This weekend we are at our Seed-Peace Corps IST, which I think means Interim Service Training. We are a little over 1/3 of the way through our GHSP year and we rode to Lilongwe on an AXA bus. AXA busses are large and modern and comfortable. And safer than minibuses. (A minibus just crashed in Mzuzu, colliding with a truck and a regular bus, killing 30 people.) They also cost about 10x what a minibus ride costs. On the trip I finished Jane Smiley’s A Thousand Acres, which I started and abandoned years ago. This time I couldn’t put it down. Previously I hadn’t gotten to the revelations of the extremely dysfunctional family and merely dismissed the father as an unpleasant control-freak. It is a magnificent work.
We are gathered at a lodge outside of Lilongwe to reflect on our experiences so far and to think about how we want to complete our service. I think it is a good idea, since we can share ideas early enough to course-correct.
The place we are staying, an old resort behind a high brick wall just off the main highway, lacks quite a lot: hot water for showers (in our room, at least. Some other rooms appear to have it.), internet (which costs extra), and electricity most of the time (so no internet even if you pay the premium for it). The food is pretty mediocre, our round hut is cute from the outside but lacks ventilation and is very dark inside, and no one comes to make the bed. There is a nice pool and tables scattered around the grounds at which to sit and talk and eat or write. We are captive, as there is nowhere pleasant nearby to walk or hike.
As the 20 of us share our varied experiences from 4 different cities in Malawi, we hear about power outages in other hospitals, so that no surgery can be done. Ventilators, when they exist, don’t work without power so people requiring them must be manually ventilated. That is 12-14 squeezes per minute for an adult and you do the math for 24hours or more. Labor intensive. Weather has been in the 100 degree range in Mangochi; of course, there are no air conditioners in the hospital. Even if there were, they are electrical appliances. There is a faculty strike at the school of nursing in Mzuzu so there are no nursing students to teach or to work in the hospital. All against a backdrop of chronic insufficiency—of facilities, materials, equipment, medications, trained staff. But there are also reports of innovative teaching plans, pain management programs, and steady, consistent, creative, show-up-on-time teaching of nurses, nurse-midwives, and medical students. Also, teaching and consultation with residents (Registrars), interns, and Clinical Officers (non-MD’s who function as physicians, doing surgery, prescribing medication, and running hospitals and clinics).
Linda travelled to a district hospital to teach a group of 4th year midwifery students last Monday. They felt they were—and they were—on their own and were pretty scared at having to manage labor and delivery without supervision. They were so grateful and seemed so frightened that she returned on Thursday to support and teach them. Their lives aren’t easy; at 11AM the first day she asked who had eaten anything that morning. None of them. So she talked to them about Maslow’s hierarchy of needs; if a basic need like hunger isn’t satisfied, higher needs cannot be adequately addressed. And the students must rotate from site to site, finding their own lodging and food. This group had to carry their water from a nearby river. But they were eager to work and learn.
Any large ideas I’ve had about reforming the system (like thoughts I had before analytic training of re-writing Freud and the psychoanalytic canon—a bit of grandiosity there. No small plans!) have melted in the face of the reality. I’ll make a little contribution, what I can, and hope some of it sticks. While I want the students to be able to recognize and think about the diagnosis and treatment of mentally ill people, I am as interested in helping with their attitudes as physicians: to see nurses as co-equals, generally with valuable information and perspective on shared patients; to treat patients with curiosity, humility, compassion, and respect; to approach their life in medicine as a gift they have been given as the fortunate recipients of a growing body of skills and knowledge; and to treat the prerogatives of being a physician, privy to intimate confidences and as a direct witness to suffering, with gratitude. This all may be too much for students bombarded with myriad facts and experiences and tests and responsibilities beyond their capacities to take in fully, but it’s worth a try. As a result of one of our Open Space discussions yesterday, I’ll add a brief PowerPoint presentation, discussion, and role play on death and dying, since they will be immersed in it. One in 5 women dies in childbirth. Every morning report in the hospitals is punctuated with the number and names of those who died during the night. And often they were obviously preventable deaths if only the a) needed medication, b) piece of equipment, c) electricity, d) greater number of nursing staff was available. One of the worst parts of being traumatized, as we have felt since the election in the US, is the accompanying sense of overwhelm and helplessness.
A regular Peace Corps Volunteer, Anya, whom we met at the Kutu Nature Preserve is making cooking briquettes with a small press out of leaves, cardboard, dried manure, rice hulls, corn husks, and basically any dried organic material. (I wrote about it earlier.) Instead of cutting trees for firewood, people can plant them for the leaves, reforesting Malawi. I was taken with the idea and last week went to the Blantyre Central Market to an area where they make furniture and doors. I talked with a carpenter, Boswell, and showed him photos of Anya’s press. I explained its function and asked him to manufacture one for me. It took a lot of mutual head scratching, since I had photos but no dimensions. And inadequate Chichewa. At one point there were 12 people gathered around me, all talking and adding their suggestions. We got the concept straight, I estimated the dimensions, and we negotiated a price. Two days later I got a call that I had to come get it. It was done and it could be stolen from the market at night as there was no place to keep it safe. It was late in the day and I don’t have lights for my bike so Boswell suggested he could bring it if I paid for the transportation. I agreed, thinking he’d get a taxi which would cost about $2.70 (MK2000). He showed up with the transporter, another guy from whom he’d likely get a small cut, carrying the press on his shoulder. He’d done a terrific job building it, with two morticed joints and a fine weld on the metal guide. [See photo above.] I paid the transporter about two thirds of the exorbitant fee he demanded and Boswell vowed to return the next day for some fine adjustments. He came, did the work, I paid him, and now I have a press.
It isn’t for me, as we cook with electricity or our gas burner when the former is out. It is for the vocational training program at the orphanage where I consult once a month. I’m pretty excited about getting a grant I submitted to scale it up with more presses, as is Boswell, who wants to build more, and Edwin, the vocational teacher. Perhaps that effort will survive my departure, with teenage orphans sparking a green revolution in Malawi!
As we get more into our work here, both Linda and I fantasize, again, about staying another year. We’d be more effective a second year, knowing the ropes, and we would have the satisfaction of seeing the students we are now teaching graduate. However, given my age and stage of life, I need to consider every commitment carefully. I have unattended business in the US, both in California and Maine, and I hear the call clearly.
A psychiatrist in Malawi 