"We Treat, God Heals"

I was discussing last week about how tempting it is as a doctor to feel like it is the physicians who have the responsibility to bring cures and healing. From my training and my faith to my clinic motto: “We Treat, God Heals” – I know that even when I do my best, sometimes people will be healed and sometimes they will not. But as one who conscientiously wants to do my best, help people, and achieve goals, sometimes I carry burdens on my shoulder for a patient’s healing, even when only God can do the final step and make someone whole.

For example, last week a nurse brought her mother-in-law to see me. She had been sick for weeks and had already taken the strongest antibiotics available, but she continued to have fevers and feel unwell. Her vital signs were not great, she was badly ill, the type of illness that we give the red-flag of Systemic Inflammatory Response Syndrome; the type that we watch closely, treat aggressively, and try to find a source of infection and a cure. I gave her the strongest antibiotics we had, a renewed course. I checked for other infections and found something concerning in her urine. That earned the diagnosis of Urosepsis and an admission in the hospital. She got 3 liters of fluid and a couple doses of antibiotics and started to improve. Her full blood count was pretty concerning before she saw me, but on the day I saw her, the inflammatory cells were back to normal. With that value and her improvement on the second day, I was ready to promise her an early discharge and praise God for a miraculous healing. But then the full blood count on the third day showed an even worsening picture, so bad that the good-looking initial blood tests looked like an error (and probably were) in retrospect. We continued antibiotics, even though they might not fully help. We continued to give her fluids, although she was starting to get a little swollen in her feet. We drew cultures, trying to see if we could grow bacteria from her blood and urine. Recently there has been more and more antibiotic resistance in our communities, and for some patients there is no medication that would still work for their infections.

She had high sugars and signs of acid in her urine, which could be a complication of diabetic ketoacidosis or simply an indication of a bad infection and dehydration. We had an ultrasound of the kidneys and we knew that she was having kidney trouble, but we didn’t have fancy tests to know whether the problem was originating in the kidneys or elsewhere. We didn’t have the fancy blood tests to know if there was acid in her blood, which would lead us to treat her slightly differently. I kept feeling like we were missing something, I racked my brain for esoteric conditions I might have heard of in medical school a dozen years ago.

But in the end, we didn’t have the testing to know more about what was going on. We didn’t have the specialists to assist with a more complex diagnosis or the machines to help stabilize her more. I wanted to do more, but I was at my limit in this context. I worked closely with my colleagues, and we waited for the results of the blood culture. Finally we found the infection in her blood, and the right medication to treat it. She improved and was sent home after a week, longer than I would have hoped, but sooner than I had feared.

I have to admit, it was so hard for me to wait and not be able to do anything as she worsened or recovered in the hospital. As much as I pray for God to heal and as much as I trust the handover to my national colleagues, in practice, I still try to grab up control and still want to do something myself to push the healing to come sooner. Clearly I have a lot more to learn about what it means to treat and who truly beings the healing.

Family Medicine Doctor

Just over ten years ago, I was writing personal statements for residency programs. Sometimes I go back through those statements and remember where I was then, and what life is like now. I remember specifically thinking that I wanted to pursue Family Medicine as a specialty because I wanted to care for a whole family; I wanted to help deliver babies and then see them grow up. I also thought that Family Medicine would fit in well with Global Health. Back then, I imagined a life with a good fit and a nice balance, and for the most part I am doing what I hoped to do. Real life is sometimes a bit more exhausting, often a lot more fulfilling, and always more amazing than I could have imagined. It’s vivid, impactful, chaotic, and overwhelming.

A couple weeks ago, I was helping a woman manage her thyroid and low mood when she mentioned that her baby had a near-drowning experience the week before. After listening to her struggles with the experience, I heard her saying that the child had a cough the last night. We were heading into the weekend, so I mentioned that this would be about the time that pneumonia could develop from inhaling liquid. We were going into the weekend and I wouldn’t be around physically, so I wrote a prescription for an x-ray that she could use at any time, and sent her off with a prayer for mother and child.

She emailed me the next day, saying that she had gotten the xray and that it showed pneumonia. I didn’t notice her message at first, I was busy opening the gate for a meeting about community development and another about mentorship and health systems in Malawi. This woman’s adopted brother is one of the few patients who has my phone number, and he dropped me a quick message just to let me know that she had gotten the xray and sent me an email about it. I knew that my patient had brought his mother and father and friend to see me, but I didn’t even know he was connected with this other family. “I guess you’re officially my Family Doctor” he said.

After a couple weeks, mother, child, and entire family are doing better, and my patient and his parents are also optimizing their health. I’m not really delivering babies, but I do have dear patients and whole families who I have walked alongside for 5 years now. It’s the concept I imagined when I went into Family Medicine, but it makes all the difference now that I’m not just imagining caring for patients but actually sharing life with people I know and care for and share journeys with.

Another Day in my Life

I wake up around 7 to the pouring rain. That’s great because I needed extra sleep after staying up late. And there’s power this morning, so I’m excited to brew tea and make toast and oats for breakfast. The rain is so heavy that we can’t run like we planned, but that’s probably a good thing, because we have no running water, and so I’m better off without sweating this morning. That way, I figure I can wait one more day to wash my hair.

I put in an hour of work helping my friend Chifundo pull together a summary of the mission, impact, and budget for his Nkhoma-based nonprofit Alinafe. He asked for help earlier in the week and I’m just getting to it today. He might have found a donor to support the year’s programs, but he needs help with documentation. Luckily I have our grant submission on file from 2021, so it’s easy enough to update and send over. I tell him that I can meet with him tomorrow to discuss, but for today it’s off to the village.

The training starts at 9:00 today, but by 9:15 we’re still waiting for Ishmael’s friend to finish copying the rest of the handouts. With power difficulties throughout the city, we’re really down to the wire getting worksheets to the training participants. This “phase two” training in Mngwangwa includes five chiefs, the men and women who participated in conservation farming since last year’s training, their spouses, and a few pastors from other areas who want to learn what is going on. We meet up with Pastor Nzunga at the Mango Market in Area 25. Although we’ve been to his house countless times in the last 5 years, the roads are so bad with the rain that we need to take a new way today. I shudder remembering the last time we drove here in rainy season and got stuck in a ditch. But today everything goes well and we arrive before teatime. Teatime at Thoko’s is always fun. I use a teaspoon each of milk powder, sugar, and tea leaves. Greg takes his tea more Malawi-style with a third cup each of cream and sugar.

Thoko is excited to show us her fields of maize, which are growing taller than any others in the village even though she didn’t purchase any fertilizer. Even the agricultural trainer can’t believe that the farming demonstration field is doing so well this first year. Thoko points to a nearby field with maize about half as tall. “I planted this at the same time and it died, I had to replant” she says. “I used fertilizer for this field, 10 bags, so that’s 300,000 Malawi Kwacha.” That field cost about $350 to fertilize, compared to the composted demonstration field which looked much healthier and already had some cobs growing. It will be exciting to see how the harvest goes.

We go back to the house and talk about projects and budgets. The Blantyre CHE training was moved from March to May, we’re trying to squeeze in a preacher’s training in mid March, and Thoko wants me to talk at a women’s meeting in early March. I offer her a few topics I have in mind and she encourages me to go for Diabetes and Hypertension. “Everyone struggles with those” she says. It’s true, at least one in three Malawian adults has hypertension, and one in five has diabetes. We talk through the budget for this training. Everyone who attended today from Mngwangwa contributed 65 cents to pay for the maize flour, fuel, and veggies for the 3 days of lunches, and our partners provided the daily protein. We’re about $10 over budget but that’s not too bad – what’s $1.50 per person per day if it can bring food security to an entire community? And we’re hoping that the ideas will spread to other communities, too. Our partners and donors have been very generous this year, and my US-based work is offsetting most of our living expenses, so we have enough left over to help a pastor fix his motor bike and to pay for tuition to a community development teaching course for three lead pastors.

Soon it is lunchtime. We joke about the amount of starch each of us is taking. Today Thoko made boiled chicken and grilled chicken, both so delicious. We finish our food early and walk over to the church where community members are eating. Thoko told me that the women were excited that I was coming because they had questions for me. I expect questions about everyone’s health – that’s what they usually ask me. And we do stop to talk to a chief at the door to the church about his back pain. I recommend stretches and physiotherapy, but he wants an x-ray. I tell him he’s welcome to come to the clinic any time, and I can even help pay for the bill because he’s such a great supporter of the programs in this church. He says he’ll bring the money, it’s important for him to pay his own way. Inside the church the women gather in a half-circle around me and Thoko. They have been discussing budgeting today. “Now we see that a woman should help with the family finances” one woman relates. “But what do we do when our husbands take all the money and spend it on beer and cigarettes?” another asks.

“How many of you are attending this training with your husbands?” I ask. About half of the women raise their hands. “Those of you here with your husbands, do you think that they will let you have a say in finances this year?” The women say that they think the training will help their husbands save money for the future and involve their wives in the plans. “What about the women whose husbands are not here? What can we do for them?” The group discusses, and several ideas come up where pastors or church members can help explain to the absent husbands the importance of financial security and sharing money and money decisions with their wives.

The next questions are as practical as they are difficult: “We’ve learned about starting businesses, and we’ve been told not to borrow to start a business. But we don’t have anything to start with? Where can we get a starter pack for business?” Suddenly I wonder if showing my face in the village today, the presence of a wealthy foreigner, might undo much of the assets-based community development in which we had invested. “How many of you were part of the women’s saving’s group in the church last year?” I ask. About one quarter of the women raise their hands. “How many were part of the conservation farming committee this year?” About half. This leads to a discussion about the groups already existing in the community to help women start businesses and build financial security. I leave the group with a final consideration: “You don’t always need money to get started with a business. In the Bible, one widow got out of debt by collecting jars from her neighbors and filling them with oil. If you wanted to start a donut business, you could gather flour from your friends in this group here instead of taking out a loan. If you made manure this year, you could sell it next year for a profit without having to start with a lot of money. Harvest should be good this year - If you save a bag of maize after this, that can become your ‘starter pack’ for business investment later. This community has resources you can use. Keep listening to the rest of the training and I think you will get ideas.”

I am sure that was not the answer they wanted, but if I had committed to give even $20 to the group, it would have undermined the entire process of helping this community break cycles of dependence and poverty. I needed to provide just enough foreigner presence to help them believe in themselves, and maybe to believe that they couldn’t count on outsiders to fix things. Thoko and I walk back to her house. She already has ideas for forming a savings committee for women in the community. An entire bag of maize might be too difficult of a buy-in, but she estimates that most women could spare half a bag, which could serve as security for any borrowing they might do from the group. She plans to let the women form a committee and let them decide all the details. I smile, relieved that my work here is done.

Greg and I get back in the car, loaded up with two new skirts Thoko tailored for me and two bags of chicken manure. The smell is terrible so we keep our windows down the entire way back. We arrive home at 5 pm. I’m so tired that I just cuddle with a dog on the couch for 20 minutes. I should take more times of rest like this. Dinner is leftovers and dessert is more than half of a chocolate delicious chocolate bar. There’s still no water for a bath so Greg and I watch a quick show. It’s over by 7 and I sit down for just a little more work. I’m polishing up an abstract to submit to a Preventive Medicine conference, and communicating with a resident about opportunities at County and making a plan for moving forward with our program deliverables in California. Before I know it, it’s 9:45, definitely time to stop working.

It takes a while to get to sleep, a couple cups of calming tea and a bit more of that chocolate bar. I walk around the yard until just before midnight, I really wanted to get my 10,000 steps for the day. I resolve that I should put some effort into being less goal-oriented and resting more. Starting tomorrow, I tell myself.