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400 inpatients, 256 beds, and one doctor
Malawi, in southern Africa, is ranked among the poorest countries in the world, and many of its hospitals have only basic facilities. Rebecca Hodgkinson shares her elective experience, which she spent in a district general hospital to the south of Lake Malawi
Malawi is a country of contrasts. On one hand it is a country of awesome beauty with tropical beaches and a huge freshwater lake set against the background of the Mozambican mountains. On the other hand, it is a country burdened with malnutrition, HIV, and infectious diseases. It is also ranked among the 10 poorest in the world. I decided to spend my elective working in the district general hospital in Mangochi, at the southern tip of Lake Malawi, close to the Mozambique border.
Key facts
- Population--11 million
- Languages--Chewa and English
- Capital--Lilongwe
- Currency--Malawian kwacha
- International code--+265
Tuesday 23 April
*Cups of coffee: 0; weight lost: 2 kg (mostly water); women at clinic: 200; times I have pinched myself to prove I am actually here: 54
Today we went to Mangochi and met the people we will be working with. It is a different world. Cows and goats wander around the dirt drive of the hospital. Some women queue at the hospital's sole water pump. Two hundred other women wait patiently outside the shack that houses the under fives clinic for immunisations; there are
children everywhere and people are breast feeding everywhere. Behind the hospital, crowds of people had set up camps. I find out that these are the guardians, who travel miles to provide food and laundry for their sick relatives in hospital--no one else will provide it. These guardians have no facilities; they sleep under the stars and carry their sacks of maize with them to the hospital.
The village's health centre is the main healthcare provider; there are no specialist services outside the cities. At the time of our visit, the hospital had more than 400 inpatients, 256 beds, and one doctor. The role of the doctor in the hospital is very much hands off. Three clinical officers serve the hospital. They are trained for three years, but only in basic procedures, and not in any of the basic sciences. They do caesarean sections, see ophthalmology outpatients, do ward rounds, and have theatre duties, among other things. Being on call 24 hours a day, seven days a week every third week, the clinical officers work extremely hard for their monthly payment of £20 ($34; €).
Wednesday 31 April
*Caesarian sections: 2; normal deliveries: 2; stillbirths: 1; volume of water from taps in the past 8 hours: 0 ml; outside temperature: 40°C
Pathology is so obvious here, which makes it much easier to learn medicine than in the United Kingdom. We spent much of our day in theatre--the only place in the hospital below 35ºC. There are no scrubs available for women so we entered the theatre in comic attire--nurses' uniforms, cloth hats and wellington boots that were at least eight sizes too big. Concepts of anaesthesia are interesting here; caesarean sections are done under spinal anaesthetic, but no infiltrating lidocaine is given, and it is a nurse who usually does this procedure. I am amazed how stoical these women are and how tough their lives are--they have lots of babies, many of whom are stillborn or die young, they work from dusk to dawn, and they have no autonomy from their husbands or society. I am not sure whether I should pity them or be inspired by them. Another thing--we have had no running water all day in the hospital. We had to use precious bags of saline for hand washing.
Resourcefulness is a useful skill in Malawi, and the health service relies on it. It is surprising how much can be achieved in a service that operates with so little. To improve public health, each village has a health committee, which guides the ill villagers to the correct health service. It also has birth control advisers, who are local women trained in contraceptive education and are able to distribute the oral contraceptive pill. Another small group of villagers form the drug revolving committee, which sells basic drugs at cost prices. This money is used to refill the stocks. It is a real education managing without electrocardiograms, blood tests, x rays, expensive drugs, and specialist advice. You learn to rely on clinical judgment and to prioritise.
PHILIP IDE/REX
Friday 2 May
*HIV prevalence: 25%; septic wounds after caesarean section: 50%; times I could have cried: innumerable
The most distressing cases I have encountered so far involve pregnant women infected with HIV. Often there is a great dilemma between ensuring the greatest chance of survival for the two patients--mother and fetus. With sparse neonatal facilities and few measures employed to prevent vertical HIV transmission, this dichotomy is often unsolvable. Young girls are struggling to survive long enough for their unborn babies to have some chance at life. But for what benefit? Unborn babies, if they survive, are likely to contract HIV, and with no mothers to breastfeed them what chance do they have?
Exact prevalence of HIV is unknown for Malawi as few tests are done. Estimates, however, are around 25% and there is ample evidence of infection. Death is an everyday occurrence, and Malawians take funerals seriously, often requiring several days off work. Health education of the young is a big problem. Girls as young as 10 years old undergo initiation ceremonies--for example, "chinamwale," in which they are taught how to pleasure their husbands and then encouraged to practise what they have learnt. Young girls may be "initiated" by an uncle, helping the spread of HIV to continue. The community health department is targeting these ceremonies as a means of re-educating the misinformed and thereby reducing HIV infection. But it is a long process.
ACTION PRESS/REX
Friday 9 May
*Hours spent travelling over potholed dirt track: 3; babies immunised: 96; babies who cried: 95; needlestick injuries: 0
Today has been an adventure. We visited an outreach clinic in a village called Manjawira, which is an hour's journey over a bumpy dirt track. When we arrived, 100 women and children were waiting in the centre of the village, and they started to sing when they saw us. We set up our equipment for immunisations in a mud brick hut, and 96 children came to us for immunisation. Giving out balloons got us absolutely mobbed. The local people treated us like celebrities. It was an exciting day; I felt we had made a difference.
Hospital outreach clinics aim to improve the public health and provide care to people who are unable to travel to the district hospital. Children are immunised against tuberculosis, diphtheria, polio, measles, and tetanus. Although conditions in the field are not ideal, sharps practices are good: needles are for single use, and sharps boxes are easily accessible.
Rebecca Hodgkinson medical student, University of Birmingham
Email: Becky_hodgkinson@hotmail.com
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