While traveling to Lake Malawi, journeying the African Bushes in Zambia, and eating/exploring mightily in the capital were truly amazing experiences, I can easily say that my stay in Namitete has been the most meaningful (and fun). Here is a list, in no particular order, about the many entertaining and exciting things I have done around Namitete during my free time. Before beginning, I have to give credit to the Blantyre interns for starting this movement of blog lists versus blog posts.

1. Use tomatoes and onions to create as many unique dishes as possible

Two of the most constant and affordable items in the market have been tomatoes (4 medium-sized for 25 cents) and Onions (4 medium-sized for 50 cents). Thus, it was only natural that essentially every meal we cooked incorporated one or both of the above. We easily consumed 30 to 40 tomatoes a week amongst the three of us. Honestly, cooking dinner has been a relaxing daily routine and one of our group’s most pleasurable activities. We’ve made bruschetta, soup, pasta, spaghetti, chole (chick peas), batata nu shaak (Indian curry with potatoes), etc.

1 (Part 2) Learn to cook Nsima

A journey to another country is incomplete without engaging with the local cuisine. For Malawians, there is nothing like Nsima. We’ve had good fun watching and helping Anne as she instructed us on how to make this staple dish. It’s really something to observe the technique and strength employed by Anne in preparing this food. (Note: Since number 1 was about cooking, figured I’d just lump this one with it).

2.   Meet incredible local and international people

Living in Namitete these past 2 months, we have come across many amazing individuals. Most people in the village and the hospital are extremely warm-hearted and we’ve felt welcome from the very beginning. Moreover, we’ve made some great local friends and have enjoyed their company over dinner, around the market, through personalized tours, and of course, simply conversing. While I have no idea when I’ll be back to Malawi, I will always carry the memory of these kind people with me. In addition to locals, we have had the fortune to come across so many people from around the world at the Zitha Guest House. We’ve met construction workers from Rwanda and Germany installing Solar Panels to Luxemburgish teachers planning workshops. Moreover, as I mentioned earlier, we found a lifelong friend in Katharina, a German volunteer physician. Just interacting with such a motley group of people has been truly fun and by the far one of the most interesting aspects of living in another country.

3.   Attend a local football match

In the last two weekends, we went to nearby football pitches to watch a Malawian league game as well as the hospital team tackle the community club in a friendly. I definitely recommend this for all future interns! Football is such a big part of Malawian society; it was great to sit pitch-side and cheer alongside the locals. Moreover, the atmosphere was electric when the home team scored a goal. The kids go crazy and storm the pitch, doing cart wheels while incessantly screaming.

4.   Enjoy the breeze as you glide towards Namitete on a Bike Taxi

I say “glide”; however, maneuvering a bike taxi is no easy task. Since the start, I’ve been wanting to ask if I could ride the bike taxi versus the other way around. I finally got around to this today. Though I received some initial awkward looks and then thunderous laughter when my request became apparent, I am so glad to have attempted this. Despite, huffing and puffing when I reached Namitete, I felt a satisfaction unrivaled. However, on the return, I let the pros go to work. I have no idea how they can physically do this all day. Anyways, bike taxis are definitely a blast, but, with the comforting breeze and rhythmic pace, they also serve as the perfect opportunity for contemplation.

5.   Go for a run around the villages

While only going twice, I have to say running around Namitete was truly exhilarating. Besides, inhaling dust aplenty, it’s a fantastic and safe way to explore the surrounding areas. However, beware that there will be considerable staring as you go about. An adult running or exercising, for that matter, is not a common sight outside of the football pitch. Regardless, you get used to and appreciative of the attention.

6.   Eat delicious food at the beautifully set Duck Inn

The Duck Inn was established at the end of last summer (or winter for Africa) by the Grey’s (the family I always love talking about, because they’re just that awesome). This restaurant, which is open on the weekends, is set across a quaint pond and provides unmatched ambience at only a 15 minute walk from the hospital. Moreover, on each occasion of dining, I have devoured a lentil veggie patty burger (one of the top burgers I’ve had the fortune of enjoying). We will truly miss sitting by the pond, letting the hours fly by as we munch on our delightful food. Not to mention, the company of the Grey’s, the couple who made the restaurant so magical.

7.   Abide by the Malawian midnight

10 O’ Clock equals bed time here in Malawi, at least for me. With things wrapping up so much earlier here than in the States, time always feels much later than it truly is; this encapsulates the sensation that 10’ O Clock approximates midnight. I’ve personally enjoyed hitting the sheets early and rising with the sun. I guess this one’s very much a personal idea of “fun”, but I promise it gives a remarkable rhythm and routine to your day.

8.   Accept the very slow internet and limited communication possibilities

Although this doesn’t sound like the most pleasant of experiences, it’s absolutely a blessing in disguise. You don’t realize how much time is consumed using the internet and staying socially connected until it is no longer easily accessible. All this “free time” has allowed me to read countless books, relax by playing card games and better interact with those who are actually physically next to me.

9.    Attend Sunday mass

The church forms a central point of congregation and unity for many of the villagers. While only attending briefly, I was impressed by this atmosphere as well as the beautiful singing of the choir. It was truly a soothing environment.

10. Take pictures of kids and show them.

While strolling through the villages, we are always met with the familiar chanting of “jambulani, jambulani, jambulani.” The kids and even many of the adults love it when you bring out your camera and snap away. I’ve never seen so much enthusiasm for pictures! It’s phenomenal. This also a splendid way to interact with the locals and frankly, have a good time.

 

There’s definitely certain fun things I missed in this list, like stargazing or venturing to the local stream. However, I hope this provides some insight into how one can spend their free time here in Namitete. Anyways, I strived to do my level-best to leave Malawi on an up-beat and fun manner. For now, I’ll enjoy my last few hours in Namitete. Good night/morning!

 

I find it hard to believe that we only have a few days left in Malawi. This past weekend, we said goodbye to our good friends, Katharina, a German doctor who had easily become our closest confidant, Suave, the Palliative Care Clinical Officer and our unwavering supporter, and the Grey’s, whose generosity and good-nature have left an indelible mark. Our departure becomes more real by the day. However, with that being said, we have had many activities to keep ourselves occupied this last week. We were recently tasked to go to three CHAM (Christian Hospital Association of Malawi) Hospital’s near Lilongwe to gather maternal and child birth data. Beyond this, we continued our work on Morphine Tracker. Also as I skipped out on blogging last week (whoops!), I’ll also briefly describe our experiences building the Ob-Gyn Stirrups with local shops and personnel – yeah that’s right, 3 topics in 1 blog.

Collecting Data from CHAM Hospitals and the Pumani bCPAP Study

The Pumani bCPAP (Bubble Continuous Positive Airway Pressure) is a student-initiated technology that has been expanded to all central hospitals and 14 district hospitals in Malawi. This system, which generates flow and utilizes a water bottle to adjust pressure, can deliver ambient air/oxygen to babies, particularly pre-terms, suffering from respiratory failure, a leading cause of neonatal mortality. With its success in reducing mortality, overall low cost (a few hundred dollars versus multiple thousands) and greater durability, Rice hopes to magnify its impact through implementation in CHAM hospitals. Our role as interns is to gather data about child births, delivery methods, newborn complication, etc. to assess what the needs of the particular hospitals are, if the Pumani bCPAP would provide benefits and if so, how many machines would be required. Personally, while the recording was tedious, it was still a great feeling to be able to contribute to such a large effort. Moreover, having spent so much time at St. Gabriel’s, it was interesting to see other CHAM hospitals. Unfortunately, that also meant a few extra days on the road instead of enjoying our Namitete-home a tad bit more. One random lesson I gained from this experience was how challenging it was to plan our trip’s agenda in a foreign environment. Things don’t work as they do in the States, where you can easily schedule a specific time and then pop in and take care of business. Proceedings occur here in Malawian time and style; it was a real cultural experience trying to navigate this system while still maximizing our limited time.

Morphine Tracker: A More-Phriendly Method of Data Collection

Morphine, a potent pain reliever for severe conditions, is highly regulated and heavily monitored by the Malawian government. Often the government calls or asks for reports regarding the number of patients currently on this drug, the amounts used, etc. However, due to the current method of manual recording, this often takes many days to compile. Furthermore, there is a disconnection between the needs of the population for palliative morphine use and availability of stock. For example, the hospital was without morphine for multiple monthly periods this past year. By integrating a tracking aspect to the database, where the user is warned upon “low” stocks of this drug, this system can more effectively alert health professionals prior to complete exhaustion. This higher awareness can possibly improve resource allocation and distribution. Moreover, this tool provides quick and easy metrics such as total patients using various morphine strengths/types, the totals consumed in periods of time, specific dosages for different patients, etc. We hope that Morphine Tracker has the potential to improve morphine reporting function and improve data accuracy and timeliness.

We had a chance to demonstrate this electronic medical record (EMR) to the Palliative Care Association of Malawi in Lilongwe to understand the needs and gather additional perspectives on the system. Moreover, we implemented the program on a pilot basis at two palliative care centers in Malawi, St. Gabriel’s Hospital and Ndi Moyo. Joao ventured out to Salima, Malawi yesterday for this very purpose while Truce and I toiled away at a hospital collecting data. There’s definitely excitement to see how this project pans out in practice; however, it is important to recognize the challenges in transitioning from concept to used product. First, the information flow begins with the original paper booklets at the pharmacy and then later, involves input in the computer. However, two specific criteria, age and gender, are not included as part of the Ministry of Health ordained morphine usage book. These two aspects, especially age, were described to us by clinicians to be of essential value, yet were not even recorded. In addition, age serves as a huge analytical criteria in Morphine Tracker. We were faced with a system that incorporated more tools, but was incapacitated without the information. This forced us to backtrack and add these fundamental values into the original data collecting method. Further issues to consider have included computer literacy, commitment to record keeping, and training, to name a few. There are so many factors to think about regarding adoption and future effectiveness; however, the enthusiasm that we have garnered through Morphine Tracker pushes us onward through these obstacles. Special shout out to Truce and Joao for their absorbed dedication to ensuring the best product possible! While our time is limited, we believe that this database can eventually help many other clinics in Malawi and beyond. It’s up to next year’s interns to use the feedback and information received to further improve this EMR and use the ties formed this summer to continue to expand the system incrementally.

Ob-Gyn Stirrups: Additional Functionality to Hospital Beds

The Ob-Gyn Stirrups were originally designed for traveling physicians from developed countries to conduct outreach pelvic exams. They include portable stirrups, curtains, lights and stools, forming essentially a moveable examination room. This is particularly effective in reaching the vast majority of females in developing countries, in fact over 90%, who have never had such an evaluation. This physical assessment can be instrumental in diagnosing cancers in early stages, detecting infections and finding other problems. However, the Ob-Gyn Stirrups’ transportability had little influence for St. Gabriel’s, which does not engage in such outreach clinics. It does, though, promote pelvic examinations by adding functionality to hospital beds, which often do not allow for such clinical assessments. Made of a wooden framework, a crank that tightens it to a flat surface and cloth-based cushions for the feet, this project utilized widely available resources to uniquely address this issue. Having had a chance to work together with local stores, namely, the Namitete Furniture Shop for the framework and a local bike shop to mimic the tightening mechanism, to create a Malawi-made version really emphasized that solutions need not be complicated to be influential. While I’m not sure to what extent the hospital will maintain and use such ties to create more stirrups, it serves as a proof of concept that this solution can be locally manufactured to address a local challenge.

Concluding Remarks

Well, that summarizes the many internship related tasks that have consumed and taken up our current time here in Malawi.  I promise that the next post will be short and fun. See you all in a few days!

Picture of the old DataPall Home Screen (A). Our updates have slightly altered this, but the visual appearance is pretty similar.

If I had to point to a single encompassing experience for our time at St. Gabriel’s, it would definitely be palliative care data collection. DataPall, as I mentioned earlier, began as an on-site project by a group of interns in 2012. The expansive need for palliative care, spanning from high burdens of HIV/AIDS and Cancer, and the cumbersome method of manual recording, inspired the students to create a centralized database. With the goals of user-friendliness and efficiency, they used Microsoft Access to provide a platform to chronicle patient appointment, diagnosis, symptoms, medications, and considerable other information. (Note: DataPall can be found on SourceForge, if you’re interested in checking it out.) Even today, the palliative care staff truly appreciates the innovation. As government reporting is a major impetus for data collection, this system, with its simple reporting functions, saves tremendous time! As the interns did before us, we were tasked to understand and continue system updates based on user and personal experience. A pervasive lesson in global health initiatives is that implementation is never quick or simple; instead, it requires long-term commitment and understanding to attain its real influence. We were the third group to experience this lesson firsthand.

CORRECT data collection is VERY hard

The current methods of collecting and recording palliative care data allow for many errors. The potential for mishaps begins at the onset of the doctor-patient interaction. The nurse/clinician handwrites the patient information, such as name, village, diagnosis, etc., in a giant journal. Sometimes this data can be copied from the patients’ health passport, but often the patient must verbally provide such information. Error 1. Verbal communication – spelling spoken words is not easy. Error 2. Often a patient doesn’t know his exact birthday or name’s spelling. Then the nurse, once all the outpatient visits are completed, comes to the DataPall office to retroactively input the data. However, often the scribe and reader are different. Error 3. Illegibility. Moreover, DataPall allows for significant typing. Error 4. Unplanned Typos. Together, all of these errors, had led to large amounts of duplicate records and misspellings of common diagnoses/drugs. While drop-down menus were used, they did not provide all the options necessary to be singularly effective. Thus, human input was greatened, as they typed the diagnosis, drug, etc. in the “Other” blank. Overall, the data was not as correct as it could be.

Our first task was to improve the drop down menus and reduce the amount of typing required. Our reasoning was less typing = less errors. Joao created a program to go through all the data (over 6,000 appointments and 1,500 patients) to find the common misspellings and “other” inputs. Then, we manually corrected the spelling errors and added the additional options to the drop down features. We also converted certain original typing features into drop-down/click menus.  We hope that these corrections will make the data more useful. Having consist methods of inputting a certain diagnosis or drug will allow the program to lump the total and report correct amounts, which were otherwise lost with misspellings and variable spellings.

Second, we compiled the duplicate records. Joao created an algorithm based on name, village, age, diagnosis, etc. to identify possible repeat patients. Then, we went through and ensured the matches. This step concluded the “cleaning up” phase. Like the drop-down menus, we wanted to create an on-going method to prevent future errors. This includes a new, highly technical searching method (so glad to have Joao’s programming skills), which will alert the inputter in an efficient/comprehensive manner to possible matches.

Our final step to completing these updates is better tailoring the reports to the needs of the hospital. This is something we will soon work on. We want to move beyond just numbers and incorporate visual diagrams to convey this information.

As you can tell, our work isn’t necessarily the most glorious, but we believe it can go a long way in improving care and reporting. Proper data goes beyond just analysis. The hospital is required to report such values to the Ministry of Health. This allows the government as well as the hospital to better allocate and request resources. We are happy to assist in this process.

Beyond DataPall

Our time in the Palliative Care ward opened us to another great opportunity.to improve data collection and resource allocation – an electronic medical record focused on monitoring Morphine usage and stock. In fact, today, we had a chance to briefly showcase our project to two government officials including the national coordinator for morphine distribution. There is considerable enthusiasm and we are truly excited for its impact not only at St. Gabriel’s, but Malawi at-large. As the end draws closer, our list of things to complete seems to incessantly rise. However, we couldn’t ask for it another way; we are honored to contribute in a lasting manner. More about this and my adventures outsourcing the Ob-Gyn Stirrups to local companies next time!

It always feels rather fantastical popping into a new society and proceeding about as a silent observer, unfamiliar to the rhythm of daily life. However, I can finally say that I’m beginning to grow more comfortable in life here at Namitondo and St. Gabriel’s Hospital. While there are many factors responsible for this transition from dissonance to soothing purpose, including survival knowledge and routine, the most important is the budding awareness I’ve gained regarding my locale. It takes a lifetime to truly understand a place and its people; however, I hope you enjoy some snippets of observation.

Initial Observations/Thoughts in Malawi

Having the opportunity to stay in a rural area, about one hour away from the capital, Lilongwe, has been a particular blessing. Though our guest house provides the full array of western accommodations, its setting at the junction of villages allows for a closer appreciation for the lives of nearly 80% of Malawians who live in rural areas. Moreover, getting to see how health care is orchestrated at such great distances within a low-resource setting will bring with it many lessons/understandings. We will be accompanying the under-five outreach team tomorrow!

One of the highlights thus far has been the tour of the Namitete area given by Aaron, a local baker who took the initiative to welcome us and show us around his home. He pointed out the nearby primary and secondary school, various shops of interest as well as the local football pitch (and basketball court), to name a few. Though visiting the places was fun, just being able to talk to him and learn about how the education system worked, hearings his likes/dislikes, especially related to the FIFA World Cup, and seeing “places” with his added perspective really added to the exploration. We even got invited to watch a community football match amongst two teams!

Though basic, just engaging in novelty, has been truly memorable. One’s first always holds a special place. Likewise, I’ll always remember the first smile as I traveled on a bike taxi, the incessant yells of “Azungu!” (foreigner/white person) from largely innocent attempts for attention, my first taste of Nsima (thick corn flour based porridge) served with delicious locally-grown leafy greens in ndiwo (tomato-onion sauce) and sauced kidney beans – graciously provided by Anne, a community health worker living with us at the Zitha House, etc. These new experiences also extend to the hospital and I plan on sharing these observations very soon!

Unfortunately, amongst such novelty, budding relationships and learning, comes the very real economic inequality and social injustice evident in Malawi. Academically, I expected poverty, as Malawi ranks 170 out 186 countries in the Human Development Index and has greater than 40% of its population living on less than a $1/day; however, when confronted with it first-hand on a daily basis the effect is entirely different. Moreover, my greatest surprise came in the close proximity of wealth and poverty. In Lilongwe, there were enclaves of riches, in the form of superstores in the Game Shopping Complex where I had to remind myself I wasn’t in the US and then a few kilometers away, there were wooden huts and slums which didn’t even provide for the most basic health/safety needs. Furthermore, despite only working at the hospital a few days, one is surrounded by socioeconomic and political injustices wrapped up as disease and failed/inadequate treatments. This is an overarching influence that pierces everyday life, including the provision of health care. (Note: Check out Joao’s post for another perspective and more details about the dichotomy of life in Malawi)

 

Closing Remarks

I apologize for the scattered discussion of Malawi above. In future posts, I will focus on individual elements related to healthcare, internship activities, technologies, culture, etc. However, as beginnings are rarely ever clean or organized, it seems only fitting that this post embody such characteristics. Moreover, I really do wish to attach many more pictures, but my 3.75G Airtel Dongle is nowhere near how fast its name suggests. Anyways, thanks for reading and please leave your thoughts! The next post will be about overall health care in Malawi, where St. Gabriel’s fits in and what services the hospital provides.

After five weeks of extensive preparation which included building various health care technologies, understanding project backgrounds and crafting surveys for evaluation, the day has finally arrived to embark on the much awaited journey (36 hours to be exact) to Malawi. Here’s a brief snap shot of the student-developed global health technologies we will investigate (more details will follow in the upcoming posts):

BoxyClean, a low-cost, transportable shipping container-based sterile processing system for hospital tools

Stirrup to Checkup, a portable gynecological tool kit for mobile women’s health clinics

Phototherapy Calibration, a dosing meter allowing for greater precision in light treatment for patients with jaundice

Low-Cost Neonatal Thermometers, Joao and Truce’s design child, allows caretakers to determine fever in an intuitive binary manner (yes/no)

Temperature Sensor, an instrument able to detect hypothermia/elevated body temperature through continuous monitoring

Flow Splitter, an adaptor splitting flow of oxygen tank concentrators, allowing for increased patient treatment

Babymetrix, an integrated and affordable measuring device for infants (almost two years since initiation, it’s finally going to Malawi … shout out to the Bebevoros Team)

Morphine Dosing Clip, a more accurate morphine dosing system for palliative care settings

DataPall, an electronic medical records system for palliative care settings, is an already implemented on-site project by the 2012 BTB Interns. We will work to update and fine-tune the system.

Personal and Internship Goals/Expectations

It’s always interesting and insightful to ponder what an experience will mean and then later compare those expectations to what it actually meant. Here I layout some objective and personal goals:

• Attain applicable and comprehensive feedback on the above technologies

As a non-engineering student involved in design work, I was particularly drawn to the creativity required to think within a framework of constraints. A technology in itself is not useful without emphasis on the end-user. Forming criteria and shaping a product requires such ingenuity; however, design is also an iterative process. This firsthand interaction with the target group will be extremely helpful in further developing our “framework of constraints.”

• Understand delivery of health care in low-resource settings

Academic exploration and other forms of formal education are no doubt important; however, experiential learning provides a unique perspective. I hope to synthesize the benefits of both approaches to expand my knowledge and understanding. Moreover, from a career standpoint, I aspire to get a better sense for where I fit in the global health field and how I can best contribute.

• Learn a new culture and society through immersion and relationships

Extended opportunities to live in a foreign country are truly a blessing (thank you donors)! Having studied abroad in Denmark, I really appreciate the benefits that such exposure provides. I’ll strive to integrate myself as best as possible with the mindset of an explorer.

• Sitting at a desk, half way across the world and detailing expectations has its limits. I look forward to the goals/expectations discovered while in Malawi.