Unsurprising research
I hate the people who say "I don't know why they did this research, everyone with common sense knows the conclusion" as much as the next wannabe scientist, but here are a couple of abstracts I've found which did not surprise me at all.
The attitudes of medical students towards homeless people: does medical school make a difference? An excerpt: This study suggests that medical students may hold more negative attitudes towards homeless people at the end of their undergraduate course than they do at the beginning of it. Probably due to exposure to negative staff attitudes, and (I daresay) actual homeless people, although of course I am falling into the same trap there.
It's no secret: Measuring the security and reliability of authentication via 'secret' questions Once again: Acquaintances with whom participants reported being unwilling to share their webmail passwords were able to guess 17% of their answers. Participants forgot 20% of their own answers within six months. The ubiquitous availability of details like date of birth and family relationships from social networks does not improve the situation.
Race in Malawi, a Mzungu view
As I was walking along Mandala Road on my way to the hospital one morning, someone stopped and said how glad he was to see a foreigner walking, that it made him hopeful for the future.
The sensitive subject of race is, here in Malawi, not that sensitive. Mzungu originally referred to the British, but now extends to anyone who is not black African. When the Egyptian soccer team won the Africa Cup recently, there was apparently some disagreement in a local bar about whether they are azungu (mzungu plural) or not. It was unquestioned that, if they were, the win was preordained - mzungu privilege is palpable, even to someone who bumbles through life without noticing much.
No security guard stops me, people tend to get out of my way sooner than I can theirs. I am offered the front seat in minibuses, next to the gangster types. In daylight hours I feel totally safe on the road and walking around. It is interesting but a bit sad, and I hate being called "boss".
At night, though, we get taxis everywhere, even a few hundred metres. But while we are apparently targets, it seems to only be because of the assumption that azungu have valuables. There is no undercurrent of racial tension that seems obvious to me. It probably helps that most of the Europeans who came here were missionaries, not soldiers or settlers, there were few resources worth exploiting, and the country was a protectorate rather than a colony. Although Rhodes (who was cunning at best and downright evil at worst) and the British South Africa Company had a hand in a few nasty parts of the history, the British administration seems to be remembered as largely a tolerable affair, out of which Malawi did get something.
The white people here are still very much a class in themselves and are rarely seen pushing a broom or serving food. There is a small Indian and Middle Eastern population here, who seem to fit in somewhere between black and white, running many of the shops and restaurants. Interestingly as an ethnic group there is much more dislike of them voiced by the black Africans, although the fact I'm in earshot might change what they say.
On the whole, Malawi seems quite happy to have azungu here, either international or locally-born. I just hope we can avoid messing the relationship up.
They call Bunnings "church" here
The preachers came into the side room as we were trying to hold our ward round. "God will hear your prayers from outside", the consultant said, ushering them out again.
He laughed when he came back in, saying that the other line he uses is "God hears you even when you pray quietly", you can barely hear yourself think some days, why do they need to be so LOUD?
Religion is a much more obvious part of life here, especially for the various Christian sects. Malawi's first Europeans were Scottish missionaries, led by the famous Dr Livingstone, and church leaders have been responsible for both violent and peaceful rebellion against the colonial and totalitarian governments.
There are so many churches, of hundreds of denominations. The most impressive building in Blantyre is the church built by the original Scottish missions, and the vast majority of posters are for evangelical events. There were some slightly creepy Church of Jesus Christ of Latter Day Saints people on the plane, and a large number of American ... missionaries, I suppose, around town. Sundays in town are silent.
We were laughing at lunch one Friday. I was saying I had perhaps lost my way to God in recent years and Julia wondering if she had ever found it. The next week our lunch was backed by hymns and carols, although broken occasionally by unecclesiastical shouting.
At lunchtime the hospital is filled with preachers and nuns. My long bus rides start with complex prayers in a mixture of Chichewa and English. There is apparently a varied and complex interaction between traditional spiritual beliefs and Christianity, although I haven't really come across that myself. But there is a lot of singing, and it is beautiful and uplifting, through the city, up the mountains, and especially in the hospital.
Victim of poverty
It is an unfortunate fact that, should you be admitted to the public hospital here in Blantyre, Malawi, you have a 20% chance of not leaving with a pulse. With odds like that, taking care of six patients becomes almost a lottery, and today the inevitable happened.
For some reason, presumably my skin colour and air of arrogance, people keep assuming I am a full-blown doctor. A minute or two after I arrived on my ward, one of the junior students ran up and asked me to look at someone in a critical condition (which is medical for "about to die").
His mattress was on the floor, crammed in the space between two beds, and as the family cleared away I heard the soft gurgling sound stop. Trying not to panic, I asked why he had been admitted and tried to rouse him. "Get one of the interns", no breathing, roll him onto his side, head back, still no breathing, no heart sounds, no pulses. The intern arrived, a quick summary, she says "no breath sounds? What about pupils?" and they are dilated like little marbles, fixed wide open despite my torch, and his chest is warm but his hands are cooling quickly.
"What should we do?"
"Tell the family," who are hovering in the aisle, and she turns to do that, in a quiet voice. The wailing starts after a longer pause than I expect. The intern covers him up, and the morgue staff rattle in with a trolley as I try to focus on a chest X-ray.
There is no CPR here on the adult wards, no Code Blue, no MET staff hurrying to help. There is nowhere to put them if resuscitation is successful, so arguably there is not a lot of point in traumatising the family and scaring everyone else.
Obviously I didn't just walk away from this untouched. It came up surprisingly naturally with the consultant, who sighed and said he thought we tried too hard in the Western world to save the unsaveable, and that in ten years in Britain he'd had one patient walk out of hospital after resuscitation.
Why did this patient die? I don't know, directly, only glancing at the notes. He came in with vague symptoms like everyone here, HIV positive like 80%, had a bunch of observations and investigations ordered and was admitted to the ward. I was the next staff member to see him, almost 48 hours later. The previous day the intern and I were on-call, admitting other patients. I don't know who wrote an oxygen saturation of 74%, well below normal, in the notes, or why nothing was done about it. Unfortunately it is not just physical resources like lab reagents that are in short supply here, but minds and hands too. Plenty of patients go unseen by medical or nursing staff for days, especially when the interns are on-call and the students are in classes.
I came to Malawi for a challenge. I am getting it.
Muli bwanji!
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.
