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 ( :