My last post was pretty big picture- definitely information that I wanted to share, but nothing that inherently unique to my experience at St. Gabriel’s. Therefore, this post is going to be basically the polar opposite. This past week has been chock full of surprises- lots of interesting opportunities to learn and to serve. At the same time, Nkechi and I have agreed that it seems like we’re getting into a rhythm here. We’re on friendly terms with a fair number of the hospital staff, and for some strange reason, it seems like they like us! I think that it’s this familiarity that is opening doors for us- now that people see that we’re in it for the (relatively) long haul, our friendships are transforming into partnerships (and vice versa). The result has been our most exciting week yet!!! Here’s a brief peek at what it’s held so far:

 

1. Lunch with a nun (yeah, my Monday was cooler than yours)

On Monday morning, we were going about our business of preparing for the week when we came face to face with Sister Justina. St. Gabriel’s resident superhero, Sr. Justina has spent 50 years in Namitete, raising the hospital from the ground up and expanding support from her order in Luxemburg. At one point, she was placing IVs by candlelight in a 2-room clinic. You know, casual. We weren’t as much invited as instructed to come to lunch that afternoon. And it was great! No, not just because I got to have lunch with a nun. Sr. Justina truly is the authority on Namitete and the hospital, and we benefitted immensely from her experiences and her complete honesty. She told us point blank that one of our ideas wouldn’t work, which was refreshing and some valuable insight from a woman who has been there, done that.

 

2. Watching my first C-section (since my own)

Monday night, we spent some time on night duty with one of the clinical officers. Again, this was thoroughly unexpected- we were just starting to cook dinner when the phone rang, and we were asked if we wanted to watch a C-section. Eating took a backseat to opportunity, and we rushed over (one of the benefits of living 1 minute away from the hospital). I was surprised by how clean it was. Not the operating theater, since I was already aware of the measures taken to maintain the sterile field. Rather, I was surprised by how straightforward the procedure appeared. The incision was made smoothly, exposing the uterus fairly quickly. After a few minutes of maneuvering, it was just a matter of making a quick incision and then BAM! The baby’s head appeared. The whole process of removing the infant occurred so quickly and smoothly that I gasped audibly when the child appeared. The neonate was not breathing upon delivery, and as they were whisked to Labor Ward I was reminded of why so many of BTB’s technologies exist (and what our objectives are for the future). But the procedure itself was still unbelievable- I feel like the whole ‘miracle of life’ thing isn’t such a cheesy description of birth after all.

 

3. Hands-on teaching in Palliative Care (Morphine Tracker’s maiden voyage)

This week we had our first student! Collins is a member of St. Gabe’s palliative care team- although he (and everyone else we will be working with) has responsibilities throughout the hospital, he has been identified by Alex (the main Palliative Care nurse) as a potential ‘point person’ for the use of our software. We spent around an hour each day showing him the program and practicing. It’s been a really great way to identify potential roadblocks in future trainings or in the software itself. I also completely understand why Alex has recommended Collins for this job. He is a fast learner, devoted to the task, and has an unendingly positive attitude!

 

4. Taking a hot shower (yes, this is important enough to be on the list)

It was my first hot shower in a month. Hair was washed. Deities were praised. All in all, a pretty big moment.

 

5. Seeing Malawi’s premier incinerator (AKA only incinerator)

I think that we must be sending off some sort of sonic signal telling people to befriend us, because one afternoon, a man we had never met knocked on our door. His name was Happy, he told us, and he runs the hospital’s incinerator. Would we like to come see where he worked some time?
When someone randomly shows up at your door and asks if you want to see an incinerator, there is only one thing to do: say heck yeah.

We learned from Happy that St. Gabriel’s has the only incinerator in Malawi. While I have been unable to verify this fact, apparently their system is so comparatively advanced that they burn trash for hospitals in Blantyre and the American Embassy in Lilongwe! This tidbit raised some important concerns about waste management in Malawi- apparently, most hospitals dig pits and simply dump their waste (including delicate/organic materials such as post-surgical materials, placentas, and amputated tissues). In contrast, St. Gabe’s system allows for the complete combustion of materials, and the smoke filtration ensures low toxicity for the surrounding area. Although it may not be as glamorous as other areas of the hospital, it was still a great opportunity to understand medicine as a process that starts before the patient enters the doors and ends with the disposal of byproducts of their visit. Waste disposal seems like such a low priority, but when you consider what would happen without it, the process seems anything but trivial.

 

6. Morning rounds in the male ward (venturing into uncharted territory)

Wednesday, we snagged Gift (one of the clinical officers) to show him some BTB technology. After we finished, we stuck around for our first real experience with Male Ward. Male Ward tends to be somewhat of a mixed bag, more so than paeds (mostly pneumonia and malaria) or female (pregnancy or abortion-related, mainly). We had chances to see typhoid, probable tuberculosis, HIV, stroke, pneumonia, heart failure, psychosomatic illness, and diabetes (both types). Working with Gift and Jason, a medical student from New Zealand, gave us tremendous insight into the marriage between patient history and physical examination. It was also interesting to see how they managed patients who were in male ward for the long haul. Especially alarming, it seemed that the diabetes patients were there for the longest periods of time (almost a month for one man!) Diabetes management (which I touched on in my last post) is a complicated problem in Malawi, and seeing such gifted clinicians struggling to stabilize patients’ glucose sparked a desire to learn more about the roles of technology and policy in addressing the problem.

 

7. An ‘American Feast’ (if we dare describe our cooking as such)

Tonight, we repaid a favor to our friend Bright, who is a clinical officer. Bright was kind enough to invite us into his home for nsima with beans, a delicious piece of Malawian culture. We decided to in turn invite him for an American feast at the Zitha House! After a lengthy debate about what constitutes American food, we decided to prepare green beans, mac n’ cheese, fried chicken, and vanilla pudding (the last of these at Bright’s request). They may not have tasted just like home, but we had a great time showing our friend how to cook American specialties, learning some more Chichewa, and swapping stories.

 

This doesn’t even come close to being a comprehensive list of our week’s accomplishments! We’ve had some great experiences getting tech feedback from the hospital director, learning about device repair from the maintenance manager, playing with neighborhood kids, and preparing for our full-scale rollout of Morphine Tracker! And the best part is that our week isn’t even over. This weekend marks both the American and Malawian independence days, so I’m sure it will be one for the books. Keep on the lookout for more updates soon, but till then, tionanna!

If you hang around the morning meetings for long enough, you start seeing patterns. Diseases that appear, day in and day out, until you’re desensitized to the names.

 

Malaria, pneumonia, diabetes mellitus.

One of these things is not like the others.

 

Tuberculosis, cervical cancer, cardiovascular disease.

One of these things just doesn’t belong.

 

When we think about the nature of illness in the developing world, our mind tends to jump to the so-called ‘diseases of poverty’- things like malaria, TB, and malnutrition. Living in Houston or Chicago or almost anywhere in the US means that you are fortunate enough to have little exposure to these conditions. However, as my experience in morning meeting indicates, that by no means that the poor are exempted from the types of illness that typically hit closer to home. In fact, a 2011 UN report found that non-communicable diseases, such as heart disease, cancer, diabetes, and stroke now make up two thirds of all deaths globally (1). This indicates that a tremendous shift is occurring in the global burden of disease, to the point where the previous label of chronic diseases as “diseases of affluence” is quite the misnomer. Instead, we see that some of the world’s poorest people are increasingly bearing the burden of urbanization and global development.

 

This is known as the dual burden of disease, a phenomenon in which “noncommunicible diseases are imposing a growing burden upon low- and middle-income countries, which have limited resources and are still struggling to meet the challenges of existing problems with infectious diseases” (2). And what’s even more alarming is the fact that the prevalence of noncommunicable diseases is growing at a faster rate than it initially did in industrialized regions- it’s projected that by 2020, more than 70% of deaths due to ischemic heart disease, stroke, and diabetes will occur in low-income countries! (2)

So what’s going on here? Why are people in Malawi developing these ‘first world diseases’, and how are they treated?

 

I think that a line from a WHO report on the dual burden of disease is most telling: “Sometimes chronic diseases are considered communicable at the risk factor level”(2). Now, if you’ll allow me to geek out, public health style, for just a moment, I’ll get to the bottom line. But first: EPIDEMIOLOGY APPLIES TO NONCOMMUNICABLE DISEASES. My Epi professor would be proud. Basically, what the WHO is getting at is that social behaviors are transferred from person to person, just like a cough or HIV.

One of the greatest examples of this ‘social contagion’ in Malawi has to do with diet. The introduction of low-cost vegetable oil from industrialized countries (3) has wreaked havoc on the Malawian diet, which up until recently was mostly plant-based. The ready availability of fats has pushed the country into a nutritional transition period, with an ever-increasing percentage of people’s daily calories coming from fat and refined sugar.   Just walking around the market and eating in the hospital cafeteria, you can see the signs of this change: people are selling fried foods (fried potato wedges and ndas, which is basically a deep fried pancake), sugary treats (Fanta, Coke, cookies, and lollipops), and fried meat (don’t worry, Mom and Dad, no street meat for me). Although Nsima, a maize flour starch dish, remains the staple, the influences of processed foods are quite visible. And when that’s what your friends, family, and fellow villagers are eating, you tend to join in, too.

 

There is also evidence of genetic differences in the ways that various groups of people process calorically dense foods. Some studies suggest that many in Sub-Saharan Africa are better at retaining and storing energy from food, which is great when times are hard (4). However, when the caloric intake goes up, this predisposition backfires.
It seems like the deck is stacked against the average Malawian. Is it any wonder that 80% of cardiovascular-related deaths occur in low- and middle-income countries (4), or that people are developing these disorders at younger ages in comparison to high-income countries?

 

So how are these problems being handled?

Well, in short, not that well. Chronic conditions tend to take the backseat to the more salient ‘diseases of poverty’. Combatting malaria and malnutrition seem like the first step in increasing the standard for health care. Additionally, such diseases are ‘sexier’ to foreign NGOs and government efforts. Think about it: would you rather say you saved a kid from cerebral malaria, or helped someone manage his diabetes?

 

In the case of diabetes (mostly Type 2), the national prevalence is up to 5.6%, a rate that’s often significantly higher in rural areas (5). 85% of Malawi’s population lives in rural areas. And guess what?!? Namitando and the surrounding enclaves are pretty much the definition of rural! A study done by the medical school in Blantyre revealed that the most common causes of diabetes-related hospital visits were complications and poor glycemic control. More than half of patients had trouble obtaining metformin or insulin (common diabetes drugs), and patients from rural areas in particular had trouble accessing refrigeration for their medications (6). Even if they had the right drugs, there is no guarantee that they’ll be able to properly manage their disease- almost 1 in 3 patients who had been receiving treatment didn’t know what diabetes was!!!

 

With such tasty temptations and lack of infrastructure for chronic conditions, we are well on the way to explaining the dual burden of disease. But the real kicker is that a non-trivial number of patients, some of them extremely sick, don’t even bother to go to the hospital! Poor Economics, an incredible book by Abhijit Banerjee and Ester Duflo, actually does a great job of unwrapping this particular calamity. I don’t want to share everything because 1) spoilers and 2) I’ve rambled for long enough, but one of their points is really unique in its analysis of the union between anthropology, economics, and healthcare. They explain that traditional healing has come to serve alongside modern biomedicine in the lives of the poor. In response to the tremendous economic burden of large health problems or chronic conditions, such diseases are often viewed as problems that require spiritual cleansing (7). Limb pains? Blurred vision? Frequent urination? The rural poor are more likely to consult a traditional healer to get their curse lifted than to visit a clinic and stock up on insulin. I don’t pretend that I know enough about Malawian culture to ascertain the validity of this claim at St. Gabe’s, but it definitely adds another interesting piece to the puzzle of treating patients.

 

(1). UN News Centre. (13 May, 2011). Countries facing double burden with chronic and infectious diseases-UN report. Retrieved from http://www.un.org/apps/news/story.asp?NewsID=38379#.VZLj7GCJ38E

(2). World Health Organization. (2004). Developing countries face double burden of disease. Bulletin of the WHO, 82 (7), 556.

(3) Caballero, B. (2005). Nutrition Paradox-Underweight and Obesity in Developing Countries. New England Journal of Medicine, 352 (15), 1515-1516.

(4) Gersh, B.J. et all. (2010). The epidemic of cardiovascular disease in the developing world: global implications
. European Heart Journal, 31, 642-648.

(5). Msyamboza, K.P. et all. (2014). Prevalence and correlates of diabetes mellitus in Malawi: population-based national NCD STEPS survey
. BMC Endocrine Disorders, 14 (41).

(6). Cohen, D.B. et all. (2010). A Survey of the Management, Control, and Complications of Diabetes Mellitus in Patients Attending a Diabetes Clinic in Blantyre, Malawi, an Area of High HIV Prevalence. American Journal of Tropical Medicine and Hygiene, 83 (3), 575-581.

(7). Banerjee, A. and Duflo, E. (2011). Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty. New York: PublicAffairs.

(8). Malawi.(2014). [Graph illustrations of age-standardized death rates and proportional mortality]. Data Access from the World Health Organization- Noncommunicable Diseases (NCD) Country Profiles.

I’ve felt like I had a logical understanding of morphine use in Malawi for some time now. I’ve spent the better part of four weeks working in palliative care at St. Gabe’s, so I have the logistics down pat. The need for a software to track morphine use appeared pretty clear after reading last year’s intern blogs almost religiously. I’ve even watched patients get started down the path of palliative care while shadowing. As far as I was concerned, the need for morphine tracking software could be explained in about three sentences:

 

Problems like chronic heart failure, cancer, stroke, and advanced AIDS can’t really be treated in Malawi. As a result, patients who have these chronic conditions often enter hospice for pain management (1), (2). Morphine, the strongest pain management tool in the palliative care arsenal, is strictly regulated and hard to procure (3), so keeping accurate records is important to ensuring that patients receive their medication without interruption.

 

Simple as that. To quote my man David Bowie, “Wham, bam, thank you, ma’am”.

Until today.

 

We accompanied Alex, the palliative care nurse, on home based care visits today. When we came to the first patient, I had to stoop to enter the low doorway of the brick hut. Inside, the rooms were mostly bare. The focal point immediately became the low mat, the pile of blankets tucked in the corner. Everything was still, quiet except for the guardian’s murmured greetings. Once the community health volunteers had settled in, I could hear low moans coming from the pile of cloths. The guardian, a stoic woman of late middle age, gingerly sat on the corner of the mat and began to answer our questions.

 

The patient, age 42, was suffering from HIV and late-stage anal cancer, the latter of which had manifested as large pus-filled lesions. As the volunteers closed around the bed, I realized that my initial assumptions that the bed was just covered with rags were understandable. She couldn’t have weighed more than 70 lbs. Dull skin was pulled taut, enough that every bone in the woman’s body appeared visible. Each joint seemed ready to snap as she was positioned for examination. Every movement was accompanied by low, antagonizing groans. Even the act of being repositioned into a seated posture caused her to nearly pass out from the pain.

 

I have never in my life seen anyone look that frail, that utterly breakable.

 

It was decided that the woman’s morphine dose should be doubled. The guardian’s mental wellbeing was assessed, and then the visit concluded with a word of prayer with the patient.

 

After visiting this patient, I understand the emotional and spiritual implications of morphine treatment. Tracking morphine stocks isn’t just the difference between having a medication and going without. Because although I can dream that this woman’s quality of life will improve with an increased morphine dose, I cannot even begin to imagine what she would be reduced to without any morphine at all.

 

Palliative care will never be sexy. It doesn’t present the adventure of surgery or the warm fuzziness of paeds. But for the patient I saw today, morphine is a concrete realization of comfort and peace in her final days.

 

**Side note: I had no intention of writing this blog post. I actually had another one written and cued up and everything. But after today, this is what came out, so this is what you get. I hope it means something.

 

(1). http://www.ncbi.nlm.nih.gov/pubmed/23561750

(2). Read the context on pages 6-9:

http://www.dianaprincessofwalesmemorialfund.org/sites/default/files/documents/publications/Palliative%20Care%20Report.pdf

(3). Read the section on drug access: http://www.africa-health.com/articles/july_2011/P_care_overview.pdf

 

 

When I was growing up, my dad’s trivia was a staple of any gathering. Be it a birthday full of screaming 8 year olds, a family gathering, or dinner party, it wasn’t truly a Wettermann event until Dad pulled a trivia printout from his back pocket. He has this uncanny ability to find some vaguely relevant topic to quiz us on. Competition ran high. Details were scrutinized. Egos were bruised.

It was awesome.

Although I’m waaaaaaaay too far from Chicago to compete in Bob Wettermann’s world famous* trivia, my dad’s games have still left their mark. So what better way to celebrate Father’s Day than to challenge you, dear reader, to this time honored tradition? Without further ado, here’s some Malawian trivia in the spirit of the world’s best dad:

1. Which of the following colors is NOT featured on Malawi’s flag?
   a. red
   b. yellow
   c. green
   d. black

2. Before independence from the UK in 1964 by which name was Malawi known?
   a. Queensburg
   b. Chewaland
   c. Nyasaland
   d.Blantyre

3. What product accounts for over 50% of all Malawi’s exports?
   a.Tobacco
   b.Tea
   c. Maize
   d.Cotton

4. Which is the currency of Malawi?
   a.Malawian shilling
   b.Malawian goude
   c.Malawian bwanji
   d.Malawian kwacha

5. How many districts are there in Malawi?
   a. 7
   b. 16
   c. 28
   d. 41

6. The most common Malawian last names are Chirwa, Banda, Piri, and Manda. What percentage of the country’s inhabitants have one of these surnames?
   a. 15%
   b. 30%
   c. 45%
   d. 50%

7. What food do most Malawians consume at least once daily?
   a. Sugar cane
   b. Tomatoes
   c. Maize flour
   d. Carlsburg beer

8. Malawi is roughly comparable in size to which US state?
   a. Pennsylvania
   b. Illinois
   c. New Jersey
   d. Delaware

*Disclaimer: probably.

Answer Key:

1. B
2. C
3. A
4. D
5. C
6. B
7. C
8. A

At 7:30 each morning, the doctors, clinical officers, and nursing staff of St. Gabriel’s gathers in a conference room. What follows is a ritual known as the morning meeting. The hospital director does a roll call of each department (1), and the night shift representative for each ward methodically goes through the number of admissions, tuberculosis patients, deaths, totals, and any interesting patients. At one morning meeting last week, a representative from the Labor Ward reported that a child had died. A terrible hush fell over the room, and after what felt like an eternity, Dr. Mbeya halted the normal progression of the meeting. He told our somber group that in Labor Ward, above all other places in the hospital, there was no time to waste.

That’s the only time I’ve sensed such palpable tension in the morning meeting. And while it’s a jarring reminder that we’re working in a part of the world where the neonatal mortality rate sits around 25 deaths per 1000 live births (2), where 71 of those 1000 children will die before their 1^st birthday (3), I promised that this post would be on an uplifting and interesting topic. And I truly do think that the fuss caused by the loss of a neonate is an indication of St. Gabe’s terrific track record in that department. According to Dr. Mbeya, last year somewhere around 80 neonates died at St. Gabriel’s- I don’t have the official stats for you, but considering that the majority of admissions appear to be pregnancy-related, that’s pretty incredible. In light of this superior performance, to the staff of St. Gabe’s the loss of a single child remains as what it should be- a big deal.

To examine the roots of St. Gabe’s success in improving maternal and neonatal outcomes is to look at their preventative programs. Now, I’m a huge public health nerd (4), so in my eyes, these are some of the most important services that the hospital can offer. If incidence rates and theories of health behavior don’t tickle your fancy, I invite you to take another look at the numbers in the paragraph above. Even if you don’t appreciate the minutiae of public health programs, you’ve got to acknowledge their efficacy.

St. Gabe’s does a lot to ensure the health of the developing child long before delivery. The hospital’s antenatal clinic is a popular outpatient program where expectant mothers can come to monitor their pregnancy and learn more about how to ensure that their baby is born as healthy as possible. Nurses monitor weight gain, blood pressure, and general health of each mother, as often as every week if the women wish to come. Perhaps even more importantly, St. Gabe’s brings these services to even the most remote of villages. The hospital’s catchment region encompasses a significant portion of the Central Region district of Lilongwe, a large segment of which includes rural villages with limited transportation access. Even if an expectant mother can find a bike taxi or minibus to take her to the hospital, she still has to pay for it, a reality that makes weekly checkups at St. Gabe’s virtually impossible for the most impoverished families. In response to this problem, the hospital sends teams of health care workers to provide antenatal care remotely, increasing program compliance by taking away the hassle and financial barriers associated with commuting to the hospital.

 

Another service that has become overwhelmingly popular at St. Gabe’s is a shelter for expectant women. Starting in their 8^th month of pregnancy, a woman can come from anywhere and stay next door to the hospital. The shelter sits adjacent to the Guardian’s Shelter, a place for family members to prepare food and wash clothing for patients. These women have weekly visits to St. Gabe’s antenatal clinic, as well as ready access to clean water, well-ventilated kitchen facilities, and a warm bed. If they should encounter any complications with pre-term labor or preeclampsia, they can receive medical attention almost immediately. And when the time comes to deliver, they are minutes away- no long walks or difficult bike rides involved!

 

On a related note, the Malawian government is making sincere efforts to reduce maternal mortality rates (5). In order to do so, the government has promised to pay for deliveries, making births in a hospital financially viable for women who previously might have faced unsafe delivery in their villages. (6)

What’s really unique is that St. Gabe’s commitment to infant health doesn’t stop with delivery. Their programs for malnourished children under 5 are especially comprehensive, with inpatient services, distribution of nutritionally enhanced peanut butter and meal (7), frequent measurements, and parental education. One day, as Nkechi and I were walking back from the Guardian’s Shelter, we saw a large fenced-in garden on the hospital periphery. Curious, we asked about it, and found out that the hospital actually uses the garden to show families that nutritionally sound food choices can fit into their lifestyle! The plot was modest enough, but filled with different fruits and vegetables that can be grown locally with minimal effort. The message came across loud and clear: a family can get adequate nutrition for their children, even if they are of modest means or live in a rural area!

 

There are plenty of other public health initiatives that I’ve caught wind of in the past week, and I could write for days on all of them! But you’re in luck, because I decided a) to spare you the comprehensive catalog of my nerdvana and b) hopefully make a point about a thread that is carefully woven through the heart of one of the hospital’s biggest sectors. My experiences over these past few weeks have taught me that St. Gabriel’s has made a serious commitment to continually improving treatment for both mothers and their children. Based on the programs I’ve described and the people who stand behind them, I am convinced that clinicians here not only engage in these practices, but believe in them, continuing to set the  standard of care higher and higher.

(1).  Paediatrics, Surgical, Male, Female, Private, Palliative Care, Labor, and Maternity. I’m probably forgetting a few..

(2). From the WHO ‘s 2012 Neonatal and Child Health Profile of Malawi

(3). That ranks Malawi at 174 out of 187 countries based on the UN’s Human Development Index.

From: http://hdr.undp.org/en/content/under-five-mortality-rate-1000-live-births

(4). One of the few, the proud, no doubt.

(5). THIS ARTICLE IS INCREDIBLE IF YOU LOOK AT NOTHING ELSE FROM THIS POST READ THIS!!! http://www.un.org/africarenewal/magazine/january-2010/save-lives-mothers-infants

(6). http://www.bbc.com/news/health-29228448

(7). This would be an example of the kind of nutritional supplementation used: http://www.huffingtonpost.com/meimei-fox/the-life-out-loud-a-peanu_b_3526957.html

Renata: Well, we’ve just finished off our Friday work, meaning that Nkechi and I have spent exactly a week working at St. Gabriel’s.

 

You: Well golly gee, a week sure is a long time.

 

(this role may also be played by your 1950s children’s show counterpart in the unlikely event that you do not regularly use the phrase “golly gee”)

 

You: Surely you’re well on your way to saving St. Gabe’s, Namitando, Malawi, and all of Africa.

 

Renata: …

 

Okay, so I might have exaggerated your parts in this script just a little. At least I hope you know I’m hyperbolizing, because that would be the overstatement of the CENTURY! It’s just that, exaggerations aside, we’re taking dialogue from the wrong part of the script. What’s happening now is more like Act 1 of my work.

 

Don’t get me wrong; I’m very proud of the steps that we’ve taken towards achieving our objectives this week. Just this afternoon, I experienced the tremendous joy of fixing one of the functions in Morphine Tracker, a database that allows the hospital’s palliative and home-based care program to have an up-to-date record of how many patients are on this Schedule II controlled substance (1) (2) (check out interns Joao (3) and Jesal (4) ‘s blogs from last summer, which do a great job of explaining the importance of morphine records for palliative care in sub-Saharan Africa). My fix was a minor one, but to anyone who knows how truly awful I am at coding, it was just shy of a miracle. (This is the point where the BTB staff is probably cringing at the realization of my technological incompetence)

 

I’m also really happy with how our tech surveys have gone so far. Earlier this week, we brought a respiratory rate timer and binary thermometer to the paediatric ward, where they were put the under intense scrutiny of the nursing staff and the patients’ mothers.

 

The respiratory rate timer is an electronic device that assists clinicians in diagnosing pneumonia, a major cause of morbidity and mortality among children under 5. Once diagnosed, the young patients can be continually monitored, receive antibiotics to treat the infection in the lungs, and can receive supplemental oxygen from one of St. Gabriel’s many O2 concentrators (more on this to come). What’s handy is that there’s a reliable predictor of pneumonia. If a child exhibits tachypnea (abnormally rapid breathing)(5), it indicates pneumonia with 50-85% sensitivity and 70-90% specificity (6). In other words, those are pretty good odds that the child is indeed sick with pneumonia.

 

But there’s a catch.

Making the diagnosis requires careful scrutiny and an accurate calculation of their breathing rate, which is much harder than walking and chewing gum at the same time (7). Think more along the lines of paying careful attention to minute risings and fallings of an infant’s rib cage, doing mental math, and keeping an eye on the clock.

That’s where the respiratory rate timer comes in, keeping track of breaths and making rate calculations for the heath care workers. Seeing the timer develop over this past semester in GLHT 360 (shout out to Nkechi’s team) was pretty cool, but seeing the nurses lay hands on it was something else entirely! Their competence, their enthusiasm, and their honesty were an overwhelming combination (in the best of ways). Similarly, getting to talk to mothers who would potentially use BTB’s binary thermometers really put the device in perspective.

 

It’s definitely a small start, but I’m glad to be fully entrenched in Act 1. Because at the moment, perhaps even more important than my official tasks are the relationships I’m forming- the incredible people I’m meeting, the scene that’s set before me in the form of St. Gabe’s. I think of it as the exposition, the fleshing out of these characters. We’re starting to get glimpses of the motives and relationships that are really going to advance our plotline. This is the time when I start to understand how the hospital works, and with any luck, how BTB can partner to improve quality of life for patients at St. Gabe’s. This is still just the beginning, and I invite you to grab some popcorn (8) and watch to see how the rest unfolds.

Tionana! (see you later!

P.S. As you may be wondering, I intended to post this on Friday, but had to wait until we got Internet from Lilongwe to post. That being said, I’m looking forward to staying up to date with the Blackhawk’s likely Stanley Cup victory tomorrow (GO HAWKS!!!), and you should be on the lookout for another blog post on what I see as a really fun topic in the next few days.

 

(1). From http://www.deadiversion.usdoj.gov/schedules/

(2). Only tangentially related, but given the technology focus of this internship, II had to share an interesting development for pharmacological tech: http://www.bbc.com/news/health-32780624

(3) . https://malawi.blogs.rice.edu/2014/07/28/morphine-tracker/

(4). https://malawi.blogs.rice.edu/2014/07/10/palliative-care-morphine-dosing-system/

(5). From http://www.nlm.nih.gov/medlineplus/ency/article/007233.htm

(6).From Samin S. Shah’s Blueprints in Pediatric Infectious Diseases, pgs 64-66, ISBN 1-4051-0402-3. It’s a fantastic read. Seriously.

(7). Terrible example, I know, but hopefully you understand.

(8). Sorry for the corny line. Wait, no I’m not.

Since our departure on Tuesday, I’ve spent a day in Frankfurt brushing up on my German, a tense hour and forty minutes rushing through customs in Johannesburg, and a full day and a half at St. Gabriel’s Hospital in Namitondo, Malawi. My body is still jet lagged (seriously, our first night, I think I set a personal record for the number of hours slept straight), and my mind is spinning, but I am very happy to be here!

 

Our first day at the hospital was Friday, and although we were a bit apprehensive about jumping into the fray, we managed to start by planting our feet firmly on the ground. In the morning, we got a hospital tour from the matron, Mrs. Mbukwa. She was SO thorough and patient with our questions (and oh, there were many questions). We then helped sort pills in the outpatient pharmacy until lunch. Afterwards, we met with Dr. Mbeya, the Hospital Director and our resident guardian angel. Dr. Mbeya seems to be quite focused on making sure that our experiences here at St. Gabe’s are ones through which we can both learn and serve. I really appreciate that, and I feel that he will make a major contribution towards our ability to make a positive impact on hospital and our role as advocates for it.
Apart from the medical, we’ve been exploring Namitando and nearby (1) Namitete, meeting TONS of friendly people whose names I have yet to attach to faces, and catching up on sleep. The great thing is that wherever I’ve found myself during this past week, I’ve had the chance to pound some key ideas into my jet-lagged brain:

 

1. It’s okay to slow down.

I learned this one in Frankfurt, when we got on the wrong train not once, but twice while sightseeing on our layover (sorry, Nkechi!). When I finally settled in one place for long enough to get a thorough reading of the map, things became a lot clearer. The moral of the story is that it’s better to be deliberate in your actions than try to fit in.

The second moral of the story is that you should thank your parents for dragging you to German school.

 

2. Just because something isn’t explicitly in your job description doesn’t mean you can’t be helpful.

After getting a lay of the land with the matron, we spend some two and a half hours organizing pills. While this was not the kind of work that we have been officially tasked with during our internship, there were definite benefits to the work we did there. It gave us time to get familiar with the people who work in one of the busiest parts of the hospital, the outpatient clinic. I also feel that I gained a great deal of insight by looking at the medicines we were packing. I became more acutely aware of the problems facing the average patient at St. Gabe’s with just a glance at the labels: quinine (2), zinc (3), brufen (4), and erythromycin (5), to name a few.
So did we provide a crucial service that only we could? Not even close. But we hopefully made things a bit easier for the hospital staff, gaining perspective and a good rapport in the process.

 

3. Ask a lot of questions.

Saturday morning, we ran by Dr. Mbeya’s office at 11:30 AM (6) with a few questions. We came in with a plan to ask a few quick things about shadowing to get ideas for new technologies and possibly presenting our technologies at the hospital’s morning meeting. We left over an hour later, having gotten not only our answers, but also a chance to watch a surgical procedure and see some potential areas for technical improvements in the ward!

Although most of this can be attributed to Dr. Mbeya’s enthusiasm for teaching, it goes to show that asking questions is a great way to open doors. You could even expand this thesis and apply it to the village, where a simple “Muli bwanji?” (How are you?) can elicit a smile and response from a stranger. With these experiences in mind, I’ve allowed myself to be okay with having more questions than answers. The more questions I have, the better chance that I can take away something that’s meaningful for me, for BTB, and for St. Gabe’s.

 

(1). Nearby is a relative term. It’s a 50 minute walk each way.

(2). Quinine is used for the treatment of falciparum malaria.

(3). Zinc is used as a micronutrient supplement that is especially helpful to children with diarrhea. http://www.who.int/elena/titles/bbc/zinc_diarrhoea/en/
Increases in zinc intake are also recommended for women who are pregnant or breastfeeding: http://www.mayoclinic.org/drugs-supplements/zinc-supplement-oral-route-parenteral-route/description/drg-20070269.

(4). Brufen is a particular ibuprofen preparation that’s used to treat pain and inflammation, as well as fever, especially in children.

(5). Erythromycin is used to treat a range of infections, spanning from skin infections and strep to respiratory infections and various venereal diseases.

***2, 4, and 5 utilize the British National Formulary’s BNF 59, from March 2010.

(6). The majority of the hospital staff leaves at noon on Saturdays.

Greetings from Chicago! Right now it’s a rainy 45 degrees Fahrenheit- who would guess that this time next week, I’ll be finishing off my first week in Malawi?

I’m celebrated my little brother’s graduation this weekend (shout out to Gregor, the kindest and smartest kid I know); I know it’s cheesy, but I’m getting a bit nostalgic and thinking back on the hopes I had in high school for what my future would hold. The BTB internship program was one of the key factors that drove me to consider Rice, and having the opportunity to participate in this experience is completely surreal! I was hoping to use this post to say a little bit about my motives for participating in this program, but I think that a combination of binge-watching the Walking Dead and a deep-dish pizza coma are making it difficult to be articulate. Do you know what I am still good at?

Making lists.

The past month or so has been chock full of lists: parts lists for our medical devices, Chichewa words I need to cram in my brain, packing lists. So it seemed only natural to add one more list: the things that most excite and concern me going into this experience. I assure you, my posts will get shorter and more picture-heavy once I’m on the ground in Namitete. But for now, without further ado:

The good stuff (abridged for your benefit, otherwise this would be a novella)

1. Flexibility: St. Gabriel’s Hospital has given us some idea that we may be working on Morphine Tracker (more on that later), and BTB has given us an amazing assortment of student-designed technologies to present to clinicians at the hospital. But in general, the internship will largely be what we make of it. And I love that! I’m thrilled at the range of opportunities I have to make a contribution in a way that both meets the community’s needs and utilizes my skills.
2. Distinctiveness: I’m sure I’ll be able to speak in tomes to this once I get there, but the impression I get is that there is a HUGE contrast between St. Gabriel’s and Queen Elizabeth Central Hospital (where several of the other BTB interns are working). Located in a major city, Queens is Malawi’s premiere teaching hospital (1). In contrast, St. Gabe’s is a small, privately run hospital in a rural area. It will be fascinating to compare the two: Which medical problems are most pressing? What personnel structures exist at each hospital? What is the role of various technologies? What are the predominant cultural influences on treatment and physician-patient relationships? Stay tuned and take a look at the Blantyre interns’ blogs to learn more.

3. Perspective: I firmly believe that the greatest resource we will explore during this internship is the wisdom the people we meet along the way. Getting feedback on BTB’s student designs is one of the aspects of the program I’m most excited for; my GLHT 360 design project, the bCPAP heater will be getting some attention, which is an immense privilege. Malawian clinicians’ input will be an invaluable contribution to making these devices viable solutions for low-resource settings! I’m also looking forward to developing relationships with people in the village, as well as my awesome fellow intern Nkechi (check out her blog as well).

 

The stuff that’s keeping me awake at night (for now)

1. Flexibility: The same element that gives this experience so much potential could easily blow up in our faces. I know that coming in with fewer concrete plans means that it will be up to me to reach out, ask questions, and speak up. I hope I’m ready for the challenge.
2. Programming: This is oddly specific, but one of our tasks is to take a look at Morphine Tracker, a student-created database that records morphine use in St. Gabe’s palliative care unit. It’s a cool project with incredible potential, but my lack of coding background has me a bit wary. Like everything else in this process, however, I am ready and eager to learn!
3. Assumptions: One of my greatest strengths coming into the process is that I have 4 summers-worth of experience in Haiti. It is a place that holds a large portion of my heart, but it’s also a connection that makes me wary of my perspective on Malawi. I don’t want to assume that Malawi and Haiti somehow get lumped together in this giant nebulous label of ‘the developing world’ (2), (3); although I am privileged to have the opportunity to draw comparisons between the two, I hope to take more away from this internship than a giant Venn diagram of Haiti and Malawi. *Disclaimer: I’m still not ruling out the possibility that I’ll post a chart at some point.

Well, I hope this hasn’t been too lengthy or introspective. I’m hoping to write up a summary of our student technologies in the near future, but the internet situation will be quite the adventure in the next few days, so we’ll see. For now, feel free to reach out to me with questions or comments at ryw2@rice.edu.

 

1. From the abstract of: http://www.medcol.mw/commhealth/mph/dissertations/Idana_Ibrahim_disseration_280906.pdf
2. https://www.globalcitizen.org/en/content/27-myths-about-the-developing-world/
3. tangentially related and remarkably interesting: http://www.cnn.com/2014/02/07/world/africa/africa-is-not-a-country-campaign/

 

It’s hard to believe that today is the last day of my ten week stay here in Malawi. Although I am excited to see my relatives in Taiwan, leaving will be very bittersweet. Blantyre has gotten quite homey for me. I’ll miss buying fresh groceries from street vendors on the way home. I’ll miss the lazy Sundays where we all just lay on the porch and relax. But most of all, I think I’ll miss all the wonderful and amazing people that I have met and worked with here.

This summer has truly been and incredible experience and I am so thankful that I have received the opportunity to help out with the CPAP study here at Queens. From travelling up and down Malawi for data collection, helping with implementation, and hanging out with many doctors and nurses, I have learned so much about Malawian culture, healthcare, and the power of dedicated and compassionate people. During the last training that I was at, one of the trainees wrote this as a suggestion on their feedback form: “Continue training more and more nurses doctors and clinicans to improve the quality of our neonates and children for a better Malawi.”

Hopefully one day I will be able to return to Malawi and Queen Elizabeth Central Hospital to work alongside all the inspiring doctors and nurses. For now, Zikomo kwanbiri. Tionana Malawi!! (Thank you very much. See you later Malawi!!)

Our family at the CURE Guest House for my final Malawian Monday:

This past weekend the housekeeper at the Cure Guest House, Alfred, got married! Eager to attend Aflred’s wedding and experience a part of Malawian culture, I biked over to the wedding. When I arrived, I found myself to be the only foreigner in a giant hall of hundreds of Malawians. I definitely got a lot of stares and “ASUNGU!” yelled at me, but overall people were very friendly and I had a great time there.

The bride and the groom were dressed in a tux and a white gown and holding a basket while dancing in the front. While upbeat music was playing, the emcee would call up groups of people, and group by group people would come up and dance with the newlyweds and throw money at them. I joined in with the party and threw money at the newlyweds. Then at one point, another person from CURE Hospital and I presented the CURE gift. We held the gift together and danced down the aisle, presented the gift, and then did a little dance up front. Something that I love about Malawians is how much music and dancing is in their lives. And it seems like they are all amazing singers and dancers. This was definitely reflected in the wedding.

Congratulations Alfred and Brenda!