“That health center is difficult”

February 7^th 2015

This is a common exchange during a chat with a person I am meeting. 

 “…You are a doctor? You are here working at Queens?”  (The large central hospital in town.)

“No I am working at Ndirande Health Center.” 

“Oh…”  long pause. “How is it working there… or why are you working there?” 

Why would a doctor come to Malawi and not work at Queens?  It is not common for doctors to work outside the central hospitals.

If a doctor is going to work outside the central hospital why would she be working at Ndirande? Ndirande Health center is in the middle of a poor community that has a reputation for being rough.

Why would a doctor come to work in a place that is so under-resourced?   

Ndirande Health center

The road just outside the health center

The market adjacent to the health center

Let me insert some context.  Malawi has a population of 16.3 million people.  Patients first contact the health system in the health centers or district hospitals which are staffed by clinical officers (similar to physician assistants), nurses and medical assistants.  These clinicians are well trained to see the most common conditions and to offer treatment usually based on well-designed national protocols.  At many busy health centers one clinician will see up to 150 patients per day.  Their job is to treat the patient and / or send them to see a doctor for a higher level of care.  If a patient needs to see a doctor, she will be referred to one of three central hospitals in the country because, except for missionary and other visiting doctors, there are no physicians posted to work outside of the Central hospitals. 

To the question, I explain that Family Medicine is just starting in Malawi.  The hope of this new specialty is to provide high quality primary and secondary care close to patient’s communities and to offload the overcrowded central hospitals.  Family Medicine will be training physicians outside the central hospitals.  The hope is that Ndirande will become a facility that can function to provide quality care and become a training site for family medicine in the future. 

Then I get a satisfied nod of understanding.  Everyone with whom I have spoken about this get the concept instantly. Philosophically it is not a hard sell.  But then come the practical concerns which turns into an effort to show me sympathy.

“That health center is difficult… !“ long pause.  “Do you really think you can accomplish something there?”

The first time I heard this, I did not make much of it.  But now that I have heard this many times I am beginning to understand what is going on in the background of this discourse.  Health centers have a reputation of being ineffective.  There are negative assumptions made about the skill level and work ethic of the staff.  When it comes to prestige, there is none.  The conditions are vandalized, grimy and debilitated.  A health center is a structure, there are people employed there, it is a place for patients to go when they are sick.  But I think most people thing it is façade; medical care is not actually delivered there in any meaningful way.  Ndirande Health Center is supposed to be the medical care for a population of 250,000 people (which is more than a third of the population of Seattle.)  There is a certain level of acceptance that this township of quarter of a million people is sealed in this predicament.

our short stay ward...in need of some improvements

 

If you spend a few hours observing what happens at this health center, you may come to the same conclusions.  You may feel hopeless or cynical.  Patients will wait an entire day to have a 2-minute consultation with a clinician. They will be prescribed a medication that may or may not be the right medication for their illness. The patient will go to the pharmacy, which may or many not have the medication in stock.   A patient will come in labor.  They may or may not have a bed, electricity to provide light for the delivery or even water to clean between patients.   If you come for the morning meeting you will see tired clinicians dreading to start the day and if you come at 3:30 there will be fewer than half of the providers still working.

If you spend a few months observing what happens at this health center, you will likely come to the same conclusions that I have come to.  Staff show up to work, they see a seemingly endless line of sick patients. They are unable to use the knowledge they have to properly evaluate because they do not have time.  They are unable to use the skills they have been taught because they often do not have access to supplies.  And they often cannot offer treatment because of lack of the correct medications on hand. 

They do this all day after day with very little acknowledgement or appreciation.  They are often paid very late or not at all.  There is little chance for professional development or collegial interaction.  And on top of all this, they know the sentiment in the medical community: that the health centers are little more than a façade of medical care. 

For the past few months I have worked with the staff at Ndirande. Their experience and medical wisdom is exceptionally good. Their eagerness to learn is exuberant.  We have started with small activities that are meant to acknowledge and appreciate the work that is being done day in and day out.  

Emily (one of the residents doing wednesday teaching on neonatal resuscitation)

We have morning meetings and weekly teaching.  We have had a party to try to get to know each other a bit outside of work and we try to enjoy an Nsima lunch together.  


We consult each other, ask for help and correct each other. We acknowledge each other’s strengths and try to fill in the gaps when they exist.  I believe there is a desire to work as a team to build something that works well.  It seems that people are changing.  maybe it is just my perspective. But I feel that people are enjoying their work more, that they feel some reason to come to work and smile and some reason to stay a little later to see patients.  I have seen people genuinely happy with a patient who gets better because of the care we have delivered and people upset because the system will not let us do a better job. 

Teaching a medical assistant some ultrasound basics

hanging protocols on the wall to have easier access to information needed consistently 

These changes do not cost money.  But it is my hope that a culture of affirmation, acknowledgement, teamwork and collaboration will lead to better care for the 250,000 patients who depend on Ndirande for care.

Though I though we would have had Malawian medical students by this time in the year at Ndirande a few months ago, I understand now that this is providential.  What we are building now is a functional primary health care team that involves providers of different levels working together to try to provide integrated care across the health center. We are building this health center with the principles of family medicine.  It is into this culture that medical students hopefully will see family medicine in action.

It has been a while since I have blogged.  I think I have felt a little discouraged at times with regard to the slow progress and the fact that our time is already ½ way gone.  I have lamented that my role here, to help build family medicine in Malawi is not a one-year job it is a 3-5 year job and maybe I am a fool to think that I can really do anything.  But I am beginning to truly accept that lasting change happens slowly and will span many people who come with the same job description.   Acknowledging the small steps that are part of something bigger is very helpful to me….I should really blog more often.