Report from Elective in Malawi, Africa

Rebecca Armour, MD
Graduate of the College of Human Medicine
Michigan State University, 2002

As a fourth year medical student at the College of Human Medicine, I had the opportunity to participate in an international medicine elective in Malawi, Africa. This elective was supported by the Blake Smith Memorial Endowed Scholarship. The following is a report of my activities during that international elective.

From January 7 through February 15, I participated in a Pediatric rotation at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. Malawi is a small country in southeast Africa, bordered by Mozambique, Tanzania, and Zambia. Blantyre is the largest city in Malawi.

The Pediatrics Department there consists of about ten faculty members and ten residents. The services for pediatric patients at QECH include a Pediatric Accident & Emergency area, Moyo House (a malnutrition unit), a General Pediatrics ward, Pediatric Oncology, Newborn Nursery, Neonatal Intensive Care, Pediatric Surgical Bay, and a Malaria Ward. The department is extremely busy, with a large census of between 150 to 200 patients. The hospital, however, has only half this many beds. The patients share beds, with some of the children being held by their mothers on the floor.

The faculty and residents are extremely dedicated, caring for the patients with great motivation, and under circumstances of limited resources. My days at QECH started with morning report at 8 am. At that time, the resident "on call" reviewed the number of admissions and discharges for the previous day. Then the residents reviewed each of the deaths from the previous day to see if there was anything that should have been done differently. We also reviewed prevalent cases, such as if there were a number of children in the past week who presented with symptoms consistent with cholera. Next the residents and students presented two cases of educational interest. At that time the child and his or her mother would come to be examined during the teaching session. After morning report, we had the opportunity to follow the physicians to any of the pediatric areas of the hospital to participate in rounds. The afternoons were spent admitting new patients to the hospital through the Pediatric Accident & Emergency area.

The hospitals resources are limited compared to in the US. The only antibiotics consistently available were penicillin, chloramphenicol, and gentamicin. Nurses were understaffed, with sometimes just one nurse for as many as sixty patients.

During my time in Malawi, I also took language lessons at a cultural center in town. Most of the patients at QECH only speak Chechewa, their native language. The residents and nursing staff helped us translate. By mid-rotation, I had learned enough Chechewa to ask the medical questions on the admit form to the hospital. This was a valuable part of my experience.

The statistics of a week's worth of patients will give a good image of the medical issues most commonly dealt with. These are the pediatric statistics during one of my weeks in Malawi:

Admissions: 695
Most common admission diagnosis, in decreasing order:
1. Malaria
2. Fever
3. Malnutrition

Total Deaths: 36
Age of death
0-6 months 9
6-12 months 7
1-5 years 14
> 5 years 6

Time between admission and death of the patient
Within 24 hours 12
24-48 hours 6
48 hours to 1 week 11
> 1 week 7

Cause of Death
Malnutrition 8
Sepsis 7
Malaria 5
Anemia 5
Pneumonia 5
TB 2 (1 miliary)
Cholera 1
Bronchitis 1
Cerebral Palsy 1
Head Injury 1

On most weeks, the most common cause of death was malnutrition. The impact of HIV on the pediatric population was seen in many settings in the hospital. For instance, the children who were the most malnourished also commonly showed signs of immunocompromise consistent with AIDS. Pneumocystis Carinii pneumonia, fulminate dermatologic infections, and rectovaginal fistulas were illnesses seen in the patients at QECH which pointed to the prevalence of AIDS.

But despite these cases, there are many happy patient stories from QECH. During my six-week rotation I witnessed numerous children admitted with malaria who were successfully treated. At admission, they were often carried in by their parents, febrile and listless. A simple blood smear in many cases makes the diagnosis. In some instances the child needed a blood transfusion because of anemia. But in most cases, the treatment required was merely a few days of Quinine and Sulfadoxime-Pyrimethamine. These children were discharged smiling and active.

My Malawi experience was incredibly educational. The patients there exhibited exam findings rarely seen in the States. These included massive splenomegaly and hepatomegaly, periorbital edema from nephritic syndrome, cardiac thrills and heaves, and severe dehydration with sunken eyes and skin tenting. A list of some of the illnesses seen in our patients included marasmus, kwashiorkor, spinal TB, cutaneous TB, miliary TB, caudal regression syndrome, hydrocephalus, conjoined twins, pneumocystis carinii pneumonia, malaria, Kaposi' sarcoma, Burkitt's lymphoma, rheumatic heart disease, situs invertus, congenital syphilis, gastroschisis.

The most important lessons that I learned in Malawi, however, were not the medical lessons. Instead they were the lessons I learned from the Malawians about living with and overcoming illness. The staff at QECH were examples to me of how much of a difference a physician can make in the lives of patients, even in the face of very little resources. Their determination to improving the health of the people of Malawi was an inspiration to me.

I want to express my gratitude to those who support the Blake Smith Endowed Scholarship. The scholarship helped enable me to have this international medical experience in a developing country. Through this experience I learned many lessons about the medical needs in developing countries. My experience in Malawi has shaped how I view my calling in medicine. I have seen firsthand how a physician can have a meaningful career in a limited resource setting. The physicians in Malawi modeled how their work was very satisfying to them-rather than get discouraged about the great unmet health needs, they concentrated on finding fulfillment in the patients they were able to help. Already, as I start my residency, I believe my experience in Malawi has deepened the respect with which I treat my patients and has shaped how I view my calling in medicine. I see more clearly my responsibility to reach underserved populations and incorporate service into my career.

For More about the Project in Malawi