Correspondence Tropical Doctor 2014, Vol 44(1) 3–5 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513515162 tdo.sagepub.com
Voice Chris Bem
Five days ago I returned from Malawi, where I had been for almost 4 weeks. I had often thought whilst there of an upcoming creative writing meeting and the given title for that day, ‘Voice’. Voice: a word, a name, a sound, but much more. Voice declares the presence of a person, an identity, an individual crying, speaking and wanting to be heard and recognized. Voice, a word so powerful and yet so many of those who have the human capacity of speech have no voice. Of course we all have voices and we all are heard, even if not by many. The children in Malawi, whose ubiquitous presence by the side of the roads, playing free, shouting and laughing, had made a big impression on a visiting purveyor of surgical instruments. He was in Africa, for the first time in his life out of Europe. He contrasted their freedom and carefree joy with those children he knew back at his home in Scotland. A voice had awoken inside him, asking whether those children at home, with all their digital wonders of computers, televisions and gameboys but confined and restricted play areas, had the better or worse deal for life in the 21st century. I also heard voices, many voices, whilst in Malawi, even though I did not travel far from my base at a lodge close to the centre of the city of Blantyre. From this lodge, an extended home run by an elderly, kind and dear Malawian woman, situated on a hill overlooking a shanty-like part of the town. Views stretched out before me, out to the hills that rise like large ant-mounds within and around, views out further to the mountains in the distance and up to the clouds that sometimes rushed and sometimes lingered over the hills, clouds and mists that at times draped the valleys and filtered the colours of the rising and setting sun. This I called the Voice of Distance and Perspective, for how often do we in city life have a chance to look out over its structures and take in a bigger world? Too often do we hear only the voices of those near to us. However, from this lodge and from its balcony shared by all its residents as a place to eat, talk, work or sit and meditate, I was open to the voice within the heart and to the voice of the earth which we share. Each day, each morning as I waited for my friend to pick me up to take me to the hospital and each evening
if I should return before dusk, I would sit on that balcony and acknowledge the message of the earth and hear of the gifts it gives us with open arms – a place and home for our bodies and souls. I also, though, heard its cries of anguish as we despoil and take for ourselves its fruits of beauty, forests and colour. For Malawi wishes to develop and become like the rich occidentals who seem to have everything. Malawians wish, as we have done, to replace the gifts of Nature with concrete and tarmac, and replace Life by things, Realities by images. Few of Blantyre’s hills now have trees. Mountains have been laid bare, every tree cut down for money by the rich or for firewood by the poor. The creep of urban life makes its way up the slopes of the nearby hills – the dwelling places of those who have abandoned the countryside. It may not be long before they who live there will want to return to the fields and live again amongst the trees, but perhaps by then the countryside will have abandoned us. Yes, it was a powerful time for me; a voice did speak to me and not just that of our earth, an earth mocked, ignored and abused. For, as I sat on the veranda of the lodge, as I did each evening, I had time to listen to the voice of life and thought. Voice gives and brings meaning. Voice distinguishes itself from noise by giving messages and messages give us purpose and bring us understanding. Four weeks away from the immediate pressures of work, 4 weeks away from those who speak insistently to me, gave me time to hear those voices speak to me and for me to listen to the rhythms of a life that go beyond. Each working day I made my way to the Queen Elizabeth Central Hospital, founded in 1954 during the time of British Empire and still in its core much as it was in those days – and still the tertiary hospital for the country, a hospital where people come when Consultant ENT and Neck Surgeon, Bradford Teaching Hospitals NHS Foundation Trust, UK; Honorary Senior Lecturer, Leeds Medical School, UK; Visiting Lecturer in Surgery and ENT, Malawi School of Medicine; Health Ecologist, Permaculture Organisation Corresponding author: Chris Bem, Bradford Teaching Hospitals Foundation NHS Trust, Bradford, UK. Email: [email protected]
Downloaded from tdo.sagepub.com at EASTERN KENTUCKY UNIV on May 28, 2015
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Tropical Doctor 44(1)
disease has become too much to ignore. I noticed the woman on the mattress by the wall, whose ranula of the floor of her mouth had become so large that she could neither speak nor eat and barely drink. I saw another woman whose eye, many weeks already blind, was now two inches in front of her nose, pushed forward by pus oozing slowly over the weeks into her orbit from the frontal nasal sinus. I was there when the 6-year-old child with no voice and almost now no sound, was carried into theatre almost without breath. Thankfully, my friend and colleague, skilled with the laryngoscope, was nearby and was able to push a tube past the obstructing vocal cord papilloma into the trachea. The child survived to regain again a voice. To speak of all those who suffered silently would take pages, books, encyclopaedic volumes, but sometimes one story can speak so that others will hear and listen. Whose story that will be, though, is impossible to predict. Could it be the man curled up in pain on the floor of the surgical ward, his left arm not functioning properly due to an irregular hard cancer of the lower neck arising from the thyroid and infiltrating into the brachial plexus and for which he had received no diagnostic or therapeutic procedure from the time it had started. He, like others, came when it was too late to change the course of the disease. Others come and are offered hope. They wait, sitting in the corridor, to come in for surgery – but there is not time, or equipment, or medicines for more than a few. These have no voice. They suffer silently, unheard. But there is always a voice that does call and some respond. Two years ago, an announcement in Malawian newspapers for a new 18-month diploma course in ear, nose and throat (ENT) surgery and audiology appeared. This was a popular invitation for the medical assistants across Malawi, who, after 2 years of training, provide much of the primary and secondary care across Malawi as nurses are few and doctors even rarer. In ENT, for the 15 million population of Malawi at the last count there were just four audiologists, three clinical officers dealing with ENT and just one ENT specialist. This man, Wakisa Mulwafu, loves and is committed to his country, and with multiple pitches of tone, story and emphasis has already gained funds from within and outside of Malawi. He has built an ENT clinic with rooms now equipped with one microscope, some suction machines and some audiometers. He has also built operating theatres (two, but yet to be equipped) and a ward for 20 beds (still empty, for it awaits those beds). The diploma training programme for clinical officers was initiated by him, inspired by similar programmes that already provide orthopaedic, anaesthetic and ophthalmic services across Malawi.
During my 4 weeks in Malawi, my third visit there over the past 9 months, I met again and heard the voices of those 15 medical assistants, chosen from over 100 applicants and enrolled as the first cohort of locally trained ENT specialists. Their voices now have names and their voices are beginning to have biographies and characters. I am learning about their ambitions, their worries and the motivation that brought them onto the course. I also wanted to give them a voice in a more formal way, a collective voice that others could read and take note of. In a world where the voices of people are drowned out by the agendas of the media and of commerce or the demands of objective scientific evaluations, this seemed important. An open qualitative interview was conducted with each of them, asking questions that they together had chosen for me to ask and which were formally written up as their testimony for the organizers of the course, which had included myself, and others who might want to understand what it means to want to do better for oneself and also for others in a land where opportunities are few. The students spoke of their desire to move forward in their careers, gain knowledge and help others. They recounted seeing cases of ENT misdiagnosed or mistreated and of their hopes to bring ENT services to district hospitals. They recognized the difficulties, the absence of any equipment and, importantly, the need for professional support and encouragement in conditions where patients may well expect far more than they can at present give. Of course, in a country that is poor, they also spoke of their own needs for improved standards of living for themselves and their families. They addressed the content and organization of the course, and spoke of lecturers who did not turn up for classes because they were not paid, of the bad accommodation at the college and of the terrible food they are given to eat – eggs and maize meal day after day – for what can be bought today, anywhere, for just one dollar a day, the sum provided by the government to their hostel for their keep. They have few books, limited access to computers and the internet and they know that in 6 months most will return to district hospitals to provide ENT care without – as yet – tools, instruments or access to investigations. Despite this, each was filled with hope and the knowledge that, at last, they were being given a chance to learn more, to pursue a career and move into a better life and future. One voice of those 15 medical assistants spoke especially to me. In April, he had not been around – he was recovering from a motorcycle accident. This time, he told me the story of that accident. He had been travelling from his farm alone through the deserted hills back to Blantyre as dusk fell. Half way along his 120 km journey, the tyre of his motorcycle had come off, the front wheel spun back on itself and the handlebars hit
Downloaded from tdo.sagepub.com at EASTERN KENTUCKY UNIV on May 28, 2015
Bem
5
him in the abdomen as he fell off his machine. He was alone, darkness was approaching and he was weak, unable to get up. He also had pain in the left shoulder, a sign that he knew indicated a ruptured spleen. Hope came as three people approached along the track but he heard only how they thought he might be a decoy and bait for an ambush and robbery – and so they walked on, passing him by. Half an hour later, another person approached and this time he was a person prepared to help, which he did by repairing the motorcycle wheel and helping seat the injured medical officer back on the bike to motor on by himself as the passer-by was heading in the opposite direction. He managed the 15 km to a village where, too weak to continue, he asked for help. Two villagers, one sitting in front and one behind him on the motorcycle seat, keeping him upright and preventing him falling off, took him in this fashion another 10 km to a small rural hospital. There was no surgeon at this place but there was an ultrasound machine, confirming a ruptured spleen; intravenous fluid with which to resuscitate him; and transport to take him another 30 km to the next hospital, where he arrived around 2am. At this hospital a surgeon was available, a non-medical clinical officer; but there was
a problem – no anaesthetist, or rather the anaesthetist was in bed, too tired to get up, or perhaps just not bothered enough to get up. Only around 6am that morning could he be persuaded to anaesthetise my friend. At last, close to his end, he was taken to theatre. The ruptured, bleeding spleen was removed and the 3½ pints of blood in his abdomen was returned to him by auto-transfusion. He gratefully shows me the scar on his abdomen stretching from his xiphisternum to his pelvis and tells me that his life was restored by the Grace of God. No doubt this is true, but it was also restored by those willing to listen to the voice of God and to act, despite the lack of resources available to them. The story of this medical officer had echoed the voices I had heard at a meeting 2 months before in London calling for essential surgery to be made available to all and calling for a global training programme in 15 essential generic surgical procedures. The availability of such procedures for all would mean that no one would have to cry out for a life- or limb-saving operation and be denied it. And so I ask you and others to give Voice to the global campaign of Fair Health for All.
Downloaded from tdo.sagepub.com at EASTERN KENTUCKY UNIV on May 28, 2015
Voice Chris Bem
Five days ago I returned from Malawi, where I had been for almost 4 weeks. I had often thought whilst there of an upcoming creative writing meeting and the given title for that day, ‘Voice’. Voice: a word, a name, a sound, but much more. Voice declares the presence of a person, an identity, an individual crying, speaking and wanting to be heard and recognized. Voice, a word so powerful and yet so many of those who have the human capacity of speech have no voice. Of course we all have voices and we all are heard, even if not by many. The children in Malawi, whose ubiquitous presence by the side of the roads, playing free, shouting and laughing, had made a big impression on a visiting purveyor of surgical instruments. He was in Africa, for the first time in his life out of Europe. He contrasted their freedom and carefree joy with those children he knew back at his home in Scotland. A voice had awoken inside him, asking whether those children at home, with all their digital wonders of computers, televisions and gameboys but confined and restricted play areas, had the better or worse deal for life in the 21st century. I also heard voices, many voices, whilst in Malawi, even though I did not travel far from my base at a lodge close to the centre of the city of Blantyre. From this lodge, an extended home run by an elderly, kind and dear Malawian woman, situated on a hill overlooking a shanty-like part of the town. Views stretched out before me, out to the hills that rise like large ant-mounds within and around, views out further to the mountains in the distance and up to the clouds that sometimes rushed and sometimes lingered over the hills, clouds and mists that at times draped the valleys and filtered the colours of the rising and setting sun. This I called the Voice of Distance and Perspective, for how often do we in city life have a chance to look out over its structures and take in a bigger world? Too often do we hear only the voices of those near to us. However, from this lodge and from its balcony shared by all its residents as a place to eat, talk, work or sit and meditate, I was open to the voice within the heart and to the voice of the earth which we share. Each day, each morning as I waited for my friend to pick me up to take me to the hospital and each evening
if I should return before dusk, I would sit on that balcony and acknowledge the message of the earth and hear of the gifts it gives us with open arms – a place and home for our bodies and souls. I also, though, heard its cries of anguish as we despoil and take for ourselves its fruits of beauty, forests and colour. For Malawi wishes to develop and become like the rich occidentals who seem to have everything. Malawians wish, as we have done, to replace the gifts of Nature with concrete and tarmac, and replace Life by things, Realities by images. Few of Blantyre’s hills now have trees. Mountains have been laid bare, every tree cut down for money by the rich or for firewood by the poor. The creep of urban life makes its way up the slopes of the nearby hills – the dwelling places of those who have abandoned the countryside. It may not be long before they who live there will want to return to the fields and live again amongst the trees, but perhaps by then the countryside will have abandoned us. Yes, it was a powerful time for me; a voice did speak to me and not just that of our earth, an earth mocked, ignored and abused. For, as I sat on the veranda of the lodge, as I did each evening, I had time to listen to the voice of life and thought. Voice gives and brings meaning. Voice distinguishes itself from noise by giving messages and messages give us purpose and bring us understanding. Four weeks away from the immediate pressures of work, 4 weeks away from those who speak insistently to me, gave me time to hear those voices speak to me and for me to listen to the rhythms of a life that go beyond. Each working day I made my way to the Queen Elizabeth Central Hospital, founded in 1954 during the time of British Empire and still in its core much as it was in those days – and still the tertiary hospital for the country, a hospital where people come when Consultant ENT and Neck Surgeon, Bradford Teaching Hospitals NHS Foundation Trust, UK; Honorary Senior Lecturer, Leeds Medical School, UK; Visiting Lecturer in Surgery and ENT, Malawi School of Medicine; Health Ecologist, Permaculture Organisation Corresponding author: Chris Bem, Bradford Teaching Hospitals Foundation NHS Trust, Bradford, UK. Email: [email protected]
Downloaded from tdo.sagepub.com at EASTERN KENTUCKY UNIV on May 28, 2015
4
Tropical Doctor 44(1)
disease has become too much to ignore. I noticed the woman on the mattress by the wall, whose ranula of the floor of her mouth had become so large that she could neither speak nor eat and barely drink. I saw another woman whose eye, many weeks already blind, was now two inches in front of her nose, pushed forward by pus oozing slowly over the weeks into her orbit from the frontal nasal sinus. I was there when the 6-year-old child with no voice and almost now no sound, was carried into theatre almost without breath. Thankfully, my friend and colleague, skilled with the laryngoscope, was nearby and was able to push a tube past the obstructing vocal cord papilloma into the trachea. The child survived to regain again a voice. To speak of all those who suffered silently would take pages, books, encyclopaedic volumes, but sometimes one story can speak so that others will hear and listen. Whose story that will be, though, is impossible to predict. Could it be the man curled up in pain on the floor of the surgical ward, his left arm not functioning properly due to an irregular hard cancer of the lower neck arising from the thyroid and infiltrating into the brachial plexus and for which he had received no diagnostic or therapeutic procedure from the time it had started. He, like others, came when it was too late to change the course of the disease. Others come and are offered hope. They wait, sitting in the corridor, to come in for surgery – but there is not time, or equipment, or medicines for more than a few. These have no voice. They suffer silently, unheard. But there is always a voice that does call and some respond. Two years ago, an announcement in Malawian newspapers for a new 18-month diploma course in ear, nose and throat (ENT) surgery and audiology appeared. This was a popular invitation for the medical assistants across Malawi, who, after 2 years of training, provide much of the primary and secondary care across Malawi as nurses are few and doctors even rarer. In ENT, for the 15 million population of Malawi at the last count there were just four audiologists, three clinical officers dealing with ENT and just one ENT specialist. This man, Wakisa Mulwafu, loves and is committed to his country, and with multiple pitches of tone, story and emphasis has already gained funds from within and outside of Malawi. He has built an ENT clinic with rooms now equipped with one microscope, some suction machines and some audiometers. He has also built operating theatres (two, but yet to be equipped) and a ward for 20 beds (still empty, for it awaits those beds). The diploma training programme for clinical officers was initiated by him, inspired by similar programmes that already provide orthopaedic, anaesthetic and ophthalmic services across Malawi.
During my 4 weeks in Malawi, my third visit there over the past 9 months, I met again and heard the voices of those 15 medical assistants, chosen from over 100 applicants and enrolled as the first cohort of locally trained ENT specialists. Their voices now have names and their voices are beginning to have biographies and characters. I am learning about their ambitions, their worries and the motivation that brought them onto the course. I also wanted to give them a voice in a more formal way, a collective voice that others could read and take note of. In a world where the voices of people are drowned out by the agendas of the media and of commerce or the demands of objective scientific evaluations, this seemed important. An open qualitative interview was conducted with each of them, asking questions that they together had chosen for me to ask and which were formally written up as their testimony for the organizers of the course, which had included myself, and others who might want to understand what it means to want to do better for oneself and also for others in a land where opportunities are few. The students spoke of their desire to move forward in their careers, gain knowledge and help others. They recounted seeing cases of ENT misdiagnosed or mistreated and of their hopes to bring ENT services to district hospitals. They recognized the difficulties, the absence of any equipment and, importantly, the need for professional support and encouragement in conditions where patients may well expect far more than they can at present give. Of course, in a country that is poor, they also spoke of their own needs for improved standards of living for themselves and their families. They addressed the content and organization of the course, and spoke of lecturers who did not turn up for classes because they were not paid, of the bad accommodation at the college and of the terrible food they are given to eat – eggs and maize meal day after day – for what can be bought today, anywhere, for just one dollar a day, the sum provided by the government to their hostel for their keep. They have few books, limited access to computers and the internet and they know that in 6 months most will return to district hospitals to provide ENT care without – as yet – tools, instruments or access to investigations. Despite this, each was filled with hope and the knowledge that, at last, they were being given a chance to learn more, to pursue a career and move into a better life and future. One voice of those 15 medical assistants spoke especially to me. In April, he had not been around – he was recovering from a motorcycle accident. This time, he told me the story of that accident. He had been travelling from his farm alone through the deserted hills back to Blantyre as dusk fell. Half way along his 120 km journey, the tyre of his motorcycle had come off, the front wheel spun back on itself and the handlebars hit
Downloaded from tdo.sagepub.com at EASTERN KENTUCKY UNIV on May 28, 2015
Bem
5
him in the abdomen as he fell off his machine. He was alone, darkness was approaching and he was weak, unable to get up. He also had pain in the left shoulder, a sign that he knew indicated a ruptured spleen. Hope came as three people approached along the track but he heard only how they thought he might be a decoy and bait for an ambush and robbery – and so they walked on, passing him by. Half an hour later, another person approached and this time he was a person prepared to help, which he did by repairing the motorcycle wheel and helping seat the injured medical officer back on the bike to motor on by himself as the passer-by was heading in the opposite direction. He managed the 15 km to a village where, too weak to continue, he asked for help. Two villagers, one sitting in front and one behind him on the motorcycle seat, keeping him upright and preventing him falling off, took him in this fashion another 10 km to a small rural hospital. There was no surgeon at this place but there was an ultrasound machine, confirming a ruptured spleen; intravenous fluid with which to resuscitate him; and transport to take him another 30 km to the next hospital, where he arrived around 2am. At this hospital a surgeon was available, a non-medical clinical officer; but there was
a problem – no anaesthetist, or rather the anaesthetist was in bed, too tired to get up, or perhaps just not bothered enough to get up. Only around 6am that morning could he be persuaded to anaesthetise my friend. At last, close to his end, he was taken to theatre. The ruptured, bleeding spleen was removed and the 3½ pints of blood in his abdomen was returned to him by auto-transfusion. He gratefully shows me the scar on his abdomen stretching from his xiphisternum to his pelvis and tells me that his life was restored by the Grace of God. No doubt this is true, but it was also restored by those willing to listen to the voice of God and to act, despite the lack of resources available to them. The story of this medical officer had echoed the voices I had heard at a meeting 2 months before in London calling for essential surgery to be made available to all and calling for a global training programme in 15 essential generic surgical procedures. The availability of such procedures for all would mean that no one would have to cry out for a life- or limb-saving operation and be denied it. And so I ask you and others to give Voice to the global campaign of Fair Health for All.
Downloaded from tdo.sagepub.com at EASTERN KENTUCKY UNIV on May 28, 2015
