It was a relief to had finally step off the airplane to face the welcoming sign announcing the Malawian Interntaionl Airport. It was hard to imagine that Elizabeth and I only left Houston three days ago. The long airplane rides and the lessons we learned along the way all seem to blend into a murky dream. Stepping foot on the airport where people are all jostling to find their bags on the only conveyor belt and where the sounds of squeaking go carts pierce the air quickly awakened me to the nostalgic atmosphere of the wonderful country Malawi. To make our travel adventures short some lessons we learned along the way:

–          Never eat beef and cheese burgers on the airplane or else risk the body forcefully ejecting it out (i.e. I threw up)

–          When the check-in and carry-on bags must be switched, make sure to switch the liquid substances as well or painfully observe brand new toothpaste and body wash discarded

–          Always arrive an hour early in Johannesburg airport to check-in. We had to rebook our flight from Johannesburg to Lilongwe—in the process, staying an extra night—because we missed the mark by about 15 minutes.

Driving from the airport to St.Gabriel’s Hospital, I was filled with an intense déjà vu; after all I had been here before on this exact road a year ago. However, what was so strange to me was that nothing has changed. Malawi seems to stand still amidst its red dust. Everywhere kids and adults alike were walking barefoot on the red sandy sidewalks beside the paved road. Woman were balancing huge baskets of produce as they walk while babies were strapped saddle on their back; men, riding their black bicycles carrying goods or their families; kids, playing outside or trying to sell mice on sticks to passing cars. The towns were filled with animals and people conversing outside buildings that badly needed repainting or even reconstruction. Homes are still isolated villages of clay and straw huts with open fires to cook. Strange half-finished brink constructions sat on the side of the road without a shadow of a worker in sight. In fact, the only change I saw was a diversion of traffic and the road for the new, blindingly white Parliament building in front of a billboard that promised the roads would be fixed at a “record rate”….

Starting our first day at St.Gabriel’s Hospital, I was glad to discover many changes. The ART ward that I saw was in construction the last time had been opened for six months now. I remember the days when HIV patients would line up crowding the OPD hallway to wait for their check-up and next dose of medication. Alex, the nurse in charge of ART and community outreach, would see patients in a narrow room where one side there would be a small table and the other side, shelves of crammed records and medicine. Now the ART ward is a spacious building where patients can wait outside in the open air under the shade to wait their turn in the reception room. There were rooms for each of the jobs: dispensing and storage of medicine, pill counting, records keeping and offices. I think the ART clinic opened at an opportune time as Malawi has a HIV prevalence rate in the teens; it shows that the hospital realizes and places importance on the HIV/AIDS issue.

A hospice and palliative care unit also opened adjacent to the ART clinic. In the past, Matilda– the nurse who worked with a previous intern Z on the community health worker backpack—would ride a motorbike to check on the patients on palliative care (I still remember the time when the motorbike broke down when I was with her). Now patients are housed in this clinic where the nurses and doctors can try to make the last few days for them as painless and peaceful as possible. The project is something new the hospital is trying out. Patients are referred from the wards where proper assessment of the condition is used to determine whether the patient can move to the ward in order to minimize overcrowding of the small unit. Foreign doctors seem to head the effort for this project as the Canadian resident Ilene (on a 6 month program) is the main doctor who makes rounds in the afternoon. She along with the nurses for the ward work part-time as they have other hospital duties in other wards the other half of time. We had an opportunity to sit on their bi-monthly meetings where they discuss challenges they encounter such as mothers who refuse HIV testing or caregiver fatigue. One particular problem is related to the free-of-charge policy the hospice has enacted. Many patients in the wards request to be admitted because they know that care is free. Despite the problems, the nurses and Ilene recalled fond memories of patients who passed away and the grateful thanks they received from the family members.

I am once more glad and proud to be in this small but exciting hospital. While the landscape may not have changed, the hospital continues to explore new ways to bring healthcare to the quarter million Malawians it serves. The downside this summer is that the hospital is experiencing an internet crisis. We barely have 10 minutes day, segregated at random times of the day that are hard to catch. We would have to travel to Lilongwe to use internet cafes to use the internet.

Wednesday June 9, 2010

This morning, Jasper and I went on a quick run before our first day of work. I run in long leggings with long basketball type shorts over that and a largish t-shirt. The road we went on was busy with people starting the day and the air was filled with haze from the morning fires. All of us (Jasper, Tiffany, Yiwen and myself) went to the 7:30 doctors meetings. Here they discuss the status of the patients in the various wards and interesting cases. It seemed like they were presenting in a way to Dr. Heim, who is a German doctor, who deals with surgery. After this we went to meet Sister Annie, who is filling in for Matron Kamera, our mentor while at St. Gabriels. Unfortunately Matron Kamera is out this week, so Yiwen and I will have to wait to discuss our technologies with her.

The hospital is pretty and very open air. The grounds are very well kept with even green laws, and blooming tropical looking flowers mixed with plants I recognize like shrimp plant and impatients.

We worked today in the new HIV clinic sorting pills, using the Deering scale that we bought. There are already two digital scales, but run out of batteries really quickly. The Deering was not very practical for counting the larger pills, because the maximum mass measurement is 10 g but we were weighting out 18 tablet doses of large paracetemol tablets. The Deering worked better with the smaller pills though. Yiwen would measure out 30 small pills on the Deering, and I would count them to check how accurate we were, and to correct any errors.

Before lunch we walk into the market which is a cluster of little storefronts, that don’t appear to have much of store back, and a row of stands shaded by a stick covered roof, selling tomatoes, onions, okra, eggplant and fish. Immediately upon entering the market, children ran up to us to hold our hands. In particular there were two girls of probably six, and a small boy, who knows how young. I took turns holding their hands and asked about the names of things in the market, hoping to hear the Chichewa name, and was surprised to hear the girls call them by their English names “tomato” and “fish”. They are already learning another language, much better than myself at that age.

On Thursday, Yiwen and I worked with the nurse in the peadiatric ward. We got to help spike the IV bottles, which we first have to partially empty so that the volume is appropriate for children. Pills are dispensed 3 times a day and all the mothers line up to get what is indicated on their treatment sheets for their children.

The internet doesnt really work here at all, so its lucky if I get to check my emails or post blogs, probably the most challenging part of the internship yet.

Yesterday (Wednesday, June 16), we met with the Matron of the hospital to show and demonstrate all of our technologies. It looks like we will be shifting the attention of our microenterprise project towards HIV support groups instead of the community health workers, especially given the hospital’s current efforts to boost the financial stability of HIV patients by providing seedings for crops and livestock, which is especially applicable given the region’s focus on agriculture. Tomorrow, we will identify promising support groups that will be able to especially benefit from the microenterprise project and impart knowledge gained from our program to other support groups.

It also looks like “Malawi Sally,” our hand-held centrifuge developed for hematocrit detection without power is going to be a BIG hit here. I can’t emphasize enough the need for accurate anemia detection, especially given local health problems such as malnutrition, HIV, and malaria. These conditions all can cause anemia, which can lead to dizziness, heart palpitations, overall fatigue, and possibly even serious cardiovascular complications. For pediatric patients with severe anemia secondary to malaria, it is crucial to monitor recovery in these patients by assessing either hemoglobin or hematocrit. Rapid blood loss during childbirth may be fatal for anemic mothers, especially if anemia is not properly assessed beforehand.

Portable hemoglobin/hematocrit assessment technologies currently exist, but they are extremely expensive for application in low-resource areas. St. Gabriel’s has received a HemoCue device designed to assess hemoglobin levels. However, because the single-use, plastic cuvettes are so incredibly expensive ($0.70 each for 10,000 patients is at least $1000 in recurring costs), the hospital does not dare to use it except for extremely dire situations. Instead, the hospital rely on less accurate, clinical signs such as checking the inner membrane of the eyelid (conjunctivae) and paleness and sometimes a Full Blood Count (FBC) machine, which is very overused and often breaks down.

“Malawi Sally,” our hand-held centrifuge for hematocrit detection, is a solution to this problem with anemia diagnosis, as it is affordable (<$30 in cost), accurate (within 10% of results from regular laboratory centrifuges), and fast (as many as 30 samples in 10 minutes). Today, we tested 40 patients in the antenatal clinic, and the majority of mothers were mildly anemic, which the matron said was normal with these pregnant women. Moderately anemic patients that were assessed by “Sally” were submitted for further and more conclusive hemoglobin/hematocrit testing in the lab. I’m glad that these patients will be monitored more closely to possibly prevent any further complications due to anemia in the future. The nurse we were working with was delighted by the “Sally” centrifuge, especially with the ease-of-use and affordability of the device. Tomorrow, we will continue testing of “Malawi Sally” in the pediatric ward, and I already have a feeling that “Sally” will be very popular with the pediatric nurses, as well!

Namitete is a fairly small and remote town in Central Western Malawi (look below @ the Google Maps for a more exact location.  There are a lot of house structures in Namitete connected by dusty, roads of brown/reddish dirt. The market of Namitete is a modest collection of stands where vendors sell their foodstuffs that they have grown (including dried fish from Lake Malawi over an hour away, freshly baked bread for about 6 cents a piece, and delicious small potato french fries steeped in oil for about 30 cents).  At night, there is no power at the market, but it is quite eerie to see the townspeople and children walking around and conversing in normal in near darkness interspersed with LED flashlights and lanterns in the stands.  I’m amazed at how much they are able to do without power, and how much for granted those of us in the developed world take electricity for granted.

St Gabriel’s is one of the main complexes that makes up Namitete, and relative to the rest of Namitete, is quite modern.  The St Gabriel’s campus is quite beautiful with its lush courtyard gardens and spotless red tile floors (which are cleaned hourly to keep from getting dirty from the brown dirt from the rest of Namitete).

These past two days, June 8-9th were our first days working in the hospital, and we went to work in the ART (Anti-Retroviral Treatment for HIV) clinic counting ART pills (Co-trimoxazole) to facilitate dispensing of this ART medication for HIV patients at Namitete. RT treatment is completely subsidized by the Malawian government, and I think that this is a great start at combating the HIV/AIDS problem that is epidemic to the country.  We needed to count 60 pills per bag, and had over 12,000 pills to get through.  We used this time to use test a BTB “pill-counting device” and compare it to a basic, digital scale also available.

This was a perfect opportunity to test out one of our technologies, a “pill-counting device” that is essentially adapted from a Deering 10 gram scale for measuring diamonds.  Right after mentioning this to Sister Annie, she promptly brought us a small, tare-able, portable digital scale (about the size of a deck of cards) with a receptacle, with a concept very similar to that used in standard scientific labs.

We ran into two main problems:

1) 10 grams is way too small for measuring the 60 pills all at once.  The weight of one pill was approximately 7 grams, and 60 pills was about 420 grams.  Therefore, our pill-counting device had a practical capacity of only 10 pills.  When going through tens of thousands of pills, counting in sets of 10 to achieve the required 60 per bag was just not fast enough when compared to a 6-fold increase in speed from using the digital scale for counting.

2) The Deering 10 gram scale sometimes seemed a bit TOO accurate.  There was a variance of 0.4 grams per pill, and this difference was enough to tip the scales.  Therefore, it would seem like we didn’t have the desired 10 pills even though we actually did.

However, our digital scale ALSO ran out of power (2 AAA batteries) during our pill-counting experience.  Hence, the no-power nature of the manual pill-counting device was superior.  Therefore, perhaps the best way to combine the best of both worlds would be to have a small, digital, portable scale with solar cells for power with a capacity for at least 500 grams.

Monday June 7, 2010

Casa Velha, Round Two

Yiwen and I are in South Africa (SA) … for an extra day. It all started when the British Airways staff started a strike and our original flight from the US to London and down to SA got rebooked to earlier. So we would have to spend the night in SA at a guesthouse called Casa Velha overnight, returning to the airport the next morning to catch the flight with Tiffany and Jasper to Malawi. At the airport in Houston, we ended up having to check the bags we thought we would carry on, and carry on the bag we wanted to check, so there was some packing confusion. (I left my camera in the checked bag and Yiwen had a bunch of liquids in her carry on) The flights weren’t very smooth either, very turbulent, but we made it to SA just fine.

The Casa Velha, which means “old house” in Portuguese, is run by Janine. Janine is engaged to George, and their son Bryan, along with his friend Jared, came to pick us up at the airport. The accommodations were very comfortable and after almost two days of flight and next to no sleep, I went to bed quickly. Janine, Yiwen and I agreed that we should leave at 9:30 for the airport to catch our 10:20 to Lilongwe.

Now, most of you (especially you, Mum) are probably saying just now “what were they thinking!!!” which is pretty fair considering. Im going to blame it on my general sleepiness, and maybe an underlying assumption that “things are different in SA”.

9:45 am the next day, Yiwen and I get out of the car at the airport, but realize we have left a bag with technologies in it at Casa Velha, Jarred drives back to fetch it while Yiwen waits and I run, with bags in tow, to the check in desk only to met by a lady insisting that you must check in one hour prior to departure to be accepted onto the flight. I plead, please, we have 30 minutes, we can make it, but she says no. Then I hurry dejectedly and a little panicy to the ticket desk to rebook. I learn that there aren’t any other flights to Malawi that day, let alone to Lilongwe, so I go ahead and reschedule, call Tiffany to let her know what is up and return to Yiwen.

We headed back to Casa Velha with Jarred, and are going to stay on another night, no mess ups tomorrow! Hopefully we have expended all the travelling bad luck allocated for this trip!