The advent of Obamacare and the discussion of insurance policies in America has politicized the field of healthcare. The same trend is true in the Malawian healthcare system, albeit in a different way. Politics rules the healthcare system in Malawi at nearly every level. This isn’t always a bad thing–usually it means that the government is genuinely interested and involved in bettering health policy. However, it can sometimes result in the inefficient delivery of healthcare to the people at the end of the chain.

One example of the intersection of politics and healthcare is found in the story of Chatinkha Nursery, where Karen and I have spent numerous hours over the past two months. Gogo Chatinkha, for whom the nursery is named, was former president Kamuzu Banda’s grandmother. While Banda was in power, the nursery was extremely well taken care of. However, when he lost power in 1994, funding and care for the nursery declined significantly. After years of relative neglect, Chatinkha is now being renovated and expanded, allowing it to return to its prime. In Queens, entire wards are donated or sponsored by various donors including corporate sponsors like Sobo (a soda company that financed the Paediatric Oncology ward) or charitable organizations like the Lions Club of Blantyre (a group that helped build the Delivery Suite).

Politics also pervades the system at lower levels than the government. For example, since QECH is a government hospital, it should be run by Ministry of Health doctors and officials. However, since the College of Medicine also uses it as a teaching hospital, they claim some of the leadership responsibilities as well. In effect, every department at Queens has two chairs now: a clinical head and an academic head. This makes the chain of command more complicated and inefficient, but it also allows brilliant Malawian doctors to rise in the ranks and lead departments at the biggest government hospital int he country.

Politics and healthcare coexist in an uneasy but inextricable relationship. The goals of doctors and nurses can often clash with the plans of health policy makers at the top. However, when the clinical and political sides work together, health projects can take on a bigger scope and reach a broader base of customers and patients.

It’s easy to think of places in Africa as a collection of rural villages based on images portrayed by the media. That’s not to say that it’s an entirely inaccurate image. We’ve driven through numerous villages composed of the mud walls and thatched roofs that perfectly echo any foreigner’s idea of Africa. However, too little credit is given to the burgeoning cities of Africa. Blantyre is the perfect example. It’s a relatively small city in terms of geographical area, but the experiences we’ve had here have showcased the incredible diversity and dynamism of Malawi.

Restaurants

Our group likes to daydream about the delicious food scene of Houston and its diverse offerings. But this is not to say that Blantyre’s restaurants are bland or uninteresting. In fact, we have had some incredible food over the past weeks. There’s been Indian food delivered to our doorstep, Italian food enjoyed at a suave new cafe, burgers devoured while overlooking the track at the Blantyre Sports Club, carrot cake savored in the vibrant gardens of Cafe Mandala, warm mandasi guiltily scarfed down outside the CPAP office, and Ethopian curries shared over warm injera bread along with delicious spiced coffee. The restaurants of Blantyre hint at the numerous cultures and influences that shape the city and the country as a whole.

Ethiopian Spiced Coffee

Religion

I was extremely impressed by the diversity of religions in Blantyre. From churches to mosques to temples, we’ve seen numerous houses of prayer throughout the city. Though Christians make up a majority, there are always hints of other religions. For example, we got a day off for Eid, which was a national holiday. Malawians love to boast about how peaceful and kind their country is, and they’re not wrong. More than just tolerating differences, the people here embrace them whole-heartedly.

Grocery Stores

Our group loved to cook our own food in addition to sampling the restaurants of the city. So we became very familiar with the standard grocery stores. Chipiku: the all-purpose store that is a little like a Kroger or an Albertsons. Superior: the meat market, restaurant, and gourmet foods store (they have Nutella and Magnum bars). Shoprite: the South African megastore that, to quote our taxi driver from Lilongwe, “literally has everything.” Game: the electronics/house supplies/furniture store that we call the Walmart of Malawi. These stores demonstrate Blantyre’s international connections and increasingly cosmopolitan nature.

The Market

It wouldn’t be right to talk about grocery stores and food shopping without mentioning the Blantyre Market. It’s an enormous area filled with stalls and booths that has almost everything you could want for day-to-day life. There’s a giant produce section, electronics vendors, bookstalls, and chitenge sellers (my favorite), just to name a few. It also seems endless. While the produce market is in a wide-open area, Sarah recently introduced me to what I now call the labyrinth. It’s a winding maze of stalls that holds suprises around every corner: you’re never sure if you’re going to run into a fragrant booth selling freshly-fried chips, a wobbling light over a covered-up pool table, a stack of fried rodents, uneasy chickens in a giant cage, or a tailor’s shop with beautiful fabrics. It’s one of my favorite places in Blantyre so far and though I tried to take pictures of it, these photos don’t really do it justice:

Stalls at the Market

Inside the Labyrinth

A selection of cacti and chicken coops

I had originally intended this post to be a sort of overview of our current projects, an answer to the unspoken question of what all we’ve been working on in Malawi during these past months. But when I sat down to write, the phrase in the title kept rattling around my head.

 

What do we do when it’s not working?

 

It’s a question that has actually been forming in my mind since Week 1. Not the cheeriest of things to think about, but definitely something that has become an increasingly salient issue during our time at St. Gabe’s.

You see, we arrived loaded with potentially life-saving technologies- including two devices that Nkechi and I helped design ourselves. In the warm glow of the OEDK and the BRC, our solutions seem to address pressing global health needs almost perfectly.

 

Unfortunately, the real world is a great deal messier than life inside the hedges. We arrived at St. Gabriel’s to discover, almost immediately, that two of our star technologies were being underutilized. Morphine Tracker and Data Pall, the brainchildren of previous summer interns (1), have not been updated regularly since last September. Also, although the hospital’s Rice bCPAP (2) is functional, and there is one nurse and a foreign doctor who are trained in its use, this life-saving device is not always used. We remain unsure to what extent this is due to lack of training, and how much is simply that there aren’t as many babies as we imagined who can benefit from the device at this particular hospital.

 

I’m not going to lie, it was tremendously disheartening to see our beloved technologies in have not been used as much as we anticipated. However, I have a semi-ridiculous combination of optimistic and Type A tendencies, and thus was not content to just mope about the problem. Instead, we have been using these setbacks in order to take a step back and reevaluate. So what do we do when it’s not working?

 

Here are the answers so far:

1. Don’t assess blame.
   BTB was not being unrealistic by sending us here. Nor are the St. Gabriel’s staff shortsighted for not using our devices to the extent that we originally thought that they would. We just haven’t yet arrived at an optimal solution. Playing the blame game represents a lack of generosity towards all members of this program. Moreover, anger is not a productive emotion. People can sense your frustration, hindering collaboration. End Yoda rant.

 

2. Ask questions. Even hard ones. To everyone.
   In our very first week here, we launched ourselves into this process with Morphine Tracker. Not only did we learn more about the palliative care nurses’ opinions on the software, but we also asked nurses about the record-keeping practices. We asked the HIV clinic’s data manager about differences between palliative care and the highly successful ART (3) program. Upon doing this, we’ve learned that a lot of things that initially seemed rather counterintuitive actually play an important role in the palliative care system. As our internship has progressed, we’ve developed closer ties to people throughout the hospital. They’ve had good times with us- teaching Chichewa, sharing jokes, playing pool at the hospital cafeteria, even sharing meals- and they’ve seen us buckle down and work- doing everything from the unglamorous tasks of paperwork and pills to becoming flies on the wall in order to get a better ideas of how things (and people) work here. As the weeks have progressed, our message has come across loud and clear: the BTB interns care about St. Gabe’s. We’re here to learn, and we want more than anything to help the staff treat patients successfully.
   And lo and behold, because we’re starting to understand and continuing to care, people have responded with refreshing honesty. We ask why Morphine Tracker or the bCPAP aren’t being appropriately utilized, and people are willing to give their two cents without being offended or afraid of retribution. In this way, we’ve learned that hard questions require solid foundations of trust and sincerity.
3. Focus dually on people and systems

Call me biased, but Morphine Tracker is a pretty great system: easy to use, and addressing a vital need that (as far as I know) no other program in Africa is addressing in quite the same way. Unfortunately, the few people who knew how to use this tool left palliative care around the same time (either for work on another ward, or for a different hospital altogether). This is kind of a freak occurrence for a ward that usually boasts relatively low turnover, but it still illustrates an important truth about medical technologies: implementation requires both a decent system, and a team of rock stars to champion it. In response to the discovery of this dual nature of tech implementation, we’ve both redesigned elements of Morphine Tracker and put an emphasis on training people to use it. A huge part of this training actually isn’t that technical- it instead focuses on discussions within Hospice about why this will improve their jobs and increase quality of care to patients. This approach to education acknowledges the tremendous role of personal agency in creating sustainable change (4). Even if our database remains less than perfect, the idea of having people who are knowledgeable and enthusiastic should translate to better outcomes in the future.

 

4. Remove as many barriers to use as possible

To do this for Morphine Tracker, we’ve adopted a three-pronged approach. First, we have altered the tool itself to better suit current needs. This has involved labeling parts of the database more intuitively, changing the charts types to facilitate use for quarterly reports to the Ministry of Health and donors, and redesigning paper records to include the information needed for Morphine Tracker.
Secondly, we’ve been talking about Morphine Tracker with doctors, clinicians, nurses, and other team members- even those outside of palliative care. The hope is that by making Morphine Tracker a name that is recognized hospital-wide, support for its use will increase. Time will tell on that part, I suppose.

Thirdly, we are working to ensure that training for Morphine Tracker is as sustainable as possible. If the Morphine Tracker ‘experts’ are sick, on holiday, or take a new job, people should still have the opportunity to learn. This training should be independent of the BTB internship schedule as well, allowing people to develop skills or just answer a question in the quickest way possible. To do this, we have written a user manual, something that was previously not available for the program. This picture-heavy manual features a hefty FAQs section, and will be left behind in hard copy and digital edition. On top of that, we’re currently developing video tutorials, giving people the option to learn or refresh on Morphine Tracker at any point to come.

 

5. Smile!

Yeah, it stinks when things don’t completely go as expected. But that’s life: life in a hospital, life in Malawi, life in engineering, I suppose. After a particularly challenging day, I love to unwind by having a dance party with neighborhood kids or making some pancakes for dinner (5). But even just walking around the Family Centered Care Unit, I find that it helps tremendously to smile! Smile at the nurses and clinicians, smile at Nkechi, smile at the patients. Everyone here is working towards the same goal of alleviating suffering and preserving human dignity: isn’t that something that deserves a few pearly whites?

 

(1). http://malawi.blogs.rice.edu/2014/07/28/morphine-tracker/

(2). http://www.rice360.rice.edu/bubbleCPAP

(3). Antiretroviral therapy, the current standard of care for patients who are HIV+.

(4). Holy buzzwords, Batman! Sorry about that.

(5). Which I’m sure my mom is super happy about.

In the last couple of posts, I’ve written about clinical decision making and the way that physicians at Queens make day to day decisions about individual patient care. That’s something that I’ve noticed during the time I’ve spent in the wards, but in the CPAP office, I’ve also noticed how increasing availability of information leads to better ideas and outcomes for programs like the CPAP implementation project.

Last week, Tanya and I spent a lot of time in Chatinkha Nursery, the equivalent to the neonatal intensive care unit, working on a project to create a system of identifying jaundiced babies. While we were there, Florence, one of the CPAP nurses that has been with the project since 2012 when it began, mentioned that she had been thinking more about the CPAP Coordinator Meeting which she had attended with us as a CPAP mentor.

Since the CPAP project is based out of Queens, the hospital doesn’t have an official coordinator position, but most people would agree that Florence is the unofficial coordinator here. She had wanted to present the Chatinkha CPAP data at the meeting, but she didn’t currently have a way of compiling her data in a simple, straightforward way. So with that information in mind, I’ve been working on creating an Excel template for her where she can input patient totals by diagnoses and outcomes to automatically generate survival rates and trend graphs looking at several aspects of CPAP care.

Each month, inputting the totals from her handwritten log book will take her between 5-10 minutes, and the monthly summary will give her a graphical representation of how Chatinkha is performing when it comes to CPAP and oxygen patients. In addition, at the end of the year, the template takes the numbers from each month and generates a yearly report to show trends across a longer block of time. The summaries are geared towards giving Florence and other coordinators the information with which to critically evaluate their nursery’s CPAP performance and make changes or continue successful practices accordingly.

As Alfred and Norman repeatedly stressed at the Coordinator Meeting, data is a powerful tool for advocates of neonatal care. Hopefully, this template can be a sustainable tool for CPAP coordinators to document the strengths and weaknesses of their implementation efforts, not only to identify areas for improvement but to identify which strategies have worked best for bettering patient outcomes in the long term.

Hey! So this is Part II of my lengthy (and yet not at all comprehensive) comparison of Malawi and Haiti. You can read Part I with the similarities here:

http://malawi.blogs.rice.edu/2015/07/19/malawi-vs-haiti-part-i/

Differences:

Language: So this one seems like a no-brainer. They don’t actually speak the same language in Eastern Africa as they do in the Caribbean. Surprise!
My brain’s been having a harder time with this one, probably because my Kreyol vocabulary is more extensive and esoteric (I can’t ask about someone’s water filtration habits or vitamin use in Chichewa, unfortunately). I’ve definitely tried to say something in Kreyol to a tomato seller in the market. It was pretty embarrassing…

The interesting thing about Malawi is that while Chichewa and English are the official languages, they are by no means the only ones spoken. Most people in the Central Region (home to both Namitete and Lilongwe) speak Chichewa, and many conduct business at the hospital and elsewhere in English. However, many people also speak a third language. Malawi is home to several different tribes, or ethnic groups, each possessing a unique language and culture. It’s not uncommon for children to speak Chichewa in the village, English at school, and their local language with their family. My question asking and readings have both suggested that major tribes include the Tumbuka (in the North), Chewa (in the Central Region), and Yao (in the South and along the lakeshore) (1). Given Namitando’s proximity to the borders with both Zambia and Mozambique, this melting pot is further complicated by the introduction of Portuguese and various local languages. In the face of this complexity, Chichewa serves as a bridge, creating social unity and facilitating trade. In contrast, Haiti is all Kreyol all the time. Unless, of course, it’s a formal setting, and then it’s French. Which leads me to…

 

Schooling: The school systems in both countries are far from peachy. Nonetheless, I’ve been comparatively impressed by Malawian education. As Dayo Olopade points out in her book “The Bright Continent”, Malawi is significantly closer to achieving universal primary education than many other Sub-Saharan African countries (2). Although both countries struggle with the still-prohibitory expenses of primary school (uniforms, books, school fees), Malawi is poised to have a better chance of accomplishing the UN’s Millennium Development Goals related to primary education (3). Of course, just because students have the opportunity doesn’t mean that the curriculum is good, that they will have capable (or even present) teachers. But one way that I think Malawi has the leg up on Haiti in this situation has to do with something that seems fairly intuitive: children are taught in their native language. In Malawi, students learn in Chichewa throughout primary school (excepting English class), and then switch to an emphasis on English in secondary school. In contrast, Haiti’s education system is focused on French, the colonial language that is considered a mark of the educated and genteel. Kreyol is widely considered to be a crude or illegitimate language, and people didn’t even bother recording the grammar and vocabulary of this unique French-African hybrid until the last 50 years or so. Having worked in Haitian schools, however, it’s easy to see that teaching in French is holding Haiti back. Students stare blankly, blindly copying lessons written in a language they’ve never spoken and never been officially taught. Pupils simply turn up for the first day of kindergarten and BAM! Now it’s time to speak French. While some groups are lobbying for a change in this seemingly backward system (4), I fear that Haiti has some major catching up to do if increasing primary school enrollment will actually mean anything.

 

The public medical system: In Malawi, if you go to a public hospital, it’s (*theoretically) free of charge. You can also be referred to a public hospital from a health center or private hospital –like St. Gabe’s- that lacks the equipment or personnel for adequate treatment. We’ve seen patients referred to Kamuzu Central Hospital (KCH) for everything from blood transfusion when there’s none to be found in the blood blank (5) to the necessity of a CT scan to plan surgery to relieve a subdural hematoma (bleeding into the brain) following a automobile accident. In Haiti, on the other hand, the public hospital is the last place you’d every want to be. Reserved for those individuals whose abject poverty is so stark that they have no other options, public hospitals like Lopital Jeneral in Les Cayes are dramatically under resourced. Power goes out during surgery, and I once saw a woman going into labor on the hospital steps because there was no delivery room available. Moreover, service in such hospitals is pay-as-you-go; you can’t get so much as a physical exam until you purchase a pair of latex gloves for the physician. What’s important to note is that both countries’ systems afford significant opportunities to fail their most vulnerable patients; simply getting patients to come to the hospital can involve complex webs of social and income-related challenges, not to mention the day-to-day care and feeding that in both systems requires family members to drop their work to nurse the patient.

 

Cholera, chikungunya, and dengue (oh my!). Haiti has some unique epidemiological events occurring at the moment. The story of cholera is both increasingly complex and worryingly political (6), while chikungunya has infected tens of thousands (myself included!) over the past year (7).

 

Climate: Haiti’s tropical locale makes pretty much every day prime time for catching malaria and other mosquito-borne diseases, while Malawi’s seasons make such illnesses relatively seasonal (like catching the flu in November in Chicago). This also produces differential effects on agriculture, which serves as the backbone of both of these largely rural societies. While Haiti’s crops do have seasons (such as mango season, my all-time favorite!), it’s possible to be growing year-round. This says nothing of the influence that NAFTA has had in prompting much of the nation’s food to be imported instead of grown, but still, it provides some stability to know that people can theoretically grow food (or catch fish) year round. Malawi, on the other hand, gets one main shot. Maize harvest occurs once a year, meaning that if a year happens to be bad (low yield due to disease, natural disaster, or lack of seed and fertilizer subsidies), people are pretty much up a creek without a paddle. The implications for malnutrition, especially among youth, are alarming.

 

Expectations about language: So in both countries, it is assumed that foreigners (azungu/blan) don’t necessarily speak the local language. However, I was warned that you would still be considered rude if you don’t greet everyone with a “Bonjou/bonswa” along the roads in Haiti. I haven’t encountered such customs in Malawi (or if they exist, no one has alerted me that I’m being impolite). Instead, “Mwadzuka/maswela bwanji” is used for acquaintances you meet along the path or people you randomly make intense eye contact with (to the point where it would be rude to ignore it). The bar for me to know these Chichewa greetings appears to be lower as well; on countless occasions, I’ve had my greetings met with peals of laughter or whispers after they think I’m out of earshot (talking in Chichewa about the weird azungu who spoke in their language).

 

Foreigners: The azungus/blan- or more broadly, the expatriates- form different communities and relationships in Malawi than they do in Haiti. For one, there seem to be a significantly larger number of Europeans in here. Whether this is due to the relative proximity (Note: RELATIVE. Malawi is still a 10-15 hour trip from Germany or Ireland), or the fact that we’re working with hospital that’s supported by a Luxembourgish Catholic order, I have no idea. Nonetheless, while Haiti is teeming with Americans, we appear to be the minority among the minority here. Additionally- though this may again be due to the fact that we’re in a rural community here in Namitando- I get the feeling that expats working in Malawi are here for the long haul, whether as development workers, medical professionals, or traipsing around Africa looking for adventure. A lot of the non-Haitians I met were staying in Haiti quite temporarily- journalists on assignment for 3 days, or large groups of tee shirt clad missionaries. I’ve met exceptions to these rules in both places, no doubt, but it’s an interesting contrast, nonetheless.

 

National identity: Haiti was the first black republic, founded through a bitter and bloody revolution against France. Malawi has never been involved in a war. Even these simple statements tell you a great deal about the differences between national identities for the two countries. I’d venture to say that I’ve heard most Haitians brag about their independence- their abilities to persevere under trouble and maintain their sense of self in times of trial. Malawians love to remind us that this is the “Warm Heart of Africa”- a place where the people are friendly and giving like no one else on Earth (*probably).

 

Water: In Haiti, you can’t go all that far without seeing a way to get water. Kids sell water in hand-held plastic bags by the side of the road (a pretty ingenious answer to the costly disposable water bottle), and Culligan filling stations line the road. There is also a significant push from development organizations to focus on clean water, perhaps in light of the cholera outbreaks of the past few years. The village where I worked already had a town pump and several filling stations, and I was working on a water filtration project! In contrast, water doesn’t appear to have anywhere near the same level of ubiquity in Malawi. Although I’ve seen a pump at the primary school, the village has limited retail options for water- the only things I’ve seen is the expensive bottled stuff. While I haven’t really thought to ask about water procurement until I started writing this blog, I feel like it says something that I haven’t been able to observe potable water in passing. I’d hypothesize that this has to do with the frequent consumption of beer and soft drinks by most Malawians I’ve met, and I definitely wouldn’t hesitate to draw connections between the consumption of sugary beverages and the alarming prevalence of diabetes and hypertension at St. Gabe’s.

(1). http://www.earth-cultures.com/cultures/people-of-malawi

(2). The Bright Continent- Dayo Olopade

(3). http://www.unesco.org/new/en/education/themes/leading-the-international-agenda/education-for-all/education-and-the-mdgs/goal-2/

(4). http://www.nytimes.com/2014/08/02/opinion/a-creole-solution-for-haitis-woes.html

(5). A situation that’s significantly more common than you’d imagine- patients in need of a transfusion typically need to recruit friends and family as donors.

(6). http://edition.cnn.com/2013/10/09/world/americas/haiti-un-cholera-lawsuit/

And this is just the tip of the iceberg. Just Google UN + Haiti + cholera to see how contentious this is.

(7). http://www.cidrap.umn.edu/news-perspective/2014/06/haiti-dominican-republic-cases-push-chikungunya-total-past-260000

Haiti has been my ‘first love’ in terms of global health, so it’s only natural to me to try and compare it with Malawi. Throughout my internship so far, there have been many times when I start a sentence with “Well, in Haiti…” And in my defense, for every time that I’ve drawn a comparison, there are three other times when I could have done so, but kept my mouth shut. After all, I definitely value my time in Malawi as a unique learning opportunity and a chance to fall for another part of the world.

Nonetheless, the similarities have been uncanny; the differences, even more striking.

So, I just can’t help myself. I’m going to share some comparisons of my experiences and views of Malawi and Haiti (each in more or less detail, depending on how self-explanatory it is). Keep in mind that these are my sweeping generalizations, and should be recognized as such. The lines that I’m drawing are hardly as clear as I may make them out to be, and both cultures are far more complex than I can hope to capture in a few thousand characters.

 

Similarities:

Public transport: Malawian Minibus=Haitian Tap Tap. The main differences are aesthetic-Tap Taps are brightly adorned pick up trucks, often with speakers blaring kompa out the back, while Minibuses resemble 15 passenger vans in the States. Both, however, will be packed with 20+ people, chickens, crops, and other cargo, and both will allow passengers to get from pretty much anywhere in the country on a modest budget.

 

Colonialism: Malawi was part of the British Empire, while Haiti was under French control. Nonetheless, the influences that these outside cultures have made appear like a little kid’s fingerprints: subtle, but smudged over pretty much everything.

 

An azungu in Malawi= a blan in Haiti. Both are terms for foreigners or outsiders, with the Haitian term in particular implying Caucasian heritage. I’ve heard ‘azungu’ a fair amount, especially at village events (like the football game this afternoon) and in the market. Not all that shocking that I get labeled this way, considering that I’m the WASPiest thing since Wonderbread.

 

Religion: Religion seems to play a pivotal role in the life of most Haitians and Malawians. Again, my perspective may be skewed by the fact that I’m currently working at a Catholic mission hospital, and that I worked with mainly faith-based groups in Haiti. Nonetheless, I think that all you need to do is take a glance around to start understanding the role of faith in people’s lives. In Malawi, women sport chichenges festooned with patterns for their local dioceses or evangelism conference. Rosaries stay around people’s necks during exams, and people in both places name their businesses in a way that acknowledges God’s role in their success. In many places, it’s less than a stone’s throw between churches, and Sunday services are a capital E Event that requires the majority of the town to turn up in their finest. People are eager to turn inward and pray in times of trouble, and frequently focus on evangelism (questions about my religious beliefs frequently become a matter of conversation with casual acquaintances or hospital staff). However, ‘ancient’ or ‘tribal’ religions also play a large role. For example, there’s a joke about Haiti being ‘90% Catholic, 90% voodou” that’s not too far from the truth. Many patients we’ve seen at St. Gabe’s run into trouble because they’ve come in days after their chief complaint first manifested. They try the local healer first, only turning to biomedicine after traditional methods fail. Similarly, hougan (voodou priest) practices often run counter to the way a hospital doctor would treat a patient. Treating a pregnant women with turtle blood may not be conventional, and not nearly as effective (read: NOT effective) at preventing HIV vertical transmission as ART. However, in the minds of the patient, the old ways may be even better, adding a layer of complexity to treatment in both Malawi and Haiti.

 

Malaria, malnutrition, HIV, STIs, and much more. Diseases of poverty run rampant in both places, which makes sense if you look for each country on the Human Development Index (1).

 

Music! Kompa and Rara are the soundtrack of Karneval, beach trips, pub nights, and even tap tap rides in Haiti, while Malawian urban music plays alongside Nigerian imports from cell phone radios to massive speakers. Although these are still wildly different styles, both feature heavy drums laying down a beat that just won’t quit. I also appreciate the diversity of music in Malawi and Haiti: topics range from the typical American party song (bragging about partying and girls) to protest music against government corruption, to uplifting ditties about changing the future through unity (very “We are the World”). So I guess when I say that music is ‘similar’ in both places, I really mean that I like it better than whitewashed American pop. It’s certainly better to dance to!

Note: So I got too excited (surprised?) and verbose (even less surprising…), so I’ve decided to break this post up and spare you the novella. Stay tuned for Part II with the differences (and oh goodness, there are many!)

 

(1). Human Development Index  (which is a very interesting metric, by the way): http://hdr.undp.org/en/content/table-1-human-development-index-and-its-components

As I mentioned in my previous post, there are two major types of information gaps that doctors here face during clinical decision making. I already wrote about the lack of reliable patient histories, but lack of diagnostic and monitoring technologies also places a significant burden on doctors and nurses at Queens.

To use another example from the maternity ward, Tanya and I were observing in the High Dependency Unit (HDU), which is essentially the equivalent to the maternity ward’s intensive care unit. There was a woman on the ward who had been in the hospital for 15 days post-delivery, and she was so ill that she was unable to consume food without a feeding tube. She had been having this issue for the duration of her stay, so even though her vitals had stabilized, she was still lethargic and unable to continue improving and gaining strength.

There happened to be a British doctor visiting the ward that day who brought a small creatinine and lactate measuring device with him, so clinicians were able to actually quantify how severely malnourished she had become. With this new knowledge, they realized the urgency of developing and following a new treatment plan that included removing her feeding tube and transitioning her back to solid, more nutrient rich foods within 12-24 hours. However, this entire decision was spurred by using this expensive monitoring device brought in for a two week stay with the British physician. With the device, it was easy to see what the next logical treatment step was for this woman, and they could also monitor her creatinine and lactate levels every 4-6 hours to evaluate whether or not the treatment was working. Without the device, the process would look a lot more like a guess and check method, and the severity of the condition could have been discovered much later in the process.

In a way, situations like this one require Malawian physicians to have an incredibly adept ability to analyze what little information they have at their fingertips to make the best decision for their patient, but it also places significantly more mental and emotional burdens on them. For example, while the Malawian doctors were excited and grateful that they had the chance to use this monitoring device to better understand how to care for their patient, there is of course an element of frustration in knowing that when the visiting physician leaves, the device leaves as well. It’s difficult to continually have these experiences with high-tech, expensive devices that are incredibly helpful but also incredibly out of reach for Malawi’s current healthcare system.

This is just one area where the need for low-cost, well-designed diagnostic and monitoring technology becomes so clearly apparent. While Malawian doctors do the best they can with limited resources, seeing these instances is a constant reminder that there is still a long way to go in medical technology development, and it is important to keep low-resource settings at the forefront of our minds as so many great advances are made in medicine.

Throughout our time in the maternity ward and in the Pediatric Department morning meetings, one issue that often arises is the lack of information doctors have for clinical decision making. This lack of information comes in two forms: first, doctors often don’t have a reliable patient history with which to make a diagnosis, and second, the wards lack access to technologies like glucometers or ultrasounds to feel completely confident in treatment choices and monitoring. While patient care always involves a degree of uncertainty, Western doctors are lucky in the sense that they have so much information at their fingertips.

However, these two types of information gaps represent fairly different needs. A lack of well-recorded patient history demonstrates a need for a public health related intervention at the local level, while a lack of diagnostic and monitoring equipment demonstrates a need for accessible, low-cost technologies that can be sustainably manufactured, purchased, and maintained.

For example, while we were working in the maternity ward with Dr. Kommwa on pre-eclampsia observations, he pointed out the need for stronger antenatal care programs in the communities. Each mother in the Labor and Delivery ward comes into Queens with her Health Passport, the equivalent to her medical chart or electronic medical record in the U.S. Patients keep these passports with them from birth to track anything from vaccines to major medical procedures. In theory, this is a great tracking system, but looking at the passports also reveals major gaps in availability of preventative monitoring and treatment, particularly during pregnancy. In this instance, Dr. Kommwa showed us each patient’s antenatal care page, and a mother with more than two antenatal visits was extremely unusual. Compare this number to expectant mothers in the U.S. who see their obstetrician every 3-4 weeks during pregnancy, and you already begin to see the potential for much higher numbers of high-risk pregnancies going unmonitored. In the case of pre-eclamptics, blood-pressure monitoring is critical for reducing risk to both mother and baby. Early identification of the condition can drastically improve outcomes, but without consistent antenatal care, it’s impossible to know who needs treatment and to what extent until they arrive at Queens already in labor.

In addition, a lack of patient history also complicates things like the decision to induce. Oftentimes, the estimation for gestational age of the baby can be off by almost 3-4 weeks. To know gestational age, you must know the date of the mother’s last menstrual period, but again, this information can be pretty tough to recall 8-9 months after the fact. Without having a recording of this date, memory is the next best option. As you can imagine, doctors would make different decisions on how to treat a 35 week mother as compared to a 39 week mother, particularly when deciding whether or not to induce. Something as simple as an accurate gestational age estimate would have a significant impact on how doctors in the Labor and Delivery ward make decisions.

Health Passports are an incredibly useful and well-designed method for tracking individual patient data, but in order to reach their full potential, the passports must actually have a chance to be used. The gaps in passport usage reveal upstream factors at play that public health interventions such as community-level antenatal care could address. Not only would these types of programs provide better care and lead to safer pregnancies for mothers, but they would have the double effect of improving labor and delivery by providing physicians with a more complete understanding of the patient upon arrival at the hospital.

These are just some of the many examples of the ways that lack of patient information affects diagnosis, and I’ll discuss the second type of information gap in treatment choices and monitoring in my next blog.