We; Vanessa Viljoen, Lisa van der Merwe and Rachel Wood, are three 4th year medical students from Stellenbosch University, South Africa. We had the privilege of spending 4 weeks at Nkhoma Hospital, Malawi, for our medical elective from mid October to mid November 2014.
Nkhoma Hospital is a missionary hospital situated 50 km (approximately 1 hour's drive) south east of the capital, Lilongwe. The hospital currently has 220 beds and provides care for a large rural community with a catchment population of 64 000 people. It is well renowned for its excellent provision of health care (despite limited resources), throughout Malawi, and even in its neighbouring countries.
The hospital is divided into paediatric, surgical, general medical, tuberculosis, maternity and private wards, a labour room, 2 general theatres, an outpatient department, family and ARV health clinics and supportive departments including physiotherapy, a pharmacy and administration. There is also an associated ophthalmic hospital on site.
Why Nkhoma Hospital?
As medical students in South Africa, all 3 of us have developed a huge passion for rural medicine and Africa as a whole. Our heart as future health practitioners is to be able to provide care to those in greatest need. One of our lecturing professors worked at Nkhoma Hospital for many years, some time ago, and spoke very highly of it. His stories about rural medicine in Malawi inspired us and further fuelled our desire to get involved. Through this connection, we got into contact with Nkhoma Hospital. Many months (and a lot of planning) down the line, we found ourselves in Malawi.
What did we do?
Through communication with Dr. Ter Haar, medical director of Nkhoma Hospital, we established their need for assistance with some research on non-communicable diseases (NCDs). We decided to accept the challenge by becoming part of the research. With the help of our supervisor at our university, Professor Bob Mash, we spent several months working on our proposal and applied for ethical clearance through Stellenbosch University. However, as is often the case with rural medicine in Africa, things don't always go as planned. On arrival, we realized the necessity for our research plans to be altered, to better suit the needs of the community. A quote by Albert Einstein perfectly described our situation: “If we knew what we were doing, it would not be called research, would it?”
Hospital work
To gain a better understanding of the health system of Malawi, and the specific functioning within Nkhoma Hospital, we worked in the wards for our first week there.
Two of us (Lisa and Rachel) worked in the paediatric ward, while Vanessa worked in the general medical wards.
During the time in the wards, we attended ward rounds, were included in discussions around patient care, examined patients and assisted with procedures.
With regards to paediatrics, in stark contrast to the South African setting, tropical diseases carried a more significant burden. Specifically, our knowledge about malaria exponentially grew during the week. Meningitis, neonatal sepsis, pneumonia and malnutrition also demanded attention.
We had the privilege of going on one of the “under 5” outreach clinics to a remote community in the surrounding area. Mothers queued in their numbers, babies on their backs, waiting to be seen. Very basic care was provided, generally by giving empiric medications.
In the medical department, we depended on clinical examination and reasoning skills, limited by basic investigative procedures to aid us. Language barriers were by and large overcome by a well put in place system of translation, a nurse accompanying expat doctors and elective students on ward rounds.
Throughout the period of our elective, we attended the morning reports held at Nkhoma Hospital, which occurred every Monday, Thursday and Friday. All medical staff are expected to be present. Difficult cases and hospital issues were discussed, and academic presentations were given at times.
Research
Our research comprised of a baseline audit of the quality of primary health care for non-communicable diseases in the Dedza District. We specifically looked at care for hypertension, diabetes mellitus, asthma and epilepsy at the 5 health centres in this district. Nkhoma Hospital acts as their referral hospital, and currently carries an extra load of patients due inadequate care in the periphery.
We performed surveys, interviewed health staff and attained data from the health centre registers to assess current care. Data was then assimilated to establish the baseline quality of care.
During our last week at the hospital we presented our findings to the hospital staff at one of the morning reports. Our aim was to highlight the importance of good quality of care for patients with NCDs. This would hope to prevent potentially associated morbidity and mortality, including financial implications, on patients, the health centres and Nkhoma Hospital. A formal research report is currently in progress and we will be happy to make it available on completion.
What did we learn?
We were humbled by the fact that despite the under-resourced circumstances in which Nkhoma Hospital has to operate, they provide exceptional care. Their major strengths include collaboration within and between departments, consistent empowering of staff and the goal to continuously expand one's knowledge base.
In contrast to South Africa, Malawi's health system includes mid-level clinicians who make up a great percentage of their work force. This includes medical assistants (2 years training) and clinical officers (3 years training). If this system is well organized, as in Malawi, it can be of immense benefit to the care of the patients, having a substantially larger number of clinicians.
In rural situations, as may be assumed, innovation is key. At Nkhoma Hospital, this is seen in many fields of its work. For example, a solution was found for the management of the considerable number of malnourished children. Pre-packaged nutritionally enhanced peanut butter sachets were developed. This would limit the need for long-stay inpatient care and eliminate the contamination risk of to-take-home treatment. An organization called Peanut-butter & Jesus (PB+J) was established for its production.
Despite the admirable work done by the hospital, challenges are a part of the package of rural medicine. There were wide-spread cultural barriers to good medical care. One such barrier we encountered in the paediatrics ward. Sadly, we lost a little girl to a case of severe malaria, complicated by severe renal failure – presumed to be due to the consumption of traditional herbs, given to her by a traditional healer, whom her family had first consulted. Another challenge was illustrated by a complicated paediatric case where the diagnosis was a mystery, due to the lack of sophisticated special investigations to aid the clinicians.
Something that really touched our hearts was that at Nkhoma Hospital, and apparently at most other Malawian hospitals, family members act as “guardians” to hospitalized patients. Because the hospitals do not have the funds to provide food to in-patients, each patient needs a guardian to do so. A patient's hospital admission therefore places a considerable burden on their family. The provision of food was definitely something we had previously taken for granted, even in the South African setting.
Through the conduction of our research, we developed many different skills. We learnt the value of patience, how to be flexible, and how to improvise (all when dealing with “Africa” and research as an entity). Communication skills were constantly tested and expanded, especially given the language barriers created by our inability to speak the local language, Chichewa. Statistical and analytical skills had to be developed as we navigated the academic world of research. Of great value was the fact that our research project enabled us to develop a broader understanding of medicine as a whole. We discovered how care is influenced by numerous different factors, and we believe this knowledge will ultimately assist us in providing the best care for our future patients.
On a personal level, we cannot ignore the hand of our Father God during this time. We could see Him in the people around us; be it the man who helped us to find a minibus, the reverend that invited us for tea to pray blessings over us, or the lady that translated for us on the bus. We saw Him at work in the hospital; through the staff, the patients and the selfless guardians. He invited us to see His joy through the lively services at the hospital chapel, and experience His generosity through a traditional meal prepared for us by a kind Malawian.
He made our path straight, and we never felt unsafe. Through our experience in Malawi, from nature to people to hardship, OUR lives have been changed.
Summary
In summary, Nkhoma Hospital and Malawi provided us with an unforgettable 4 weeks. We grew both as individuals and future doctors through the experience this time provided.
We were inspired and motivated by many of the staff (local and foreign) at Nkhoma Hospital and how they had joy in service amidst great hardships. These people, the challenges that they face and those that we faced, molded our characters and opened our eyes.
The community we found ourselves warmly welcomed into at Nkhoma, was a tremendous blessing. The hospitality and friendliness of its people is something extraordinary, even by Malawian standards. The hospital staff, other elective students and volunteers, as well as the community as a whole formed a special support network for us. Nkhoma quickly became a place we were happy to call “home”, as we experienced first-hand “the warm heart of Africa”.
We are extremely grateful to have had the opportunity to spend our elective at Nkhoma Hospital, Malawi. To everyone who helped to make this superb experience possible, we cannot thank you enough. Thank you for your generous assistance. We will forever be influenced by this blessed time.
Zikomo, zikomo.
Thank you, thank you.
