Hello everyone! I have just finished my fifth week here in Malawi. This week I spent a lot of time at Queen Elizabeth Hospital shadowing in different wards, specifically in the pediatric surgery ward, maternity ward, and audiology clinic. I also spoke with three different pediatric surgeons from Blantyre, Lilongwe, and the UK about our gastroschisis silo bags and got some great feedback from them.

 

Starting out with the pediatric surgery ward, I was able to observe Dr. Eric Borgstein for two days on different surgeries. He gave me a whole scrubs outfit and I got to wear crocs around for the whole day, which is always a win.

 

 

The first surgery was a lung decortication on a two-month-old baby. They took a layer of peely semi-liquid like substance off of the lungs to allow them to expand properly. This is the first surgery I had ever observed and I think the part that surprised me most was the ease with which the doctors were able to cut and make decisions right on the spot about what to do next. I had never realized that so much of a surgeon’s job is improvising on the spot when the patient’s condition presents differently once actually on the operating table than the doctor originally anticipated.

 

I was able to stand a few feet behind the operating table itself and ask questions to the surgeon once in awhile and even peeked over his shoulder at times when he wanted to show me something. The environment was much more relaxed than I had thought it would be. They had calm classical music playing and even carried on some light-hearted conversations whilst operating.

 

I saw the improvisation more so in the second surgery I shadowed in on when they were operating on a 15-year-old cancer patient. She had a burn many years ago that was never properly treated and it eventually lead to her cells multiplying uncontrollably and becoming a tumor. Dr. Borgstein had to remove the tumor and when he tried to take out her lymphnodes he found that the cancer had spread to the rest of her body. In that moment, he had to decide if he was going to continue with the surgery and try to remove more of the cancer or stop operating and close her up. Deciding to close her up, they stitched the patient and the surgery was over.

 

I am so in awe of the way a surgeon is able to think of all of the possible future scenarios for a patient in just a few moments, decide what they think is the best course of action, and confidentially go forward with it. I guess that is another lesson I am learning from the doctors here, not just from Dr. Borgstein, but from the OBGYNs, pediatricians, and nursing staff.

 

When resources are limited and costs are high, the doctors must decide how to maximize what they are given and do so without wasting materials. They also cannot second-guess themselves, which is something that I tend to do when I wonder if I am making the right decision, or not. Here, when there is neither time nor resources for a doctor to try multiple care options for a patient or weigh the pros and cons of a treatment plan at length, they trust that the decision they have made is the most educated they could make and move forward.

 

I also got to shadow in the maternity ward this week with some of the medical students and Dr. Sam Meja. We went on a round of the labor ward where the medical students assessed each mother, checked her for contractions or complications, and determined if she was in labor yet or not.

Most of the interaction with the mothers was done in Chichewa so I did my best to understand what they were doing through visual cues and then ask questions afterwards. I noticed that the environment in which the doctors assess mothers is very different in Malawi than in the US. In the US, everything is done very privately and the doctors and med students take permission from the mother before doing any physical check and ask questions very carefully. In Malawi, check ups are run much more publically and for this reason there were very few men in the maternity ward. I noticed mothers were rarely ever difficult about a test and overall talked very little to the doctors or asked questions.

 

After spending lots of time in the hospital this week I had a new found appreciation for how hard working, and for little recognition or pay, the doctors and nurses are here. I am so thankful to them for teaching me so much without even realizing they are doing so.

 

Over the weekend, we went to Cape Maclear at Lake Malawi and wow, was it beautiful. I have never seen such blue water in my life or a sky so clear and so filled with stars. We got to eagle watch, snorkel in the lake, and eat the freshest fish out there.

 

 

Warm Wishes,

 

Sajel

This second week has been one of eye opening lessons and challenges. I started the week in the CPAP office working on my data project. I am entering data related to the supervisor visits. As I started to learn more about the CPAP project and reading, I realized that treating infants with a CPAP related issue is just one small aspect of having overall healthier babies. The Rice CPAP team has found that a common denominator for infants with respiratory distress syndrome, sepsis, birth asphyxia, or other condotions is hypothermia among infants to some degree. So often times even if these babies are successfully put on CPAP, they are hypothermic which can lead to severe life threatening complications if not addressed.

 

This surprised me as I hadn’t really thought about hypothermia as such an important concern and made me realize that providing for basic health needs and general infant care is an equally if not more important issue to focus on. When I had thought about healthcare concerns in resource limited countries in the past, I had thought about things very one dimensionally: what is the problem at hand? How can we provide something low cost and easy to use? How successful is treatment of this single condition?

In the hopes of expanding my learning on the hypothermia issue as well as other basic healthcare concerns, I have started working on a hypothermia guide for mothers that can be put up in the NICU. This guide goes over basic preventative measures and things mothers can do for their infant if they are hypothermic.

 

Here in Malawi, mothers do something called Kangaroo Mother Care (KMC) to keep their infant warm. They place their infant on their bare chest so there is skin to skin contact between mother and child and then wrap the infant up with their clothing. In every hospital we visited, they had a Kangaroo Mother Care ward for mothers who have healthy infants who just need to be kept warmth. They also use radiant warmers and hot cots to keep the infants warm when mothers cannot do KMC or if they infant is not healthy enough to be outside of the Neonatal ICU.

 

Alongside working on that, I was able to connect with a doctor from Lilongwe (the capital city of Malawi about 4 hours away) on my gastroschisis project. Gastroschisis is a condition in which an infant’s intestines are born outside their body. This congenital birth defect affects about 1 in 2000 infants and tends to affect more premature infants, so the condition is more commonly seen in Africa than in the US. This past semester at Rice, my team worked on a low cost, easy to use solution to treating this condition. We developed an alternative prototype bag that essentially covers the intestines and allows them to naturally descend back into the body cavity. I brought this prototype along with me to Malawi and was able to connect with a pediatric surgeon in Lilongwe who has attempted to treat the condition in three infants using a female condom. He has not had success yet, and says that one of the main reasons why is because the basic nursing and surgical care cannot support gastroschisis infants.

 

This lesson of the importance of basic patient care is one that threads together many of the projects I am interested in here. It is very difficult to treat a complicated condition such as gastroschisis without being able to provide a conducive environment to care for infants after the surgery for those 4-6 weeks in which they must be looked after in the hospital and be administered IV fluids, nutrition, and constant monitoring. I am meeting with the head of pediatric surgery at Queens in the upcoming weeks and am looking forward to getting his feedback on our prototype as well as learn about how they do the surgery at Queens.This work week taught me a lot about adjusting to others needs and understanding that a strong foundation in basic patient care is needed in order to move towards sustainable improvement of healthcare in Malawi.

 

Over the weekend, we had the Malawi interns we are working with over for a barbecue. It was really fun to socialize with them as I don’t see them on a day to day basis. On Sunday, we hiked Michiru Mountain and the view from the top was absolutely incredible. We could see mountains in every direction and could even spot Kabula lodge (where we are staying) from the top. We are hoping to work our way up to more difficult mountains in the next few weekends…stay tuned for my attempt at a fitness regime to get ready for that.

 

 

Warm Wishes,

Sajel

Hello! I just finished my first week working with the Rice 360 CPAP team. As the only non-engineer in the group (social policy analysis major), I am working with the Rice CPAP team at Queen Elizabeth Central Hospital while the rest of the group is mainly working at the Polytechnic University. There is a group of about 7-10 CPAP team members in the office and I am their intern for the summer.

 

I wanted to give a quick overview on what the Rice CPAP project is. A CPAP is a device that provides continuous positive airway pressure to help open up the lungs of an infant who is put on it. Often times, when infants are born premature, their lungs are not fully developed and they have difficulty breathing on their own. They can develop respiratory distress syndrome, birth asphyxia, or other conditions associated with lack of oxygen to the heart, lungs, and brain. In the US, these CPAPs costs thousands of dollars and are too expensive to be implemented in district and central hospitals in Malawi and the surrounding countries.

 

About 7-8 years ago a group of Rice undergraduates designed and prototyped a lower cost CPAP device called the Pumani to address this concern and after successfully creating the device, the Rice CPAP team started a clinical trial at Queen Elizabeth Central Hospital. The clinical trial was successful and 5 years later, the team has implemented the CPAP devices in all 28 government hospitals in the country as well as other partner hospitals and teaching institutions. They have conducted training visits to train nurses and clinicians on how to use the devices, do routine supply check ups, and also conduct supervisor visits to evaluate the nurses using CPAP.

 

 

The main project that I am working on this week is helping the team create a database and system for entering and analyzing data pertaining to the supervisor visits. When supervisors go to district hospitals, they fill out data sheets on how well the nurses are performing and using CPAP based on both qualitative and quantitative information. They must check whether the nurses are checking the infants vitals, whether they are correctly diagnosing CPAP patients, and other routine steps involved with successful CPAP delivery. They also evaluate the general quality of healthcare in the nurseries based on criteria such as the facility layout and the protocol for infection prevention.

 

I am working with excel as well as the raw data from these visits to create a system that makes entering and analyzing the data efficient. It’s been challenging but I am learning a lot from my main mentors, Sara and Sammy, about how to parse through large amounts of data and pick what is most important and be able to present that information most clearly and effectively. Out of my own curiosity, I am also able to read through the data on common conditions such as prematurity, respiratory distress syndrome, sepsis, and birth asphyxia that affect newborns and do my own reading and learning about how they are addressed here in Malawian hospitals.

 

After a busy and exciting first week, we spent the weekend at Majete National Game Reserve on a safari. We were able to do an afternoon/evening safari where we saw a beautiful sunset, a morning safari as the sun rose, and a boat safari along the river with hippos and crocodiles. The best part was finally getting to see elephants (my favorite animal in the world), especially the baby elephant with its mama. They are so calm and peaceful. Looking forward to more adventures here and to continue on with my project!

 

Warm Wishes,

Sajel

 

“So, tell me more about Hinduism and how your family practices it”, Mikah asked me as we were both struggling to cut a piece of bone chicken with a fork and knife. Startled, I sat back in my chair for a second. A young college student like I, Mikah and I met at the Rice 360 faculty and student dinner in my first week here. He explained that he was religious but admitted that it is often difficult to practice when he is away from home and something that he wishes he could better at. I was surprised at how this fellow student who I had just met maybe 30 minutes ago was able to ask such insightful questions that delved beyond the usual academics and college life. We went from talking about religion and race to discussing how we both deal with homesickness during the semester. There was a refreshing depth and complexity to our dinner conversation that I was beginning to see in many of my interactions with the Malawians and Rice 360 staff here. I realized just how humble all of the Malawians I have interacted with are and how comfortable they are with the idea of imperfection. They are able to open up about their own vulnerabilities. Back home, I have noticed how rooted our culture is in chasing perfection and we have a hard time facing our shortcomings. It is inspiring to be able to observe and I hope I too will able to delve into how I perceive myself and others and be more confident in discussing weaknesses and areas of growth.

As the week went on, I was cognizant of this phenomenon at the different district hospitals we visited. In Malawi, there are two large central hospitals: Queen Elizabeth Central Hospital in Blantyre where we are and Kamuzu Central Hospital in Lilongwe, which is the capital city about 4 hours away from where we are. These hospitals are where the most complicated surgeries, deliveries, and cases are seen and where a very small percentage of the population ends up going. Surrounding these central hospitals, there are district hospitals. These district hospitals are smaller in size, have fewer human and capital resources, and where most Malawians go if they have a serious health concern. When we visited district hospitals, we focused mainly on the maternity and the nurseries as the wards we wanted to talk to the nurses and staff in and gain as much insight into how they deliver healthcare. These district hospitals rarely have even a single MD so nurses and students end up taking on many of the duties that a doctor would perform back in the US. We asked the nurses on staff questions and wrote down as many things as we could keep up with.

I again noticed that these nurses had a depth to them that is not only hard to come by and but also difficult to uncover in the US. After having only met them for 15-20 minutes, they were able to open up to us about the hardships of healthcare delivery in Malawi. For example, in the labor ward, where protocol states that nurses should check the fetal heartbeat during labor every 30 minutes, when there are only 2-3 nurses for the entire labor ward who must perform deliveries, check all the mothers vitals on a rotation and all of the infants vitals on a rotation, they have a hard time doing everything. In addition to the lack of human resources, they explained that they do not have a working electronic fetal doppler to check the fetal heartrate during labor and so they must use a manual one which is harder and more time consuming to use.

 

 

Issues like these were common among all the maternity wards and nurseries we visited and while it was hard to see their hardships and I ended many of the visits to the district hospitals feeling somewhat defeated, seeing the raw truth of healthcare here and its successes and weaknesses was so important. I could not be more grateful to the nurses and students who took time out of their already busy schedules to answer our questions without a single complaint. They always did so happily and did so honestly. I am so excited to continue learning and digging deeper into the stories of the nurses and people here.

 

Warm Wishes,

Sajel

We stepped off of the Malawian airplane onto the tarmack and I was immediately greeted by a smiling face ushering me off the plane stairs and onto the tarmack. Looking out to my right, I saw miles of grassland until the land met the mountains. Never in my life have I stepped off of a plane and seen such untouched beauty. There was something so pure about it. The airport was a simple one room building with one baggage claim, a ticketing booth, and dozens of kind faces ready to help us. And, they all love to have a good time. After watching us take pictures for ten minutes, an airport employee approached me and asked if he too could take a picture with us. At first, I thought he was being serious, and then realized he was joking and I laughed, embarrassed. Here is to embracing the touristy-ness! 

Since leaving the airport, from our drivers to my mentors at Queen Elizabeth Central Hospital (QECH) where I will be working, we are always met with encouraging words and kindness. So far, we have been able to take a tour of QECH. We were given a tour of the maternity ward and neonatal ICU where I will be spending most of my time and met some of the nurses and doctors. The nurses and staff were eager to hear from us and I am so excited to learn from them for the next seven weeks. 

We also toured the Polytechnic University in Malawi where some of my fellow interns will be working and we met multiple university students. They were smiling from ear to ear as we asked questions about their studies and they asked us about Rice. One student answered all of our questions patiently, and after a few minutes sheepishly admitted that he must get back to studying for his finals which are going on right now for the Malawian students. I can’t wait to hear more about their studies and lives as students here. 

We are slowly settling into our home at the Kabula Lodge. Our home has an incredible view of the mountains and because of the clear air we get to see a full sky of stars every night. We took our first group trip to the grocery store and it was surprisingly so interesting to browse the rows of foods and find similarities and differences between US and Malawian grocery stores. After buying food and coming home, still exhausted from traveling this past week, I made the most gourmet of dinners: a peanut butter and jelly sandwich and Parle-G biscuits. My mom would be so proud. Let’s hope that this weekend my cooking improve as we continue to explore, learn, and immerse ourselves in this incredible country. 

Warm Wishes- 

Sajel 

Stepping onto the plane at George Bush International Airport in Houston, I took a deep breath and while I looked calm on the outside, on the inside my mind was freaking out. Up until now, the idea of going to Africa for two months was just that. An idea. Forms I signed for my program coordinators. Trips to the doctor to get my malaria pills. Late night talks with my mom about how I, someone who barely knows how to make pasta, would cook meals for a whole summer or do all of my laundry by hand. 

I know these things will all be learning experiences and help me learn and grow this summer alongside five other incredible interns. I am so humbled to have this opportunity! As part of this global health internship, there are three main parts:  

1. My main project in Malawi will be at Queen Elizabeth Central Hospital working with the Rice 360 CPAP team. These CPAP’s are being implemented in neonatal ICU’s all over Malawi to treat infants with respiratory distress syndrome and my project will be working closely with the team to find ways to analyze and improve this system to make it more successful. 
2. My fellow Rice interns and I have brought multiple different small technologies from Rice to ask for feedback on from doctors and staff here. These technologies include a cervical cancer training kit, a temperature monitor for mothers during labor, and a silastic silicon bag to treat infants with gastroschisis: a condition in which the infants intestines are born outside their body. 
3. We are also doing needs finding at the different hospitals we travel to. We will be taking notes on current challenges and gaps in treatment and care at different facilities and bring back ideas for new projects that students can pursue at Rice. 

My team started our journey on Monday, June 4th on an overnight flight from IAH to Frankfurt, Germany. I spent most of the flight trying to sleep and was unsuccessful so I instead started writing my thoughts down and most of it was my frenzied stream of consciousness. Upon reaching Frankfurt on June 5th, tired yet equally determined to step foot outside of the airport, we went out and toured the city for a day. We went on a boat tour of the city, ate the cheapest food we could find (they are right when they tell you how expensive Europe is…I had to pay 0.5 euros just use a bathroom in a store), and after a day’s worth of sightseeing made it back to the airport. The best part of my day honestly was the $8 I was able to pay the airport staff to take a hot shower at the airport. Best shower ever. It’s the little wins I tell you… 

That evening was our second overnight flight to Johannesburg, South Africa. Out of pure exhaustion, we all passed out on the plane and reached South Africa smoothly on Wednesday, June 6th. Those german airlines do know how to treat passengers well… everyone got an entire bar of chocolate as part of our breakfast! Once we got to South Africa, we had one more flight left from Johannesburg to Malawi. This two hour flight flew by and in no time it was time to finally step foot in Malawi. This long dreamed about idea just became real.  

Warm Wishes,

Sajel