Mchinji District Hospital (Impressions, 2008)

Dr. Mac Calder, an emergency medicine physician who practices in Traverse City, Michigan, first ventured to Malawi as a medical student working with Dr. Terrie Taylor from Michigan State University. After this seminal experience, he returned to Malawi a few years later and explored beyond the booming central hospital in Blantyre to a district hospital on the border of Mozamibique. The following are his words as he described the district hospital to friends and family in April of 2008:

Greetings from the southern hemisphere! Things here in this forgotten
corner of the world are chugging along just fine. I am happy and
healthy, and have so far thwarted attempts of various parasites
setting up shop in my body. So life is great!

Since most of my days here in Malawi are spent in Mchinji District
Hospital, I thought I'd share some of these interesting experiences
with you. Every single day presents me with many challenges, placing
me in unique situations unlike I've ever experienced in my short
medical career. Each day has moments of joy, like watching a child
being born and taking her very first breath, and moments of sadness,
like watching a patient slowly die and eventually take his last
gasping breath. Despite being faced with challenges on a daily basis,
I do feel like I'm making a difference, if not to the system as a
whole at least to the individual patients I see. For this reason I am
enjoying my days at the hospital, finding the work rich and rewarding.

Mchinji District Hospital is a sprawling brick one-story structure
just off the main road. It has an open layout, with many hallways
having just a roof and no walls. The floors are gray concrete and
actually very clean thanks to the legion of moppers perpetually
working their way up and down the halls. During storms the rain
crashes down on the corrugated tin roof like a locomotive, and the
leaks create an obstacle course of drips and puddles in the hallways,
much to the moppers' chagrin.

The power goes out in the hospital regularly, just like in the rest of
town, but it doesn't really matter too much. Windows provide all the
light during the day, and candles are lit at night during outages. We
don't have any ventilators or cardiac monitors or any other vital
equipment that needs electricity. Most Malawians don't have
electricity anyway. They use candles and cook their food over the
coals of a fire. In fact, less than one percent of households in this
district have electricity. There are two turbines at the
hydroelectric dam on the Shire River that provides all of the
country's power. The upstream hippos churn up the shoreline during
the rainy season, and set afloat large islands of soil and grass that
clog up the turbines causing the temporary blackouts. But it doesn't
really phase us.

The hospital is divided into several sections known as wards, each
branching off of a long central corridor. There are five wards: male,
female, maternity, pediatric, and tuberculosis wards. Chris works
mainly in the female ward, and I work mainly in the male ward, but
there is considerable overlap throughout the hospital. Each ward is
compromised of two large gymnasium-like rooms with yellow plaster
walls and open slat windows for breeze, separated by the central
nurse's station. There are about fifty-or-so beds in each ward, and
often twice as many patients. A patient in bed 34-and-a-half, for
example, would be found in between beds 34 and 35, curled up on a thin
mattress on the floor. The exception to this system is in the
pediatric ward, where there are 4 children per bed, all of them lying
sideways across the mattress so they can all fit, and their mothers
camped out on the floor between the beds.

In each ward there is also an isolation room for patients with
suspected tuberculosis and other such highly infections conditions.
Isolation, however, is more of a fancy title than true physiological
barrier because of the open doors and windows, with the breezes and
insects helping to facilitate the spread and reproduction of various
virulent organisms. I suppose it's like sitting in a restaurant at
the invisible border in the non-smoking section just one table over
from the smoking section. The isolation room is usually full of
ill-appearing patients hacking and spewing on each other,
inadvertently sharing gobs of sputum and diarrhea and other
foul-smelling body fluids. We are required to wear a "mask" when
entering that room, but I hope you're not picturing any kind of
tightly fitting filtering device, or even anything that could be
construed as being protective. The so-called mask consists of a
corrugated nano-thin piece of tissue paper with elastic loops that
hook around your ears to keep it in place. It stretches out to
partially cover your mouth and nose, and is completely ineffective.
If I sneeze the mask only filters my sputum into a finer mist that
sprays on whoever is in range, and the mask seems to attract and hold
more pathologic microbes closer to the opening of my respiratory
system. In fact, the only function the mask serves is to hide my
horrified facial expressions when experiencing the aforementioned
bodily fluids, and the myriad creative ways individuals expel them
from their various orifices.

Our mantra at the hospital is, "Let's do the best we can with the
limited resources we have." That's just a nice way of saying, "We
don't have a lot of stuff." What we do have, however, is a few basic
lab tests, an x-ray machine, and an old ultrasound machine. We have a
small pharmacy that stocks a few basic medications. And most
importantly we have our clinical skills, the ability to get a good
history, and a friendly smile. I do my daily rounds in the wards, and
also work in the intake department admitting patients. I am involved
in both the bedside and formal teaching of the Clinical Officers, the
clinicians who see the patients of a daily basis. In turn, they are
teaching me the practical and improvisational approaches to rural
tropical medicine. It is a satisfying exchange of medical knowledge
and ideas.

The diseases here are outstanding and dramatic. Some conditions are
the same as we have back home, such as pneumonia, strokes, fractures,
and trauma, but many conditions are rare or non-existent in North
America. There is a significant amount of malnutrition, such as
kwashiorkor and marismus, and some severe wasting in the HIV
population. Some of these people are mere skeletal shells of
once-healthy people, often too weak to hold themselves up. There are
many opportunistic infections that you or I can easily fight off, but
the defunct immune system of an HIV patient cannot. In this
population we see lots of pulmonary tuberculosis, oral and esophageal
candidiasis, kaposi's sarcoma, and various exotic types of meningitis.
We see lots of tumors, some wicked festering wounds, and spleens the
size of footballs. It's almost impossible to live here and not
occasionally acquire some parasitic infection. We see lots of
schistosomiasis, filariasis, nematode (worm) infections, and of course
the granddaddy of all parasitic infections, malaria.

Malaria is a leading cause of death in this region, and is probably
the world's most important disease, adversely affecting social and
economic development throughout the history of humanity. It is one of
the neglected diseases, and is both controllable and preventable.
Malaria infects 500 million people a year, and kills about a million
people per year, mostly children who are the most vulnerable to the
disease. In Africa, 6,000 children die every day of malaria. In
Mchinji we treat well over a hundred malaria patients every day with
effective medications, but even so death is common with the late
presentations and high parasite loads. Malaria causes severe anemia,
and I am amazed at how low a child's hemoglobin can get. A normal
level is about 13, but it is common to see surprisingly low hemoglobin
levels of 4 or 3, values seemingly incompatible with life. I saw one
kid the other day with a level of 1.7! I made him the fifth honorary
mzungu in town because of his pallor. We transfuse blood if a
hemoglobin level is less than 5 if there is any in the blood bank, or
if a family member donates some.

HIV and AIDS is also a huge public health issue in Malawi, and usually
steals the spotlight from the less glamorous diseases like malaria.
Worldwide, there are 40 million adults and children with AIDS, with
sub-Saharan Africa being the epicenter of this epidemic, with 26
million people living with HIV/AIDS. Malawi has one of the highest
HIV/AIDS prevalence rates in the world of 14%. Life expectancy has
plummeted from 54 years before the epidemic, to 39 years now. The
number of orphans related to the AIDS epidemic is 700,000, with 60,000
added every year. Obviously this is devastating to family structures
and economic development, and thus further contributes to poverty,
crime, and political instability.

Thankfully the government provides free health care for everyone (like
most industrialized countries) including antiretroviral drugs. About
half of the patients in the male and female wards are HIV positive, as
are about 90% of the patients in the TB ward. Obviously getting an
accurate history of HIV status is very important, and so I discreetly
ask my patients if they've been tested for HIV, but I've learned to
use the much more accepted euphemisms "immunocompromised" or
"seropositive." "HIV" is something that is not uttered aloud. It is
the Voldemort of the infectious disease world,
the-disease-that-shall-not-be-named.

Malawians don't complain. You'll never hear an angry word about a
power outage, or a grumble about sleeping on the floor between beds,
or protest for not being seen for several days, or about a lab result
that takes a week to get back. Malawians are tough and roll with the
punches. I am certainly starting to appreciate the uncertainty of
what's going to happen next in my day, to curiously anticipate what's
going to go wrong and need troubleshooting. Our society plans too
much, and we often get bent out of shape when things don't go exactly
according to plan. You have to relinquish control a bit to sail
smoothly. It is refreshing to improvise, to revert to plan B or C, to
have your feathers ruffled.

So there's a quick overview of medicine in Mchinji. I am definitely
out of my element, a fish out of water, and I kind of like it. I
believe there is value in being uncomfortable sometimes. It makes you
appreciate what you have.

That's the news from the hospital. I'll try to scrub up really well
before I return so as not to bring home too much of other people's
bodily fluids. Until then I'll be sure to keep my mask on in the TB
ward.

Pathologists for Malawi (Vol 1, No 1)

We have recently begun an effort to bring volunteer pathologists to Malawi for the next 4 to 5 years in an effort to provide continuous service coverage while the COM and MOH transition to having full time Malawian patholists in place in Blantyre and Lilongwe. Below are the most recent updates for this project.

I have learned from my fantastic colleagues at UNC and KCH in Lilongwe that Dr. George Liomba will be spending a few days every two weeks in Lilongwe to read slides and interpret them. This is an excellent arrangement and I am delighted George is able to move the KCH pathology lab forward! We will be coordinating the Blantyre volunteers with George's schedule so that we maximize coverage in Lilongwe and avoid overlap.

Dr. Kamiza has finalized the process for obtaining a medical license for the visiting pathology volunteers (fee is $250 US). The process will require that the volunteer provide a copy of their CV, a certificate of good standing, copy of professional degree and to complete two online forms which can be found at the following links:

http://medicalcouncil.org/printregistration.htm

http://medicalcouncil.org/declaration.htm

The primary medical council web site is: http://www.medicalcouncil.org/

I have compiled a "Case Log" which shows ~half of the cases that were encountered during one year. This electronic record was created as part of a research project so the diagnoses represent those that my students were collating from the attached appendix. You will note that MOST of what is missing are non-diagnostic or normal biopsies. This gives you an excellent flavor of what we see in Blantyre. Also note that, although the case numbers are deleted, these are IN ORDER as received so you can see how some clinics seed things in batches. One important aspect of pathology service which can be reiterated by our clinicians at QECH is that the pathology service is currently underutilized so that VOLUME of cases may increase dramatically as we improve turn around time with volunteer presence. For example, KCH estimates that only about 5% of patients who NEED biopsies are receiving them.

Pathpedia is a unique forum to discuss pathology including global health and can be found at this link: http://www.pathpedia.com/Default.aspx

Our first two visitors will be Dr. Petr Skapa and Dr. Chris Hansen. There is quite a buzz about potential utilization and possibly training in FNA techniques during our volunteer visits and I think this is an excellent opportunity if QECH can accommodate them. My suggestion to the clinicians is that the pathologists be allowed to work at COM in the mornings (to complete the day's sign out) and then schedule with the clinicians (on the days that make the most sense) to come in the afternoons to work on FNA techniques, etc. The most efficient way to achieve this is an open line of communication between the visitors, Dr. Kamiza, and the clinical teams at QECH. I look forward to this potential improvement and hope it can greatly impact the care of our patients in Blantyre!

Research Capacity: Building for the Future

The University of Malawi College of Medicine recently announced that it's 13th annual Research Dissemination Day would be held on Saturday October 17th, 2009 on the main campus in Blantyre. The focus of this years conference is "Capacity Building for Research in Malawi."

Capacity building in any setting is a required but often expensive endeavor when the ultimate goal is increased productivity, expanded opportunities, and institutional advancement. Capacity building in "remote" parts of the world (i.e., any location for which shipping/transport and/or local manufacturing is not established to the point of feasible economy) faces several challenges which may not be anticipated by "outsiders" wishing to help. For example, the donation of a chemistry analyzer to a hospital, clinic, or even research laboratory within a school of medicine by a foreign donor is of little to no value to the receipient unless it is provided with several years of reagents and a service contract for machine maintenance. In addition, careful shipping of such peices of equipment can add significant cost for simply getting the machine to the right spot. Technical expertise with the operation of a such a piece of equipment is easily achieved by training local bright enthusiastic minds (which are readily available) but still requires getting a technical expert to the country for an extended period to perform the training. Despite these challenges, if a piece of equipment can be delivered, service and reagents provided, and technical training completed, the functioning device can have immediate benefits including providing research data for analysis, providing laboratory data for economically depresses populations, and generating revenue by providing laboratory data for paying populations. An example of such a successful process includes the Magnetic Resonance Imaging Center at the Queen Elizabeth Central Hospital in Blantyre which was donated by General Electric (including transport and set up of the machine to Malawi) and is supported for performance and maintenance by research grants as well as revenue generation from private pay patients. One of the most successful aspects of this particular event, however, was the presence of a Malawian radiologist who was already an expert in his field who provides the day to day productivity of the machine.

This example illustrates one of the MOST important aspects of capacity building: people. The Research Dissemination Day at UOMCOM is an excellent opportunity for faculty of the college (both foreign and domestic) to highlight the range of fascinating and important projects happening within the College. In recent years, 4th year medical students at the College are now required to perform a research project during that year. With ~60 students per year, this requirement allows exploration of the breadth of research possible within Malawi and allows students who may be interested to have a concrete experience. It is these very students who must be nurtured in the 5th and 6th year with more exposure to research and it's uses if there is any hope of retaining them as "research scientists". Can every student be a "research scientist?" The answer is, of course, no. Primary care, surgery, obstetrics, pediatrics, nutritional support, and infectious diseases training for the care and treatment of the population of Malawi is still the highest priority as the College tries to fill the void of physicians which is common in much of Africa. However, it is not too early to recruit handfuls of students per year who may wish to pursue research careers.

Retention of highly skilled and well trained people is ALWAYS a problem for any business. "Brain drain," as it is called, is NOT a unique problem of Africa. Africans who choose to pursue careers out of their home country for increased salaries and benefits for their children can not be blamed for this behavior. Just like any major academic center, the people who work within these institutions spend much of their time teaching, providing clinical service, and possibly devoting a little or most of their time to research--often at salaries much less than they could expect in private practice or within commerical biotechnical companies.

Michele Barry, in her Presidential Speech to the American Society of Tropical Medicine and Hygiene "urge(d)...members to host...overseas scientists and create collaborative field sites to enhance research capacity around the world" with an emphasis on "fund(ing) young scientists from developing countries to return to their indigenous countries with financial and institutional support". This concept, although simple in principal, is extremely important, perhaps the most important aspect of establishing feasibility for a young Malawian scientist to make his/her way. They must be provided support which includes a living wage and enough initial support to establish themselves as scientists and seek out grant and other funding to move forward in their career.

Seeing this as paramount, the UOMCOM has made strong efforts to recruit young enthusiastic scientists to its fold. The results of these efforts will be easily surmised by attendees of the upcoming Research Dissemination Day. More is still needed to dramatically change the environment in Malawi including post-graduate advance medical training IN COUNTRY; however, the progress that has been made is not only impressive but should be equally encouraging to young Malawians as evidence of the feasibility of a career as a research scientist in their home country.

Welcome Dr. Milner!

We would like to warmly welcome our first blogger, Dr. Danny Milner!  

Dr. Milner is an Associate pathologist and assistant medical director of microbiology at the Brigham and Women's Hospital. He is an instructor and an adjunct lecturer at Harvard Medical School and Harvard School of Public Health, as well as a honorary visiting lecturer at University of Malawi College of Medicine in Blantyre, Malawi. He has been collaborating with the University of Malawi's pathology department in the past nine years to help develop capacity and transfer technology. 

He is an exceptional researcher, teacher, mentor, and an extraordinary human being, and it is a privilege to have him write for our blog! 

Global Medical Knowledge: New Blog about Malawi

Visions from Malawi is a blog created to unite those interested in health and Malawi. 

Please continue visiting us to see updates from physicians, academics, students, and others on their rich and unique experiences in Malawi. 

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This blog was started by the GMK team, please see our site for more information on our organization: www.globalmedicalknowledge.org