By Daniel Dyer, M.D.
August 20, 2019

During my time here in Malawi I’ve been contemplating solidarity. One fear I had before going to medical school was that having an MD might make it difficult or impossible to truly connect with people. My trepidation was that the degree, the status or the education would prevent depth of relationship, something necessary for true healing and community. And that fear has been largely proven true, although the barriers may just as equally be said to be time limitations and the EMR. 

Here in Malawi the barriers are even more substantial but of a different kind. Almost every friendship and relationship is colored by the vast difference in socioeconomic status as well as the cultural and language barriers. Unfortunately, I’ve learned to be wary of friendships or overly friendly people as even very sincere appearing people often have ulterior motives. The difference in wealth and culture sometimes seems to preclude the ability to form genuine relationships.

There have been times, though, that I have had true connection here, mostly around food. As background to this story, the Neonatal Ward consists of about 15 warmers, mostly wooden contraptions with lights under where the baby rests as a source of heat. All of the moms sit outside the ward and come in together every 2-3 hours to breast feed. At lunch they gather in small circles and share pots of nsima (maize ground up and boiled together, sort of like grits if you’re from the south but with the consistency of mashed potatoes. If you’ve been to subSaharan Africa you have probably seen it or something very similar). At night the corridor is lined with sleeping women, their colorful coverings over their heads. One day as I was leaving Neonatal Ward for lunch an older woman beckoned to me, but I didn’t understand what she wanted. She was saying “Kareko “ repeatedly. I excused myself while trying to be polite and relying on their forgiving my ignorance. However I quickly turned around because I had forgotten to check something. Before I left the Neonatal Ward again I asked one of the nurses what the word meant and they burst out laughing, asking who had said that to me. The word meant, “come and eat with us.” As I left the ward a second time I made a quick decision. As the invitation was repeated I sat down with the lady and her family. We couldn’t communicate with words, but I learned that she had 4 daughters and one of them had a baby in the Neonatal Ward. She showed me how to roll the nsima in my hands and then combine it with vegetables or fish. When I would stop or eat too slowly, she would gesture for me to eat more, indicating with her hands that she wanted to fatten me up. Every day the rest of that week she invited me to eat with them. I usually excused myself, but one other day I joined her for lunch. Another day on the ward I shared lunch with some of the nurses. You could feel the relationship shift to something deeper as I ate the lung from some animal together with them.

The other place I have found connection is in true concern for the patients. Whether this is shown in donating blood or helping to pay for a transport fee or coming to check on the patient late into the evening, I have noticed that a few of the staff have opened up to me in ways that seem truly genuine. There seems to be a new trust that was not there when I began. The children also respond to continued presence. One of my patients, a boy named John was very shy at first. But every day I waved at him and gave him a big smile. After a few days I started to get a small wave or smile in response. Before he discharged, he was the one waving to me in the mornings. Another patient, Eness, was incredibly fussy at first as we tried to get her into and adjust her CPAP. Whenever I even entered the room she would cry. By the time she left she would give me a huge smile whenever I walked into the room and a little giggle.

I still have a lot to think about as I prepare for long term missions. How can I enter into community and share in solidarity with people who have so much less than I do? Can there be true relationship in such an unequal setting? What does healing look like? Practically, can I live on a mission compound with many modern benefits while my patients lack proper roofs, running water and electricity? Can I invest money and create a 401k while taking care of patients without money for food or medicine?

I do know that there are things that can bridge some of these gaps—faithful presence, humility, food, learning from others. But I also know God may call me to give up more in order that I can love more fully. I hope I can be faithful to that call, to say yes to the invitation to “come and eat with us.”

Pictures of John and Eness

By Daniel Dyer, M.D.

8/12/19

Life in Malawi has been a microcosm of heartbreak and triumph. Almost every day has moments that leave me scratching my head, wanting to cry, smiling and wanting to scream in frustration.

For example, the child I mentioned in my last post with bronchiolitis. The patient was weaned off of CPAP but continued to need O2. After several days, the mother started demanding to leave. Her initial reason was that she had another sick child, however it also turned out that she was polygamous relationship and was worried about losing the attention/favor of her husband. We discussed the child with her for a long time. She was discouraged that the child didn’t seem to be getting better and when told that the child could worsen and die if she went home, stated that she understood and what would happen would happen. When I came by the room again later, the patient and her mom were gone. So much for my example of hope, but perhaps an important lesson. Life here is complex, as is the provision of aid. Behind every story is a weight of culture, family, untold (or untranslated) story and even the long shadow of imperialism. When I attempt to reduce all of this down to a nice story to illustrate a point I inevitably obscure some of that complexity. The story might miss the weight of a bill for a hospital stay on a family already uncertain where to find means for food and school. It misses the social complexity of a prolonged hospital stay and required absence one of the parents of frequently large families. Often it underestimates the burden and stigma of a new chronic disease diagnosis. We know in part...

This morning I helped stabilize and transfer a patient to the large central hospital. It’s difficult to describe what it’s like to bag a patient on a seat in the back of an ambulance in Africa as you fly down a crowded road at 140km/hr. The 2yo boy had come in vomiting (or coughing?) up blood with significant jaundice and was found to be unresponsive by the night team. When I walked into the ward in the morning they were in the process of resuscitation. We were able to get the patient intubated and stabilized but didn’t have a ventilator, so I used the bag for a couple hours while we worked on further diagnostics and trying to find an ICU bed for the patient. Thankfully there was one available. It was a whole new experience trying to organize a transport to another facility. In the US the transfer teams are very competent, have extensive equipment and are experienced with troubleshooting and stabilizing . In Malawi it is you. So after coming up with all the medications we might need and the ability to maintain the airway, we made the transfer to the backseat of the ambulance. The ride was harrowing. Siren blaring (which mostly didn’t phase anyone) we zoomed around corners and in between cars. Driving in Malawi is an adventure at the best of times. This was something else. But we made good time and soon we were pulling into the central hospital. Amazingly, a PICU doctor from the US met us in the stabilization room. She had just arrived two days before. There was one last ICU bed available that our patient took. As we were driving, I was praying for the patient as there were times when things appeared to be heading down hill. Modern medicine has done so much and made significant improvements in our ability to treat illness, but I’m becoming convinced that sometimes we still need a push in the right direction. I believe God was watching over this child and using us and others to meet some of those needs.

Working with sick children here in Malawi can be draining and discouraging. Death always seems to be near. But so also are family and friends (almost every child has a guardian in addition to their mother, often a relative or neighbor who helps to take care of the patient in the hospital). And so also is God.

Daniel Dyer, M.D.

8/12/19

From: Daniel Dyer, M.D.
August 1, 2019

Muli bwangi! (A Malawi version of hello and how are you)

It’s hard to believe it’s my fourth day at Nkhoma. I’ve been so busy trying to get used to everything that is new that it has gone relatively quickly. No matter how many times I’ve worked abroad it always is still such a challenge to transition to a new place, especially into a new language and health system/hospital. 

I’m going to keep my blog posts brief as I have to write them on my phone. There is no WiFi here and the only way I can get internet is through data on a network plan (sorry Elisa! I really owe you this time).

There are two things I want to focus on. First has been the challenge of walking into a new hospital and not knowing what my role should be. As a resident I don’t fall into any easy category here. A lot of the hospital is run by clinical officers. As far as I can tell, they are the equivalent of residents in the US, but they don’t need (or get?) the same supervision. They are much more proficient than me in some things, for example procedures and managing certain diseases, but seem to lack skills/experience in creating a differential and thinking critically through a treatment plan. I have struggled thus far in knowing what role to take as I’m new, don’t know a lot about Medicine here in Malawi, but also want to help if I can and use what I know. And technically, as a doctor, I can be the one to sign off on something for a clinical officer if there is a question, which adds one more confusing part to the puzzle. I’ve mostly tried to listen and ask questions, occasionally giving suggestions of something to consider. But my main objective has been to be a sponge.

One interesting hung that I have found is that a lot of decisions are based off of protocols. Once a diagnosis and severity have been established, a protocol can be followed. It’s a system that tries to leave little up to chance in order to improve outcomes, which has the benefit of making sure medications are started promptly. This seems to come at the cost of appropriateness. For example, antibiotics seem to be prescribed for almost all patients, whether or not they truly need them. It seems to me that the doctors who have been here for a while still struggle with this a little, but benefit from being known by the staff and knowing the protocols (and reasons for them). 

On a very different note, I also wanted to share a story of one of my patients. Her name is Witness and she is 6 years old. She came in with fever, weakness in her arms and abnormal arm movements. She was started on Ceftriaxone for fever (like almost every child admitted here). Overnight she became very agitated and would periodically yell. When I examined her the following morning she was confused, seeing people that weren’t there, but had calmed down and seemed to have periods of lucency. We did an LP that was normal. However, on talking more with mom, one of the nurses learned that she had been bit by a dog about 3 months ago. I had to dig out a Pediatric text book to read more to confirm my suspicion. The incubation period of rabies is 1-3 months. It migrates from the peripheral bite to the CNS, so the incubation depends on how distal the bite is. As the virus migrates, it can cause local neuropathy until it reaches the CNS. Symptoms usually start with a prodrome of viral symptoms-fever, malaise, chills, etc. they may additionally hame photophobia and paresthesias with proximal radiation (which is what our patient reported). After this classic symptoms may develop leading to hydrophobia, hyperactivity and eventually paralysis, coma and death. Witness began to exhibit these symptoms before she was discharged home to die.

I find I almost have to intellectualize encounters like this or the sheer terribleness is overwhelming. Witness was a beautiful, sweet and curious girl when she was lucent, but would disappear in terror and pain as the disease progressed. Like so many diseases here, this could have been prevented, but has been perpetuated by poverty and ignorance. I have never seen rabies before this, like so many of the diseases we now have vaccines for, but it is one of the worst diseases and ways to die I’ve seen. It creates an almost primordial fear, this organism that has been present for so long and we still have no way of curing it. For a child with so much already stacked against her it seems almost unbelievable to add on a rare disease like rabies, but such is the current state of our world.

I don’t want to end on that note, so very briefly, we have a 3 month old child who came in earlier this week in significant respiratory distress. I had seen children like this die in PNG. But due to USAID, they’re are a couple CPAP machines here and we were able to support the child through the worst of their disease and today they looked significantly better and are now off of CPAP. Good can and is being done, even if there is so much more to do.