Mostly Infruriating but Slightly Hilarous

Last August Clement submitted the paperwork and fees to apply for a passport. Our goal was to obtain it in time for him to travel to Zambia with my parents in October. In December he was told the passport should be ready soon. He went to Blantyre to collect it but after many phone calls and trips to various offices he reached his contact person who told him to go to Zomba. Dutifully he went to Zomba and was told that the person who had it was not around. They said they would bring it to Lilongwe. The guy came but there was no passport. A month later he went back to Blantyre and found out that his original contact left his job and the person who took over the position had been away but, “luckily just came back.” When Clement met that man he was told that his passport simply needed the signature of someone else, who was sick but “should be in tomorrow.” The following day he found the man of the highly desirable signature who then told him there was something wrong with his birth certificate. After some discussion he reconsidered, the birth certificate was fine but Clement needed a letter from the hospital requesting urgent processing of a passport (after 5 and ½ months!). (In my mind I was hearing something like, “How about $100” but Clement insisted that, he just really needed a letter.) While Clement stayed in Blantyre his friend Mavuto spent an entire day running around Lilongwe to different administrative offices trying to convince any other person in possession of an authoritative stamp and signature to sign the letter. The next morning I faxed the letter. This mollified the Blantyre signature man who then said the passport would be out within the week. The following Friday (the third or fourth day Clement called) he was told that the passport was out and that he could come pick it up. Clement called his father in Zomba who said he would go collect it Monday. Monday afternoon Clement’s father called and told him that the man who supposedly had the passport was in police custody. He was told that hopefully the man would be released on bail Tuesday and then would be able to hand over the passport. Clement says if the man is not released he will personally visit him in his cell and demand to be given his passport. (Apparently no one else at the office can find/give him the passport.)

As if that is not enough, another ridiculous drama is running concurrently. Clement - along with the other interns who have been assigned to Kamuzu Central Hospital - is fighting to receive a salary. After graduation, clinical officer interns must complete a year internship at a government hospital or clinic where they are posted by the Ministry of Health. The hospital or clinic in turn is supposed to provide them with housing and a small stipend. Now two months into their internship, those allocated to KCH have yet to receive anything . . . Okay, that’s not entirely true, they have been provided a small house (supposedly for 10-15 interns) located about 5 kilometers from the hospital. The house is furnished with a single twin bed and the interns have not been given any money for transportation, or even food.

Daily, a rotating group of interns visit the various administrative offices at the hospital and Ministry to beg. Of course the people they seek are often in meetings, and when they are caught in the office unaware they point the interns in the direction of someone else in another office across town who points them right back. “Come again at 5pm.” “Come back tomorrow.” “Get a letter from the hospital saying they can’t afford to give you anything,” etcetera.

Without pay or housing the interns are still expected to work 60-80hrs per week. Unlike residency programs in the States - where immediately after graduation you occupy the lowest rung of the medical hierarchy, with layers of experienced physicians above you, accessible for consultation and who ultimately remain responsible for the patients - these intern step into full wards alone. (Consultants are often not present at all or are completely overwhelmed by their own patient lists and responsibilities.) Interns have little to no informational resources, minimal medical resources, and little to no supervision; setting up a precarious situation for everyone involved. But, the alternative is wards full of patients without anyone to assess and treat them.

THE HOSPITAL DESPERATELY NEEDS CLINICIANS and the administration is essentially chasing them away. Several of Clement’s peers have already left KCH and those remaining are already becoming disenchanted by the government system. Hospital administrators should be grateful that they have enthusiastic clinicians willing to work in overcrowded hospitals for as little as $50/mo. I feel like screaming at the administrators, “HAVE YOU SEEN THE WARDS IN YOUR HOSPITAL?! WHAT ARE YOU THINKING?”

Certainly the people who attend KCH need these interns. Just a small illustration of that. . . Clement told me that he had a patient yesterday with pleural effusion who had been pushed from one person to anther without any investigation or treatment. By the time he reached Clement he was breathing with great difficulty. Clement drained the fluid, drew labs, and ordered a chest x-ray. Even without the results, the man was so grateful to be helped that he insisted on having Clement's phone number. Telling Clement that the next time he had a problem he would contact him directly. Clement told him that he might not be at KCH the next time but the man persisted, he said he would come to Clement regardless if he had to travel across the country. He also told Clement that he wanted to visit him at his house to which Clement responded that he didn't have a house. The man unwilling to be put off and still holding out his hand said dismissively, "I'll find you and we'll chat."

Last night when Clement narrated the most recent episodes of these ongoing sagas all I could do was laugh. Clement is applying for medical school in a few other African countries moving closer to his dream of becoming a pediatrician and serving those who have the most difficulty accessing care, but not surprisingly he is also looking forward to a few years outside Malawi.