Some days I really struggle as a Preventive Medicine doctor. My ultimate goal in global health is helping local people solve local problems with local resources. But sometimes it’s painful participating in that process without taking everything into my own hands. There seemed to be great local buy-in for community education. International donors partnered with our hospital to train various levels of community health workers (Health Surveillance Assistants or HSAs). But when it came time to go into the communities, they wanted twice as much added incentive than budgeted according to hospital policy. We worked with our Environmental Health officer to brainstorm modifications to the program that could still reach people. We developed curriculum to disseminate. We met with stakeholders and contacted hospital management and district health office management. We were told that we could not go into the communities without the HSAs, but that the HSAs would not go with us without twice as many funds. We were told that we couldn’t even work with Malawi-based nonprofits targeting the elderly and disabled in communities if we didn’t have HSAs with us. The nonprofits were willing to go without extra financial incentives, but the HSAs were not. In the end, our local hospital leadership decided that we had done enough in community education by training the major chiefs in our area and equipping the HSAs in our area. We had plans to either return the remaining education project money or to meet in person with the District Health Officer who oversaw the District Environmental Health Officer who oversaw the HSAs. That decision came last week, and made me a bit sad since I was so enthusiastic about our training resources and the need in our communities.
Then came our first COVID-19 case, a pregnant woman who would have died if we hadn’t separated her out in triage and gotten her oxygen right away. She was the sister to a woman who died in childbirth the week before (First case form www.malawimillers.com/post/i-do-what-i-can) and suddenly that earlier unexpected mortality made sense with the potential of a COVID-induced thrombus. After the first known positive case was sorted, it came upon our Environmental Health Officer and the District Health Officer staff to go into her community and test family members for COVID-19. The testing went well but this weekend when the team returned to tell 4 out of 5 tested contacts that they were positive, the community said they had no faith in the government’s COVID response and started picking up rocks to stone the team. Our hospital has been told by the chiefs that they should be sure their ambulance is not seen in that village again or there will be trouble. Now hospital leadership is talking about how much community education is needed. They are planning to return in an unmarked car with a police escort in civilian clothes possibly with a parliament member and a senior chief. I wonder if our original educational program would have made a difference to prevent this situation? Maybe there are parts I don’t understand – like maybe the HSAs didn’t just want money, but they were afraid to spread this message among people who didn’t want to hear? Maybe this is just the way that health works in Africa – people are so busy responding to crises and demands of communities that there is no time to be proactive about prevention?
Of course it’s a lot of factors, many of which I will never understand. I want to take matters into my own hands. I want to push programs that will prevent this kind of disaster. A small ugly part of me wants to point out that people should have just listened to me and gotten with the program initially. So I guess that’s the hardest part of helping local people solve local problems using local resources – it doesn’t get done in my way in the timing I like. But maybe deeper, more systemic changes will happen when what I think is a worst-case scenario actually begins to play itself out. That’s the worst – waiting to see people sink down before they see the depth of their need and are willing to use their own strength to pick themselves up. It goes against my grain as a doctor, a Christian, a missionary. But if we keep pushing our own programs in our own timing with our own resources, how can we expect changes that those who trudged before us were not able to achieve?