Author: Dr. Barbara Edwards | Princeton, NJ

Today we started the day with a meeting to discuss the successes and challenges of the 3 days of clinics as well as the way forward to address these challenges. It is interesting to see how things changed over the years as they learned how to do things better. They have organized things better each year and they were very open to improving things even more in the future.  Examples of ideas for improvement included adding a morning huddle at each clinic with the prescribers and the pharmacy to clarify what meds are available.  Another was to have a laminated cheat sheet, which showed the difference between American and Malawian medical abbreviations.

In the afternoon we made home visits.  We visited a girl named Triza who is sponsored in part by our church (Nassau Presbyterian). We presented her family with gifts and we presented her with a school uniform. The uniform fit her perfectly and she seemed delighted.  I think it is rare that she gets something new.  Apparently she is an excellent student: 3rd in her class of 60 fourth graders.

We then visited 2 other families. One was an older woman and her blind husband who lived with their granddaughter.  The girl was 9 and goes to school.  The grandfather is unable to do anything because he is blind so the grandmother does all the farming herself. We were able to go into their house, which was made of mud bricks and had a tin roof and glass windows.  It was clean and I was glad to see that they used mosquito nets.  They had no electricity or running water, of course.  It gets dark at 5:30 so it is difficult for the children to study at night.

Our last family was a 90 year old woman living alone.  Her son and his family lived next door.  She still farms on her own but only harvests 1/2 bag of corn.  She also has chickens living in her house with her. One hopes that her son helps her out when she runs out of food.   She lives in a mud house with a thatched roof.  She reports that it was built in 1984 and that the thatched roof needs to be replaced every 4 years.  It does leak in the rainy season. We gave each of the families blankets, clothes, vitamins and we examined them and treated any illness that we found.

 

Today was the last day of clinic.  It was incredibly busy but we all worked faster and we had learned how to treat the conditions we are seeing here.  We saw tons of malaria. At one point we ran out of malaria test strips (a quick test for malaria that we could do with a finger stick). We had to treat empirically for the symptoms until they brought new ones from another clinic. I learned that most people know what it feels like when they have malaria, so I could use their impressions as a guide as well.

I had to make a home visit to a woman with a fever who was unresponsive.  She had a stiff neck and a positive malaria test.  I was worried that the stiff neck signaled meningitis so I had the ambulance bring her to the hospital 15 minutes away.  However, she just may have had a seizure due to malaria.  In that case, she might have been better off getting treated at our clinic.  We had better IV meds for malaria than the hospital.  Often if we treated with IV meds at the clinic the patient would wake up and improve enough to go home and could then finish the malaria treatment at home.  It was not an easy call.

At the end of the day we all took pictures and exchanged emails with the Malawian medics and translators.  One makes friends quickly in such an intense situation.

Tonight after dinner we sat in a circle in the classroom and talked about what was best about the day.  I talked about going on the home visit and then walking back to Kalupe Clinic because I had sent the ambulance to the hospital.  I kept meeting people along the way. I recognized what a privilege it was to be welcomed into people’s homes and villages.

The medical resident I went with talked about how she was angry on the first day of clinic because we had to see people so quickly but also how she realized, by the third day, that it was the only way to see the volume of patients that we needed to see.  We saw almost 5700 people in 3 days in 4 clinics.  We saw 679 the last day in our clinic alone.  I know that we saved hundreds of lives just counting those who would not have been able to get malaria meds because the government clinics were out of stock.

VIP also trains medics in Malawi who then work in the villages for at least 5 years and provide continuity of care throughout the year.  They also dig and maintain wells, build schools, train teachers, build roads and bridges, and give families goats and chickens to maintain their food supply.  (In Malawi there are chickens and goats everywhere, and they live in the houses with their families.  Somehow they find their way home at night.)  VIP also brought electricity into Kalupe, built a corn mill for the village, and is now building a rice mill as well.

 

Today we went to church in a Presbyterian Church in Khanda in the region near Lake Chilwa.  It was a great service that lasted 3 hours! There were 3 choirs and they were all fabulous, especially the children’s choir.  Sixty children sang in harmony.  It sounded glorious!  All the choirs danced while they sang and we got up and danced with one of the choirs too! The Americans practiced singing Amazing Grace in Chichawe and we sang as the “American Choir. ”  Liz preached the sermon and Daniel translated for her.  What an inspired sermon it was!  She preached about Mark and kneeling before God.  It was the story of the woman who touches the hem of Jesus’ garment and is healed and the story of the rich merchant whose daughter dies and is raised by Jesus.  She talked about rich and poor people all kneeling before God.  After church the women of the church prepared lunch (rice, greens, pidgeon peas, chicken), which we ate in the church. I learned how to cook the food.  I also spoke to a woman who walked barefoot 2 hours each way to go to church!

In the afternoon we hiked up a hill behind N’amanghazi Farm. It was halfway up Zomba Ridge and really steep, sweaty and buggy.   It was a beautiful view, though, and a good work out! Joe led the way and we moved quickly!

 

Today was the second day of clinic work.  I am at the Kalupe Clinic, which is the largest and closest clinic to the hospital. It was the first satellite clinic established in the area. There were four of us seeing patients: two medics from Malawi, a nurse practitioner/student from Xavier College, and myself.  We are supported by a whole triage system of nurses and a pharmacy staff.  We have anti-malarials and other antibiotics including anti-parasitics, pain meds such as ibuprofen and acetaminophen, eye meds, some seizure meds, and BP meds. I work with a translator at my side (Emma) and I was somehow made the official “Gynae Consult”. Yesterday I did not see that many patients because I did mostly GYN exams.  I am not sure that is the best use of my time because I did not really have the meds I needed to treat anything besides PID.  Today I did fewer GYN exams and treated malaria, headaches, fevers, colds, rashes, body aches, as well as PID.  I am learning again how to recognize malaria.  I have not seen as much HIV as I expected. Yesterday seemed chaotic and overwhelming, but today we felt more under control.  Our NP student is doing really well.  She asks questions and has a good clinical sense.

Both today and yesterday we had lunch with Emma, my translator, in the village of Kalupe.  She lives in the village so she arranged for our food. She says, “These are my people.” I bring her snacks every day. She especially likes the squeezable applesauce.

Emma is a teacher in the primary school built and run by Villages in Partnership (VIP).  VIP paid for her training and is sending her to college to earn a teaching diploma so that she can teach in the new secondary school that they are building. She teaches during the week and goes to school on the weekends. She lives with her husband and daughter.  Her daughter attends the school at which she teaches. She says that she is a beneficiary of all that VIP has done for the region.

After clinic the nursing and NP students played with the village kids with soccer and beach balls.  The children hardly have any toys of their own and were so very excited to play with the balls!

In the evening after dinner, we gather to talk about the day in one of the classrooms and we pass around candy, chocolate bars. Yum.  Today we told our highs and lows, “happy’s and crappy’s.” Tomorrow is church and a hike in the mountains.

 

Today is day 2 in Malawi.  We arrived yesterday after a 20 hour trip, 15 hr to Johannesburg, a layover, and then 2 hours to Malawi.

We are staying at N’amanghazi Farm in Zomba, a working farm owned by the Balantyre Synod of the CCAP (the Church of Central Africa Presbyterian).  Twenty seven of us are housed in four different buildings. Workers cook food for us every day: fried chicken, goat boiled with onion and tomato, veggies, rice, potatoes, eggs and Nsima, a corn flour dish similar to grits, but finer and stiffer.  There are not a lot of veggies, some cabbage salad and mustard greens. The buildings are rough but clean.  I believe this was previously a youth hostel, but is now a Presbyterian conference center. Most of the time we have electricity; and we have hot and cold running water and toilets with seats!

Today we met the clinic teams, organized all the meds, and visited the local hospital. The hospital reminded me of the hospital in Liberia that I worked in as a medical student 30 years ago.  But it is larger, more disorganized and not as clean. It is heartbreaking to see the conditions of the hospital when we have so much back home.

Tomorrow we will create 4 clinics from scratch in empty buildings with no electricity or running water. We will bring furniture, meds and equipment.  Testing will all be “point of care” including glucose, hemoglobin, malaria and HIV testing by finger stick.  We expect it to be busy because rumor has it that the government clinics have run out of malaria meds.