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The items on the agenda for last week’s staff meeting were nothing new: problems procuring Internet dongles for staff; insurance issues; the status of recruitment for two open positions. I took up my usual position in the back of the conference room, one ear tuned to the meeting, the rest of my sensesfocused on replying to the bevy of emails that had flooded my inbox since last night. But when the head of the office Social Welfare Committee took the floor, something caught my attention.According to the Committee head, three of my fellow staff members had received bereavement funds from the Social Welfare Committee for the loss of a family member over the past month.

Three people inan office of thirty.

Ten percent of the office staff.

To me, this was a staggering percentage. But as I scanned the faces of my coworkers, it seemed I was the only one shocked by the statistic. And when you look at Malawi’s demographic indicators, you can start to understand why. Average life expectancy in Malawi is 54, compared to 78.5 in the United States (http://www.cdc.gov/nchs/fastats/lifexpec.htm). Malawi’s crude death rate (total number of deaths per year per 1000 people) is 13, placing it just outside the top 20 countries with the highest crude death rates (https://www.cia.gov/library/publications/the-world-factbook/rankorder/2066rank.html). Maternal mortality in Malawi is 675 per 100,000 live births, one of the highest rates in among all African countries (http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_mwi_en.pdf), while the under 5 mortality rate (http://www.unicef.org/infobycountry/malawi_statistics.html) in Malawi is 92, compared to 8 in the US (http://www.unicef.org/infobycountry/usa_statistics.html).

The effect of high mortality rates on development has been well documented, particularly in regards to the HIV/AIDS epidemic, which has eliminated vast swaths of the population aged 18-35 in many African countries. But what effect do these rates have on the mentality of a people and a nation?What happens when three deaths among coworker families over the course of a month is the norm, or at least not out of the ordinary?

When the head of the Social Welfare Committee read out the names of those who had received bereavement funds last month, his face was placid, his tone neutral, as if he were checking off items from a grocery list.Here in Malawi, death is a part of life, discussed as matter-of-factly as the weather or the price of fuel.One could look at this as a positive adaptation, a coping mechanism that allows people to move forward with their lives in the face of life’s harsh realities.

But part of me wonders if it is in fact maladaptive, if becoming so inured to death infuses a certain amount of fatalism and apathy into the culture and people. If life – to put it in Hobbesian terms – is so nasty, brutish, and short, what’s the point in planning for the future? Over and over again during my time working in Africa I have been stunned and completely frustrated by this pervasive lack of forethought and planning. In Ethiopia, government workers told me at the eleventh hour that the permits for my Masters research were not valid, even though those permits had been in their hands for over two months prior. In my current placement in Malawi, I may have to leave the country next week since my organization still has not secured my temporary employment permit, even though they have known since May that I would need one. It’s not hard to see the impact this lack of forethought could – and, in all likelihood, does – have on public health and development efforts in Malawi and throughout the continent.

In a recent post in The Enterprise, Charlie Fiske talks about the many challenges – or “lessons to be learned” as he so diplomatically puts it – facing an expat living and working in Malawi, chief among them this lack of forethought that I’ve mentioned.

So many times I simply want to say, “What were you thinking?“… “If you are traveling 200 kilometers don’t you think it makes sense to have more than 3 liters of fuel on board before making the trip?”

Ultimately, Fiske concludes that any change in planning or forethought “needs to be initiated by Malawians themselves…change has to be initiated by those who live here.”

The question for me, though, is this: How canforethought and strategic planning be instilled in a country where sickness, death, and the fatalism they foster are so pervasive? How can we flip the switch and turn apathy into action?

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One thought on “Fatalism and Forethought

  1. This is definitely something I struggled with in my internship in Zambia. I had a baby practically die in my arms as I was handing it back to its mother – its last breath merely seconds from my release. Granted I was working on a disease that causes 1/5 of under 5 deaths world-wide – the biggest global killer of this demographic. But the way the hospital placated the issue and spoke words of hospital death so simply was astonishing. One of the physicians of my study had his brother die from a random heart attack in his 40’s, not far in age from my colleague himself. Sadness ensued, but it was also just a normal occurrence, almost like paying your taxes – painful, but facts of life.

    I worked with a pediatrician from BMC who was in the midst of his residency at the Brigham, when he came over to work on our study. One day he stormed out of the hospital (very contradictory to his normally soft demeanor), unable to cope with the 4 infant deaths we’d had that day. He’d seen his share of challenges in the States, and it wasn’t his first “calling the death”, but when we decompressed about that heavy day later, his clinical and cultural insights were some I had not life experience enough to tangibly be aware of. He said, in the States, money is negligible to the value of a human life. We will shovel out millions to save one child of some rare outcome, requiring extreme interventions contrary to the basic interventions needed by our kids in our hospital in Lusaka. In a US hospital, if a child doesn’t make it, doctors mill over paperwork to try to figure out what went wrong, why did this happen, how can we prevent this in the future. And parents cry, unable to function for weeks due to their loss.

    This is in sharp contrast to Africa – “we didn’t have enough oxygen, it happens.” The parents sad, and definitely holding a spot in their heart for the rest of their life, yet talking about a lost child later on in the same intensity that you would about a broken bone you once had. Well, why wasn’t there enough oxygen? Why is there only one oxygen dispenser in a room with 50 infant beds, three children to a bed? Where was the forethought in that and why is it always someone else’s problem to fix? Why are you reading the newspaper when you could be on the wards hourly checking whether our patients are hypoxic? Why the helplessness in action? I don’t blame them, to set the record straight. I can’t begin to point fingers without having grown up in their culture or having to work in their systems (many are quite messy due to lack of resources). But I can say that there are MAJOR problems, and what on earth are we going to do about it?

    There is this extreme level of fatalism – what will be will be, it was God’s plan. Inshallah (If God wills it), as many Arab cultures say. We have many a Christian in the US who still fight against death on a daily basis. On the other hand, if you experience so much death, particularly as a hospital worker, let alone as a community member, you begin to put up a defense mechanism. I know I was immobilized after that child died moments after leaving my arms, my skin still warm from its radiating heat. I was in shock when I saw our deceased babies wrapped in chitenge, tied with string, and put on a shelf for the time being. How on earth do you cope with that much death ALL the time? You begin to feel helpless, if you didn’t already feel so from learned helplessness from your culture. I can’t say it ever got easier for me in those 6 months at the hospital, but I did experience a level of helplessness from lack of clinical skills, inability to navigate the system due to cultural/lingual/systemic barriers. It is so frustrating when a simple intervention could save a life…just a bit of forethought.

    Either way, it is a major shock for expats no matter how the cookie is cut. I don’t think that we necessarily value life differently, but we sincerely have a different world view, likely stemming from our economic standpoint and ability to “do” something both with resources and the will that comes from having those resources at hand. I had colleagues going to funerals all the time – car accidents, heart attacks, random illnesses I’d never heard of. Part of the paradox is the fatalism combined with the BIG deal they make out of funerals. You get days off work for mourning/funeral preparations – no questions asked (even in healthcare where your absence can impact mortality itself), your colleagues get work off to go to the funeral too, everyone comes together to celebrate that life with the community that so represents African cultures. Yet death is commonplace at the same time, something that happens all the time. It’s part of the influence of the high fertility rate, too. Having a number of kids ensures you will have a healthy number in the end because death of some is inevitable. Well, my world-view says it’s not, and it is a shock for expats to see it any other way.

    To be true, I have not come to any conclusions myself. I have no words of wisdom about what truly defines or leads to these differences, I have only experienced that they exist. We definitely have to work within the culture to influence change, which is where I agree with Fiske. But I think first we have to understand WHY there is this difference and help instill motivation, offer up resources to counter helplessness, help to visualize what can be. Make them agents of their own change, motivating with the values they hold close. Culture is one tough beast to tame – so we have to work within it (as Bicknel says, “Culture eats everything else for lunch.”) And that’s why systems are so important as well – put the things in place that work to get the results we want. Not so simple if we can’t define the inputs quite yet! But something to think about for sure.

    Love your thoughts, Jen! Glad we can have these musings via blog if we can’t have them via walks/commutes/wine-drinking at the moment. Someday we’ll solve a few global issues and improve a few lives if we keep at it 😉 Loff!

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