The Malawi Project, Inc.

Tuberculosis in Malawi
        Malawi has declared tuberculosis a national emergency. Currently over 27,500 people are being diagnosed with the disease every year, but this figure is estimated to be only 50% of all cases in the country. The USAID estimates the total number of new cases each year to be 52,000. The Malawi Ministry of Health has called for urgent and extraordinary actions to halt the spread and fatalities of TB in the country.

        In March 2007 the visiting WHO Regional Director for Africa, Dr. Luís Gomes Sambo appealed for national and international solidarity to fight TB in Africa. Dr. Sambo made the declaration of emergency while on a four-day mission to the continent with the UN Special Envoy to Stop TB, the former President of Portugal Mr. Jorge Sampaio. At the meeting the Malawi Ministry of Health announced a new five-year plan to address the emergency through increased access to TB diagnostic and treatment services, TB and HIV services and community involvement.

HIV/AIDS Gets The Most Press Coverage
        In spite of the prevalence of the reporting by the world’s press concerning the HIV/AIDS pandemic in Africa’s sub-Sahara there remains a critical crisis with tuberculosis that receives far less attention. The seriousness of the problem can be seen in the following USAID website report:

    "The Malawi National TB Control Program (NTP) has been implementing Directly Observed Therapy, Short-Course (DOTS) for two decades, achieving nationwide coverage. The NTP also provides for home-based care using community "guardians" to observe and follow up with TB patients. Despite these advances, the high HIV/AIDS prevalence has had an impact on the success of the TB program. Case detection has remained between 36 and 40 percent during the past five years, well below the 70 percent international standard. Treatment success has remained steady at about 73 percent over the past five years, which is below the 85 percent target."

    The report draws a strong parallel between HIV and T.B.

    "In 2004, Malawi had an HIV/AIDS prevalence rate of 14 percent, and more than 1.7 million adults and children in the country were living with HIV/AIDS. An independent, countrywide survey indicated that 72 percent of all TB patients were HIV-positive, a much higher percentage than previous estimates. High rates of HIV infection led to increasing numbers of patients with difficult-to-diagnose smear-negative pulmonary TB, an increasing case fatality rate in patients with all types of TB, and an increasing rate of recurrent disease."

    According to the World Health Organization the total incidence rate of TB in all forms is 8,811,100 with South-East Asia leading the way at nearly 3,000,000. Africa is second at over 2,500,000 cases.

Zuze Moyo -  A Solitary Man in the Dowa Valley

    It is sometimes strange how your eyes will catch on a single person in a crowded place. Something about them gets your attention; perhaps their attractiveness, or perhaps their outgoing personality, or maybe it is simply because they are the only person directly in your line of vision.

    None of these reasons fit on that morning when we entered the tiny village of Kasitu located deep in the Dowa Valley east of Lilongwe. Of all of the people that crossed my line of sight I found that my eyes had locked on Zuze Moyo. It was not for any of the reasons I have just mentioned, for he was not attractive, nor did he have an outgoing personality. Nor was he directly in my line of vision as I got out of the car and started walking toward the church building where the meeting was about to begin.

    Zuze was stumblingly clawing his way through a high patch of weeds trying, it seemed, to get away from the line of travel of the people going to the building. His crippled features and his tattered clothes made him stand out from the other village people who lived nearby or from those who had come for the meetings. For a long moment I could not take my eyes off of him, then we passed and I was hesitate to look back. We greeted a number of the men and women near the door of the building and then started to enter. A single look back and again he was in my line of sight. He looked bewildered, confused, and alone. Perhaps he was mentally unbalanced, and unaware of the world in which he lived. Or perhaps he knew everything that was taking place and knew he was repulsive to those who eyes touched on his pitiful features.

    For the next three hours the prayers, teaching, and singing consumed my mind and my view of the world around me. Then it was time to go across the road to a house where lunch would be served. I wondered if I would see Zuze again. Just as I stepped out of the building he again came directly in my line of vision. He was sitting in the path that lead to the road and on to the buildings on the other side. We had to pass directly beside him. I tried not to look as we approached. I did not want to embarrass him. His head and eyes seemed to sway with the fluid scene around him and still I could not tell if he was aware of his surroundings or if his world was one that none of us would ever comprehend or understand.
    As we passed him on our way to the meal the pattern of a Bible story began to form in my mind.

    "30 Then Jesus answered and said: "A certain man went down from Jerusalem to Jericho, and fell among thieves, who stripped him of his clothing, wounded him, and departed, leaving him half dead. 31 Now by chance a certain priest came down that road. And when he saw him, he passed by on the other side. 32 Likewise a Levite, when he arrived at the place, came and looked, and passed by on the other side."     Luke 10:30-32

    We crossed the road and shared a typical Malawi meal; village chicken, nsima, rice and greens. Everyone was in a good mood and the conversation was upbeat and positive. Yet, the scene across the road still dominated my thoughts. Who was Zuze? What was his real condition? Did he understand that everyone was ignoring him and looking the other way when they passed him?

    Meal complete and time to go back over for the afternoon sessions. I wonder if he will still be there? As we stepped out of the small house my answer was right there in front of me. Zuze was sitting on the ground almost directly in front of us. Still he looked confused, as though he did not know how or why he had gotten there.

    For the next two days I would watch for him. He was always there. And I always felt like we were playing out a continuation of the story of the man who had fallen among thieves. Zuze had not suffered that plight but perhaps his was worse. His would never improve. He was trapped for the rest of his life. No medicine would change his condition. No trip to the doctor would change his status. And too, I was afraid that there was not a Good Samaritan that would come by to help him. By the end of the day I sought and gained some information about him that helped to ease my mind … some.
   
    I learned Zuze has been in this condition his entire life; crippled, confused and helpless. Now he lives with his aged mother. His siblings and his father have all gone from this life and the two of them are somewhat alone. I learned that he fully knows and understands what is taking place around him and he sits along the path to beg for some good person to offer him some substance so he can eat. It was strange the next thing I learned; he likes to watch football (soccer). A crippled man watching his friends and neighbors run freely across a field playing a game in which he will never participate. What dreams go through his mind as perhaps he struggles to imagine himself racing along the field, friends and family cheering him on, then to cross the finish line and score the game winning goal for his home village. I learned he is 48 years old and I wondered if anyone ever recognizes his birthday. But the best news I learned in this story of pain and despair is the fact that the church is helping to support him and his mother. It brought to mind the best part of the story of the man who fell among thieves. Now I can complete the verses in my mind.

    33 But a certain Samaritan, as he journeyed, came where he was. And when he saw him, he had compassion. 34 So he went to him and bandaged his wounds, pouring on oil and wine; and he set him on his own animal, brought him to an inn, and took care of him. 35 On the next day, when he departed, he took out two denarii, gave them to the innkeeper, and said to him, ‘Take care of him; and whatever more you spend, when I come again, I will repay you.’ 36 So which of these three do you think was neighbor to him who fell among the thieves?" 37 And he said, "He who showed mercy on him."  Then Jesus said to him, "Go and do likewise."

Not All Days Bring Success

Editor’s Note: The following story played out in the largest hospital in the capital city of Lilongwe, Kamuzu Central Hospital. Reporting is Renee, a 3rd year Australian Medic Student. She had come to Malawi for the summer to work with the Malawi Project. Kamuzu Central Hospital (KCH), is a 1,000-bed, public tertiary care hospital operated by the MOH that serves a population of nearly four million persons.

    The sounds of a baby’s wails filled the air.  He was obviously unwell.  Only one month old, this tiny child was very wasted, with skin loosely hanging off stick-thin arms.  His eyes were huge against his thin face.  In sharp contrast, his abdomen was very distended, with loops of bowel clearly visible against his taut skin.  Every time we pressed his stomach, he wailed more.  His parents explained, fear in their eyes, that their child wasn’t feeding and hadn’t passed a bowel movement for six days.  They had brought him in to the hospital when he started vomiting feculent matter.  The stethoscope confirmed what was clinically obvious – we couldn’t hear any bowel sounds, proving that this tiny boy had an intestinal obstruction.  Urgent surgery was needed.   But this was Malawi, the third poorest nation on earth, and we would have to wait.

    The baby began to vomit up a bright yellow bile-stained liquid.  We quickly put him on an examination table, laying him on his side so that he wouldn’t breathe in his own vomit.  The young doctor threaded a clear plastic tube through the boy’s nose to his stomach in the hope of removing some of the fluid.  At first it appeared successful – bright yellow liquid flowed out of the tube and into a waiting bottle, but without any suction the flow soon stopped.  It wasn’t long before the fluid began dribbling out of his mouth and nose once more.  The doctor hurried off to fetch the head of surgery, leaving one nurse and me to look after the tiny boy.  I couldn’t help but feel overwhelmed – in Australia, emergency specialists and experienced pediatricians would be crowding around this baby, doing everything possible to save his life.  Here in Malawi, I was alone with a very ill child with nothing but a scrap of fabric to clear his mouth.  I cradled his tiny head in my hand as I fought to remove the liquid from his mouth and keep his airways open, but there was little I could do.  The cloth the tiny boy was lying on became soaked in fluid.  He stopped wailing and began to draw gasping, gurgling breaths as the liquid went down his airways and into his lungs.  His tongue and lips started to turn blue.  We tried to get a machine to read what the levels of oxygen were in his blood, but he was too cold for the machine to work.  We piled blankets on top of him and tried again, but still no luck.  The doctor returned and told us that the surgeon still had four more patients to see, but would come as soon as he could.  All that I had read about the understaffing crisis in Malawi hospitals suddenly hit home.  I showed the doctor the child’s blue lips and asked for a tube to be put down the baby’s windpipe to keep his airways open.  If the worst happened and the baby stopped breathing, this tube would also allow us to breathe for him.  The doctor agreed and left to get an anesthesiologist to put the tube in.  Meanwhile, the nurse worked desperately to place a needle in the boy’s veins so that we could put some fluid into his bloodstream and re-hydrate him.  She asked me to clamp my hand tightly around the baby’s upper arm so she could find a vein – not even one tourniquet was available in the entire ward.  My hand easily encircled his thin little arm, but the nurse couldn’t find a vein.  The same thing happened when she tried his left side.  Things were getting desperate.  The nurse pulled out a small blade and shaved one side of the baby’s head.  His soft black curls fell to the floor, exposing his scalp veins.  But he was so dehydrated that even these veins had collapsed, and the nurse was unsuccessful once again.  The doctor returned for the second time, said the anesthesiologist was on his way, and ordered that the baby be immediately transferred to the high dependency unit of the paediatric ward.  His mother scooped him up and cradled him as we all moved into HDU.  The eyes of all the parents in the crowded paediatric ward followed us as we left.  I know they were all thinking the same thing: thank God that’s not my child.

    In HDU, the resources were a little better.  We were able to use a suction tube to get rid of the liquid more effectively, and place an oxygen tube into his nose to try to help his breathing.  His parents, standing silently in one corner of the room, were asked to wait outside.  The anesthesiologist arrived and not only managed to place a tube in his windpipe, but also found a vein in his foot and began infusing some salty water.  Slowly, the fluid dripped in his veins.  I attached the oxygen to his tube and pushed air into his lungs with a bag.  But he was breathing on his own, so after a short period of mechanical ventilation we left him alone.  But he wasn’t crying at all any more, and his wide-open eyes were glazed and unresponsive.  The anesthesiologist, having performed his job, left.  The young doctor left to see other patients.  The HDU nurses, laughing, commented how they always get the dying patients because it looks bad for a child to die in a general paediatric ward – but it’s politically okay if they die in HDU.  “I don’t know why we’re bothering,” commented one nurse conspiratorially.  “He’s brain dead anyway”.  One by one, they left to check on their other patients.

    So I sat alone with the tiny boy, searching his face for any sign of recovery.  His chest raised rhythmically up and down as he drew each shallow breath.  Although his eyes remained open, his stare was blank and unseeing.    His skin grew steadily cooler despite the warmth of the blankets.  After an hour I left him, a tiny form on an oversized bed still waiting for his surgeon to come and save his life.  As I walked down the halls of the paediatric ward I saw his mother, sitting on a bench waiting to see her boy.  Tears filled her eyes but she held them back – Malawians aren’t supposed to cry.  As I passed her, I thought of how different the outcome might have been in Australia.  A one-month-old boy wouldn’t be hovering near death for the want of a surgeon.  Maybe one day, Malawians will be as lucky as the children in my own country.  Or maybe that’s just a dream.  But it’s one that I’d dearly love to see fulfilled.

Post note – The one-month-old boy in the story died at 3am the next day.