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.