases with them, I was less cranky.  Then started thinking about the health system here and how there is no money and they are in a hiring freeze so all of these fantastic students we are training will never get jobs here.  They are forced to look for work in South Africa, Swaziland, Lesotho. If they are lucky they might find a job in a private clinic, or with an NGO, or on a foreign-sponsored research project. Despite this, they work incredibly hard.  They are the ones spending the time to explain how to use an inhaler to a family, counseling mothers when their child dies unexpectedly, and chasing down lab results.  So it is not easy knowing that the future for them is very uncertain.  I question almost daily if I should be here, or if it would be more beneficial to just pay one of the many qualified Malawian doctors who would love a job in their home country.

I considered making some comments about the election, but I'm not really sure what to say.  Although I'm still in shock that this man can be president,  I am mostly depressed by the number of intolerant and angry people it has revealed, especially in the aftermath. I think I knew our country still had a lot of this, but maybe wasn't sure of the extent. I at first thought I am sheltered from it, living in California.  But the truth is, I'm really not.  It exists in my own family, on my street, all over my hometown.  And I have made excuses because I know these people will not change their beliefs based on what I say, so I gave up arguing.  But I could have done more to let them know that this is not ok, and I want to start doing that now.  How I am going to have the courage to do this, I'm not sure. Something to think about.


Some less dismal things recently:

my malawi welcome from our gardener


and from my malawi fam


views of blantyre from mt soche


soche!


Malawi hallowatermelons

home

I am sitting in SFO right now waiting for my delayed flight. A flight that starts the long journey back to Malawi.  I thought about writing while I was home, but it was hard. Both hard to fit in and difficult to know what to say.  I didn't realize how much I missed home until I got here. I felt a little guilty about it.

I loved every minute of being home.  Even flying around to 7 cities in 3 weeks and living out of a suitcase.  I saw some of my favorite people (don't worry those of you I couldn't squeeze in, you are still my favorites too) and was overwhelmed with the love and support you gave me for what I am doing. Plus interviewing for something I love to do and meeting others who are just as pumped about it was pretty awesome. It is not easy to leave this and go back to somewhere that I am so far away from all of that.


Examples of support: interview words of wisdom from my mom

I also missed my Malawi family a lot and felt really disconnected from life there.  I was thankful for the texts and pictures from everyone so I still felt a little in the loop.  And the requests for all the goods I am trafficking home :)  It was just starting to feel more like home when I left, so I am hoping it will feel that way when I get back.  It is hard going back knowing that from here I won't be home again for another 9 months. Knowing I'll miss Thanksgiving and Christmas (for the 3rd year in a row) is pretty awful.  But I knew that when I signed up for this and I know the Malawi crew has some fun holiday plans.

Some highlights from my U.S. tour:

residency buddies and skyline views in philly





















Walls of pez in our Air bnb in portland



being cool at portland shows and catching up with an old friend






BFF, beer, and amazing views in portland




























hiking and matching cargo shorts in reno.  Plus tons of dogs including murphy and her fave vodka-themed toy :)





beach views, old and new friends in SD

Plus many many more awesome people and friends and stuff and things that I couldn't capture.  I am eternally grateful to those of you who opened up your homes, offered advice, met up with me to catch up on such short notice. It meant so much to me that I'm traveling back to Malawi with a full heart.  Overflowing.  I know Malawi is where I need to be right now, despite how hard it is to say goodbye again.  I'll miss you all and there is an open room for any of you waiting in Blantyre if you ever want to visit.