Malawi

Kim reports from Mzuzu

Last Day!

July 19th, 2007 by Kim

Today is my last day working here in Malawi.

 I am so excited about going home!!! (So much so that I would use multiple exclamation points. That’s quite a lot of excitement.)

I’ve spent the day, so far, sitting in the pharmacy. I’ve gotten to do some dispensing, but it’s been a rather slow pharmacy day. (Though, the doctors are apparently incredibly busy. There’s 3 doctors seeing patients and the stack of charts to do seems to be about 10 high at all moments so far today.)

 Tomorrow morning, Dr. Anjalee and I are going to go to the wood market (because I’ve decided there are a couple more things that I want) then the driver is picking me up from her house at 11AM. My flight takes off at 1:35PM.

Malawi has been a really great experience, but I am soooo ready to go home. (Plus, my birthday is July 29. I definitely wanted to be home for that!)

A very sad case

July 18th, 2007 by Kim

I’ve been following the case of a 10 year old boy all week. It’s been very interesting and very sad.

 He’s 10. And HIV+. But he didn’t get it vertically. (His mother is negative, meaning she can’t have passed it to him.) His father and twin brother are also negative. This leaves us with very strongly suspecting sexual abuse. (There is a possibility as well that he got it from poor biohazard practices of a traditional healer. His mother swears up and down it isn’t sexual abuse but that he also hasn’t been to a traditional healer before he started getting sick a lot.)

 He’s also in severe physical pain from 3 arthritic joints. His right wrist, left ankle and his left knee are very swollen and warm. He can’t move them because of the pain. He’s completely nonambulatory. He cries when you move him around.

 We did a lot of tests– xrays, blood tests, and a joint tap– but haven’t gotten any useful results. Well, the xrays show that the joints are not septic (because they aren’t degrading). His white count isn’t elevated (maybe. It’s hard to know because we don’t know what his baseline is… as that’s affected by the HIV.) The lab didn’t do any of the tests on the joint fluid because they don’t have reagents. (They probably just chucked it but didn’t tell anyone so the poor family waited around all day for lab results.)

 Really, we don’t know what’s causing this and can’t get helpful information. It’s very sad.

Teen Club

July 15th, 2007 by Kim

Saturday, I came to the clinic for the monthly Teen Club that they do. It’s a really cool program.

 In the morning, the kids get medical care– either a doctor or a nurse visit, depending on what they need. Then they get a free lunch. And, then, there are a variety of games for them to play.

 I saw patients with Dr. Anjalee, which was interesting. I met a kid who got switched off first line therapy, not because he failed adherence and built up a resistance, but because he was experiencing side effects. (Peripheral Neuropathy, to be specific.) But he was doing a really great job of following the more complicated second line regimen. (He had a huge jump in his CD4 count, which is really nice to see!)

Lunch was a typical Malawian meal, except that it had rice instead of nsima. (Which is good, because I like rice more than nsima.) I ate with Amanda and Jenny, two nursing students from Seattle who have been around for a while.

After everyone is done eating, the kids form a huge circle and start chanting/singing in Chichewa. It took us quite a while to figure out what was going on, but we decided that they must have been introducing the newcomers. They dragged in a group of 5 English people, all of whom were very nice (Patty, Simon, Katherine, Sophie and Chris.) Then, they dragged in Amanda, Jenny and me. It was fun and a little embarassing.

 Then, we had the kids divide up based on what activity they wanted to do. (They could choose between football, volleyball, song and dance, and arts and crafts.) I ended up playing football with them. It was really fun, but I’m so bad! I haven’t played in years, and when I did play I was a goalie. So, my fieldwork is really quite terrible. The kids were nice, though, and didn’t laugh at me (much.)

It was really nice to see these HIV positive kids be so happy and healthy and excited. But it was sad to realize that the kids who were alive and playing were fewer than those who had died of the disease by this time. (75% of children born with HIV will die by 7 years of age if they don’t recieve treatment.)

Presentation and Plans

July 15th, 2007 by Kim

I gave a presentation Friday about the Beyond Traditional Borders program and my project here. Overall, it went really well. It was pretty informal and had a smaller audience than Friday Journal Clubs usually due (because a lot of people were out of clinic for a variety of reasons.) People still really like my senior design project! Sadly, I didn’t get any more new design project ideas. 

 I’m going to spend time running around the clinic. I’m going to spend a day (at least) in the pharmacy. That will involve showing Westin (the pharmacist) my device and doing pharmacy stuff. It should be good. I’m also going to spend some time with the nurses doing vital signs. And some time in the blood draw room watching them draw CD4 counts. Overall, it should be a good end of the week.

A lot has happened

July 11th, 2007 by Kim

Sorry for the long silence, I’ve been without internet access for quite a while.

Since I’ve been away, I’ve spent a while in Rumphi (about an hour north of Mzuzu) at their District Hospital. The training there went relatively well, but they have had some trouble with implementation due to lack of supplies. The lack of basic reagents is a huge problem everywhere here.

 I’ve also been to Chitipa, which was quite a journey. Natives call Chitipa “the forgotten North of Malawi” and they really aren’t exagerating very much. It really does have a sort of forgotten feeling. It is about 7 hours away– 4 of which are on really terrible, bumpy mountain roads. (Supposedly, the government has been promising to fix the road between Karonga and Chitipa since the 70’s and about a kilometer has been accomplished.)

However, Chitipa is pretty self-sufficient. Their hospital workers were thrilled about our training because it’s rare for trainings to make it all the way up to them. They also seemed to have a really good knowledge base and had very well reasoned answers to questions. All in all, it seemed to have been a really successful training.

 Speaking of success, or the lack of it, the other sites are starting to run in to trouble. The Mzuzu Central Hospital is in rather desperate trouble right now because they haven’t been filling out the register correctly. There are many numbers that have been given to 2 or more children (bad! really bad!) and there are about 70 mastercards with no numbers on them. Essentially, they are goin to have to scrap about a month’s worth of work and start completely over with more close supervision. It’s really sad.

Now, I’m back in Lilongwe. I’m staying in the house I was in for the first couple weeks of my internship (and I’m actually not very happy about that. But that’s a whole different story.) Right now I’m preparing a presentation to give on Friday at “the journal club” which is really a weekly presentation about a topic to people from the clinic and any other HIV/AIDS interested group (local hospitals and health centers, the Ministry etc). This week will be “Beyond Traditional Borders Summer Internship.” At least, that’s what I’m calling it because as far as I can tell, it is supposed to cover my design project and what I’ve done in the North.

Small District Hospital Lab

June 28th, 2007 by Kim

… in more ways than one.

 The space itself was tiny. Itsy bitsy. Maybe 12 feet by 6 feet. And that’s a pretty generous estimate.

They have a hematocrit centrifuge and reader, a microscope and a tabletop centrifuge. They also have 2 sinks, the stains for malaria and TB slide readings, a bed for blood collection, an insulated container for blood bags and a small desk.

They have a blood chemistry analyzer and a still (for distilling water) but no space to set them up. And the blood chemistry analyzer reagents are probably expired. They don’t have sticks for the rapid urinalysis. (I watched them just dump a sample immediately after recieving it because they had no way to check for protein in the urine.)

I also watched a person donate blood to a relative. The child had a hemoglobin count of 3.7, which is suuuuper low. The man came in and they checked blood type, syphillis and HIV. Then the man got on the table and the lab tech put on the tourniquet and hit the vein on the first try. (Amazing!) Eventually the little bag filled up and she tied a knot in the tube from the needle to the bag. Then, disturbingly, she cut off the needle, recapped it and put it in the regular trash, not the sharps box. EEK. She transferred some of it to a pediatric pack by sticking a needle into the part of the tube left on the first bag and it filled up. She then tied knots in both strings… and again threw the needle in the trash. Quite distressing.

Sadly, no new device ideas. The only complaints I could get from there were that they need more space and more reagents. Sadly, neither of those can really be fixed by a senior design project. The reagent shortages are honestly a government mismanagement of supplies. It is such a widespread problem.

MCH Lab

June 26th, 2007 by Kim

The district hospital lab was an interesting experience. I got several good ideas for possible design projects and I learned a lot about the limitations that they’re working with here. Tests that we take for granted in the States aren’t possible here on a regular basis, and some not at all.

The blood chemistry analyzer is out of order (and has been for months) so all of those kinds of tests are impossible. No cell counts. No enzyme levels. No basic diagnostic tests like those!

 The automatic hemoglobin reader was also out of order. They were doing hemoglobin measurements by taking a hematocrit (they fill a capillary tube with blood, spin it in this special centrifuge, then use this device with an arm that you point at the division of plasma and blood and read off the packed cell percent. They then divide that number by 3 to get the Hb.)

 They were using a glucometer like the ones that are over the counter in the states for diabetics to do blood and CSF glucose levels. For now, this is working. But when they run out of the proprietary test strips, they’ll be out of luck on glucose tests.

 They don’t have a histology department anymore because the pathologist left.

They do the “heat until the fluid begins to vaporize” step of the TB stain procedure by lighting a piece of cotton wool on fire and holding it with tongs. So not safe. (I watched the guy nearly light his sleeve.)

There is one person who spends his entire day reading malaria blood smears. (Most are negative, as it turns out.)

 I’m interested now in seeing a rural health center (if I can) when we go out to Rhumpi or Chitipa. Because those are where the bulk of health care in Malawi actually happens, and Ellie says they are woefully underfunded and understaffed. She says it will be even less capable of conducting basic tests than the MCH lab. What a thought.

Plans for the week

June 25th, 2007 by Kim

Tomorrow, I’m going to go to the Mzuzu Central Hospital Lab. Mostly I’m just going to sort of follow the director around. At least, I think so. If he isn’t at Ekwendeni doing follow up on the dry blood spot training he conducted on Sunday. It was a little unclear when I talked to him today what I’ll be doing tomorrow.

 But he invited me to the Central Lab on Wednesday because they’re doing a blood campaign. That should be really interesting. They have some of the same requirements as in the states, but not all of them. You do have to be 17 to donate. They do an HIV rapid test on the blood (but don’t tell you the result unless you ask for it specifically.) They do a syphillis rapid test on the blood. They also do a hepatitis rapid test on the blood. They don’t, however, check your hemoglobin like we do in the States. I also don’t think they type it ’til later.

 Thursday, we’re going to Nkhata Bay. Ellie will spend the day with the ARV clinic. I will spend the day in their lab.

 On Friday, we start training in Rhumpi, which is a little more than an hour from Mzuzu. We will be staying in a hotel there, so this glorious, constant internet access is going to disappear!

But it will be a fun, interesting week!

Branching Out A Little

June 22nd, 2007 by Kim

Ellie and I were talking on the drive back from the first round of Infant Diagnosis Training at Ekwendeni Mission Hospital today about how I have down pretty well what this Infant Diagnosis thing is all about and how the implementation works. She thinks I should start some other small projects to give myself something more interesting to do.

We’re thinking that for one I’ll do some data analysis and review/revisions of the pre-tests and post-tests for the trainings. (Since this is a pilot project we’re working on and they intend to scale it to the national level next year some time.) The tests need a lot of work, actually. Some of the questions are phrased very poorly. It is also interesting to see where the common misconceptions about HIV/AIDS related topics are here. (For example, the first question on the test is about the HIV prevalence in Malawi. The right answer is 15% of pregnant women are HIV+ which is about 90,000 women. Most people anser 5%, about 10,000 people.) That should be interesting.

I’m also supposed to put together a quick presentation/spiel about what Senior Design is, what I did for my project and what I would like health care providers here to do for me (provide ideas of possible projects.)

I’m going to spend a couple days now in a variety of different labs. Sometime this week I’m going to spend the day in the lab of the Mzuzu Central Hospital. The lab director invited me to hang around for a while and gave me the idea for the presentation about Senior Design and my project. I’m also hoping to drop in on the labs at other places while Ellie is doing some follow-up with the ARV clinics. Thursday we’re planning to go back to Nkhata Bay (just for the day) and I hope to see the lab there and compare a more under-funded district hospital lab to a relatively well funded one (MCH). I also want to see the lab of the Mzuzu Health Center, which is distinct from a hospital and is supposed to be a much different laboratory experience.

Ellie would also like for me to come up with something that would make tracking of the success of the ARV clinics at treating children. Essentially she wants an Excel spreadsheet that you can enter raw data (like the number of new children, the number of new adults, etc) and do some pretty basic computations.

It’ll be exciting to do some other things.

Nkhata Bay

June 21st, 2007 by Kim

Our trainings for this week are for the Nkhata Bay District Hospital. We’re staying in a rather dilapidated lodge that seems to be frequented primarily by Malawians (rather than muzungus like us!) So far the trainings seem to be going very well. Though, yesterday I took the day off and walked up to a more mzungu lodge (the Mayoka Village) and had a nice day of sitting on the shore and watching the lake and reading a book.Apparently, Saturday’s training was quite lively. Ellie said it felt like people asked questions about every slide and nearly every statement. Which meant she was gone for quite a long time! But if it means that people know the material better, that will be great. (I hope they do. The pre and post test comparisons from St. John’s were a little disheartening. There seemed to be very little overall improvement.)

Sunday’s practical session about DBS collection has gone well. The people seem to know what’s going on. I suppose that makes sense because several other trainings that many of these people have been through involve the technique of collection, though they haven’t ever done it before. They’re currently in another room practicing on one another.

 The onsite visits also went very well.

 The paediatric ward tested 2 children on our first day and the ARV clinic tested a baby that came in with a mother who wanted VCT (voluntary counseling and testing.) Her story is interesting and a little sad. The mother had recently lost about 20 kg (from 85 down to a really malnourished looking 65) and had had a number of other illnesses. She also has a 4 month old baby and a whole breast abscess on one side. (She was worried about the baby a lot because she was concerned she couldn’t produce enough milk with just one breast.) The mother tested positive (and she was relieved to know why she’d been having problems. It was actually a kind of strange and unexpected reaction to a positive HIV test.) We then tested the baby and will get the results in 2-4 weeks. (Well, I’ll probably never get them, but her family will.) The mother qualified for supplemental feeds and will probably qualify for ARVs at the next ARV clinic that they have. It was nice to make a positive difference in the lives of a mother and baby.