Road Trip: Malawi

I

My last night in Malawi, I was awoken at midnight by my uncomfortably bloated belly. I had eaten a bowl of instant ramen four hours earlier.  I went to the bathroom, and promptly vomited up my undigested dinner.  It relieved the discomfort somewhat, but my GI tract remained uneasy; the diarrhea started shortly thereafter. I was heading to the airport in six hours, to embark on the 36-hour journey back to America. Of course this would happen as I was leaving.  It was an apt metaphor for my two weeks in the country.  Life had been challenging.  And I simply could not stay any longer.  

I calculated. I could make the two-hour flight to Johannesburg, and possibly the 8 more hours to Paris.  The 6-hour layover would be a drag, but I knew my way around Jo-burg’s OR Tambo Airport (the Atlanta of Southern Africa; “you cannot get there directly”) enough to find a place to quietly crash.  At any rate, if I needed urgent medical care, I could go into the cities of Johannesburg or Paris, where I knew people.  Where there would be soap and running water in the hospitals.

In the morning, there was no electricity in the flat. I was grateful for the little hot water that remained in the tank, enough for a shower.  I drank a Coke, both for carbonation and for caffeine. I dragged my bags and my shaky, weakened self down three flights to the car.  I drove to the hospital for the last time, where my ride to the airport would meet me.  In my feverish state, I stalled at an intersection.  The 2-mile drive to the hospital took an eternity.  By the time we got to Blantyre airport, my GI tract had stabilized enough to board the plane. I breathed a sigh of relief as I touched down in Johannesburg.  I had met my only goal in Malawi: “Don’t die in Malawi.”

II

Another African city, another horror, more chaos—glary light, people crowding the roads, the stinking dust and diesel fumes, the broken fences, the vandalized shop fronts, the iron bars on all the display windows, the children fighting, the women heavily laden, and no relief in sight.

Paul Theroux  Last Train to Zona Verde

Life is hard for the million inhabitants of Blantyre, Malawi’s second largest city. You find the trappings of modern urban life—cell phones, supersized malls, roads glutted with cars, motorcycles, and minibuses. But there is a failure of infrastructure.  There are daily power outages, unpredictable in timing and duration. The water supply is tenuous, even more so during the drought of the dry winter season. There is no mass transit, the communal minibuses serving as ride shares.  For all the cell phone towers dotting the hilly landscape, Wi-Fi remains elusive.

Staying healthy is a challenge.  Public bathrooms, including those in the hospital, are often without running water, toilet paper, or soap. Shake hands at your peril.  Hospital rounds are conducted without hand washing or anti-microbial gels.  Dressings are removed not with scissors but with razor blades.  Scrubbing in the OR involves a remnant of bar soap at the sink. Sterile technique is a misnomer. Malaria accounts for 40% of hospitalizations.  HIV prevalence in adults is 10%.  Such is the reality of health care in Malawi.

For Malawi’s 15 million people, there are fewer than 10 orthopedic surgeons.  Most of the orthopedic care in the country is provided by non-surgeons, primarily the Orthopedic Clinical Officers (OCOs).  OCOs are general medical officers or medical assistants with advanced training in orthopedic care. They can perform minor procedures such as debridement of wounds, fracture reductions (“manipulations”), and application of skeletal traction. 

My project as an Orthopedics Overseas volunteer was to instruct the clinical officers and OCOs in training at Blantyre’s Queen Elizabeth Hospital (“Queen’s”), the largest public hospital in the city.  The teaching was to involve in-patient (“ward”) rounds, practical teaching in the clinical and the OR (“theatre”), and some lectures which I had prepared in advance.  My responsibility also extended to visiting several district hospitals in the region, providing advice and support for the OCOs working there (often without any supervising surgeon).  I could review the ward patients and decide if any needed to be transferred to Queen’s for further or definitive surgical treatment.

III

When I arrived at the Blantyre airport, I was met by Mr. Christopher Ngulube, the head instructor for the OCOs, and an experienced OCO himself. He was my main contact during my two week stay, and was exceedingly kind in helping me with the logistics of life in Blantyre. He took me to the grocery store, helped get a SIM card and Wi-Fi access, and most importantly, showed me how navigate the Malawian roads. The visiting orthopedic volunteers have use of a car during their stay, in order to drive in the city and to the district hospitals.  The driving situation will be discussed further in some detail, as it was a source of both stress and freedom.

I was fortunate to be staying in a flat in Sunnyside, one of the nicer parts of the city.  The flat had a hot water tank, stove, refrigerator, and washing machine.  Using any of these was all contingent on the power supply.  The one time I used the washing machine, it got curiously quiet during the rinse cycle. I investigated, only to find that the water had drained directly onto the floor, resulting in a minor flood in the bathroom, kitchen, and hall.  I spent a couple of hours bailing out the water as though I was on a sinking ship. That same night my watch stopped working, probably in solidarity with the kitchen clock, which was permanently set at 4:50.  I found most clocks in Malawi were not functional, adding to the sense of suspended time.  

Rarely was the power on when I came home from the hospital.  Sunset being at 5:30 pm, most of my evenings were spent in candlelight.  The scene was less romantic than you would imagine, given the chorus of howling street dogs and crying babies.  Deforestation is a problem for Malawi, and the burning of charcoal discouraged. But mothers have to care for their families, and are left with few options if they have no power. The smell of burning charcoal, combined with the smell of burning plastic garbage, left me with a baseline nausea and headache.  I can only imagine the toxicity inflicted by constantly breathing these fumes, especially on the children.

   

My evening routine involved walking around the flat with a headlight on, debating between making a peanut butter and jelly sandwich or a salad for dinner. (If I happened to have power around dinnertime, ramen was the third option.)  I tried to channel Meriwether Clark (I was reading “Undaunted Courage” at the time), documenting exciting discoveries in a strange new land. But writing in darkness, both literal and metaphoric, proved to be difficult.  Most of the time, I read or worked on lectures, waiting for daylight.  

I am no stranger to the living conditions and chaos found in the urban areas of the world’s poorest countries.  I’ve been here before— Madagascar, Myanmar, Nepal.  In Africa, there can be an underlying threat of violence, bred of extreme poverty, hopelessness, and desperation, which makes safety at night a concern.  Even in a relatively affluent neighborhood such as Sunnyside, houses were surrounded by high walls, topped with barbed wire or glass shards.  My own flat had two separate locks, and an additional lock on my bedroom.  I was warned about walking or driving alone in the dark.  I was dubious about my newly acquired manual transmission driving skills, and had no desire to test them in the dark.  As I had come on my own, and knew no one in the city, I spent most evenings at home.   

IV.

Christopher and Master (another OCO at Queens), and the OCOs from the district hospitals I visited, were gracious towards me. We discussed cases, exchanged ideas, and saw patients together.  This is where I felt I was making a sustainable contribution.  Whether I was teaching a relatively simple technique, such as a digital block or revision finger amputation, or some clinical decision making skills about wound care, surgical, or traction management, I felt my presence was appreciated.  One of the things I love about orthopedics is being part of a collaborative team. 

In contrast, my general reception from the students and hospital staff was a disconcerting blend of indifference and entitlement.  While I had come prepared with three lectures, the OCO students were under the impression that I would be giving an hour lecture daily.  I disabused them of this notion, explaining that my time commitments to clinical teaching and visiting other district hospitals prevented the seven additional lectures. When I suggested more informal teaching during ward and clinic rounds, they were not interested. They kept insisting on formal lectures.  Not on any particular topic, or because of any particular academic interest, but to prepare for exams.  “Who will give us these lectures?”  If there was no time to present a lecture, they were also fine with downloading a Power Point presentation or articles from my laptop.  It seems the students are accustomed to a passive learning model, and the concept of independent and self-directed study seemed foreign to them.  Oh, and could I give them some books? This request despite their having a rather extensive orthopedic library already.

Anyone who has visited the developing world is well acquainted with the constant ask.  Something is always being sold, and even in the absence of goods, there is the constant demand for money. That is the economic reality of the extremely poor.  In Malawi, vendors sell their goods by the side of the road—or rather in the road, since there are no sidewalks or shoulders. People will hold out a puppy or chicken, potatoes or strawberries, quartz crystals or wooden carvings as you drive by.  One time I walked by a vendor near my flat and asked what he was selling. “Phone cards,” he said.  When I said I didn’t need a phone card, he chased after me.  “What do you want to buy?”  Sensing this could lead to a world of trouble, I just kept walking. 

In the parking areas of my apartment and the hospital, there were men who made their living washing the cars. Payment would be demanded as you were driving out.  Whether you had actually wanted your car washed was irrelevant. (The Malawian equivalent of a squeegee man.)  After this happened the first time, I explained to the car washer that I did not need my car washed daily and would not be paying again.  I pointed out the car was a 2002 Toyota Sprinter and a little long in the tooth.  I was a little worried that I might lose some essential protection for the car while it was parked, but I don’t think the car was any worse for wear. 

My point here is that I am well accustomed to being asked for money and I understand that people do what they need to survive. But this was the first time I had encountered this expectation from those who are educated, with skills and resources of their own.  I met a European surgeon, one of the few on staff at a district hospital, who was unhappy he had not been made aware of my visit in advance.  “We would have scheduled you to give a lecture. You can’t just visit after all.  You need to give something back.” What is it with the lectures?!  And give something back?  As if I had chosen to come on some extravagant holiday to Malawi and was being a big drain on their system.

Malawi, of all the countries I have visited or lived in, carries constant reminders of its dependence on foreign aid.  Every theatre room or lecture hall has a plaque with the name of some foreign donor, whether an organization, a university, or an individual.  There was a Unicef trailer at Queens. During my time in Blantyre there was a conference of Specialists Without Borders (no relation to Doctors Without Borders), an Australian group of physicians who gave, wait for it… three days’ worth of lectures to the students.  And Madonna is funding the new pediatric building at Queens.  So given this constant influx of money, influence, and medical support from abroad, I guess it’s not surprising that certain expectations arise towards foreign visitors, along with a baseline indifference. 

In my past overseas living experiences—e.g. in Myanmar, South Africa, Rwanda, I have found the local medical staff to be warm and supportive.  There is a collegiality that develops when sharing challenges of daily living, whether dealing with non-existent air conditioning or a water strike.  I understand that people have busy lives, with families and jobs outside the public hospital. Yet something as simple as a greeting or an offer of tea can make someone feel welcome. In Malawi, when I tried to engage the OR staff, asking their names or trying to be helpful, I was met with a stare. Once in a weak attempt at humor, I asked whether the scrub nurse was feeling strong enough hold a leg for a difficult case.  He snapped back, “Give me money for lunch, and I’ll feel stronger.”  

Perhaps because I was only there for two weeks, it was not enough time to get accepted. Perhaps it was a language issue—while English is the official language, Chichewa is the main one spoken.  My knowledge of the language remained limited to Muli Bwanji (hello, how are you?) and Zikomo (thank you).  But as I have found when taking care of the patients we don’t need to speak the same language to convey kindness or concern.  Perhaps because the disconnectedness in an urban setting is so much more alienating.  At least when I was in rural South Africa, living a pretty basic life in an old-fashioned hospital compound, the lack of power or water became a common excuse to hang out with the neighbors, share a cocktail and some laughs.  

I try to be self-sufficient when I travel.  On this trip, I brought my own scrubs and OR shoes. I packed a lunch, and always carried water.  Once I learned to drive the car, I got myself to Queens, the district hospitals, and the shopping mall.  Despite the semblance of an occupation, a home, and a routine, everything was foreign.  There was simultaneously the sense of timelessness and transience.  This mode of existence can be quite unsettling, made even more so by lack of a social support system.  I am thankful for the close friends back home that sensed my discomfort, and communicated with me regularly.  I will never underestimate again the power of the “check in.”  I gladly risked draining the power on my cellphone to stay connected.

V. 

We conclude with the greatest challenge of my Malawian trip.  It was not dealing with the poor sanitation, risk of illness, lack of power, apathetic students, or the threat of violence.  The surgical issues did not phase me.  I was capable of managing the endless pediatric elbow fractures (aka mango tree injuries), gunshot wounds, and road traffic injuries. What caused me stress before I arrived, and continued to do so to some degree throughout my visit, was learning how to drive a manual transmission.

I had attempted learning when I was a teenager, but after a few bad episodes (hitting the side of a well in India, hitting a curb in the US, a failed group attempt at renting a car in Ireland), I stopped trying. I created a false narrative in which I was simply not capable of driving a stick.  And this apraxia and phobia almost overtook me. Before I conquered the fear, I had to give myself a talking to: “You can do this.  You do ten more complicated things a day than driving a stick.  This is how the rest of the world drives.  They all do it, even people less clever and coordinated than you.  And here’s the thing—this is not optional.  You must do this so you can get on with your work.  There is no driver, no Uber.  So put on your big girl pants and get a move on.”  Despite this talking to, I had a clenched fist in the stomach anxiety (which I can only comparing to the anxiety of being on call), for the entire time  I was in Malawi.

I had friends teach me the basics in the US, and Christopher had helped me with driving the car in Blantyre.  One drives on the left side of the road, with the driver sitting on the right side of the car with the left hand managing the shifter. There were no road signs, so I navigated with landmarks (and my poor sense of direction).   Once I stopped overthinking everything, and I stopped obsessing about stalling in a crowd, I relaxed and let myself drive. The car did not have a tachometer, so I focused on the sound and feel of the engine. I found the sweet spot (aka “biting point”) as I released the clutch where the engine accelerated. I grew adept at the hand brake on a hill, slowing/not stopping at the police stops, and taking turns.

Driving in Malawi meant sharing the road with people —some using the street as a sidewalk and shopfront, animals (eg dogs, chickens, goats, antelopes), bicyclists, and motorcycles. And watching for the endlessly stopping and starting minibuses, careening through traffic without braking or signaling.  Driving was truly an exercise in mindfulness.  I could not afford to be distracted, not by a cellphone, beverage, not even the radio. I drove listening only to the sound of the rattling Toyota, hot dusty air blowing through the windows.  I missed a few turns, went off-roading a few times, and had my share of stalls.  I kept a close eye on the oil and tire pressures, and managed to keep the car in decent driving condition. 

I can’t say that I mastered the manual transmission or that I particularly enjoyed driving in Malawi.  What I did appreciate was the independence of being able to see more of the country.  After visiting the district hospital in Zomba, I spent a weekend on the Zomba plateau. The countryside was cool and hilly, with opportunities for hiking and horse back riding. I even watched a wedding from my patio. 

I drove 2.5 hours to Mwanza, on the Mozambique border. You know it’s a tough place when Doctors Without Borders is already there. There is apparently a large influx of patients/refugees who cross the border to get their medical care in Malawi.  I met two experienced OCOs at the hospital who were so appreciative of my being there.  They were happy to do ward rounds with me, reviewing some patients and X-rays.  I recommended transferring one of the pediatric patients to Blantyre for further treatment, formulating a plan which relieved some stress.  I felt bad leaving after only a few hours. I had a lecture to give in Blantyre.

The following Friday, I spent time at the district hospital in Chikwawa, helping the new OCO there. He was on his own and was happy to have some help. Afterwards I went to Majete Wildlife Reserve.  The reserve is managed by African Parks with an innovative program in restoration, conservation and community outreach.  I was in my happy place that weekend.  I met an outgoing young Malawian woman who runs an adventure travel company in Lake Malawi.  I will seek her advice if I were to return to Malawi.  There is a lot more to see of the country…

VI.

“What am I doing here?”

There is a complicated calculus involved in assessing the value of volunteering overseas.  On the one hand, there is the inherent physical and emotional discomfort involved.  There are the lost wages, and the cost incurred of the travel, housing, and living expenses.  Simply donating money is an easier solution, whether to Partners in Health, Doctors Without Borders, or to any number of humanitarian aid organizations.  In areas where I have no particular expertise (e.g. Environmental or Conservation efforts), this seems a good option. On the other hand, the years and cost of my training, and the surgical skills I have subsequently acquired, are priceless.  My donation of time and knowledge is more substantial than any financial contribution I can make.

So then I consider the value of my visit. Have I helped improve patient care in a meaningful and sustainable way?  I would like to believe,  I need to believe, that my time was not wasted. I spent hours with clinical officers in clinic, reviewing the basics of an orthopedic history and exam. I taught them how to read and describe X-rays.  I taught the district clinic officers how to improve their non-operative and surgical techniques, and helped with triage and patient management.  As for the lectures that I delivered and downloaded for the OCOs—I’m not sure how much about work up of metabolic bone disease or management of wrist fractures they will remember after they pass their exams.  If I were to come back to Malawi, I would focus my efforts on the district hospitals, helping the OCOs who are already there and taking care of patients.  

There are also more personal benefits to consider:  The joys of discovering a new country. Of fabricating a new life.  Of meeting interesting and kind people.  Of learning a new skill and navigating new lands.  Of testing the limits of my tolerance for discomfort and isolation.  I have not completely worked out the cost-benefit analysis yet.  I’m taking a break from Africa for a while.

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