Just Another Day in Paradise

I wake up just after 6:00. I had dreams about people singing, influenced no doubt by the roosters crowing at all hours of the night and morning. By 7:30 I’ve polished off a couple cups of fruity-flavored tea, eaten peanut butter toast, prayed, read my Bible and stretched. By 8:00 I’ve started in on work – today I’m working from home one a project to teach doctors about healthy lifestyles. It’s not a new project, but I’m working on new balance. I stop for a veggie break at 10:30 and then drive to ABC Clinic. I didn’t have patients scheduled this morning, so I take the time to meet with people I always pass buy when I’m busy with other work.

10:50 - I pop in at the pharmacy. Mrs. Chibwana, the department head, is looking beautiful in a green dress. I tell her she always looks beautiful, which is definitely true, and she compliments the yellow wrap-around chitengi skirt I chose today. She hands me some copies which will help me explain healthy lifestyles to my patients. As I pack them away in my office, I ask her if she can print a final sheet for me, so that I have plenty to share with my clinic colleagues. Everyone was very interested after the Continuing Professional Development talk yesterday and wanted copies of their own. She graciously agrees and I step aside so she can deal with some boxes coming into the pharmacy. I step over to the front desk and check my schedule for tomorrow. Fully booked for the afternoon – my first two patients are a Muslim man I saw last week who is getting his diabetes under control and a Muslim woman who is still reeling from the death of her husband recently. The last two times I saw her I prescribed several medications for her multitude of symptoms, which is unusual for me to do but spoke to the plethora of her struggles and the little I could do to help. I will start praying for tomorrow’s clinic now.

11:00 - I stride over to the inpatient ward to see if we have COVID vaccines in stock. Still out – there’s a national shortage, so this is no surprise, but I hope Greg can get vaccinated soon. Due to our COVID infections last December, Greg didn’t qualify to get a vaccine earlier, and now everyone is out. I have only had one shot of AstraZeneca myself and hope that will be enough to protect me for the time being.

11:05 - I run into Jane, one of the hospital chaplains. She has looked over the materials we put together for helping mothers keep their children healthy. She is interested in putting the materials together in a booklet which she can use when she talks to women in various villages. We’ve discussed translating these materials into Chichewa, and she thinks it would be good to have a version for English speakers and a version for Chichewa speakers. We talk about people who might be able to do the translation, and I think of a university student I know who might be able to help with the design of a final brochure. Next steps planned and a phone number for Jane in my phone, I’m ready to meet with Christina. Christina works at ABC’s front desk and always has a smile on her face. We joke that we are twins because of our names. Today I learn for the first time just how much Christina does to make sure that patients feel cared for at ABC clinic. She keeps track of the time every patient arrives and checks in on them after one hour. She makes sure that they know how much longer they will be, whether they are waiting to see a doctor or to get the results of a lab test. I have a student working with me this month, and we are hoping to help with patient wait times. Christina helps me come up with ideas of a tracking sheet and areas to deploy my student tomorrow.

The clinic isn’t too busy this morning, but if I don’t get away soon I will be tempted to stay all day. So I drive home. Greg asks me on a date to a new café not far from our neighborhood, so I head up some leftovers (going to a tea shop hungry is a bad idea for me) and jump back in the car with him. By 12:30 we’re sitting in a lovely garden for the next hour and talk about life: how things are going, strategies for future ministries, opportunities and people in which we want to invest, how to keep in touch with friends and family back home. It’s a fun hour, the strong local tea and fresh scone are fun. We stop at a local bakery on the way home, and we pick up some fresh lettuce, homemade croutons, a vanilla scone, banana chips along with a loaf of fresh cranberry sourdough bread. We also pick up a basket to carry it all home in – that will help us keep the office more organized in the future.

2:30 Back home, I check messages – there’s a patient with a question via e-mail and a friend in the refugee camp trying to help a young girl with dizziness. It’s amazing what conditions can be assisted over a distance these days. Another patient needs a new prescription, that will have to wait until tomorrow. I take a brief break, sitting on the back porch reading a comic book, watching the wind in the trees, reading about tea. Then it’s back to work. This time I’m working on a project to help teach specialized doctors about maternal health and improve outcomes in San Bernardino. We just got this grant and so for now my work is very preliminary – how we will track outcomes, how we will follow up on recruits, how to get access to the systems I will need. That work carries me through to the evening.

5:15 - I start a pot of veggie soup and go for a run. I love running with my dogs. I don’t quite have time for a shower or an ab workout before jumping straight onto my video call with faculty from the American College of Lifestyle Medicine at 6:00. It’s a great meeting, we’re moving forward on modules to help doctors learn about lifestyle. It’s work I enjoy and I might even be able to become board-certified in Lifestyle Medicine by the end of these projects. I have a checklist of things I want to work on next for this project, but I put the list on the side of the desk and decide to take a break for the day. I try hard not to work more than 8 hours each day, and I’m on 8.5 at this point.

7:30 - I join Greg for soup and rolls for a late dinner. We rest on the couch and watch some shows, surrounded by our dogs. We chat with his mom and I e-mail a friend. I go to bed just after 10, which is pretty good for me. This was truly a fantastic day- filled with health, balance, and plans for the future. Possibly one of the best Mondays ever, and all the better because it’s a rhythm that I should be able to maintain for quite a long time.

Pregnancy

She came into my office alone, without a family member as a guardian, and she didn’t want a student to sit in on our meeting; her issue was a private matter. It only took a few questions for me to understand her concerns. She had abdominal cramping, nausea, and her period was one week late. She and I both knew that she was concerned about a pregnancy. She had been pregnant before, I inferred that things did not go well, maybe she lost that child. She was not planning for a baby any time soon but feared that her contraceptive methods had failed her.

I remember the last time I cared for a woman like her, the first time I discussed an unexpected pregnancy. Many years ago, that woman sat stunned for a while and cried and then left my office, and I never heard from her again. I’ve been a doctor twice as long now, have been in Malawi four more years. I want to provide more support for today’s patient than the woman from years before.

So even before ordering the test, I ask her what she will do if it is positive – who can support her through this unexpected time. She mentions a friend who can support her, but she’s not sure how she can get through. If I was working in California, I would be required by law to connect a woman to pregnancy-ending resources if she asked. Here in Malawi, there are no legal abortions. That removes some stress away from my counseling options, but puts a lot more pressure on her struggle. If she seeks illegal means of ending this pregnancy herself, it could easily cost her life.

I know that a urine pregnancy test might not show a pregnancy yet, but she can’t really afford the $20 blood test. I ask her to think about what options she has, and what she might want to do as she waits for the test to come back. I pray that the test will show the truth about her condition one way or another. Then I send her to the lab and then the waiting room and together we wait. Is there new life growing in her womb? Will her life be forever changed based on this one test result?

I peek into the lab thirty minutes later. The test is positive. I take a deep breath. At this point, at least it is better than not knowing. I grab her from the waiting room and sit her back in my office. I tell her that she is pregnant. She takes a deep breath this time. “I thought so” she says. At least now we know. So now we return to discussions. What are her plans? She says that she wants to keep this baby. I tell her that I admire her courage and that I know it won’t be easy. She can’t tell her family, she says, they won’t understand. I probe a little bit. Will her boyfriend be supportive of her? Will he be a good father? She nods and says that they were going to get married at some point, that he brought her to the clinic and has been sitting in the car this past hour waiting for her.

I ask if I can bring her fiancée into the room. I don’t usually feel compelled to pry like this, but I can just imagine what it would be like if this woman had to tell him alone. Better to have this discussion in an official room with an authority figure in a white coat encouraging and affirming them both. She thinks about calling him, and decides it would be better if I go bring him from the parking lot. She gives me his name and license plate – “he’s in a silver car,” she says.

I’ve never done something like this before, walking out to a carpark, coming up to a car, greeting a guy I’ve never seen before, asking him if he was the one I was looking for. He takes it incredibly well, says that he is the fiancé, and readily follows me into the clinic, down the hall, into my room. We sit in a triangle, all facing each other. I count to 5 and since my patient doesn’t start I begin by telling the results of the test. She is pregnant, and she wants to keep it. I share about how proud I am that she can make this decision, how I would like to offer any support possible. I ask him what he thinks about the situation. “We expected it.” He says. “We weren’t planning for it, but we were going to get married. I will support her, I will help raise this child.” That’s saying a lot in Malawi where men often come and go, leaving women to care for babies and children themselves. I tell him how much I admire him, that I know times will be difficult but that I am impressed by their decision and want to support them. We talk a bit more, about timing or prenatal tests, abut supporting each other, about planning ahead for when times get stressful or difficult. I give them my e-mail. They can contact me at any time. I’m not the best at delivering babies myself, but I can connect them with a lot of resources about staying healthy during pregnancy.

I pray for this young couple as they check out and pick up their antenatal vitamins. I’m going to be praying for them every morning this week, I decide. It was an unusual visit, I reflect. I had time and flexibility I never would have had in America. But this setting brings with it unique challenges. For once, I am happy for my white coat, for the authority foisted upon me in this context. Maybe hearing that I believe in them and that I’m supporting them will help them through the difficult times to come.

Focusing on Assets

The settings couldn’t have been more different. A couple years ago in rural Malawi I sat down with a team of two clinicians who provided care to 30,000 people with just a few medications, and even those weren’t always in stock. Yesterday I had a virtual meeting with a public health team providing care to over 2 million people in a high-income country. The situation was a bit similar: both times, I came in representing a hospital-based team of trainees who wanted to come alongside the existing community team and help create sustainable programs assisting the population. The ensuing discussions mirrored each other closely enough to trigger dejavu. Each time, I introduced the situation. We valued their roles, we wanted to assist them in the good work they were already doing. We had some ideas for program plans, but ultimately we wanted to help them set and reach their own goals for their target population. We planned to come alongside them for years to come. We wanted to help created sustainable programs that they could lead indefinitely in their own context. Then, after each introduction, I stopped talking and asked the teams for their thoughts, comments, and questions.

Both teams, separated as they were by time, location, and context, replied in a similar way. They were already overworked, understaffed and underfunded. Both groups said that they needed us to bring them resources if we hoped to help bring change in their context. Both times, the group was happy to work with us, and believed that new programs were important, but they wanted us to know their limitations and expectations. So each time, I acknowledged their words and affirmed that they were already doing so much with so little. I explained to them about some resources which we could bring to the table, resources which wouldn’t be exhausted like funds or materials. Our trainees could bring teachings to expand the impact of their providers. Our faculty could help develop protocols to extend the capacity of their care. We could help them develop specific programs and track those outcomes, and then we could help them look for funding opportunities that would be sustainable and specific to their context.

And both times, paradigms shifted. Instead of focusing on needs and scarcity of personnel, time and resources, both groups allowed us to imagine with them what self-fueled and self-sustaining interventions could look like. In Malawi, we walked alongside the team as they started their own hypertension and diabetes clinics. We helped them request medications form the government which were previously unavailable to them. Our trainees screened their population and helped them develop protocols for testing and treatment. Now when we follow up with them, the team no longer talks about what materials they needed, but they share about the progress they have achieved.

It was similar with the team in the high-income country. Our first meeting was only one hour, but by the end, the team was considering what type of teaching and facilitating resources would help them leverage their existing strengths. The communication helped them realize some funding they already had which could be better utilized to free up personnel resources. They began to see themselves readily filling a leadership role of initiatives and networking which they thought impossibly overwhelming an hour before. We started imagining together feasible plans for this first year, plans that could bring easy victories even while they were stretched thin. Then we dreamed of possibilities for following years when they could expand capacity based on pilots, and where the team could decide for themselves what direction to go next, after systems were established and problems were defined.

By the end of the meeting, I was bounding down the hallway and beaming at Greg. I never thought I would have the chance to influence a prestigious and influential group of peers towards paradigm-shifting mindset change, from thoughts of scarcity toward leveraging existing assets. The same models which I learned in missionary training and practiced in clinics, churches, or communities in Malawi now is making a difference within health systems in a high income country. Realizing the universality of assets-based development, seeing these kinds of mindset transformations first-hand is so incredibly life-giving, affirming, and energizing. I definitely feel like I am thriving, doing what God created me uniquely too do.