"She may have myositis."

"Stunned" describes my response when one of our Malawian physician assistants summarized his findings.  This employee had long struggled with managing sicker patients.  I had for years tried to focus his attention on the key facts of the complicated cases. 

Slowly, surprisingly, his evaluations became more cogent, his treatment plans more effective.  And, now, these improvements came to fruition in detecting a challenging (and potentially limb- and life-threatening) condition of the muscle.  (For more about this disease, common in Africa, see an article I wrote from Kenya.)  Two weeks later, following appropriate antibiotic therapy, the patient had improved greatly and was on the road to recovery. 

What if he had not made the right call?

In most African clinics, this diagnosis would never have been entertained, much less been treated successfully.  Often when I see Malawian patients, particularly from areas outside Lilongwe, they don't even know "how" to be examined:  When to breathe deeply, to open the mouth and say, "Aaaaahhhhhh," to sit and lie on the table.  More than one person has literally crawled on all fours on top of the clinic table.

The proverbial "Don't give fish, teach people how to fish" is a long, slow, and trying process.  It usually doesn't happen through a short-term seminar but rather through a long-term commitment, by knowing what is culturally appropriate and locally possible, by doing and showing more than lecturing and PowerPointing.

In 2005 the University of Maryland asked us to begin a training program at Kijabe Hospital.  The Maryland faculty wanted a place where people could "see what is possible" through good clinical care.  My colleagues and I determined that there were more than enough lecture-based "trainings" based in nice Nairobi hotels.  We meant to actually show people what to do.

To accomplish this goal required more trainers.  For two years I had worked side-by-side on a daily basis with two fine young physician assistants, Kenneth and Nancy.  They knew what I knew about HIV care in Africa and became the first teachers.

Nancy has since moved on to work with Doctors without Borders at their HIV clinic in Nairobi.  Kenneth turned the small initial effort into one of the few effective and innovative preceptorships in the region.  Two thousand trainees have completed 1-2 week mentored blocks.  According to surveys, most remain at their rural institutions, receive added responsibilities, and institute reforms.

Do the math:  If each of those people improves care for just one single person per day--just as the Malawian physician assistant detected the case of myositis--for 20 years, the effect is to reach nearly half a million people in two decades.  And the Kenyan national TB program wants us to train 3,000 more health workers.

Two weeks ago our HIV treatment counseling team brought together members of a dozen different support groups.  The goal was to multiply our community efforts beyond what the four team members could do alone.  The volunteer health workers--all HIV-infected themselves--would serve as the "early warning system," referring clients before they became deathly ill.  The Tigwirane Manja ("We should hold hands") staff had already been doing this, but there are so many patients it is impossible to reach them all.

When we began the community effort two years ago, the staff knew very little.  All are bright individuals, but they had never held the medicines, learned the dosing, or witnessed the side-effects first-hand.  Lectures were initially necessary but were followed by many mentored home visits.  Now, one of our staff can come to me and say, "I visited Thokozani.  She started the ARVs three weeks ago, but she is coughing and losing weight.  I think she has TB immune reconstitution inflammatory syndrome."  And he's right.

I stopped by the training.  The learners, under supervision from Mike and his colleagues, were holding the medicines, laying them out in any number of possible combinations based on side-effects and clinical condition.  Maybe I could answer questions?  "No, we are fine."  Maybe I needed to demonstrate something?  "We're OK."  The support group members were thrilled.  One remarked that no one had ever taught her in such a fashion.  A strange emotional mix of irrelevance and satisfaction came over me.  The successful fishing teacher has precarious job security.

Watching the team teach and transfer, I reflected on the nature of knowledge and change.  What had the program really provided?  Resources, yes, for salaries, transport, phone credit.  What I really saw was the culmination of a long-chain.  In medical training, I had absorbed content.  In Kenya, I had absorbed context.  In Malawi, I passed it on.