Wednesday I visited Ngwelero, Malawi a very rural clinic run by Dignitas in a remote part of Zomba district. Over 80% of this country's population lives in a very rural setting. Indulging me in one obscure musical reference to reach it one literally must drive on a road to nowhere. An hour away by truck with the last twenty minutes on a very bumpy road past very modest homes, it provided an example of a Dignitas success but at the same time illustrated to me clearly how far this country still needs to go to develop even something approximating a cohesive healthcare system.
This hospital is a primary care hospital, the most basic level of care in the Malawi healthcare system descibed earlier. From an MoH perspective it provides essentially some simple out patient care, some minor suturing and as a main component, labour and delivery. Dignitas' running of an HIV clinic, assessing health, and dispensing antiretroviral medications was a core part of the work on this day. Antenatal screening and post natal baby care was also on display.
The labour room and post labour room generally provide good care but clearly are many levels away from our sensibilities in Canada.
I looked at the log book and saw in a typical month, March 2016, there were 97 deliveries. Seven of those mothers were HIV positive. It really is a superb success that these women are identifed during their pregnancies and kept on treatment to limit transmission. Exposed babies get tested to ensure they are okay. This is all logged and now digitized back at the Dignitas office.
Today in the antenatal screening and testing room there had not been one positive test so far today but it was still early.
Nevertheless the clinic itself highlights many of the challenges in this healthcare system which must be applied more broadly to leave anything sustainable:
1.There is no anaesthetic service. Any obstructed labour requires a call for an ambulance, which may or may not come, and a drive back along that bumpy road to Zomba. One can see why perinatal complication and even death remains a big issue in Malawi. Good luck turning up with a basic but potentially life-threatening surgical emergency such as appendicitis
2. There are still deep cultural barriers at the village level. Educating everyone in the family unit and overcoming old practices is very difficult. Malawi, I have come to see is a very patriarchal country. Condoms were handed out to every woman along with their meds on this day. Despite this, Mathilda (seen right with our driver Macdonald), the incredible Dignitas nurse who came with me said that 50-60% of these women will still come back with another pregnancy down the road. Clearly STD education dispensed at the clinic is not being consistently practiced. I am told it is better than it once was.
3. In a clinic full of women and their kids there was only one man I saw accompanying his wife today. Again, it will be very difficult to implement complex consistent primary care with these sorts of barriers. I am also struck in my broad experience here that men don’t tend to come to clinics at all. For their own health issues they present very late, often with insolvable problems which further then jeopardizes the family construct. Again in the OR Thursday what I had to contend with was very advanced, neglected cancer. We turned back another with uncontrolled hypertension. Championing a men's health piece from basic primary care and education vis a vis family planning, infection control and control of common ailments such as hypertension must be an important goal. Urological cancer (prostate, bladder) account for 2 of the 6 common malignancies. The women wait patiently with their kids to be assessed and treated if necessary. The line up at this weighing station was at least 50 deep.
The resources are limited but one senses a commitment among these moms to access the best care they can for themselves and their children. We will need to do much better with the men.
Ultimately all of the gaps in care in any resource poor setting, whether it be HIV, cancer or better anaesthetic coverage for surgery has to be addressed in a cohesive, coordinated way. At a primary care level such as Ngwelero, both men and women need to be assessed, The ART clinic needs to be understood as a wellness clinic as well. Primary prevention of disease needs to be understood by both women AND men. Bladder cancer is almost uniformly related to Schistosomiasis, a parasite transmitted by snails in freshwater. That can and should ultimately be addressed as a public health initiative. HIV forced the brighter lens in Malawi. Its unfinished work is a result of the lack of coordinated care. Infrastructure that allows for more timely access to transferred and referral care needs to be added. While this help can and should come from the developed world, the will, ownership and leadership of the way forward will need to come from within the country. The administrators and medical leadership will need to get serious to tackle these issues. It will take a signifcant cultural shift internally not just international resource. For urology and surgery in general I would want to see some internal changes to go along with whatever tools and equipment we may bring. Surgical checklists, better preoperative assessment and a committment to timeliness are among such things. A surgical consent process that truly is informed would need to be a starting point of discussion.
On the way back I paid closer attention to the lansdcape. The ground in this particularly poor region of the country is very parched. It is nearing the end of harvest season. The rainy season ended a few months ago but there was far less rain this year and harvest yields Mathilda told me are significantly down. I saw a river bed completely bone dry. The emerging catastrophe of climate change with its ultimate impact on food security will be more severly felt in Africa and will make life in this part of the world even more difficult.
As you can see from an outing last Sunday it is a beautiful world and needs to be protected in its entirety.
We should all take ownership of that