Jody Olsen, PhD, MSW, Chair of the HVO Board of Directors, writes this installment of Trends in Global Health, sharing a personal experience with using storytelling to identify the unique strengths and limitations that affect health systems in resource-scarce settings to illustrate why storytelling is a powerful tool to improve global health.
We all have histories, cultures and traditions that influence how we practice as health professionals. Those we serve – patients, clients, and colleagues – have equally important backgrounds that affect their health status and health outcomes. Better health care begins with relationships built from the exchange of these personal stories, so how do we uncover the stories of others as we share our own?
Three years ago, I took an interprofessional team of 12 senior graduate students studying dentistry, law, medicine, nursing, pharmacy and social work, to Chikwawa, a rural district in Malawi, southern Africa. The purpose of our trip was to review the 12 maternity clinics in the district through the lens of the WHO Safe Motherhood research methodology guidelines, a project that was signed off on by the district health ministry.
Malawi has one of the highest maternal mortality rates in the world. As of 2015, there were 634 deaths per 100,000 live births. Comparatively, the U.S.’ rate is 14 deaths per 100,000 live births. Malawi’s Ministry of Health is working to change procedures to save more mothers’ lives, but with limited resources and long-standing traditions, change comes in tiny steps.
At the first clinic we visited, expectant mothers waddled uncomfortably across the tamped down and swept rust colored dirt floor of the two-room building, their swollen bellies obvious beneath the yards of brightly flowered cotton cloth swathed around their bellies, hips, and legs. They paced, whispered to each other, and stirred corn paste in bowls on charcoal cookers. We noticed that each woman carried a purse or bag, bought for a few cents at a roadside used clothing market – an unusual accessory for Malawi women. These bags had been discarded by their original US or European owners. The bags were made of cotton, plastic or leather, and had likely originally been used to carry groceries, cosmetics, books or computers. No two bags were the same, and each bag had a story unknown to the women who now carried it.
These women, and thousands like them throughout Malawi, had been encouraged by the clinic to buy and pack the bag when they reached their seventh month of pregnancy. If the women went into labor and began the hours-long walk to the clinic to deliver, their newly created “delivery bag” would be stocked with a fresh bar of soap, a large bottle of clean water, two new or freshly washed large pieces of cotton cloth, and a new razor blade—all necessary as the birthing clinics were without water, electricity, or basic supplies. When they reached eight and a half months in their pregnancy, expectant mothers walked several hours to the nearest clinic and, with others like them, set up camp outside and waited for labor to begin. These were the women we observed.
Working in pairs, our team separately interviewed expectant mothers, other patients, and staff at the clinics we visited. We reviewed delivery charts, available equipment, and the facilities themselves. We spent a full day in each clinic introducing ourselves, sharing our backgrounds, and listening to stories, experiences, fears, and traditions. The students were experiencing their first trip to Africa, their first time working in maternity clinics, and their first time working together as an interprofessional team. We took copious notes. We visited all 12 clinics, and even risked losing our van to a river we crossed to be sure we saw each one.
After we completed all the visits and prepared a detailed report on each clinic, we brought the 12 clinic directors together to thank them and share the results of our visits, clinic by clinic. Each director was given an individual report on our visit to his clinic, and each spent time with ‘his student’—a team member assigned to review details and outcomes of this report.
Before the meeting, as the students reviewed the results and prepared the reports, they feared they had taken valuable time and human resources from the clinics without giving back. “We used them,” was one comment. “We learned so much from the clinic visits, but we left nothing of consequence behind.” They wished they could have brought blood pressure cuffs or thermometers as a way to say “thank you.”
As the group of directors and students finished the afternoon meeting and shared snacks and soft drinks, the students asked the directors if they had any additional comments or questions for the team. The students were stunned by the directors’ appreciative responses. “You spent a day with us, listening to us. No one else has done that.” The directors also commented that they appreciated that the students cared about what they did with so few resources; that they had learned from the students’ interviews that patients trusted the clinics; and that they were grateful that the students had reviewed their carefully recorded medical reports page-by-page. No one had ever asked to see these reports before the students arrived. The clinic directors were heard, and they were shown respect for what they did day-after-day. They wanted to be sure our report was delivered to the minister of health so he would know how hard they worked. We delivered the report—their story—to the minister. This was how we were able to say “thank you.”
Our visit to Chikwawa was the first step toward change – a step that included building trust through the sharing of stories. We believe this trip laid the foundation for a path forward, comprised of many small steps toward better maternal health outcomes and future partnership with interprofessional teams.
HVO volunteers may not always be sure how best to use their medical knowledge to support their colleagues in resource-scarce countries. During our visit to Malawi, my students and I learned that actions that seem small to us—exchanging stories, listening to our colleagues, asking questions and acknowledging their work—might make a tremendous difference to the providers we seek to support. Sharing histories and traditions with health workers in resource-scarce countries is a critical step toward improving global health outcomes. Positive change often begins with time spent sitting together as equals.