Brian Barnett, Fulbright-Fogarty Fellow in Public Health
April 17, 2014

Facing many structural and economic realities, Brian Barnett learned to appreciate the culture of waiting and the extreme patience required to do clinical research during his Fulbright-Fogarty Fellowship year in Lilongwe, Malawi.

For much of my time in Malawi I struggled to grasp even the basics of Chichewa, the most widely-spoken indigenous language of the country. However, there was one oft-repeated word that I learned very quickly, without difficulty. Ironically, that word, pang’onopang’ono, translates in English to, slowly, slowly. During my initial months in-country, whenever I heard it terror would envelope my mind, as it was often being used in reference to an unfinished task related to my research that I had assumed would have already been completed by the speaker. With time though, I found that the word was applied to many other situations and that its true meaning is much more complicated than the English words it translates into. You see, instead of being a simple reassurance, pang’onopang’ono represents a prominent facet of Malawian consciousness. For someone who had come to the country to carry out productive clinical research, my discovery of this concept was not an entirely new one. 

barnett labEarly on in my research, my mind was often consumed by concerns that the entrenched bureaucracy,
staff shortages and systemic inefficiencies surrounding me might prevent me from accomplishing anything at all with my time. I had come with expectations that I thought were realistic for a year—I would work with Malawian colleagues to determine the prevalence of multi-drug resistant tuberculosis in the city of Lilongwe, while learning to conduct effective clinical research and observing the Malawian way of life firsthand. However, as I began to look around, it seemed that everything occurred too slowly for my liking—the movement of lines at the grocery store, the speed of the traffic, the bandwidth of the internet and so much more. It wasn’t uncommon for people to be late for meetings or even late for work. In short, it was the antithesis of what I’d experienced my whole life growing up in the United States. As I dwelled on the situation more and more, I eventually found myself wondering if the quantification and measurement of time was just a Western concept that our ancestors had forced upon other cultures, with varying success, through the physical and structural violence of the colonial era, comforting one, though it was perhaps the most educational aspect of the time I spent immersed in that culture.

Then came the political deterioration. Poor sales of the preceding year’s tobacco crop—the country’s main source of self-generated income—and political controversy that resulted in the withholding of foreign aid left the country severely lacking in foreign currency. A new normalcy built upon chronic shortages of fuel, medications and sugar quickly developed. People waited in line for 12 hours or more at a time for gasoline and diesel, often returning home empty-handed even after having endured such an unfathomable wait. The black market responded quickly, with gasoline being smuggled into the country and domestic gasoline being resold at $23 a gallon. In response, the buying power of Malawi’s currency, the kwacha, corroded with each passing day. Before long, waiting, something I despised and hadn’t done much of for many years, had become an unwelcome and prominent part of my daily life. Much of that time I spent silently fuming, but sometimes I found myself being drawn into nearby conversations in the fuel and grocery lines. They usually focused on politics and sports, but were wide-ranging, providing me with an unexpected and unfiltered view of Malawian culture that I could have never found otherwise. Despite the extreme nature of the chaos surrounding us, I found that the Malawians’ response to it was one consisting of patience and grace. Of course, some of them complained as any human would. However, having come from the US—where we expect our pizza to be free if it isn’t delivered in 30 minutes and cringe when the elevator has to stop to pick up another passenger—their complaints were mild and completely understandable. Many expressed hope that things would improve, though they were quite aware that any positive change would come as it always had—pang’onopang’ono.

At first my concerns about the fuel shortage were quite selfish. Would it prevent weekend excursions for me and my friends to the beautiful shores of Lake Malawi or trips to a local bar to play volleyball on Wednesday nights? In fact, it did, leaving my friends and I sitting around idly frustrated many weekends. As the situation continued to deteriorate, however, I bore witness to a much more significant consequence. The lack of fuel was significantly intensifying the already desperate poverty of those living around me. Minibuses, the primary form of public transportation in Malawi, began taking much longer to fill than in the past, as passengers felt the squeeze of fare increases and inflation. The streets subsequently overflowed with pedestrians, and the main roads became almost completely devoid of cars at times. Protests and clashes between frustrated street vendors and police became commonplace, leading to the periodic appearance of warnings for US citizens from our embassy in my inbox. The people of Malawi pressed on though, undeterred in their efforts to lead productive and enjoyable lives no matter how extreme the adversity.

Predictably, the patient flow decreased at the HIV/TB clinic where my team enrolled patients for our study, creating further headaches for me professionally. For a study that was already experiencing problems attaining sufficient enrollment numbers, my worries about our suboptimal recruitment intensified. Pang’onopang’ono, the patients came through, usually on foot and often with no shoes, to seek treatment for tuberculosis (and often concomitant HIV) that had gone untreated for months in many of them. Sometimes they arrived alone, sometimes with a baby on their back and sometimes with a guardian helping them stand when they couldn’t on their own. Attempting to envision the mountains of obstacles they must have conquered on the way to the clinic—being in the throes of severe illness, lacking money, having difficulties with transportation and traveling long distances just to name a few—it was impossible not admire the resolve of these determined individuals. Even after having navigated the aforementioned obstacles, waits of several hours at the clinic awaited them due to systemic inefficiencies despite the low patient volume. They had expected this though and endured it admirably. What was a few more hours, when you’d being experiencing pang’onopang’ono your whole life?

Unlike the sterile, silent waiting rooms back home in the US, the area in front of our enrollment room was open to the elements and filled with patients talking to one another and smiling far more than I would have ever expected in a group of people infected with such devastating illnesses. Though these people likely possessed little material wealth, the richness of their interpersonal interactions was more impressive than any fortune that could ever be amassed. I found myself consumed with envy as I wondered how my own culture had lost such an appreciation for the moment and the ease of establishing interpersonal connections with total strangers. Pang’onopang’ono, I realized, had many benefits that I had not been able to previously perceive.

If the patients were diagnosed with tuberculosis we invited them to join our study. Amazingly, most did. No matter how long they had waited, how hungry their emaciated bodies must have been or how far of a journey lay before them, they greeted the study staff and myself like relatives and gave me respect reserved for someone far above my pay grade. Their faith in the work we were doing, though they most likely did not understand its intricacies, reminded me of my initial motivation for seeking a research career in the first place—to use my talents for the creation of knowledge that would benefit those unable to help and advocate for themselves. Unfortunately, my memory of this had been clouded by the stress created by my desire to be productive and the development of the egocentric worldview that can insidiously take over during medical training if one is not mindful of its presence.

In retrospect, it’s fascinating to trace the evolution of the concept of pang’onopang’ono within my mind from an initial annoyance to a powerful philosophy that reminds me to slow down, live within the moment and give attention to those around me, as they deserve. Now that I’ve returned home to the US it’s rare that I wait long for anything. However, when I do, I remember how Malawi allowed me to regain appreciation for that time and reminded me of why I sought a career as physician-scientist in the first place.