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You do not see this in Canada!
22 January 2010
As we drove to Likuni Hospital this morning we slowed right down on the road as there were 100s of people all around. I had never seen the road so busy and there was something not quite right about the situation. Glenda explained to me that a truck had just dropped off refugees from Somalia and left them in the middle of nowhere. The sides of the road was lined with men, women and children who had nothing but the clothes on their back. The police were on their way, and everyone would be moved to the refugee camp. The impact of this situation was hard for me to handle, we really have no idea how fortunate we are to be from Canada.
This afternoon we had a meeting at the District Hospital, where I was exposed to the death of a young child in the paediatric ward. All of the sudden I could hear wailing and mourning from many women - it grew louder and louder broke my heart. The body was moved swiftly to the mortuary. Within an hour, a really large truck appeared and the body was loaded into the truck with about 40 people surrounding it. They would take the child back to the village and have a traditional ceremony that will last for 3 - 5 days. Life comes to a standstill here for funerals. I did not know the child but this reinforced what a common sight this is here. When you are driving along the road, one often sees leaves across the road, which indicates that someone has died. One is obliged to slow right down out of respect for the family.
The sun is shining today and it is about 32 degrees. For the rainy season, it is not raining enough. This is crop growing season and the impact will be large for Malawi if the skies do not open. The people continue to be incredibly hospitable and happy. We are located next to a school and I can hear the kids reciting their lessons - a great way to put a smile on my face today.
Kristin
John Chilembe Day
18 January 2010
Friday January 15th was a national holiday John Chilembe Day. Chilembe was the first freedom fighter in Malawi and died in 1915, he is actually the face on all of the Malawi currently, Kwatcha ($1 CDN = K 143 ). So, not having to work we spent the day in town to check out the local markets. They are bustling with people and teaming with everything from food, to pots and pans to second hand clothing. I actually saw a man wearing a Calgary Flames shirt! The market has a fish section, both fresh and dried (salted), and it all comes up from Lake Malawi. Fruits and vegetables are all locally grown and are brought in from the rural areas - under the project One Village One Product. Fresh tomatoes, cucumbers, peanuts, and pumpkin to name a few. Nsima (a maize based product) is a staple dish that everyone will eat three times a day and can be bought pretty much anywhere. The sites and smells are incredible and the people so friendly. We feel extremely safe and welcomes by everyone we meet.
On Saturday, the Palliative Care Association of Malawi held a meeting to finalize their Palliative Care Guide for Home Based Volunteers. Eleven stakeholders were brought together to finalize the manual. the next step will be to train trainers, who will then in turn train the over 10,000 volunteers across Malawi who deliver home based care.
I have not yet heard from Dr. Buchman who is down south in the Zomba district. The internet connection is quite unreliable so it is not too surprising. I did read in the weekend newspaper that the hospital where he is working, St. Lukes, has not been able to pay their staff their December salaries. The Director of the hospital was robbed of K 3.3 Million while leaving the bank - so sad! I know it sounds crazy to think that he had that much money in cash, but in Malawi it is a cash economy. One can only use a credit card at the big hotels, everywhere else it is cash.
Yako, Burkina Faso
15 January 2010
It’s just after midnight on the 14th and I should be in bed, sleeping. The late evening is the witching hour for me - the time when my energy is spent, when I am the most discouraged. The trip to Yako today replays itself in my mind over and over. Yako is situated in an extremely dry area, where desertification is a major issue.
Today we had a meeting with the head of the department that coordinates community health issues and the HIV testing and treatment clinic, the managers of the various areas, a volunteer from Montreal who has been on site since November, helping with communication issues for SEMUS, the physician who is my liaison while I'm here, and the chargé d'affaires for EUMC.
The program for the next two weeks had been worked out in advance, and I was anticipating that this meeting was to ensure that all were informed regarding the schedule of events. Although I had a growing sense of discomfort and feelings of being somewhat lost, I could not voice any objection to the plan so I thanked them for their efforts and agreed to proceed. Then, quite quickly, suggestions were made that threw everything out the window. Boom… the plan was history.
I felt like a fish out of water while I attempted to follow the discussion that followed. Eventually, a new plan was set in place and although I was again asked for my opinion, of course I could add nothing. Afterwards, we walked a few metres up the road to an outdoor cafe that consisted of a few old outdoor tables and chairs in a dusty lot next door to the very basic building that housed the kitchen. We ate grilled chicken and French fries from a communal plate, talked about football (soccer) as there is a major tournament underway in Angola right now, as well as local, national and African politics - all topics that I am famous for knowing nothing about.
Earlier in the day I had been shown my room in the "centre d’hébergement." It was very hostel-like: small, with a bed, a desk and a chair, as well as a bathroom with a toilet (no seat), a sink and a shower. It was not until I returned from dinner that I realized that they had been working on the plumbing but had forgotten to turn the water back on. As well, my bed had only a single sheet covering the mattress. I'll be sleeping under my emergency airline blanket and I'll be scruffy-looking when I show up for work in the morning.
I am feeling defeated, but I remind myself that I knew that it would feel this way. I hope that by tomorrow I will regain my enthusiasm and confidence.
Martin Labrie
The need for palliative care in Malawi is urgent.
14 January 2010
The need for palliative care in Malawi is urgent. Malawi like other countries in Sub-Saharan Africa, is struggling with the enormous burden of the HIV/AIDS pandemic. There are more than a million people living with AIDS, and about 25 thousand living with cancer and countless others living with other diseases for which there are no curative treatments available at this time. It is estimated that about 80 % of cancer patients will have pain in the terminal phase of their disease, and that 25% of HIV/AIDS patients suffer severe pain during their illness. These figures do not address the suffering caused by other symptoms and psychological and spiritual distress.
While here we are working with the Palliative Care Association of Malawi (PACAM). PACAM is the national voice for palliative care in Malawi. It supports, develops and promotes affordable and culturally appropriate palliative care in Malawi through advocacy, education, training, coordination and networking. With over 500 members it has representation in all districts in Malawi. PACAM envisions a country where people with life threatening illnesses are free from pain and distress. One of their focus areas is Education and Training which focuses on standardized and accredited palliative care resources and training.
PACAM develops capacity building resources and delivers training to increase the knowledge of health professionals and home based care volunteers to deliver palliative care to patients.
Successes to date:
- Palliative care training manual for health professionals and accompanying training of training manual. IMPACT: 13 Palliative care master trainers, 48 trainers and 700 health care workers trained.
- Palliative care manual for community home based care volunteers. IMPACT: under development
- Palliative care guidelines. IMPACT: Under development
- Integration of palliative care into ARV training curriculum and undergraduate medical curriculum at College of Medicine. IMPACT: All new graduates receive training in palliative care.
- Delivery of continuous professional development for medical practitioners. IMPACT: Ensuring medical practitioners have access to up-to-date palliative care resources and training to keep their skills advanced.
PACAM also advocates for essential palliative care drugs and services. Access to morphine is very limited in Malawi and mostly only available in tablet form. Only the central hospitals in the large city have access to liquid morphine. The challenge at the moment lies with the current controls and regulations in place for strong pain drugs.
Kristin Smith
Dzaleka Refugee Camp
11 January 2010
Today I had the opportunity to go to the Dzaleka Refugee Camp, one hour north of Lilongwe. The Camp is a United Nations Camp and holds 11,000 people from 8 different countries. Rwanda, Congo and Burundi are where the majority of people are from. I had braced myself for what I was going to see, and much to my surprise it was 100 times better than I had anticipated.
In fact, I have seen much more poverty else where in Malawi. There is a primary school on the grounds as well as a health clinic. I visited the health clinic that serves not only the Refugee Camp but the surrounding area. They have 2 clinicians and 6 nurses and are very much overwhelmed with patients. The clinician told me that they manage to see 500 patients a day, which shocked me, and I am still wondering if I misheard him (although I did clarify with him again).
They had a small lab with one microscope. The clinic had a maternity ward and provided pre and postnatal care for mothers. In the month of December they delivered 65 babies. Mothers were able to stay at the clinic for 48 hours after giving birth. I had the opportunity to meet 6 mothers and their babies who had all been born within the last 2 days. The delivery room was sparse to say the least. If a C-section was needed the patient is transferred to the central hospital over an hour away, across a very bumpy dirt road. About 200 meters away from the clinic was what looked like an old army tent; in fact it was quarantine for cholera cases. Despite standing in the sun for hours on end waiting to get into the clinic, people were warm and friendly and had wonderful smiles.
We then went to the Student Refugee Program, run by World University Services of Canada. Fifteen of the top students from the camp, between the ages of 17 and 25 are chosen, tutored in English and sit the TOEFL exam. Should they be successful in the exam, they are supported to go to Canadian Universities. I cannot describe the passion to succeed that each of these students had. Their choice of studies ranged from medical doctor, dental hygienist, economist, to agriculture specialist.
I was very proud to be a Canadian today.
Kristin Smith
Likuni Hospital
9 January 2010
Likuni Hospital is on the outskirts of Lilongwe. It serves a catchment area of about 170,000 people. It is a mission hospital and is not run by the government. People must pay small fees to be admitted and treated but they treat all who come. They have a capacity of about 150 beds and there are 25 “private” beds that cost about $20 per day and help support the rest of the hospital.
I spent my first day there Friday and was impressed by the staff’s determination to do their best with the resources they have. The physician I am staying with is a Dutch National who is working here for a couple of years. We did rounds on the female ward. Every other patient had malaria and was receiving treatment for resurgence of the disease, which is common during the rainy season.
Closely behind malaria in terms of prevalence is HIV. In Malawi, about 12% of the population has HIV. One of the patients we saw was a woman in her 20s who came in unconscious the night before. It was presumed that she had HIV (no lab was available overnight). She was diagnosed with cryptococcal meningitis and was given IV fluconozole. This was the first time she had presented to hospital with her disease but she was in such an emaciated state it was clear she had had the illness for many months. Her mother was at her bedside and her child was running around being cared for by relatives. Last night she was unconscious and looked as if she would die. This morning she was opening her eyes and speaking a little. The staff was very happy about this and the physician assistant was going to town to pick up more IV fluconazole for her.
In the markets we have noticed older women with very young children – a situation which reflects the sad impact of the African AIDS epidemic. The childbearing generation has literally been wiped out by HIV. Fortunately, in Malawi there is hope that this will change. There are now anti-retroviral (ARV) medications available that are being provided free by the government. According to the treatment criteria here about 1,000,000 people qualify for ARV but 250,000 people currently take them. While one could see this as inadequate, it is in fact the best coverage in Africa and Malawi is clearly making progress in getting its people treatment. People are now surviving and feeling better, and are able to have children who are free of HIV as we saw in the HIV outpatient clinic on Friday afternoon.
There are major problems with access to healthcare personnel and the drugs in rural areas but there is clearly the willingness and the growing capability to make this happen. We are impressed by the publications developed by the Ministry of Health and HIV specialists that assist in the prescribing and monitoring of the ARVs.
Staff here are also keen to learn all about palliative care. In fact, they have a whole program planned for me to educate them over the next two weeks, which seems totally appropriate.
On Friday, I was able to visit a man with widespread Kaposi’s Sarcoma secondary to HIV. He had his left leg amputated at the hip and had multiple lesions present in the soft tissue as well as in his lung. He has constant pain in his head, legs and chest wall as well as phantom limb pain. He is receiving acetaminophen only but the staff are keen for me to see him and we started him on regular morphine 10mg every 4 hours. I am looking forward to seeing him in follow up and hope that all goes well as he will make an excellent learning case for the staff if they can see this man do well on the morphine.
Romayne Gallagher
Lilongwe, Malawi
7 January 2010
After a 42 hour flight we were warmly greeted by our counterparts at the World University Service Canada Malawi and the Palliative Care Association of Malawi. Our Physician Travel Packs (with medication for 3000 people) arrived safely, with no losses!
Malawi is landlocked country and shares boundaries with Mozambique, Tanzania, and Zambia. It is one of the most densely populated countries in Africa. It is listed among the world most developmentally challenged countries, with 65 % of the population living below the poverty line. The life expectancy at birth is estimated at 42 years dropping from 52 years due to HIV/AIDS.
It is estimated that over 1 million people in Malawi have HIV/AIDS, with only 250,000 having access to ARVs. 88% of transmission is caused by unprotected sex with an infected partner, followed by 10 % mother to child transmission and lastly other modes such as blood transfusion and exchange of infected needles. Because of the unavailability of resources or access to health institutions there is often a reliance on local traditional remedies which may even increase chance of HIV infection or aggravate AIDS.
So what are we doing here? We are here to help strengthen the capacity of health care workers in the area of palliative care. Unlike Canada, where HIV/AIDs is considered a chronic disease, most people here die in hospitals and outlying villages due to HIV/AIDS. With the absence of proper health care and access to drugs we want to help their end of life process be as comfortable and dignified as possible.
Day 2 has turned out to be amazing, we are learning so much from wonderful and warm Malawians! Romayne has gone to Likuni Hospital and Sandy to St. Luke’s. Stay tuned for updates.
Pre-departure volunteer training – Dec 5 & 6th
11 December 2009
We’re down to the final days and the final details as the Canadian Medical Foundation’s first volunteer team in our Medical Outreach program prepares for a trip to Africa that we all know will be life-changing. We’ll all be working to build the capacity of medical teams in palliative care as related to HIV/AIDS.
Together, Drs. Pierre Allard, Doris Barwich, Sandy Buchman, Romayne Gallagher and Martin LaBrie, along with me, Kristin Smith, Director of Communications and Programs for the CMF, prepare for our overseas assignment for the month of January in Malawi and Burkina Faso.
The physicians will be working under the guidance Uniterra, one of Canada’s leading international voluntary programmes, that is jointly operated by CECI and WUSC and is present in 13 countries. Uniterra offers citizens and organizations the possibility to make a contribution towards the achievement of the Millennium Development Goals (MDGs). Their staff have been hard at work training the team.
We have been learning some critically important things about communication, teaching and learning in another culture, and practical advice on how to deal with the culture shock that will be part of this shift to a reality none of us has known before, certainly not in a professional context.
One of the real blessings about the preparation was that participants also had the opportunity to speak with a resource person from their destination country who could answer some of the practical questions about weather, living conditions, food, and culture.
Anna Anderson, a palliative care nurse who spent 12 months volunteering in Malawi was able to share fabulous insights as to what physicians could expect when on the ground. Dr. Labrie also delivered an HIV Care Update to the group.
You might wonder what motivates these physicians to volunteer? According to this group, it’s all about four things – wanting to help develop capacity for addressing the suffering caused by HIV/AIDS in resource poor areas like Malawi and Burkina Faso
It’s about the opportunity to be “hands on” in helping to strengthen the resources of medical teams in Malawi and Burkina Faso, and to be directly involved in building stronger relationships between Canadian organizations and hospitals and the developing world so that our institutions and our individuals can help to strengthen medical capacity in Africa.
Finally, for each and every one of this physician team, the trip represents a four-week opportunity of a lifetime to really learn how to be far more sensitive and aware of the needs of different cultures. This is something that will have immediate payback when our physicians return to Canadian clinics, hospitals, and practices.
Next blog entry will be from the road on January 7, 2010– in the meantime, our anticipation and excitement is mounting every single day.
Kristin Smith