Mother and child
Clinical day
The sun is warm even early in the morning as I am driven to work in the college car by Samuel, one of the more talkative drivers and the one who stops so I can buy a paper in the morning. I had to be picked up very early today because I must meet the students at the hostel at 7:15 AM. When we arrive the students are all outside gathered in small groups with their green coats or aprons and white uniforms. They are chattering away in Chichewa except for the three Dutch students. Some sixty students and I board the bus and the chattering and laughter are unbearably loud. We drive a short way through city streets and then turn into a very rutted dirt road that goes past small houses and shops. As always early in the morning, the streets are full of school children and adults on their way to work, the market, the garden, or school. We make several turns onto increasingly rutted roads and pull up in front of the Kawale Health Center. Thirty students alight laughing and chatting. Some have stethoscopes, others bags with water, and perhaps a thermometer. All have the small Pediatric handbook for Malawi and a larger spiral bound book that contains the protocols for treatment developed by USAID. The bus is quieter as we drive a short way on a dirt road to pick up the main tarmac heading towards City Center and eventually Area 25 which I am told is “way out”.* [A word of explanation- city center is not the center of the city it is the area around the new government buildings that contains mostly banks, embassies and consulates, and a few businesses. This area is about 3 miles from the true city center. All the neighborhoods in Lilongwe are named by Area. Unfortunately there is no rhyme nor reason to the names. Area 3 is next to Area 29 and Area 47 is close by. Everyone asks where do you stay and expects you to name an area – the locals all know where each area is, we mzungu don’t. I go to church in Area 3, Regina goes to church in Area 29 and the churches are a mile apart. We live outside of town so we don’t live in an area we just tell everyone we live near Bunda turnoff]
We drive out in the direction of the airport (to the north of town) on a road that parallels the airport road. We go about 6-7 miles and arrive at the Area 25 health center. The area around the health center is mostly open fields planted with corn and other crops. There are many women with children tied on their backs holding the hands of small children walking toward the clinic. The clinic is a collection of one story flat roofed brick buildings. Off to one side is a roofed over area with a concrete floor but open sides. Inside are a large number of women and children sitting on concrete benches. Other women and children have formed long lines at the doorways of the other buildings. I follow the students to the open building where following a prayer; one of the students gives a short presentation on Family Planning in Chichewa. The student is very engaging and the women participate by smiling and answering questions. Following the presentation the women and the students sing several lively songs that are about family planning. Everyone knows the words and the singing is enthusiastic and melodious. About half way through the singing I notice that the faculty member responsible for these students has arrived. She stays with the students in the open area as this is the well-baby and immunization clinic. I go off with the other half of the students to the under 5 sick children’s clinic. We enter a large space with the ubiquitous concrete benches in about 15 rows. The building is very dark as the only light comes through a series of openings in the bricks on the far side. The benches are full of women and small children. The students spread out one taking each row and begin to see the children. Using their protocols they ask a series of questions and use the algorhythm in the USAID book to decide what to prescribe. The two students I am working with are careful to do a thorough assessment and are thoughtful about what they decide to do. I am aware however that some other students are less careful skipping assessments and jumping to conclusions. The first child we see is 6 months old and even I can see that the child is very small for age. Each mother and child has a health passport in which immunizations, health visits, and for children ht/wt graphs are kept. Sure enough this child is below the acceptable range for her age. The mother is complaining that the child is not eating but I observe her taking the breast quite vigorously. I wonder if mom – who is very young probably about 15 – has adequate milk and whether the child is getting any additional food – the women here usually feed maize gruel from about 3 months despite the recommendations of health professionals to wait. I suspect that the mother does not get adequate food herself and likely neither does the child. The student focuses on the child’s eating and encourages the mom to give the child maize porridge in addition to the breast milk. The next child is about 9 months old, has a fever, and gunky sounding lungs. According to the protocol she should be treated with co-trimezole for pneumonia and be given panadol for fever, but the health center has no panadol and the parent likely has no funds to buy it. The next child clearly has a cold, as does every other child in the family – he has a fever and could use some panadol but there is none. One problem with the protocol is that if there is fever malaria is to be suspected and a finger stick test to confirm done – however this health center has no test kits today so I think many children who do not have malaria are being treated. The treatment LA ( Lumefantrine Artemether ) is not benign and in my short time here I am aware that a great many people receive treatment for malaria who clearly do not have malaria – unfortunately this drug can be bought OTC so many people self treat. [A nursing faculty member wanted to treat herself for malaria when she felt achy and tired but had no other symptoms]. The next child also had a cold and was sent home with advice and no treatment. Suddenly the room which had been so noisy I could hardly hear the student speaking in my ear was much quieter as the children were seen. The students had no faculty in the clinic with them except me and only the students near me asked for my help. There was a “clinical officer” available whose training is close to but less than a PA. She spent her time sitting at a desk reading the newspaper and answering questions for students but I never saw her ask them questions. I know a lot of kids got antibiotics that day who did not need them and I worry that this country cannot afford the drug resistant bacteria they are breeding.
When the sick kids clinic slowed down I went outside to the immunization clinic and watched what was happening there. Since it was outdoors the light was far better as was the noise level. All children got a quick head to toe, height and weight graphing, and moms got questions about family planning. The immunization schedule is similar to the US and all immunizations are free. Everyone gets BCG (against Tb) at birth along with Hep B. Most of the mothers were very young and the older ones had 3-6 children. Girls “marry” here very young – as young as 13 especially in the villages. Malawi has the highest number of teen pregnancies and the lowest marriage age on the continent and that is saying a lot. I learned about some interesting practices related to fontanels in this clinic. Apparently there is a belief that the soft spot makes the child vulnerable to spiritual assault so the area is covered with a gluey black material to protect the child. I wondered what people used for diapers and I certainly found out in the immunization clinic – EVERYTHING! Towels, pieces of worn chitenges (the wrap skirts worn all over Africa), torn t-shirts, an occasional cloth diaper but much to my delight not a single “disposal diaper” because no one can afford them. Although everyone assured me that students never recapped needles – I saw a lot of recapping in this clinic.
Neither of these clinics had any facilities for handwashing except in the staff bathroom which was far from the clinic buildings, there was no waterless handwash, so they went from child to child without washing. I talked to both Regina and the Principal about this situation and suggested at the least they could provide basins with bleach and some towels.
At the end of the day, the faculty member took me on a tour of the rest of the buildings – a very small overcrowded family planning and antenatal clinic and the labor and delivery and post partum ward. In the Labor and delivery room I found four post registration students (RNs) who are enrolled in the nurse midwifery certificate program. One of them had just delivered her first baby all alone except for the other students and a health care worker – not a midwife. Regina who is a midwife was livid when she heard about this saying “this should not happen”. Nevertheless the mother and baby were healthy and the student was glowing with delight in her accomplishment.
About 1130 the bus arrived and we all piled in for the trip back but we were held up when we got to the airport road because the President’s convoy was due in from the airport and sure enough a large number of big saloon cars, 4WD vehicles and screaming police trucks soon went roaring by. [Some day I will write about the “official vehicles” here and a bit about the politics which are interesting and complicated]
I will be going to the outreach clinic in a village next week as well to the clinics at Kawale so I should have more stories.
Meanwhile just a bit of information to put poverty in perspective. The minimum wage for an urban worker (not a farm worker or a person employed as a servant, maid, houseboy, or gardener) is 129 Kw per day that’s 0.86 cents. Monthly income is $15.00 and yearly income is $289.00. Maids, houseboys, gardeners etc may make $5-10.00 a month but they are often housed at their employer’s expense. People who farm their own small plots in the country may make $300/yr if their tobacco crop sells high, otherwise they just keep from starving by growing their own food and selling a little excess for money for salt and oil. Causal laborers may get $3.00 for 5 days work. Even the smallest hovel costs $10.00/mo and even if all you eat is nsima (maize porridge) you still need at least 10 kw a day per person for one meal. Government employees in professional capacities may make $500 a month. Now consider this – I had my hair cut today and it cost $17.00. The President’s new wife was appointed National Coordinator of Safe Motherhood and Early Childhood Development by her husband the President. Her salary is $7586.00/mo plus two cars and her presidential housing. This job was previously held without salary by the Vice President. The gap between rich and poor here is enormous.
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