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Jun 30th 2016

Ngwelero. A visit to Primary Care in Malawi

Ngwelero.  A visit to Primary Care in Malawi

Wednesday I visited  Ngwelero, Malawi a very rural clinic run by Dignitas in a remote part of Zomba district. Over 80% of this country's population lives in a very rural setting.  Indulging me in one obscure musical reference to reach it one literally must drive on a road to nowhere.  An hour away by truck with the last twenty minutes on a very bumpy road past very modest homes, it provided an example of a Dignitas success but at the same time illustrated to me clearly how far this country still needs to go to develop even something approximating a cohesive healthcare system.

 

  

This hospital is a primary care hospital, the most basic level of care in the Malawi healthcare system descibed earlier. From an MoH perspective it provides essentially some simple out patient care, some minor suturing and as a main component, labour and delivery.  Dignitas' running of an HIV clinic, assessing health, and dispensing antiretroviral medications  was a core part of the work on this day.  Antenatal screening and post natal baby care was also on display. 

 

 

The  labour room and post labour room generally provide good care but clearly are many levels away from our sensibilities in Canada.  

 

 

I looked at the log book and saw in a typical month, March 2016, there were 97 deliveries. Seven of those mothers were HIV positive. It really is a superb success that these women are identifed during their pregnancies and kept on treatment to limit transmission.  Exposed babies get tested to ensure they are okay.  This is all logged and now digitized back at the Dignitas office.  


Today in the antenatal screening and testing room there had not been one positive test so far today but it was still early.

           

 

 

 

Nevertheless the clinic itself highlights many of the challenges in this healthcare system which must be applied more broadly to leave anything sustainable: 


1.There is no anaesthetic service. Any obstructed labour requires a call for an ambulance, which may or may not come, and a drive back along that bumpy road to Zomba. One can see why perinatal complication and even death remains a big issue in Malawi.  Good luck turning up with a basic but potentially life-threatening  surgical emergency such as appendicitis


2. There are still deep cultural barriers at the village level. Educating everyone in the family unit and overcoming old practices is very difficult. Malawi, I have come to see is a very patriarchal country. Condoms were handed out to every woman along with their meds on this day. Despite this, Mathilda (seen right with our driver Macdonald), the incredible Dignitas nurse who came with me said that 50-60% of these women will still come back with another pregnancy down the road. Clearly STD education dispensed at the clinic is not being consistently practiced. I am told it is better than it once was.

 

                                                                                                                                                                

                                                                                                                                                                        

3. In a clinic full of women and their kids there was only one man I saw accompanying his wife today. Again, it will be very difficult to implement complex consistent primary care with these sorts of  barriers. I am also struck in my broad experience here that men don’t tend to come to clinics at all. For their own health issues they present very late, often with insolvable problems which further then jeopardizes the family construct. Again in the OR Thursday what I had to contend with was very advanced, neglected cancer. We turned back another with uncontrolled hypertension.  Championing a men's health piece from basic primary care and education vis a vis family planning, infection control and control of common ailments such as hypertension must be an important goal. Urological cancer (prostate, bladder) account for 2 of the 6 common malignancies. The women wait patiently with their kids to be assessed and treated if necessary. The line up at this weighing station was at least 50 deep.  

 The resources are limited but one senses a commitment among these moms to access the best care they can for themselves and their children. We will need to do much better with the men.  

 

 Ultimately all of the gaps in care in any resource poor setting, whether it be HIV, cancer or better anaesthetic coverage for surgery has to be addressed in a cohesive, coordinated way. At a primary care level such as Ngwelero, both men and women need to be assessed, The ART clinic needs to be understood as a wellness clinic as well. Primary prevention of disease needs to be understood by both women AND men. Bladder cancer is almost uniformly related to Schistosomiasis, a parasite transmitted by snails in freshwater.  That can and should ultimately be addressed as a public health initiative.  HIV forced the brighter lens in Malawi.  Its unfinished work is a result of the lack of coordinated care. Infrastructure that allows for more timely access to transferred and referral care needs to be added. While this help can and should come from the developed world, the will, ownership and leadership of the way forward will need to come from within the country. The administrators and medical leadership will need to get serious to tackle these issues. It will take a signifcant cultural shift internally not just international resource.  For urology and surgery in general I would want to see some internal changes to go along with whatever tools and equipment we may bring.  Surgical checklists, better preoperative assessment and a committment to timeliness are among such things. A surgical consent process that truly is informed would need  to be a starting point of discussion.

On the way back I paid closer attention to the lansdcape. The ground in this particularly poor region of the country is very parched. It is nearing the end of harvest season.  The rainy season ended a  few months ago but there was far less rain this year and harvest yields Mathilda told me are significantly down. I saw a river bed completely bone dry. The emerging catastrophe of climate change with its ultimate impact on food security will be more severly felt in Africa and will make life in this part of the world even more difficult.

 


As you can see from an outing last Sunday it is a beautiful world and needs to be protected in its entirety.

 

  

   

 

              

 


We should all take ownership of that

 

 

Rajiv 

Comments

Posted: July 02, 2016

By: reg bronskill

Raj, very good reading, Thanks for your ongoing commentary. The trip does sound extraordinary, even given the shortcomings of the Malawi health system. Bravo!

Posted: July 02, 2016

By: Edward Collis

You are a great man, Rajiv.

Possibly even better than me.

The world needs more like you.

Your friend,
Eddy

Posted: July 02, 2016

By: ron roacgh

You are a very good man Dr Singal

Posted: July 02, 2016

By: Edward Collis

Hi Rajiv;
Is Final Post like the Last Post?
That is a very sad military bugle call.
Hopefully your tour has not been totally sad.

Eddy

Posted: July 03, 2016

By: Tasker Kelsey

My wife and I have followed your blogs with great interest and admiration.You are our poster boy Doc.

Posted: July 03, 2016

By: Roman Dubczak

Rajiv

Thank you for passing your posts along. I am a former director of Dignitas but reading your first hand accounts of the humanity and socioeconomic situation in Malawi reminds me of the tremendous impact the organization can make there. I sincerely respect your decision to make the trip and further your advocacy for the cause. Good to have you back home though.

Very best regards.

Roman

Posted: July 03, 2016

By: Michael Bentley Taylor

Congratulations Rajiv

Changing culture is so time consuming and difficult
Washing your clothes in water the children haven't peed in and snails don't cohabit is a hugh challenge.
You have made little reference to the Malaria that so devastates society.
Trust you will return
Angola has the SAME problems
Corrupt leaders a hugh challenge
How do you make the leaders value the poor

Mike

Posted: July 03, 2016

By: Megh

In settings where household economies are too vulnerable and can't afford even a paracetamol, their dependence on socialized health care is imperative. Malawi's health is characterized by fragile health systems. Your narrative provides substance and makes a case for reflection by aid workers, health care professionals, programmers and the government, on triangulating poverty, health seeking behavior, and health care.

Posted: July 03, 2016

By: Melanie Ornstein

I have followed all your emails and find your reflections heartening
and frustrating at the same time. It sounds like it was an amazing experience!!!! It certainly makes me appreciate all our resources!! We are very privileged to live in Canada!!

It is a small world though and what happens so far away ultimately effects the whole world! Food for thought!!

Thank you for sharing your experiences

Posted: July 03, 2016

By: Neil Nawaz

Don't how you found the time and energy to write these posts, Raj, but I'm glad you did. They made me think hard about the massive resources and infrastructure that's required to maintain a good healthcare system.

Posted: July 04, 2016

By: Lana Freeman

I have read every one of your posts and an amazed at the information you have shared - it certainly makes us realize the good fortune we have in Canada.

Thank you for sharing these experiences,

Lana

Posted: July 04, 2016

By: Hume

Welcome home Rajiv. Having lived as a teacher and then director for five years with CUSO in Sierra Leone in the late 60's and early 70's I really appreciated your commentary on health care in Malawi. Many thanks.

Posted: July 12, 2016

By: Brian and Jan

Thanks for the glimpse into another world Rajiv. We really have to feel very lucky to live in a country like Canada.
Thanks for sharing your blogs...

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