We are heading home in 3 days. I have no idea if I will ever see Malawi again. It is has been a strange trip for me. I come from a small family in which I am the only child. My world at home is a world of peace and quiet. Malawi, on the other hand, is a tiny sliver of landlocked land that contains 19 million people, with more being born day in and day out. When taking pictures of scenery, it is often difficult to do so without a person entering the frame, or noticing someone’s house in the background after you have taken the photo. It is the starkest contrast to my own understanding of the world that I have yet to come across. Malawians live their entire lives in the social realm: they enjoy roomfuls of people; sound and loudness, they dislike being alone or in silence. Lucy, the founder of Ndi Moyo Palliative Care Centre, showed us the Centre’s meditation room and told us that the room is often only used by foreign visitors and religious leaders. Malawians prefer to use the mediation room to charge their phones because they dislike the quiet nature of the room. Malawians congregate outdoors in large groups, play political messages at high volumes from huge speakers on the back of trucks, and will chat you up at the first opportunity. It is hard to be an introvert in Malawi.
Nevertheless, I have felt at home here. I have adapted and grown to enjoy it. Did this happen because I knew it was only for seven weeks? Perhaps, but I know nonetheless I will miss it. I find myself staring out the window on our car rides trying to soak the last of it all in, watching Malawians and their culture played out on the roadside, as it so frequently does, trying to carry it home in my memory. I hope it will not soon be forgotten, replaced by the familiar world of Montreal and Canada and the excitement of family and friends, of work and school, of the future and the adventures it holds. I will hold the warm heart of Africa in my own heart and let the memory of it shape me and guide me forward
On Monday, April 29th we visited Ndi Moyo, a Palliative Care centre in Salima District. I had the opportunity to visit Salima District Hospital to see palliative patients who have been admitted there due to complications of their diagnoses. Rex, a palliative care nurse from Ndi Moyo, was performing rounds on palliative patients under his care when the ward nurse pointed out to him a woman with breast cancer, who is not part of his program but who should be seen as soon as possible. She is sitting on the concrete floor of the hospital with only a blanket underneath her, and is leaning against her husband for support. It is clear that without his help she would be too weak to sit up. She is naked from the waist up, and is only covered below the waist by a chitenge (a traditional cloth wrapped around the waist). With her breasts exposed, it is clear that a tumour is growing in the right breast, which is swollen and misshapen. As we review her history with her family, we learn that her initial diagnosis when she first sought medical care was stage 3 breast cancer. With this diagnosis there was no surgery that could be performed because the cancer had already spread. She had been receiving chemotherapy until she became too anemic to continue, so her family had brought her to Salima District Hospital 10 days ago in the hopes that she would receive a transfusion.
As Rex examines her, he finds her quite weak with pale conjunctiva, a telltale sign of anemia. Her family also mentions that she has a pressure sore (a wound which can be caused by pressure on one area of the skin from staying in the same position for too long). Rex proceeds to lay her down on the floor to assess the sore. As he uncovers her buttocks, the foul smell of the wound makes me take a step back and Rex confirms what I already suspect based on the smell. “Her coccyx is gone”, he says, by which he means that the skin protecting the coccyx bone is no longer there. It has been worn away by sitting on the concrete floor for 10 days. I ask why she was not put in a bed on admission and the ward nurse tells me that the ward was full when she was admitted, so the only place left for her was the floor. But now as I look around the ward I see a free bed, so I insist that she be transferred there. Why did she not get transferred to a bed with a mattress when one became available? It is a hard truth in Malawi that sometimes there are no answers to questions such as these, and this is immensely frustrating. Now in addition to being burdened with cancer and anemia, this woman will have to hope that this wound, caused be no fault of her own, will be able to heal without infection
On our first day at Kamuzu Central Hospital in Lilongwe, we passed by posters advertising Operation Smile. I have heard about Operation Smile at home in Montreal. I know they provide services to repair cleft lips and cleft palates. The organization assembles teams of doctors, nurses and surgeons who travel around the world to provide surgical tools and expertise to medical hosts in countries such as Malawi, enabling hundreds of patients to receive surgeries that they might not otherwise have received. As we pass through the doors and stand in the entrance of the operating theatres, we are met by a nurse from Australia who is part of the team and she happily takes a few minutes of her time to outline the selection process of patients and the logistics of a medical mission of this sort. Operation Smile was based in Lilongwe from April 4th to 13th, and during that time they expected to complete over 350 surgeries.
Operation Smile is just one of many groups whose aim is to provide quality medical care in third world countries. So many medical professionals from the first world give up their vacations and personal time to come and contribute to this worthwhile cause. As we approach graduation and begin our careers, I am wondering what my impact will be on someone else’s life. I hope to be a part of something good, now it is just a matter of finding my place
I am paired with another student on the Female Medical Ward. The ward contains more than 60 patients and just two nurses. Besides the nurses, there are various medical students from years 1 and 3 and clinicians who are rounding and giving out new orders. It is place where a patient can sometimes fall through the cracks. Coming back to the ward after a break, we find a patient in distress. The patient in question is a 34 year old woman, a mother of four, the youngest of her children is just 4 months old. She has been diagnosed with postpartum cardiomyopathy, a condition I know nothing about. The room she is in contains 5 other patients, as well as multiple guardians, clinicians and students. “Privacy”, under the circumstances, is a challenge. The patient is struggling to breathe, she is not responding to her name being called, her hands and feet are cold and we struggle to find a radial pulse. Suspecting respiratory distress, a clinical officer is called to the room from another ward and he begins to examine her. He finds her blood sugar dangerously low and begins to intervene by giving her intravenous dextrose, a type of sugar. After several injections, she becomes somewhat responsive and we all breathe a sigh of relief. She is stabilized and we leave for the day after confirming with the medical students that they will continue to monitor her case.
Four days later, we return to the floor, curious to see the outcome of this case. We find the medical students with whom we were working that day and inquire about the patient. They tell us “She died”, about 2 hours after we left the ward. We talk to them for a few minutes and then leave the ward, deflated. Did we do enough? Should we have stayed with her? Would staying have made a difference? Why did she die? In death, there is always the question, “why”? Often there are no good answers: the answer to “why” is just not as clear cut as we would want it to be. I feel sad that she died, sad for the family and children she leaves behind, as though we have failed them somehow. But death is not a failure, and it does not define my skills or character as a nurse. In reflection, I find myself reconciling her death, and the motivation to continue to improve and grow from this experience.
In nursing care, the term “Guardian” may be one that you are not familiar with. I must confess, I was unfamiliar with the term myself, before coming to Malawi. In Malawi, guardians are the caregivers of the patients, they are patient advocates, they bathe and clean and feed the patients. Imagine a hospital that runs without orderlies, PABs, nursing assistants or even a cafeteria, then you will begin to imagine a Malawian hospital. How do all the essential tasks that these missing staff execute now get done? The guardians bathe the patient, get the prepared medications from the nurse and ensure the patient takes them, makes sure the patient eats and drinks, assists the patient to the toilet and to change their clothes and bedding, which are provided, once again, by the guardians. A guardian can be a direct family member or a close friend, and more generally is someone to advocate on the patient’s behalf when the patient is unable to do so for his or herself. Imagine that you have a family member who is hospitalized and you must abandon your other duties at home and at work because you must now care for this patient in the hospital. You have come a great distance to ensure they get good care. During the day, you are at the bedside as much as the staff will allow, caring for your loved one and keeping them company. When you are not at the bedside you must be fetching food and water, perhaps building a fire to cook on so you can feed yourself and the patient. A night, you sleep in a shelter with all of the other guardians who are on site hoping their family members will recover and come home with them. It is an enormous burden to bear. I think back to my father’s hospitalization and how frustrated I felt when the staff did not have time to wash his hair and shave him, so I was forced to do it myself. I will never again take for granted the support staff we have in Canada who go to great lengths to accommodate our patients and support the patients’ families in their time of need.
Three weeks ago Makupo village lovingly opened its arms to welcome us into the fold. Right from the outset, we were embraced and accepted by the villagers, from youngest to eldest. Everyone in the village had a role to play in our well-being, and keeping us safe. It was a wonderful start to this incredible journey and as we bid our farewells I feel a strange sadness that there will no longer be a crowd of children to welcome us home at the end of a long day, to sing our names to get us to come and play outside, a group of men we have talked to and gotten to know to guard us and look after us day after day and ladies who brought well water for us to wash and cooked us the most excellent Malawian food we could hope to eat. We have been truly blessed by this unique experience and I regret that we did not appreciate it for what it was until it was almost over. We are now moving on to Lilongwe and Kamuzu College of Nursing, where we will be staying in residence, housed in dorms surrounded by the noise and heat of the city. It is a new experience that will bring with it fresh challenges to overcome and hopefully good friends and memories on the horizon. As they say in Malawi, we are learning and absorbing “Pang’ono pang’ono,” which means “little by little”. I am looking forward to it all, and I can’t wait to share my stories with you!
It is Thursday, and the children’s ward is busy. The ward contains about 28 beds, of which more than half are occupied. One of the beds holds baby E, whom we first met on Tuesday. Baby E looks like a newborn; she has fine hair and frail limbs, but she is already two months old. She was born prematurely and her mother died three days after birth. Her grandmother (Agogo) already had 3 other children to care for, so baby E was given up to the local orphanage. Almost all babies in Malawi are exclusively breastfed, so a child without a mother to feed it poses an unusual problem. Baby E needs to be fed properly mixed formula prepared with clean water every 3 hours so she can grow appropriately during these first critical months of her life. But the orphanage where she is staying has 81 other children to care for, as the matron of the orphanage explains. Will she get the care she needs if her care is so labor intensive? For now all we can do is hope.
Baby E’s grandmother is present at the hospital today. I wonder who is caring for the other children she is responsible for while she is here. I also wonder why she is so determined to be present for a child that she has chosen to give up. What will become of baby E when she grows up and realizes that her family chose other children over her? I try to imagine the difficulty of having to make that choice and the heartbreak that this child is destined to feel as she grows up without a family. I ask the matron if there are ever children who are abandoned on the doorstep of the orphanage. She replies that yes, this is a regular occurrence. I feel the tears start to well up in my eyes as I realize that these children will never know their families and I am reminded of how much I value my own family and heritage and the comfort that knowing where you come from affords. It is a privilege that we forget to recognize.
Tuesday marked my first visit to the pediatric ward. The clinician visits every patient, assesses their status and writes new orders in the chart, much the same as we would see at home. There is a lot going on: in the nursing office IVs are being placed and medications administered, clinicians rounding assessing patients and giving new orders, and trying to get equipment to work. To be a nurse or clinician in Malawi means you must truly be a jack of all trades, as there are no support staff to fix equipment if it is broken or malfunctioning. The pediatric ward has a single oxygen concentrator on hand and a another machine which enables up to four children to receive oxygen at a time. A break of either of these two machines means that no child can receive oxygen. Children in need of oxygen therapy are grouped together in adjoining beds so that those in need can all receive a supply, and we cross our fingers that a fifth child does not require oxygen as well. How do you choose to divide your resources when there is not enough to go around? It is a sad fact here in Malawi that is all too common. The clinicians and nurses are faced with these choices on a daily basis, but we as outsiders are shocked by the hard realities of medical care in the third world: someone will be forced to go without because there is simply not enough to go around.
As the clinician begins to round, one of the first children we encounter appears unconscious with shallow breathing. The clinician calls out her name, to which she does not respond. He then proceeds to rub on her sternum with his knuckle, which should evoke a flinch and cry of pain. The action brings about the desired response. He is testing her level of consciousness, which will give an indication of how sick she is. The child was brought in at 5am after having a convulsion at home. The diagnosis: severe Malaria. An IV was placed on admission and the first of three doses of anti-malarial medication was given. To me, the clinician appears cold and unfeeling considering the condition of the child. She appears to be seriously ill and he is casually proceeding with his examination without a sense of urgency. This is his day to day reality as a clinician in Malawi: Malaria is one of the most common afflictions that cause people to be hospitalized. I wonder about how I would treat patients if I saw people this sick day in and day out. Is his reaction one of apathy or that of an experienced clinician who knows this child will recover
On Friday I was assigned to the labour ward for the first time. During morning report we learned that a woman had come in overnight as a transfer from Kansugu District Hospital (KDH), a public (free) institution. She had been in labour and leaking amniotic fluid since Monday. While she was at KDH she had been told conflicting information about her progress and she grew concerned about whether she was getting appropriate care, so she transferred herself to St Andrews Hospital, a private (paid) institution. Assessment at St Andrews revealed that she was still only dilated to 3cm and she had a very small pelvis, which meant it was highly unlikely that she would deliver vaginally. A C-section would be required, which meant there would be a risk of hemorrhage and need for a blood transfusion, but St Andrews ran out of the supplies to perform the necessary tests (type and cross match) that are used to test blood compatibility.
We were faced with a dilemma that in Canada would never have been an issue. If we performed the C-section and the patient hemorrhaged, there would be no way to give her the vital blood she needed and she would risk death. But on the other hand, if she was referred back to KDH, where she already left because she was dissatisfied with the care she had received, she risked being further ignored and risking her own health and the health of her unborn child. I felt torn: what was the right choice to make? In Canada this situation would not even have occurred: we would have had supplies for type and cross match readily available so we could easily perform a blood transfusion if one was necessary. The medical team decided to test the patient’s blood to check her hemoglobin levels: if the level was high enough she would be better able to withstand blood loss without the need for a transfusion. When the results came back the team determined that it was safe to proceed and a healthy baby boy was delivered at 11:21 weighing 3.5kg. The C-section proceeded without event and the patient had minimal blood loss, so a positive outcome for all!
On our first day at St Andrews Hospital we had orientation to the wards and met the staff. There are clinical officers and clinicians, which are the equivalent of our doctors. There are nurse-midwives who can work in any ward (male, female, pediatric, labour) and midwives who can work in only the labour ward. Midwives can have a variety of training: certificate level, diploma level or degree level. Depending on the level of training, they can perform various procedures to assist birthing mothers. Midwives are as common as nurses in Malawi, as the birthrate is 5.7 compared to 1.2 in Canada.
As we passed through the labour ward there was a woman on the hospital bed behind a simple curtain. We could see her as we passed through the room, a grimace spread upon her face. As we passed behind the curtain, we heard her moaning through painful contractions, crying out “Amayi”, which means “Mother”. It sounded like she was pleading for the pain to stop. In Malawi women are not regularly treated with analgesics for pain during labour. If they are fortunate they may get Paracetamol (acetaminophen) or Bufren (ibuprofen). On the other side of the curtain from the labouring mother, two midwives were chatting away as if on a break. They seemed unconcerned that the woman was in pain. I was a bit taken aback that they could continue on with their conversation and not offer the woman support. As we continue to learn about birth in Malawi, it appears that the midwife is only there to support the woman in the event of a complication, like a breech presentation or placenta previa. If a mother’s labour is progressing normally it seems like she is left to work through labour on her own, which is in stark contrast to what I saw during my obstetrics rotation in Canada, where mothers are supported almost constantly and given analgesics and epidurals to facilitate the birth. The contrast makes things seem very cold and unfeeling here, but as the birthrate is so high and birth is such a common occurrence as compared to Canada, it seems that there is a very different attitude towards the process of childbirth.