Time is a funny thing, it seems like just yesterday that I arrived in Malawi; yet my first day, when everything about Lilongwe was foreign and new, seems like such a long time ago- a distant dream. In two months the guesthouse became my home, its inhabitants my family; my coworkers became good friends and KCH and the Baylor clinic became familiar places of work. Simultaneously, throughout the summer I remained an outsider in Malawi and never ceased to be shocked, awed, horrified and amazed by my everyday experiences. Time is also funny in the way that it flies by. I wrote the below as I was flying out of Lilongwe, but haven’t had time to sit and reflect in order to complete my final entry until today, August 22, a month after my departure:
This will be my final blog entry for the summer, as my work at KCH concluded on Friday. I will now be traveling to Tanzania where I meet my parents for ten days of safari before traveling to England and then home to start second year of medical school! When I try to summarize my summer, what I learned, how I changed, what my impressions are I find that there is no concise answer largely because there is no consistent answer. In 48 hours in Malawi I went from correctly diagnosing a child in sickle crisis (when my attending initially disagreed with my conclusion), to spending hours at the guesthouse after work feeling bored and confined, to meeting President Clinton, to seeing children die in the clinic. Beyond highs and lows, this summer was marked by contrast: boredom and overstimulation, joy and horror, the list goes on and on.
Even a final status update of my work is troublesome. I successfully completed final drafts of all of the enrollment forms and constructed the data dictionary which will be used by UNC database developers to collect and organize data. It is hard to explain how five 5-page Word documents, and five Excel spreadsheets feel like a full summer’s worth of work. Creating these documents was at times mind-numbing: reformatting, rewording, re-numbering- the subtleties and details to attend to were endless. Yet these forms in all of their minutiae were important. In working on the ground level of the study, it was essential to get all of these elements right so that the data collected once enrollment begins can be meaningfully analyzed. It may seem a stretch, but I truly believe that I was able to contribute to the study by creating these forms. (To those who are incredulous, believe me, I have had many doubts about how meaningful my contributions to the project were and are.)
A month after my return when I reflect on what I have taken away from my experience in Malawi contradictions continue to abound. When people ask me how my summer was my first answer is always “Great! I had a wonderful time!” and then they ask what I was doing…and I get flustered because how do I explain that I was working with HIV-positive infants all summer and having a wonderful time? The truth is that often, in the moment, I wasn’t. It was often painful, frustrating, and humbling work. Yet I am so thankful for this opportunity to see the non-glamorous, non-Western side of medicine. I believe my work this summer helped me appreciate what is truly at stake when I say I want to be a doctor. It helped me understand the value, fragility and transience of life. More importantly (for a budding M.D.) my experiences helped me understand that physicians are alternately uniquely empowered to save lives and utterly powerless against the host of diseases, aging processes and accidents that the human body is subject to.
By taking on this profession I feel that I am becoming even more mortal, even more vulnerable to these forces. As a doctor your job becomes part of who you are; to me, my potential to be a good doctor is already inextricably bound to my potential to be the best ‘me’ that I can be. That means I am volunteering to subject not just my body, but my esteem and my psyche to the onslaught of disease, age and trauma. I am training to spend my life battling back these forces, and more often than not (as we all die of something), I will lose and will have to accept these losses so as to help my patients do the same.
When I consider the question of whether I would like to do something similar in the future and my advice to others who plan to do similar work abroad a variety of answers and an even greater abundance of questions arise. First and foremost, my answer is yes, I had an amazing and intense and growth-provoking summer that solidified my desire to do similar work in the future. Furthermore, I would certainly recommend such an experience to other medical students. There are, however, many caveats to that answer.
The first and most important caveat is that when working in a resource-limited setting I think it is imperative to consider the resources you consume in contrast to the services you are able to provide. Often American students are congratulated for their giving spirit when they travel to the ‘developing world’ to ‘volunteer’. Personally, I am under no illusion that I contributed more than I consumed this summer. What I hope is that this experience will form a cornerstone of my medical education that will allow me to provide better care for my current SHAC HIV clients and for my future patients, wherever those patients may be located.
In terms of recommendations for students who are interested in similar work, I would say the two most important keys to success are to find a mentor and, above all to be flexible! I was assigned my mentor, so I can’t take credit for, or offer much advice on, finding a good mentor. I can share are the qualities of this relationship that I believe were critical to the project’s success. My mentor and I shared the same set of values and basic viewpoints on academic medical work in the developing world. This was important because I was confident that he wouldn’t put me in situations where I felt my values were being compromised. We also saw eye-to-eye on goals for the summer, and while my mentor was happy to work with me to set goals, he was also great at challenging me while offering resources for support. He allowed me to work independently, but made sure that I knew where to go if I reached impedance.
In terms of being flexible, there is no set of instructions I can give on how to be flexible (speaking of contradictions!) I find that for myself, being humble helps me to be flexible. The project didn’t get IRB approved until after I left Malawi, which meant I wasn’t able to work on patient enrollment. This was disappointing, but I don’t posses some set of patient enrollment skills that were critical to the project. I was able to contribute in other meaningful ways and learned a lot doing so.
When I would set up meetings with people in the hospital more often than not, they didn’t show up. The second best option was that they were at least 45 minutes late. Again, this was frustrating, but I had a summer off; I had time to wait around. If my meeting was with a counselor or clinical officer or physician there time was more valuable than mine. Moreover, being open to learning from observation allowed me to use the hours I spent sitting with patients in waiting areas of the hospital to consider the healthcare system from the patient’s perspective, to learn more about family dynamics, and to reflect on my daily experiences.
It is difficult to sum-up my two month experience in Malawi (hence the length of this post.) In closing, I would just like to express how thankful I am. For the financial support of the UNC EPS Fellowship Program and Carolina Medical Student Research Fund; for the emotional support of my family, my friends and my adopted guesthouse family; for the academic support from the UNC ID and UNC Project faculty and from the Baylor Pediatric AIDS Corps physicians and clinical officers; and for all of you who followed my summer of adventure through this blog.
After a week of classes as an MS2 I find that this summer left me feeling revived, ready to take on another years worth of medical school. Somehow, from all of the chaos, the joy, the pain, and the heartache I witnessed and experienced this summer I have been able to find an intangible peace and resolve which are the most significant things I have taken away from this experience. So to all who made this possible, zikomo kwamberi (thank you very much).
