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