DAY 8 JUNE 24, 2012

Up at 4:15 in the morning to travel to Lilongwe.  Oh what a beautiful morning. Oh what a beautiful day...

The rumor mill had it that Air Malawi was on strike so we were not 100 percent sure that we would be able to fly and instead have to drive for four hours to Lilongwe.   Everything worked out and by 8:00 AM we arrived in Lilongwe.  We quickly arrived at our next place of lodging, the Cluny Lodge.   This too is a lovely place where I relaxed, answered emails, worked on the blog and was very thankful for a safe journey.  I do my best to drink up the beauty and wonder of Malawi.  The land is vast and unspoiled.  I love this place...


The week ahead is packed with activities as we continue our work with the Global Health Fellows.

Cluny Lodge

Cluny Lodge in Malawi

Hosts -  Marines & Bev

Hector -  the Mastif

Hera -  the Chocolate Lab

Entrance to the Cluny Lodge

I could not resist taking a photo of this old phone.  The only modernization is that the individual numbers are "push bottom" instead of the finger dial -  oh well.

DAY 6 June 22, 2012

MORNING ACTIVITY

This morning I was very excited to visit with faculty from Department of Pharmacy to witness Objective Structured Clinical Exams (OSCEs).  This was the first time that these exams were conducted in their pharmacy program.  The third year students were presented with four cases in which they played the pharmacist and the faculty member was the patient.  Students were tasked with taking a history from the patient, determining the nature of the problem, making a diagnosis, and either recommending a product for self-care treatment or referring the patient to a physician.   The students were very gracious to agree to let me listen in and I sat off to side so that I would not be in their direct view.  All of them did a great job given this was the first time that they participated in this type of assessment.  Not easy!

Of course I was intrigued to see how these exams would be conducted as we have been doing formal OSCEs at our school of pharmacy (UCSF) for the past two years.  The fundamentals are basically the same and we now have an opportunity to share patient cases, assessment instruments, and methods to evaluate if the OSCE process is doing what we intend it to do. 

EVENING ACTIVITY

Our evening activity was a Braii at the home of one of our fellows Genesis.  A Braii is the Malawi version of a cook out or grilling of meat.  The hospitality of Malawians is so warm and generous.  You truly feel at home and that we are one big family.   We are blessed to be able to work with our Malawian colleagues.  Our team from the US learn just as much if not more about dealing with the challenges of life and working in health care systems from our experiences in Malawi.  It is all of our desires as health care providers to deliver the best care we can to our patients.   But still sometimes the system(s) fall short and they are not everything we hope and dream they should be for those we care for… 

BRAII BEEF

BRAII CHICKEN

DAY 5 JUNE 21, 2012

Morning - Tour of the Adult Emergency and Trauma Center at Queen Elizabeth Central Hospital (QECH)

These services are new emergency care services at (QECH).  The interesting observation is that the ER is used for a lot of primary care services.  Not surprisingly similar to what happens in emergency departments in the US.  Patients who arrive at the center are triaged in red (seen right away), yellow (seen within 1 hour of arrival) and green (seen within 4 hours).  The transportation is always an issue, either not having the money for transport or the vehicles to get to the hospital. 

We saw resuscitation rooms, OR theaters, lab, facilities, and triage rooms – patients of all ages with all levels of medical needs.  A major challenge – not enough staff (nurses, physicians, technicians, etc.) to take care of the many patients that visit the center on a daily basis.

Afternoon - University of Malawi, College of Medicine

The group visited with the Chair of the pharmacy department and the Dean of Faculty of the University of Malawi College of Medicine.   The department chair Dr. Louisa Alfazema is one of the Global health scholars and stayed with me during her time in San Francisco last November.  In the country of Malawi there are 95 registered pharmacists in the country!  Clearly there are not enough pharmacists to meet the needs of 15 million people.   The pharmacists who do work in country have received their pharmacy education outside of Malawi.   

I had the opportunity to meet with the faculty from the department of pharmacy.

As with my prior visits with pharmacy faculty, most recently in Tanzania, they are all quite interested in how we teach our courses in the US.  I am most interested in how they teach and how it relates to the pharmacy care needs of Malawians. 

The program is a fours years and most of the times is spent in the classroom.  The pharmacy practice and clinical pharmacy courses are taught during the last two years of the program.  The program is fortunate in that the basic science courses are taught in conjunction with medical students.   The intention and desire is to have the students do more experiential learning, but the challenge is having prepared faculty in the school and in the filed to teach the students. 

Changes in the curriculum are important and there must be infrastructure in place to support the curricular changes.  A large faculty/preceptor development program is needed to give faculty the opportunity to acquire the necessary skills and competencies.   

DAY 4 JUNE 20, 2012

Tour of Zomba Mental Health Hospital

Treatment of mental illness is challenging in Malawi as it is everywhere.  Medications are minimal.  Today we visited the one and only mental health hospital in Malawi.  Out tour guide is one of our Global Health Profession scholars Genesis who is a mental health nurse.  

There are adult and adolescent patients.  The building is clean and neat and of course the care appears to be very good.  There is only one psychiatrist in country, several nurses who can care for the patients but it is an area that needs to be developed.  Mental health medications are very expensive therefore in Malawi the health care providers still use first generation of antipsychotics such as Thorazine.  The pharmacy is managed by a nurse because there are no pharmacists in country who are interested in working at the hospital.  The medications have horrible side effects and one could argue that it is better than nothing.  Most of the patients appear to be walking around in a medication fog.  It is the only way to try to treat symptoms and control behavior. 

The stigma of mental illness plagues villages, communities and the country at large.  The Malawian healthcare providers who choose to work with this population of patients are quite dedicated and do all that is humanly possible to provide quality care. 

It makes my head hurt to think that there is one mental health hospital that is available to serve a total population of about 15 million people.   The need is tremendous however in talking with the hospital staff there is hope…

DAY 3 JUNE 19, 2012

This morning was a tour of Queen Elizabeth Central Hospital.  This is one of the central hospitals in Malawi.  It is a teaching hospital for medicine, nursing, and pharmacy students.  We saw an array of patients, both adult and children.  The conditions seen which require hospitalization include malaria, fractures, respiratory diseases, and hernia repairs to name a few.   I also visited the pediatric oncology ward.   The care provided to the patients is wonderful – the nurses and the doctors are very compassionate and do all they can to help the patients.  Follow-up with patients is difficult because of lack of money or vehicles to transport patients from the village to the hospitals or health centers.   Family members or guardians as they are referred to, provide a lot of the care, even at the hospital.  You see them camped outside doing laundry and preparing meals. 

With sickness often comes death in Malawi.   Next to the pharmacy is the mortuary.  Daily you see family members and friends gathering to pay their last respects.  One can hear a mixture of crying and singing during what I call the “going home” service.   Family and friends are left hurting and grieving, but the loved one who has crossed over, is no longer suffering…  

Next to the hospital is the School of Nursing where we meet with our Malawian colleagues to discuss their scholar projects and our case study during the afternoon hours.  The cultural and educational exchange is so very rich as I discover the tee are indeed more similar the new are different.  The same issues that we struggle with in the US are struggles 
experienced in Malawi.  We are at a point now where we can help each other and learn form one another's experiences.  The topic of our group case study is the procurement of medications in Malawi to treat malaria.  The World Health Organization compiles lists of essential medications for resource limited countries.  A major problem experienced by the health community in Malawi is having a reliable source of medications to treat various diseases, including HIV/AIDS.  The purpose of the case study is to provide a mechanism for others to learn about the processes involved in procuring medications, specifically in Malawi, and to determine what interventions are needed to help improve the current processes in place with the government, the central hospitals, district clinics, and local heath centers and perhaps recommend new strategies.  

DAY 2 JUNE 18, 2012

My first visit to Malawi was in October 2001 with the Global AIDS Interfaith Alliance (GAIA).  The organization's mission in short is to address the suffering caused by the HIV/AIDS epidemic through a variety of activities.  GAIA provides resources that allows for those impacted with HIV/AIDS to have orphan care, home-based care, HIV/AIDS education, women empowerment programs, and scholarships for students.  During my early visits the devastation of the epidemic was palpable.  People were afraid to be tested as it meant to them an automatic death sentence.  Medications were not available or too expensive and access to health care facilities was difficult.  Stigma in the communities prevented people from talking to each other about their situations, asking for help, and reaching out to those in need.   Now as we fast forward 11 years, so much has changed, at least from my perspective for the better.

Today we visited the GAIA Elizabeth Taylor Mobile Clinic in Mulange.  These are mobile clinics that travel to remotes areas and are funded through a grant from the Elizabeth Taylor Foundation.  

Times have changed…  I witnessed a few people get tested for HIV and receive counseling.    The most exciting part was to see the husbands along side their wives being tested.  This does not occur every where but the willingness to know their HIV status is growing.  I was very impressed to see a young man who was 20 years came to get tested so that he would know his status. 

The rest of my time was spent observing the activities of the clinical officer who is the primary care giver for the villagers.  Care is provided in an old church.   Many people come form all over the area to seek medical care.  The mobile clinics have designated areas to which they travel to once a week.  The cases seen included positive tests for malaria, elevated BP, complaints of general aches and pains, fever and cough, and a young boy with complaints of blood in his urine.  Of course when I heard that I was concerned about why this was happening.  Apparently the boys enjoy playing in the river and they become infected by organisms that live in the river.  A very common occurrence.


The nurse and the clinical officer provide the most compassionate care I've seen.  Their spirits are warm, friendly, professional and very caring.  It isa sight to behold given that they see a multitude of patients daily.

Care is provided to patients in this old church building 

Later in the afternoon we visited a village by where were welcomed with singing and dancing.  The people of Malawi are a happy people and are not bashful about expressing their gratitude and thanks.   I have come to anticipate seeing this outpouring of grace and joy and I am always moved by the women and men who participate in the performances. 

We were also welcomed by the chief of the village.  Following protocol that the chiefs are notified of our coming and he expressed his thanks for the work of GAIA and how his village has benefited from the community health workers in taking care of the orphans and those suffering from HIV/AIDS.

Community Health Workers singing and dancing 

Community Health Coordinator Welcoming us to the Village

DAY 1 JUNE 17, 2012

MOUNTAINS IN MULANGE - MALAWI

MOUNTAINS IN MULANJE - MALAWI

Oh how wonderful it feels to place my feet upon the "Motherland" in Malawi once again.  I really love this place and it has been 3 years since my last visit.  I came to Malawi for the first time in 2001 and after more than a decade of visiting I am comfortable speaking two phrases in Chichewa, "Hello, how are you" and "Thank you". 

The scenery is gorgeous and the weather is quite pleasant this time of year. This is the beginning of the winter season in Malawi where the days are warm and the evenings are cool and windy.  

The most exciting news coming out of Malawi these days is the swearing in of a new president, the Honorable Joyce Banda.  She is the first woman president of Malawi and the second on the continent of Africa.  The political scene in Malawi in the past year has been tense to put it mildly with a declining economy, fuel shortages, and very unhappy Malawians.  Currently things are better but there is still a lot of work ahead of the Malawian government and its people.

I am in Malawi with my colleagues from the UCSF School of Nursing - Sally, Susan K, Susan C, Ellen and Amy.  This trip will be a wonderful adventure as we interact with our colleagues from the University of Malawi KCN School of Nursing and School of Medicine’s Department of Pharmacy.  I will attempt to describe the highlights and the wonders of my travels.  

We are staying at House Five in Blantyre.  A modest but wonderful estate with terrific lush views.  It is truly one of God's many wonderful creations.

 BACKYARD OF HOUSE FIVE