Sustainability

December 30^th 2014 

I am sitting in an air-conditioned room (the first one I have been in since arriving in Malawi) having just spent a few hours playing in lake Malawi.  We have cold water to drink, warm water to swim in, plentiful food in buffet style, comfortable beds and guaranteed electricity. For the past 3 days we have been far away from any discomforts.  We had been anticipating this vacation for a few months. The boys are on their 3^rd of 4 weeks off for the Christmas break and have been eager to be on break as a family.  I feel like I have been going pretty hard for several months putting my work goals ahead of our family.  I was looking forward to switching gears to truly cherish them and time together.

We decided on a Safari and some time at the lake. Bill and I have a hard time with planning vacations and this came together only at the last minute.  In thinking about where to go, I think we feel paralyzed by the number of good options.  We wanted to make our time “count.”  It was not really the struggle of choosing from any number of desirable destinations (one should not really feel too sorry for this hardship) it was that a vacation for us means leaving Dr Emmy Davison (the current resident here with us) by herself in Blantyre.   I agonized about whether this was the right decision—will she be adequately supported, safe, orientated?  Will she have a good enough time in Blantyre when she is not working.  Will she be overwhelmed, sad, frustrated and without someone to talk to?  Whenever I put my 30 y.o. resident self into her shoes I concluded that I would not want to be “left alone.”  But Emmy is tougher than I would have been and she assured me that she would be fine.  She is resilient, positive, and ready for any challenge. She took call on Christmas Eve and has run the busiest clinics we have had so far.  And—because of holiday vacations—there have been the fewest number of clinicians around to support her.  Not only to I have great admiration for her, but also I appreciate the gift her attitude to send us away with her blessing.     

Three days ago, we drove from Blantyre to Mvuu Camp at Lewende national park to experience the bird and wild life of Malawi.  Mvuu Camp sits on the banks of the Shire River where crocodile and hippo are more plentiful than logs or rocks.  
                                     
After recently watching the Big Year (a movie worth a watch!) it was difficult not to eagerly tick off rare birds as we spotted them, though we saw only a fraction of the more than 350 species of birds that live there. Liam and Micah were won over by the African Kingfisher as they hover like hummingbirds before diving into the river to capture small fish. 

 
   I am still in complete awe of the elephant.  Their social behaviors, migratory patterns, role in their ecosystem, species survival are qualities all fascinating to learn about. Their long eyelashes, attention to their young, playful behavior, and grand silent steps are breathtaking to watch.  Their instinctual behaviors to protect themselves and their young from humans warrant much respect.   

So when two babes with their mom are less than 10 feet away from your window at 1 am, this is a pretty effective adrenaline rush.  Pictures are better than words to capture the wonderful experience there.  Our boys had a blissful time as did we.  

Our home for a few days in the African bush, neighbors to Elephants

After two nights we drove north to Senga Bay and are staying in one of the oldest hotels in Malawi. It was built in the 1930s and is absolutely perfect. 

Last night Liam checked in with us about our financial status, this is not unusual for our slightly anxious, responsible son.  “You guys are spending too much money!  Are we going to run out of money?”  Though I can’t help but quickly reassure him that we are okay and we are not going to run out of money, I deeply appreciate his questioning.  I think this reflects a number of things going on in his quickly developing brain.  First, we pay cash for everything here.  Imagine, for a moment, going on a vacation without using your credit or debit card.  The only way for us to transfer money from our bank account to the hands of the beneficiary is to withdraw cash from an ATM in qualities limited to 80,000MWK per day (80,000MWK = 80 x 1000MKW bills = ~$160), stock it up and then bring it with us to our destination whether a shop or a luxury hotel.  The stacks of money reach sizable heights and it is very clear that this x, y, or z item has a cost that is different than when you hand a credit card to the cashier.  Second, the consequences of poverty are part of our moment-to-moment reality.  Living without a car, eating Nsima everyday, carrying the water you need on your head is the reality of our neighbors.  To a child, the disparity makes even less sense to them than it does to us.  What makes us different from these Malawian neighbors is not a profound question to them (it only becomes profound as we have more life experience.)  If these neighbors had a stack of money--only one inch high--their lives would be so much better.  And we are spending inches of money right before their eyes.  Third on a daily basis, we are careful with the money that we spend.  Buying a superfluous item is an acknowledged treat, we did not have many Christmas presents this year, and Bill is known to work hard for a bargain in the market.  The juxtaposition between our daily reality of frugality with that of this vacation is incongruous.  Liam’s second question “Are you guys going to run out of money” is a question that has a mathematical probability associated with it.  I can answer that it is unlikely that we would run out of money because we have saved and budgeted for this time.  However, his first statement --“You guys are spending too much money!” is much harder for me to respond to.

I have been thinking a lot about the concept of sustainability.

I believe in the work that I am doing here. I believe in training African Family Physicians to work within the communities to deliver first contact care within those communities.  I believe in helping to develop Ndirande Community hospital into a pilot that functions in this way so that other community hospitals have a model to emulate.   There are so many needs, there are ways that I can contribute and there are ways that I cannot.   But what is constantly on my mind is how can I contribute in a way that promotes an outcome that is sustainable.  I am reading a book now called “The Challenge for Africa” by Wangari Maathi who won the Nobel Peace Prize with her work in Kenya called the Green Belt movement.  She describes the current reality in African development; the progress is inseparable from the damage done by colonial rule.  African progress is both dependent on and stagnated by foreign aid.  She advocates not for cessation of aid but well appropriated aid, aid that empowers local leadership in their efforts to address critical problems facing Africa.  Every day I think about these principles and whether or not our efforts are contributing to or detracting from forward progress.  Coming with SEED Global Heath—a well connected and informed organization--makes me feel confident that contributing to teaching and propagating of a robust health system is grounded in principles of forward progress.  It is the days when I am buying candles and flashlights so the nurses have light by which to deliver babies when the power goes out at night, or when I am fixing locks so that clinicians feel safe on call at night, or when I myself am seeing a long line of patients and treating them with my western trained medical knowledge which might not be appropriate that I question whether I am contributing to or detracting from progress.  Using my money to make these changes is not sustainable.  Just as Liam would state with some concern, “You are spending too much money” I wonder if I am inappropriately spending my money and the money of those who are generous to help. 

But as is the case with this vacation, it is not sustainable to be living like this forever. This vacation is doing more for us than providing us with luxury for a few days.  We are also buying memories, rest and rejuvenation, time together as a family and perspective on why we are here.  I hope we are buying a fresh start to the New Year, energy to poor into the challenges that inevitably lay ahead.   I want to think of the money that we are spending and raising for Ndirande in a similar light.  We cannot fund this health center forever.  But we can buy some momentum to get it running well, to show what it has to offer.  We are investing in the vision that is being promoted by Dr Makwero and other Malawian leaders.

When they are swimming in the lake, playing with a new toy or watching a kingfisher dive into the Shire river I see the boy’s spirits come alive.  I believe this is healthy for their development as exceptional humans.  

And when, at Ndirande, the nurses feel that someone cares about them or when the work environment becomes more conducive to the good work that is being done, I see their spirits come alive. I believe this is important for the development of this program. 

Happy New Year to all. May you find ways to help your spirit come alive. 

Bill dancing with one of the Health Surveillance Assistants at boxing day Ndirande party

... because I could not resist! 

On a peak

November 21^{st
(Beware, this is a long, esoteric blog post that Liam thinks will bore everyone.)} 

I am not sure if it is because Malawi is about 60 degrees warmer than Seattle right now and I am thinking of the crisp clear skys and beautiful views over lake Washington but I find my mind wandering to a mental picture of the Olympics on a clear day.  From far off, it looks like you could walk along the ridge summiting peaks, appreciating the effort it took to get to the view but then seeing there is another higher peak ahead with a valley or two in between.    

Today, I am on a peak, I feel full of hope; I am admiring the view. 

I spent the past 2 days in Mangochi.  Mangochi is a 3.5 hour drive north of Blantyre. It is known for being home to the Yao—a large group of predominantly Muslim people, its humidity, proximity to the Southern tip of Lake Malawi where many people vacation, and the site of first district hospital where Family Medicine Physicians will be trained in Malawi.  The purpose of the trip yesterday was to meet with the DHMT (District Health Management Team), discuss the terms of agreement between the College of Medicine and Mangochi District Hospital and sign a Memorandum of understanding.  Regardless of what actually happened during our meeting, the fact that this meeting was happening represents a long story of hard work and dedication. 

Starting in 2011, two Malawian family doctors began laboring to promote the idea that Family Medicine as a speciality can improve health care in Malawi by being clinical leaders in the district hospitals.  These two family doctors have carried enough passion and perseverance to continue the efforts even when it seemed no one was listening.  Today, November 21^st 2014 is a day of celebration.  But given there has been so much foundational work done in the last few years, sometimes I feel I am cheating by entering the story of family medicine in Malawi at this pivotal time when the fruits of their hard labor are being revealed.   I would like to take a moment to illustrate the depth of the celebration today. 

Concept #1: 
Starting less than 10 years ago, a movement started in Africa to incorporate Family Doctors into rural hospitals to provide the spectrum of care that is required to meet the needs of the community they are serving.  The concept of the African Family Doctor has been described as “physicians trained to have a body of knowledge, skills and attitudes required for the provision of primary, continuing, comprehensive, personalized and holistic care to individuals, their families and the community”.[1]   An abundance of literature describing the need for FM in Africa is already in circulation. But at the same time there is an acknowledged lack of consensus about how to define FM training in Africa--as the role of the Family Doctor will be very different in setting that have unique needs.  Malawi has been sited in many of the foundational articles that have wrested with this dual realty. 

Concept #2

Within Malawi there is consensus from people in high places about what the role of the family doctor might look like: as a clinician, health manager and team leader who provides consultation to other health workers within the team (in their unique setting) and provides emergency surgical and obstetric care.  From the side of the Ministry of Health, there is motivation to promote Family medicine: if a family doctor can function as a well trained clinician who can treat patients for a wide range of conditions, in a timely and evidenced based manner that health outcomes in Malawi can be improved.  The College of Medicine has articulated that they are invested to support the concept of training physicians in a district setting—for the first time. 

Concept #3

Building a residency curriculum in the US—where FM as a specialty is well established and the spectrum of training requirements are fairly well defined—takes a lot of time and effort.  Building a residency curriculum in Malawi--where the concept of FM is completely foreign and the work of the family doctor has never been piloted—is a herculean task.   And it was only two family doctors who decided to take this task on.  Today—after many meetings, closed doors, set backs and reiterations--Dr Dullie and Dr Makwero’s residency curriculum was accepted by the medical council.   This curriculum defines the role of the Family doctor in Malawi and specifically outlines a robust 4-year curriculum. This accomplishment has been done by only a handful of African nations. 

Concept #4

A curriculum is nothing without residents.  Recruiting Malawian Medical Officers (who have completed medical school and a 18 mo internship and are qualified to practice in Malawi) to take up a role of student again for 4 years, AND move to a rural setting is not easy. 

Finding a district hospital that is willing to incorporate medical residents into a system that has no precedent for this is also not easy. 

Yesterday a memorandum of understanding was signed between this rural hospital in Mangochi.  And in about 3 weeks the first residents will begin their training at this site. 

Recently published an article entitled “Understanding Family Medicine in Africa” describes the complexity of this process that is happening all over Africa.

(Understanding Family Medicine in Africa. Br J Gen Pract. Mar 2013)

The world is watching to see if it can happen in Malawi. 

Concept #5

As of today, Mangochi represents collaboration between a district hospital and the college of medicine that is brand new.  This site has the potential to showcase a profound success. But, it is expected that FM is not going to be easy to implement on the ground.  Already is it clear from the two Family Doctors (who have come through SEED global health and GHSP) that the work to teach through example, to slowly earn the right to be clinical consultants, to slowly work to develop systems that will accommodate FM doctors is very difficult and at times profoundly discouraging.   This trial is likely to take many years and a lot of patience.  Although one can intellectualize that the way to change systems is from the inside, slowly and humbly, much credit should be given to those visiting family doctors who are doing this hard work.

Concept #6

I came here with a notion about how I could help propagate the expansion of FM in Malawi.  Though this notion was shallow and naïve, I now believe strongly that a long term academic partnership between WWAMI and Malawi will be fruitful in the months and years to come.  This strong belief is founded on what is happening as a result of the work of incredible R3s from Swedish who have come to work alongside me (Beth Thompson, Ben Davis, Kannie Chim.) 

Swedish R3s are working full time at Ndirande Health Center in Blantyre.  The goal is that over time this health center will grow from a struggling health center into a well functioning full spectrum district hospital to meet the needs of over 200,000 patient who seek care there.  When this hospital is formed it will be a second model site for training both medical students doing their clerkship in FM and for residency training.  This vision will come to fruition slowly, over months and years.  For now, the work is not well defined, the resources are extremely limited and the relationships between “us” (the white doctors) and them (the clinicians—who are not doctors—who have been running this health center for years) are complicated.  There is limited space, no money for anything, and hundreds of patients everyday.  The conditions are grimy, there is rarely any water and we don’t speak the same language. I ask the resident to go: see patients, take overnight calls, build relationships with the clinicians and nurses, work on the small quality improvement projects we have started (with humility and patience) and keep the long term goal in mind.  They are demonstrating resilience and hard work to an extent that I never imagined possible.  I am not only proud of them but I think that there is potential for Ndirande to be a model site for Malawi and even for other nations in Africa. 

Ben and Beth left two weeks ago, nurses and clinicians enquire about them, they are missed here.  They are missed for their hard work, their willingness to work as part of the team, the teaching and the clinical resources they developed while they were here.  Kannie arrived two weeks ago went to a rural community yesterday, worked with a clinical officer and an eye doctor and evaluated the patients who had been waiting for 6 weeks to receive medical care.  She was on call last night and delivered a baby alongside Malawian nurse midwives with whom she has built a relationship of trust.  Emmy is coming next and is already on the teaching schedule for our new Wednesday afternoon didactic sessions and we have patients returning for care that will have seen Ben and Beth, Kannie and Emmy.  We are part of this team.  We are patient and have big goals. 

None of this would have happened without the foundation built by Dr Martha Makwero and Dr Luckson Dullie.  We would not be here without the risks these two took on to incorporate us into their vision.  But both of these things happened and we are now confidently working together in partnership toward a shared vision that will hopefully change the health system in Malawi and maybe even beyond.

The financial needs are vast.  This vision will not come to fruition without monetary support.  I am realizing that my role here is 1/3^rd clinical (at Ndirande), 1/3^rd with the college (helping to organizing the medical student clerkship rotations that happen every 6 weeks) and 1/3^rd to help with grant writing.  … and at the moment I type this bit about grant writing on this page, the vision of the Olympic Mountain range comes into my mind again.  I picture heading into a valley.  I am not a grant writer.  But I will try.  Dr Martha Makwero—who is a hero of this blog post, my colleague and partner this year, and my friend—has been telling me, in her Malawian accent “you CAN!”  And I have to believe it and keep moving toward the peaks and through the valleys. 

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[1] Luckson Dullie MD “Developing Family Medicine presentation, AAFP Global Health Conference 2014

(Bill) Anonymous Wish

As I type this post, the power has just gone out and we’ve been without water for a day and a half.  So, we are letting the yellow mellow and flushing down the brown with water that we’ve been storing in buckets.  Our drinking water is now coming from other water containers that we’ve been keeping full for just such an occasion.  We have a decently large hot water tank, so there is some reserve.  But we are going into full conservation mode, just in case. 

We typically have 2-3 short water outages during a week, but longtime Blantyre residents tell us that it is not unusual to be without water for days at a time.  We’ll be grateful and dance a little jig when the water comes back and next time I’m at the store, I’m going to buy another couple of buckets.  When the power comes back as well, that will be a nice little bonus and I’ll be able to upload this to the blog!   

I’ve been considering the concept of anonymity quite a bit recently.  Frankly, I would like to be much more anonymous than I am in Blantyre.  I leave our house at least 4-5 times a day and sometimes that number is up to 7 or 8.  But I never leave unnoticed.  Of course, I first pass through the gate that our day guard, Brenda, has to open for me and I give the obligatory wave and smile.  Then, 10 feet past the gate, I pass what I call the “guard collective” consisting of other neighbor guards and gardeners that hang out near our home entrance.  This prompts another set of waves and smiles.  If my daily errands require the upper end number of trips (7 or 8), that is 14-16 wave and smile sessions with Brenda and the guard collective as I come and go.  I wave and smile because the alternative is unpalatable to me.  I’ve tried on for size the “ignore-and-look-straight-ahead-with-sunglasses” approach but I feel too entitled and too much of a jerk to do this consistently.  So, I wave and smile.  A LOT!

My runs (okay, jogs) are also a spectacle.  As Elizabeth has detailed in her posts, you can’t just pound the pavement in quiet and solitude.  First, there are people EVERYWHERE you might consider running and if you were running in places where there weren’t people, it probably isn’t a safe place to run anyway.  So, I always have an audience for my beautiful, effortless glide (okay, shuffling, wheezing, sweaty slog).

When I drive Elizabeth and the visiting residents to the Ndirande hospital, the road I navigate runs through a crowded market and people are packed all about Black Mamba.  Almost every trip (about 4 times a day), I hear people young and old shout through my open window (no air conditioning in the Mamba), “Azungu!”  This literally means, “White person!”  After living here for almost three months, I still don’t quite know how to respond to this greeting.  Most of the time, if it is a small kid and there is a look of wonder in their eyes like I have a horn growing out of my head, unicorn-like, I will smile and wave.  I don’t want to disappoint the lucky viewer!  But if it is someone older, certainly someone who has seen plenty of white people in their lifetime, I usually look ahead and ignore.  I confess it’s kind of annoying and I’d rather not be noticed at all.  Can you imagine shouting out in greeting to the people of Seattle their primary identifying feature?  “Hey, (fill in the blank)!”  Strange. 

When I walk into the office to pay the water bill (for what it’s worth!), I’m the only azungu and stares follow me.  When I go to the forex to exchange money, I’m the only azungu and stares follow me.  I don’t feel that these are malevolent stares, but without any interesting kitty or rainbow posters on the walls to look at, I must be more interesting than looking at the floor.  At least I hope so! 

I’m not offering any profound insights here.  It is just the reality of living as a distinct minority.  Perhaps this will develop in me renewed compassion for people who visibly don’t fit in to the dominant culture, whether it be here in Blantyre or Seattle or anywhere.  It perhaps helps explain the palpable lifting of weight that Elizabeth and I felt when we returned to Seattle from Kenya 14 years ago.  We experienced the same craving for anonymity then as we do now.  But don’t be surprised if when I next see you and you greet me with a boisterous, “Hey, white person!” that I look straight ahead and ignore you.

(Update:  We gained our water in the middle of the night last night after being out for 60 hours!  It was like Christmas morning around here.  We were prepared to raid our friends' pool this morning for some buckets of water to flush our gross toilets.  We had completely run out and all we had left were two large bottles of water for drinking. We also got our electricity back this morning (and was able to post this) when I had the brilliant thought to check our panel and switch back on the breaker that had been tripped.  Duh!  This was a 24 hour outage of self-imposed stupidity.  Oh well, the boys probably appreciated going out for dinner last night and reading Lord of the Rings by candle light.  Ahh memories....)