Retirement

It was an exciting and affirming day. Mrs. H and Mrs. K were retiring from their work at Nkhoma Mission Hospital. Both worked as hospital cleaners, both worked in medical ward, where I spent most of my time last year, and both had worked longer than 11 out of 12 other people who retired this year. Mrs. H worked for 28 years. She had the biggest, most welcoming smile. And she always helped me when I wanted to serve tea to the staff on medical ward, and helped me clean up the cups and my office afterward. Mrs. K worked for 33 years. She woke up before dawn and walked in the dark with a few other women to arrive by 6 am. She participated in our ward trip to the beach last December. It was her first time seeing lake Malawi, and when we turned the corner and beheld the water, her face lit up ecstatically. She didn’t have a bathing suit, so I loaned her my shirt as she later splashed in the waves. Toplessness wasn’t a problem for most village women, but with Mrs. H’s son taking pictures to commemorate the trip, I figured it was better to have everything covered. I think Mrs. Msosa, the medical ward charge nurse, was especially happy that the lake trip happened before Mrs. K retired. After all her years of hard work, she was able to have a great memory from her last year.

Both women earned about $2 per day and were more comfortable speaking Chichewa than English. Our team tea parties might have been one of the first times that they were invited to sit at the same table with doctors and nurses, patient attendants and visiting students. At first they were shy and hesitant, but towards the end of they year, they were the first ones in the room, rightfully claiming the bigger pink cups that matched their uniforms.

On their final day, we held a celebration on Medical Ward. Mrs. Msosa collected funds the month before, enough to buy a beautiful new bolt of cloth for each woman. She wrapped these up along with pretty pink teacups from my office. I told the ladies that I wanted them to have a piece of us as they left, and we would miss them as we saw the tea cups gone from the set. We printed some pictures into a card which all members of the ward signed, and took more pictures that final morning. Mrs. Msosa helped me prepare gold-rimmed certificates thanking them for their service to Medical Ward. She made sure the wording was perfect, which took me a couple extra printing attempts. Those certificates were created following the same format which I used to print a thank you commemoration for Hon Rev Dr Chakwera who visited a few months ago and made a donation to our COVID disaster preparedness. I wonder what those women would think if they knew their certificates matched the one we gave to the nation’s current president. There is a chance they couldn’t be happier with their official-looking certificates even if they knew.

After the Medical Ward ceremony, we took the women back to my office for a final tea party. They chose pictures from my computer to print and laminate and take home to remember their times with the ward team. They even tried to help clean up, but we wouldn’t let them. As they headed off to the hospital retirement ceremony, they beamed about how they would receive a 3rd certificate there, in addition to the golden certificate and the photo collage they had just received from us. The hospital gifted them a large mattress as well, and there was singing and dancing to celebrate their contribution. It was an exciting day, a nice opportunity to honor two women who had given so much – two unsung heroes who kept things clean and sanitized at Nkhoma Mission Hospital for decades. We appreciated them so much, and were blessed to be able to honor their faithful work. These days, it seems like I spent the larger part of my time here encouraging and affirming my fellow workers, with barely any time treating and curing individual patients. It might seem like a surprising balance for a missionary doctor, but if each co-worker I encourage and equip goes on to encourage a dozen of their colleagues, and bless hundreds of patients, then I think there’s no bigger impact I could aim for.

Livestock

As the days become drier, we have had some unexpected encounters with village livestock. Due to the fact that our dogs like to chase and eat local chickens and goats, we have been careful to keep them behind our fences and inside. I have taken our dogs on runs around Nkhoma recently, and have been happy that they no longer try to chase the roaming animals at all costs – these days they are able to whine a little and just jog by.

But there’s an area in front of your yard, just outside our gate, where our grey water runs off out, and this results in lovely green grass even in this dry season. We laughed last week when a huge bull was nonchalantly munching away on it. We encouraged him to go back the way he came through the bamboo that skirts the side of our yard, before our dogs decided to make him angry. I knew our chain-link could hold our dogs, but I wasn’t sure about a full-grown bull. Later this week Greg had to chase out a whole herd of cows that were trudging through. It seems like our little patch of grass will be a temptation at least until the rains start coming.

Then there are the goats. Yesterday we were so concerned about keeping our dogs inside while a plumber worked on our pipes that we didn’t think to close the gates to keep the neighbors’ animals out. Two mother goats and their adorably cute kids trotted in. They were so desperate for food that they tore down our compost bin to get to the leaves neatly piled within. Unfortunately, when we tried to escort them back out, they kept running circles in the yard and even abandoned their babies in a corner. In the end, Greg picked up the two cornered kids and stood outside the gate with them, letting their cries direct their mothers out.

It was a trick he used last week when we found a newborn goat separated from its mother on the side of our house late one night. The mother had trouble finding the kid, then had trouble getting it to move out of the bushes where it was hiding. Greg picked up the kid and walked it to even ground. The mother followed after a while and then trotted home with her newborn as Greg set it down. We hope that those two at least got away from the hyenas and home safely that night.

At least the chickens are staying out of our yard these days. There have been a few tragedies when chickens in the past found their way into our dogs’ domain. And the monkeys stay clear of our property as well, much to Greg’s regret. I guess we’ll have to enjoy their shenanigans when we’re away from home in the future. It’s a bit of a different life than our first years living in a more urban setting in Malawi. It’s fun to see the surprises of the changing seasons in this new-to-us house.

Dissection

“The patient with dissection is no more” I was a bit surprised by the text from my senior-level medical resident. My specialist colleague Catherine and I had just returned from the bedside an hour before. The patient wasn’t looking good, but we didn’t expect him to die within minutes. An aortic dissection is a medical emergency with complicated treatment in any circumstances. In our facility with no advanced imaging, no ICU, and only one intravenous blood pressure medication, the outcome was bleak from the beginning. Yesterday we were thinking of referring the patient to the central hospital an hour away, but they wouldn’t have taken him in the afternoon, and by the morning he wasn’t stable enough to go.

It’s hard not to become desensitized to death as a doctor, especially a doctor working on this medical ward. Just this week, we counseled five other families about end-of-life issues. Stroke, fibrotic lung disease, varieties of cancers. I know that these can be life changing times for family members, or for patients themselves. I know that impacts of long-lasting, even eternal significance can be made during this time. We teach our residents to prioritize having these difficult discussions, and our residents teach us how to be more sensitive in their high-context culture while making the decisions. Our senior resident is focusing on the sickest patients on this rotation, and it seems like more than half of them die. I try to stay sensitive, to think how I would like for my family to be counseled when going through a crisis. We saw the patient struggling with his breaths and I thought what it would feel like if I was the one lying there. When I was the one lying there. But my moments of mindfulness and empathy are propelled towards trying to find a fix, trying to deal with the next crisis.

Today, after our discussion, we asked if the family wanted a chaplain to come and pray with them. Even though medicine might not be able to help, this is a mission hospital and we believe in miracles and the healing that God could bring. They were enthusiastic about meeting the chaplain, but the patient died before he arrived. I should have prayed with the family while I could – even my English prayers could have helped ease some of the pain and struggling. Catherine tells me she can hear the wailing from our office window – she’s working from the hospital as I prepare for a call to help us apply for a grant aimed at building capacity for intensive care and higher flowing oxygen.

I told our resident last week that he was essentially running an intensive care and a palliative care service. In America, when Family Medicine residents rotate on medical wards, they expect most of their patients to be discharged. Most of the cases would be relatively straight forward for a primary care doctor there. But not here. I wonder if my resident will even send home half of his patients this month. It’s a different world over here. I pray that we can continue with high levels of care and continued sensitivity to humanity in spite of the complex cases and the low resources. That we can bring light, and teach these young doctors to be lights that continue to spread in this place long after we are gone.