December 22, 2012
By Jamie:
As part of my orientation to Malawi medicine the Medical Council
has mandated that I spend six weeks orienting at Queen Elizabeth Central
Hospital, or affectionately “Queens”.
Queens is the largest hospital in Malawi with over 1200 beds. You are probably imagining a multistory
complex with shiny windows, but on the contrary the whole hospital is single
story. It is a labyrinth of large brick
rooms connected by covered corridors. I
said 1200 beds, but it may be more appropriate to say 1200 mattresses, or some
form of bedding. Most of the wards are a
large room with 60-80 patients in them, some on beds some on the floor.
There is a well established benchmark at Queens that 75% of
all admitted adults are infected with HIV.
Most of them are admitted with AIDS or an adverse reaction to their HIV
medication. Tuberculosis, Cryptococcal meningitis, Kaposi’s Sarcoma, and HIV
related cardiovascular disease are everyday admissions in the hospital. You probably know that AIDS has been the
scourge of Sub-saharan Africa dropping the life expectancy to well below 40
years in many countries including Malawi.
Thanks to international donors including the United States treatment for
HIV has become much more accessible, and in the last five years life expectancy
at birth has already increased by over 10 years to put Malawi back around the
50 year mark. The sun appears to be
rising again in the “Warm heart of Africa”.
This is not to say there are no other hurdles. Currently the country is in an economic
downturn with inflation and instability.
In the last three years the local currency (the kwacha) has devalued by
over 100%, and continues to inflate. A
relative drought has left an estimated 20-30% of Malawian families with
marginal to insecure food stores. With
growing treatment for HIV, an aging cohort of chronically ill individuals is
emerging. Treatment for HIV is well
established to promote the metabolic syndrome – increasing cholesterol, blood
pressure, and insulin resistance. Stroke
is already the third most common cause of death at Queens, and the next decade
will witness a dramatic shift from infectious to non-communicable diseases in
this poor country. This will pose new
challenges to the current system. At
Queens (the largest Central hospital in the country), it is currently not
possible to measure a patient’s cholesterol, and medical treatment beyond
aspirin is not available. Diabetes care
is a little more developed with availability of random/fasting blood sugar
tests, metformin, glimenclamide, and insulin (sometimes). Recently, the hospital pharmacy ran out of
insulin which resulted in a dramatic spike in admissions for Diabetic
Ketoacidosis (DKA). Treatment for DKA
amongst other things includes insulin, how are you supposed to treat it without
insulin? Creativity and ingenuity.
Death is common in Malawi.
I suppose it is common all over the world, but it is common at a much
younger age in Malawi. Most patients who
die leave behind young families with on average 4-6 children. Critical care at Queens consists of the “High
Dependency Unit” or HDU. In the HDU you
can have access to an oxygen concentrator which will concentrate up to 5 L of
O2 by nasal cannula. Ventilators and CPR
are unknown in Malawi, and for those needing more than 5 L of O2 there are no
other options. In the last week cases
who I saw die included Fulminant Hepatitis (likely from ART), Lactic Acidosis
(probably from ART), Sepsis, and of course, TB.
Average age was 35.
I’ll be honest, all of this can be a little overwhelming.
The tyranny of the urgent infectious plague on the backdrop of a mounting
non-communicable epidemic makes prioritization of necessity precarious. I think
hard-working problem-solving Westerners like myself can easily burnout as bad
outcomes are so common. It reminds me of
the message I need to hear, “Come unto me and rest”. Beyond bad news and statistics there is a loving
Creator seeking a wounded creation. My job as long as I am here is to help the
next one.
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