Nanthanje Outreach Clinic

Nanthanje PIH Outreach Clinic (Posting Date 10.30.08)

I wanted to take a few minutes to reflect upon the Nanthanje clinic we went to on Tuesday morning. We all met at PIH, and after morning chapel, 6 of us piled in a jeep and drove ~20 minutes outside of town (I still haven’t figured out which direction is North!). Within 5 minutes on the road, we were in rural Malawi—there are certainly no suburbs here. We would pass several small villages, which usually consisted of a few round mud huts with thatched roofs, maybe a central kiln/brick stove, and usually a few random farm animals, mostly goats, wild dogs, and chickens. Often there were women cooking, and small kids following their parents around; occasionally a man or a child would pass by on a bicycle. While we were on a highway that was paved, all of these villages were surrounded/accessed by roads. Often, “minibuses” would stop on the side of the road at these villages and pick up a traveler or two.

We arrived to Nanthanje by way of a dirt road with very large “potholes”—worse than what you see in any city with a winter. Upon arrival, we parked beneath the lone tree in the medical complex, which consisted of three small brick buildings with windows and cement floors, along with one area for expectant mothers. Outside the first building, which was the primary care clinic, there was a line of about 20 mothers and children, all in beautiful traditional African prints wrapped around their waist, or around their backs with their children secured firmly. As a side note, the men dress much more western than do the women, except for businesswomen, who dress particularly modern, with pantsuits or suits with mini skirts and high-heeled, pointy toed shoes. But back to the clinic….

After getting a quick tour of the complex, we split up into teams, with Eri and I shadowing two of the clinical officers, people who are 1 level below physicians (maybe the equivalent to a nurse practitioner) but with a great deal of clinical and surgical expertise (ie: COs do deliveries, C sections, hernia repairs, numerous procedures, and run many of the clinics). Jessica, one of the Mzunga (white) nurses from PIH, and Anna, another nurse from PIH, checked in all the HIV patients, and ushered them to benches outside the exam rooms. Patients were seen in order, and the whole visit consisted mostly of an evaluation of the patient’s HIV history, their compliance with medications, and investigation into any recent complications. Because the volume was so high, rarely did we have time to do an exam, talk in detail about the psychosocial aspects of their disease, or do any meaningful amount of documentation. Instead, patients were often given refills of their medications, and their clinical status was documented in their health passport—a paper book about the size of a passport, that contained brief notes from all their clinic appointments. We had one patient with a new cough and a right upper lung consolidation on exam, and began treatment for pneumonia; we asked her to submit a sputum sample for the evaluation for tuberculosis, a diagnosis much more likely in her compared to community-acquired pneumonia. But other than this one patient, most of what we saw was fairly straightforward rural HIV medicine. That is to say, we don’t have the means to do CD4 counts frequently, and these patients in the rural clinics rarely ever have a viral load or HIV genotype done (both of these tests we would use frequently in the States to adjust treatment regimens). Now this limitation is mostly from a resources standpoint—Malawi simply doesn’t have the means to pay for these tests. In addition, Malawi only has medications for 4 types of HIV regimens. You see, HIV care is often like a buffet of food—you pick 1 or 2 meds from category A, add another from category B, and if they are doing poorly, add something from category C or D. Not so for Malawi. Currently, the Ministry of Health only purchases drugs for 4 regimens. Everyone gets the first line regimen called Triomune (a combo of three drugs); if patients develop side effects, or intolerance of the medications, they are switched to one of two alternative first-line regimens (1a or 1b), or if they develop resistance (virologic failure), they get placed on the second line treatment. There are no more options should someone develop bad side effects or fail the 2nd line treatment, which often happens over time, and especially if patients take their medications inconsistently. And unless you can find someone or some company to make a significant financial contribution, this will be the protocol for the next many years (probably through 2010).

In total, we saw approximately 30 patients that morning. We actually brought patient back with us to PIH for further evaluation, as she had developed a very bad skin rash to one of the meds in Triomune, a very common reaction requiring a change in medication. Because the local clinic did not carry this alternative therapy, she had to come to PIH for the medications, a trip that will be very difficult for her to do in the future, as it is several miles away, and she has no money for the bus. Talk about access to care…

Well, it is off to Mvuu camp and the Shire (pronounced Shear-ray) river safari, where we’ll see hippos, elephants, crocs, and lots of rare birds. In fact, over 260 species of birds live in the Liwonde National Park, where Mvuu camp is located. This camp is run by Wilderness Safaris, a group in Africa that is dedicated to keeping the wilderness of Africa pristine, while also reinvesting the proceeds from the organization back in the local community. For example, they built a school for the local children outside the Liwonde National Park. I’m sure it’ll be a blast, as long as I keep my hands inside the boat, and I hope to have many great photos to share. I’ll write more soon, and will try to post this weekend about the experience. Until then, be well, and have a great weekend!



Chase