Elective Series: Malawi
Malawi is known as ‘the warm heart of Africa’ and even has a ‘Miss Warm Heart of Africa’ competition (not open to Australian entrants). I spent eight weeks there last year, working in a rural hospital, and found it certainly lived up to its reputation for hospitality and friendliness.
Malawi is one of the poorest countries in the world (life expectancy is 44 for men and 51 for women), and the hospital at which I was working was facing some major challenges. HIV, TB and malaria were rife, and treatment options were limited or non-existent. I had read lots of articles about healthcare in Malawi before I left, and I thought I was reasonably prepared. I was wrong…
WEEK ONE: THE DANGEROUS DRUGS CABINET
On my first day, I open the cabinet marked ‘dangerous drugs’. And find Omo. Apparently the drugs ran out a while ago, and the Omo kept going missing, so now there is a lockable Omo Cabinet. But still no drugs.
WEEK TWO: WE RUN OUT OF DIAZEPAM.
Week two and I’m on the paeds ward, surrounded by very young children with malaria, pneumonia, sickle cell anaemia and HIV/AIDS. It’s mostly the kids who die of malaria here, although virtually every patient has it. A baby with cerebral malaria starts convulsing. The hospital protocol (helpfully displayed on the wall) calls for diazepam and a paediatric airway. I don’t have either; in fact, I don’t have anything. The baby dies. I confirm her death, explain it to the large extended family crowding round the bed watching me (one of the nurses interprets for me as I can’t speak Tumbuka), and start dressing her in the little pink dress that is the only outfit she owns. She is wrapped up and placed on her mum’s back to be carried home.
WEEK THREE: WE RUN OUT OF FUEL.
I spend week three in the male ward, where a slightly unorthodox approach to patient confidentiality is adopted. Rectal exams are carried out in full view of the other patients; ward rounds involve a nurse pointing to each patient in turn and announcing “this one – his scrotum is swollen”.
The hospital has bigger problems than the odd swollen scrotum however: there’s no fuel. There’s a national shortage in Malawi, which means obtaining hospital supplies like gloves, syringes and drugs is next to impossible. Mobile health clinics in surrounding villages have to be abandoned, and the ambulance is useless.
WEEK FOUR: NO FUEL MEANS NO POWER.
Malawi is plagued by power blackouts. During my stay, there was a blackout lasting from a few hours to a few days almost every day. There was never any power on Sundays.
The hospital had a generator, but for my first few weeks it wasn’t working. Then it was working (thanks to a roving engineer from Scotland who happened to drop in), but it needed diesel. There wasn’t any.
Without power, surgery was completed by the light of handheld torches, headlamps and mobile phones. Several patients on supplemental oxygen died during blackouts; one baby died when the lights went out during an emergency c-section and he was overlooked in the ensuing confusion.
WEEK FIVE: WE RUN OUT OF GLOVES.
I’m in the maternity ward now, and there’s a slight problem: we don’t have any gloves. A combination of a lack of fuel and a lack of funds has meant that basic supplies can’t be obtained.
I knew I was going to a rural hospital in an impoverished area. I knew I wasn’t going to be surrounded by doctors, RNs, drugs and MRI machines. I understood the hospital would not have a little shop selling balloons with ‘It’s a Boy’ written on them. But I really, really didn’t think I’d be working at a hospital without any gloves.
Most days in the maternity ward began with one of the nurses doing the rounds of all the other wards to beg for a few pairs of gloves. When even that source dried up, women stopped getting vaginal exams and we delivered babies wearing heavy-duty rubber cleaning gloves. In an effort to protect themselves from HIV, some staff would wear the same pair of gloves when going from patient to patient.
WEEK SIX: WE RUN OUT OF IV FLUIDS, AND THE STAFF DON’T GET PAID.
Week six and I’m still in maternity. We’ve got hold of some gloves (some are those loose gloves you get with packets of hair dye, but some are actual hospital gloves), but we’ve run out of IV fluids and oxytocin. Meanwhile, the staff haven’t been paid for two months. The whole village is suffering as a result of this; in an area with around 95% unemployment, the hospital staff are the only people with any disposable income to spend in the tiny shops that line the main street of the village.
I realise that I’m surrounded by people who haven’t been paid for months, who often have no means of protecting themselves from HIV or other infections, who are dealing with children dying every day, and who are still turning up to work and doing their best.
WEEK SEVEN: WE RUN OUT OF CHLORINE.
I had been wondering why the hospital smelled like Lambton pool, and now I know. The only cleaning supplies are chlorine and Vim. Every morning, the hospital cleaners do the rounds of the stone floors with a mop and some chlorinated water. Except that now we’ve run out of chlorine, so the entire hospital is being cleaned with water alone.
WEEK EIGHT: WE RUN OUT OF SYRINGES.
The entire hospital has now run out of syringes; some wards are re-using syringes on patients who require regular injections.
I think maternity is the hardest place to be– I’m spending part of almost every day desperately trying to resuscitate a neonate whilst his or her agonised mum looks on. I think this is the worst thing. I was with my father when he died, and for months afterwards I would see his face at the moment he died whenever I closed my eyes at night. I can only imagine what the mums of these babies see when they try to sleep – virtually their only memories of their baby will be of frantic resus efforts failing.
I am incredibly lucky that the hospital is currently home to “Dr Ross”, a Scottish obstetrician in his 70s who spends six months of every year in Malawi. There are many, many children alive today solely because he was there when they were born. He is keen to teach me, and tells me it’s OK to be unable to sleep. 50 years into his career, and he still feels the same every time he loses a baby.
WEEK NINE: I RUN HOME.
I come home to a comfortable house, running water (hot water!), three meals a day and a constant supply of electricity. Six weeks later, I’m back in a major trauma centre watching the hospital helicopter landing and practising my resus skills on a dummy neonate. And planning my next trip to Africa.
INTERESTED IN AN ELECTIVE IN RURAL MALAWI?
Information about Embangweni Mission Hospital, including contact details for the hospital director through whom electives can be arranged, is available from http://embangweni.com/hospital.htm. Alternatively you could just do what I did: google “Malawi” and “hospital” and see what you find.