Aparna in Mozambique

Sunday, February 25, 2007

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!



Blogger ashwin said...

Hi Aparn, the stats you gave are very sad. As I look forward to my medical career and my classmates complaining about the large salaries they will be making soon as not being enough, this is very humbling. It makes me grateful for all the opportunities I have and hearing these things motivates me to want to contribute in some way. Hopefully, I will get a chance in the future. Thanks for the enlightening post. Peace.

12:40 PM  
Anonymous Anonymous said...

Dear Aparna,

I am exited to see all the comments other people send it to u.
There is no solution to problems, unless u educate people, getting jobs and funds are appropriately distributed.
It will take lot of time,like its happening in India.


4:33 PM  
Blogger viarota said...

"...no easy solutions... has to involve incentivizing the health care field so that people want to stay in the country and contribute."

Aparna, I just wanted to give you some encouragement from China to Malawi. There is so much I share with you when I read your posts, and remember from my summer in Africa...

And yet, here I am in Asia, where the rule seems to exploit weaknesses, to fund corrupt governments and businesses at the expense of their people's wellbeing. And as long as this cruel aspect of humanity exists, as long as hundreds of millions of racist people are self-absorbed in their wealth and status at the expense of an entire continent, it truly remains on young people like us (not Africans, not aging philanthropists, not volunteers, whom they do not respect) to ensure that doing good is the only thing status-approved to do.

Otherwise, it will be a heartbreaking thing to see people die slowly from crisis on one side of the globe while the those on this side purchase the conflict resources to enable them to play golf on this side instead.

7:57 PM  
Blogger Ana said...

I am receiving a lot of energy from your words. Somehow I feel you are getting back energy and motivation that you had lost in the last year. It's so inspiring for me, Aparna.

I also think donors' investments are counter-productive in many occassions because they are motivated by political interests rather than on obtaining effectiveness.

The thing about the nurses leaving I had heard before. It is kind of a dilema between self interest and the interest of the community and the country were you were born. Both my grandfather and my uncle got their medical degrees in the capital of my country but they decided to go back to their city of origin instead of staying in the capital (where they would had much better opportunities); they did that mainly because they considered it was the right thing to do..........

Does it happen in any case that those nurses who left for Britain come back to Malawi after saving money and getting training there?

Thank you for sharing so much information.........and experience.


11:19 AM  
Blogger Fahmina said...

Aparna omg I'm so glad you have dedicated your time on helping people in Malawi i hope one day i can do the same

love u always Fahmina

1:49 PM  
Blogger Farah said...

I love hearing your stories. I'll write more when I get the chance. Thinking of you...


2:30 PM  
Anonymous Anonymous said...

I love hearing your stories, especially since I am now studying public health as well. I think I might share your blog with my professor. Keep them coming.
Love, Raquel

6:51 AM  

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