Bush Medicine 101: Lesson 7 - Just Be Grateful (My Mum says)
First World Problems vs Third World Problems?
Dear Family, Friends, Mentors, Colleagues and Jane-Your-Younger-Self,
I hope this finds you well? We are well. And grateful to be well!
“Just be grateful” was a common scolding, coming from a place of exasperated love, that I got from my single Mum when I was younger. Which I deserved.
Returning from South Africa back to our home town Fort Dauphin on the south east coast of Madagascar where we live as expats, I am again reminded to just be grateful.
Just being grateful is a lesson every Bush Doctor needs to learn, otherwise you’re not going to enjoy learning to become a Bush Doctor and this job isn’t for you.
Just being grateful is a lesson every person needs to learn, particularly those in the first world, otherwise happiness will never become you.
I’ve repeated the same thing to our 2 privileged kids (aged 11 and 13) who are growing up in Madagascar in a home with 2 parents, in a brick house with a flushing toilet built in-doors (most locals practice an “Open Defecation System” / ODS in open fields or the beach because naturally the beach flushes away the waste), running water and electricity at the flick of a tap handle or switch (when the town water and electricity supply is functioning).
Most local Malagasy people use water out of buckets and containers which they collect each day at designated town water points.
To put it in simple medical terms, tuberculosis (TB) and malnutrition are not illnesses that we have to worry about.
Even if exposed to someone coughing TB in close proximity to us in our local market place.
Because.
We don’t live 10-15 people to a 4 x 3m wooden hut with poor ventilation so TB will be dissipated.
We generally are not living with a family member or three who have already had TB which would put us at risk of infection.
We have enough to eat and we are very far from malnourished so our immune system will more than likely fend off the TB exposure.
We have food on offer 3 meals a day with the availability of snacks in between.
Though I am all for humanity and my adult family eating 2 meals per day because I consider 3 meals excessive, unnecessary, and obesity-inducing.
FYI I read somewhere that obesity rates in the USA were shown to increase when sugary and carby snacks between meal times were introduced along with fast foods.
I don’t feel like I really need to support this statement with the research paper because I think it’s a pretty obvious common sense conclusion why obesity rates would be directly proportional to number of meals and the food quality of the meals.
Similar to health and safety instructions on washing your hands regularly to keep yourself healthy from all sorts of bugs (including COVID and Cholera).
Similar to badly translated instructions on not to put your finger into a plug socket or lick the inside of a toaster (Sigh – first world problems for those with electricity).
I often joke that to be a doctor in a third world country, or any country for that matter, it does not take a genius or a specialist doctor, or, even a medical degree, it just takes someone with common sense, who washes their hands regularly and between patient consultations, and, who teaches patients the life saving value of regular hand washing and the importance of drop toilets and non open defecation systems.
(And of course the other life-saving lesson also requiring no doctors degree, on not eating sugars, no simple carbs like breads / pastas / biscuits / sweets, no processed foods like anything coming out of a packet, max 2 meals a day, the importance of movement and managing blood sugar spikes which for many people result in a horrific hormonal cascade of insulin, cortisol, weight gain, cardiovascular disease and death).
But back to being grateful for third world problems.
According to WHO, diarrhea is one of the top 10 causes of death in developing countries, usually affecting children under 5 years of age.
Try to imagine where in a developed country would you have a child die of diarrhea? It is virtually unheard of. Because after the 3rd to 4th episode of diarrhea the parent would seek help, there would be someone to help, and treatment would be started early.
By the way, and I digress, for those who may not be familiar with what exactly an open defecation system is, it is literally that. Open.
An open field or piece of ground next to a locally built wooden house which is the designated family and / or community toilet, where the defecation lies on top of the earth and are not buried in the earth, because local belief is that the dead, and hence the hallowed spiritual ancestors and guides in the after life, are buried in the sacred earth. Therefore out of respect for the dead feces should not join the ancestors.
Except that some of the ancestors became ancestors (and thus dead) because of poor health and sanitation due to Open Defication Systems.
Thankfully toilet practices are changing, but change is slow and it will take a generational change.
Living as an expat in Fort Dauphin on the south east coast of Madagascar for the past 14 years has taught us / me a few things, and these lessons are reiterated to me when I get a taste of first world (a trip to South Africa) which reminds me of the contrast of first world vs third world problems.
“Just being grateful” rates pretty much top of that list. To the point where I regularly experience what survivors of a mass casualty situation might call “survivor’s guilt”. Guilty sometimes for having access to 3 meals a day. Guilty that my kids will have access to the best education available in town (which is an international French school), and beyond when they hopefully go to university.
I established my “dream” Robin Hood community clinic in 2012 with spit, prayer, 1 x stethoscope, 1 x otoscope, a rented 3 bedroom 1 bathroom house (our old house), and my bull-in-a-china-shop attitude that I could conquer my French-Malagasy speaking world, languages I couldn’t at that time yet speak, to set up my vision and dream of providing the Have’s and the Have-not’s access to my internationally standardized Primary Health Care services.
My world, besides my family, is my clinic, which I have shared with several international privileged passers-through.
By “privileged” I mean that they own a passport, they have means to travel, they live abroad in a brick house with flushing toilets, running water, a house, access to government health care, family planning and education.
By “passers-through” I mean medical students of all levels, qualified doctors, and other interested international philanthropic parties.
When I receive these international requests to “volunteer” at my clinic, I have learned to ask the question, “what are your expectations?”.
Because Students, Doctors and Do-Gooders tend to come with an “I’m coming to save the world” attitude.
I used to have it, so I don’t judge. With experience comes wisdom.
But, after 17 years of marriage (and still married, and anyone married a few years will understand this is a feat in its self), as one learns, the game of happiness and a successful anything (marriage, motherhood, parenthood, life, a Robin Hood community clinic, becoming a Bush Doctor, and everything in between) is all about Expectation Management.
So when I meet my younger self in these international Students, Doctors and Do-Gooders, I hold back my judgment, my sigh and my eye roll, and I patiently ask my favorite question, “what is your expectation from your time in Madagascar?”.
And then I wait in anticipation to hear their answer.
Because there is a not so right and a more right answer to this question.
If their answer is, “I want to come and help and do something good for your clinic and the community”, I patiently and kindly respond that by visiting Madagascar, and putting yourself out there for the experience, you will not be able to help much or do much in 2- 4 weeks.
However.
I follow this up by telling them that Madagascar and their experience is going to rock their world and change them in ways they cannot imagine or anticipate.
Silently, I know that they will return to their home countries more grateful than when they left. But I don’t tell them that, I let them find this out themselves.
For many passers-through, it’s just witnessing the level of poverty and coming to terms with their own form of “survival / first world guilt” at living such a privileged life.
For others it’s getting past this first phase of privileged guilt to witness the courage, the strength, the beauty and the skill set it takes to navigate and survive a third world and developing country where everything feels chaotic, death and corruption are common, and the basics like where to safely go to the toilet is a point to consider every day for some.
As an interesting aside to give you something to think about, toilet paper is not a big seller in Madagascar.
When COVID hit, it was only the expats who rushed out and bought up all the toilet paper.
My Mum, who we’ve been blessed with having live with us since 2016, and I say this with no sarcasm intended because a multi generational home often works better if all the generations are mentally stable and thankfully we are more or less.
Well my Mum, with her years of wisdom, at the beginning of Covid Crazy went out and purposefully bought me hair color, gin and tonic.
Not that I’m a big drinker, maybe 1 on a weekend, less these days with my age (46!) catching up with me.
But.
Mum’s just know best and for this I will always be grateful, that she didn’t bother with the toilet paper but prioritized the hair color, gin and tonic. So grateful for the not-small-things like a Mother’s love and support.
Getting back to the international privileged passers-through and their life-changing Madagascar experience, it’s things like witnessing what many from the “First World” would consider “Child Labor”, and the rest of us would call real life for the majority of the developing worlds.
ABOVE: What some might call child labor. My natural instinct is to insist she goes to school one day. But, for the family, children contribute to the work required to earn their daily bread from a young age. The family may ask, why send a child to school until 18 when they can be working from the age of 5?
There are organizations fighting against child labor in developing countries. Very often these child laborers are kids going to work with their Mothers who cut granite stones (for paving and building), sort mica (a shiny silicate mineral used in thermal and electrical insulation, cosmetics, paints etc) or cut sisal (a fibrous leafed plant used for making organic rope, geotextiles etc ).
ABOVE: Digging up mica from mica deposits
ABOVE: A sisal plant, fibre and twine / rope.
Very often the kids are taken to work by their parents because leaving them in their village with a drunk uncle or an abusive community member is not the safest choice.
But all the world sees is child labor. Not a parent trying to protect their child.
ABOVE: A Mother and her Child working in a granite quarry, the child a safely in view a few meters from her Mother putting stones in a basket. Is it child labor or child safety?
For years we’ve been involved with kids education program, sending around 100 kids to school.
To begin with the idea was to try get the kids off the street into schools.
Some might say, it’s a good idea. Perhaps a noble one. Surely a life-saving one? Me included.
After 13 years of experience, we have come to the conclusion that the most successful school programs are those in the middle-to-low class groups where the parents have a basic house with or without a toilet, not necessarily running water or electricity, 2 meals per day, where one or both parents are either formally employed on a minimum wage or self employed (think small table selling vegetables / biscuits / sweets / cell phone credit) and the parents themselves value a better life for their children and thus value the education they are supporting their children to get.
By “success”, I measure it by my personal expectation of what I would want in a similar position (however I am not in a similar position so is putting my value system into this third world context then correct?).
Success would be my impoverished child obtaining a school leavers certificate.
For some parents “success” would be basic literacy and mathematics.
For others it would be a school leavers certificate plus tertiary education.
Tertiary education is ideal. But. Only available for the privileged few in Madagascar.
Community surveys done in rural Guinea and Madagascar show that when asked (the community) what improvements they want to see in their communities, education did not even come up as one of their top 5 points of importance. Let me repeat that, not one of the top 5!
(Jobs, roads, water security, agriculture / food security and electricity were the communities top priorities...not education).
It completely defied my first world logic and code I have been living by for all of my life third world privileged life.
I have planned to arrogantly save the world in my immediate surrounds by way of education and free family planning.
However trying to force street children to go to school with out the bottom rung of Maslow’s Heirachy of needs, which includes housing, food and safety, is like trying to do a highly skilled advanced cardiac resuscitation in remote Madagascar with no post-cardiac resuscitation ward to ventilate the patient and give intravenous titrated Adrenaline or Dobutamine (medication to increase the blood pressure) in order to keep the patient alive after the patient’s pulse has returned.
It’s futile and a waste of resources.
Very often it’s futile because the parents themselves stop their kids from going to school so that they can go and beg for their and their family’s daily bread.
But.
We Bush Doctors and Do-Gooders do it anyway (try to educate the street children and try to do a cardiac resuscitation in a low resourced setting) because it makes us feel better.
ABOVE: Maslow’s Hierarchy of needs
To reiterate my point, I have never had a successful advanced cardiac resuscitation of a third world patient with pre-existing medical illnesses (diabetes, hypertension, cardiovascular disease etc). Versus the first world where we might have had a chance saving our patient if we had a cardiac catheter suite and a cardiologist on hand.
Which is why I now directly tell patients when they are overweight with lifestyle diseases that they are officially admitted to “Dr Jane’s Virtual Resuscitation Ward” and that their successful resuscitation starts that day when they’ve consulted me.
If they do not take my advice, sleep 7-8 hours, loose weight, eat wisely, they will die in an unsuccessful resuscitation because they have failed to get their health care under control.
We have no cardiac specialty access. We cannot do cardiac angiograms / imaging and stents to open up the blocked heart vessels.
We have no CT scans, we cannot thrombolize and break down blood clots causing strokes, nor do we have neurosurgery so we cannot remove the blood clot.
Doctor treat thy self. Sleep 7-8 hours. Move. Eat wisely. Find ways to stress less (stopping excessive device use would go a long way).
However one cannot say that to a street child, that unfortunately life has handed them a really shitty hand and they’re destined to a life of poverty and early death, with diarrhea being one of the top 10 causes if they are a child under 5 years of age.
Most people consider South Africa, my home country where I was born, bred and trained, to be a third world developing country.
But it’s not.
South Africa is developing but it’s closer to first world than to the Madagascan third world where we have called home for the last 14 years, and South Africa has several first world privileges (despite the power outages called load shedding that everyone is complaining about).
Returning to Madagascar from South Africa and listening to “first world problems” I am reminded to “just be grateful”, and at times I want to remind privileged passers-through, future Bush Doctors, Do-Gooders et al around me to also just be grateful.
Madagascar changes you because often you come with the expectation to change and save the world, but you can’t, and you don’t, and the irony is that the reverse happens.
You leave Madagascar feeling.
Grateful.
You witness communities living with a lot less and yet look, dare I say, happier, and more grateful for the really small things. the things we all take for granted.
No flushing toilets (but open defecation systems or the beach).
No running water (but buckets of water collected at town water points, when there is not interruption of supply).
No electricity (but a fire for cooking and perhaps a candle, because each light bulb in a household is charged for).
One to two meals a day (but no obesity and subsequent problems).
No mobile smart phones (but also no insomnia and subsequent health problems).
Returning from South Africa and listening to people’s first world complaints, and wanting to mentor privileged passers through, future Bush Doctors and Do-Gooders, I want to tell them what I have learned to be grateful for so that perhaps they come prepared to be changed.
And in so doing, perhaps learn just to be grateful.
Because I am….
I am grateful for an indoor flushing toilet. Not an open field or beach where I am conflicted about my ancestors and after-life mentors inhabiting the ground where I wish to do my business.
Grateful I don’t have to take my own toilet paper to public toilets. I don’t even have to pack a packet of tissues for “just in case” (but I do anyway out of third world habit).
Grateful I have electricity more often than not which not only supports several light bulbs which I am not individually charged for (but charged for non-the-less), but a fridge and several family electronic devices (the latter which diverts our attention and causes dopamine addictions, sleep deprivation and subsequent mental health issues – like the world needs more mental illnesses).
Grateful I have access to an unlimited food supply (which could be to the detriment of my weight, my cholesterol and my good quality longevity if I don’t manage this responsibility well and teach my kids to do the same).
Grateful myself and my family will more than likely not die from Tuberculosis or diarrhea.
Grateful my kids go to a school where they can obtain their internationally accepted school levers certificate, and a passport to travel, which ultimately gives them choices in life which privileged few have (relatively speaking to most of the 28 million people living in Madagascar).
Grateful I’ve been happily (80/20 - as in 80% happy, 20% rrrhh) living my dream job for the past 11 years, establishing and running my Robin Hood Community Clinic (aka Centre Medical de Taolagnaro).
Grateful, despite working in our frustratingly low resourced third world setting, that just by washing my hands, teaching others about washing their hands, and trying to change toilet behaviors, we can save lives.
Next time you’re faced with a problem or a frustration, perhaps consider asking yourself whether it’s a real problem or just a first world problem.
And echoing the words of one of the wisest women I know, who I have had the privilege of being raised by to be who I am today, just be grateful!
Kind and mad regards,
Mad Madagascan Mum and Medic,
Jane
ABOVE: My Mummy and I, My Wise Woman who first taught me to to just be grateful.