On being a woman: Men are from Mars, Women are from Venus

I have been asked to comment about how I have been received here as a female physician? Especially given concerns about how women are traditionally viewed in sub-Saharan Africa. What we have heard  about life for women in rural Malawi is discouraging.  Admittedly, we have mainly been hearing about local culture in conversation with other non-Africans who live here. They say that the women do all the hard labor, raise the kids, cook, often work a job, keep a garden, etc.  And that they cannot refuse their husbands or they will be beaten. In this culture, they also cannot refuse the advances of any male relative. But, I have not heard this directly from a local woman. Though, I do hear it from trusted sources. As I build local friendships and start to have my own clinic, I am will be able to have these conversations with women myself. (It is disheartening as we see the number of patients in the hospital with HIV/AIDS and try to prevent further spread of the virus. For example, we heard of the case of a man with HIV but his wife was negative…apparently it was not going to be the case that the man would be expected to abstain from unprotected sex with the wife to avoid transmission to her.)

But I digress. The question was for how I have been received here as a female physician. Actually, there are already many female physicians working here. From various ethnic backgrounds: mainly African, European, & Asian, but also some from the US & UK.  In fact, the head of internal medicine department at the gov’t hospital and the medical directors of both Malmulo Mission Hospital and Blantyre Adventist Hospital are all three women (1 European, 1 American, 1 Philipina). So, the many women physicians who have come before me have paved the way already.

How I am treated actually varies by location immensely. I spend most of the day for this 6-week orientation period at the gov’t hospital, where in general, I think rather than being viewed as a man or woman, I am viewed as a complete alien. But a privileged alien. I might as well be from either Mars or Venus. I am mostly ignored as I walk through the halls, but I can walk anywhere I want. During most hours, the corridors and wards are open. But even before lunch or in the afternoon when the guards are blocking others from entering a ward or a corridor, they always let me pass. Without asking me who I am or where I am going, or why. As I approach the door or gate the crowd (if there is one) stands aside, and I am given a free passage. Perhaps they assume I am a doctor? But I actually don’t think they even care about doctor or about gender…I think it is as a Mzungu (foreigner) I am a considered to be different.  Once out on the wards with the patients, no one talks much to me. Some of it is undoubtedly because they don’t speak English and thus there is often a language barrier. Most of the families in the wards speak very little English. I try to tell the family results of an echo or something that I have done, but just get blank stares. I have learned basic phrases in Chichewa, but even when I say something to them in their language, they do not engage me very much. Maybe my accent is so bad they don’t know I am trying to speak their language. Or maybe they realize I wouldn’t understand their questions or comments if they made them in response to me. Seeking out a translator and sitting down with a patient to ask questions sometimes improves the odds of getting good interaction, but not always. Maybe because the nurse, intern, or medical student procured for the job is also busy with other things and rushing it. Maybe because the questions are not interpreted accurately (the official interpreters in the clinics tell me there is no word for “fever” in Chichewa…so they struggle to interpret that question…interesting in the setting of the majority of admissions being for infectious diseases. And I doubt some of the cardiology diagnosis and issues are translated very easily ... it's hard enough to explain to patients in hospitals in the US who speak English as a first language!).  Maybe because they often minimize symptoms and hardships and avoid socially taboo topics (HIV/AIDS is mostly a taboo topic, and yet they say on average 80% of the in-patients in that hospital are HIV positive). Maybe they say what they think I want to hear. Maybe they are suspicious of a Mzungu. Maybe they are frankly too sick or in too much pain to engage. But the end result is that I often feel I do not have the whole story, I have not been allowed in, I am still a stranger and alien not to be trusted with the whole story. I doubt that my gender plays much of a role in that setting.

Out on the streets in Blantyre, it is a different story. People do look at us, but not usually to stare or point. There are many other light-skinned people around Blantyre, so we don’t gather unusual attention, though we still do stand out! We are often greeted and people usually smile. Children will come up asking for money and food. At first, an occasional vendor tried to sell us souvenirs, but even that is becoming less frequent (we’ve been here 5 weeks now). In general, there is friendly interaction and likely nothing to do with gender or profession, though I am almost always with Darryl and undoubtedly their interaction with us is biased by our skin color. I have not felt unsafe while walking in town, but do not walk alone or at night. No one (except the guy who sold us souvenir postcards at an exorbitant rate) seems to have cheated us or charged us extra money for being Mzungu. I am not sure how we would know for sure that we weren’t getting overcharged though…

Once we get home, there is a definite gender bias held by the workers helping renovate the house. They insist on referring to my husband as “doctor” and not me. It amuses me. He tried for a while to correct them, but with little effect. In the hospital setting it is easier, as I have a stethoscope and am introduced as the doctor. But when we are not inside the hospital, it is usually presumed to be Darryl that is the doctor.

In the private hospital and clinic, I have not noticed any issues about being a female and I am not treated as if I am from Venus. People are glad to meet an American Cardiologist. The majority of patients here are middle and upper class and speak English or have brought a family member who speaks English to be with them. Being the only cardiologist in the country I think ends up trumping most other things in the hospital setting.  Most people are thrilled to have a US-trained cardiologist here and don’t mind saying so to me directly.  Of course, I would love to have a Malawian cardiologist come back to Malawi to work! Or an anesthesiologist. There is no residency training in Malawi, so post graduate medical training must be done out of country. Best I can tell, few, if any, Malawian physicians return to Malawi after an external residency program. There is clearly enough heart disease here for several cardiologists! There is enough for one at each hospital in town! Certainly more than I can deal with on my own. But why is there is such a shortage of physicians in Malawi? Why has there been no cardiologist here for years? Questions without great answers. And Malawi still has one of the lowest doctor-to-patient ratios in the world. I wish I knew why there is such a shortage and how to obtain residency & fellowship training for Malawians who will ultimately return to practice in Malawi.

So, that is my round-about way of saying I have not yet felt much of a gender bias against me for being a woman physician. But, I am surrounded by other women physicians and I am a specialist…and thus viewed as a rarity here. I do hope over time to find out on a more personal level what it is like to be a Malawian woman living here…(-Tiffany)

Working Hard

I have tried to keep track, and estimate I have already done over 70 echos in the past 2.5 weeks with the Vscan, plus over 30 echos using the larger ultrasound machine that Queen Elizabeth Central Hospital (QECH) has in their radiology department! I have been seeing anywhere from 10-20 per ½ day clinic. At QECH I have been helping in the hypertension, chest, diabetes, and pediatric cardiology clinics.

There is a once-weekly pediatric cardiology clinic where one of the pediatricians with an interest in cardiology follows > 200 kids with heart disease. Both times I have attended this clinic, we saw > 30 children for the ½-day clinic! There is a committee in Malawi to which all cases requiring care outside the country are petitioned. So some of the children with congenital heart disease do get referred to that committee for consideration. I hear that they are limited to sending about 100 cases per year out of country (including all the non-cardiac surgery and the adult cases too) and there is a rumor that it can take about 18 months to get through he process and get the surgery done (usually in South Africa).  There are very few families who can afford to skip the committee and pay out of pocket for these surgeries elsewhere.  Yesterday we saw 2 children with Patent Ductus Arteriosis (which would be likely be fixed percutaneously-using catheters inserted from a blood vessel in the leg-at most any Children’s Hospital in the US) but we also saw 2 children with tetrology of fallot (which is not so simple and would usually require open heart surgery).  If anyone reading this blog is an interventional cardiologist and wanted to come to Malawi for a week or two, please contact me!

During the day, in addition to helping with clinics here at QECH, I have also been doing consults on the in-patient wards as needed. Usually it would either be doing an echo for suspected pericardial effusion or heart failure; or as a consult for management of arrhythmia or rheumatic heart disease. And, of course, almost every day I have been called by the General Practitioner’s at Blantyre Adventist Hospital (BAH) for advice with 1 or 2 of their patients, which I usually have to do before 8am or after 4pm when the afternoon clinic finishes at Queen Elizabeth. Once my orientation period is finished at QECH, we will officially open the Cardiology & Internal Medicine clinics at BAH, as well as a weekly ½ day clinic at Malamulo.

In my spare time, I have also been trying to work on the ICU. I have been making a list of expectations and guidelines for the ICU nurses. We are now advertising for an ICU charge nurse and 6 regular ICU nurses, there is a committee to help me choose out of the applicants. I am also trying to figure out exactly what we already have available and what we still need to try to acquire before we can open the ICU.

On a more personal note, progress is being made on the repairs at the house we will be renting , so hopefully just 2 more weeks before we can move in there. And, Darryl & I celebrated out 6^th wedding anniversary last weekend.  We took the opportunity to hitch a ride with Ryan & Sharlene Hayton up to the Zomba Plateau for one night away from the patients and to-do lists, which was wonderful! We met some of the other Malamulo crowd to, which was nice. Elisa Brown and her brother Randy & family. We took some wonderful pictures (I think) but after they were downloaded onto our computer and deleted from the camera, the computer crashed and we have thus far been unable to revive it…

ADDENDUM: we have rescued some of the pictures from our trip!

Vscan

The hand-held ultrasound machine generously donated by the non-profit organization Youth Outreach Unlimited has already been invaluable!  It is small enough to go with me on rounds to both hospitals in Blantyre and down south to Malamulo too.  I have used it about a dozen times in the first week. And the amount of heart problems here is big! If I ever doubted that they could keep a cardiologist busy full-time…no longer! For those interested I have been keeping a rough tally of cases so far: the majority are cardiomyopathy (weakened heart muscle) of some type, hypertensive heart disease, right heart failure, palpitations, chest pain, and pericardial effusions (almost all of which are TB).  In just the first week I have seen a probable case of severe mitral regurgitation from rheumatic fever, two cases of severe right ventricular failure, and cardiomyopathy from hyperthyroidism. So, the scanner is being put to good use! Thank you so much to all who donated toward the echo machine and hand-held ultrasound!

Orientation

It is the custom of the Malawi Medical Council to require an orientation and evaluation of physicians trained outside of Malawi when they first arrive. So, I have been assigned 6 weeks of orientation at a large government hospital here in Malawi. The hospital provides care, free of charge, to the public and serves as a referral center for the entire region. I cannot verify this statistic, but heard someone say there are about 250 physicians in Malawi, and 80 of them are at this hospital! The hospital is quite large with multiple medical wards.

My first day I accompanied a physician from Europe on rounds. Part way through I got sweaty and lightheaded. Sat down for a minute, the threw up. I, of course, stepped out. Unsure if I was ill from new food & water or from the overwhelming suffering surrounding me, I drank some tea and walked around again. This time more aware of how much my body had been filtering out the first time. The sounds and smells. There is a shortage of beds and of nurses, continually. There is no central cafeteria or kitchen. So, instead, there is space around the outside of the wards for family to camp, and they provide most of the meals and care for their loved one, the patient. So, the wards that are already over-crowded with patients, are also filled with family members attending to the needs of the sick. Still not feeling well, I rested for a minute and then called for a ride back to the hotel early. I had fevers, chills, and muscle aches through the afternoon and into the following day.

Slowly, I improved enough to head back to the hospital late in the afternoon the second day to do a cardiology consult as requested for an older man who presented with a large stroke and had been found to have severe hypertension and an irregularly irregular radial pulse. An ECG had been done, one lead at a time, along a long thin strip showing atrial fibrillation. I did a cardiac ultrasound at the bedside that showed an enlarged left atrium of the heart and thickened heart muscle consistent with affects of long-term high blood pressure. Treatment is with medications to lower the blood pressure and aspirin to reduce the risk of another stroke, which they can obtain (free of charge) 30 days supply at a time from the hospital pharmacy. Unfortunately, of course, the choice of medications is limited and intermittently out of stock.

I have now spent a total of 1 week on orientation there. I am amazed by the amount of true sickness and poverty on the wards. It is very different from my other experiences, even time spent at other (albeit private) hospitals in Africa! I’ll spare all the readers the medical details…but it is quite sobering. Meningitis, TB, profound anemia, malaria, and HIV are very common. Sometimes all in one patient! I need to continue to refresh myself on Tropical Medicine…bacteria, virus, protozoa, helminthes! And diagnosis/treatment with limited resources. But, the physicians I have been orienting with inspire confidence in the power of the clinical acumen from history & physical exam! They seem very capable of initiating treatment for these severe illnesses with a few lab & radiology tests. And then broadening treatments and testing as needed for those who do not improve.  (However, given the sobering statistics on Wikipedia about Malawi, there must be many who do not make it in for treatments, or who can’t continue with the full treatment, or in whom with such advanced disease that treatments are merely palliative.)

Remodeling

One of the first things we found out here is that the house we will be staying in isn’t ready for us yet. The hospital CEO has been eliciting help from the other physicians and their wives to get the house ready for us. The most wonderful thing they have done is added a bathroom! The house is 3.5 bedrooms and had only 1 full bathroom. Just in the last two weeks they have added a very nice master bathroom.

They also had plans to redo the kitchen counter tops, the living & dining room floors, and the inside paint! They were just waiting to surprise us and have our input on the final choice of colors etc.  Apparently, the house we will be renting is the 4^th house to get some updates and the plan is to slowly continue to update all the houses owned by the hospital! We know they want us to feel at home, and stay in Africa forever! They also say, that keeping up the houses is good for resale value of the homes, so we are glad be involved in the upgrade.

While this is a very nice surprise for us, it also means we are staying in a hotel for a few weeks. The hotel they picked for us is very nice: within walking distance to the hospital still, and we have the use of a pool, access to the internet while in the lobby, and use of the hotel kitchen for cooking. We even got to make a few Skype phone calls home this week! Though, even here, the electricity & internet have been off a couple of times for several hours.

It has also sparked some internal debate about cost. We are trying to walk the (fine?) line between graciously accepting their offer; honoring the desire to put their best foot forward versus remembering that we are here to serve not to be served. So, though I find it moderately distressing, I have been convinced that the hospital is using a small part of their funds to maintain the houses they own, and part of that means a new bathroom and kitchen for us to use!

Since I have been in the hospital most days, Darryl is supervising the remodeling of the house. We hope to get it finished in time for the container with our furniture to arrive. We have learned that it crossed the ocean safely and has landed in South Africa. They say it is headed overland toward Mozambique! 

The Warm Heart of Africa

We left Orlando, Florida around 8pm with our 6 50-pound suitcases. Mental note to never move to another continent with that much luggage again. Jet Blue airlines was very accommodating about the luggage and graciously accepted our letter requesting exemption for extra baggage as we were carrying medical equipment for humanitarian use. We got only a brief 2-hr nap at JFK airport before flying out to Cairo, Egypt. Given the choice of 6, 30, 54, and 78 hr layover in Cairo…we chose to take the latter and a friend insisted we stay with his mother. This was our first encounter with the “warm heart of Africa.” We were treated wonderfully and felt very safe. Our taxi driver was recommended to us by our hostess and he drove us around Cairo for 2 days. Admittedly, we stayed mostly in tourist areas (the Pyramids of Giza, the Egyptian museum, the Citadel, the Cave Church etc) but did spend half a day exploring Heliopolis on foot.

Then an overnight flight south to Blantyre, Malawi where we arrived together with all 6 pieces of our luggage around noon the next day!

We were immediately welcomed to the official “Warm Heart of Africa” as Malawi is known.  Special thanks to all those who welcomed us so warmly in both Blantyre and Malamulo those first few days. We were invited to several “welcome” parties and invited over for dinner to many people’s homes. We indeed felt we had landed in the warm heart of Africa. Special thanks also to our new friends the Haytons, who moved to Malamulo Mission Hospital in September, and met us just off the airplane with all the things we would need for the first few days of living out of suitcases in a new place…bottled water, some snacks, fresh fruits & veggies, dry goods, soap, detergent, and some wonderful homemade bread! Sharlene thought of everything!

Up and Running

Finally got our stress testing going in the cardiology clinic!

Learning to use the echo machine

Some pictures of getting and then learning to use the new echo machine. Special thanks to all the friends and family who donated money and time towards getting it! Especially those at University of Utah, in Loma Linda, at Helme's fundraising party, from the National Auxiliary, and Adventist Health International who donated time & money to make it possible...and those at GE who provided a great price for our humanitarian project!

A first world city inside every third world one

Darryl and I are sitting in our hotel in Orlando, Fl. We spent Christmas with my mom & cousins in Roseburg and Bend, Oregon. Then flew here for some R&R on our way to Africa. As we contemplate the idea of "luxury vacation" our thoughts turn to the socioeconomic divide in Malawi. We are grateful to our parents, who shared their timeshare points with us for this lovely luxury hotel. The kitchen in this hotel suite is nicer than the kitchens in the first three apartments we lived in after we were married! Imagine!! And two TV's... we haven't even had that in our nearly 6 years of married life.

Today while searching the internet for a cell phone in Malawi, I stubbled across a very interesting article by Martin Lucas on this website: http://www.mobileactive.org/one-laptop-child-v-cellphones-view-malawi. He writes an interesting opinion of Malawi as one who is there to help. And he touches on some excellent points. It is a long read...I actually read the whole thing out loud to Darryl while he made lunch...but worth the time. One of the things that stands out is his reference to the "post-globalization dictum" that there is a first world city inside every third world one and a third world city inside every first world one! Darryl and I have been talking about this concept for a while, but didn't realize someone else had put a name to it.

I will be moving to Africa as a physician ... but I don't think it will be like the stories we've heard of mission doctors to Africa from the last century. I will be living in a city. In a normal looking house. Probably on the row of elitist hilltop homes Mr. Lucas references. I will have internet access and a trip back home to the United States every year. And I'll have a computer at work. And one of my goals is to be able to provide care to a city that has both "first world" and "third world" inhabitants in the backdrop of one of the poorest countries in the world.

The need is so great...Malawi is said to have the lowest doctor-to-patient ratio in the world. One physician for every 60,000 Malawians! How do you even begin to care for 60,000 people as a single person? Blantyre, where we will be living, has over 700,000 people and I will be the only cardiologist. There must be a balance between seeing the middle & upper class who have health insurance or pay cash; and seeing the very poor who cannot afford even the free health care provided at Queen Elizabeth Hospital because of time and travel costs to get there.

Food for thought, a Gedanken experiment if you will, for those following along...think about which parts of your own current city of residence are "third world" versus "first world." As I think of the two places we lived most recently,  Salt Lake City, Utah and the Inland Empire, California, I think there are definitely parts that qualify as third world. I hope as the US pulls out of the recent economic downturn, those places are addressed.

Tiffany

R & R

Pictures from our rest & relaxation time before moving to Malawi. We spent time with family in Roseburg & Bend, Oregon and Orlando, Florida and Freeport Bahamas.