Today was my last day of work at St. Joseph Mission Hospital in Nguludi. So much to do and so little time. In the other hand a single person can have a significant impact over a short stay. My main task before coming was to implement an electronic inventory system for their pharmacy. This was what the hospital had identified as a need. After my briefing session on arrival, I discovered that the initial thought of inviting a pharmacist had germinated from a need with their palliative care unit and their difficulty in securing morphine supplies. I was not sure how I would go about that since morphine is provided at a deep discount to hospitals (12.5 % of the cost) by the government and supplied from the national provider are limited. The physician of the hospital, the clinicians at the palliative care unit, the staff at the pharmacy department all identified the need for acquiring more morphine but had limited expectations as far as potential success in acquiring supplies. In Malawi the strong analgesic of choice is morphine with the liquid form being the most readily available. Here at St.Joseph Mission Hospital it is the only form available. When asking one of the clinicians at the palliative care unit how they managed patients over night, I was told that “We double the dose before going to bed.” Not very effective to last the night, I would suspect. “And if we run out of morphine, we use acetaminophen or ibuprofen, sometimes we have acetaminophen with codeine but not always”. So everywhere I went, the Phamaceutical Supplier in Limbe (which happened to be just across my hotel), the Malanje Mission Hospital, the Malanje District Hospital, I asked about how to get morphine. In Limbe, I have learned that you can get morphine but only one supplier in the country has stocks. Since the government supplies morphine at a deep discount their is no incentive or market for the private suppliers. But their was one potential source that could import morphine from outside the country albeit at a much higher price, but there was some hope. With sufficient finances i could get morphine, even long-acting morphine. At Mulanje Mission Hospital, a sister hospital of St. Joseph’s, they have a significant donor and they had a whole 4 liters of liquid morphine just sitting on the shelf. So the possibility was there but the chance of being successful was slim in the long-term due to financial constraints. I was a bit discouraged and started to feel the same desperation as the people at St. Joseph’s. This was until 2 days ago. At lunchtime, a met a pharmacist from France who was working with the organization Medecins Sans Frontieres. Start to talk to him, what he was doing. He told me about his work and most what he did revolved around the provision of antiretroviral agents and that they were moving away from lopinavir/ritonavir based regimens to atazanavir/ritonavir and that they were doing some training about that next month. In passing I inquire about possible source of supply for morphine. To my surprise, they also provide free morphine as HIV is not their only target area but also cancer and palliative care. Not only they can provide liquid morphine but also long-acting morphine, and tramadol which is one of the only other strong analgesic available. The only request that he had was for the hospital to supply him with estimated quantities that they would need and they would supply them for free, and over the long term. In addition, he said that they usually had good quantities in stock. A goal that sounded improbable to reached was accomplished. A basic need to provide palliative care patients access to medications to relief their suffering.
According to the local newspapers there is a drug crisis in Malawi. There is a 95% shortage of medications which they define as hospitals and pharmacies having only 5% of their needed inventory. Not only funds to buy medications is an issue but also the suppliers do not have sufficient stocks to distribute even if one has the funds to purchase them. The picture on the left and in the middle, at the top, depicts the extend of the variety of medications that is available at the outpatient pharmacy of the hospital in Nguludi. Malaria, TB, HIV are the most common medical conditions seen at the hospital. There are only a few people presenting with CVD but remember the the life expectancy is only about 46 y.o. The only oral medication available for diabetes is metformin and insulin. Insulin is a challenge with the problems with refrigeration and frequent power outages. For pain, there is basically only acetaminophen, ibuprofen, and oral short-acting morphine. There was tramadol at some point but there has been no supplies available for a while. Morphine is available from the government at a very subsidized cost (the hospital pays 12.5% of the actual cost) but availability from the central supplier is patchy.
The actual process of dispensing medications is very different from what we are use to. At Nguludi there is no pharmacist but they have a pharmacy technician which is more than most hospitals can say. A clerck dispenses the medication in the outpatient pharmacy, she is all by herself and may be seeing 40 -60 patients a day. There is no checking process in place. The medication are provided in small plastic bags (see picture top right) which has pictogram for morning lunch supper and bedtime under which she indicates the number of tablets to be taken and for how many days someone needs to take their medication. In the city you can get most medications without a prescription with possibly the exception of antibiotics and morphine. Physicians are very rare to actually prescribe medications and only very basic ones are available. When locals get a fever they assume that it is malaria and treat themselves for it. If it does not get better than it most be another infection of some sort and then seek medical attention. Very few diagnostic procedures are available so that when people have cancer it is detected very late.
I have heard today that sometimes people bring medication as donations but it sometimes remains untouched due to unfamiliarity with them. A lesson to be learned. If you ever consider volunteering as a pharmacist and consider bringing medications there is a good document from the WHO which addressed best practices. Do not bring samples being one of them. If bringing medication bring some that the people will be familiar with and that they have on their national formulary, etc.
Yesterday, there was a child seizing on a ward, and a nurse arrived flying in the pharmacy to know how to dilute it so she could administer it. No reference books available in the pharmacy, no access to the Internet on a regular basis, no package inserts in with the actual medication,…
Today there was another child who had swallowed a coin which got stuck in his throat. They started operating on him to remove the coin but the power ran out, so the child had to be woken up and transferred to the larger district hospital.
I had an interesting conversation with my driver on my way back from work today.
It takes about 30 minutes to drive from Limbe (adjacent to BLantyre) where I stay to the hospital where I work. I have been driven the first first days in a minibus but today I was picked up by the hospital ambulance. The ambulance is not what you may think. It is a pick up truck with a cab to cover the back and the word Ambulance on the front.
So today on my way back from work, while riding the ambulance, I was taking to the driver which had many questions for me and how things are where i come from. He was interested in the types of crops that we grow, our main food / dish, our religion, etc.
In talking to him, i found out that many people are walking from Nguludi (where the hospital is located) to Limbe where they work. This on average a 2 hour walk, morning and night. Needless to say that people are very fit here. Women maybe even more so than men as they do most of the physical labor and always seen to be carrying something, most often on their head. Whether it is some produce to sell on the side of the street like corn or laundry, all the way to full size tables, and every thing in between.
If they are not walking, people usally get around on a bike, or on minibuses which are loaded to the max. A minibus will not leave for its destination onless is is full with people. And when I say full I mean full. Typically they have 2 seats at the front and 1 banquet seat for 2 people and 2 banquet seats for 3, for a total of 10 passengers. They actually manage to fit 3-5 people per banquet seat, plus groceries, bike parts, etc, plus someome who deals with the tickets floating between the side door and the seats for a total up to 17 peoples. Quite a circus act.
One of a staple in their diet is simba (not sure of the spelling) which is made from corn flour. It is a kind of side dish. The also have “Irish” potatoes, and sweet potatoes which they grow locally. For the ones who can afford it then they also sometimes have rice.
One important cash crop for the area is tobacco which seems to be sold mostly to China. Despite that only a few people actually smoke.
A small number of people can afford to have a television, in rural areas, less that 25%. My driver can only dream of having one. He said: “One day I have asked my friend how can he get anything done since he has a television. If it was me I would be in front of it watching every day, all day.” My driver cannot afford a television because he is supporting his brother who is going to school. His parents died and he is the main bread winner.
Here children from a young age go to boarding schools. Another of my drivers, who has 3 children between the ages of 5 to 12, only has the youngest living with her at home during the school year.
Another intereting fact is that homosexuality is illegal in Malawi. If someone is found to be gay he may be sent to prison.
Today was a good day. The first day time I could see the sun after a week being in Malawi.
We also got a lot done at work and progessing well with the development of their inventory management system. I am also teaching Jezman (pharmacy technician) and Sister Mary (pharmacy worker), 2 young kids between the age of 20 – 25, the basic elements of MS Access programming so that ther are part of the developement process but also that they can carry on with it after I am gone.
On Tuesday, i was oriented to some aspects of the country and the documentation that will be required for my project. On Wednesday, I traveled by car from Lilongwe to Blantyre (4 h), and got oriented to Blantyre by 2 other volunteers on Wednesday. I am staying in a hotel in Blantyre which is about 30 min from the hospital were I work. Jay Graydon stayed at the hospital last year but they have provided me with a hotel room instead since there were no running water in the apartment were Jay was staying, The electricity and running water is a hit and miss even in this hotel which seems to be one of the nicest around. I am very appreciative of that.
Today, I started working at the hospital and learned about their inventory management system which is all done manually. Each product on the shelf has a log sheet beside it to keep track of inventory. Acquisition of the drugs is a huge challenge due to the availability of the drugs themselves but the limited funds to buy them. There has been a dramatic devaluation of the local currency, the Kwacha, over the last 1-2 year. In the past 12 months the price of goods have basically doubled. I have exchanged a $100 dollar bill for 36,500 Kwachas which I have received in 500 Kwacha denomination which ends up being about a 1 -1 1/2 inch stack of bills. The locals have difficulty keeping up.
There is almost no check taking place from a pharmacy point of view. They have a pharmacy technician but no pharmacist. The only thing that I can see so far is when someone is on antibiotics they verify if the patient had been on it the previous day or not so that it is OK to continue.
Only one physician serves the whole hospital with some “clinicians” that have less training but can also prescribe medications. Only the physician does surgery.
The Internet is extremely slow but can be accessed. It is not used very much.
I am just getting a sense of the scope of my project (implementing an electronic inventory management system). Hopefully, I will be able to complete it during my stay here but from what I saw today it is far from a sure thing.
After an fairly smooth trip from Toronto to New York then to Johannesburg and finally to Lilongwe, I am finally in Malawi. Hopefully I will be able to say the same about my suitcase tomorrow.