Retroviruses, Riots and Returning home

Jennifer and I have written quite a few blog posts and barely mentioned HIV throughout. That’s not because there isn’t any here, but more because there is so much it almost blends into the background. It has certainly carved out it’s own little niche.

So throughout Malawi, the prevalence of HIV is 11.8%, which means that in hospitals one would expect many more of the patients to be reactive (HIV positive). We did meet a visiting ex volunteer doctor , who had worked here in the late 1990s (before Malawi had any medication to treat HIV),  who reported that when he was here the wards were full of patients with HIV, male, female and paediatrics.

Around 2006, Malawi started to get anti-retrovirals (ARVs) – the drugs that treat HIV – and a guideline was drawn up to maximise the use of these drugs. Malawi only had a very basic first-line regime, and if those didn’t work there weren’t many other choices. However, it seems to have worked to a certain extent and there are fewer patients than I would have expected in paediatrics who have a positive result when I ask for them to be tested.

The process relies on people going for voluntary testing either as a response to various awareness campaigns or medical advice, which is free. At testing they get counselled about what is meant by a positive or negative result, and then have a test done. If it is positive they get sent to the out-patient department for clinical assessment of the stage of disease. World Health Organisation (WHO) have created 4 stages depending on clinical signs and symptoms. If you are stage 3 or above then you will require HIV drugs (highly active anti-retroviral treatment, HAART).

HIV does, however, often underlie a lot of the deaths that we come across. If a patient is admitted with malnutrition and HIV then their chances of survival are very slim. I can only remember one paediatric patient who had that combination, weighed about 4kg at the age of one year, who managed to thrive and be discharged. Another similar case but aged 2 years was discharged to the nutrition unit. but was readmitted with fever or diarrhoea or something else three or four times before they died.

It’s hard to find any reliable data, but one paper from Zambia (a country that borders Malawi), suggests that 50% of children born there with HIV die by the age of 2 years. I couldn’t find any information on survival beyond that age.

In July, Malawi began the process of changing the treatment protocol for patients with HIV. They had started training and by the beginning of August we had one doctor, one clinical officer and a few nurses trained in the new protocol. The national plan includes having a special clinic for people with HIV but not yet on treatment (pre-ARV); changing the first line drugs for certain patient groups to a more powerful regime; treating more “exposed” but not yet confirmed newborn babies for longer; treating more pregnant women and testing more people.

The pre-ARV clinic sounds like a good idea. But at Trinity we estimate that there are at least three times as many people who would be eligible to attend this clinic, as compared to those who are currently registered at the ARV clinic (1500), and each ARV clinic, which run twice a week, has an attendance of 100-200 patients. So in order to have a fully functioning pre-ART clinic we would have to run it three times a week, probably for the whole day. Currently, with the staffing levels of just four clinical officers for the hospital, and two medical assistants, it is difficult to see how this can be done.

By the time we left Muona in the middle of August, the hospital had yet to receive it’s first batch of drugs for the new treatment protocol. During our year there it wasn’t uncommon for us to run out of testing kits, and for a while we were low in stocks of the old regime of ARV drugs.

And yes, by the time we left in August we were up to two medical assistants. We started the year with three. Two left in May; one to be with her husband in South Africa, and another to begin her training to become a nun. A third was going to leave to start further training, but the funding was not in place at the time of the course starting, so that has been postponed. In August, a new medical assistant started with us which has eased the workload pressure in the out-patient department significantly.

One of the reasons for the delay in this instalment of the blog is due to power cuts. I am currently writing this on a laptop plugged into a power socket on a train heading to Aberdeen, which just shows how much we take electricity for granted. Power cuts “normally” happened 2-3 times a week for 2-3 hours in Muona for most of our time there. There were a couple of weeks when we had no power at all for the whole week. The hospital would rely on a back-up diesel powered generator that would be used when operations had to be done at night.  However, from the beginning of June until the beginning of August there were power cuts everyday from about 5-6pm until 9-10pm, which happened to be the time when it was dark. We got through a lot of candles and charcoal! There were also frequent power cuts during the day. We discovered this was part of a planned programme by the power company (ESCOM “aiming for power 24 hours a day, everyday”), but the reason for the programme was unclear. We aren’t sure if we were affected worse than the cities, but we do know that we weren’t aware of any power cuts when we had to go to Lilongwe at the beginning of August.

The power cuts were one reason why the population took to the streets to demonstrate at the end of July. Over the last year, various organisation reduced or withdrew their donations to Malawi. These included the World Bank, Britain (DFID), and Germany to mention a few. Britain withdrew some of its funding as the High Commissioner had been “ejected” from Malawi as it was discovered he had made a private comment criticizing the President for becoming increasingly autocratic. There have been increasing concerns over human rights in Malawi as more laws have been passed restricting the freedom of expression, and lecturers at the main college had gone on strike after the President had become concerned over their teaching related to Human Rights. Further the economy, although allegedly developing at a faster rate than some similar African countries, seemed to be deteriorating on the ground. Petrol and diesel were frequently in short supply with people queuing for many hours to fill their cars. Tobacco, which constitutes about 80% of Malawi’s exports had fallen greatly in value, and could not be sold. Drugs were becoming increasingly scarce in government hospitals. We heard of shortages of paracetamol, LA (the first line antimalarial), and anti-seizure drugs. Meanwhile, the MPs and even the President’s wife. were receiving huge salaries and perks. So people in Malawi felt their quality of life was deteriorating.  Therefore a group of Malawian non-governmental organisations, collectively known in the news as the Civil Society leaders organised a demonstration the three major cities of Mzuzu, Lilongwe and Blantyre. Everyone was to wear red and walk peacefully along planned routes.

The government tried to stop this through various methods. A law had been passed saying that if anyone was planning a demonstration they would have pay a deposit of 2million kwacha. The president planned a public “lecture” on the same day, which he instructed people to listen to instead of demonstrating. An injunction was taken out against the civil society leaders.  Government “supporters” claimed they planned to demonstrate on the same day, seeking preference over the route. The day before the demonstrations, apparently, a government supported youth group were seen driving around brandishing machetes.  Until the day it actually happened, no-one in Muona really thought the demonstrations would go ahead. We were been advised by VSO to stay away from the route of the demonstration, not to wear red and not to discuss politics.

Due to our VSO contacts, intermittent access to the internet and Facebook we were able to stay more up to date than anyone else in Muona. The demonstrations happened in the three big cities mentioned above. Initially they were peaceful, but eventually disintegrated into riots that lasted two days before things settled down. 20 people were killed, with the worst violence happening in Mzuzu in the North. I have heard reports that shots were fired at Queen Elizabeth Central Hospital in Blantyre.

Nothing happened in Muona.

The president initially agreed to talk, then said he would arrest the leaders of the civil society. Another demonstration was planned for the 17th August.

Meanwhile we had several visitors to Trinity Hospital, several projects to finish off, and had to plan to leave. The first set of visitors only visited the hospital briefly and came from a Scottish religious youth organisation. They donated some money towards the special care baby area. The second set of visitors were students from St Andrew’s University. They are planning to start a charity to mark the 600th Anniversary of St Andrews University, with the aim of supporting the hospital and the wider community in Muona. We had the opportunity to explain not just the material and building needs of the hospital, but also the difficulties the community faced being able to afford healthcare after the increase in hospital fees.  I think they had enjoyed their visit, but were astonished at the situation they found, and left with plenty of material for their fundraising campaign. The paediatric ward had between 5-10 inpatients at this time and it stayed like this for the rest of our time at Trinity.

Empty paediatric ward

A German elective student arrived at the end of July, and he stayed for 3 weeks. He spent most of his time with the primary care team, and decided to save money by staying in a nearby guesthouse (visitors hospital accommodation is 3000kw per night). He was very resourceful as he managed to hire a bike to cycle in every day, and found someone to cook him local food daily. However, in the first week he did have one night when a patient with mental health problems left the hospital and tried to break into his room. Fortunately, the patient was stopped and sent to the only psychiatric hospital in Malawi (Zomba).

Then during the last two weeks, two English work experience students arrived. We had little to do with them as we were busy with other things. However, I can report that they survived.

During this period I managed to complete a basic set of paediatric protocols for the hospital, based on the drugs and diagnostics Trinity has, and designate 2 beds as “HDU.” The HDU beds were next to the nurses station. The hospital workmen moved a power socket closer to the beds so that we could move an oxygen concentrator into the ward next to these beds, with an oxygen splitter to that oxygen can be given to 5 patients at the same time. One of the things we discovered when asking the local population why they wouldn’t accept oxygen therapy is that they didn’t like it when patients got taken into a separate room to have oxygen. Hopefully by always having the concentrator on display we can improve uptake. Special equipment has also been bought to support these beds, such as a glucometer, a nebuliser, and suction machine and a pulse oximeter. The staff have also been trained in using the equipment appropriately.

Jennifer has fully established the diabetes clinic, which runs regularly every month. She managed to get some money to support a trip to Blantyre for the staff that help with the clinic, to show them how to take it to the next level, and improve their education of patients. By all accounts the trip was a success, but one of Jennifer’s concerns about the clinic is the cost to the patients. Care for chronic diseases is a big challenge, and the bill for combinations of drugs to control blood sugar and blood pressure as well as tests for monitoring and screening for complications can mount up, and be difficult for patients to support on a regular basis.

Our weekly teaching sessions continued until August. My proudest moment came when the sister in charge of maternity told me that since the teaching on neonatal resuscitation she had resuscitated 3 babies with confidence!

More patients are being given inhaled salbutamol first for asthma, rather than intravenous aminophylline, and since introducing clocks into the OPD more patients have a full set of vital signs done on admission than before, allowing staff to make a more objective assessment of the severity of their illness.

At the beginning of August we had to go to Lilongwe to have a police check (to get a certificate to say we had committed no crimes during our stay) and our VSO exit interview. To get there, we had to get a bus from Muona to Blantyre, stay a night in Blantyre then get another bus the following morning to Lilongwe. The two buses were incomparable. The first started in Fatima, and had a man give a sermon before the bus started. Despite its hard, narrow seats that meant I had to sit at an angle, it quickly became full, with people standing in the aisles, including the chickens (live) and bags of coal or maize. The road was, as usual, incredibly bumpy, several times we were bounced out of our seats, and at times it felt like the bus might tip or get stuck in a ford.

The Reclap bus that goes from Blantyre to Fatima and back – on a wing and a prayer!

The second bus had no people standing, a walk in toilet, and played a film during the journey along tarmac roads. We also got a complimentary snack and bottle of coke. Lilongwe is the capital city and nothing like Muona, with many cars, traffic, shops, coffee shops, and lots of foreigners. We were able to catch up with some of the other volunteers based there who had started at the same time we did, and catch the tail end of a small fashion show organised by a local designer!

Both the police check and the exit interview were surprisingly efficient and we had time to do some window shopping and treat ourselves to a very nice meal at a local restaurant before heading back the following day (another two day journey).

We had three remaining things to do on our wish list and managed to tick them off over the remaining three weeks. The first was to take a boat on the Elephant Marsh. This is part of the area where we were staying, and a crocodile bite hotspot. It is also famous for seeing many varieties of rare birds. The elephants were all killed off 100 years ago by hunters, but in this “hidden Eden” we did see trails left by hippos.

To get to the port where boats take tourists we first had to take a one hour ride on the back of a bicycle taxi. It was surprisingly the most comfortable journey along the dirt road we had, probably because our drivers could avoid the pot holes. Then we had to negotiate our fees with the “professors of the marsh.” They were able to give us a very good tour of this area, knowing the scientific and local names for many of the birds we saw. We both agreed it was one of the most enjoyable things we did, and highly recommended.

Fishermen on the MarshA Goliath Heron

A “Bilharzia Eradicator”

The second was to climb Sapitwa peak in the Mulanje Massif. This is the highest peak in Southern Central Eastern Africa (ie Malawi, Zambia, Mozambique, Zimbabwe, South Africa) at just over 3000 metres. We had planned to do this in the last week, but as that was when the second set of demonstrations were planned, we brought it forward by half a week. We had some money from the sale of our car, so we decided to do it in style and booked through a company. For our extra money we got an extra porter each, and excellent guide and cook, and three course evening meals every night. No-one formally lives on the Mulanje Massif, but there are huts that are looked after by caretakers paid for by the park authorities and through tips from visitors. The huts vary slightly with some having rooms, and others being open plan with a wood fire in the middle. The views on the way up and down were incredible. The guide insisted we had a swim in a small rock pool just beyond the first hut, which was freezing. The climb from the base camp to the peak was probably the hardest climb I have ever done, and involved a bit of being pulled up by ropes, scrambling, crawling as well as hard walking. Not the simple walk we had been told by others!

We arrived back in Muona at Trinity Hospital the day before the planned demonstrations. Despite much talk and excitement, these never happened. The UN intervened and insisted the president engaged in dialogue with the civil society leaders. An injunction was also taken out and the civil society leaders were also threatened with the cost of any damage that occurred during the demonstrations. So it was called off, but another provisional date has been set for September.

The third thing was get Jennifer an outfit made out of the local material. It caused quite an impression when she wore it on our last day:

The last few days were quiet, but on our last day at work there was a meeting held in the afternoon to which we brought cakes, cookies and drinks, thanked the staff for their support during our time. In reply, the staff sang several songs and thanked us for the help we had provided. The laboratory technician was particularly pleased with some pictures of slides I had given him that I had originally purchased for my diploma course!

We left Trinity on Saturday morning in a Land Cruiser ambulance, with some nuns traveling to Blantyre and the two English work experience students. On the radio we heard that the president had dissolved the cabinet, but never discovered why. On arrival at Blantyre we had to join a queue for petrol and diesel for the hospital generator and vehicles. The restaurant in the airport was unable to provide us with half of what was on the menu.

So arriving in Johanesburg and then London was a bit of a shock to the system. The next few weeks will be spent unpacking and visiting relatives up and down the country before starting new jobs.

The end of one adventure and the beginning of new ones!

For those people interested in some statistics, over the year we played 54 games of scrabble. Jennifer won 15 of them. Our scores did not improve over the course of the year. The best variation was Chichewa rules – Ls and Rs are interchangeable, with five bonus points if you lay a word with those letters swapped (the bonus applied before doubling etc)!

We did loose weight. I went from 76kg down to 70kg and settled at 72kg. Jennifer went from 60kg down to 51kg. I guess that’s what a no fat diet for a year does!

As a final word, we’d like to say a huge thank you for all of the support that we have received during the year.  From the generous sponsorship for our coast to coast cycle ride, to all the text messages, phone calls, comments on the blog, e-mails, letters and packages.  They have all been very much appreciated and played a key role in helping us to survive. There are many lessons we have learned from this year, and one of them is realising just how important our friends and family are to us.

Cancer, Clothes, Cash and the Mystery of Oxygen Concentrators …

Cancer is certainly not the first disease you think of when you think of tropical medicine, however, there are a few that are more or less unique to the tropics. The two big ones are Kaposi’s sarcoma and Burkitt’s lymphoma. Kaposi’s sarcoma is a form of skin cancer caused by a member of the herpes virus family (the ones that give you cold sores), and usually only manifests itself in older patients with HIV. Tom Hanks developed it at the end of the movie, “Philadelphia.” You can also get it in the mouth, oesophagus and lungs. The main treatment is anti-HIV drugs (HAART), but other drugs such as vincristine (chemotherapy) also help. We don’t have any vincristine here, we have never been able to work out why, and because of the distance to Blantyre and Queen Elizabeth Central Hospital, where the patients would have to attend on multiple occasions, we are rarely able to send anyone for treatment.

Burkitt’s Lymphoma is much more common than Kaposi’s in children in the Tropics. It affects HIV positive and negative children alike, and no-one  really knows exactly what it is caused by, but the is a definitive association with the glandular fever virus, EBV, malaria and hot humid weather. It doesn’t really occur very much in Europe. It causes fast growing lesions often around the face, that are highly sensitive to anti cancer drugs, so relatively easily treatable.

We have had two paediatric cancer diagnoses in Muona since we arrived, and typically for me, neither were Kaposi’s or Burkitt’s. The first was a rhabdomyosarcoma, or a form of cancer of the muscle, growing out of the bladder, and the second was a histiocytosis lymphoma, with masses on the scalp, lungs and abdomen. Both were in school aged boys, and the challenge was first to convince the parents that there was a significant problem, then that they had to go to Queen’s for treatment – and pay for the transfer, which is expensive at 4000kw. Once at Queen’s, the unit there can provide diagnosis, prognosis and some basic treatment. They also pay for expenses, so if we have the diagnosis right, they will get the cost of transport back. All of this is provided through charity money and doesn’t com out of the government’s health budget, such as it is. My understanding is that both are doing well, but the boy with the lymphoma, who was very sick when he left, but was sitting in the sun in Blantyre last I asked, has a poor prognosis and the doctors there may start to engage him in palliative care.

A while back, I started going for an occasional jog with a Malawian nursing student called Frank. Frank and some of his nursing colleagues went on a community attachment sometime ago and were astounded that some of the children weren’t at school because the children couldn’t afford uniforms. Like the UK there are private and state run schools. The state run schools are free, but the children need to have uniforms, exercise books and pencils/pens. So a group of the nursing students got together, went to town with a blood pressure machine and asked for donations towards paying for school uniforms for some of the children in exchange for having a blood pressure taken. For 18 uniforms, books and pens they were just short by 4000kw, which Jennifer and I donated. Today (Saturday 2nd July),  was the handing over ceremony of the uniforms to the children and parents. The ceremony involved a song and a drama routine, which in a bit of improvisation, included a section about how if you go to school you can go to university and become a doctor, just like Dr Jennifer! 

There are some pictures below:

The ceremony took place in one of the classrooms. There were 45 desks, and we think there would be two to three children at each desk…

But now, thanks to Frank and his friends, 18 more will get some education.

In one of the last blogs I mentioned that the cap on fees was going to be removed. To recap, when we arrived, some of the user fees for the hospital were paid for by the local government, but many of the patients had to pay a fee, which was, at the time a small amount.  Then, in February, the fees were doubled and the number of patients we had fell dramatically. Jennifer and I lobbied the management and we got the fees reduced by a small amount. There was also a cap on the fees, which meant that adults would not have to pay more than 10000kw, and children would not have to pay more than 5000kw. The excess was paid for by charity money. However, the problem is that the nuns who for the last 50 years have provided the charity money to support the hospital, are no longer able to do so. So, from the 1st of July the cap on fees has been removed, and patients will now be responsible for the entire cost of their stay, at the rate introduced in February. The community has been warned about this. There were no new admissions on Thursday 30th June, nor by the time I left on the 1st July, leaving us with only 4 paediatric inpatients. I don’t know what is going to happen over the next few months, or where sick people are now going.

Malawi has only one electricity company, called ESCOM. On Wednesday it announced that for everyone in Malawi there would be power cuts from 4pm until 10pm every day until the end of the year. We haven’t been able to find out when this will start, but as I write this we have just had another power cut. We have already had one earlier today and at least one everyday since the start of June. They are unpredictable, but often occurring at breakfast and/or lunch and/or dinner time. If it is in the evening we have to get our headtorches on, light the candle and get a fire going in our charcoal stove.

Fortunately we have lots of rechargeable batteries for our torches.  

But to make matters worse for us, the water pump for the area is broken again. I have been told that this is because of fake (Chinese) parts, and they hope to get it fixed soon. It broke at the beginning of the week, and the first we realised was when Christina, who helped us last time the pump broke, came to our house at 6am to tell us and offer to collect some water. She can carry two large buckets in one go, when Jennifer and I struggle with one together! We saw some activity near the pump today, so we hope it will be fixed soon.

Almost since I arrived in Malawi, one of the things that struck me was the reluctance of people to use oxygen. All beds in UK hospitals will have oxygen nearby, and in Malawi oxygen is usually provided though oxygen concentrators that seem to be relatively widely available. However, the patients or the guardians often refuse. Myself and some colleagues in Blantyre thought we would try to find out why. It started out with the idea of doing a questionnaire, but soon developed into doing a qualitative study using focus group analysis and interviews with staff and patients. It has the support of doctors in Blantyre and the local healthcare team, and community also thought it was important to do, but it took several months to do all the planning, gain ethics approval and get the project funded. We finally started collecting data two weeks ago, through a Malawian facilitator called Collins, and last week he came down here and to gather data from the rural village focus groups. Hopefully, he will be able to give me some feedback in a few weeks that I can pass on to the Primary Health Care team so that they can educate the local community.

We have less than 50 days left in Malawi, and still have some things we would like to achieve and challenges to overcome!

The Beginning of Winter…

We have been told it is now the cold season. If we hadn’t been told this, I am not sure we would have noticed! During the day it can still get very hot, but as the sun does not get as high and sets earlier it is cooler at night, and sometimes we have even had to have a blanket to cover us! However, it is raining much less frequently than in the rainy season – maybe once a fortnight – and the main river, a large tributary to the Shire river, looks almost dry.

Citrus fruit such as lemons and grapefruit seem to be in season, so Jennifer has been making homemade lemonade. Papaya also seem to be coming in, but we haven’t seen many of these yet. Bananas, as ever, dominate the market.

Respiratory infections, such as colds, bronchiolitis, and pneumonia, have been increasing in frequency on the paediatric ward since March. They are now nearly as common as malaria. So to me it is feeling a little bit like working on the wards in the UK from November to February!

I noticed early in our time here that very few patients accept oxygen as a therapy. Many believe it kills. This is for a variety of reasons, but largely because it is offered late to very sick people, who die whilst they are receiving oxygen therapy. This perpetuates the myth that oxygen kills. It is offered late because WHO guidelines have criteria for oxygen that mean that a patient has to be very sick before it should be given. Acute respiratory infections are the second biggest killer in Malawi. So I discussed this with a variety of people. The nurse in charge of the primary health care gave talks to the general population telling them that oxygen was safe in early March. The anaesthetic clinical officer gave a talk to the staff showing them how to use the oxygen concentrators, and I encouraged the clinical officers to be more liberal about using oxygen. We still have a lot that refuse, but have also had a lot more accept. At one point we had  nearly a quarter of our paediatric patients on oxygen! We can give oxygen to up to 6 patients at the moment, as we found an oxygen splitter that divides the oxygen from one concentrator up into five separate amounts, and we have a further oxygen concentrator that stays in the treatment room. Sometimes it is simply the lack of oxygen tubing that limits our ability to give oxygen.

Prof. Broadhead has informed me that Malawi hopes to introduce the pneumococcal vaccine this July, and this should prevent, or at least reduce the severity of a lot of infections.

We have also had a small outbreak of measles. Measles can kill and we have frequently had patients on the ward in a side room with measles and pneumonia, or measles pneumonitis. However, in April we had 5 patients arrive over a very short space of time with a measles rash, cough, coryzal symptoms and some respiratory distress.  All did well and went home. It turned out that all came from the same village in Mozambique, but as we were the nearest hospital they had come to us. None were vaccinated (I am not sure about Mozambique, but certainly in Malawi children are offered the measles vaccine). We did hear that a health centre nearby was dealing with more cases, but we haven’t seen any more since.

Our inpatient numbers remain low. Although we reached a peak of just over 30 paediatric inpatients in May, the total number of admissions was just 120, when normally there would be 200 or more. Currently there are 10-15 inpatients with problems like pneumonia, malaria, meningitis, malnutrition, tuberculosis, fractured legs, and severe burns. No crocodile bites at present. As far as we know there is still no government support and patients are still having to pay all their costs and this is keeping them away.

The financial situation is not getting any better. We have just found out that the staff have had the cost of renting their home from the mission site doubled.  To recap; this hospital was founded by German nuns 50 years ago, and had been sponsored by them since. The staff are paid by the government, supported by a 52% subsidy (i.e. everyone gets a 52% bonus paid on top of their salary) by the DFID (Department for International Development, British Government) with a top up for living in an isolated area and doing extra hours. For a clinical officer, from what I have been told it amounts to about £250 per month  before tax at 30-40%. The patients pay a fixed amount for seeing a clinician in the out patient department and a daily rate for staying in the hospital (less than £1/day). They also have to pay for procedures and medication. The charitable fund means there is a limit to how much each patient will pay – 5000kw (less than £20) for a child, and 10000kw for an adult. Before Christmas most of the fees for children and pregnant women would have been paid by the local government, now all of it comes from the patients, most of whom are subsistence farmers and have no real income.

Since Easter, things have been getting even more fragile. For reasons that can be found from Google, the Malawian government declared the British High Commissioner ‘persona non grata’ resulting in his expulsion from Malawi. Britain is the largest donor to Malawi (approx 40% of all donations), and so some would say this wasn’t a wise move. Subsequently, the UK government has been reviewing it’s “relationship” with Malawi, with the threat being that it would remove financial aid. The main area this would have an effect on would be to the health sector as the 52% salary top up for all health workers would disappear, plus other money that goes to supporting hospitals. It would also affect other sectors as Britain also supplies a subsidy to fertiliser. Malawi is largely an agricultural country, so this is very important. We expect a decision to be made at the end of the month. In addition, other countries and agencies, such as Germany and the World Bank, have withdrawn aid. Norway is even asking for some money that was misspent to be paid back. And unsurprisingly, Japan has said they can’t afford to build any more roads in Malawi. Tobacco is the main cash crop and the price has crashed, with no one being able to sell it. And when was the last time you bought Malawian tea or coffee (although it is very nice)? Despite all this, the government remains unrepentant, and is planning on raising taxes and cutting costs rather than reducing corruption, improving human rights and apologising to Britain. This will likely make things even worse financially for the hospital and the people dependent on it.

And as if that wasn’t bad enough, we are now facing a staff crisis. We did have three medical assistants (MAs) who ran the outpatient department, seeing, managing and referring patients. They also did the first on-calls at night. However, in early May one left to become a house wife in South Africa. Another has officially left to become a nun, but is currently still here doing locum work, because the third is on holiday. However, if she is accepted, the third one will leave to become an anaesthetic clinical officer. The next batch of MAs won’t graduate until October, and the management here has no incentives to offer them to work here. So far this week Jennifer has spent most of her time in OPD seeing patients with the help of the student nurses, but she can’t do it every day a she also has to go out with the primary health care team and do the diabetes clinic.

Despite all this we have managed to spend some time enjoying ourselves. Jennifer’s parents came to visit, so we took them to Lake Malawi, where we met other VSO health volunteers, many of whom were having to cope with less drugs than us and poorly motivated staff, with much higher numbers of patients, and one was trying to manage corruption in her pharmacy. However, we got to go for walks along the beach, a swim in the lake and watch the sun come up.

Then we went to Mua Mission, a cultural heritage centre based around an old mission site, where there is an excellent display of art and history of culture in Malawi.

After that we went to Dedza, where there was a famous pottery centre (from which we bought a teapot), and also visited some ancient cave paintings.

Before they left we took them to Majete, a national game reserve that Jennifer I had already visited, where we saw hippos, zebra, a variety of antelope, warthogs, a tortoise and lots of elephants.

Quite a busy and exciting fortnight!

However, we knew we were no longer tourists when we saw our bus back to Muona leave early as it was more than fully laden. We had to take 2 minibuses to get down to where the dirt road ends, before we found a truck willing to take us back to the mission site. Jennifer got to sit in the cabin (with 2 other people plus driver, and a chicken on her feet), whilst I had to clamber on the back with about 30 other people cheek to jowl. It was about a 3-4 hour ride, an not something I want to do again soon!

Catch up!

What a relief to be typing the blog entry on a proper keyboard rather than a phone touch screen! 

At the hospital I’m pleased to say the charges have been reduced to somewhere between the original level and the increased charges that came into effect on 1st February.  Everyone noticed that the numbers of patients coming to the out-patient department, and onto the wards seemed to have decreased dramatically and it was felt that this probably reflected the increased fees. Since the revised prices, which came into effect on 11th April, there has been a gradual increase in attendance again, and the number of paediatric in-patients is consistently in double figures. This is a relief as Chris was beginning to wonder what to do with himself after his very short ward round!  We’re trying to focus on working towards our VSO objectives, as well as doing the day to day work. Usually there is less activity in the afternoons, so that’s when we get a bit of time to do something non-clinical.

We have increased our efforts to learn Chichewa with a teacher from the local secondary school.  She is very patient with her adult learners, and puts a lot of effort into preparing for our twice weekly lessons.  We are gradually increasing our vocabulary and starting to be able to form our own sentences. I won’t ever get to the stage where I’m happy to have a proper consultation in Chichewa, but people appreciate me trying, and sometimes it makes them smile! 

Three weeks ago Matthew (my brother) and Monique (his wife) came to visit us.  We really appreciated their company, not to mention the supplies they brought with them.  It was good to be able to show them our house, the hospital and our everyday life, as well as do a bit more exploring.  We went to Liwonde National Park where we enjoyed a canoe safari and two game drives.  We saw elephants, hippos, wart hogs, various species of antelope and lots of birds. It really is amazing to be able to watch these animals in the flesh, in their natural environment. We stayed at Bushman’s Baobab, in thatched tent shelters. This was excellent value, and despite also catering for large groups we were well looked after, including very good food.  We’re looking forward to more exploring when Mum and Dad come to visit in a few weeks – the advent calendar is back in use to count down the days!

Back On-line!

I am very pleased to report that we are now back on-line!  This is mainly thanks to Matthew and Monique who very kindly took delivery of a new lap-top, brought it with them when they came to visit, and took the broken one back with them. We also have a dongle for connecting to the internet just in case the modem on the phone was what caused the problems. We’re gradually getting caught up with our electronic tasks and getting to know Windows 7 (why do things have to change?) so I thought I’d try out Windows Live Writer for the blog entries.  Once I know it works, a full entry will follow shortly!

Challenges!

I thought it was about time I wrote another entry on our blog. It will be short due to technical limitations!

Just after posting our last entry our laptop decided to stop working. That was also just after we’d transferred all our elephant and zebra photos and before we backed them up to our portable hard drive. We thought it might respond to an overnight rest but no such luck. With the help of the internet on Chris’ mobile and very helpful advice from a family IT expert we think the problem is with the graphics card, one of the components and we’re hopeful that the data including the photos will be recoverable. I have realised the error of some of my ways – setting up outlook so that it downloaded emails without leaving a copy on my own email server for instance means that there is certain information that I won’t have access to until we get it home and get the data retrieved. And I will certainly be much more careful about regular back-ups in the future.

Just to add insult to injury there was another laptop made available for us to use and we thought everything was ok, back to full screen internet access and the potential to watch dvds. However after a few days it also suffered breakdown and is currently in town being repaired. I never thought I’d say this but I’m grateful for smart phones!

The experience has made us realise how dependent we are on our gadgets and on the web as a means of communication.

On a more positive note we have had a second last week because the gifts that people sent to the wrong PO box address arrived! Just the thing to cheer us up, especially the chocolate which has been savoured. On a similar note it is now less than 3 weeks until Matthew and Monique arrive (my brother and his wife) so we are really looking forward to seeing them and having some time off to do a bit more exploring. I decided to use the advent calendar that arrived in January to help me count down the days but I’m not tearing off the doors so that I can use it again for Mum and Dad’s visit.

Yesterday was the away leg of the Fatima vs. Chikwawa social football so a trip organised for the players, the netball team and supporters. We assembled at 6am and when the transport arrived (a pick-up truck) approximately 50 of us clambered in. Now I understand why local people don’t like it when you suggest they go to hospital in Blantyre if this is the only transport available. After 2 hours along the dirt road (and later 2 hours back again) my bottom is just a little bit bruised, not helped by the fact that it’s less padded than it used to be. The football was a draw, a good result considering the high temperatures in the midday sun. We were then served lunch before going on to visit Kapichira falls, a large hydroelectric dam which supplies power to a large area of Malawi. The staff there were very helpful showing us round and explaining how various sections worked. We returned to Chikwawa for the netball match which we unfortunately lost, then a group of hot and tired people got back into the truck for the return journey. All in all an adventure!

On Friday the hospital team marked world aids day at a health centre in the area. Yes, world aids day is in December but for various reasons it wasn’t possible to mark it at that time. The theme was human rights and HIV. There were focus group discussions, dramas and songs on the subject as well as traditional dances. I really enjoyed seeing the enthusiasm for this event as well as having the chance to sample some of the local culture.

I think I will end for now as I’m finding typing in this touch screen a bit of an effort. Hopefully we’ll be back to normal fairly soon!

Malaria, Money and Majete

Muona lies quite low, at the level of the Shire river. This floods slightly in the rainy season, creating the Elephant Marsh, an ideal breeding ground for mosquitoes. The female Anopheles mosquito is the beast that transmits plasmodium falciparum, which is the bug that causes malaria. So during the rainy season, malaria, which is already common in Muona, occurs much more frequently and affects those under five years with no immunity more than indigenous adults. In most cases it causes flu like symptoms, but in others it kills. So during the last few months we have mainly been dealing with cases of severe malaria, that is, cerebral malaria, severe anaemia, acidosis and pulmonary oedema. The team here are very good at spotting and treating malaria – the treatment is pretty standard – but my role has been to pick up on the patients that are misdiagnosed and don’t have malaria, and for those that have severe malaria make sure that the seizures are treated appropriately, and supportive therapy such as IV fluids are introduced.

If you have been keeping up with the news, Bill Gates recently launched a new campaign to try to eradicate malaria, and there has been much chat in the medical journal The Lancet, about whether or not this is feasible.

One step in the right direction is indoor residual spraying (IRS). This is where teams go to people’s houses and sprays an insecticide onto the walls, doors and ceilings, so that when the mosquito lands, it is killed. The insecticide can be effective for up to six months and it has the additional benefit of killing other creepy crawlies that are found in Malawi.

And so this year the local government selected a few areas to try out IRS, including Muona. However, for reasons we don’t understand our little house seems to have been missed, but we don’t mind too much. No-one we have spoken to has noticed much of a difference in mosquito levels, except they may have increased, whereas all the other relatively harmless creatures, some of which may have been controlling mosquito levels, eg, spiders have fallen!

Although the number of patients we have had on paediatrics has fallen dramatically,  I don’t think this has anything to do with IRS. Trinity is a mission hospital and relies on charitable donations to operate, and charges a small fee to the patients. It receives government support to pay the clinical and nursing staff, and the local district health authorities are supposed to pay a service level charge so that pregnant mothers and children under five from their areas can be treated for free. Everyone else, ie people out of area (e.g. Mozambique or another health district) or not covered by the service level agreements have to pay. Through charitable support the amount they pay is subsidized and there is a cap on the amount they pay in total.

However, with the financial crisis, charitable support has fallen, and is less reliable. When we arrived in October the hospital had service level agreements with Nsanje and Thyolo health districts providing health care to children under five years and maternity care. The service level agreements with the local districts have gone amok, as they haven’t paid, and so currently we only have an agreement with Nsanje district to cover under fives and maternity care, although there wasn’t even this a few months ago.

 So the hospital had to increase fees to cover costs. The costs doubled over night, and reciprocally, the number of patients halved. We are not in a position to say if the costs are fair, but the effect on my workload has been dramatic. I think we have also noticed people being a bit more cost conscious, and we have had to think hard about tests and treatment we suggest.

For the record, we don’t get paid by the hospital; we get a small allowance funded by DFID.

At the end of what started as a busy month, Jennifer and I decided to treat ourselves to a small break and we went to Majete Game Reserve. This is a compact game reserve with tents, lodges and a restaurant. We opted for a half day game drive, during which we saw elephants, hippos, nyala, zebras and lots of other animals. Hopefully we have relaxed enough to start March with renewed enthusiasm!