01 Aug Seven Years On
Seven Years On: A Return Visit To St Andrews Hospital, Mtunthama July, 2018
Working at St Andrews hospital during the later part of the afternoon you’ll sometimes hear the wonderful sound of the All Saints Church choir drifting down on the breeze as they rehearse in the church. The sound of an African church choir is something difficult to describe. Rather than having a conductor’s baton to follow, a Malawian choir will keep time with each other by dancing – stepping lightly from one foot to the other, swaying their hips and swinging their arms to the same tempo. When their voices break out into song it is rich, soulful and joyful. I would almost say it is worth travelling to Malawi just to hear them.
My name is Philip Delbridge. In 2011 I spent a month visiting St Andrews hospital as a medical student on elective. These days I’m a registrar (a middle grade doctor) specialising in Emergency Medicine. So I normally work in the UK’s busy A&E departments.
Earlier this year, at the end of July, I travelled back to Malawi with my wife, Kate, who is also a doctor. It had always been my intention to return to the country after I’d fallen for it as a student. Luckily, my wife also loves Malawi and has worked here in the past. We live in the south – in Blantyre, the country’s largest city (although the capital is Lilongwe) – where we’re both working as volunteer doctors.
Since returning to Malawi, it has been in my mind to revisit St Andrews. Recently, I had the opportunity to go and do just that. This is a report of my observations, going back to St Andrews after seven years.
When I arrived at St Andrews in August of 2011, the Forsyth Operating Theatre and Surgical Ward had just been added to the hospital. Since then so much more has been done to expand the facility. There is a new Paediatric wing, which has also inpatient NRU (Nutritional Rehabilitation Unit) beds. The old Paediatric ward has been taken over by the expanded male and female adult wards. The Shrewsbury School Eye Clinic has been added, where Ophthalmologist Mr Amos Nyaka performs monthly operating lists. Additionally, there is a new section of the hospital for the Accountancy and Human Resources teams as well as a large Pharmacy storeroom. All of this is new to me. The Pharmacy is well stocked and well organised, a stark contrast to many other hospitals in the country (and I’ve worked at some of them) where medication is often in short supply and poorly organised. All of this progress has been made possible thanks to the kind support of all of Medic Malawi’s followers.
Returning to the hospital, I was delighted to see that some old friends were still working there. Mr Peter Minjale, the lead Clinical Officer, was Medical Director of the hospital when I was there in 2011. He’s a lovely man who has been working diligently at St Andrews for such a long time now. All the staff at the hospital still look up to him, referring to him as ‘Chief’, which is a very Malawian way of showing deference to a respected individual.
One of the changes that struck me about St Andrews hospital and also other hospitals in the country is the changing demographic of patients we are seeing. When I was here seven years ago, malnourished children made up a significant amount of our workload. Thankfully, this situation is changing. Projects like the NRU at St Andrews are beginning to make an impact and malnutrition seems to be less significant. Much of the work on this front has been moved out into the communities where the aim is to improve the prospects of at-risk children before they get to that stage of severe malnourishment that requires admission to hospital.
Life expectancy in Malawi has been on the increase over recent years, which is excellent news. But just like in the UK, where a rising population of elderly people creates challenges for the NHS, the rising number of middle-aged and elderly Malawians brings different healthcare challenges and it is something that the country’s healthcare system is not yet equipped to deal with. In the UK, if you suffer from a long-term health condition such as High Blood Pressure or Diabetes, you will normally be able to access your GP or a Practice Nurse who can help you manage the condition, either with advice, life-style changes or through medication. In Malawi the Primary Healthcare is simply not in place to manage these sorts of problems and the availability of medicine such as Insulin, to control Diabetes, is not there. As a result, patients with chronic conditions such as Diabetes and High Blood Pressure often go untreated, which leads to their condition getting out of control. This can result in serious complications such as Strokes and Heart Attacks as well as other emergencies. The hospital staff at St Andrews are recognising this pattern as well and during my time with them I was asked to do some teaching on subjects such as Hypertensive Emergency, a condition where blood pressure spirals out of control, or Diabetic Ketoacidosis, where poisoning of the blood occurs as a result of uncontrolled Diabetes. These sorts of cases are very much on the rise in Malawi.
Another factor in all of this, which is rather interesting, is that it is desirable in Malawi to be big. In the West, the stereotypical portrayal in the media of an attractive individual (especially a woman) is usually someone slim. This is what we’re meant to find appealing and indeed many people do. In Malawi it’s very different. Being big is associated with wealth and strength and good health. Within living memory Malawi has experienced food crises. The years 2002 & 2005 were particularly bad but also as recently as 2012-2013 there were significant shortages of food in some parts of the country. So it’s perhaps understandable that a Malawian might like the idea of a potential partner who carries a bit of weight on them. The other aspect is HIV. This disease still has a certain amount of stigma and fear associated with it. The thinking is that HIV normally makes you lose weight and become skinny, so if someone is fat they’re unlikely to have the virus. Indeed, there is a certain amount of truth to this (although for patients who are on effective treatment weight loss should be less of a problem).
In Malawi, the hot season usually reaches its peak around October and November. These months bring vivid colours in the flora of the country – notably the scarlet ‘Flame’ trees, the purple-flowering ‘Jakaranda’ trees and the multi-coloured ‘Candelabra’ trees. Now that we’re moving into December we’ve seen the dry season coming to an end and the arrival of the rainy season, which is heralded by characteristically spectacular thunderstorms. Once the rains set in the landscape is transformed. Dry and dusty terrain turns to lush green as the grass grows tall and the skeletal Baobab trees break out in leaves.
This is also a very busy time for the Malawian people. Only 3% of the Malawian population live in cities. The remainder of the country’s 18.6 million people live in rural areas, predominantly in small villages. The vast majority of these people are farmers and in fact even the city-dwellers often have a plot of land in the countryside where they can grow their maize, which is the staple crop of the nation. With the rains, the people are hard at work tilling the land and planting their crops. There are no tractors to speak of so it all has to be done by hand and much of the work is carried out by women. A simple hoe is all they use to work over the soil and break it up. After spending an afternoon working over the garden at the AMAO orphanage in this way, I can say from first-hand experience how tough going it is.
Nobody wants to be ill at any time but this is perhaps the worst time of year for a Malawian to become unwell. Should they be unable to plant their land in a timely fashion they risk going hungry for the rest of the year. It’s a real worry for many of the villagers around Mtunthama, where the majority of St Andrew’s patients come from. As a result, the number of inpatients at the hospital is currently lower than average with people desperate to stay at home to get on with the required work. However, the worry for clinicians is that people will leave it too late before seeking help when they do fall ill.
Madalitso (the name means ‘blessings’ in Chichewa), a five-year-old boy I saw on the paediatric ward with his mother, had been admitted with severe Malaria just a couple of days earlier. Malaria is a parasitic infection of the blood. Mosquitos spread the parasites from person to person. It is still one of the most common illnesses you’ll come across in Malawi. In fact, pretty much every Malawian will get the infection more than once over the course of his or her lifetime. Children are more severely affected. By the time a Malawian reaches adulthood they will normally have built up a degree of immunity to the disease. Whereas most adults in Malawi experience only a mild illness when the infection strikes, children don’t yet have this tolerance to the disease.
In Madalitso’s case, the Malaria was bad enough to cause a severe anaemia as the parasites had attacked his blood cells and caused them to break down. Anaemia is a common complication of Malarial infection. Although he was really very ill, thankfully Madalitso started to improve after St Andrews provided him with treatment including intravenous anti-Malarial medication and a blood transfusion. Two days later and he was conscious and able to sit up in his bed. Our plan was to recheck his haemoglobin levels (haemoglobin is the iron-based molecule in red blood cells that carries oxygen). On admission he had less than half the normal amount of haemoglobin. However, his mother was impatient. She wanted to take Madalitso home. There was work to be done in the fields.
In such cases the clinicians at the hospital try to be sensitive to the needs of the people they’re looking after. They know the pressures that Malawians face. Madalitso probably needed one or two more days in hospital ideally but that might mean his mother wouldn’t be able to get her crops in the ground at the right time, putting the family at risk in the year ahead. So a compromise was reached. We would check his haemoglobin levels first thing that day and monitor him over the course of the morning. If he remained stable and the results were satisfactory he could be discharged with some iron tablets to help his body recover the lost blood and some oral anti-Malarial medication to get rid of the last of the parasites. He went home later that day.
The other strength of a charity like Medic Malawi is the way in which it passes responsibility back to the local Malawian people. The charity and the local leadership maintain a discussion about how funding is allocated. The infrastructure that Medic Malawi helps to fund is run locally, not overseen from the outside. The onus is on the community to make the most of what is provided. These sorts of arrangements tend to work better than when a charity comes in and tries to dictate everything. To my mind, a charity that works alongside local communities in the way that Medic Malawi does is the right approach.
Malawi is a country full of potential. It feels like a work in progress, somewhere unfinished. It is a country full of charm and beauty but also grief and loss. Sadly, it remains one of the poorest in the world but there are steps forward being made. In supporting Medic Malawi, you are a part of that process, and that is surely a wonderful thing.