Malawi Week 2

Ben and I have finished week 2, which means we are halfway done with our time here. It is going by quickly, especially because we are in the early phases of establishing what the clinic and rotation for other residents will entail after we leave. But, this kind of thinking/planning is really fun and rewarding -- there is a lot to learn along the way!

Week at a glance
This week we continued to work at Ndirande in the mornings -- except for Wednesday, when we were invited to help grade medical student OSCEs (more below)! The weekend was lovely and relaxing and involved a car trip to the Tea Estates. We left the dry dusty city for the beautiful green hills of the Tea Estates. We spent the afternoon with 2 other young families on the grounds of "Huntingdon House," where we were served tea and cake while the little boys played croquet. It was very British and so refreshing! A highlight of Sunday was observing a wedding reception taking place in the gym of the SportsComplex where I worked out. The wedding colors were bright red and yellow, the music was extremely loud, and there was lots of dancing and money-throwing :).

Ndirande update
Each small improvement feels like a step in the right direction. Our "accomplishments" from last week include -- we developed a schedule for our team (EHutch/Resident(s)) and proposed specialty clinics (diabetes, hypertension, procedures, etc). Of course, this is likely to change as we gain a better sense of the health center's needs. Also, we developed a way to track the patients we see and the desired diagnostics, so we can make a case for getting specific resources; and, we finally found a list of the essential medications in Malawi (all of which should be available at Queens, though the head pharmacist admitted there will constantly be medications out of stock). At least we know WHAT we can prescribe for patients.

These small steps are good, but we expect the overall process to be quite slow. It will take time for there to be mutual understanding and collaboration. We had a staff meeting last week (yes we did! And it is planned for this week too!), and Elizabeth suggested that we and other subsequent residents could be of help in certain ways. This meeting took place in the labor room (which was silent except for the meeting, though there were 3 women in active labor just 4 feet behind me). The labor nurses looked at us suspiciously and there was little response to the questions Elizabeth (and Martha posed); certainly no comment was made when it came to the new residents. I'm imagining foreigners coming to the First Hill clinic (my residency clinic) and offering to be of help to our struggling situation, just for a month at a time...It's not quite the same, because they acknowledge they are desperately in need of resources; but it's hard to welcome new people with open arms without experiencing how they will contribute to or integrate into an environment.

The Culture of Medicine... is different and challenging my framework for medicine.
--Clinical officers serve in most clinical roles and work independently at district health centers. These officers are medically trained but not physicians -- they are about the equivalent of a physician assistant, and operate based on symptom algorithms (often without an exam). These algorithms allow them to see the high volume of patients that wait to be seen each and every day; but unfortunately, I have observed those algorithms used incorrectly, such as applying an adult algorithm to a child and using a medicine unsafe for children.

--They, along with brand new interns, perform c-sections without supervision. Many OB-GYNs here don't use their skills for c-sections; rather they are called upon to manage the post-op complications of cesarean sectons (infection, ruptured uterus, "ruptured abdomen" as Elizabeth saw --the woman's intestines were protruding from her post-cesarean surgical wound)

--Many clinical officers are wonderful, but some, once they achieve a senior position, become less invested, and don't always come to work. I've hypothesized that some of that is likely related to poor pay, some is related to accountability (lack of a true structure to ensure accountability) but some is probably due to emotional fatigue -- the problems are so great that a day spent at a clinic giving out 40 prescriptions of Bactrim (more to come on that) without having the capacity to do much else feels like a miniscule gain; thus not participating in that process for a day or two feels like a minimal loss.

Medicine in Malawi (for my medical friends reading this...)
--Yes, there is antibiotic resistance here. One of Elizabeth's colleagues at Queens is here from the UK conducting research about Bactrim (or "Cotrim") -resistant Strep Pneumoniae, a common bacterial cause of pneumonia. The main problem stems from life-long PCP prophylaxis for HIV patients, regardless of CD4 count; but, as alluded to above, at least at Ndirande, Cotrim is prescribed for any fever/URI that is not malaria. One of our eventual goals will be to have some teaching sessions on viral vs bacterial infections! Sounds familiar...

--If you are ever concerned about a ruptured ectopic pregnancy in an under-resourced setting, don't hesitate to insert a needle into the posterior fornix and attempt to aspirate blood. In retrospect, I think I learned about this in med school (culdocentesis) but it has  been far from my mind until I witnessed Martha doing this in our clinic last week. 

--If you are a pregnant woman coming to deliver at Ndirande, you need to bring your own basin, sheet, and garbage bag to serve as an undersheet. You will labor in a small room with beds almost touching and if there aren't enough beds, you will labor on the floor. No matter what kind of patient you are, you will always bring a "Health Passport" to the clinic. It will have your name and date of birth and a few scribbled notes from the last clinician who saw you (as long as the handwriting is legible, this is actually extremely functional in the absence of an electronic medical record! It requires a level of patient responsibility with which I am quite impressed!)

Global Health
The topic of global health is emerging as more and more complex as we focus on the small microcosms of Ndirande and the Malawi College of Medicine. I am so thankful that immediately preceding this international rotation, I was able to take an elective through UW entitled "Global Health Leadership" (this is an advertisement to all second year Swedish residents reading this). It was a class made up of residents from UW (except me) that met on weekday-mornings to learn about and discuss important/relevant topics in global health. I became more aware of issues of funding/aid, infrastructure, health technology, as well as disease and public health. My observations are thus within this new framework of knowledge, though Malawi as a country has its own complexities to learn. For instance, the Ministry of Health provides housing for all appointed clinicians (medical doctors) at various posts (including "registrar" or residents). If we are advocating for Malawian family medicine registrars to work at Ndirande, we also need a plan about how to house those registrars...  

Medical school
This was a funny place to observe similarities and differences. One thing was quite similar -- the medical students were nervous for their OSCEs (observed clinical exam)! They were extremely polite, shaking hands with each actor or standardized patient, even when the prompt clearly placed them in the middle of an encounter (no need to introduce oneself again). There was discussion about retaliation for disappointing grades and the need to abide by the College's official grading system (I may have heard of US students challenging grades once or twice...). The topics of medicine are similar but all within a cultural context --one of the scenarios was a patient with asthma and few of the students had ever seen an inhaler. I graded a prenatal counseling visit -- and common advice for women to deal with labor pains was to "distract yourself" (there is quite a culture pressure, I'm told, of being quiet so as not to irk the nurses). One scenario was about sexually transmitted infectious, and students are not yet taught to ask questions about multiple partners, genders of partners -- principles that are drilled into first year medical students about taking a sensitive sexual history.

That's all for last week! New things are happening all the time so more to come!

-Beth Thompson, SFH R3