Medicine in Lilongwe

In case you don't have time to read this whole posting, I'll try to give you a "high-yield" summary: The major differences are patients are sicker when they seek care, CT/MRI/echo/nuclear medicine is not an option, specialist consultation is either unavailable/weeks away/in South Africa, pain medicine is either ibuprofen or Panadol (cousin of Tylenol) and people are typically very thankful for your care. Our clinic is equipped with x-ray, ultrasound, laboratory (basic chemistries, CBC, microbiology, with access to advanced labs), an OR suite (currently not used), pharmacy, and HIV counseling/testing. Our hospital is capable of inpatient care, and our new pediatric ward will be able to care for up to ~24 children at one time. I'm honored to have two colleagues who are wonderful to work with: Mark Boersma and Diane Young. Mark is an internist/ER doc from Ruston, LA; Diane is a generalist from New Zealand. The practice is varied in scope: rule-out malaria (lots), cough, HIV (lots), broken bones (both new and follow-up old), prenatal care, tuberculosis, gastroenteritis, rashes, low back pain, diabetes, and hypertension among others. I'm settling in daily. Soon I should feel somewhat capable, I pray.

Now for the unabridged...
We live about 150 meters from the clinic and hospital. We see patients from 08:30 to 16:30 weekdays, and we have a clinical officer who sees patients on Saturday mornings. Mark and I share call. That usually doesn't mean much, but occasionally we go down to the clinic at night to run a malaria test on college staff person (malaria seems to affect Westerners faster and more severely than Malawians). We have two Clinical Officers (Danford and Rashid) who practice as physician-extenders (like Nurse Practitioners in the States). We see about 14,000 patients a year (not sure of more accurate number). Most patients speak English, and I have good translation through my nurses when a patient only speaks Chichewa.

I have been constantly challenged. Of course I took care of a few HIV patients in Alabama, but never without Infectious Disease specialists on the case. Orthopeadics referrals were a given for fractures. Radiologists read all of the films in the US, but I'm not sure there is one in Malawi. Sometimes patients would really benefit from an CT or MRI, however they'd have to travel to South Africa to obtain one (~2 hour flight). Mammography is available in Balantyre (a 4 hour drive). It is challenging. However, things have been more difficult in recent history, so I have much to be thankful for. Until about 2003, treatment for HIV cost about 3000 kwacha per month, which was about $40. To give a reference point: a bunch of bananas costs 150 kwacha and a standard monthly wage is about 8000 kwacha. The government now subsidizes (through grants) much of the HIV care. Good HIV care, on this scale, is expensive, both in medicines and laboratory, putting an enormous burden on a country like Malawi, where somewhere between 15 and 30% of the population have the disease. I diagnose a new case about 2 or 3 times a week. Just convincing patients to get tested sometimes is quite challenging. Just today, I was trained on using antiretrovirals (ARVs) by Perry Jansen, MD, at Partners in Hope (PIH). PIH is going to start offering HIV testing for follow-up: CD4 counts (for 500 kwacha [$3.50]) and viral loads (for 2500 kwacha [$17.50]). In the US, those tests would likely be several hundred dollars each. This will allow us to better treat our patients and help us detect drug resistance sooner.

I've now administered my first round of chemotherapy. For privacy reasons I won't go into details, but I would like to give a snapshot. This patient was diagnosed with non-Hodgkin's lymphoma around September 10. How providential it was to have Dr. Ted Moore, a pediatric oncologist from UCLA, visiting with his church's medical team over the last two weeks. Ted has been able to direct the chemotherapy, while we administer it and follow the patient. The therapy will continue every 3-4 weeks for 6 treatments. Without his expertise, this patient would have a very poor prognosis, but now we are very hopeful for a cure. She will not receive radiation therapy, but, Lord willing, she has a very good outlook for recovery. During her night in our hospital, I even checked her potassium and creatinine in the lab myself. . .I'm learning a lot to say the least.

While Dr. Moore's medical group was here, I got the opportunity to go a local village with them to help take care of general medical problems. It was quite an experience. My camera battery was dead when I arrived there, but I will try to link to some of the group's pictures when they get them on their website. When seeing patients in the village (about 40 minutes from ABC), I was struck by how much I have come to rely on the facilities at ABC Clinic, such as lab and x-ray. In the village, you basically only have the history and physical exam to guide your diagnosis and treatment. In Malawi, you call it "syndromic care." That means you treat what it seems like and move on. Prayer takes a much more (appropriately) central role. Even as I write this, I'm struck by how often I rely on myself for answers. I easily forget to remain in the shadow of the cross and rely on His power.

God has been gracious to show us more specifically why He has brought us here at this time: to give Mark some refreshment and relief, and to open the new pediatric ward, which the Whittier Area Community Church from Whittier, CA, has dontated to ABC. This is a busy time for ABC Community Clinic, and it is clear now why the Lord brought us here. While knowing details is not a requirement for our service to the King, it is such a blessing to be able to have such clarity.

Thank you for praying for us.