She lay in bed, a different child, alert, alarmed, and blessedly full of life. I left Moyo house (the malnutrition ward where I work) dejected Friday after attempting to resuscitate this lethargic child spiralling slowly into respiratory failure. But with the appropriation of a CPAP machine from the special care ward and finally correcting her severely low potassium (my part) she survived. She survived!!!
The past week brought me to a new level of acceptance. Finding a balance between acceptance and action proves difficult. Passivity and complete clinical detachment stops us from empathy. Over-involvement emotionally and constant frustration at the barrage of failures leads to burnout. Each without balance takes us away from caring properly for our patients. How do we find the middle ground, where we are empathetic, detached, and still proactive about correcting faults? I find that the emotions of Malawians are less strongly expressed and that demeanors seem more flat. From the outside it would seem that the nurses and even some of the registrars don’t even care or don’t understand the importance of acting quickly with an ill child. Amazingly, the nurses are actually told not to cry. As in you are not allowed to cry. Ever.
Perhaps it is an overbalance towards detachment after the trauma of witnessing such high mortality rates. I can’t even imagine what the staff in the adult world feel, where mortality rapidly outstrips the pediatric world. Perhaps it is that most are completely overworked and underpaid. A visiting nurse from the UK working on training here shared with me that in an epiphanal moment, the nurses she was talking to finally told her that they simply don’t understand why they are doing. How can we expect someone to act quickly when they don’t understand what a sick child looks like or the difference between administering antibiotics to a child with meningitis (asap) versus to a child with an ear infection (needs to happen but not emergent)? A few of the older nurses are extremely good. They have a clinical acumen and an understanding of triaging work that would benefit their younger counterparts. Unfortunately sometimes they work alone in our ward for up to 20 patients. How can we expect them to be able to sustain an acceptable level of care without support?
I learned also about the need to feel useful. As a “super-numerary” in my ward, perhaps my clinical attention is helpful to my patients, but I don’t have any confirmation that I can actually make some sort of lasting impact on the community I serve, no matter how small.
Is it too much to expect to improve my environment? Is it right to only take (experience, however traumatic), and not be able to give in equal or greater measure?
Fortunately, the medical students rotate a week through our ward on their six-week pediatrics rotation, so I have had the opportunity to corral them into a more thorough orientation to our ward and some teaching on malnutrition as well as basic gastroenterology (intestinal medicine) topics. The students surprised me with their interest and their answers, especially one in particular who went levels deeper into the mechanisms of immune suppression in malnutrition. Wow. In comparison, some of the students have difficulty even coming up with a differential for diarrhea (not hard). The students are the future, so filling them up with knowledge and the ability to analyze and problem solve will only improve the community within which we work. I will keep telling myself that, at least.
Burnout seems a large problem for the physicians here as well. In a department staffed mostly by ex-patriates on either permanent or several year positions, the improvements in the individual wards move like the land: barren, fertile, then barren again. Changes made sometimes stick but often devolve as the spearheading leaders leave. Malawian staff seem to have little cost or moral incentive to stay in a hospital whose bulk swallows their efforts of reconstruction. From my limited perspective, I wonder if the medical system of this large public hospital will change much in the next ten years. I choose optimism.
Taking a break
The hammock swung gently to the rhythm of the waves. Above me leaves fluttered their salutations to the wind, below me the grass grew soft and spongy. Cape McLear.
To a person accustomed to dramatic ocean and yards of sand unspoilt by the frequent interruptions of aggressive vendors, Cape McLear may seem more trouble than its worth. As the weekend went by, though, I found myself lulled through the sunshine and the rhythmic strokes of my kayak through the blue green waters into a calm and peace of mind rarely felt in Blantyre. I went through it all that weekend: homesickness, frustration, fear, loneliness, pain physical and emotional, economic hardship (temporary and nothing compared to the real hardship around me), and ultimately, peace. Well at least until we left and drove in our rickety minibus through an incredibly scary storm on an unlit main road lined with soaked pedestrians who blended into the darkness.
Cape McLear gifted me with many memories. Kayaking through a grotto of metamorphic stones, finding that I was spied on by little gopher-like animals (rock hyrax) peeking through the rocks, holding the hands of many many beautiful children of the beach with their simple readiness to be loved, watching lights float slowly over the water as the fisherman went to their nighttime catches with four or five glass lanterns held by a bar over their hand hewn canoes, playing Bawu (like mankala) with local men who taught me and then playfully beat me.
Sunday morning, trying to visit God’s house, I made my way into the small village behind the sand strewn shore. Roughly thatched houses perched awkwardly over unmarked plots of sandy land and chickens scratched for their mid morning snack under strings of drying laundry. After zig-zagging through the playing children and overly small pathways, the village opened up to a large stretch of farmland overlooked by the impressively formal and large building of a Catholic church. I walked in to one person. Hello, I heard there is Mass today, now, actually? Oh, no, the priest comes once a month. Mass was 7:30 am (two hours ago) in Monkey bay (half an hour away). Oh. We do have prayer services every week. In english? No, in chichewa (the national language in addition to English). Okay.
I stayed through the 2 hour Chichewa service of prayer, songs, Bible readings, and multiple collections (not sure if each was for a different church but every collection basket was linked to a Saint’s name read aloud). As the narrow pews slowly filled, many came up to greet me, the one Muzungu (white person/foreigner). Surprisingly, men and women sat separately as they sang back and forth. A male leader would start followed by simple starkly beautiful harmonic response. The melodies were simple and repetitive enough that even I could join and could harmonize easily. At the end all the visitors were asked to come to the front to introduce themselves and where they are from I said a little anxiously in Chichewa in front of the whole smiling congregation “my name is Suzanna. Blantyre. Canada. Thank you very much.”
My name is Suzanna, Blantyre, Canada, Texas. Thank you, Cape McLear.
