Expressions of gratitude

June 8^th

               I turned 41 last week.  Based on the suggestion of Dr. Mo one of our recent visitors, I was challenged to make a list of 41 goals for the coming year, a “41 at 41 list.”  One of the things on that list is to write more thank you notes.   In other words I want to be a person who expresses gratitude.  Three days ago I experienced gratitude that has put “writing thank you notes” into perspective: aa grain of sand is to the sand on a vast beach, a thank you note is to this experience. 

                  Friday was my final day at Ndirande health center.  Friday started as a normal day. I arrived at 8am, went to the “handover meeting” where the maternity and medical cases are presented by the labor nurse and the post-call clinician.  Dr M, myself and Dr Z offer some teaching relevant to the presented patients and announcements are offered.  That morning I was told to be ready for something at 2pm.  I proceeded with my morning: rounding on antepartum and the short stay ward, and then I started seeing the patients who line up daily in the “queue” to be seen by the “consultant.”  Seeing patients in the queue usually lasts the better part of the morning (until about 1:30) and then we break for lunch and complete the day with more outpatients, emergency cases, procedures, or OB consults.  I know this routine well.  My interpreter and I have a comfortable and efficient rhythm.  The patient’s common problems, routine procedures and even many of the individual patients are familiar to me now.   I know our room, the smells, the dust and the broken faucet.  I know the limitations of working in this environment and how to navigate to try to provide the best care for the patients who come.  The other clinicians and nurses are comfortable with asking me for help or advise and even pointing out things that I did not do correctly.  I am comfortable interacting with them as colleagues and friends.  There are people whom I greet every day and am given a big smile in return and there are the daily predictable stares by people who are silently acknowledging that it is strange to see an Uzungu (white person) around Ndirande.  I am used to this place. 

As 1:30 approached and the queue was coming to an end I starting taking pictures of seemingly mundane things that would allow me to keep the memories of this feeling alive after I return home.  

sign for the consultant clinic on the door

the sink and window in our consultant room.

one of the two examining tables and our ultrasound machine

looking out our door at the health center

Working together with me this day, Dr M would periodically express sentiments of sadness about me leaving which I tried to ignore for fear of tears erupting.  I feel like it has been a gift to me to work here. As I anticipated coming to Malawi I had wishes.  (I will not call them goals as that sounds too practical and serious.)  These wishes were the things that I would think about in my daydreams. 

* I hoped for the residents that they would find joy using all the skills they have learned in residency to take care of patients no mater age, condition or circumstance.  I hoped that they would feel part of a team that was vastly different from the team with whom they work in Seattle; I wanted them to gain both a sense of confidence that they can adapt to a different setting and contribute to the vast needs that exist here but also experience humility realizing how much they can learn from those around them. 

* I hoped for myself that I would be a model of patient centeredness and principles of family medicine.  In a country that does not know this approach to patient care, I wanted to do my part in a small corner to demonstrate what this can do.  I wanted to lose some of my fear that I “can’t do it, I do not know, I am not capable, some is better than I am .”  I wanted to become more of an African doctor—just do it because it needs to be done. 

* I hoped that I would be able to look back and say, that place functions better, the Malawian clinicians have higher job satisfaction and those patients receive better care because we were there. 

Friday afternoon was a daydream coming to life. At 3pm I was invited around the broken gate to the houses behind Ndirande.  Chairs, a sound system and a barbecue were being set up.  Crates of sodas were being carried to the scene.  Slowly my colleagues were arriving in beautiful clothing (different from the uniforms they had worn in the morning), chitenji wraps, decorative headpieces carrying bags of food and gifts.   When the smoke from the barbecue filled the air and the music was bumping the festivities commenced.  “The order of events today will be opening prayer, speeches, food, dancing and closing remarks” announced Dr Z in a perfectly balanced combination of honor and friendliness.  I wished that I could have captured the things that my colleagues and friends said that day.  Not only were they generous with their words toward my efforts of working in Ndirande and contributing funds to help support changes in the physical structure, but also they spoke of improved teamwork and collegiality and a sense of their work being purposeful.  The words were illustrated in the scene around me.  We had a gathering post Christmas, a time for people to gather and share food. It was a nice time.  But this was so different.  There were three times as many people and three times as much a much laughter compared to the December party.  Everyone was dancing and I could tell it was because their souls was joyous. I saw clinicians and nurses hugging  (not something that would have happened readily 5 months ago) and they wanted their picture taken together. 

In a setting where people think twice about buying a hot lunch for one dollar, people were feasting on meat, samosas, fried banana bread, potatoes and salad. Drinking of Fantas, wine and beer was plentiful.  Smiles punctuated with laughter went on for hours .  

Mr Phiri—clinician lead, a man who has started and ended this year with me, taken the residents on dermatology outreach trips and shared call with them--gave the closing remarks.  The rate of his speech was turned down a notch reflecting the influence of 3 hours of wine drinking but his smile was as exuberant as ever.  He spoke about the significance of the year by acknowledging each resident by name.  “First there was Ben and Beth. The first ones, they worked hard, they were so friendly and funning.  I heard that Ben donated some money after he left. Then there was Kannie who loved everyone, she was one of my favorites.  And then Emmy and Emily and Laura…”  He kept going on and on with each resident, in order, without notes, acknowledging their personalities.  “And Janelle, she spoke Chechewa and she will be back… and then there was the BIG THREE….” (Referring to Dan, Nick and Rebecca.)  This speech took a significant amount of time such that people were tapping their wrists playfully reminding him  that the sun was setting as he was giving his closing remarks.   

            I was given beautiful chitenjes to wear, a dress made for me by a certain tailor who had my measurements and matching shirts for my family, a large cake, and a bottle of non-alcoholic champagne to pop ceremoniously.  The residents left behind six white coats and I was able to give six white coats to the six clinicians who have been with us on this journey as well as some laminated photos that I had taken throughout the year. 

This party was so much beyond what I deserve and it represents financial sacrifice that is incomprehensible to me.  But it was one of the best days of my time in Malawi.  I am so deeply grateful.  I am not sure that writing a thank you note will be sufficient for this.  But I will do it anyway since it on my 41 and 41 list. 

We are traveling home in less than two weeks.  The tension between coming home and the desire to stay here in this life is like a taught guitar string.  It is a good place to be.  I suppose with this analogy we can imagine that this is the music of a rich life. 

waves of change

April 10^th 2015

The longer I am here my perceived successes and failures become more nuanced and my goals less clear. 

In the days and weeks surrounding our transition away from the US and into Malawi, I was stalked by the hymn “Take my life, and let it be.”  I kept hearing this song everywhere I went. I found this to be both eerie and profound and it became a sort of spiritual mandate for my time here.  As I understood it through the lens of this hymn, I took my mandate to be: I should go with faith that the work that needs to be done in Malawi would become clear if I was open to direction from something greater than myself.  This was a very comforting and restful mandate at the time--I felt immersed in newness completely unqualified to set goals for my time.  Over the past 8 months I have tried to listen to direction from outside myself and I have tried to be a servant. I have tried to figure out how to help propel forward motion and to carry on the good work that had started before I came and would carry on after I left.  I knew that did not want to start something new that would not be finished. Over the past 8 months I have learned a lot about how things work here, I have become passionate about my specific work and I have developed my own personal goals amidst the larger goals.  However, insidiously, my own agenda became important to me.  In my mind, clarity grew that I was here for three reasons.  I verbalized these reasons during casual conversations with people who asked why I came to Malawi.  I meditated on these reasons as I planned out my days and weeks and allocated my time.  I had woven these reasons into the fabric that will be my memories of my time in Malawi. 

The three reasons:

1) To help Dr. Martha Makwero continue to develop and strengthen Family Medicine in Malawi by helping with teaching and curriculum development for the medical students new residents. As of January 2015 Dr Makwero was quite abruptly appointed Head of Department of Family Medicine; she needed a co-director this year and this is what I became.  We work well together and we have made some very good progress. 

2) To build a foundation for an academic partnership between the Family Medicine programs affiliated with the University of Washington and the Family Medicine program in Malawi.  For years I have wanted to see this type of partnership come to fruition. I have been compelled by the potential dual benefit of academic collaboration between developed and developing programs.  If our academic institution could assist with mentoring, teaching, faculty development and added human resources to fill gaps, and our residents could travel to a known place, learn from Malawian clinicians and enrich their medical training then everyone wins.  Since we have been in Malawi, we have welcomed 12 residents to work in this country.  Each resident has gone from being awestruck and overwhelmed to being part of the clinical team over the course of four weeks.  The clinicians with whom they have worked have appreciated their help and are sad to see them go.  No resident has been eager to get home and I can tell that every resident will hold Malawi in his or her heart forever. 

 

3) To help Martha build Ndirande Health Center into a community hospital which can take better care of the 250,000 people it intends to serve and to eventually be a training site for family medicine.  This is where I have spent most of my time.  This is where the US residents have been working.  I have been seeing patients, interacting with the Ministry of Health to advocate for including Ndirande into the city’s strategic plan, working to improve quality and teamwork within the health center and raising money to support these improvements.  Along with Martha, my growing aspiration was that in five years Ndriande would be a community hospital providing quality care to this impoverished urban community and would be a model family medicine training site where Malawian and US trainees would work side by side.  This would be a place where money would be raised to build an academic partnership that benefits patients, the Malawian health system, US and Malawian trainees.  It is a place that would test the feasibility of this model so that other health centers around the country could follow. 

Ndirande township 

Patients waiting to be seen 

Though I described three separate goals which individually occupy portions of my work week and involve different stakeholders, they are interconnected.  Family medicine development needs a model and it needs human resource support.  Ndirande can be one of several such models and the academic partnership can fill some of the human resource gaps.   I felt satisfied that I had been brought to a place that needed my skills and I was working hard to continue the momentum for positive change. 

About a month ago, my sense that I understood my purpose and had a sense of control, started to evaporate.  I had envisioned the pieces falling into place one way--when in fact the pieces were falling a different way.  I had envisioned that the work and the academic partnership that had started this year at Ndirande would continue for many more years to come--when in fact it became clear that the academic partnership would not continue at Ndirande.  I had envisioned ongoing help and support from doctors and donors and had discussed this with my new Malawian colleagues--when in fact I can not promise this at all anymore. 

What happened? Mangochi District Hospital (about four hours north of Blantyre) is currently the primary site for family medicine training in Malawi and it is dependent on outside family medicine faculty.  There have been two faculty in Mangochi this year and there is need for at least two more to replace them.  At this point, there are only two faculty coming next year to Malawi and there are at least three needed to replace this year’s three volunteers (myself and two other SEED volunteers).  The two that are coming are  UW faculty whom I recruited (NN and AM) UW residents will go to Mangochi next year, the will go to Mangochi next year. The fact is at least two faculty are needed in Mangochi next year and the residents will be a huge help to family medicine training there next year.  But that leaves Ndirande to function with the budgetary and human resource strain that it had before I came and helped make it a priority.

This is not the whole story.  Writing the whole story would be too long and not that interesting for you reading this.  But it is enough of the story to share that I felt deeply deflated by this turn of events.   I questioned my coming, my work here and could not bear to think that I was doing what I never wanted to do: come and build something that would not last.  I felt sad, worthless and a bit ashamed. 

And then the words of the hymn came back to me.  Once again, I was suddenly in a place that I recognized: I did not understand the needs, felt overwhelmed and completely unqualified to set goals for my time.  Once again I just had to surrender my agenda and go back to the mandate to go with faith that the work that needs to be done would become clear if I was open to direction from something greater than myself.  So now I am waking everyday trying to do my best at what is in front of me.  I do not feel that all is lost. I know Ndirande will not be forgotten, as there are people who are passionate about this place even more than I am. I know the residents have learned a lot from their time here and will continue to hold Malawi in their hearts. And I know that Mangochi is likely a better fit for this academic partnership in the future.  So I am once again filled with a sense of purpose. But that purpose is no longer easy to communicate in a three point elevator conversation.  

with Dr Martha Makwero, a wonderful family doctor, my colleague and friend

If you know of any family doctors who would like to come live and work in Blantyre, let me know ( :

(Bill) So THAT'S what a scrum feels like!

Yesterday, I ticked off one of the boxes of things that I hoped to do before leaving Malawi.  As a former British colony, Malawi has inherited its rugby tradition and culture.  Though it is not a sport of the masses on the level of football (sorry, soccer), it has a strong following that is apparently growing.  I have been getting acquainted with the sport by playing "touch" rugby Thursday evenings at the Blantyre Sports Club.  Liam's teacher, Mr. Staines, and the school's PE teacher, Mr. Ferguson, invited me to come along last fall and I've been slowly trying to improve my game.  Most of the guys that show up have been playing most of their lives in various places of the British commonwealth and they move naturally and can huck the ball around with ease and accuracy.  I felt that playing an actual full-contact rugby match would be out of the question and that these experienced players wouldn't want a rookie American on their championship squad.  Well, they needed bodies on Saturday and felt that I was finally ready for the big time. 

 This, of course, set my cautious son (Liam) into a week-long fit of stress certain that I would be maimed and quite possibly killed.  I guess I had some fears along those lines as well.  There are some big dudes that play rugby and Mr. Ferguson had recently dislocated his ankle as a fresh reminder of the sports' violence.  The guys placed me in the second line of the scrum.  I won't get into the rules of the sport, but my focus was to push as hard as I could into the right buttocks of a 270 pound (or so) Malawian behemoth nicknamed "The Beast".  Very quickly you get acquainted with the players on your team as you grab and hold and lift and pile on top of each other.  That is me #22 (above) pushing behind The Beast.  Liam's teacher, Mr. Staines, is #9 and he plays the equivalent of a quarterback once the ball pops out of the scrum.

At the end of the day, we lost the match to our division rival comprised of teachers and students from Saint Andrew's High School.  This was a championship game for the 15 aside season and the BSC team was down players, thus my playing opportunity.  Seeing those high school boys run around with so much speed and power made me recall my very distant youth.  There was a ton of testosterone and lots of big hits.  Plenty of exhortation (I'll just keep it at that).    One guy was carted off and there were several injury stops.  Fortunately, I only came away with a black eye and sore everything else.  The 7 aside season starts soon and I'm hoping to get into some more action.  Sorry, Liam.  (=

We had a big laugh as a family reading this peanut packaging.  There must have be something lost in the translation.  If someone can figure it out, please let us know!

(Bill) The boys look great in makeup

Don't be scared.  This is just Micah in traditional vampire makeup for the local St. Paddy's Day celebration.  Last Saturday, we joined in the fun with much of the Blantyre expat community  to celebrate all things Irish (see: vampire face painting).  There were three legged races, potato sack races, potato on spoon races, tug-o-war, traditional Irish bouncy castles, wheel barrow races, lots of races.  We had a great time and we were introduced to an Irish sport called hurling.  No, this does not start with chugging 6 pints of Guinness.  To play, you wield a long handled, flat-faced club and just whack the snot out of a leather ball to your teammate.  You do this to advance the ball and score points.  Later in the afternoon, there was a hurling competition for distance.  I'm pretty sure I won it, but people got distracted and lost interest (see: Guinness).

Below is our favorite crocodile taking a bow in his school play, Alice in Wonderland.  Opening night was last night and we were so impressed with the quality of performance.  Wonderful costumes, makeup, sets, and special effects.  The acting was wonderful as well.  Liam was disappointed to only have one line (nailed it!).  He sounded interested in getting more involved with drama productions in the future.  We hope he means drama productions at school.

My last blog post promised that Micah would get his sporting glory at the school Infant Swim Gala (for Kindergartners through second grade).  This is a country where swim suits are called swim costumes and swim meets are galas.  So regal!  Look at that steely stare as Micah sights the finish line across the width of the pool.  Seconds later in the water, he would take a left turn and completely take out two of his neighbors.  Whatever it takes, Micah!

There are several people at home (okay, just Mom) who are keeping track of my traffic ticket tally, or TTT.  I'm happy to report, Mom, that it has been three months since my last moving violation on Christmas day (for the record, going almost 2 miles over the speed limit).  Now that I have the proper paperwork and stickers for the car, I can't even seem to get pulled over recently.  Elizabeth theorizes that I must just have a different look about me as I drive--a certain confidence or swagger that acts a mosquito repellent.

(Bill) Sports in Malawi

There are many opportunities to be active in Malawi.  Liam and Micah have had plenty of pool time through their classes at school, but Liam decided to get more involved and joined the swim team.  He is a good little swimmer, especially at breaststroke.  Two weeks ago, he had the opportunity to swim in the National Meet held here in Blantyre.  Only here in Malawi where the swim community is relatively small would Liam get such an opportunity.  

 Liam has also been able to play sports that aren't played as much in the U.S.  Here is Liam playing in a touch rugby match against a rival school.  He even scored his first "try"!  In the fall, he got to compete in cricket and his excellent arm and eye/hand coordination came in handy.

 Of course nothing beats the most accessible sport of playing baseball in the backyard.  Micah is amazing with a bat!  Need to get him on a baseball team when we get home.  Tomorrow morning, Micah gets some sports glory in the "Infant's Swim Gala" at school.  He is eager to show off his ability to do the butterfly stoke.  He's pretty good at it too!

 This is our triathlon team "Young At Heart".  Elizabeth, our friend John McGrath and me signed up to compete in the "young adults" division in a local team triathlon competition.  I was the swimmer, John on the bike and Elizabeth ran.  Well, we won!  Oddly, the sponsor for this event is the local sugar producer and so we each took home a bag of sugar and a few other cool prizes.

 Elizabeth also competed in the over 40 "master's division".  Her team won as well.  Here is her teammate, Tim, handing off.

 Hello from all of us!

(Bill) Elliott

Most people reading this blog wouldn’t know Elliott Walters, but I want to tell you a bit about him.  Elliott died last week and it has been very sad for our family.  He was a remarkable man who will continue to live in our memory. 

Elliott came into our family eight years ago when he began dating Elizabeth’s mom, Christine.  We knew a few things fairly quickly about this man.  We knew that he had had a wonderful first marriage and had lovingly cared for his wife for many years as she suffered Alzheimer’s at the end of her life.  Together, they created a wonderful, warm family with four kids and many grandkids, most of them still in the Seattle area.  Elliott had served in the Korean War through the Marines and was a retired insurance man.  Though an older man at 79 when he met Christine, we could tell that Elliott had plenty of life and love to give.  

The more we got to know him, the more we realized that Elliott was a man of many irrepressible passions.  One standout interest was with trains.  Our eyes were like saucers stepping into the train room of his house for the first time.   Not many people would modify their home to accommodate train tracks running in and out of the walls, but Elliott did!  He had put together a room with mountains, sky, lakes, and towns crisscrossed by tracks.  And all to perfect scale!  With great pride, he showed us the replica trains that he had collected and could send them on their way with a central controller with coordinated Johnny Cash music and puffs of smoke from the stacks.  My sense was that his greatest pleasure was sharing his love of trains with many kids that were invited to take it all in. 

Elliott’s passion wasn’t solely with trains.  Flags anyone?  Elliott had a large flagpole in the front of his house and he faithfully ran different flags up and down every day to mark special days on the calendar.  I’m not sure how many flags he owned and stored by hanging on pegs in his front hallway, but the number is impressive.  

How about squash or tennis?  Elliott was quite the athlete winning numerous squash trophies as a younger man.  He kept up his racket sport passion faithfully playing tennis several times a week and making many friends along the way.  Not many octogenarians have asked me if I wanted to hit around.  Very impressive.

Elliott was very active in his church.  He was particularly excited when “Nigerian Sunday” rolled around and the Nigerian congregants that shared the building would combine services with his.  He had a genuine faith in God and would insist on giving thanks for meals with the traditional Episcopalian grace:  “Lord, for what we are about to receive, make us truly grateful”.   And he was indeed truly grateful for all he had. 

He loved politics and reading books on history.  I didn’t always agree with Elliott in discussing various topics, but I could count on him having an opinion that, again, he was passionate about.  He loved to host parties and he was delighted to have friends and family around him.  He and Christine did an amazing job with various gatherings throughout the year:  birthdays, Christmas, Easter, Thanksgiving, or just because.  Only Elliott could be seized with the idea to have an entire pig roasted and served up on their back patio.  

The greatest passion in Elliott’s life was his family.  It was love at first meeting for Elliott and Christine at the opera guild small group.  When you’re 79 years old, you don’t mess around with a long courtship and he made plain that he was looking to marry Christine on the second or third date.  We’re so glad they did go on to get married.  They shared a wonderful marriage and friendship and it seems that they were partnered for longer than the eight years they knew each other. 

We could see the quality and depth of his relationships with his biological family, but we were so blessed that he invested deeply in our family as well.  He absolutely LOVED our boys.  At first, we maintained a formal title of “Mr. Elliott”, but this title didn’t seem appropriate, as he loved Liam and Micah as his own grandsons.  “Grandpa” and Christine would regularly take the boys on adventures as they explored La Conner (the site of their once-monthly dog grooming sessions) and everywhere in between.   Over meals, Elliott demonstrated his passion for the boys as he would pepper them with questions about their lives.  He genuinely cared about what they had to say and would shush any adult who tried to speak on their behalf!  Not many 6 or 10 year olds have an adult in their lives that really wants to know what they think about something.  He would try to get to the boys’ sports events and school plays.  Not many men his age could be as playful and loving as he was with such young children. 

The same interest he took in the boys is the same interest he took in Elizabeth and me.  When I shared my excitement in looking at birds here in Malawi, Elliott immediately bought and sent a book on African bird watching.  He regularly bought us books that he thought might be interesting to read or would cut out articles to share.  He was generous and kind.  He was able to affirm me and encourage me in ways that are unique from an older man to a younger man.  He showed me so much about the kind of life I want to live, not just when I get to be 80, but now! 

Thank you, Elliott.  You lived an amazing life.  You loved and served well.  You have your reward, but we will all miss you.