Malawi Week 4 (Africa Week 5)

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My time in Malawi is winding down and while I am really glad to be here, I am also very glad to be going home soon. This has been a positive learning experience about Tropical medicine and medicine in resource limited settings. More importantly, it has been a good opportunity for personal growth and development.

Quote of the week

Malawian Doctor 1: “Hello Brother, brother form the other mother.”

Malawian Doctor 2: “Yes, mother. Not the father…he is the problem.”

Runner up..

Dr. Taylor: “I wrote ‘Diagnosis: Less complicated Malaria’. Ha”

<strong style="mso-bidi-font-weight: normal;">On the wards….

I spent week 4 in the Malaria Research Ward. This is a much more organized ward than most. It is run by Dr. Taylor, one other American doctor Carl and a staff of dedicated Malawian nurses and clinical officers (same as physician assistants). There is at least one dedicated clinical officer on staff at all times of the day and the patients are rounded on twice a day, once in the morning and once in the afternoon. Many, but not all of the patients, have been recruited to a research study. There are multiple going on at any given time. There is a study to compare different drug dosages and durations for treating malaria, one for looking at long term outcomes in survivors of cerebral malaria, and another looking at different treatment interventions for sepsis. If you haven’t guessed, malaria is endemic here (as well as about 90 other countries around the world, however morbidity and mortality from malaria is the greatest in sub-Saharan Africa) and a frequent cause of admission for infants and young children. It is for this reason that I must take Malaria prophylaxis and sleep with a mosquito net. Every Malawian adult has already had malaria at least once in their lifetime and has gained some immunity to it. So, even if they become infected it is goes on asymptomatic.

Most children admitted to the research ward are infants to toddlers, but you get the occasional 10 or 11 year old. Children are not usually sent to the research ward unless they have a serious case of malaria, have probable cerebral malaria or are already in a study and have been admitted for a related any reason. In a week’s time I saw children arrive having seizures and/or in a coma, receive treatment and go home relatively unscathed. There is one child still in the ward who has had persistent fever and seizures for over a week. The team has been able to drastically reduce the number and frequency of the seizures and get the fevers under control. However, the seizures have not completely gone away…she is still having at least one a day. She also has some paralysis in her left arm. It could be post seizure paralysis (Todd’s Palsy), but it is hard to say until we can get her seizure free. When I left on Friday, she was finally opening her eyes, feeding and responding to stimulus. Great improvement, but there is more work to be done.

There was an unfortunate story. A 15 year old boy was admitted with a recent history of seizures, now in a coma with positive Malaria Parasites on blood smear. After two days he did not show any signs of clinical improvement despite receiving proven effective treatment. Interestingly, this was his first ever episode of Malaria. He had typical retinal findings of cerebral malaria, confirming a diagnosis of cerebral malaria. On Friday we were nearing the end of rounds and I asked about the boy. That’s when I found out he has passed away overnight. Despite frequent encounters with poor patient circumstances, poor clinical outcomes and rampant resource limitations, I was surprised to hear that this young man had died. Even in the arguably the most well staff and best resourced (albeit still limited) ward in all of the hospital, every child cannot be saved.

On the wards in the coming week...

I am in the nursery and neonatal intensive care unit for week 5. Today was my first day and aside from being ridiculously warm in there (so warm that I had to go outside to cool off), it was a great day. Not only did I see lots of interesting cases, but I was thanked for my help today! I can’t wait to summarize this week.

Weekend Excursion to Zomba Plateau

The Zomba plateau may be my favorite destination in Malawi thus far. It offered the perfect combination physical activity and reflective meditation. I enjoyed brisk walks through scenic landscapes with some mild hills and relaxing monkey gazing from a wraparound porch facing the valley below the plateau. Combined with much needed casual reading and journaling, I'd consider this an unexpected reprieve after many weekends of awesome, but exhausting travel. All of that and only 45 minutes from Blantyre...perfect.

We arrived to Zomba mid morning and checked into our hostel, La Casa Rosa. This is a newer establishment, so none of Dr. Taylor’s other students have lodged there before. Being the adventurous group that we are, we decided to check the place out. It turned out to be absolutely lovely. Our group was divided among the dorm and one of the private rooms (the only guy in our group finally got a room to himself…I am sure a much needed break from all of us women). The dorm was in a modified barn in the back of the house. It had a shower house with 3 showers and three toilets attached to the back. It sounds strange, but it was neat.

Once we dropped off a few items and switched out our bags we hopped back into our mini-van with our faithful driver, Tomandon (he has been our hired driver for every excursion so far), who skillfully drove us to the top of the plateau via a very rough, unpaved but relatively safe road. Along the way we saw men, women and children hauling bundles of sticks and lumber on their heads down the hill. I admittedly got a bit nauseous and got very close to getting and walking. For a few segments of the drive I could have easily kept up with the vehicle if I maintained a brisk pace.

Young men and boys were dispersed at various points on the plateau selling crystals that they had recovered from nearby mountains. They looked like the kind of crystals you would find in an overpriced souvenir shop, except these were a bit rougher in appearance. I have to give them credit for presentation though. Many of them set up shaded stands, rinsed the stones in water, and displayed them in a very organized fashion. Sometimes a “the crystal boys” would run up to the car with their crystals laid out on a plank of wood, saying “I offer you a great price.” No, I did not buy any crystals…but I came close.

Not much is written about Zomba plateau in the travel books, but there are two lookouts mentioned, Queen’s View (named after Queen Elizabeth after her last visit in to the area in 1957) and Emperor’s View (named after Emperor Haile Selassie of Ethiopia during his visit in 1964). Here, you can look out over the vast Phalombe Plains south of Zomba. We could also very easily see Lake Chilwa and Mount Mulanje (the mountain we hiked 2 weeks ago) off in the distance. We spent a little time on the top taking in the scenery and talking purchasing crystals from a young man who helped us find the two lookouts. Afterwards, we descended partway down the plateau and had lunch at the Ku Chawe Inn, a beautiful but pricey hotel on the plateau. Mmmm…it was one of the most delicious lunches we have had in a while. The meat eaters all got burgers and chips (fries), while I and the other vegetarian enjoyed the Thai vegetables and rice. We dined outside in the garden, which boasted lavish landscaping and views of the valley.

I could go on and on about the rest of our story in detail, but I will try to keep the rest short. After lunch, we all took various walks to either see the falls or the dam, followed by an excellent Italian dinner and drinks at our hostel, La Casa Rosa. The following morning was restful with a complimentary breakfast of bread, butter/jam, and coffee/tea. I joined some of the group on a prelaunch walk to find the botanical gardens. We did not find the gardens, but we did experience Zomba’s forest of Cypress trees, Mexican pines, Mulanje cedars, patches of Bamboo, large colonial style houses, beautiful personal gardens and immaculate landscaping and scattered wild flowers, ferns and orchids. Before departing¸ took in two AMAZING cups of espresso…sigh, I miss that espresso.

<strong style="mso-bidi-font-weight: normal;">Random Malawi observations…

Petrol and diesel:

So the Malawian president did some things to upset his international allies, so the country has short supply of everything from electronics, to medications to petrol (gas) and diesel. As a consequence, people wait in long queues (lines) at the petrol stations when either diesel or petrol is available. One doctor told us he waited as long as 14 hours in one queue only to find out they ran out of petrol. He then went to another station and waited in queue for another 8 hours before fueling up! One business man says he owns a car that runs on diesel and another that runs on petrol…that way he can fuel up on whatever is available. I won’t even venture to translate the cost of gas here because I would have to convert it to dollars and gallons (380 Malawian Kwatcha per Liter with an approximate exchange rate of 170 Malawian Katcha per dollar). ---> someone told me that's about 8.00 USD

The Minibuses:

These are the equivalent to a very plain church. The van is beat up with a not so gently used interior. These are the most economical form of travel short of walking short, so they are frequently used by locals with no other means and a few brave azungu. There is a driver and another guy who sits in the front or the tiny little folding seat by the door. The man not driving has the job of filling the bus beyond capacity with passengers. The fare is very cheap, the equivalent to a few bucks for most distances, more for longer distances but always cheaper than a taxi. There are many many minibuses driving up and down the street all day long. It’s kind of funny to walk past a “stop” because the more aggressive “busmen” will reach out to grab u or try to vigorously persuade you to get onto the bus weather u want a ride or not. This has only happened to me once. Other times they shout at you out of the windows as they drive by as if that is somehow going to convince you to get onto their overcrowded bus. I rode on minibuses on the way to Malawi but have done my best to avoid them since arriving here. Seatbelt..I think not. Personal space, definitely not.

Women and Children:

First of all, it is rare to see a man with a baby. I have seen it a few times and he is usually on the way to the hospital or at the hospital. Add to that, babies and young children are not transported by stroller, instead they are carried on their mother’s back, secured only by a single long piece of fabric that holds the child snuggly with little feet poking out on either side of mom’s waist. A single...maybe double tie of the fabric tie just above her breasts completes the job. It’s amazing what the women can do with child in tow...they carry containers of produce or satchels of whatever on their heads, bend over to wash clothes in a stream while baby sleeps and just basically go about their daily business.

Walking barefoot carrying heavy loads:

It’s not uncommon to see people walking around bare foot or with one shoe on and the other in their hand...not sure why the latter happens, but I have seen it more than once (maybe the other shoe is broken). I saw a svelte man (no more than 145 lbs, maybe a few inches taller than me) walking barefoot up a steep incline with a huge sack of potatoes straddling his shoulders. It must have been the length of his arm span and 4x his width...easily 2x his weight. Meanwhile, I was jogging up the same hill in my fancy trail runners and with my iPod strapped to my arm…hardly a comparison. My thought as I ran by was “you are more tough than me!”.

That’s all for now!

Cheers!

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