Students for International Mission Service (SIMS)

As I sit on the wooden bench of the hospital courtyard, I feel the sun and warm humidity of the day wrap around me. I watch the chickens scavenging through the short grass of the yard, looking for rice dropped by careless children during the morning meal. Beyond the small yard is the inpatient wing of the hospital, and, with the windows open, I can see many dark faces and colorful clothes on the beds of one of the rooms. From the large number of people filling the outside benches it appears as though a new admission has come. It is always in the first few days in the hospital that great love of the patient is shown through many visitors bringing their gifts of bananas and sugared manioc. The children sharing my bench suddenly run off, scaring the chickens. Apparently, the novelty of sitting next to the only white person in what feels like a thousand-mile radius has worn off.

I hear the rattle of wheels of the surgery cart bringing the next patient. As I look over at the inpatient wing I see the trolley wheeling a woman through the courtyard and over to the doorway where I sit. She is covered with a sheet, her braided hair hanging over the edges of the cart, and talks rapidly in Malagasy with the surgery tech. As they move toward me, I part the curtain under the sign “Bloc Operatoire” and follow them directly to the operating room. I begin the scrubbing process while waiting for Dr. Sakifear, and in a random combination of French and Malagasy, I gather from the surgery technician that we are going to operate for appendicitis. I am going to assist the doctor alone because today is the vanilla market, and the usual technician must help his wife carry their baskets into town.

While the woman lies naked on the trolley in the center of the room, we prepare for surgery, laying out the enormous “elephant needles” and string for suturing, the suction device for collecting the blood, and finally asking her to roll over for the administration of anesthesia. During this time, she has had many questions to ask the technician regarding this “vazha doctor” (stranger or foreigner) and why I am here. The parts of the explanation I understand involve me being a student from the United States near California who wanted to see the country of Madagascar.

This summer, I was able to work and travel in the African country of Madagascar through a medical missions program organized by LLU, and this story is from one of many mornings I spent in a small hospital there.

Madagascar is home to one of the world’s less widely known human cultures. Situated in the Indian Ocean, 250 miles off the southeast coast of Africa, the island is not really a part of the Dar Continent, especially as Malagasy cultures—particularly the Malagasy language—have more in common with Asia, especially Indonesia, than they do with Africa. Despite this diversity of mixed Malayo-Indonesian and African-Arab ancestry, the island is united by one common language, which stems from Malay, Indonesian, and Maori. Malagasy is the national language, while French is the second official language and is widely understood and used in all tourist areas.

The physicians I was able to work with had the needed advantage of being native Malagasy with a medical school preparation in the capital city of Antananarivo. Because of this education, they were regarded by the lay population as the elite of society. They are understood to be incredibly rich and are often unapproachable in the market or on a dirt path in town. However, in clinic or the hospital, the patients overcome this attitude and often move to the other extreme of completely disregarding what the doctor may tell them. Prescriptions are taken as the patient sees fit, follow-up visits occur along with waves of sickness, and if immediate cessation of pain is not brought about, they will move on to one of the many dispensaries or “village doctors” for attempts at another cure.

This type of misunderstanding stems from lack of education and communication within the population at large. It is reflected in areas beyond medicine as well, especially in projects of public health and community development. Examples can be seen in the areas of latrines. The infectious diseases passed by human waste are many, and they are all seen often in clinics throughout Madagascar. There are always villages down the river who use the water polluted by another village’s night soil to water their plants, wash their clothes, and cook with. For this reason, the government required the building of a certain number of latrines in each village. Yet, after a year when the latrines were inspected, some of them had never been used. The village complied with the building, but the people couldn’t understand why you would want to use a communal bathroom. The latrines smell, become dirty, and aren’t convenient to the houses. It was much more pleasant to continue to use the bushes as they had always done.

The frustration felt by public health officials, especially those from America and European countries, is understandable, yet the explanation of the Malagasy people is logical. The impact of improvement projects is slow to none, and attempts must be made to deal with the reasoning of the villagers. Pictures and diagrammed posters of latrines, bushes, bugs, and sickness are wonderful, but one must find a way to prove that the decreased level of sickness is actually of greater benefit than the annoyance of using the latrine. Following this logic, projects aimed at decreasing the incidence of STDs have adopted the educational approach. Rather than giving a Malagasy a talk on the dangers of sex, English clubs use safe-sex reading material for teaching English. This combined approach takes advantage of the fact that the younger population, with the rising rates of disease, wants to learn English above all else. If a free club is offered, they will return weekly and eventually the pictures of the diseases and the use of condoms are communicated. The essential element in any project is patience and taking the time to understand why certain approaches don’t work. This same baseline can be applied to the practice of medicine in the United States.

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“I said at that moment a short prayer that I ended up repeating again and again, ‘God, don’t let this child die.’” David Creamer sophomore School of Medicine

While in the United States, doctors commonly share the same language as their patient, the cultural backgrounds may still be different, and this difference affects the relationship. Culture incorporates assumptions, beliefs, and lifestyle practices in such a way as to unconsciously direct the actions of its members. Individuals are molded by their family experiences and current situation, and often this is overlooked in medical treatment. While my experience in Malagasy culture enabled me to clearly see the difference between my American paradigm of medicine and theirs, it also opened my eyes to the more subtle variations in fellow Americans. My trip heightened my realization of the importance of understanding your patients’ environment and how this factors into their use of the medical facilities offered. I want to understand the background of my patients and their needs so that together we can take the best care of them.

[Outlook 2002]

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