Inside Bottom Hospital

    Bottom Hospital sits in the old trading center portion of Lilongwe Town, a short distance from the big mosque, and just east of the Lilongwe River. Highway M-1 passes a block to the north and the visitor passing through town may miss it entirely. It must have derived its name because it sits at the bottom of the valley, but one must wonder if its name is symbolic of being at the bottom of some sort of an imaginary list. It is a montage of mismatched buildings, some of them beige, while others are a dirty weather beaten off white. A much larger group buildings are a brownish orange color that mimics the ground on which the decrepit facility rests. Bars on most of the windows bemoan the realization of the amount of petty crime and theft that is rampant in many parts of this tiny nation nestled in one of the deepest pockets of poverty in the sub-Sahara. In spite of all of the efforts to control the problem it is still rampant in an “everyone does it” attempt at justification by those who cannot find a way to stop it. Almost everything can and does disappear from the medical facilities in time. And this includes not just the “small stuff”. It goes all the way to actually including mattresses and beds.
    Spotted along the dusty footpaths and broken pavement outside the buildings are the nurses who are coming and going in spotlessly white uniforms that defy the surroundings in which they work. They appear at duty stations with a manifestation of purity, cleanliness and commitment that dare the believer to understand, when they are seen in the environment in which they must work. One need only to watch them in their harsh and unpleasant environment in order to gain a new respect for the nursing profession as it is being played out in the harsh surroundings of poverty stricken Africa. One would be hard pressed to explain how a nurse can enter the workday in a white uniform, and end the day with it still appearing white and spotless.

Minor Gains Against Major Problems

Today the hospital looks much different than it did even one year ago. Fresh paint can be found in some of the wards. This is progress even though old, chipped paint still holds the count for supremacy. Old beds and mattresses still outnumber newer ones. But there is some gain. One can see a gallant effort that is showing some results that is gaining a toehold in the battle against death, disease and despair. The staff is gaining one inch at a time. Nurses do not handle as many deliveries per shift as they were doing just a year ago, although the patient to nurse ratio is still at unbelievably high levels that shake any western nurse all the way down to her spotlessly white nursing shoes. To the question of “how can they give good heath care to patients when the patient load is so high” comes the dreadful, but honest and candid answer of, “they can’t!”

The Untrained Care for the Patients

There are not enough nurses in the hospitals so an untrained family member must always come with the patient in order to provide for their care. These caretakers remain with the patient night and day the entire length of the patient stay. They prepare patient meals, clean the patient, change the beds, and carry out the care that would normally be assigned a nurse or nursing assistant in any western medical facility. At best it is wholly inadequate. The patient almost never sees any type of patient gown, or a clean sheet, or any type of blanket that is not brought with them. When they arrive the beds are often bare and the mattresses have no linens. They place their linens from home on the beds when they enter the facility, and these often harbor the disease and cross contamination that may be carried from their home area or village. While some new mattresses seem to have reached the facility in the past three to five years, most of the mattresses are of such an ancient vintage that fine French wine looks like new grapes in comparison. Most of them are ripped and torn and open to any kind of human excretion that has touched their surface in months or years. This is true in almost every government hospital in the nation, not just at Bottom. One is forced to wonder how many patients have illnesses compounded because they have entered a heath care facility in order to get better, only to pick new diseases and infections in the medical environment of the hospital itself.

    Entering the wards one sees crowding like few other place else in the world. Beds so close together one must turn sideways to walk between them. Family members sitting on the floor everywhere around the room, and a stench that cannot be described hangs heavy in the rooms. Partially eaten meals sit on the floor beside the beds and flies hover around the remains. Clothing of all sorts and age are strung around the room and again the recognition that cross contamination is everywhere around you is evident. Babies enter this new world without the benefits of a clean environment in which to take their first breathe.

Passing the Caretakers

    The call to prayer, from the nearby mosque, touches lightly on our ears as the late afternoon traffic jams into the crowded streets of Old Town, a short distance from the hospital. The late afternoon African sun is beginning that mad dash for the horizon as we cross the broken pavement on our way to the next set of dingy looking buildings. Just outside the maternity buildings, in the red dust earth around the hospital, sits nearly 100 women. Some have babies on their backs. Some have small children in tow. And still others have a small array of small pots and plastic containers sitting on the ground around them. In most cases these are the village women. They are the caretakers. They have come with the patient who is near delivery, and it is their job to cook, clean, and care for the expectant mother for as long as it takes until the new baby is born, and the mother and baby go home from the hospital. There are no hotels nearby for them to stay. There are no restaurants they can afford. And there is no one else to come and relieve them from the endless hours they sit on the ground and wait. Many of them appear to be mothers, or grandmothers, but a surprising number may be sisters or village neighbors. There is no food or hygiene supplied to the patients and family members, or friends who come with them. If no one comes they are given little care. If a complication occurs there is just not enough hospital staff to care for all of the patients. It is not a matter of cruelty. It is because there is no option. It happens because of poverty. It happens because there are no resources. It happens because there is no choice or option. One is struck by the fact that there are no bed linens, except for what is brought from home by the patient. One writer said an African believes the reason he goes to the hospital is to die. One has to wonder if the hospital is actually helping or hurting the problem. The hospital personnel fight a loosing battle in an attempt to keep the facility clean but nothing can hold the line against the contamination that is carried into the facility nearly every hour of the day. The fight is a loosing one, just as is the attempt to have the supplies on hand that are needed in order to give adequate patient care.
    No mother can look forward to their new baby being wrapped in clean, crisp swaddling clothes, no mother can look forward to a delivery in a clean, western style delivery room. No mother can look forward to her child beginning life in a contaminate free world. It just can’t happen here. Here in the heart of the fourth world, is a world of forgotten humanity. It totals 12,000,000 that by and large, the rest of the world has forgotten. This is the way it has been, and what will ever make it different?
Smiling nurses’ rush here and there trying to do their job against impossible odds, in spite of being underpaid and overworked. The western medical profession faces no comparison to what a nurse faces in this part of the world. Twelve million people must share less than 100 doctors. The rest of the doctors have left the nation, died of disease, or gotten out of the profession.
    Meanwhile, unnoticed and unreported, in the room beside the patient, or cooking outside on a wood fire, or just sitting and talking with the person beside them are the caretakers. Without them the patients would surely die.

The Mental Ward Is Next

    Leaving the maternity ward and the caretakers, one takes a deep breath before moving south along the drive and over to the mental health unit. Here again some new paint challenges a dingy past. Most of the building still appears to have been painted the last time in the days of the western frontier. Again a gallant effort is moving forward an inch at a time. Hope seems to spring eternal even in the face of the odds that would cause most people to pack up and move elsewhere. Even with the progress there is still the site of patients in crowed rooms with bars on doors and windows, wallowing in the agony that has imprisoned them in their own minds. It makes most western visitors back instinctively toward the door when they unexpectedly confront the scene. No warning will suffice, for there is nothing in their western experience to give them a parallel to what they are about to encounter. Naked men walking around talking to themselves. Screams coming from isolation rooms. Women with blank stares, searching for an unseen past. Humanity pleading for help.   Many a deep gasp has been left at the entrance door as the visitor determines they have seen enough and seeks the relative safety of the parking lot.
    Since Bottom Hospital is still primarily a hospital for TB, orthopedic care, delivering babies and for the care of the mentally ill, we decide to end our visit with the later two departments. And in many respects that is far too much. Leaving the hospital one must try to get a western mind around the disappointment and despair that is felt when realizing that mothers are delivering their babies in an unsterile room on a black garbage bag they were required to bring to the hospital. These are used in order to be able to clean up after the delivery because so little sanitation and sterilization equipment is available. Tears come easily as one considers how a mother must feel when she is giving birth to her first baby and it must be done on a trash bag! A lot of things bring tears when viewed through the prism of Bottom Hospital. Many will chose not to make a return trip to visit there again. And there is understanding as to why they feel this way.


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