Thursday January 29, 2009

Friday January 30, 2009

Thursday February 5, 2009

"I spent today with mobile clinic A. We headed out a dirt road about 30 minutes to a clearing with a building that the community built for home based care classes. This is used as a site for the clinics. It has a large room where the patients wait and are seen by the Clinical Officer (C.O., like a physician's assistant in the US). The under-fives are seen in their mothers' laps and if the C.O. needs privacy with a patient, he moves to the corner behind the screen.

"The mobile clinic nurse sees patients in a separate small room attached to the building where she performs ante-natal checks and does HIV testing. A 55 year old woman came for testing. She has been having chest pains that were not responding to antibiotics and feared she may be HIV positive. She permitted me to watch the test and said I could photograph it being done. I was impressed by the nurse's manner with the patient. She had a very gentle and quiet way and listened closely to all that the patient said. You could see how this built the patient's trust. This time the news was good. The patient tested negative. Her joy at the news was palpable, and I felt touched to witness this good news with a woman so close to my own age. She will continue on the antibiotics for another week and return if her chest pain is not resolved.

"Outside the building was the medication box and a small table for dispensing medications and teaching patients about their treatment. I have described this process in detail in my notes on the clinic we saw the next day. The same process is used by both clinics. The nurse aide assists the nurse with dispensing medications and helps with other general go-fer type duties. They see over 100 patients every day, and some days as many as 150. They can process so many because some women coming with children only need a weight check to assure the child is growing.

"Even the driver gets involved, helping to triage patients so the sickest are seen first.

"The vehicles themselves are used to transport the crew and equipment to the sites and then for transport of severely ill patients to the health center for emergency care. Several times they have had to transport children who are having seizures secondary to cerebral malaria.

"Each of the clinics has five different implementation sites in the catchment areas. The areas were chosen after Alice spent 2 days touring the district with the District Health Officer who pointed out and chose areas with the poorest coverage by the Ministry of Health facilities. For example, the implementation site I visited today is 10.7 km from the nearest health center, 2-3 hour walk. The clinics rotate through the sites, Monday through Friday, so the villagers know that the clinic will be at a particular site, for example, every Monday. Churches and community buildings serve as sites.

"The biggest challenge is responding to the overwhelming number of patients. Originally they thought they would be treating 50 to 60 patients a day, but they often treat three times that number.

"We also visited the Mobile Clinic A office located in a centrally located small town, The district health officer required that each vehicle have an office for security of medication storage. It is a pleasant building with two large rooms and secure storage for medications and supplies. They showed me the drug inventory procedure. They place their order for medications with the GAIA the project officer; the medications are logged in as received at the office and then noted as dispensed to the clinic when they go out each week. The balance remaining is noted on an inventory sheet each month. Some supplies and medications, for example TB sputum cups, are provided by the DHO.

"The office has a computer for data entry, although there is no internet connection. Staff members are learning to use the computer and doing quite well. The project officer collects the reports on her bi-weekly supervision visits using a memory stick. The vehicle itself is parked on the grounds of the nearby Mulanje district hospital at night and on weekends to assure its security.

"In the afternoon, we visited 2 Home-Based Care patients in the GAIA villages. The first patient we visited was 35, painfully thin, and lying on blanket on the little mud porch of his hut. His mother was with him. The patient had been a casual laborer, working in Blantyre, when he collapsed on the job. Earlier, he had been diagnosed with TB and was on treatment at the time of his collapse. He was diagnosed with Cryptococcal meningitis; his neck was frozen and his legs were paralyzed. He was found HIV-positive. His wife left him and kept his two children. He returned to the village where his mother is his main guardian. A friend helps him get to the hospital when he needs treatment. He is also on antiretovirals, and his health is slowly improving. He can now walk but is extremely thin. He said he appreciates the daily visits by the caregivers and the help with household chores, especially getting water.

"Then we visited a young woman aged 25, and her husband, who is 31. The woman had developed swelling in her legs during her second pregnancy which she thought was due to the pregnancy. It didn't go away after she gave birth and she was diagnosed with Kaposi's Sarcoma and found HIV positive. It is likely that her husband is HIV positive as well. Her legs show large black patches and one bulging 4cm tumor. She is on Vincristine for the KS, although Alice said that in her experience it doesn't work very well. She is also on antiretovirals. She has 2 children, ages 5 and 3. She talked about how much she appreciates the faithful daily visits of the caregivers, the likuni phala and the soap.

"A tiny, lively woman is the GAIA caregiver for both of these patients. I asked her how she liked her work as a caregiver. She replied that she enjoys it and is proud of her bank account and is planning to build a house with the stipend she is saving.

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"After reaching Mulanje, we headed on a road to the East and South and climbed 40 minutes up a very rough dirt road, high into the hills opposite Mulanje Mountain. We stopped at a church at the edge of the road, and, stepping over the ditch that edged the road, climbed up to the entrance.

"Inside the Mobile clinic B was set up and over 100 people were waiting on benches inside the church. The clinical officer was at the front of the church on a chair, with another chair opposite him for clients to sit in. He was seeing the under-five patients and was examining a baby as his mother held him. Next to him was a portable table that serves as the prescribing station. All of the bulk bottles of medications were set out on it. A large water container with cups stood nearby, so that patients dosed with medications to be taken right away could take them there. After the C.O. has seen the patient and written in the record, the patient is sent with their health book to the prescription table. Here teaching concerning taking the medication properly is done. The pills were dispensed in small packets marked with the medication and the dose using little icons showing the sun rising, the sun at noon, the setting sun, and a night sky (designed for people who have poor literacy and little access to clocks).

"The nurse aid was manning this table. Under the nurse's direction she counted out tablets and placed them in packets as the nurse gave patients prescriptions. As throughout Malawi, patients keep their own medical records in a small health book, which they are to bring each time they visit a clinic or health center, and the diagnosis and treatment are recorded inside it. This information is also recorded in the Clinic Patient Register from which data is taken and submitted to the DHO. The indicators and data monitored at the GAIA mobile clinics is the same as at all Ministry of Health facilities, so it means the collected data can be merged with that from other health facilities in the district.

"A screen was set up at the front of the church. Behind this was where ante-natal care, family planning, and HIV testing are done. Shortly after I arrived the nurse, left her station at the prescribing table to begin the family planning session. She would come back later in the morning to fill the prescriptions for the patients that the C.O. was seeing.

"Three women were seen for family planning. All are using Depo-Provera injection as the method of family planning. They come every three months to get the injection. Condoms are also distributed by the clinic for family planning, but there is less demand for these, likely because the women cannot control the method, and so it is not reliable for family planning, though, of course, used regularly, they would be of help in reducing transmission of sexually transmitted diseases.

"After finishing with family planning, the nurse began seeing women for antenatal screening. A lovely, bright faced 25 year old came in, looking healthy and pleased. The nurse asked her if the GAIA project officer and I could observe the visit. She agreed. The nurse weighed her, took her blood pressure, which was normal, and then had her lie down on a mattress to examine her belly. The baby was head down, not breach. She listened to the fetal heart. While doing this she chatted with woman, who said this was her third child and she wanted to have four altogether. She is married to a business man. She is the second wife. His first wife lives in the neighboring district. The woman had consented to be tested for HIV, which is now done for all pregnant mothers on an opt-out basis when they come to the clinics. She was also tested for syphilis. The nurse drew the blood by finger stick and ran both tests.

"While they were waiting for the result, the nurse asked her how she would react if the results were positive or if they were negative. I was impressed with the nurse's manner which was kind, and forthright. The woman said that she wanted to be tested and would follow whatever the nurse told her regardless of the results.

"It was time to read the results, whereupon the project officer stopped translating what was being said. The nurse spoke at length with the woman, and then the project officer did too. I suspected that one, or likely, both tests had turned up positive and that the project officer did not want to reveal this to me in front of the patient. In an instant, this lovely young woman's future had changed completely.

"Later the project officer explained to me what happened in the session. Both the syphilis and HIV tests were positive. The woman wanted to be put on antiretovirals right away, but the nurse explained that at the moment she was very healthy, and that after delivery she would be evaluated on a regular basis. She would be put on antiretovirals when the clinical signs warranted it. The woman said she would not reveal to her husband that she was HIV positive as she feared he would abandon her, leaving her without support. She was also afraid of stigma from the community, worried that she would be the talk of the village. The GAIA project officer encouraged her to reveal her status to a trusted family member. Her mother and other relatives live near by. The project officer told me that in general, it is harder for women to reveal their positive status to husbands that vice versa.

"The nurse said that she should tell her husband about the positive syphilis test because he should be tested and treated as well, and the first wife also. The patient was understandably upset by news of the tests and told the nurse and the project officer she needed their support. She was asked to return to the clinic each week for follow-up counseling and monitoring. She was told that in her eighth month she would be given oral Nevirapine to take at the onset of labor to prevent mother-to-child HIV transmission. She was also told that she should deliver in the local health center so the birth will be attended by a skilled person and so that the baby can receive Nevirapine within 72 hours of delivery. Should she end up delivering in the village with a traditional birth attendant (TBA), she should bring the baby to the local health center for a Nevirapine dose within 72 hours. Alice says they are working with the Traditional Birth Attendants to be sure this is done.

"The woman was given a penicillin injection, oral follow up antibiotics, iron tablets, and SP prophylaxis for Malaria. She folded the medications into her chitenje (the wrap-around garment the women wear) and expressed anxiety that the pills would disclose her HIV status. The project officer explained no, these were not antiretovirals but the same medications people take for other kinds of conditions.

"The second woman I saw the nurse examine also tested positive. By then Alice had gone to help at the prescribing table, so I didn't have translation and did not have a chance to chat with the woman before the test. When the nurse told this woman the results of the test, tears came into her eyes. I felt I was intruding on an intensely private moment, so I quietly got up and left the nurse to continue her post-test counseling. Once again, I was impressed by the nurse's caring and kind manner.

"While we were at the clinic the nurse saw six antenatal patients. One was on her second antenatal visit and had already been tested, but the other five were tested for HIV. Four of the five tested positive. The nurse said she usually sees between 12 and 15 antenatal patients on each clinic day, not all of those would be tested, because some would be seen for a repeat visit.

"Then I sat with the C.O. for a while as he examined one person after another, mostly sick children. Many had symptoms of malaria or GI disease. One child had a severe case of otitis media that had perforated the ear drum. The ear was draining with swollen lymph nodes evident around the ear. Other kids had bellies distended with gas, and a history of several days of diarrhea. One of these also had an earache. The C.O. was going to put this child on antibiotics for the otitis, and oral rehydration therapy for the diarrhea, and said the antibiotic also sometimes helps with the diarrhea. The kids were listless, but stared at me. Azungus (white people) are rarely seen in these villages so I think I interested them. With the great number of patients, the C.O. has only a few minutes with each, but his presumptive diagnoses made sense to me. In general, people are treated and told to return the following week if there is no improvement in symptoms.

"It is difficult to convey the power of today's experience. What I witnessed was intense need and people who are very grateful for the help that has come to them. To be with people when they learn they are HIV positive is disturbing. It is, of course devastating for anyone to learn they are HIV positive, but I know how very different this experience is for people who learn they are HIV positive in the developed world. Finely tuned care and many more resources are available to them. I marvel at how much things have changed in the US since I took care of my first HIV patient in 1982.

"What we have to offer in Malawi pales in comparison. It is humbling to witness the courage of those who get tested and to stand with them as they try to take in the news and move forward with the resources we have offered them.

"After we left the mobile clinic, we visited the office for this clinic in an attractive small adobe building in Mulozo. The nurse aide lives at the back of the building in three or four small rooms fitted out as an apartment. Some family members appear to be living with her. This arrangement helps with security and means she is there during weekends when the security guard is not guarding the vehicle.

"Then we visited the District Health Officer (DHO). The GAIA project officer said he has been very helpful with setting up the mobile clinic project, setting up protocols and coordinating all work through the district health office. He is by all accounts hard working and extremely dedicated. He said, "I'll just be straight with you. We could use two more ambulance vehicles to transport people from the health centers to the district hospital." He has only 6 ambulances to serve 600,000 people and it is not enough, especially in the area we are working in where he has 5 health centers that basically have no transport to the district hospital, except for two motorcycle ambulances.

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"We visited the microloan project in Luchenza. I met with all of the staff in the Luchenza office: the project officer, the credit clerks, the bookkeeper, and the office assistant.

"The Project Officer has created an extensive manual for the project detailing all the procedures which has been translated into Chichewa and has been very useful. Another 750 women in about 30 clubs have been added to the project bringing the total number of women served to over 900. Each loan club must come up with 10% of the loan total for the club as a group to be put into savings before they can receive the loan. The savings account can then be used to pay on schedule should a member default.

"Most of the women still are doing trading businesses, chiefly bananas. They buy the bananas in Mulanje, hire a truck together, take the bananas to Lilongwe or sometimes Blantyre and sell them over a period of about 2 weeks. They sleep in the open in the market place while they sell the bananas.

"After meeting with the staff, we headed out a dirt road, riding for about 20 minutes before coming to a school yard where we met with one of the loan groups. About 20 women were gathered. The chairwoman was a very energetic and competent woman and the group appeared to have good cohesion. The women have 20,000MK ($142) in their group saving account and all have been paying on time. A few of the women told me about their businesses. One woman sold bananas; her loan had been for 10,000 Mk ($71) and she had made 5000MK profit after paying her loan (over the 6 month loan period).

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