Notes from the Field: Malawi #4 (Health System Strengthening)

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This column is the final of four from Malawi and illustrates one of the ACNM Global Health Competencies. If you are interested in submitting a Notes from the Field column, please read the instructions for submission to be considered.

Addressing ACNM Global Health Competency #9 – Health System Strengthening

When I wrote the first two articles for this column, I was in Blantyre, Malawi, and I anticipated writing installments #3 and #4 from the field, as my contract with Seed Global Health was for a year. COVID-19 changed those plans, as it has for so many. I was evacuated from Malawi on March 19th and have since been trying to work remotely. Upon my return, I had many questions, such as: Where do I go from here? How can I continue to work on my global health project from 9000 miles away? Where should my focus be now?

With nine cases of COVID-19 identified in Malawi as of April 10, 2020, the focus for many there, and thus for me, has shifted from efforts to launch a Midwifery Led Ward to how best to help in the midst of a pandemic. All the students at Kamuzu College of Nursing and at the College of Medicine have been sent home, effectively halting their studies. There is minimal capacity for e-learning in Malawi, for most people do not have internet access in their homes. Having internet access at school was a huge plus for all students. In addition, this week the faculty had to vacate their offices in the newer campus so the simulation lab space there can be used as a hospital for the expected cases of COVID-19. The faculty are now trying to work from home, but most of them also do not have reliable internet service.

I have so far heard about plans for non-pregnant COVID-19 patients, but what about all the pregnant women in Malawi? The midwives at Queen Elizabeth Central Hospital attend on average 40 births a day. There is one small triage room where all pregnant women come when they are in labor. Can enough working thermometers be found so that the temperature of everyone who enters the hospital can be taken? Those with temperatures over 38° could be cared for in a space that is different from those who do not have a fever. But what about those who are asymptomatic, yet carrying the virus and thus at risk of spreading it to others? We have no way to identify those individuals.

One thing we have learned about the COVID-19 virus is that soap and water go a long way in reducing the spread of infection. However, there is no consistent source of clean running water at Queen Elizabeth Central Hospital. What good is a recommendation for frequent hand washing if that is only sometimes possible? And, as in other parts of the world, the supply of hand sanitizer products there is woefully inadequate.

Can the many tailors of Malawi come together to make masks from the colorful chitenje cloth that Malawi is known for? Could a public health message direct everyone who is out in public to wear a mask?

What are the best ways to strengthen this healthcare system? Personal protective equipment (PPE) for healthcare workers and patients is key, as it has been for in areas of the world. Is this possible in Malawi?

Could simple face shields be made? We have learned that aerosolization during the second stage of labor is a potential health risk for midwives, and that the use of face shields, when available, has helped reduce the spread of the virus.

How important are aprons? What should the policy be for midwives who do not have access to aprons? How should their clothes be handled?

My list of questions goes on and on.

I feel so far away from Malawi as I sit in my sister’s house in Freeport, Maine. (My house in South Portland has been rented to others until July 7th, my original date of return from Malawi.) I feel lucky to be healthy and to have access to reliable internet service. This makes me ever aware that Malawi faces more challenges than we face here in the US. Poverty, close quarters, and a very sociable national ethos make the spread of the virus more rapid there. Even though I can arm some of my Malawian colleagues and students with the latest information as it becomes available, none of us are in a position to change the realities of poverty. My efforts are but a drop in the bucket. Nevertheless, I feel a deep connection to my colleagues, students, and friends in Malawi, and I will do whatever I can from afar to ease the crisis.

The staff at Seed Global Health in Boston have been very supportive of my efforts to continue working to address problems at a distance. I have many resources at my fingertips, and Zoom meetings with US colleagues have been helpful. Networking with others who are also trying to synthesize information as it becomes known is enriching and good for my soul. These are new and trying times for us all. There is a sense of unity globally as we all struggle with one virus in many locations. If we can get through this pandemic and come out the other side with some wisdom about our future challenges, then we will all be winners, no matter where we live.

My dream still is to someday return to Malawi to see The Midwifery Led Ward in full swing.