Death and Magic, in a modern-day Malawi

This week after holding a patient’s airway open in our High Dependency Unit, as blood poured intermittently in pools from his open mouth, whilst interns frantically chased for a more definitive piece of equipment, I walked despondently over to a young man, profoundly emaciated, with heavily jaundiced, sad eyes. He was lying stiffly in a bed, a large growth obscuring the whole of his left cheek, his oxygen nasal cannulae trailing across his mouth. Noticing this, I tried to move it back into place as he looked directly in to my eyes. ‘Make you feel better’, I said, struggling to get the tubing to lie comfortably on his face.

‘I don’t feel very well’, was all he said in reply. ‘I know,’ I responded, knowing he probably understood little of what I could say, ‘I know’, and tried to give his hand a comforting squeeze. He was alone, just like the patient I was tending to before, surrounded by bustle and noise, in a dark, densely packed ward. He died later that night from metastatic cancer. He was 25.

The next morning, as I walked through the bay on my ward round, I was quietly devastated, to find a newly wiped down bed of one of my other patients. An 18-year-old-boy. His grey mattress still had scattered on it, a blue dog-eared health passport, and some paper notes. Recently admitted with overwhelming meningitis, on a background of newly diagnosed HIV, and likely an expanding brain mass, with no fast imaging available, only certain antibiotics, and very few other options than what he was already being given, he had died overnight, the very same evening I had begged for a bed in HDU, to no avail, as everyone there was ‘much sicker’ than he was.

I can still remember his red patterned shirt, the smoke-stained jacket he wore, the grey, windy, cold afternoon he was getting so much better, and we collectively thought about discharging him soon, and then how he suddenly started to get so much worse, his pupils beginning to dilate and his wavering voice disappearing in a haze of soaring confusion. I can still remember his two teenage friends lovingly spoon-feeding him, changing him, and his concerned bed-neighbour telling us, emphatically, daily, ‘he is not well’. I also still remember being told the next slot for the research-donated MRI was a long 10 days away.

Death. Here, we are surrounded by it. We walk away from bodies every day. We walk on to the wards and find people dead, whether heralded by a guardian collapsing on to the floor and crying, heart shattered by their loss, or by being ushered over by a concerned medical student to a newly cold body, shrouded in a limp home-brought sheet. Here more than anywhere else, death is commonplace. This is a world without a crash bell. Without a resuscitation team. Where cockroaches crawl in the defibrillator. Where it can take a week to get an ECG.

Death occurs from a lack of facilities, a lack of resources, a lack of medication, a lack of staff, a lack of money and a lack of admission to hospital when there is still a chance something could be done. Yet, moving a patient to take up one of the 6 cyclinders of oxygen we have per ward, seems as much a herald of the end as booking an MRI (of the ten allotted slots a month for general medicine) (as both are uniformly reserved for the incredibly unwell and dying).

It would be easy to stay on the ward and run from patient to patient. Is it heartless to walk away, each day and go home to the relative comfort of a gated house, with a cheery summery garden, hot water and electricity? Sometimes it feels like it.

As often as the daily commute in to work is punctuated by the beautiful echoes of the church-going crowd outside, praying in song, it is also struck by the screams of torn-apart families, swallowed in grief.

It is unsurprising then, why faith and spiritualism is so important in Malawi. A proportion of the patients who arrive at our hospital have been to visit their traditional healer/herbalist first (estimated at just under half). My first brush with this was a young woman in general medical clinic, who had a razor blade scraped across her chest as a child, in good faith, to help release ‘the demons’. Another was a young man with AIDS who spent weeks in my bay, finally having sought help when he was overwhelming unwell, having contracted typhoid, TB and meningitis, after taking local herbs for months, with minimal effect.

They come to the hospital as a last resort’, I was told by one of our guides on a recent trip up to view the UNESCO ‘Chongoni’ Rock Art, primitive paintings traced to the Iron age atop a plateau in the forested foothills of the mountainous Dedza area, in the central territories, ‘because they are terrified – they think everyone dies there…’

As we gazed out from a cave, at the beautifully scenic panorama set against a cloudless blue sky, of scattered, green fields, where the predominant occupation is agriculture, and a large amount of children leave school at eleven years old, there were square clusters of billowing, tall trees at every village. ‘Graveyards’, he told us.

The graveyard is divided neatly in to those for ‘Christians’, and the ‘Gule Wamkulu’. Gule Wamkulu (literally ‘great dance’) is a legendary cultural heritage descending from the Malawian Chewa people, still very much shrouded in mystery and interlinked with the myths of old-age Malawi, as well as being for some, an adopted religion.

The Gule are thought to communicate with the spirit world, and the ancestors, through symbolic dances, adopting oversized masks and animal skin, to a rapid, rhythmical drumming, with their costumes pride of place, in the cemetery. ‘’Half of the people here are Gule Wamkulu’ he said, ‘and the other half are Christian’. Here, the chief of the village was Gule.

.‘Often,’ the guide added ‘people feel like the traditional healer or the spiritualists treat them better than the doctors’.

Is it so incomprehensible that in a world hit by years of poor harvests, with vast swathes of the population suffering from famine, where life expectancy only recently climbed from in its 40s and where the young die, so often, that people believe in bewitchment, in spirits, in magic, or simply in non-traditional medicine? That they seek more than what the hospital can provide them? That sometimes they simply don’t understand their illness? That they don’t understand why so many of them get so sick, so quickly?

Death should never become commonplace, we should continue to be surprised by our patients deaths, we should not just become universally accepting, but in our setting, where removing oxygen from one patient to let another live becomes a daily decision, it is easy to see how this becomes so difficult. Yet, I am acutely aware that our patients need more. Here, more than anywhere, I have found the hospital both a place of healing and of intense fear.

Moreover, from this, learning to not take the grief from the ward home with you, when there is a mortality rate of well over every 1/10 of your patients, yet also continuing to hold on to that grief, so that you keep fighting, even when it might seem fruitless, for the ones who might live, is an immensely difficult yet valuable lesson, that we grapple with, whilst in the comfort of an unchangeably stunningly beautiful Malawi.

Thank you for reading – Pri. 

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Malawi – Shades of disparity, despair and devastating beauty

Lifting off from London, the plane rises into the black abyss of the deep, cold night sky, above a magnificently intricate moving circuit board of golden lights zig-zagging across the city, tiny dotted headlamps travelling over roundabouts and into neat cul-de-sacs, flickering over bridges and football pitches. Cresting the clouds, the aircraft dips and finally leaves the familiar far behind, initially Tanzania bound.

Dawn breaks, and the sky has a rainbow of red, yellow and blue over concentric curves. As you step down from the plane in to the relative chaos of Addis Ababa airport, a wave of stifling hot humid air hits you straight in the chest, eyes blinking in the hazy blurry eyed light of dawn, army officers in khaki sitting sprawled in red berets, the airport departure board still confusingly reading flights from 22:00 to Tokyo, making the task of navigating to the next gate all the more complex, coupled with muffled incomprehensible airport tannoy announcements drowning in echo.

Finally aboard your connection, as you hit cruising altitude for your transit to your final destination, Malawi’s second largest city and centre of commerce, Blantyre, the seatbelt sign turns off, then literally less than two seconds later, turns back on, and you make a rapid, bumpy descent down to a vast sprawling expanse of a lush, green patchwork-quilted landscape.

The adventure begins.

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The first few weeks volunteering in hospital have been a blur of power cuts, jumping over gullies of water, morning student presentations, ducking under washing lines and bypassing stairs of clustered Malawians in brightly coloured, highly patterned, draped and heavy Chitenge, clutching and swaddling infants in the searing heat, occasionally, clapping, swaying and praying.

Stepping on to the dark, brown, musty, hubbub of the medical wards, patients lie strewn on beds, and occasionally, pile up in the corridor on wipe-down basic mattresses on the floor, ‘guardians’ (relatives and friends who perform most of the basic nursing duties) holding vigil, curled up in bundles beside them. Here, HIV, TB, Malaria, meningitis and hepatitis are rife.

Pride, profound food insecurity and overwhelming poverty means the local population, and particularly men, present late, and hence our patients are sick, very, very sick. Often emaciated and skeletal, with soaring temperatures, they are admitted with confusion, hypoxia, sepsis, dehydration, diarrhoea and astonishing levels of anaemia. Alongside this, only 6 of the beds in our (occasionally) 90 person male ward allow us to give oxygen. One week we ran out of blood bottles, the next week we ran out of IV fluids and then, on Friday, we ran out of IV Ceftriaxone (one of the only antibiotics we have) and blood.

Death becomes more commonplace as resources are extremely limited and variable – and this is thought to be a relatively well-stocked hospital. Patients who I would have sent to Intensive Care anywhere else lie gasping or seizing on beds and on the floor, both the elderly and the young, as you flick cockroaches off frightened bodies, trying to conduct some form of ward round, with whatever you can. At the wooden doors to the ward, women wail and are held back, as bodies are wheeled out cloaked in white blankets, a cross depicting the departed. Sometimes I only find out my patient died by walking on to the ward and looking for them, the other patients indicating the fact that they are no longer there. There is no resuscitation equipment, but then of course, there is no post-cardiac arrest care.

It is easy to feel pointless, confused, despairing and helpless sometimes. It is easy to feel like on the wards you are constantly wading through misery, and suffering, where you often lack the basic materials to implement any  sort of meaningful or effective change. It often seems strikingly unfair that the worth of life has such disparity as you cross country borders and continents. It seems horrifically unjust that the patients, in a world of modern medicine, often do not get the chances that our patients at home would have. There aren’t even curtains around each bed or mattress as you sit, holding a patient’s hand, with the rest of the bay staring, and try to tell them, through interpreted Chichewa, that there are no more options for active treatment and that the best you can do is to try and control their symptoms.

The patients themselves and their families are dignified and even stoically accepting. They feel deeply, and strongly for one other, the ‘guardian’ lovingly cooking nsima (fluffy maize product) and bean meals for their relative, washing them down, and single-handedly carrying them to the toilet when they can’t walk, booking their Xrays and filling their prescriptions, yet despite the enormity of the burden upon them, I am yet to see a single person question their plight, and ask ‘why me?’ In fact, heartbreakingly, despite the outcome, you often find relatives thanking you for what little you have been able to do, even when you have told them that their loved one is very unwell. Even when that loved one has now inexplicably had a stroke and has subsequently become confused and agitated. Even when that loved one is younger than you, at only 25 years old, and a father of two small children. Even when that loved one might very possibly die that night.

All of this sits to the backdrop of what is an incredibly beautiful, bustling country. A country packed full of leafy National Parks with roaming gentle elephants, prancing zebras, bounding Bushbuck, snapping crocodiles, jumping Impala and scurrying wild boar. A country full of cloudy, moody mountain scenery like the Zomba plateau (where I was lucky enough to spend my birthday), dancing fields of wildflowers, or swathes of sandy beaches with spectacular sunsets set amongst the tranquility of the famous Lake Malawi.

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This is a country bursting full of kindness, which despite its inequality, resonates with a warm love of music, and of life, with choruses of voices singing in harmony, to the upbeat patter of drumbeats, melodic calls to church and the mosque spiralling over town.

Hence, from the hospital, to the streets, from the hills to towns, with the contrasts and differences at times so stark, this trip has been all shades of everything; wonderful, heartbreaking, frustrating and magnificent all in one.

Thank you for reading – Pri.