I worked as an independent Family Physician after my residency for fifteen years before I changed to near-end-of-life care in the community. In the early 1980’s, I volunteered as a general physician for two and a half years in Malawi, Central Africa.
As I approached the completion of my Family Medicine Residency, my best friend and I discussed how we felt we had been given so much in life. Perhaps we could give back by volunteering within a remote community. I contemplated working in a small town in northern Canada close to where I had lived in the Yukon for three years during my ‘army brat’ years. I asked my parish priest if he would have any contacts through the church system to help narrow down the possibilities, explaining that I was newly graduated and had no independent medical practice experience. He stated that he had previously spent some time as a teaching assistant in a diocese in Mzuzu, Malawi, Central Africa. I politely refused the offer of his help, explaining that I would be too inexperienced to be helpful and I could not physically handle a tropical climate. I left the interview thinking I would need to use another strategy to find volunteer work.
Six weeks later, I received a letter from a sister belonging to the Medical Missionaries of Mary, who was the administrator of St. John’s Hospital in Mzuzu, Malawi. She started her letter by saying, “You are the answer to our prayers.” I could not believe what I was reading. Obviously, my parish priest had written a letter on my behalf.
My initial thought was, “I could not possibly agree to work in Mzuzu.” However, to my great surprise, I did not generate negative feelings indicating this would be the wrong decision for me. In reviewing the offer, I found that, though Malawi was near the equator, Mzuzu was situated 4000 feet above sea level. No matter the season, the nighttime temperatures were always comfortable for sleeping. It was a climate in which I could work. In the letter, I was told that I would be well supported by an experienced physician from Scotland who had worked many years in Malawi and understood that I was inexperienced. So, without much further thought, I agreed to go to Mzuzu and spend at least six weeks. Within that time frame, I would know if I could be helpful to the hospital staff. If yes, I would stay for a few years. Otherwise, I would return home. I stayed within that “family” of colleagues for two and a half years.
St. John’s Hospital, a 200 bed unit, was built and run by missionaries based in Ireland. The sisters provided the administration, nursing care and teaching of the Malawian nurses. Their goal was to provide the necessary medical care, over ten to twenty years, for patients with acute illnesses until they were able to support and teach the Malawian physicians, nurses, and medical assistants to run the hospital themselves. At the time of my stay, the sisters were still recruiting physicians from outside the country. A second complimentary goal of the nursing sisters was to bring mothers and their children together, either at the hospital or in a distance village, for prenatal visits and early childhood clinics to teach them the basics of nutrition, infectious disease prevention, and to administer vital vaccinations.
In the first year, I was integrated into the team, and assigned the primary responsibility for the care of children and pregnant women. My physician colleague supported, taught, and supervised me through the most important operation at the hospital – the cesarian section for women who could not deliver their babies vaginally. Occasionally I would join the nurses, nursing students, and the medical assistant in the outreach clinics.
In that first year, through all my experiences working as an integral member of team at St. John’s Hospital, and after I added basic surgical skills to my scientific knowledge, I started to believe I could deal with the most common medical crises. As I relaxed a little, I slowly started to go into my ‘observer’ mode more frequently. I assessed the delivery of our care based on what I thought were clear ‘scientific and logical’ decisions. I learned that these decisions were significantly impacted by very complex factors.
I was now providing medical care in a country foreign to me, in a very different context from my educational experience. The impact of that context on my medical decisions was very real and led to very different approaches to each problem. The following examples illustrate this statement.
In Malawi, in my experience, the practice of obstetrics was the most evident example of the complexity of medical decisions impacted by social and political factors. Malawi was essentially a totalitarian state with a small population. The ‘Life President’ wanted to increase his country’s population quickly. So, he mandated each family to have at least six children. If a woman could not provide six children for her husband, it would be acceptable for him to divorce her and find another woman who could do so, leaving his previous wife to fend for herself.
The factors challenged scientific medical reality. If a woman was able to have a vaginal delivery at the end of her first pregnancy, her subsequent deliveries would be very likely vaginal deliveries – the first child having prepared the way. Therefore, her ability to have six children was possible. On the other hand, if a woman had a cesarean section, an operation that required cutting through the wall of the uterus, to deliver her first child, she would likely require a similar surgical procedure for all her children. The medical reality was that the uterine wall became scarred, less elastic, thinner, and more prone to rupture with each subsequent operation.
The conclusion of obstetrical experts was that it was not safe for a woman to have more than four such operations. The chances of a life-threatening rupture were too high. If women tried instead to have a vaginal delivery in subsequent pregnancies, the chances of a life-threatening rupture of the uterus were equally as high. Based on the experts’ opinion, it was our policy to ask every pregnant woman who had had a previous cesarean section to spend her last two months in or close to a hospital to have the medical expertise available to perform a cesarean section upon the start of labour.
Terry Fox’s run raised the awareness of cancer in Canada, as well as, concretely, increasing funding for cancer research: In Ottawa, a brand-new Regional Cancer facility was built on the main floors of two of the Ottawa Hospital campuses, emphasizing early diagnoses, research, and timely treatment.
Palliative care residences and outreach programs opened in Victoria, Vancouver, Ottawa, and Toronto: Initially, palliative care was set up for patients dying with cancer, spurred again by the Terry Fox phenomenon.
The impact on the lives of families with mothers facing vaginal delivery vs cesarean operation was monumental. Therefore, though we needed to approach each delivery using the science of obstetrics, we were more likely to try very hard to achieve a vaginal delivery in the first pregnancy, taking a few more risks than we would in Canada – without ever putting the lives of the mother and baby at risk.
These risks of repeated cesarean surgery were theoretical, but the real consequences became evident to me one day when I was the only physician available, within a 500 km area, to perform complicated vaginal and surgical deliveries. Admitted to the hospital, we had three mothers pregnant for the fourth time; all had had a surgical delivery for each of their children. They were all near term waiting to start labour and have their fourth cesarean operation. Unknown to the staff, a traditional healer visited the hospital, boiled up a concoction including an herb known to induce labour and offered her drink to the three patients. All three went into very active labour within a few hours of each other. I performed three difficult cesarean sections over the next eight hours.
With each patient, when I exposed the uterus, the front uterine wall was so thin I could see the baby through it, and in each patient, several locks of the baby’s hair had already penetrated through small tears in the uterine wall. If we had not been available to operate on these three patients quickly, all three would have suddenly ruptured the uterine wall, bled profusely, and likely, each mother and baby would have died.
Another story, taken from my pediatric experience, demonstrates how, despite minimal technology, we could still do our best to care for these little ones. But we needed to find an ‘elegant’ solution by using our best science and available tools while integrating the family into the care through teaching and support. Baby Ester demonstrated to us that success could be achieved way beyond expectations.
Baby Ester’s astounding story started in her village where she was born very prematurely without medical help. Her mother brought her to the hospital within a few hours of her birth. She weighed under two pounds, fitting into the palm of our hand. The sisters and I looked at each other, and clearly, we all thought it was amazing that Ester was still alive. We believed that to have a chance to survive, she would need an incubator and equipment to insert intravenous lines for fluid and medications, but we had neither.
We all agreed we should care for her as best we could. We found a large box, lined it with layers of warm blankets, dressed her warmly, added a little bonnet for her head, and put the tiniest feeding tube we had into her nose, down into her stomach. Her mother and other family members were at her side 24 hours a day. We demonstrated to feed her very slowly, one drop at a time through the tube using her mother’s breast milk. We visited every few hours, thinking we would soon need to support the family when she would be close to dying but this little fighter continued to survive.
About a week later, Ester developed a fever, likely because she aspirated a little milk into her lungs caused by being fed a little too quickly. Again, the nurses and I were sure that she would die soon. But, as we did with all our babies with a fever, we could at least give her the best chance to survive by starting a course of antibiotics through the feeding tube. We continued to support and praise her family for their care but emphasized the importance of feeding very slowly, stopping for a while when she demonstrated signs of coughing and choking. To our amazement, Ester survived! We innovated using the best scientific approach available to us and taught the family to help with the care – but, really, none of us believed she would survive. We were wrong and learned a very poignant lesson in humility. We knew that we could not have succeeded without the integration of Ester’s willpower and her family’s constant presence and perseverance.
Over the two years, my colleagues and I often had discussions about our approach to medical care in our hospital and outreach clinics. We would review the patients we admitted to the hospital. Many had illnesses that were easily preventable, especially the children with malnutrition. Occasionally, I would join a team of nurses and medical assistants to set up an outreach day clinic in a distant village, attracting people from several surrounding villages. We would screen babies, young children, and pregnant mothers. The medical assistant would see adults with minor ailments. The nurses would intersperse teaching sessions throughout the day, mostly through songs addressing breastfeeding, nutrition and public health topics about clean water and prevention of the spread of infectious diseases. As a gift for participating in the session, the mothers would be sent home with a supply of powdered milk.
The day after these outreach clinics my physician colleague and I had discussions about what we felt the best approach to the population’s medical care should be. If we spent more time in the villages, explaining preventative care, and if the villagers believed us and adopted the principles, there would be far fewer patients requiring admission to the hospital. That would seem to us to be an excellent use of our time and resources. However, if we did not have a well-staffed hospital able to treat the emergencies and the breakthrough cases, proving our care was effective, the villagers would not trust us and have no reason to believe what we taught during the teaching sessions. We always came to the same conclusions. We needed to provide both branches of care – teaching and prevention alongside acute curative care even though we knew that with our limited resources, our ability to succeed at both branches of medical care would be lower than we wished.
The sisters had engaged in this debate many times during their stay in Malawi. To make sure that they, as foreigners, were taking the best approach to help and empower the Malawian population, every year, several of the sisters were sent to seminars organized by the World Health Organization explaining these very concepts. I was invited to participate in one such event entitled “How to Approach Providing Help in a New Village?”
I have never forgotten that seminar – not for what it taught me for our practice in Malawi, but for what it taught me for my future community practice in Canada. The principles were the same.
| Step 1: |
Understand yourself. Know your values. Know your ideal goals for family medical care. Know the realistic constraints with medical care in the home and your community and know your boundaries. |
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|---|---|---|
| Step 2: |
Assess the new family, their present situation – listen and observe quietly. |
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| Step 3: |
Make four lists using the headings:
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Keep these lists in your mind only. Do not speak yet. LEARN from both lists 1 and 2. Lists 3 and 4 may be different. Do NOT act yet! |
| Step 4: |
Start to build TRUST. Quietly, compare your list of deficiencies with the families’ list of needs. Identify a need in common – a high priority for the family, the potential for a positive solution with your help. Work together to resolve this problem. Teach and listen through the process. |
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| Step 5: |
Identify a severe need not understood by the family that is a high priority for you and has a good potential for a positive solution. Explain your concerns. Ask if you can work together to try and solve that problem. |
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| Step 6: |
Empower the family. Address as many of their perceived needs as possible. Continue to work together and educate each other. |
|
| Step 1: |
Understand yourself. Know your values. Know your ideal goals for family medical care. Know the realistic constraints with medical care in the home and your community and know your boundaries. |
|
|---|---|---|
| Step 2: |
Assess the new family, their present situation – listen and observe quietly. |
|
| Step 3: |
Make four lists using the headings:
|
Keep these lists in your mind only. Do not speak yet. LEARN from both lists 1 and 2. Lists 3 and 4 may be different. Do NOT act yet! |
| Step 4: |
Start to build TRUST. Quietly, compare your list of deficiencies with the families’ list of needs. Identify a need in common – a high priority for the family, the potential for a positive solution with your help. Work together to resolve this problem. Teach and listen through the process. |
|
| Step 5: |
Identify a severe need not understood by the family that is a high priority for you and has a good potential for a positive solution. Explain your concerns. Ask if you can work together to try and solve that problem. |
|
| Step 6: |
Empower the family. Address as many of their perceived needs as possible. Continue to work together and educate each other. |
|
Ester’s story was a success, but many patients did die from illnesses. Most children died of severe viral diseases, including measles and whooping cough, malaria, and severe malnutrition. We did our best, but often it was not enough. The families were always present. When death came, we were obviously on the sidelines, looking on. They had their own culture where family and friends supported them. Death was not an unusual event for each family.
We had a few patients admitted to the hospital with signs of advanced cancer, hoping for a cure. Cancer was not a frequent diagnosis in our hospital for several reasons. The life expectancy of the population in Malawi was between 45 and 50 years of age. Most cancers decreased the body’s immune system and its ability to fight against infectious diseases. Therefore, most patients with cancer would have died of infections, the apparent signs of infection mostly masking any early cancer symptoms. If we did diagnose advanced cancer, we would explain to the patient and family that we could not reverse the process. They did not stay in the hospital. They returned home to their villages to be cared for by their extended families.
There were times when we were faced with the loss of patients that we felt should have survived. Near the end of my stay, we admitted three babies within a few weeks with what seemed to be minor problems which we quickly addressed. At first, they improved, then suddenly they became very ill and quickly died. We could not figure out why. We started to doubt ourselves and wonder if we were doing something wrong. Perhaps we missed some critical symptoms. During the same time, my colleague and I noticed a change in previously stable patients suffering from Tuberculosis, who were assessed monthly at our outpatient clinic. Suddenly, we observed what we called “fulminant tuberculosis”. These patients were admitted with high fever, chills, coughing, difficulty breathing, and died within a week. We just did not know what was happening.
On my return to Canada, I heard about a new virus called AIDs or HIV. The virus originated in Central Africa. On reflecting on our experience with the babies who appeared healthy but died suddenly and the patients with fulminant tuberculosis quickly progressing to death, it was very likely that they also had this new virus, reducing the body’s ability to fight its other active disease. While I was in Malawi, I did not know AIDs existed.
The introduction of AIDS/HIV into Canada: A viral disease with no cure and very little effective treatment at the onset forced a whole population to focus on near-end-of-life.
I knew that my experience in Malawi, the first time I had lived far away from my nuclear family for an extended time, would be a period of personal growth for me. However, the responsibilities of my work throughout my stay took precedence and did not leave me much time to reflect on myself.
I was given one excellent opportunity for reflection. During my stay within the nursing family, they invited me, and the female lay missionaries working at a nearby school to participate in a five-day retreat dealing with the question, “Who am I?” During the late 1970s, the diocese of Mzuzu began to implement some of the principles of the Second Vatican Council by recognizing the ongoing stresses of sisters, priests and brothers working as missionaries in a foreign land. They set up a program that required them to attend a retreat led by a trained advisor once a year. To some, the retreats provided a rest from the responsibilities of the work. To others, it was a time to share experiences and re-evaluate their continued desire to continue in this type of work. By the end of the retreat, we were asked to search for the one word, the one inner feeling that described us the best.
I learned that I used nature to center myself. Malawi, being very close to the equator, has sunsets almost at the same time each evening; the process happens very quickly over less than thirty minutes. Often when I finished a busy day at the hospital, I would return to the sisters’ residence just at sunset. I would stop and quietly watch this beautiful phenomenon relentlessly occurring each day no matter what events transpired through the day. Later in the evening, after supper with the sisters, during the short walk to my house, enveloped by the very dark stillness of the night, I would look up to the sky and see the bright and glorious Milky Way – all those worlds, millions of light-years away though still within our universe. These two scenes were anchors for me. I could ‘be still’ for a few minutes and experience the vast display of the power of the universe. In that stillness, I could sense my very tiny but unique part within the universe – I was filled with my most special feeling, ‘peace.’
When I reflected further on these moments over which I had no control, I started to understand that there were other moments in my life, small events over which I did have some power that generated the same feeling of ‘peace’. These small events included: a moment’s interaction with someone I made smile; a busy day trying to do my best realizing honestly that I was not always successful; a frustrating, tiring day when I somehow still found the strength to take the time to listen and care for others and find the wisdom to allow others to be themselves. These moments also filled me with a sensation of peace.
‘Peace’ was the one word that described me the best!
Then the responsibilities took over all my energies, leaving me no time to further reflect on myself until I was ready to leave Malawi.
Just before I left Malawi, my colleagues, the nurses, sisters, fathers, and brothers held a celebration for me and gave me cards with short expressions of how they ‘saw’ me – how I had ‘touched’ them.
“You give the impression of being very much at ease with yourself, of being a deep lake with not a ripple or ruffle on the surface . . .”
“You have quiet strength and courage which comes from knowing fear and carrying on; your concern for the sick is great, nothing is ever too much.”
“You make everything go smoothly so that any tensions and troubles are avoided.”
“Teaching the students was very effective.”
“The charts of inpatients could never be found, until one day you saw the problem and the boxes were numbered, bound, and all the statistics books suddenly had a new look . . . and all our reserve medications were organized for the next two years.”
“You always wore a smile on your face though in difficulties. You were called up at night, at all times, without complaining. Every one of the staff nurses used to run after you for help, and you gave us help at the same time we requested it. You have cured hundreds of sick patients.”
I was so touched by their comments. Still, I wondered, “Did they really ‘see’ me? I knew I had used my ‘observer’ mode very frequently in crises and appeared calm and comfortable on the outside, trying to find the ‘elegant’ solution before I acted. I also acknowledged that I had a super-power – I could fall asleep at anytime and anywhere and awaken quickly, ready to address a crisis. I was pleased that some of my efforts to try to support all those working with me had succeeded.
I strived to achieve this inner fortitude my colleagues observed in me, but did I succeed consistently? Did I have these gifts of strength, confidence and inner peace?
