There has been an unexpected, but welcomed, change in my assignment. I have been working in the PEDS A/E (accident and emergency) department supervising some of the 68 students assigned to Queen Elizabeth Central Hospital in Blantyre for the remaining 6 weeks of their pediatric clinical rotation. It’s been a great experience and I have enjoyed (am enjoying) my time in the South of Malawi.
From here, I can sense time moving. Reaching ¾ of the way through my Peace Corps service has taken my mind, body and spirit to various shallows and depths of experiences and exposures with people, travel, organizations, communication, health care delivery, education, culture, relationships, disease, adventure, poverty, emotions, food, wildlife, politics, systems and the human spirit. Some are twists of the familiar…others are completely unfamiliar…etching new pathways to ponder, problem solve and place. Testing mental strength, resiliency, self-confidence, trust, knowledge, vulnerability, common sense and self-assurance. Each one seemingly posing a challenge or a lesson along the way, sometimes without clear understanding, meaning or purpose…or maybe there is no intention of any challenge or lesson, but rather, simply, its just life showing itself in the world around me.
Some days my frustration cloud thickens more than desired…other times its thinner than expected. Regardless I manage at some point to find a way through or around it…depending upon my perception on any given day.
…The rains fall and I find myself standing a vulnerable victim to mother nature – at times a very serious mother nature – when the “road” upon I am walking becomes a rapid river in literally minutes…and I go from happy and dry to defeated and severely drenched (most times, neither the umbrella nor the raincoat can provide shelter against the rains of Malawi Mother Nature).
…I walk the path to my house…and a 1 meter black mamba slithers quickly away in front of me…luckily away from my footsteps and toward the vast cornfields that now surround my house.
…I decide to travel within this beautiful country that is Malawi…and wait upwards of 1-1.5 hours for the minibus to fill up with 10 too many people/chickens/rice sacks/logs of wood/(insert: anything else) so the journey to my destination (which is approximately 1 hour) can begin. Within 5 minutes of departing from the bus depot, the minibus runs out of petrol…and is now blocking a quarter of the road as the driver jumps out of his seat, grabs his jerry can for petrol and scrambles to the nearest petrol station. Upon his return he puts some, not all, of the petrol into the tank…and then drives to the petrol station to put in just enough petrol to make it to the next stop (usually none of the gauges work on the dashboard anyway – just one of many deteriorating and dilapidated features of the minibus) leaving the rest of the petrol in the jerry can which is kept in the back of the minibus (note: filling the petrol tank on the minibus to full is bad practice…for fear that someone might siphon gas – which is expensive – equaling money lost). For them, it’s figuring out how to get through each day and make it to the next. I get it. For me, waiting longer to depart the bus depot than it actually takes to arrive to my destination – taking into consideration the many potential delays of multiple stops, flat tires and fallen off door blunders along the way – has just become part of the escapade. I roll with however it plays itself out – arriving safely without incident is the goal. The phrase “time is money” has very little meaning here.
…I have the pleasure of the “Malawian non-service, customer service” experiences. The concept of customer service…well, is basically non-existent. The best examples are during my outings to Airtel (the store to purchase “Airtel money” so that I can pay my electric bill, put internet time onto a dongle plugged into the USB port on my Mac or put airtime onto my 1990 Nokia mobile phone with T9 for text messaging – jealous yet?). Literally, I stand in line and wait appropriately for my turn, as Malawians will cut the line for a more strategic placement then when they first arrived – without question. Once I make it to be “next” in line (because I will still follow my ingrained American culture habit of actually respecting one’s place in a line – waiting patiently and fairly – for my turn)…the Airtel representative may…or may not acknowledge my presence as actually being the next “customer” to assist. S/he may blatantly tend to other business with other customers (who are not in any line per se) or play leisurely on his/her cell phone or use the time to take a personal phone call or just chat it up with a co-worker for a hang out sesh at work…all the while I am standing there staring them down for their attention…until they are good and ready to assist me (yes me, the one who is actually the next “customer” in line). It’s a glorious experience…said no American ever.
…A visit to the ATM machine…turns into a half-day’s event…if you can hold out that long (depends on how badly you need funds – which is ultimately the driving force of your now “mission accepted”). When the ATM machine here on the KCN campus (super convenient…right? – well in theory) is working, it’s great! However, more often than not it is destined to be out of cash or temporarily not available or only allowing for single bill transactions (literally it will only give you one 1000 MK bill per transaction). From here, I am then left with the option to walk the 25-30 minutes to the next nearest ATM…and hope for an oasis of change. My reality undoubtedly slaps me square in the face to remind me…son, the first world this is not. Once I arrive, I will be greeted with a line of Malawians hoping to accomplish the same task of retrieving money for the day. Regardless if there are few or many in line, strategy has no place here, and this is why: what appears to be just one person in front of me…may actually be 6 (say what?!). Ahhh yes, – this is because they, in addition to their own ATM transaction, are also unselfishly handling transactions for a parent, a sibling, a spouse, a friend AND (not or) a neighbor. So the 1 person is now 6. Multiply this possibility by just 3-5 people in front of you…unlucky. Multiply this possibility by 10-15 people in front of you…sheer madness. Patience is tested. Outwait. Outlast. Outstay.
…“Yes” means no…and “Yes” means well…yes. This continues to be my experience…some days I can work within its cultural structure…and other days I’m less amused. Last week working with 8 of my students during clinical I was reviewing formulas and equations – testing their knowledge and math skills with conditions, medication and fluid treatments for things like malaria, hypoglycemia and burns in pediatric patients. This scenario is much better heard from my mouth than I could ever do it justice typing, but here it goes. Regardless of what question I ask – do you know the clinical signs of malaria? Do you know the dose of quinine? Do you know the formula for dextrose 10% and how to make it? Can you tell me the fluid resuscitation volume for a burn patient? Inevitably, the answer is always “Yes”. When asked specifically to list some of the clinical signs of malaria? Or tell me the dose of quinine for a 10 kg child? Or show me the volume in mls of dextrose 10% for an 8 kg child? Or explain to me how you administer the fluid resuscitation volume to a burn patient in pediatrics? Often, more times than not, I will get a blank stare…radio silence. In the past, I would point out the inconsistency of their original answer “Yes”, but now I just try to reword the question (when possible). Truthfully, they say, “Yes” because they do not know the answer and the fear of disappointing you is too great. Which is THE LAST thing a Malawian would want to do. So they say, “Yes” because they know that is the answer you would want them to say (it doesn’t matter if its actually true or not). I struggle with this aspect, morally. My culture teaches me to value truth and honesty with integrity. My culture also respects, mostly without judgment, to answer, “I don’t know” when truly I don’t know. This concept is especially important in nursing and medicine while in clinical practice. A patient’s life could be dependent on my honesty about a medication administration, a procedure or my knowledge to use specific equipment (dramatically worded, yet potentially true). I remind my students that it is ok to tell me, “I don’t know” but they must follow it up with, “but I know where to look to find the answer” and actually go to find the answer to share with me. Even still, the phrase “I don’t know” is very difficult for a Malawian to verbalize. This cultural norm transcends many questions of any nature. In examples nonspecific to the above, I often walk away from conversations not actually knowing what may…or may not have been said.
…The communication and information highway here…is less highway and more of an abyss. Based loosely on a “need to know” now…or never basis. Typically, when I receive messages from one of the faculty members at KCN informing me about a department meeting, a presentation, a lecture, a workshop, an exam vetting, an exam grading session or a (insert anything here). The information delivery usually presents in either one of two forms of communication – both very last minute in nature (my favorite part). The first is if they happen to see me on campus walking to my office, I will discover that at that very moment they are speaking with me is when they are deciding now to inform me about any said event from above. Seems logical, because it is happening now (thanks for the heads up guys). The second delivery method is via SMS (text), which will typically inform me of a said event from above that it is happening in 5 to 15 minutes from now. I refer to this information jokingly as “hot off the press”… but in all seriousness to a Malawian it is standard operating procedure. Truthfully, I find it exceptionally disconcerting because I will be in the middle of supervising students or have had other things planned for that day (which by the way is my fault…planning is a loose term here – something that is meant to be flexible and rarely followed through). As an example, at one point on a Monday morning in mid-JANUARY, I was setting off from the office to the hospital to supervise my third year students in their pediatric clinicals and I happened upon a fellow colleague who informed me the medical-surgical department (my entire department) was in the conference room grading exams…for the week! Ok seriously guys, you couldn’t have told me about this any sooner than TODAY? So instead of supervising students at the hospital that week and holding our 2 skills lab sessions for both the first and third year students…the entire department was on lock down for 4 days as we graded exams, by hand, with each exam reviewed twice by two separate lecturers –including essays, for 150 first year students, 177 third year students and 100 ish fourth year students from their theory classes in NOVEMBER. It turns out; efficiency is another loose term applied here.
…The start of my day is performing chest compressions on a 5-month-old twin who has most likely been suffering from too many days of vomiting and diarrhea complicated by malaria…or the potential electrolyte imbalance from too many days of dehydration.
…Attending mortality rounds each Friday morning to find that in certain circumstances emergency equipment was faulty, non-existent, misplaced or gone unnoticed by staff to suction a child or provide oxygen.
…Witnessing the volume of children admitted to Queen Elizabeth Central Hospital in Blantyre (or KCH in Lilongwe) who are placed shared in a bed as they battle their diagnosis of malaria, pneumonia, sepsis, meningitis, anemia, malnutrition, hydrocephalus, trauma, HIV or cancer…and wondering if true infection prevention and control will ever find its place in Malawi.
…Wrapping my brain around the concept of capacity building…and wondering about the likely possibility of effectively training an intake of next year’s projected nursing class of over 300 students…when I feel the quality of education and clinical competency of the existing 177-250 students in each class is being compromised.
So I am left wondering…
How does a developing country meet the demands of their own broken health care system? How does a misguided government purpose to effectively prepare to graduate the gross number of nursing students per year that is being suggested by the Ministry of Health? How can an overwhelmed university provide a quality education while maintaining accountability for the competency of their students who will graduate to clinical practice? How do overworked and under resourced lecturers, clinical instructors and nursing staff work together to produce knowledgeable and competent students who will practice and care for the children of Malawi in their own health care centers, district and central hospitals?
Are the solutions being presented reasonable? Can a country move forward with goals that appear unrealistic for even the most ambitious of people? I teach my students about making the goals of their nursing diagnosis and interventions to be SMART (specific, measurable, attainable, realistic, timely). Are their own government, their own ministry of health, and their own university doing the same for them for their education and training?