Hales in Africa

It was only when I landed in London that I realized what it was I love about Malawi.

The scene greeting us at Heathrow airport was almost funereal:  a sombre, tired, shuffling mass of neutral blacks and navies, mortician grey walls and floors and…everything.  No relief, no splash of colour, no flashing smiles, no music, no raucous laughter, no one breaking out in song (no kidding), no signs of  joy.  All sophisticated quiet decorum and all so “bloody boring”! 

Contrast this with Malawi:  The signs of life everywhere you look.  Pulsing, bounding, pounding, racing.  Moving, living waves of humanity, music, laughter, colour, energy.  Even the vegetation grows with enthusiasm adding colour and life to every scene.   It seems so ironic that in a country like Malawi, where death visits so often, that “life” seems so much more prevalent.

In our movement toward progress and modernity and our quest for order it seems we have lost so much.  And this is not unimportant.  I am sure of it. Colour and music and laughter and singing make us happy – everyone knows that.  So why have we abandoned them??  To investigate thisfurther, I tested the acoustics in the in the 6 minute tunnel from the airport to the hotel (singing “I’ll Fly Away” which seemed appropriate on many levels).  I discovered that 1) yep, it felt great! and 2) I quickly lost my nerve and started feeling slightly ridiculous when I saw travellers approaching because… well… it just isn’t done – I was afraid I’d be carted away.  How sad.  Observation #2 was the was the reaction both Josee and I had taking our first breath of fresh air in about 24 hrs – a small bit of elation at feeling the air and sun, even for a few moments,  even though there was almost no nature in sight, only ugly grey overpasses and freeways, construction sites, ever more ugliness….  Still, even a hint of something real and alive (air and sun) felt great!  So far, pretty subjective, unquantifiable research, I know.  But the final clincher was when I emerged from the official, business (customs, passport, security) section of the airport and into the commercial section – and there, the evidence:  music, colour, light (though still subdued by Malawian standards and still nothing green or actually alive))   Now this is probably Level one evidence of the connection between atmosphere and mood because industry marketers are always way ahead of the science community when it comes to the psychology of consumer happiness.  I am sure that marketers have done randomized, double-blind control trials on this and have proven that light and music and colour do boost sales by making people feel happier.  Still, the people didn’t look any different – all the consumption really wasn’t making them any happier perhaps, but at least there was something, the marketers were trying.

In Malawi, I noticed in myself a definite almost hypomanic happiness and noticeable decrease in stress levels.  Part of this was the stimulation of a new environment, new, challenging and interesting work,  but it was very definitely also related to the more openly visible happiness I would see around me, the women bursting into song on the bus, the kids, the smiles,  the music.  Like almost everything in Malawi, this spirit is contagious.  Mental health workers take note.  Perhaps we need to start wearing more colourful clothes, bringing in more plants and playing more upbeat music in the waiting room. 

The thing I can’t reproduce at home or at the office is the society-wide scale of the phenomenon or the beautiful, organic way it all comes together in a place like Malawi. Not contrived or clean edged or ordered but an organic flow, careless and beautiful in its lack of rigidity and precision, in a way even a brightly designed interior would never be and, for me, there is something very relaxing in that.

At home we need to maintain an image of clean clinical precision and order which is tense and serious.  There is constant pressure and an expectation for perfection (a good thing, of course, in the medical field) but it comes with a price.  Stress is literally killing us but we accept it anyway in exchange for certainty, predictability and control. 

Perhaps there is no way to escape the burden of stress / anxiety / depression – either we stress out with too much control or we get depressed from the result of not enough, like in Malawi where sometimes, lack of attention to detail can result in tragedy.

But for me, there is no doubt my stress levels plummet every time I work overseas.  Despite working long hours with many challenges, the other aspects of life in the developing world tip the balance in favour of Malawi for my own mental health.

Heading into the last miles of my journey I am reminded of something called the “Last Mile Problem” which I referred to in an earlier blog:  The problem of how to transfer knowledge and technology from the developers (often in the north) to the end users, (often in the south.)

Getting “Best Practice X” to the farthest reaches of the most remote countries doesn’t seem unsolvable but it has defied global health workers for as long as they have been doing global health work.  Despite the tremendous advances of the last century in reducing morbidity and mortality on almost all fronts, many people in the world still lack access to turn of the (last) century technology.

On the surface it appears to be an infrastructure / distribution problem.  Even the term, “The last mile”, suggests this.  But large multinationals like Coca Cola have proven that even the most remote village can be accessed with enough money and profit motive.  Those hurdles are not insurmountable.  Granted, multinationals are experts at marketing and distribution (something the health field might learn from) but it goes beyond that.  Coke tastes good.  Coke satisfies a tropical thirst immediately and almost universally without the need for anyone to educate you on when and where, how and why you should drink a Coke. 

The biggest problem with distributing health information and technology is not developing the technology to begin with or even getting the product to the people who need it.  It is trying to figure out how to get people to actually accept the technology and use it.

This is now being referred to as “Behaviour Change Communication” (BCC) which has replaced the previous term “Information and Education Counselling” (IEC) reflecting the new understanding that simply giving accurate information is not enough.  Sharing information is only one small step towards actually inspiring change, even more so when working across cultures.

In order for people to accept  a recommendation, they first have to believe that what you are telling them is true and then they actually have to be motivated enough to do it.

When you think about it, there are all kinds of reasons why an uneducated Malawian villager would decide not to believe us.   For starters, what we tell them often makes no sense in their worldview.  Giving children with diarrhea more fluid doesn’t make sense if your primary frame of references is a leaky bucket – to keep pouring water into a bucket that is pouring it out a hole in the bottom makes little sense. When you and everyone else around you believe that the cause of your child’s illness is a curse from the witchdoctor then the only logical place to go for help is another witchdoctor.  It is quite a stretch to convince someone of the existence of microorganisms causing disease for someone with no formal education, since microorganisms, for anyone without a microscope requires no less of a leap of faith than a belief in witchcraft.  Unfortunately people are often receiving competing messages from more credible and convincing local leaders and, really, who would you believe?  Your trusted local church leader who you have known for many years and has helped your family in times of trouble, or some foreign or foreign-trained government agent from away who might have some ulterior motive?

Our “product” is also often not very attractively packaged and delivered:  painful injections that make the children cry or bad tasting medicines that have side effects that make you feel as bad as the illness itself, lots of complicated instructions about how exactly to use the product.  Accessing the services often requires long walks or expensive transport, meaning a day away from work on the farm.  Busy, over-worked, underpaid health workers sometimes provide a cold, rough, user-unfriendly service making the experience at a health facility unpleasant.  Since people often die in hospitals there is a fear of them as well as some of the technologies used (many people believe that oxygen causes death as it is so often used in moribund patients that now many parents or guardians will refuse oxygen treatment). In so many cases, there is no immediate, tangible benefit or gratification.

So how do we avoid these pitfalls?  The move towards increased use of local village health workers attempts to address many of these problems.  Medical anthropologists might hold some of the secrets to understanding resistance to ideas in different cultures.  Increased basic education, of course, would go a long way.

But what about changing a behaviour once people actually believe what you are telling them is true?  From our own culture, we know that this, too, is rarely easy.  It is hard to get people to quit smoking or lose weight even though there is almost no one who would argue that they don’t know these things to be unhealthy.

Experts in behaviour change have identified a number of important factors in motivating change or encouraging cooperation.  First of all, a person needs to feel a sense of autonomy about the decision – no one likes ideas forced on them.  There has to be some more immediate, tangible benefit to compliance – increased relatedness (inclusion in a group of or lack of exclusion from a given group of peers), there has to be a perception that the program is fair, there has to be a level of certainty that the intervention is actually going to succeed and finally, it helps if somehow, there can be a perceived increase in status or power from making the change.

So there is some promise in this work, many avenues we have not yet fully explored.  More education is happening, more village health workers are being employed, some people are starting to look at more creative, appropriate ways of introducing new ideas, health workers are talking to community leaders and trying to get them on side.  But we can still do much more research and use the evidence as we do in other fields of medicine so the “best practices” for disseminating best practices can be shared.  Unfortunately, all of this takes money and lots of it.  To achieve health for all, we have to go beyond the hard science research and put more emphasis on the social research so we can achieve excellence in actual outcomes consistent with the belief that every human has a right to health care.  Just because the model we are using for distributing health care at the moment is not always working is no reason to write-off entire populations as non-compliant or uncooperative.  If they are not complying then we have not done our job of adequately educating them and their communities about the benefits.   I don’t believe that there is a mother out there anywhere who would not want her baby to be properly treated for cholera to save his life, if that mother truly understood what we were trying to do and why.

This morning I resuscitated a baby while visiting the hospital where I used to work.  I was going around to greet all my old colleagues.  There were no staff in the labour ward so I sat down to wait (something I am getting very good at) and then a student nurse walked in carrying a limp baby from the theatre, fresh from a Caesarian section.  She put the baby down and was looking around to try to hook up the oxygen but the baby was apneic and the pulse was faint.  Remembering a similar incident about four years earlier which has haunted me ever since, I didn’t hesitate before giving the student the bag and mask and told her to just start ventilating the baby which she did, expertly.  She had obviously done this before.  The heart responded nicely and the baby started making efforts to breathe on his own but his tone was still poor.  After a short while we stopped ventilating but then the heart rate and breathing slowed again.  The student didn’t seem to notice or care and I looked at the neonatal resuscitation protocol I had posted beside the improvised resuscitator years ago and realized it didn’t really say what to do after you get the breathing and heart going again.  She was unhurriedly removing the wet wrappings and again trying to get oxygen and suction going.  So we walked through the resuscitation, talking about the importance of vigilance and constant observation until it is certain the baby is out of danger, the importance of keeping baby warm, about how room oxygen and suction are no longer routinely recommended and certainly not as important as adequate ventilations.  I spent about an hour there with baby and student, baby’s tone and colour gradually improving, and eventually, to our delight, starting to cry although I would not call him vigorous.  I left town a few hours later having done a little less visiting than I had planned so I don’t know if the baby was OK, if the nurse stayed to watch him as I had asked her to do.  I don’t know if she had that luxury of time to devote to one precarious little life.  I feel relatively optimistic that he will survive, at least his neonatal period, unless there was some other underlying problem but I am also fairly certain that, had I not been there, the resuscitation would have ceased after the first efforts at ventilation and the baby would have died, recorded as yet another of the many, many neonatal deaths “due to birth asphyxia”.

This incident left me curiously deflated.  I  know I should have been glad, even elated to have a had a chance to save a life that day.  “What a wonderful profession and how wonderful that you would come here to Malawi to share your skills and knowledge with those in need!” I can hear everyone saying at home.  All I can think is, “Yes, but what about the next student nurse who is left to conduct a resuscitation without supervision on the next flat baby and why is this topic being ignored?”  During my last time here (2007-2009) I did trainings and did many real life demonstrations of how successful resuscitations can be done and it seemed, at the time that at least some of the staff was responding.  But even then, it was clear that inspiring behaviour change involves far more than simply sharing new information.  To someone in Canada it seems so simple:  they don’t know about how to do neonatal resuscitation, you come here and show them how to do it and then they do it.  After working in global health for many years now, I know it is never that simple.

People working in the field of international development have struggled with this issue for as long as the field has existed.   We have the knowledge and often even the materials to do “Best Practice X” and when we do it at home it works for us and our morbidity and mortality numbers reflect this.  Why on earth, after all this time, are there still babies dying due to lack of something as simple as bag mask ventilation???  It is not that programs can’t work or people here can’t learn.  There are many excellent programs that are run well by bright, capable Malawians but these tend to be the programs that are heavily funded – a lot of money and staff time goes into training, implementing, monitoring and evaluating successful programs like those for TB and HIV.   PMTCT is another program that is being scaled up across the country with good results.  What happens when some programs get the attention and time of the workers, is that others necessarily suffer.  So it is, it seems, with neonatal resuscitation.  Although there are programs here promoting neonatal survival, they ‘re just not yet reaching a critical mass of personnel to establish the concepts as the accepted norm.

So what is a keen and committed doctor like me to do?  Certainly, I have long ago discarded the naive expectations about coming here short term and hoping to make huge sweeping, sustainable changes.  Yet still, I come back.  Why not just give up?  In Malawi, at least, I see glimmers of hope often enough to sustain me and my passion for this work.  Armed with my Serenity Prayer, I start every new task, new project, new day with a knowledge  that often I am only planting seeds whose fruit I may never see but also with a belief that others will follow me, fertilize and water the seeds of a good idea and one day, as I have seen with so many projects, the fruit will come.

IN the short term, I need to cherish the fact of saving even one small life and try not to despair that I cannot save them all.  But for me, one life at a time is not enough.  I find myself going  through an evolution to what I consider a higher calling in global health.  From pre-medical global wanderer and student of the people of the world, to bright-eyed and eager medical student researcher, to fully fledged medical doctor in the trenches, to capacity builder, working with teams of clinical officers in hospitals.  I now find myself setting my sights even higher – on working to treat not individuals, one by one by one but by looking to working with national programs working with big international organizations with deep pockets who can help me.  People who believe that a national scale up of Saving Newborn Lives Program, for example, is worthwhile.  I don’t know if or when this newly hatched dream will be realized, I just know I want to do more.  My time here has been too short and I feel I am leaving many things undone but practice at home awaits so I will take some more time to  process all that this experience has inspired and wait to see what comes next in my global health career.

See also the previous post describing my experience of four years ago – “Babies”

Monday at Likuni Hospital is the busiest day for the antenatal clinic.  Before we even arrive, there are almost 200 women crowded on benches, sitting on the floor between benches and spilling out the doors of a fairly small room, preparing to spend the better part of the day here.  The clinic follows  the standard format of others in Malawi, starting with group health education talks on breast feeding, , nutrition and preventing mother to child transmission (PMTCT) of HIV among others. Then women get basic bloodwork (haemoglobin, syphilis and blood type), blood pressure, weight , vaccinations if needed and are referred over to the HIV testing building for counselling, done in groups of about 15, then testing and  then back to the antenatal clinic for “palpation”, final assessment and collection of their malaria prophylaxis, folate and iron pills.

With my “PMTCT advisor” hat on, I accompanied a group of women through this process, specifically focusing on the women who tested HIV positive..  My first impression was that, compared to even two years ago when I was here last, many, many things have changed for the better.  One of the biggest hurdles in the past was even getting women to accept being tested, now they are at almost 100%.  Another big problem was that even if women were tested, there was so much concern about stigma and protecting patient confidentiality,  that the results of the test were often buried somewhere deep in their health passports (personal medical records that all patients carry with them) and often recorded in some kind of code , making it very difficult for a health worker looking at the passport to know the result.  The problem is that the patients, even those who are illiterate, all figured out the “codes” as quickly as health care workers could develop them and so I was delighted to see the new health passports redesigned with a specific place to record HIV test results.

Women who test positive are immediately sent for CD4 counts, which can be done on site (though you can’t even do a basic test like creatinine or electrolytes!) and then referred for more post-test counselling and support from the “Mothers to Mothers” counsellors.  These are a group of women living positively and specifically trained to help other mothers who are dealing with HIV in pregnancy.  Depending on their CD4 counts, clinical stage of their HIV and gestational age, the women are then either referred for counselling on starting  antiretroviral (ARVs) treatment or prophylaxis or simply given doses of specific ARVs to be taken at the start of labour.

PMTCT is an exciting area which finally seems to be getting the attention it deserves.  Part of the reason I accepted this position was because of my strong belief that PMTCT is an area where we can really make a difference.  Prevention is so much better than having to deal with the depressing prospect of lifelong treatment (or early death) of children who are infected.  With no attempts at trying to prevent transmission, 20-50% of babies of HIV positive mothers will be infected by the time they finish breastfeeding.  By comparison, with all of the very best care, as in developed countries, the rate plummets to as low as <1%.  In countries like Malawi, there are many challenges, but also many stories of success where, even if the mothers breastfeed, which most have to do because there is no safe, sustainable, affordable, feasible option, some fairly simple interventions can reduce rates of transmission dramatically.  Although recommendations have been changing since the introduction of PMTCT programs in about 2000, when single dose Nevirapine given to Mother at the start of labour was found to cut transmission by about half, the general focus now is to get women on some form of antiretroviral  treatment with at least two but preferably three drugs, starting as early as 14 weeks gestation and continuing through to the end of breastfeeding. Unfortunately, this is expensive and complicated but most sites in Malawi and other countries are now able to offer ARV services and so extending the program to pregnant mothers appears feasible.  Malawi still has plans to implement an enhanced PMTCT strategy (ARVs for life for all infected, pregnant women) later this year but it is not clear where the finding will come from.

Infant feeding recommendations have also been shifting from the initial intuitive assumption that infected women shouldn’t breast feed at all (because they  can pass on the virus through breast milk) to the current belief based on evidence that shows that, for most women in low income countries, the benefits of breast feeding (less malnutrition, diarrhea and other infections) still outweigh the risks, especially if the mother is on ARVs with a low viral load and so the WHO is now approving breastfeeding up until 12 months and Malawi has made the recommendation to continue until 18 mo or until a safe, alternative is available.

Through group sessions, meetings, one-on-one interviews, observation and local research, I have been compiling enough information to provide the staff at the hospital with a look in the mirror to see how their PMTCT program is doing compared to previous years, other hospitals and the country as a whole,  In response to requests from the staff I have done several training sessions and shared, at the same time, a new approach to adult education which can be fun and interactive.

This work is challenging, interesting and very rewarding. My colleagues here were already utilizing many of the recommended strategies to help prevent transmission.  The country as a whole has scaled up its program in the past five years from almost no PMTCT programmes in place to 2010 when 58% of women and 41% of babies were given some form of PMTCT treatment.  Through a cooperative problem solving approach, my colleagues and I are aiming to get that number as close to 100% as possible. Every time we implement one more PMTCT strategy, we know it could make the difference for an unborn baby – whether they become infected or not.  To me, that is time well spent.

“This is the beauty of the child spirit.  It is one of the purest and most powerful forces for peace and happiness and this is why it must be protected and nurtured.” *

After  a heavy rain during the rainy season the creeks and rivers run heavy and red with dirt and the ditches overflow across the roads and the world is one big mud bath until, miraculaously, an hour later, all the water is gone, absorbed by the thirsty earth.  During the aftermath of these rainstorms I notice many kids along my minibus route to and from work all shovelling dirt out of the ditches to keep them flowing.  One day I even saw a boy, maybe about 10 or 11 years old with an above knee amputation, manoeuvering around (with an ingenious  crutch which also had a carefully placed loop in the design of the shaft that doubled as a  prosthetic where he could insert his stump) who was gamely joining in.  My first impulsive thought was, “Oh those poor kids, having to work at such a young age, no exceptions even those with disabilities, what a tough life, blah, blah, blah” until I asked the nurse I was riding with and she said, “Oh no, they are just playing.”  And when I looked again with new eyes, I realized, of course, she was right.  Playing as kids do anywhere, like our kids play in the sand box or in the inanely fabricated “lazy river” feature at new swimming pools… same thing, different look.  What kid could resist all that flowing water and mud and the chance to move it around with shovels?  “My kids would love it too,” I thought. 

And I also thought how easy it is to be influenced in what we see by what we expect to see.  How hard it is to keep our eyes open and really understand what we are seeing in such a short time.  Warned of the misery and hardship and suffering we see misery and hardship and suffering.  Informed by an exaggerating media that “a generation has been wiped out from HIV/AIDS” we enter a village and see only children and grannies, confirming our preformed idea, only to later realize that all of the “missing” people of working age generation are out in the fields, working. 

It has been a long time since I first encountered the beautiful spirit of the African children who I had previously know only from sad pictures of pot bellied, malnourished World Vision posters.  That spirit remains despite the statistics and stories we hear in the west.  It really seems to be an uncrushable force and I am grateful for it because it gives me hope and strength to keep on going too.

“Shap-bo-o little brothers and sisters!”

See also “The Beauty of the CHild Spirit” – (Part 1)

Life immersed in a new culture always makes you think a lot.  You have to think about almost everything, it seems with a new light, in your new context. 

Even something as simple as tipping a waiter becomes a heated, ethical discussion.  At home there is a standard formula which almost everyone adheres to – 10-15% to the waiter, more or less depending on the service and any of us who have served in restaurants knows that this is an important part of the server’s wage so it is not up for debate.

After dinner almost every night here, we have the awkward discussion about whether or not to leave a tip and if so, how much?  Tipping is not the custom in Malawi.  It is not expected by the waiting staff.    The advice we were given was vague but suggested that tipping was not necessary.  Not necessary but, surely, the staff would appreciate a couple of dollars which to us is nothing?  “Surely in a country as poor as Malawi we should be giving and sharing as much as we can?” comes the argument from one half the table.  In our money and material focused culture, it is considered by most as an absolute – giving is good and kind and almost everyone is happy to receive money or material things.  No questions, no debates. The drivers of our consumer culture like to fuel this as well, encouraging us to buy, buy, buy and soothing our consciences about over consumption for ourselves by also encouraging us to buy for others. 

But as guests in another culture, the question becomes more complex.  Rule number one in cross-cultural adaptation is, “Do as your hosts do” even if it is not immediately apparent why they are doing it.  So if the custom in Malawi is to not tip, who are we to come in and start changing the rules to suit ourselves and do what is most comfortable for us?  Why should we introduce our own customs and values when we don’t understand what implications it might have?  Though I don’t yet understand the whole tipping issue yet,  we had a disturbing experience one night where, after leaving a modest tip (500 MK which is about $3, five times the average daily wage) for the waiter on the table, the owner immediately swooped in and took the tip.  Noticing this, we asked the waiter about it and he said shyly, “Oh, no, we don’t get the tips”.  After a brief discussion, we decided to ask the owner about it and awkwardly (for both of us) he tried to explain the system which sounded vaguely like he pools it all and then splits it up but it wasn’t clear how much of the split goes to the owner and how much to the servers.  Maybe we just helped the rich get a little bit richer?  So one thought was, “well next time we will give it directly to the waiter” but again, what implications might that have?? We just don’t know  and our own hosts and local counterparts aren’t always able to explain either (just as we can’t always explain why we do things in our own culture – we often just do because that’s the way things are done.)

And  what about giving to beggars on the street?  Giving out candies or pencils or Canadian pennies or pins to the children as you walk through a village? What about “Shoeboxes” of stuff sent to children in remote villages around the world at Christmas time?  Container loads full of stuff that we no longer want shipped thousands of miles to be donated to orphans or schools?  We love our “stuff” and have been heavily conditioned to want ever increasing amounts of it, convinced that more stuff will make us happier so we assume that surely other people want it too.  And perhaps they do.  There is no questioning the delight on a child’s face when you give him a toy or a candy.  Generations of visitng “mzungus” giving out candies and pens in villages has had the effect on communities that now every white face is greeted, not with the traditional greetings but with the few English words that most kids know:  “Give me money” or “give me sweets”.    Not only is this rather awkward and unpleasant for visitors, it is disturbing to try to think about what this reflects about the mindset that is being cultivated.  The fear of encouraging dependence on handouts is a very real one in a country like Malawi, a “donor darling”, where 60% of the GDP comes from foreign aid.  The Malawian government is clear on their position:  they are about to pass a law penalizing people who give money to children on the street.  Their rationale is that these children should be in school but they and their parents know that they can make much more money by begging and so their parents will send them out to beg.  But for that child’s future, for their sense of self-worth and their dignity, I think the government is right.  It is hard to imagine that perpetually being on the receiving end of foreigner largesse could be in any way empowering or anything but psychologically damaging.

Giving into a context we don’t understand often has other implications.  A container load of donated clothes flooding the market in a small village from a beneficent donor in the north will put the local clothes sellers out of business for months.

 Refusing to haggle for prices at the market may drive up prices so that locals can no longer afford to purchase there or at least in times of scarcity, sellers will only sell to the rich since they will be able to get a better price.  Every time a foreigner pays ten times the price for something, not only do they think mzungus are stupid and vulnerable, it sends a very loud message – we have so much, we don’t even care about paying way too much and I wonder what this does to the psyche of the people.  The grandiosity with which we sometimes come in and buy everything in sight regardless of the price can make us feel big but does it make the others feel small?  Resentful?  Angry? Insulted? Inferior?

In a culture that encourages strong family ties, it is sometimes expected, accepted and understood that the family members of the Shoebox or FosterParent plan program coordinator, already one of the better off in the village, whose children will see most of the benefits, further increasing the disparity.

 Distributing medical supplies or medications that are unfamiliar to local practitioners can result in them being either inappropriately (perhaps dangerously) used or, more likely just dumped or burned (with all of the environmental consequences) or left to fill storerooms for years to come.

 Distributing vast quantities of food (usually surplus dumped from our own stores in years of excess and generally self-serving to preserve our own farmers and also look good in the eyes of the world as this dumping counts towards our annual aid budget) undermines local producers and can sometimes, like with rice farmers in Haiti, wipe the industry out completely, making them dependent forever.  Distributing donations is complicated by difficulties in ensuring fairness and preventing the strong and aggressive from taking more than their fair share and leaving the weak and hungry, even weaker and hungrier because they weren’t able to get to the front of the line.  In Haiti after the earthquake, clever Haitians set up extra “ghost tents” in the tent cities so that when donors came by with supplies and counted the tents, they would get more. 

People everywhere are resourceful, creative and determined to survive.  The question for donors is how to harness and use this creativity and drive and energy in a way that is less focused on simply getting the most possible out of donors and more focused on finding a way to true independence and self-reliance?  Again, these concepts are perhaps based on my own beliefs of what is good and important or perhaps it would just sit better on my conscience if there were no places in the world so poor that they needed aid.

Our own society’s dependence on material things to make us happy, our love affair with consumerism is not exactly the best part of our culture, not the part that I feel we should be exporting.  Indeed with globalization, and the power of advertising and business, these things will come with time and perhaps we can’t (or shouldn’t) necessarily stop it.  People here also have a right to enjoy the things they choose to enjoy, but personalIy, I  think I will choose other ways to share.  “Donating” (aka –dumping) our cast offs ( garbage) to developing countries probably does little good for the people here and should do little to soothe our consumer consciences.

So what, then, is a well-meaning foreigner to do?  What to do with all of this stuff that people gave you to bring?  How to share and give without running into these problems? 

My fall back position has always been that I am here giving of myself, my time, my knowledge and my spirit and that, in the long run, is more helpful.  Working to “teach a man to fish” as they say, so he can eat for a lifetime.

I think we can give something too, by showing some solidarity with the people who we want to “help”, by demonstrating through our actions that we do believe they are “creative, resourceful and whole” as one of my colleagues here says.  We can work side by side with our colleagues and support the existing systems and the people who sustain them rather than showering (often inappropriate) gifts from above without actually connecting or rubbing shoulders with the people to learn more about their plans and dreams and ideas.  We can demonstrate through our actions our respect for the people, their culture and our faith in their ability to do it for themselves.

If you have to get rid of that stuff that people gave you to bring, consider giving it to a local colleague for them to distribute to avoid perpetuating the idea that white people always just bring stuff.  Consider refusing to bring inappropriate stuff and use it as an opportunity to explain why.

Even if you are here for a short time, learn about or become involved in a project that you can feel confident in, that you believe in, that is well run by local people so you can allow yourself to politely but confidently say “I’m sorry” to the people on the street.

For people back home, the same principles apply – find an organization doing work you believe in and support them, advocate for social justice, buy fair trade.

Having been unable to articulate these arguments well enough at the dinner table to convince my colleagues on the tipping issue, I will send this to them now and perhaps tonight, we will decide not to leave a tip.  Then again, habits are hard to change and even I find it hard not to feel chintzy and cold hearted in the face of someone who I know has so much less than I do.  So maybe we will just leave a smaller tip….

Having lived in Malawi not so long ago, returning now feels like coming back to the familiar, warm embrace of a long lost friend.  I find myself smiling at little things as I am reminded of all that I love about this country, these people.
When I try to see the country through the eyes of someone new, someone less smitten with the spirit of the place, I see what they see: the noise, the fumes, the chaos, the sometimes unpleasant smells, the crumbling infrastructure and the often heart breaking  signs of poverty.  But what I see is different.  Through practice or exposure or maybe just determination to “love the one I’m with”, I realize that I have developed filters to interpret what I see.  I see beauty everywhere here – in the striking features of the Malawian women, colourfully done up in traditional dress and the glistening beauty of shirtless Malaiwan labourers, fit and strong from a lifetime of work.  The explosion of colour from the food markets against a background of lush maize fields washed brillliant green by the rains.  I see the confident swagger of young Malawian men, proud to be earning their living in whatever way they can or the quiet poise of the women who seem to move calmly along despite carrying unimaginable burdens on their heads and probably in their hearts.  I love the big Malawian smiles, the hearty laughter and joking, the endearing typically Malawian gestures, the surprised and delighted amusement on the faces of my patients when I pull out my rusty Chichewa.  I love the friendly calls of “Mzungu, mzungu” from the ever-present, ever laughing children and the attention that somehow always makes me feel like a bit of a rock star. 

Every school child I see gives me a surge of hope for a better future for each of them, education being the key to development, especially for the girls who will find in school the way to escape the dangers that threaten them now – death from childbirth or AIDS or a life of desperation and dependency with no options, no choices. 
I awake every morning to an incredible dawn chorus heralded by the haunting Muslim call to prayer accompanied by the night time crickets, punctuated by the calls of roosters and barking dogs then the exotic and beautiful birdsong eventually swallowed by a crescendo of sounds of the city waking. 

Our work day starts with the beautiful harmonies of the staff at the hospital singing hymns, a moving soundtrack to the dramas unfolding inside the hospital walls.  In our hospital, I see not only how different it is to what we have at home but how much things have changed for the better, even in two years.  Best practices that I struggled to introduce have now become policy; new, better treatments are available for some conditions and plans and ideas I only wished for are now being realized.
 
I have revived the ability to deal with the unpredictability of life here which would otherwise lead to frustration and resentment.  I have quickly fallen back into the rhythm of life here which is more of a flow than a pace, and one which can be soothing and relaxing if allowed to be.  I marvel at the facility with which I am able to shift cultures now and accept this beautiful chaotic country for what it is.  I wonder if, like the Malawian people around me, these coping mechanisms are what allow us to endure, what allows the Malawian people to also see the beauty in their lives despite what seems to us like unimaginable hardship and misery. 

Finding the balance between accepting and ignoring imperfection and striving for always something better is a challenge.  I will have to be mindful of the risk of succumbing to the somewhat fatalistic accepting attitude, (“Zimachitika” (“stuff happens”) which can prevent us from always working towards something better but I am still a mzungu at heart and so I am certain, in my work, that I will be able to do this. There is always much work to do.
 
A toast to my Malawian brothers and sisters – with a glass always more than half full:  “Zikomo kwambiri (thank you very much) for welcoming me back with your big hearts and big smiles – ndimakonda (I love) Malawi!”