Queen Elizabeth Central Hospital challenges every notion of a traditional hospital. Its mudbrick buildings and outdoor hallways create a haphazard facade that hides the bustle of doctors and nurses caring for their patients. Most striking is the crowd of people sitting, standing, cooking, cleaning, and eating on every grassy surface outside the hospital. A deconstructed waiting room, the wide, open courtyards at Queens are filled with families who are waiting to feed, clothe, and comfort their sick loved ones. Given the limited resources they’re working with, QECH can’t afford to provide nutritious and filling food to all of its patients, which is why families wait outside with ample supplies. These people come from all across Malawi, traveling days to get their sick relatives the best possible care at the premier government hospital in the country. Which is why they can’t afford to commute every day. Instead, they set up camp and lay out on a lawn of colorful chitenges (all-purpose cloth wraps) that sport designs as strange as eggplant-purple pineapples and political propaganda in favor of one-term ex-president Joyce Banda.

Sheets, chitenges, and aprons hung out to dry near the Maternity Ward

This community of waiting women (women still being the primary caregivers for sick family members) is a great captive audience for people who want to educate and spread news. Often, preachers come to sing songs and lift spirits in the crowd. Karen and I discussed an interesting twist on this idea: NGOs, nonprofits, and even doctors or nurses could use this opportunity to talk to women about health and sanitation practices or even teach them marketable skills.

Preachers and public health aside, the families there are waiting for a reason. The hospital has very strict times when families can visit: an hour and a half during breakfast, lunch, and dinner. At mealtimes, there’s always a long line of men and women waiting outside the entrances to the wards being told to wait just a little longer by a worn down security guard. In a lot of ways it seems unfair and wrong to make these families wait in line to provide their relatives with care and attention. The strict mealtime visiting hours definitely do not fall in line with a patient-driven approach to providing healthcare, but in a hospital with as limited space as Queens there’s no other practical way to deal with the crowds. Already, skinny walkways and cramped spaces make it a struggle to move freely in the hospital. Crowd control is a necessity. And so families settle for a system of patient waiting and limited contact.

The line of families waiting to come in during dinnertime

The dilemma of patient preferences versus practicality manifests itself in a lot of situations around QECH. This week, Karen and I got an inside look at the Maternity Ward and the Delivery Suite under the guidance of Dr. Edward Kommwa. We were there to do some research on current practices for delivering Magnesium Sulfate (MgSO4) to pre-eclamptic patients in order to prevent seizures. The procedure is fairly simple and there are two ways to do it. In the infusion method, the patient gets a 4g loading dose over 5-10 minutes and then receives 1g of MgSO4 per hour for up to 36 hours after delivery. The intramuscular (IM) method requires a 14g loading dose with 4g delivered as IV and 5g delivered via injection to each buttock. Subsequently, the patient has 5g maintenance doses injected intramuscularly every 4 hours for up to 36 hours. The latter method is extremely painful for the patient and has to be delivered with local anaesthetics. According to Edward, Queens is transitioning towards the more patient-friendly infusion method. But here’s where we run into the problem of practicality. When we watched nurses perform the MgSO4 procedures, they all used the more painful IM method. Why? Because it wasn’t feasible for these busy nurses to continuously monitor an IV drip and make sure the  patient was getting exactly 1g of MgSO4 per hour. Normally, this job can be automated by an infusion pump–a device that slowly pushes out the right dosage of a medicine into an IV line–however at Queens only the High Dependency Unit (HDU) has working infusion pumps and even the nurses in that ward rarely, if ever, use it for MgSO4 delivery.

Naomi, an HDU nurse we talked to, cited lack of adequate equipment (for example 60mL syringes) and lack of knowledge about the infusion pumps as the two main reasons why they’re never used. The first problem–lack of equipment–is something Rice 360 is trying to address with AutoSyp, a low-cost infusion pump that will hopefully allow nurses to deliver MgSO4 using the more patient-friendly approach. In order for AutoSyp to be successful, though, there has to be an educational effort to give nurses the knowledge and skills they need to successfully operate the infusion pumps in a practical and efficient way.

Karen asking Naomi about infusion pumps in the HDU

At first glance it’s easy to criticize QECH for disregarding patient preferences. After all, quality of life is an important consideration for those who are hospitalized for long periods of time. But when you look beyond the surface, the very practices that seem unfair are those that were born out of a need to run an efficient and effective hospital that can adequately address the needs of its countless patrons.