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I'm in Malawi!
I've been here in Blantyre, which is the industrial and financial capital, for a week now. I'm doing my elective term at the tertiary hospital for the southern region. It's been interesting and challenging and surprisingly fun.
Ranita talks about how hard American medical students have to work. The students here also work hard, but rather than busting their gut to learn everything there is to know about diseases, they see patients. Lots of patients. Most of the final year medical students and clinical officers (haven't quite worked out the difference) are responsible for the welfare of 5-10 patients, which means clerking them, coming up with management plans, taking them to Radiology or for an ECG, and doing procedures like abdominal fluid taps or lumbar punctures (without anaesthetic). I have done my first peritoneal drain and my first LP (with a 16 gauge needle and no local - ow!).
This week, the interns went on strike because they have not been paid. So the welfare of the patients has basically been left to the students. Unfortunately, they also have class to go to, and like all medical students are interested in doing the absolute minimum they can get away with. Patient care has suffered a bit.
The nurses' role seems limited to giving medications and taking blood. There are student nurses who do once-daily observations. Feeding, bathing, and as-required medications like oromorph is left to the patient's guardian (family member). The treatment is free but little else is provided.
The senior physicians are almost all international staff, and language is a problem for them and me. The clinical officers do a good job of translation, but they also have their own jobs to do.
The medicine is quite different. The complaints tend to be more vague, have gone on for longer before presenting, and in 80% of cases are on a background of HIV infection. Free testing and treatment is available, and I think HIV is probably less stigmatised here than at home (though it is still a problem).
"Breaking bad news" and "shared decision-making in healthcare" are two PBL topics not really on the agenda here, never mind patient confidentiality. The consultant said something along the lines off "this is a pretty horrifyingly paternalistic approach but that is the situation we are in".
I didn't really factor in any time to see Malawi in my plans, but crazy things happen. A large Malawian man wearing just a pair of shorts got chatting to me over breakfast. He expressed shock that the hospital was not providing me with transport every day, then revealed that he was the head of the Parliamentary finance committee and the member for Nkhata Bay (the most popular tourist spot on Lake Malawi).
In a manner vaguely reminiscent of The Last King of Scotland, he insisted I come to his district hospital for two weeks. Apparently he then rang the Dean of the college (who of course had never seen my face) to make the arrangements. I had to meet with him the next day; I don't think he gets too many calls from members of Parliament. It was an offer I couldn't refuse, in more than one way, so I'm heading up next weekend.
I went for drinks the other night with some of the volunteer junior doctors and hangers-on; a British barrister and I got talking over the rat race in law and finance. She is here with a legal aid organisation trying to get the constitution changed. Homosexuality is illegal here, as the paper reminds me ("psychologist says homosexuality is normal"), people get imprisoned for murder at the drop of a hat, police brutality is a matter of course, and more. I had never really thought of law as an area for volunteering, and it sounds like few of her colleagues have.
Yesterday, I went walking up one of the "mountains" around Blantyre. I think things went rather well given my cavalier approach to preparation, like forgetting my hat. The guidebook says, in entirety, "the path up Mt Soche starts at Soche Secondary School." Not having a map that extended that far, I wandered in its general direction, being invited to share nsima on the side of the road, picking up a guide or two somehow, and walking for about two hours.
The guidebook talks about "seeing the 'real Africa'", always in inverted commas, as if that's something you can do, like some of Africa is more real than the other parts. Well, of course, there was no obvious path, and the school backed onto a village rather than the mountain. So I ended up seeing some of the so-called real Africa, wandering through the village with kids shouting "mazungu! mazungu!" (white/foreigner) until I waved, past soccer games and huts of all shape and size, with songs blaring out of radios or from the churches. Soche is a poor village, but not that poor; most of the huts were in good repair, some had power, there were still plenty of trees.
As I was standing at a T-junction wondering which way to go, one man asked me where I was going, then offered to escort me, so off we went. Chris was not that familiar with the paths once we got out of the village, but together we muddled our way around and up the mountain. The mountain was filled with people praying and singing. African music followed me up the path. The view across Blantyre was pretty amazing too.
It was hard work; I'd already walked a long way and the path was pretty steep. Sweat poured off me, and my water was running pretty low. But we got almost to the top when it started to rain, we lost the path and I was getting pretty close to bingo time, so called it a day and slipped and slithered back down the now-soaking path.
I got home by minibus. They are the dominant form of public transport, almost always Toyota Hiaces converted to carry twelve or more people, which fill up and then go, and cost next to nothing. I took two to get home, the first falling into the category of held together with clingfilm and hope; it had to be push started and bumped its way along the dirt path to Limbe.
The second was almost brand new, but I sat up the front next to the driver which was a bit terrifying. People lean in the windows to sell things as the minibus moves, the driver buys things and talks to everyone, the buses get very very close together, but there seem to be basically no accidents.
I have more to say, about religion and about race, and the miracle that I have not fallen into a drain yet, but this is already a very long post. That can wait. It is hard work but fun and I'm really glad I came.
One comment
Brigida :: Monday, January 25th
David - this is absolutely fascinating stuff. Please keep posting .....
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