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 :)