Oct 19 - The Malawian Rollercoaster

The Malawian Rollercoaster

October 19

Life here seems to fluctuate from despairing over the multitude of problems and frustrations, compounded by the inability to do anything about them, to feeling as though you need to be here and ‘save the world’ for the rest of your life.

The despair
Robert, a new Dutch paediatrician who started recently, was on a Moyo ward round with me learning the ropes. Wanting to help in some way that is currently not possible, he offered the idea of simple things such as an electrolytes machine for the children as part of the project that has brought him to Malawi. I thanked him for the enthusiasm and ideas but then informed him of the sheer number of kids that this would require blood tests for, the reagents that we would then not be able to afford, the absence of anyone available to service the equipment when problems arise, the number of nursing and patient attendant staff required to take these regular blood tests, and the lack of good therapeutic measures to act upon all but the most basic of problems from the changes we detect. Although a wonderful idea, the support that would be required for such a process is far beyond simply providing a machine that looks lovely and gives a few useful answers to begin with (in saying this, the use within a very limited number of patients with specific problems, or stylizing the tests in the setting of a study to correlate with future clinical practice would certainly be useful).

This I guess raises the problems with a lot of donated goods and monies. Much of the well intentioned pieces of equipment require reagents that we cannot afford or sometimes cannot even access, they often require support staff in the form of laboratory analysis, servicing and repair that we have no money or training for, and they may not even be compatible with other equipment to run it, meaning it lays idle as we await further parts. As a great example we currently have no less than fifteen oxygen concentrators (the portable machines which provide oxygen to unwell patients in hospitals where oxygen piped through a central means is not available) that sit dorment in our maintenance department with no one capable of fixing even the smallest problem. They are all invariably made by different manufacturers and often with different electrical inputs, meaning even if we did have a knowledgeable repairman, the parts would have to be sourced from multitudes of varied companies.

Then there is the donated money. This often comes with the caveat that it be spent in a certain fashion. This can either be with the requirement that the product or service it is intended for come from the donor country itself, giving no long term gains economic development, training or education to local providers, or that the money be spent in certain areas that have no relevance to the true shortages that currently exist in service provision given the lack of consultation with ground level service providers to ascertain their true needs.

Then there’s the immeasurable problem of donor funding in the form of NGOs, religious organizations and other such benevolent bodies who come to the country with their own agenda, not linking their ideas or implementation with existing or competing interests, either government or external. This means massive duplication of services, fractured training and knowledge, disproportionate aide to certain areas and none to others and, most discouragingly, lack of long term sustainability as one project finishes and another simply reinvents the wheel. I don’t disagree that the country needs external funding and skills at present, nor that these organizations are worthwhile and important – heaven knows, the place would simply collapse without them – but there’s surely a better way of going about it… and if you have the answer, please let us know!

Of course none of this is helped by the nepotistic, self-indulgent, corruption of the government (and Malawi is one of the less corrupt on the continent) that manages to continually channel money into the wrong hands, mismanage responsibilities external funders place on them and, unbelievably, withdraw service provision to areas that are being externally funded despite these initiatives often only being short term undertakings, thus leaving the system shot with holes afterwards. Then finally, there’s the attitude of a small number within the community who see this entire process as a good excuse to exploit the system and make money.

Saving the world
Yet not all is despair. Very commonly, admittedly not quite as often as the frustrations, we are encountering inspirational people who seem to make being here a pleasure, and even make you feel like what you are doing is never enough for the plight of the country. Two of those people are fellow paediatricians (amongst other roles they have), Liz Molyneux and Robin Broadhead. Enjoying dinner at Robin’s house recently we heard many an uplifting story that made us feel quite inadequate in what we were doing here.

Robin himself has been here for the last seventeen years, moving here from the U.K. with the establishment of the University of Malawi. Throughout this time he has been one of the instrumental figures in shaping what is now an internationally recognized teaching institution that is, albeit slowly, shaping the future of Malawian medical practice. He has been a university lecturer, the Head of the Paediatric Department, and is now the Principal of the College. He has lived through the dictatorial years of the Banda government, existed without any family or close friends from home and now sits through the daily frustrations of endless bureaucracy in various meetings, and is still able to look upon Malawi and all her foibles with the most positive spin.

Liz and her husband have lived here for interrupted time over the last 40 years. After initially coming here in a missionary capacity, Liz has taken over the Head of Department position and managed to almost single handedly thrust paediatrics at Queen Elizabeth Central Hospital into a position of international renown in international developing world circles, as well as dropping the admission mortality during the wet season alone from a staggering 18% to now regularly under 5%. This she has achieved with an enviable blend of inexhaustible diplomacy and a passionate devotion to the day to day clinical responsibilities of the department. Her husband, Malcolm, has also headed the majority of the malaria research in Blantyre for the same period of time, allowing Queen Elizabeth to be at the forefront of both research and clinical practice in terms of the malaria pandemic that still to this day claims so many millions of lives every year. And this he does with a wit sharper than many, and a clinical acumen that speaks volumes of his time in the realms of such unthinkable disease.
These are only a couple of examples of such inimitable devotion to what many would see as a sinking ship. Their ongoing commitment to the development of this country makes so many other contributions seem trifle in comparison, yet at the same time motivates you to see through the daily frustrations to the bigger picture, and the small but appreciable difference that you actually can make here.