An Open Letter to the Shira Community from Dr. Naor Bar-Zeev and Sarah Lodge Bar-Zeev:
We arrived in Malawi in January 2011.
Naor works as a paediatrician in infectious diseases at Queen Elizabeth Central Hospital, and as an epidemiologist coordinating large research projects relating to the introduction of 2 new vaccines, one against the bacteria that causes pneumonia and blood and brain infection, and the other against the virus that causes severe diarrhoea. These two organisms are responsible for more deaths in children under 5 than malaria, HIV and all other causes combined.
Sarah works as a midwife at the hospital, and is coordinating the implementation of sustainable evidence based interventions that are known to reduce maternal death and disease at health centres throughout the country for the Ministry of Health. Malawi has among the highest maternal mortality rates in the world.
The Queen Elizabeth Central Hospital serves a population of about 1 million people in the southern region of Malawi. Malawi is among the poorest countries in Africa.
The Department of paediatrics sees about 90,000 children a year, of whom about a third are admitted to hospital (last year over 31,500 admissions). On an average day there are 350 children (squeezed into 280 physical beds), and in the rainy season when malaria and diarrhoea are high, there are 450 children a day. (For comparison the new Royal Children’s Hospital in Melbourne has a maximum capacity of 357 beds.)
There is a team of 8 consultant paediatricians (3 foreign including Naor, and 5 Malawian), 5 paediatric junior trainees. There are very few government funded nurses. It is only through charitable donations that the paediatric department employs 15 nurses, 2 clinical officers (who work like junior doctors do in Australia), 5 homecraft workers and 8 cleaners. All of them are pensioned and remunerated fairly.
This equates to a nurse to patient ratio of 30. (In Australia the nursing industry standard is 1 to 4.) Due to extensive efforts at improving hospital care for children, the in-hospital mortality for children has declined from over 20% some 10 years ago to now 2.5%. Very high mortality rates are still seen among premature or sick newborns, and among children with severe malnutrition and those with HIV infection.
A long queue of mothers and children waiting to be triaged in the paediatric emergency department. In the background are the doors to the resuscitation rooms where urgent cases are seen immediately.
A child with diarrhoea is assessed in emergency by a paediatric trainee. On the wall are clinical guidelines and other job aids.
A child with cardiac disease is reviewed. Most cardiac disease in developing countries is not congenital but rather acquired from rheumatic fever – an infectious disease, a condition also seen very commonly among Indigenous children in Australia. It is associated with poverty. With good preventive interventions the cardiac consequences can be avoided.
This infant has severe pneumonia. He is being supported by special nasal prongs that deliver oxygen under pressure. This Continuous Positive Airway Pressure (CPAP) machine was built locally using a fishtank-type air pump to bubble gas through a column of water under pressure, nicknamed “Bubble CPAP” – a sustainable and easy to fix technology which is life-saving. Similar but more expensive systems to provide CPAP are in use globally. Mortality from severe pneumonia has declined since the introduction of the CPAP machines. We have 3 available. The baby in the photo did well and was discharged.
Children in the oncology ward play in a small courtyard. They have Burkitt’s lymphoma, a blood disorder common in Africa which leads to tumours that can lead to facial deformity. Our paediatric oncology service has survival rates that are high compared to many developing countries. We cannot give very aggressive chemotherapy, because we do not have the capacity to support children through the difficult and often life-threatening side effects that strong chemotherapy requires.
Families enjoy the weather outside the Moyo (“Life” in Chichewa language) nutritional rehabilitation centre. Children with malnutrition often have prolonged admissions, and their care continues at home through nutritional programmes at primary health centres located in the community.
A nurse attends to a newborn in the nursery. In the photo there are 2 babies in this cot designed for 1 baby. Up to 6 premature babies are sometimes nursed on this cot alone which has a functioning overhead heater. Babies are given oxygen through a tube, and those too young to suckle are fed via tube. At the top right corner of the photo is a “lunchbox” that is the nursery’s bubble CPAP machine. In the top left corner of a photo is nestled a “splitter” – a device that can split the oxygen supply to provide low flow oxygen to up to 8 babies from 1 oxygen source. In this nursery there is very serious understaffing. I have seen a nurse not leave this room for more than 72 hours as there was no other nurse to come and replace her.
The nursery for infants born outside hospital or those readmitted. On the right of the bench an oxygen splitter can be seen, and above it a monitoring unit for vital observations that is shared by the entire ward. (In Australia each baby would have their own monitor.) On the left on the floor is an oxygen concentrator. this machine sucks in air, extracts nitrogen gas leaving almost pure oxygen. It never runs out, but is dependent on electricity. When black-outs occur (and they occur often) any child needing oxygen is left unsupported. In a crowded nursery environment like this with cots separated by a panel of wood it is difficult to prevent cross-infections. I have seen a baby come in with severe chest infection and recover only to develop severe diarrhoea from a baby on the next cot, and go on to die from dehydration due to the illness he obtained in hospital.
Under these cots are bright lamps which help keep the babies warm. The room is kept hot too, and feels like a sauna to work in.
The high dependency unit. Two CPAP machines are on the left, and a wall mounted monitor. The bed on the far right is being shared by two unrelated children, as is the second bed on the left. The entire hall is always full. There are two nurses for this hall.
The two children in this bed have become friends. Both are recovering well. Water is not fluoridated in Malawi, and although safe to drink, does not protect against tooth decay. The clothes are bought at the market. They are sourced almost entirely from donated hand-me-downs from the West. It is not unusual to see a man on the street wearing a “Welcome to Ballarat” T-shirt. Or a T-shirt celebrating Australia’s bicentenary, or Sydney swans vest… This boy got nice Bob the Builder overalls.
The newly built adult emergency department. A very limited ambulance service has to prioritise obstetric emergencies. Most other emergencies have to make their own way to hospital. For many this means paying a bicycle taxi to take them. In the middle of the night this can be unaffordable for many families, which means children often present for care very late, often too late, for a meaningful recovery.
Got to throw in a photo of a cute baby! This child is shown recovering from severe pneumonia with CPAP and intravenous antibiotics, and in the next photo is now ready to go home.
Improving child health and reducing mortality is complex, since the fundamental underlying causes of poor health are economic and political, as well as more directly biological.
They relate to literacy and female empowerment as much as they do to food security and availability of preventive interventions such as vaccination.
Malawi has engineered improvements in food security and seen improvements in literacy in recent years. It has been very proactive in introducing vaccines that have been in use in wealthy countries for many years but were unaffordable in most other countries. Hospital care for children is improving also.
But a major gap remains in availability of health staff.
With my own eyes and almost on a daily basis I see children die who would have survived if they had closer nursing care. Supporting a nurse not only provides better care for children, but also gives that nurse employment and helps her to support and educate her own family.
Shira Hadasha in Melbourne is collecting money for this purpose. All money collected is transferred into a foreign currency account of the Queen Elizabeth Paediatric Department held in Malawi. It will be used to provide employment for a nurse for the children’s wards. There are no overheads or other losses apart from bank fees for the funds transfer. All monies will pay salary, superannuation and other on-costs (eg medical insurance) for the nurse. The money in this account is regularly externally audited.
To donate to this important project please visit shira.org.au/malawi-hospital-drive
(All photos taken with permission of the parents/guardian for the purpose of disseminating information about the department for fund raising. Photos taken by Dr Sarita Depani and Dr Andrew Selman.)