FEB-C-4
FIRST FULL DAY IN
MALAWI AT EMBANGWENI,
ONE OF THE “CHALM”
NETWORKS OF ALL HEALTH CARE IN MALAWI,
MAKING ROUNDS,
DISTRIBUTING SUPPLIES,
ALL AFTER A
DELIGHTFUL START—
A RUN AT DAWN
THROUGH THE RURAL AFRICAN LAND- AND
PEOPLE-SCAPE
Feb. 21, 2002
What a wonder! I awoke as though I had been born into this time zone a very long time ago, and heard the first squawking of the abundant noisy birds that cluster around the mission station, running heavily to magpies, crows and raucous carrion feeding storks and herons. I thought it was 6:00 AM as my watch had said when I set it on the Kenya Air flight, which called out the official time in Lilongwe, but I learned later that it is actually an hour earlier, which meant that I was not due at breakfast for another two hours. Perfect!
I roused John Sutter from the next-door room, and suggested to him I would take him up on this business of the run I said I would like to try in the morning. Elizabeth was eager to try the following day, she had said. John reappeared in a scrub suit, and off we went. I ran out the road to Jenda, the mud track that is very washed out in places, but I thought I recognized several sights I had seen on the way in by car, The only life in motion were two or three oxcarts and a couple of women with a wiggling lump on their backs and a full load on their heads. After about a mile, John was suggesting that I should go ahead and catch him on return. I slowed and would run in a zig zag pattern to say I would stay with him, until the first hill when he said I REALLY should go ahead, since he would not be going the distance and pace I had set. So, I picked a distant target, and ran the African hills. It was almost like being in Assa at dawn again, with the rainy season thunderheads refracting the sunrise over green and rolling hills with deeply rutted paths and a pair of rivers that were bridged.
I made it out four miles by a half hour, and turned at the second bridge and began my trip back. By now there were a few more people stirring, some doing their crops already in the cool of the dawn, and some walking the road with loads. Once I saw an empty oxcart coming at me, a remote control drone, I thought, but later a farmer with a prod stick running in the opposite direction to catch up with his walkaway vehicle. Then came the funniest scene of the day.
A group of school children on their way to the primary school at Embangweni came up the road, and fell in behind me like a Pied Piper leading a troop of rats, some of them in partial school uniforms, their book bags and school sweaters flapping behind them, and their sandals slapping as they tried to keep pace with me. About a dozen did keep up, and were right behind me for about a mile, laughing and giggling about this adventure. I suggested that I might hire myself out as a school bus, since I certainly was delivering the kids to school earlier than any time before.
A run through the African dawn is always a good way to begin the day, but in this instance, it was a new day in an unfamiliar, yet strangely comfortable de ja vu. At breakfast with the group, I re-learned the numbers that are cruel and harsh reality. African AIDS is heterosexual and vertical (I. e., mother to child) and half of the latter is preventable by a single dose treatment at the time of birth, although the likelihood of getting to be positive is high later in life. 40% of the childbearing population is +, and that is 40% of everyone from 15 to 35. The MTCT (Maternal to Child Transmission) accounts for all those positive children below age 15, which is 28% of African AIDS here. The program set up here—first in Malawi, and possibly in Africa—gives a single dose of ARV’s (Anti-Retro Virals) to prevent half of the MTCT. Still, these surviving children are stuffed in villages chock full of orphans. An orphan is someone under age 15 with the loss of one parent, often cared for by the “ngongo”—grandparent. There are 1.2 million orphans in Malawi, a nation of 10 million people—more than 12% of the population, absorbed, in desperate situation before the addition of another mouth to feed—into the extended families of the tribe or relatives. Fifty per cent of the population is under age 15.
There are three programs for which the public support has made them among the best in Africa: Tb, STD’s and Family Planning. There are bulk drugs in the pharmacy, underwritten by various agencies that make these three problems public beneficiaries. There are a number of NGO’s that support the better of these public health programs, one being PSI, Population Services, International, based in Alexandria Virginia.
The twenty mission hospital bases in the nation furnish most of the beds and almost all of the care, especially in rural areas; they are united in a network called CHALM—Christian Health Alliance Ministry These are the heroes struggling against the very desperate odds against them in the rising tide of hunger, immunosupppression, and infectious disease. Let’s start with a window opening on this world.
We met the staff, all Malawian except the Director, outgoing Neil Kennedy and incoming Alex, with the other Wazunga, George Poehlman and I, and Elizabeth and John. We heard of the potential help they were looking for from the visiting surgeon and the chance to get a full load of cases run by the others and me this next two weeks.
We then went around. First is a ten-year-old girl who was dying without consciousness or even deep pain sensations awakening her. She had meningitis—no cultures are possible, treated by gentamycin and cloramphenicol and that is about all they have since it is cheap. This should be adequate, but there have been twenty children who have failed on this regimen, and a small amount of a very expensive antibiotic Rocephin (ceftriaxone) has accomplished a clean save of these kids. Guess what I just happened to have rescued from my attic to hand carry in my bag to Malawi? I had sequestered 600 treatments of the IV antibiotic which George Poehlman rapidly translated into $6,000 US wholesale, and any number of lives of Malawians now to be saved, since they can now move ceftriaxone into the first line for treatment of the meningitis kids.
I mentioned the large packs of everything else I had carried, and got John and Elizabeth to carry the rest of the stuff I had packed. I had especially saved out bunches of the lap pads for theatre, and had no idea in advance that they were such a hot item—they have been sewing them out of non-absorbent gauze or old pillow casings. Nut, best of all, I was carrying not one, but two units of the Nonin pulse oximeter units with all the attachments—as good as gold gets in this part of Africa and far more useful. We will unpack all these goodies later when we have the chance to unpack them later, like Christmas and everyone’s’ birthdays wrapped up in one.
Next is a fellow, Stanley, who looks like an emaciated and drowsy skeleton who has a sucking chest wound with an empyema open to the outside world and pouring out a lot of foul pus. He is, of course, HIV +, and has a Hbg of 4.5 (less than 1/3rd of normal.) He has not been getting up and out of bed, since he is so weak. He has very little future since he has no reserves from both starvation and the AIDS. The suggestion is he should have a big operation to clean out the chest wound. He should have blood transfusion first. But, most everyone around here is anemic in any case, and might have AIDS besides! I suggested, why not get a donor who is HIV + and simply transfuse him from that patient (from whom he cannot catch the AIDS he already has got) and then give him the same single dose Rx that is being given to the MTCT patients. This sounds life a really neat idea, but, of course is anathema to any first worlder. That we should knowingly transfuse blood from an HIV + donor into a patient—even though that patient is in the last stages of AIDS—is malpractice, even thought there is a mitigation for it and there is no other source practically available here. This is the kind of “clinical investigation” based in desperation that I can conceive of doing, but not reporting, which would bring down the wrath of all the purists who have no clue about the status as it persists here.
Next is a patient named Humphrey who uses English. He had a large pyomyositis of his right lower leg, and had deep abscesses drained with large areas of granulation to be covered later by a skin graft, but he also had a bad problem of contractures of each of his knees that would keep him from ever walking again. We tried to convince him that this was a serious problem for which he had to straighten out his legs, but he could not. I suggested we could splint him by probably using a pin in the bone on each side of the joint and using a Thomas splint or traction, but there was a swelling of the opposite leg, and we were concerned about putting a pin through pus into bone. We decided to try to ultrasound his legs to see if there were pockets of pus in there. But when we did so we found a lot of nodules along the skin in the distribution of his vessels, with an unmistakable exotic diagnosis—K. S.---“Kaposi’s Sarcoma.” This is a neoplastic disease that essentially only AIDS patients get, and Humphrey had already had the “VCT”—“Voluntary Counseling and Testing.”—and, of course, is HIV positive. That did not distinguish him from every other patient we had seen so far, and were likely to see in the course of the morning.
We saw a child named Jeffrey who had been dropped in a fire with a third degree scalp loss over half of his head. This might be an ideal instance of using his forehead and occiput for a bipedical skin graft and just slip his scalp from one side to the center of his head and undermine the skin on the opposite sides to cover the top with hair bearing areas. There was another burn, in a young woman who had been married for one month, and had never had a “fit” in her life until she was married when she had them at the rate of three to five per day. She was sent back home to her parents by her irate husband who did not bargain for this in the lobola he paid for his bride. She had only one fit when she returned, but that was a significant one in which she fell into a fire and burned both feet severely with the Achilles tendon exposed on both sides. She should be ready for skin grafting by this week, and I understand that we not only have an electric Zimmer dermatome, but also a mesher to expand the grafts.
In the female ward I saw one after another tragic story of Africa in this era. There was one young woman, whose child had died of malnutrition, and probably had AIDS since her mother surely did. The woman’s mother was sitting stoically at the bedside as the daughter was “fitting” as the Briticism would have it for seizing—as she had terminal HIV cerebritis. There is no treatment for this disease, and as I could hear from across the room she had the rattle of bronchopneumonia, which we elected, mercifully, not to treat. This would bring about the end sooner. She was discharged home, as far as the books were concerned, but she would unlikely clear the gate. Her mother and sister sat there stoically, completely understanding that they were the victims of the loss of both daughter and granddaughter all within a couple of days this week from an epidemic that they did not in any way understand. This family could be a poster for the tragedy of African AIDS.
Next is a very sedate older woman with great dignity. She has a large open ulcer on the sole of her foot. It is an angry looking heaped up neoplasm where she should have only the depigmented skin of this sole of the foot. However, she has big lymph nodes in her groin. One of these was biopsied, and the nodes were thick black and waxy, with the cut section showing that each node was packed by black melanoma. This is a classic case of African Melanoma. She cannot be cured of this condition, but she might be able to be made more comfortable by removing the primary tumor so as to get this smelly and messy ulcer fixed to the point that she could go home with a dressing or a skin graft—so I am booking her.
There were four women in a three bed room with seven children in with them and all four had sputum positive active TB. By statistical probability, three out of four of them would be HIV positive, and three had consented to the VCT and were positive. What I did not know at the time is that I took a photo of the woman seizing with HIV cerebritis and her longsuffering mother, and a picture of the four women, with TB. The woman with TB closest to the seizing woman with terminal AIDS looked far better than any of the others, but as soon as we had completed rounds and done the sorting of our medicine packs, we heard the ululation of the women crying and were told that a woman on the female ward had died. We figured that it was the woman with the AIDS cerebritis, but it was the woman with the AIDS and TB next to her who had died, followed moments later by the first woman we had discharged to die at home. So, I took photos of the two women in the last moments of their lives. Aids is not a chronic disease of long lingering with lots of expensive medicines made available to the victims to prolong the disease and its transmissibility as it happens in the quite different disease of AIDS in the developed world.
Compared to this litany of misery, the next patients were almost cheery: a nursing mother had a pair of breast abscesses drained. A young woman had an antimesenteric lipoma that caused a volvulus of the gut. A young girl with severe bloody diarrhea= Shigellosis, was treated with nallidixic acid.
.
A man had been seen in another hospital run by the government for phimosis and ballanitis, and, instead of doing a simple dorsal slit, which was indicated, they did a circumcision. The whole thing got infected and he lost half his glans, and was now in acute urinary retention. We successfully got a Foley catheter into him.
One woman, not yet tested, had a remarkable case of Shingles covering the half of her face including the eye. She is without doubt HIV + but has not yet been tested. There were a few other cases of less dramatic kind, but we pulled from the list only those they wanted me to consider operating on. Now, for what purpose? The fellow with the empyema and open chest would need a decortication or at least a rib resection to get better drainage, but for that he would need multiple blood transfusions, and also he would have a life expectancy unchanged from his basic AIDS prognosis. Humphrey will have no great improvement for his AIDS if we straighten out his legs at a considerable fuss, with his Kaposi’s Sarcoma now also life limiting. There is a fellow here, not yet tested, who has a sequestrum in his med-femur from osteomyelitis. That we might be able to benefit if we take out he sequestrum, but we do not have a functioning X-Ray machine to check on the position of the dead bone and the involucrum around that which remains.
There is a young woman in the ward with sickle cell anemia, with the frontal skull bossing that is characteristic of the sickle disease, but she will no doubt infarct her spleen—then what of the availability of Pneumovax or some form of treatment for her asplenic risk for septicemia from encapsulated organisms?
We talked about RIFINA—the DOTS treatment for TB, with the Malawi TB control program among the world’s best. TB, STD’s and Family Planning are three programs for which NGO’s have supplied free drugs and the programs are very successful, if the AIDS plague were not superimposed. RIFINA is Rifampicyin, PZA, Ethambutol, and Isoniazid for 14 days, then Directly Observed Treatment (DOTS) by the HSA (Health Surveillance Associates) which follow up if the patient has been missed.
THAT
WERE CARRIED A LONG WAY TO BE BROUGHT HERE,
SOME
DIVERTED ON THAT FATEFUL DAY 9/11
AND
NOW HAVE COME TO THE BEST USE THEY COULD HAVE HAD IN ANYWHERE ON EARTH THEY
MIGHT HAVE BEEN CARRIED
It was like Christmas. All of the surgical equipment and medical packs, including the two Med Packs I had given to Elizabeth to carry to Boston for my pickup and onward passage to Nepal—all diverted on 9/11, now come here with me, and Elizabeth and John Sutter. All of the stuff could not have been better designated for Malawi if we had asked for it specifically. I mentioned already that I had carried the special Rocephin for our use here in resistant meningitis, but almost each of the other meds I had packed along were either useful or critically life saving here. Add to that the portable and the Theatre –based Nonin Pulse Oximeter, and the whole kits were Godsends.
One nurse Ellen had been sent to the KCMC (Kilimanjaro Christina Medical Center) in a program I know well, run by Dr. Jonathon Shaw. She learned to do anesthesia there so she will be the second person who is a staple in the Theatre with me this week—the other being Mister Tembo, the jack of all trades. I learned that other visitors had included Newland and Joy Oldham of Duke—friends of mine from several places along the way. I spoke with Neil Kennedy about his history here, and he would like to invite me and the medical students over for dinner, despite their frantic schedule of “ground rush” upon departure. There will be a very big ceremony coming up to see them off, and that will be a cultural high water mark this weekend.
I returned for an afternoon Clinic to see several pre-ops, including a parotid tumor, a hydrocele and a couple of other cases added to the schedule while continuing to sort out and make useful all the Christmas in February deluge of good things we cold pull out as donors’ supplies. It is remarkable how many things they have been making do with or substituting and now are supplied by less than serendipity in the opening of our medicine and surgical packs.
We ended our eventful day by touring around the grounds so that we could learn something of the history and current status of this station, seeing the 100 year old church and the outgrowths around it, like the school for the deaf. The church was very large with a roof of burnt tiles, and a tall steeple and belfrey therein. One day there was a heavy storm, which the people attributed to the irritation of the sky at being scraped and annoyed by this pointed steeple poking up so high, so they tore off the steeple and planted it adjacent to the church and took off the burnt tiles from the highest part of the church to keep the skies from being pricked. The whole of the station and its schools (primary—allegedly available to everyone in Malawi, and secondary—available to less than a quarter of potential applicants and then a very sever restriction for the need of school fees, and then special programs like the Wellness Center, Family Planning Clinic and the School for the Deaf, the Shallow Wells Program, and the Nutrition and AIDS prevention programs. Many of these are supported directly by church programs, one of them in Northern Virginia.
It is an amazing collection of threadbare but adequate resources requiring a lot of teamwork to keep it going, but it has a 100-year history of keeping on going with the Embangweni Hospital being the cornerstone of the whole operation. It is good to be here, and we will start right in to see if we can contribute something more than the general encouragement our presence had brought and the big boxes of medical and surgical supplies we have carried around the world on several stops for the use of a very worthy mission effort. If it may have started out as appropriate for Nepal or the Philippines, it certainly is getting a very good use here with us, and will help even when we have gone on to our return to DC and beyond.