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.
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 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.
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.