Having spent the previous evening until quite late struggling to load web pages (via Johannesburg), breakfast again seemed very early. However, this time I was awoken not by a storm but by monkeys on the roof of my cabin! Again we broke into separate groups, and today my group was planning to be a little closer to home. First, we visit to a Traditional Birth Attendant (TBA) in Maldeco, at Adzulu village. Then, we visit a “CHAPS” village (Save the Children’s evolution of COPE into a multi-functional “life initiative”, and finally we travel back into Mangochi to visit the District Hospital.
Traditional Birth
In Adzulu, we were greeted by Mrs. Katherine Chiminga. She had accepted the role of TBA from her mother – Katherine described it as a “Job delivered by God”. Part of her training came directly from her mum, but she had also attended Government run classes at Monkey Bay (70 kms away). She first assisted a birth when she was 24 – in 1981. Katherine is now 45, and has 4 boys and 2 girls. We later met her son Isaac. He is 20 years old, and spoke excellent English – Katherine herself understood English but was a little shy about speaking it. Still, the fact that we did not speak Chichewa did not stop a spirited conversation.
The more we learnt about Katherine and her training, the more we admired what she was doing, and in fact many of us volunteered that she was more than equal to many midwives we know back home. We were especially fascinated to learn that having children was a pre requisite to being allowed to be a TBA….
All deliveries are done at her home, although she goes through a very careful pre-natal check up sequence. Any signs of the unusual, and she would refer the mother-to-be to the District Hospital. She described how she diagnosed a ruptured uterus, twins, high blood pressure, anaemia and more. Many of the “tips” came from her mother, although all seemed to have been validated by formal medical training. Her diagnoses of high blood pressure (by checking for swelling of the mother’s calves) and malnutrition (by looking at the state of the mother’s hair) were particularly telling. Whilst she was not allowed to formally conduct HIV tests, she also described how she used her experience to make the determination (with two major signs and one minor – she would not tell us the details, as she rightly felt that was inappropriate). The District Hospital replenished the critical tools she needed, including clean razor blades, but the mothers were expected to bring their own clean towels.
She demonstrated her very methodical record keeping, and weighing routines. Not surprisingly every mother who has had 5 children or more was also referred to the Hospital. Katherine considers her responsibility to include advice on diet and hygiene, and, as an active member of her village VAC, believed it was her responsibility to give advice on safe sex.
The birth process was pretty similar to back home – except that the mother or mother in law is usually present, and the husband is shooed away! Katherine applied good hygiene, wearing gloves and carefully cutting the cord etc. Breast feeding is always encouraged. She always carefully checked the placenta to be sure it was intact, therefore checking that the mother’s health was not in danger. She also showed us the concrete covered “placenta pit” which was tailor built by the local Government.
If one of her clients is from a nearby village, they would go home fairly soon. If from a more distant community, they would stay the night at Katherine’s. Of course, she would always check the baby before leaving, and give final advice to the mother. There is no formal charge for her services, although Katherine noted that mothers usually offered her 100 Kwacha “gratuity” – about US$1.40.
It was a happy visit, and we were reluctant to leave.
CHAPS program
Next stop was Michesi Village, where Save the Children was working with the local health authorities on the CHAPS program. This was a matriarchal village (Malawi is split between patriarchal and matriarchal communities, with no apparent “edge” for either). We were met by the village leadership, including “Group Village Head Michesi”. She was responsible for 14 villages, and clearly she had her act together. The estimated population was 4001 people, with about 165 orphans – a ratio that seems to ring true almost everywhere. Guesses suggested that the orphan number was 5 times that of 3 or 4 years ago. Still, the atmosphere was pleasant and businesslike – and even had its share of humorous moments.
The health workers led the discussion, although several village activists were the ones really in charge. They used posters and leaflets, covering a wide range of health issues. In the ensuing discussion, the entire group had an excellent understanding of HIV/Aids issues, and what needed to be done. They estimated, without passing judgement, that about 75% of village deaths were related one way or another to Aids. The Chief was very firm that home based care was needed, without stigma, and that counselling on safe sex could help everyone. Everyone in the community was encouraged to help, whether with their time or with food. All the children go to primary school, although the cost of secondary school meant that not all could attend. Some of the orphans were assisted by the Malawi Children’s Village, just up the road, but again, not all.
Unlike some Communities, when asked what we could do to help, the reply was not “give us money”, but “help publicize the health problems, and help eradicate corruption”. This latter was especially a concern, as it appears that not all the food from Aid / NGO programs actually gets through, being re-routed or even re-sold by some corrupt officials.
There was singing and dancing, photo ops and one on one discussion. Again, a happy visit. But we needed to go back to Mangochi to meet the others.
We had lunch at the open air “Icecream Den & Restaurant”. It may be a “trivia” point, but we all took a liking to the local fish from Lake Malawi – a flaky and flavoursome fish called Chambo. This is the most popular fish in the area. It is a member of the “Cichlids”, and can reach 30 cm long. So far, it is not too heavily over fished. Chambo & chips. Mmmm….
Mangochi Hospital
After lunch we visited the Mangochi District Hospital. Of all the things we did, this, to me, was the most telling of all.
First, a few facts. As mentioned before, Mangochi probably has the worst HIV incidence rate in Malawi, with new estimates suggesting up to a 25% prevalence rate. And right now there is also a Cholera outbreak. The Hospital itself was opened in 1981, and was run by very dedicated professionals in a clean, well organized operation. Still, whilst it was designed for 240 beds, right now it has 400 + patients, many sleeping on the floor. There is one fully qualified Doctor, who is also the Hospital Administrator. The 28 nurses manage 24 hour care, but only by having one nurse per ward at any time. As we walked the wards, there was little in the way of supplies, and we heard the patients must bring their own blankets. Maybe I missed it, but I saw no incubators in the maternity ward. And the cholera isolation ward was outside, made up of rough walls with plastic bag roofing.
I used to visit hospitals professionally, and on almost every continent. I have unfortunately seen much disease, and much suffering. But I never have seen a hospital so apparently lacking in resources. The staff were as dedicated as I have seen anywhere, and the Government is doing its best. But the situation they were coping with was something I had never experienced. Save the Children (and USAID) had helped build a training and admin centre, but there seemed to be no Corporations sponsoring aid as I would often have seen in Asia, and precious little other NGO activity.
No one knew for sure, as HIV testing was not mandatory, but the staff estimated that 50% of all patients currently in the hospital were HIV positive. Often people do not want to know, and then if they do, and are asked to go home, they politely refuse – what hope do they have at home? The main causes of death at the hospital were PCP & TB, and whilst the hospital could give painkillers, they could not give morphine for end-stage patients. In the kid’s wards, we saw many cases of children with acute diarrhoea, always nursed by their mother or grandmother. In the adult wards, most terminal adult AIDS cases had Carposis Sarcoma, with the patients usually alone.
I will repeat again. The staff were as good as you can get. It is just the problems they face that are so enormous.
On a personal note, this visit raised some significant issues. It was our role to understand and to see, to report and to publicize. To write and to photograph. But where do we stop? We must all provide space and privacy for patients. They are not just numbers on bedposts, or items of observation.
Without overstating things (easy to do – but I am writing this two weeks later, with the comfort of home around me), the emotion in all of us flowed freely that day, and none of us will be the same. I am glad we made the visit, and I will do it again.
I am equally glad that it reminded me, once more, of the need for respect for others in every situation. It also made clear everyone’s right to be treated with dignity.