It’s particularly troubling when children and newborns die because a country is so behind countries that are developed. It is especially difficult when you know all the advantages of the developed world. During our visit to the district hospitals and the central hospital of Blantyre, I helped input registers for neonates and. Death after death I thought to myself if only they were born in the States!

Many neonates here pass due to prematurity, low birth weight, respiratory distress syndrome, and pneumonia. Mothers lack proper information, education, nutrition, and health services. Hospitals don’t have the equipment, drugs, or specialized supplies for proper treatment. Healthcare workers are overextended. Simply put, they die because they are born in Malawi.

I don’t think that I am the only one who struggles with these feelings and thoughts. I’m sure everybody from luckier backgrounds like myself does too. On our last day in Blantyre, we attended morning report of the pediatric ward in Queen Elizabeth Central Hospital. There were many American and British doctors along with many Malawian doctors discussing how to best care for a newborn with a mechanical airway obstruction due to swelling of neck tissue. They did not discuss background details of this child so I can’t really explain the diagnoses further. However, I listened in on the discussion and realized a fundamental difference between the American/British and the Malawian doctors. Essentially, one side seemed to push for further treatment and some form of temporary rudimentary life support while the other seemed skeptical of the value of such care.

The Malawian doctors had legitimate concerns. They considered not only the cost of such care for the hospital, but also, what that would mean for the family of the child. There would be financial burden among other strains for a family most likely already in poverty. They also considered the abilities of the family to actually follow through with the home care needed to keep this child alive. In short, they had intuition that the child would die even with all the treatment and care they could possibly provide. The suggested treatments and plan of action just did not seem worth the price unless there was some guarantee of it actually working. I’m afraid though that there’s really no such thing as guarantees when it comes to health care in the developing world.

 

 

“So we transport the child home with all the portable oxygen tanks we have and then what?” – Pediatrician at Queen Elizabeth Central Hospital

 

For the CPAP study, we have deal A LOT with medical records. Dealing with medical records here is a very daunting task because once the patient has been discharged or died, tracking down the charts is always an adventure. Thankfully, Sam and I have become very good friends with the people who work at medical records for pediatrics and they look out for the charts that are marked for the CPAP study. They are our main teachers for Chichewa. However, only the files of patients who were discharged an go through pharmacy end up at medical records. For all other files, we have to look through an assortment of boxes that are placed around the wards. But there are times when files simply get lost. For example, every Friday at morning handover meetings, someone will summarize the deaths from the previous seven days. There was one week that out of the ten deaths, the presenter could only track down four of the files.

Almost all of the wards that I have seen here don’t have staplers, so most of the medical charts are held together with whatever they can find in the wards. The most common methods I’ve seen is tying together stacks over paper with gauze, or bandaging them together. People get quite creative. The typical common method of filing these records are to tie with gauze all the death files from a certain month together and all the discharged fileds from a certain month together. And then these tied up stacks are put somewhere.

To keep track of patient history, all patients in Malawi are given a health passport in which their medical history is recorded each time they receive medical care. The patients are quite good at bringing these with them. Thankfully this system works because tracking down their patient charts from more than a week ago would be a nightmare.

Medical Records

With CPAP training beginning next week, things have been picking up here. It was also the first week I actually believed it was winter here.  We had a couple of very rainy, cold, and muddy days, but I think it was a false alarm because the sun is already back out today! I really hope it lasts. With no heating or a/c system (and lots of open windows), it is always the same temperature in the hospital as it is outside, except in the nurseries where they have radiant heaters to help keep the babies warm. The rain also makes it a lot harder to hand wash and hang dry your clothes! I can only imagine what it’s like during the rainy season.

Yesterday Ariel and I spent some time doing the regular data collection and entry as well as helping to make some stockinette hats for the CPAP patients over at Chatinka. They are surprisingly simple to make! We officially put the new Pumani bCPAPs out on the wards and distributed the new supplies which was super exciting. The med students are also done with their schooling, so I am interested to see how things are different with all of them gone. There are so many of them and so few doctors that they seem to do a lot of the day to day monitoring of all of the patients.

Our presentation of technologies went very well this morning. A couple of people told us afterwards that it was good. We were hoping that we could get a lot of different opinions by presenting each of our technologies in a group setting at the Pediatric department morning handover meeting. We unfortunately did not get as much feedback as I would have like, but we will continue meeting with doctors and nurses individually to try and get more suggestions and advice. On the bright side, they hardly had any criticisms for us. I had braced myself for the worse and was prepared for lots of tough questions. One interesting point that was raised was the issue of people stealing power cords and batteries. They really liked the idea of the ASAP monitor made by the Spygmo team this year, especially the fact that it runs off of rechargeable solar batteries. However, we learned that people often steal the power cords and batteries to various machines (the copper wires are valuable even if the cord itself is not). They suggested putting the batteries inside the device and making it so that a clinician has to use a specific key to open the device and remove the batteries. Another issue that came up while talking about the manual breast pumps was the fact that there is little screening done for Hepatitis B, so that would need to be addressed in order for babies to receive donated breast milk or for mothers to share the breast pumps. Some ideas for new technologies included a peak flow meter for asthma patients and a more durable blood pressure bladder. Pelham also introduced the new Pumani bCPAP and overall, I’d say it was a very successful presentation.

Other than that, we are just preparing for CPAP training to begin by reviewing the training materials. The training video is not quite done yet, but already looks really great! I think the Queens nurses will really get a kick out of seeing themselves on camera. Whenever we take pictures here, and then show people the image they are always extremely amused and usually laugh at it. Tomorrow will be an eventful day as Ariel and I will get to see an orthopedic surgery over at Cure Hospital tomorrow! I have no idea what I am in for, but I’m sure it will be really interesting. I’m hoping it’s not a total hip replacement. We will also be off to Lilongwe tomorrow with Jocelyn.

 

                

Pelham fixing a CPAP                                                 Why Ariel and I want to create a map of Queens                                Making stockinette hats

 

                

Tiny hats for tiny heads!                                             Favorite hangout–medical records!                                 Florence and Chrissy with the new Pumani!

Pumani bCPAP

In 2010, a team of Rice students (including Jocelyn) designed a low-cost bubble CPAP from a shoebox, water bottle, and two aquarium pumps for their senior design project. Just a few years down the road, this device has been successfully implemented in Queens, gone through a second generation design, and received a $2 million grant to implement it in all public hospitals in Malawi. Today, we brought in the Pumani bCPAP, the latest version that is now being commerically manufactered by 3rd Stone Design, to the Chatinkha Nursery and the Peds High Dependency Unit. Pumani means to breathe in Chichewa, the most common language in Malawi. This was really exciting because from here on out, we will be bringing the Pumani to all the other hospitals.

In addition to the machine itself, we also distributed supplies including hats, nasal prongs, suction catheters, pulse oximeters, and feeding tubes. When we gave Chrissy, our awesome CPAP nurse in HDU, all the supplies, she proudly hid them in the bottom of the cupboard so no one else could find them. She said that if we don’t hide it, the supplies which are meant to last the next 6 months will be used up in a week. While it was quite amusing to watch Chrissy proudly show me that the supplies were hidden on the bottom shelf, it made me uneasy to realize how precious medical supplies are here since they never know if something that runs out will be re-stocked.

Presentation at Morning Handover

We also presented all the technologies that we brought at the pediatrics morning handover meeting. The technologies were the phototherapy light stand, a manual breast pump, the bCPAP heating sleeve, and the blood pressure monitor. At the end of the presentation, we spoke with a doctor from America that has been working in the district hospitals in Malawi as a Fulbright scholar. An interesting point that she made was that devices that we make should be designed in such a way that it is difficult to remove the power cord or batteries because it is not uncommon to have people steal them. She said it was really frustrating when someone wasn’t able to deliver oxygen from the oxygen concentrator simply because the power cord was stolen.

Later on in the day while Sam and I were collecting data in the nursery, a medical school student came up to us to tell us that we should design devices that can be made in Malawi. He pointed out that even if these devices are low-cost, the shipping cost to Malawi is very expensive. With so much international aid pouring into Malawi, I’ve realized that in order for a country to truly be independent and improve itself, the drive needs to come from within. 40% of Malawi’s government budget comes from international aid. Ambitious and kind-hearted volunteers come and go, and a project is very difficult to sustain when it is powered by an outside source. Hopefully one day in the near future, Malawi will be able to produce its own affordable medical technologies.

 

Here is a brief and interesting article about Malawian politics:
http://news.yahoo.com/impoverished-malawi-sells-presidential-jet-15-mln-095422594.html

 

[Happy Fathers’ Day! My dad is the only 50-something-year-old guy I know who cares enough about pediatric nutrition to stand and carefully examine the baby food aisle every time we go to the grocery store. In his honor, I’ve been taking some pictures and notes on pediatric food options here.]

During our first week here, my mother asked me what I was eating. I dodged the question. Luckily, we’ve since figured out where to get food other than rice, bread, peanut butter, and nsima, but finding nutritious food sources is still an issue for many people, particularly children, in the outlying areas.

Growth faltering is a delay in the onset of the childhood growth phase (measured by height for age) at the end of the breastfeeding period. Growth faltering is worst around 18-24 months, and if you haven’t intervened by then, you may have lost the opportunity. [1]

WHO statistics indicate that in 2010, 70.7% of rural Malawian children under

the age of 5 showed stunted growth– meaning that they were two or more standard

deviations below the reference for height by age. [2]

The potential irreversible damages of poor fetal growth or stunting during the first two years of life are marked by shorter adult height, decreased offspring birth weight, lower attained schooling, and reduced adult income. In the US, the government prevents this by providing formula for children under 2 whose parents can’t afford it. [1] Here, where kids aren’t yet in school, there’s no good way to distribute to that crucial age range.

Kwashiorkor is caused by sudden food deprivation. It’s more lethal than marasmus because it opens children

up to infections and tends to occur in older children. Markers are pale sparse hair, enlarged liver, wasted muscles,

oedema, moon face, poor appetite, pale skin, and apathy. [3]

Other than the obvious (breastfeeding), the food options for children under 2 in the village are pretty minimal. In stores in Lilongwe, we saw a fair assortment, though it appears that Nestle dominates the market. In the village mart, Jey Jey, the two infant food shelves hold three flavors of Nestle baby cereal and a few cans of Nestle starter formula. Children of the relatively well off (workers at the hospitals, at nearby Namitete Technical College, at the furniture factory) can afford the Nestle. Children in the villages eat almost solely maize.

Some of the hospitals that we saw this week were “baby-friendly hospitals,” meaning that they strongly encourage breast feeding. There’s not really the same stigma about public breastfeeding that there is in the States–mothers nurse their babies everywhere. [4]

The formula costs 1,570MK (Malawi Kwacha) and the baby cereal is 1,320MK; by today’s exchange rate

that’s about $9.40 USD and $7.90 USD, respectively. In 2011, 74% of this country’s population lived below

the international poverty line ($1.25/day) and the average Malawian woman had 6 live births in a lifetime. [5]

We see the signs of malnutrition everywhere. During our first week here I remarked that I enjoyed being average height here. While my 5’2” stature is probably genetic [6], for many Malawians it’s the result of inadequate nutrition. We see kids with textbook kwashiorkor every time we go play with the local kids. It’s very hard to guess children’s ages because kids are much smaller here than they are in the US. Our second day in morning report, the pediatrics ward nurse reported an overnight death due to “anemia and hypoglycemia.”

The traditional diet relies heavily on different permutations of maize. Nsima, on the far right, is such a staple of the diet that,

as Sister Justa puts it, “in the villages, if the children take food but they do not take nsima, they think like they have not taken

anything at all.”

Like most progress indicators in Malawi, the malnutrition problem hasn’t gone without significant global aid efforts. The HIV/AIDS clinic at St. Gabriel’s gives out packets of Chiponde, a fortified peanut butter paste also known as Plumpy’nut, to all pediatric patients who have a BMI below about 16. [7] Other efforts in the country have been successful in reaching a 96% Vitamin A supplementation rate and 50% iodized salt consumption. [4]

Chiponde boxes and sachets at the HIV clinic.

There are still huge discrepancies between urban and rural nutrition access, though, and this issue is linked far too closely to poverty to be an easy fix. Instead, as with most of the seemingly impossible challenges here, I’m trying to see malnutrition through the quote my dad puts at the end his talk: “It is not incumbent upon you to finish the task. Yet, you are not free to desist from it.” [8] We can’t do everything. But maybe with consistent and diligent effort, we can do something.

 

[1]: GLHT 201 Lecture notes 9/6/12, that time my dad came to talk about global malnutrition. See, dad, I wasn’t just doodling!

[2]: Unfortunately, statistics like these are often inaccurate in low-resource settings. Expect an upcoming post about stunting metrics problems and BTB’s attempts to answer them.

[3]: Had to pull this part from the powerpoint. Okay, I may have been doodling a little bit.

[4]: We don’t have very many baby-friendly hospitals in the US because of the prevalence of formula.

[5]: UNICEF. Unfortunately, they didn’t have these statistics split urban/rural, but for the two friends of mine I know are wondering (you know who you are), check out the UN report on rural gender employment inequality.

[6]: Hi dad.

[7]: Plumpy’nut is its own very google-able story. It appears to be seeing some success in Malawi, but the outlook for a more global scaleup remains unclear.

[8]: Rabbi Tarfon: Ethics of the Fathers, Pirke Avot, Chap 2: verse 21

Well it was quite a busy week on the road again. We are currently in the process of a data review for the bCPAP project. Training for the CPAP nurses starts soon, so there is lots to be done. This week we went to Kasungu, Mzuzu, and Mwanza for data collection. This involved a lot of tracking medical charts down, sorting through the charts, documenting information from the registers, and filling out new data forms.  Things went fairly smoothly and were particularly efficient with a team of 6 instead of 3. Last night we packed up all the medical gear going to the various hospitals in their respective suitcases which took a surprisingly short amount of time with all five interns, MK, Jocelyn, and Pelham all working together with some quality music in the background to motivate us. It was also great to see my fellow interns from St. Gabes this week. Now we get to show them what life is like in the big city this weekend!

                

                

Malawian style  “ceiling fan”

Last week Dr. Queen Dube met with me and Ariel to talk about the technologies we brought from Rice. We also brought a manual breast pump  as a donation to the hospital in order to help the process of designing an improved manual breast pump that would be suitable for a site like Queens. We are hoping to find out what qualities the mothers want in a manual breast pump to incorporate into the design criteria. While chatting with Dr. Dube, we learned about a future breast milk bank that is in the works at Queens.

Breast feeding is encouraged all across Malawi, but can pose a major problem when babies are too small or too unhealthy to breastfeed. Mothers have to manually produce the breast milk, and then it is fed to the baby through a small tube. This is very difficult and frustrating for a lot of mothers, and some simply can’t produce the breast milk, leaving the baby unfortunately, “out of luck”. Dr. Dube said the only time baby formula is really used is for orphans. Ariel have seen the Chatinka nursery during feeding times, and it is really discouraging to see mothers, in some cases, struggling for only a few milliliters of breast milk.  However, Dr. Dube told us about this future breast milk bank which will allow the hospital to store breast milk from women who can express and provide breast milk to babies whose mothers are unable to express. It is in the early stages, but has already been approved. This is the first I’ve heard of it, but I think it will be a wonderful undertaking for both babies and mothers at Chatinka nursery. I’m also excited for the mothers to try out the manual breast pump we brought from the US, since a manual breast pump will be a necessary element of the breast milk bank project. I think it will make things a lot easier on the mothers who have already gone through so much. Hopefully we can design something at Rice that will be suitable for something like this!

Sam was away all week travelling around to the hospitals with MK. While she was away, I stayed in Blantyre and continued to work on the new bCPAPs with Pelham. We took out the tubing of all of them and replaced them with new ones. I continued data collection at QECH as well this week.

In the upcoming weeks we are going to start training! This means that the other hospitals around Malawi are going to send people to be trained on how to use bCPAP. And then after they are trained we are going to be introducing the deivces to the hospitals for the very first time. So in order to prepare for that, we needed to decide how much supplies each hospital should get and pack it all up! These were the supplies that Sam and I brought over to Malawi in a dozen suitcases. Last night we each chose a hospital, blasted some Kesha, and started packing up the supplies. With eight people (the St. Gabe’s interns are also here visiting for the weekend), it took under 2 hours to finish it all.

Around Blantyre

Kentucky Fried Chicken

KFC is a big deal here. They recently opened one up and it is very fancy. We went there for lunch the other day and it was quite exciting. There are really no other American fast food chains here, which is surprising since it seems like McDonald’s has managed to touch every corner of the world. Fun fact: apparently, saying that you work at KFC is a good way to pick up girls here.

Taxis

Although friendly and nice, taxi drivers here are not the most reliable people. It is definitely not uncommon for a taxi driver to run out of fuel in the middle of the highway and ask you to push their car to the nearest gas station. Thankfully, I have not experienced this.

I miss Betty Crocker

We found Betty Crocker here! Except…. it costs almost $10 for a box of cake mix. Nevermind.

The Lion King

We went to a production of the Lion King produced by a couple of British and German volunteers. It was quite good. Disney has epic music.

So I was supposed to upload this video a while ago, but we just recently got enough internet to make that possible.  This is a song that the community health workers sang to us in the village Mkoko.  We’re not sure what the direct translation is but we were told it generally means thank you.  Enjoy!

Malawi Singing