A lesson on physician activism from Malawi’s legendary Dr. John Chiphangwi

Five years ago, I was a doctoral student studying the history of medicine in Malawi, one of the planet’s poorest countries. I spent my days in a dusty archive, surrounded by the soft rustle of turning pages. It was there I learned about the activism of John Chiphangwi, an obstetrician who worked in an overcrowded and underequipped maternity ward in Blantyre, a center of commerce in Malawi. When the country’s murderous dictator, Hastings Kamuzu Banda, arrived for his annual Christmas rounds in 1978, Chiphangwi had a plan.

For years, women in the ward had to labor on the floor because there weren’t enough beds. Before previous presidential visits, women in labor would be chased away or hidden. But this time, Chiphangwi refused to hide the squalor of the ward. His colleagues fled, sure the young doctor would be executed. But as Banda walked through the ward, he blushed with shame. Chiphangwi did not die. Instead, two years later, he was working in brand new ward that Banda had ordered to be built.

Today I am a resident emergency physician working in Rhode Island. I spend my nights in a raucous emergency department, surrounded by the sounds of patients coughing and gasping for breath. I am reminded of the Malawi maternity ward because my colleagues and I — in fact, all of America’s doctors and nurses — are being told we must make do with less.

In many hospitals, including mine, health care workers reuse N95 masks for an entire shift. Many health care workers then have to place their masks in paper bags so they can reuse them the next day. This is a practice the CDC says is “not commensurate with U.S. standards of care,” though it acknowledges it may be necessary in a crisis-level shortage. Hospitals and other care facilities also face shortages of the gowns, gloves, surgical masks, disinfecting wipes, and hand sanitizer that health care workers need to safely care for patients.

In the midst of this scarcity, we hear patients worry aloud about the big bills they will receive after their hospital stays, especially those who have lost their jobs and insurance coverage.

We need to take a page from Chiphangwi’s activism and challenge the narrative that existing scarcities cannot be fixed.

There are, it turns out, fundamental choices that precede decisions about how to divide paltry supplies. The political scientist Ted Schrecker differentiates “second-order” questions about resource allocation from “first-order” questions about why resources are so scarce to begin with.

To be sure, some limitations in our response to this pandemic are outside human control, particularly now that it has spread so widely. Masks take time to assemble, so the current shortages cannot be resolved immediately. But the moment we accept that our job is to apportion the meager stores of equipment from our nearly barren supply closets, the imagination that we need to fight for more melts away. The only question left to answer then is who should be protected and who should not.

But so many of the present shortages can be remedied through stronger policy responses, such as the aggressive use of the Defense Production Act. Our task now is to move the discussion from the second order question of resource distribution to the first-order question of how to get more resources.

Health care workers are, for the most part, self-proclaimed rule followers. But you know what they say about desperate days. It’s time to break ill-conceived rules and adopt the activism and tools of community organizers. Their key strategic questions are: Who can give you what you want? And how do you get to them?

The answer to the first question is clear: President Donald Trump. Through the power vested in him by the Defense Production Act, he can force reluctant manufacturers to produce the vast quantities of urgently needed testing kits, swabs, masks, gowns, gloves, and more. He has the authority to quell the free-for-all private markets in which states, hospitals, individuals, and FEMA bid up the prices of essential goods and keep these goods from going where they are needed most.

The president can bring conservative Republicans around to the necessary policies of income replacement, universal health insurance, decarceration, and rent moratoriums. He can also steel the nation for the necessary period of social distancing and can direct the massive testing, contact tracing and isolation effort we will need to open society up again.

But will he do this? Trump has proved intransigent, more eager to accuse health care workers of pilfering than to heed their pleas.

Here again there is a valuable lesson regarding activism from the history of global health. In 1999, AIDS activists disrupted then-Vice President Al Gore’s presidential campaign announcement with chants of “Gore’s Greed Kills!” Gore, it turned out, had been leading the Clinton administration’s efforts to stop Nelson Mandela’s government in South Africa from using low-cost manufacturers to produce generic versions of patented AIDS medications. Gore was so embarrassed by the public criticism that the Clinton administration quickly changed its position.

Trump is similarly sensitive to public approval and private pressure. So perhaps we should take a page from the AIDS activism playbook by supplying reporters with timely information and video (without identifying patients, of course) documenting our experiences trying to care for patients in the face of equipment shortages. We could also shame the U.S. Chamber of Commerce board members, through social media posts, op-eds, and press appearances, for their lobbying against using the Defense Production Act more vigorously.

Nurses and doctors and other frontline health care workers can provide effective activism if we do not let ourselves be muzzled. Emails and directives from hospital public relations managers warning workers to stay quiet even as we witness avoidable deaths and unsafe practices must not be heeded, not this time. Hospitals are not to blame for the shortages, but it is their responsibility to protect workers and patients by being transparent about the challenges they face and encouraging any and all advocacy to obtain more equipment.

Some health care workers have already spoken out against shortages and unsafe conditions in their facilities. Colleen Smith, an emergency medicine physician at Elmhurst Hospital in Queens, sent the New York Times a video diary documenting 72 hours in her hospital, where supplies ran short even as city officials insisted they had plenty. After the images were replayed on cable news, the city sent additional shipments of protective equipment and nurses to Elmhurst.

When another emergency physician, Ming Lin, shared on Facebook a list of concerns about his hospital’s operations, the administration retaliated by refusing to schedule him for shifts. The nation’s largest medical societies, including the American Medical Association, responded with statements calling on employers to respect physicians’ freedom to advocate for the safety of health care workers and patients. The hospital quickly announced a slew of changes to its safety practices, though Lin has been forced to find work elsewhere.

I have begun trying to live by these examples, though even small steps make me wonder how my bosses will respond. When the governor of Rhode Island recently said that the personal protective equipment situation in the state was “not a crisis” and that workers “have what they need to do their job,” I joined a group of health care workers who disputed her claim. We explained that current N95 reuse policies are deemed appropriate by CDC only in case of a “crisis” level of supply shortages. Fortunately, the governor responded that the current shortages of personal protective equipment were “not satisfactory,” an acknowledgement notable for its contrast to statements by hospital administrators that supplies of this gear were “in good shape.”

John Chiphangwi risked his life to speak out against unnecessary scarcity caused by political inaction. If today’s health care workers stay silent, they increase the risk to their own lives and the lives of their patients. Even if speaking carries its own risks, we should follow Chiphangwi’s lead.

Luke Messac is an emergency resident physician in Rhode Island, a historian, and author of “No More to Spend: Neglect and the Construction of Scarcity in Malawi’s History of Health Care” (Oxford University Press, 2020).