3 months in Malawi already – where does time go

I can't believe that I have been here 3 months already, it seems quite amazing that so much time has gone by, but then again I suppose so much has happened, and although I have written about living here and weekends away I have not really written about what I am doing here at all.

We had a week of in country training when we first arrived getting lots of really useful information about living in Malawi, the work VSO is doing and how we all fit in to this. Then moved to Blantyre and had a week to settle in before starting a 4 week orientation at the hospital.

I actually finished my hospital orientation quite a few weeks ago, but wanted to wait a while to try and put it all into some sort of perspective, and to find out as much as possible.

My orientation consisted of 4 weeks doing different placements around the hospital based on the requirements from the Malawi Nurses and Midwives Council. It was necessary for two reasons really, one to enable me to be registered with the MNMC, and therefore practice over here, and secondly even more importantly to understand how the hospital works and what happens there as I will be teaching and supervising the students here on their placements.

I think this may take a while to read through and will be rather wordy with no lovely pictures to break up the monotony of the text.

The hospital itself is very large and has over a thousand beds, (no different from where I have come from), however it probably has one and half times that number of patients, if not more at some times of the year. All the wards I worked on had more patients than beds, and nowhere near enough nurses to provide full nursing care. On my first day there were only 2 nurses on duty on the surgical ward and there were over 60 patients. Sometimes there is no space between one bed and the mattress on the floor next to it. There is a severe shortage of the most basic of equipment, such as gloves, aprons, soap, bed sheets, beds, dressing packs and the list goes on. All the basic nursing care such as washing, feeding, and general caring is done by the patient's guardians, who stay there 24 hours a day, there just isn't the time for the nurses on duty to do all of it. The guardians let you know when the IV infusions have finished, they collect the patients' medication, and they do the portering for the patients. Near all the wards are areas that the guardians stay in, this consists of some stone benches with a corrugated iron roof over the top and a wash area. If there are no guardians then the nurses do this care.

All of the ward areas I worked on had an HDU area, this is where the patients go if they require oxygen as there is no piped oxygen or oxygen cylinders, just a couple of oxygen compressors which can provide up to 5l/O2 a min, and these sometimes have to be shared between patients, the same with the suctioning equipment. Patients aren't on extensive lists of drugs like they are in the UK.

The hospital is very keen on promoting infection control and the ward areas are all cleaned twice a day, there are sink areas in each of the bays, but no towels to dry your hands on, and sometimes no soap. The cleaning solution used is 0.5% chlorine, this is also used for damp dusting all the surfaces each day at the start of the day shift, or as the sign in one ward area said dumb dusting should be done daily, which made me smile. One pair of my trousers now has red streaks on it from splashing the chlorine on them, bleaching out the dye.

Many of the wards double up during the day as outpatient areas as well, so outpatient clinics will be held in the corridors to the main ward area. At the beginning of the orientation period it was all very confusing trying to work out how the system on the wards worked, some things were very familiar and others not so, but as the time went on it all started to become much clearer, so said the blind man.

The staff on the ward know all the ways of making the most of what they have got and how to adapt for things that they don't have, tourniquets are made up of bits of oxygen tubing for example.

As I have come out during the rainy season, there were an awful lot of patients being admitted with malaria, whilst in the paediatric A&E dept, at least 25-30% of the children that came in unwell where smear positive for malaria, Blantyre is one of the high risk areas for malaria. Yes I am taking my antimalarials religiously and using my mosquito net and insect repellent! Malawi is one of the areas where cerebral malaria is a common problem. There has also been a problem with measles and cholera recently. The vast majority of the patients admitted will also be HIV positive and have been admitted due to complications of the disease. HIV infection rates in Malawi have been reported at 14% of the population, but the infection rate is coming down to about 12%. TB is also a common problem, otherwise the illness you see are much the same as at home. What is different though is that patients often present much later.

If it sounds very negative then I apologise as there is a lot of really positive work happening out here with the assistance of all the different organisations. There is lots of building work going on at the hospital to try and improve the facilities, they are currently building a new accident and emergency department, which at present consists of a couple of rooms. They have just finished expanding the ARV clinic area to accommodate all the HIV supportive care that is given to the outpatients. The unit won an award a few years ago for the work it has done in caring for the patients. There is a palliative care team at the hospital, largely looking after the patients with HIV/Aids, and developed in response to the HIV/AIDs epidemic, but does see cancer patients as well, and works between the hospital and the community.

There is a recently built ward area for treating children with malnourishment accompanied by protocols and supportive care which is also co-ordinated with community programmes. Malnourishment is another big problem out here and the unit at the hospital has worked really hard on developing all the treatment and management protocols and a conducive environment to care for the children. The sister in charge of the unit is very proud of what they have achieved over the past couple of years. The paediatric area is huge in the hospital and consists of over 300 beds in 8 different areas. I spent 7 days working in different parts of the paeds department and really enjoyed the experience. A lot of adults suffer from malnutrition as well, and both children and adults get given "plumpy nut" or chiponde as it is also called. I am not going to go into long descriptions about this but you can Google plumpy nut and find out all about it. Next time you put peanut butter on your toast.......

One of the main challenges though of trying to look after the patients is my lack of skills in speaking Chichewa, the language of the majority of the people living in the south of Malawi. I start my Chichewa lessons soon but am picking up the odd word or phrase here and there. They speak a different dialect in the north of the country. Although everyone is taught English in schools, a lot of people have not been to school, and for those that started at school many won't have completed a primary education, and therefore haven't learnt English. All education is done in English. I did whilst on the wards try and learn lots of phrases and questions, so although I could by the end of my time there ask some rudimentary questions, I couldn't understand the answers! A lot of miming had to be done. Charades will be no problem this Christmas.

One of the things that touched me most whilst doing my orientation was something that I saw far too often really, but was unchanging. When a patient dies on the ward, they are taken to the mortuary on a trolley, with a white sheet with a red cross on top of it. As the trolley leaves the ward, it is followed by the relatives who are naturally very distraught, and all the guardians of the other patients also accompany them, singing prayers and supporting the grieving relatives. As you walk through the hospital corridors, everyone stops what they are doing and stands to one side to let the procession pass. The relatives and all the other guardians accompany the deceased person all the way to the mortuary and wait until the transfer has taken place. It is really touching to see this happen and the support offered, and every time it brings a lump to my throat.

Here are some basic facts about health care in Malawi

The population on Malawi is currently about 13.5 million.

There are 4 central hospitals which are government funded and some district hospitals as well. The other hospitals are run either by CHAM (Christian Health Association of Malawi) or private institutions but these are all private and care needs to be paid for here. Care at the government hospitals is free if you are unable to pay for health care, so that is a bonus.

20% of the population live on less than a dollar a day

The average life expectancy is between 42 and 52 years of age depending on which reports you read.

Healthy life expectancy is 35 years of age here compared to 71 in the UK

The maternal mortality rates are 1100 per 100,000 births compared to 8 in the UK

Infant mortality rates 76 per 1000

Prevalence of HIV infection amongst adults over 15 years of age in Malawi per 100,000 of population is 12,528 compared to 137 in the UK.

The number of nurses and midwives in Malawi in 2004 was 7264; the number of physicians was 266

In 2006 only 5% of the population was over 60 compared to 22% in the UK, whilst 47% of the population is under 15 compared to 18% in the UK.

So what am I doing over here? One of the areas where the government has been working with the different aid agencies is to increase the number of nurses being trained (this is not the only area but is applicable to me). As they also had a shortage of nurse trainers, this made the task quite difficult. VSO is one of the organisations working over here and has a very big health programme, as well as its work in other areas. So I am working as a clinical nurse instructor to help train up more nurses. I have been made to feel extremely welcome at the college, by both the staff and the students, and have been orientating for much of the time, working with the different tutors and seeing how the college works and what the roles are. I have also started doing some teaching now, and am busy preparing lessons for the first years when they start in September. We have also sorted out which area of the hospital I will work in with the students when they are out on placement, so that we can supplement their learning in a practical environment, and help them put what they are being taught into practice, and am also beginning to get other ideas of areas that I can work on but these are at a very early developmental stage – as is appropriate for working in development!

So a not so quite brief update on what I am doing work wise as well as just generally enjoying myself.