Rapid Response

I sat in the cold, empty room. We used to meet here most days for hospital handover before we decided that it was risky to have every hospital nurse and clinician together to discuss cases during this time of rapidly-spreading virus. I spaced the chairs out so that 15 people could sit where sixty used to cram. The training was supposed to start 90 minutes ago, but so far, I was still the only one here. A lab technician dropped in about an hour ago, but since the government Environmental Health team hadn’t arrived and he hadn’t eaten, I sent him over to teatime at the Medical Ward, where I still send donuts to encourage them once a week even though I don’t work clinically on that ward anymore. I used my time to organize a list of all the teaching meetings I have attended since I arrived ten months ago. That should help us as we attempt to renew our licenses later in the month. A clinician arrives and we talk about his experiences working at the hospital over the last thirteen years. He gives me some pointers on how to avoid the mistakes made by missionaries from the last generation. He also tells me that the first day of a training session in Malawi always starts late. Everyone expects it to take time for things to get set up. He assures me that when the training team arrives, this empty room will suddenly fill.

And he’s absolutely right. Though the training team arrives two hours late, within minutes of their arrival and turning on the projector, every seat is taken with a selection of our nurses, clinicians, and health surveillance assistants. I wonder how the word spread that now it was time, how the group was able to come all together. It makes me remember how most sustainable movements happens in Africa within community. As a foreigner, I may never understand the channels of communication and networking and when to know when everyone is ready, but if I patiently wait, the impact will be bigger if we all go together when everyone is ready. It’s a great training, planning how we can reach into the community to track cases and contacts and contain this spreading virus. Everyone asks questions and plans for contingencies. It’s great to see the HSAs and nurses and clinicians so interested in this together.

The second day of the training begins just over an hour late. I still arrive on time, to be ready for anything, but I’m neither surprised or disappointed. I’m prepared to use my time well, and I brought a heavier jacket today so I won’t get so cold. This time, I read through an online journal article about physician resilience and preventing burn-out. Then a nurse arrives and we chat for some time about our families and fitting in with the community. Again, within minutes of the team arriving, every seat is full and we have another productive day of teaching. When the training is over, the team asks if we are ready to put together a list of names for a rapid-response team providing 24-7 coverage for rumors and issues in surrounding villages. But I’ve learned. I need a meeting with the heads of departments, with the co-chair of the COVID preparedness committee, and with management before we can even think about moving forward. We contact the ministry of health to clarify issues, we pilot an outreach with our Environmental Health officer along with the district team, and we sort out reimbursement issues. We may or may not be ready in time for the surge that is likely coming, but I am confident that the team will rally eventually. By the end of the week, I’m not sure how much I’ve achieved. More than half the meetings I planned were cancelled, but then there were half a dozen unexpected meetings that moved other things forward. I have to be willing to see what happens next. There’s a proverb in Africa, “If you want to go quickly, go alone. If you want to go far, go together.” It may be ironic to follow that proverb while trying to put together a “rapid response” team, but I don’t think we could make an impact any other way.

Public Health: Miller May 2020 Update

As my office printer whirled out the 22 pages of our final grant application, Chifundo and I heaved sighs of relief. Then we prayed for the thousands of individuals who this program could impact over the next year, and for many years to come. The project was simple enough – to buy 500 hybrid egg-producing chickens to fill a facility donated by a local chief and start a self-sustaining poultry project. Alinafe Communities of Hope, a Malawian-led nonprofit benefitting elderly, widowed, and disabled individuals, already invested hundreds of hours and thousands of dollars into the program set-up, and Chifundo knew enough numbers to make a grant-writer’s heart skip a beat in glee. All the program planning was already done, so we just had to explain the plan, make some calculations for disaggregated indirect beneficiaries, and send it off. Somehow it still took us about 15 hours over 3 weekends, and Chifundo’s dedication to work side by side with me in every step of the writing process was like nothing I’d seen from group projects before. I see it as a reflection of how unique the Alinafe organization is- its leaders really want to help the most vulnerable in their communities help themselves in ways that promote dignity and buy-in. And this poultry program would really make an impact – introducing protein into the diets of thousands of men, women, and children in the villages surrounding Nkhoma even as it supplied the funds for vocational training in sustainable agricultural practices. Even better, local proceeds would augment foreign donations toward Alinafe’s relief programs during cold, rainy, and hunger seasons.

I pray that this is only the beginning of partnership between Nkhoma Mission Hospital and Alinafe. I start thinking of ways to incorporate them into plans for blood pressure screening and treatment in our area. We’re already thinking of using their village groups for education and prevention during this pandemic. With their connections to vulnerable people in so many surrounding communities, they could really make a difference and prevent poor outcomes. Ah, COVID-19. I have long-since lost track of how many grants, policies, meetings, and crises I’ve been through since I started co-leading Nkhoma’s Disaster Preparedness Committee ten weeks ago. I remember years ago one mentor told me that it would be unusual for a doctor at a mission hospital to have 20% of her time available for public health or preventive medicine. But now, as my national colleagues take care of most of the hospital’s patients, so I spend more than 90% of my time on projects that can impact groups of people. We’ve found ways to protect our staff with PPE and isolation areas, protocols and stipends. We’ve developed teaching materials for health centers and community health workers, and designed programs for training. We pulled together resources for locally sustainable sanitation and mask making in a weekend hackathon. It’s impossible to say what will happen next, but we’re thankful to be here with so much opportunity to make a difference during this hard time.

Thanks for your support and prayers,

Christina and Greg

"I do what I can"

One of my Family Medicine residents came into my office looking a bit tired. It had been hard for him to focus on his research with so many other things going on in the hospital.  On Tuesday, he was treating a pregnant woman who ended up dying along with her baby.  Later that day, the family of the woman attacked her cousin because they thought he had placed a curse on her. The cousin’s house was burned down and he was in our ward with a fractured skull. We didn’t have any blood to give him due to issues with quality controls on our blood bank screening. On Wednesday afternoon, an ambulance pulled up with a woman who died soon after arrival. Her husband sliced her neck. He came in the ambulance, wanting to turn himself in at the police station, but the police ran away, the hospital guards ran also, and in the end the man was stabbed by angry relatives outside our Emergency Room.  The chaplain couldn’t pray and the doctors couldn’t treat him for the better part of an hour as the community extracted its own justice.  I asked my resident what he thought was the hardest part of the last few days, and he said it was the woman and child who died, because that was something he thought he could make a difference for.  I’ve talked to other young doctors in Malawi who really struggle with deaths that might have been prevented and carry them on their shoulders, but this resident had invested a lot in his own emotional and spiritual well-being recently.  “I know that I can’t do everything so I do what I can.” He told me.  Then he explained how he successfully completed a difficult case on Thursday and saved a woman from a ruptured ovary which caused so much bleeding into the woman’s abdomen that she didn’t even have a pulse after anesthesia was administered. But he found the rupture, sealed it off, and watched her improve on the ward after the operation.  Sometimes it’s hard to feel like a bystander, unsure how to help as things get progressively worse. I’ve seen that with the Coronavirus situation in Malawi and some other community issues, and it gets me discouraged at times. I could really learn a lot from my resident in those times – to do what I can and let go of the things beyond my control. All the while, making sure that I have emotional and physical and spiritual reserve to pull me through the darker times.