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ART Clinic Client
"The world breaks everyone and afterward many are strong at the broken places"
Ernest Hemingway
It's the children I will remember, more than anything else. The 100 or so children, waiting with guardians on a Saturday morning, for a prescription re-fill of anti-retrovirals. They don't look sick, but debilitating side effects and opportunistic infections lie in wait. Prevention is the key. Then there are the little premies, discharged at 3 lbs., to life in a rural village. How will their busy mothers manage? And, Stelia and Innocent, two of the long stay children with tuberculosis who are biding their time. What will their future be like? Then there is the image of the mother running her convulsing child into the paeds ward; an image that remains vivid in my mind. Now I understand that without a quick I.V. line start, an anti-convulsant, a blood transfusion, a push anti-biotic and perhaps oxygen, this child might not make it. The malaria parasite works fast and is ruthless.
When you hear about the importance of mosquito nets, and replacement mosquito nets, it takes on a whole new meaning after spending time in Malawi in rainy, Malaria season.
The paeds ward at St. Gabriel's has bright blue mosquito nets that are only a year old. I wonder what the exposure in the open windowed ward used to be like.
The new nets are a godsend to the patients here!
The following is a a listing of random thoughts about my volunteer nursing experience, since returning home:
1. Since most volunteers are either med students or doctors who work alongside clinical officers or M.D.'s, nurses must determine how they would like to participate. There is no orientation. There are no personnel available or time to explain how things work. You must be a confident self-starter, flexible, open minded, and willing to take on a variety of tasks. Would I recommend a rotation at St. Gabriel's? Absolutely.
2. Communication: Although hospital staff communicate in English, it is usually heavily accented English and difficult to understand. They may also lapse into Chichewan with each other, and usually with patients. It is necessary to ask for clarification often. Obviously, an ability to speak Chichewan is an enormous advantage to working in Malawi.
3. Guardians do virtually all aspects of nursing care. This can be difficult for a Canadian nurse who views holistic care in terms of physical, social, psychological, emotional and spiritual care. Orem's "self-care model" (with guardian assistance) is the order of the day. Malawian nurses take on the roles of technician, data collectors and record keepers. Due to the sheer number of patients they are responsible for, their roles are limited. When a young patient was dying of uremia and renal failure, there was no attempt by the nurse to comfort her, speak to her, touch her, or even make her more comfortable. That was left to the guardian. I found this to be difficult.
4. Cultural differences: It is not uncommon for Malawians to first seek help from a traditional healer. When treatments are not successful, they may present at hospital with tattoos - small cuts in the arms or face. Patients may have become much sicker, having waited too long for treatment of an infection, obstruction or harmful tumour.
Parents of sick children often mistakenly view oxygen as a killer. Since oxygen is usually prescribed when a child is critically ill and may not survive, parents confuse the prescriptive elements with causative elements and will refuse oxygen for their child. This is a harmful myth that continues to be problematic.
5. About 80% of Malawians are Christian, 13% Muslim, and the rest from a variety of religions. I heard many people speak of their belief that God or Jesus would take care of their problems. I also heard people speak of the gratefulness they should espouse for the positive things in life, rather than dwell on negativity. Malawians are people of great faith. They are people who must deal with the complexities of sickness, death and dying on a daily basis. They seem to rely on their faith when things crack and crumble around them, and attend long weekend church services.
They are also quick to joke and smile and laugh and enjoy their lives when things are going well. I'm told by housemates that Malawian men also enjoy imbibing in a potent liquor on weekend nights (women are not allowed in bars). It's a time for letting down and forgetting.
6. St. Gabriel's hosts inservice weekly educational sessions for doctors (not nurses). As a volunteer, I was invited to attend the sessions, (diagnosing Malaria by blood smears, treatment for discordant couples with HIV, and setting fractures). Nurses (who are tied to their units) apparently have no on-going educational opportunities. They meet once a year with Matron. The nurses I have worked with are knowledgable about the diseases and treatments of their patients. They have been well trained but are limited as to advancing scope of practice and contributing to professional development.
7. Procedures done by nurses are done quickly, sometimes without concern for patient comfort or side effects. Undiluted antibiotic push drugs cause almost immediate wretching/vomiting and the guardians must quickly offer the ever present multi-purpose chitenji cloth as a receptacle, as no k-basins are available. Nurses are non-plussed. A visiting paeds doctor tells me that ward nurses do not emote empathy. "I just wish they would show they care a little bit more", she says. I wonder if the detachment is due to excessive patient load, or due to the frequent losses they experience. Canadian Nurse recently profiled a study on International Nursing Shock. Major cultural differences that were identified were: the place of women in society, the role of nursing in health care, and the value of life. I have dealt with all three.
8. Since returning home, I have received one email from St. Gabriel's that has brought me a wonderful sense of satisfaction - "I learned alot from you and this has made me to be more determined, focused and working hard in everything I do". I have also received an email from a reader who asked what she can do to help Malawians.
My suggestion: explore humanitarian groups with a good track record. My bias is that community based project development is the best way to assist many. I favour World Vision but know there are other smaller individual organizations that raise awareness and perform miracles. Just assume that communicable disease and threats to good health in subSaharan Africa will always be problematic until poverty is aleviated, and that helping one person or one group is better than doing nothing. Also, become an advocate. Keep Canada on track by checking on adherence to millenium goals re maternal/child healthcare. Don't wait for others, be the one to ask for change.
This is the quotation I left on the bulletin board in the nursing station, for the medical nursing staff in support of their strong efforts:
"We ourselves feel that what we are doing is just a drop in the ocean. But the ocean would be less because of that missing drop."
Mother Teresa