Irony

November 9^th

It has been a long time since I have written. 

To sit down and write down thoughts has become a luxury that I have not taken amidst other things that feel more urgent these days.   However, when there has been a moment I have wanted hang some thoughts on a theme and it seems that the minute a theme comes to mind the tide turns and that theme is obliterated.    And so, a theme has been born, irony. 

critical vs unexceptional

Ben and Beth, the first of 10+ Swedish residents have been here for a month.  They have been pioneers on many levels.  I asked them to come with open minds and low expectations and they obliged me.  As each day has unfolded, they have been flexible to take on new tasks and responsibilities.  They have been models at Ndirande of what Family Doctors are capable while being humble learners and observers. They have been patient to slowly earn the right to be clinical consultants and to slowly work to develop systems to improve the way care is delivered.  They have done their best to teach through example.  Being a member of this team is likely to take months or years but they have adopted the approach that the best way to change systems is from the inside, slowly and patiently.  It has been an honor to work along side Ben and Beth. 

That sounds really nice doesn’t it?  It sounds like something that could be written in a news letter.  But their time here has not been all rosy.  Working within the system is a constant tension between: seeing the critical nature of patients failing with critical conditions while simultaneously   appreciating that within the system these same conditions are relatively unexceptional.  Working within the system is carrying with you the US ingrained tendency to rush, minimize any delays while choosing the best treatments and avoiding errors at all costs while simultaneously understanding the Malawi ingrained tendency to be calm knowing that nothing can happen very quickly.  The patient can not have the *best* treatment because the best treatment does not usually exist.  For us this is uncomfortable, foreign and at times profoundly frustrating.  But the longer I am here the more I realize that this frustration is constructed out of my world view, the world view that (speaking very generally) builds systems to avoid mistakes.  I am learning to appreciate that the worldview here is (speaking very generally) to build systems to gradually improve on the sparse foundation that exists.    Of course, this is an overly simple, somewhat critical of the “US world view” but it helps me in the moment when we are treating a sick patient with a drug that likely will not work because there is no other option or wrapping a severely burned child in dirty rags because there is no more gauze.

 

important vs misdirected

There are two Malawian Family Doctors in this country and a handful of ex-pat Family Doctors working not only to establish FM as a speciality but to implement a new training program.  is my perception that the nation--as well as the continent--are waiting to see if Family Medicine has a role in the health care system in this country.  Meetings with important people are happening all of the time.  New information brings new hope and my soul feels inspired.  Increasingly over the past 6 weeks I have felt a deep privilege to participate as a support person in this movement that is built on the following:

* There an abundance of literate describing the dual reality of the need for FM in Africa.

* There seems to be philosophical consensus that:

-       The role of the Family doctor is 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. 

-       Family Medicine will reduce the need for referrals to overburdened central hospitals. 

-       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 major problem is consensus about the role Family Doctors will have in African nations, how will they be integrated into the team of clinicians that exists now.

* Malawi is working to test this out

* The creation of the curriculum for the medical students and medical residents has only been done by a handful of African nations, Malawi is one of the few.

* The world is watching to see if it can happen.

Important.  Yes, this seems very important.  I stay up late writing emails, spend my runs thinking about strategy and proposals, plan meetings for Sunday afternoons and feel that I am bloated with importance.  But it does not take long for my sense that I am contributing to matters of global importance to burst open with the realization that I have a small view of what is truly going on.  Within hours the same things that were the foundation for my sense of importance become the foundation for my sense of being misdirected.  I lose my inspiration to write late night emails or mull over proposals.  And then the tide will change again and a new sense of importance will arise.    Perhaps this is because I am within a culture that admittedly has an indirect style of communication (and I do not get the whole story) or because I have only been here 2.5 months, or because I have an inappropriate optimism, or because I have naïve sense of importance or all of the above.  Or maybe it is just the irony that is guiding my time here.  I have come to the conclusion that I am here to live in this tension and not to run away from it.  I will continue to hold on to the optimism that good things are in store for this country and for its health care while knowing that so little depends on my efforts.  I will make efforts for the purpose of augmenting the work that is being done by the Malawian leaders in my close proximity. 

find a running partner and watch him run away

About 3 weeks ago I sold Blessings my running shoes for $3.  Before that, when he would run with me, his torn brown leather shoes would slip off his heel. Our runs together were punctuated by stops to retie shoes, lace them around his ankle, remove and replace socks (to see if that would help) etc.  This was annoying for Blessings but great for me. It gave me a chance to catch my breath so I could carry on running at his heels.   But I did feel badly for him when the laces created gashes in his ankles.  When I realized that our feet were the same size I made a calculated decision to invest in my running partner.  During his first run in his *new* shoes he said “nothing can stop me now” and make a Rocky-like gestures.  Well he is correct.  Before he came to associate with us, Blessings would run “to ward off depression” or when he needed to travel a long distance or get somewhere in a hurry.  But now, he has been running everyday.  Out of true enjoyment, he does not want to miss a day, has questions for me about nutrition, training plans, and racing .  We did our first track workout together. I explained what a “400m” is and the concept of interchanging “hard quarters” and “200 rests.”  With every quarter the distance between us grew.He becoming a fit 25 year-old male who is leaving me in the dust, quite literally.  I miss my running partners so dearly. I miss Sunday runs and misty Seattle mornings.  I miss being able to be anonymous around Greenlake.  But I am grateful for Blessings.  He has been such a gift to me here… I just might attach weights to those shoes I sold him. 

moving vs bruising

Remember the Power of One?  1992? Amazing sound track, set during WWII.  An English boy named Peekay, raised in South Africa fights for racial equality through his beautiful love of Black South Africans in a hostile environment.  Watching this movie was great for three reasons.  First, it was a family movie night!  When we can watch a borrowed movie it is a significant treat!  Second, it is moving.   Anyone who watches this film—I am sure—develops shivers of altruistic hope when they hear the songs and see the scenes of Peekay’s victory over hatred.   Third,  after the movie finished Liam and Micah engaged us in conversations about racism, inequality, injustice and how history can teach us about ugly parts of humanity… all the while our black African friend Blessings is sitting in our midst.  In the moment I was grateful that Hollywood sparked good conversation.   However, in the days and weeks to follow the songs moved out of our mind’s stereo, the altruistic images faded and the conversations returned to the mundane.  What lasted was boxing.  Boxing plays a significant role in this movie.  Boxing is glorified and basically cures the world of racial hatred.  Why not box?  Box all the time?  This is what Micah and Liam have decided to do.  There is no bad time to throw a punch these days. 

Even bruised, Liam and Micah seem to be happy, thriving children who are persistently filthy and mosquito bitten.  Their joy and energy continues to inspire me. 

So much love to you all!