February Fun

Hi All!

I realize that it has been several weeks since I posted.....lets just say that I have still been unsuccessful in uploading my pictures to the internet....but still working hard on it. Hopefully by the time Easter rolls around, I will be able to show you a little bit of my life here.

So since I left you quite a bit has happened. Immediately after my return from the village, I began a course on the Primary Health Care System in Malawi. Basically, most of the health care delivery here is primary. In the states, we have all the way up to quaternary care, which is pretty much nonexistent here. Primary health care (preventive and interventions) is delivered at the most basic health care level, the health center as well as through village health committees, rural workers called health service assistants, and other local collaborators. The next level of care (secondary) with some specialists (considered to be people that are actually doctors) is through the district hospitals....there are about 27 districts in Malawi. Tertiary health care is delivered through the central hospitals (There are two: Queen Elizabeth Central Hospital in Blantyre and Lilongwe Central Hospital). This involves some oncology, some services such as obstetrics and gynaecology, and surgery. These are all items considered to be tertiary care. In the states these would be the specialists (cardiologists, orthopedics, etc.) and quaternary care would be subspecialists (pediatric oncologists, etc.).

Given that there are approximately 1 doctor per 100,000 person in Malawi, this is pretty much obsolete. A few statistics to think about: That is 1/6th of the needed number to staff the health care system in Malawi. 33% of healthcare posts in Malawi are not staffed and 64% of nursing posts are unstaffed. While 60 nurses graduate a year from Kamuzu nursing college, nearly 100 per year leave the country, mostly for the UK.

Health centers are staffed by clinical officers (2 years of training) or a medical assistant (4 years of training) and one nurse (4 years of training). As part of the course, we visited a health center in Chiradzulu district called Chitera health center. On the day we went we met with the medical assistant. He showed us the facility, which was empty because the staff was doing "outreach." Again, we were faced with the issue of shortage of supplies (drugs, gloves, etc.) and he told us how he was seeing nearly 120 patients a day but ran out of drugs as simple as analgesics by the middle of the month every month. In addition, the facility had no running water or electricity or functional pit latrines. What that means is that the maternity ward has no place for the women to bathe after birth or even to use the toilet. The sad part is that after several weeks in Malawi, this center was looking a bit better than others that I'd seen. The great things was that the medical assistant was a very committed young man. Also, Medecins Sans Frontieres is working out of this site to deliver Antiretroviral therapies (ARVs) and had a wonderful stock of drugs in the supply room. However, this type of work is problematic as you can see that they items they bring are only available on the days that they deliver service and only for the services that they deliver. Our team was very skeptical of this type of vertical programming although beneficial...

I just wanted to put these numbers out there not to depress you, but to give you a picture of the real challenge that people are facing here as a result of the human resources crisis exacerbated by infectious and communicable diseases and limited supplies. I for one, have no easy solutions, but I am pretty sure that the answers don't lie in donors increasing their funding. It also has to involve incentivizing the health care field so that people want to stay in the country and contribute. People have to make a living and if they can't, they leave. In a country where doctors earn on average less than $5,000 a year, I can't say that I would be compelled to stay...

After the Primary health care module, I completed a module on Malaria. Again, shocked by the facts and shocked into definitely being religious about taking my anti-malarials. P. faciparum is the particular strain of malaria that most of sub-saharan africa faces. 100% of the population in Malawi is at risk for malaria and we have both areas of seasonal and year round transmission here. The most at risk are pregnant women and under 5 children. The government is working on several campaigns including Insecticide treated nets (ITNs), Indoor residual spraying (IRS), Intermittent Preventive Treatment for Pregnant Women and Infants (IPTp and IPTi) to control malaria. At present INTs are free at the antenatal and under 5 clinics and in the next year should be free for all. But the government is facing major problems in considering how to scale up their policies of IRS and IPTp and IPTi (still experimental). See, the thing is that the first line treatment for malaria is SP. Well, in Malawi this is now only 80% effective and they are seeing more and more resistance. But all the other treatments (coartem and other artemesinin derivatives) are very expensive although the best. IRS is also expensive and IPTp is safe with SP but not artemesinin. Ok, the moral of all this jumbo is that how to scale up malaria control strategies is a HUGE challenge. Considering that everyone in Malawi gets malaria at some point and that it seriously affects people's work it is really a big deal. And in severe cases (cerebral malaria or late treatment), it can result in death, which is completely preventable. Other issues are treatment in the home, lack of recognition of malarial symptoms, and available drugs for malaria in the hospitals. Its a lot to think about....I personally have had 3 friends with malaria in the brief time that I've been here and a friend who lost his 4 year old nephew to malaria last week. Its something we hardly hear about in the states but is a critical health care challenge.

So, last week I switched a bit and had a course on good clinical practice, which is the ins and outs of running clinical trials in accordance with international standards. This was good for me as it reminded me a bit of my training in human rights and was a very easy week compared to those in the past. It was a good introduction for me into my bioethics sequence which I will be doing through my MPH.

Ok, in personal news, this weekend one of my classmates invited me to his home in Mulanje. He and his wife work as nurses and teachers at the Mulanje mission hospital, where they live. Mulanje is the highest mountain in Malawi and I hope that I can return to hike. My friend warned me in advance that he was not the hiking type so we basically just relaxed with him and his children, went to the market to buy vegetables, cooked a meal for 10 people, and played pool at the local watering hole. The hospital itself was one of the best facilities that I've seen, but then again it was a privately funded institution so that was to be expected. My friends and I had a great time and they were fascinated by the fact that I was vegetarian. So, off we went to the market to buy any veggies that I had ever heard of! Yes, I was director of the kitchen...they insisted that I cook something indian so I ended up making eggplant and potato curry, which was not bad considering I had almost NO ingredients other than oil, curry powder, and salt! They enjoyed and there wasn't even a scratch left! I imagine that any self respecting indian person would have laughed at the fake curry but my Malawian friends didn't seem to mind.

Well friends, thats been my life the past few weeks. I did go to a Rotary meeting this week and they were happy to announce that they have just received funds to renovate the Queen Elizabeth Central hospital children's ward and I am happy to get involved in this project in the next few months. Also, next week I have no classes so I will be working on my assignments from the past few weeks but also volunteering with my friend Donna who is a teacher. I will be doing arts and sports with her this week at a school for orphans in the Ndirande section of Blantyre. I am very excited to be around children again!

I hope to hear some comments on my thoughts...certainly a few of you will agree/disagree with some of the statements I've made....and I can't wait to get some feedback. I promise pictures on the next post....I am going to do whatever is necessary to make it happen.

I miss you all and hope that you are safe and well wherever you are!

Warmly,
Aparna

Settling in....

Hi All!

So I am finally settling into the swing of things out here. Just to give you some updates....

The first two weeks were my orientation at the college of medicine. The first week we focused on basic principles of public health in a malawian context and prepared for a survey in the rural areas. Over that weekend, we traveled to Mangochi district, which has one of the highest HIV/AIDS infection rates in Malawi. There are 25 students in my class, which is pretty big and we all went to the village to stay in separate households and conduct different surveys. There are only 3 others from other countries: one from Congo, one from Kenya, and one from Zimbabwe. .....needless to say I stick out just a little bit:)

My partner Mabel and I were stationed at a house in Namwera village, where we stayed for 4 nights. She was really my guardian for those days and showed me how to do everything from use the pit latrine to wear a chitenje cloth like a true malawian woman.

Thats right, we stayed in the village for 4 nights with no electricity, no running water, no soap for dishes (washing the pots with mud was great) and lived pretty much like everyone else. What that meant was lights out at 8PM when it got dark and wake up at 5AM when the chores started and the chickens cuckooed. I helped as much as my american self weak hands could. I scrubbed floors, washed pots, carried water on my head although half of it fell out:) and ate nsima with vegetables every day.....The hardest part was not being able to speak much in chichewa. To make matters worse, most of the village spoke Yao so I was totally clueless. I had to rely on my partner Mabel for everything from telling stories, asking for water, and translating my surveys.

I conducted through Mabel a survey on access to HIV/AIDS treatments (ARVs). They are free through the government. I interviewed 20 people and 11 were on ARVs. The biggest issue they faced was transport to the hospital for ARVs which was expensive. The health center near them did not have ARVs or really any drugs. Actually there was no staff there either so it was a bit disheartening. On wednesday, we went back to Mangochi district hospital and debriefed. We stayed just outside the hospital and I was shocked every morning to see mothers from the village waiting with their babies from 4AM till 4PM just to visit the under 5 clinic for height and weight measurements. It is really shocking what the hospital looks like. Once I get a better connection, I promise that I will send some pics.

So, on Friday I came back to Blantyre and finally started to settle into my life here....I am staying at the college as most of you know and have been overwhelmed by how friendly all my classmates and rotary friends are. I haven't had a dull day yet and my days and nights have been filled with invitations to this house or that place to see in Malawi....

This week I am doing a module on primary care and next week on malaria. After that I am taking two weeks to do special projects with my professor most likely on access to health centers as well as starting my dissertation work.

So, needless to say, I am having a wonderful experience thus far and look forward to hearing more from you all!

I also have a phone number now if anyone is inclined to call: 265 9 386 968....

Will write more soon!
Aparna