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Many people ask about the six years I spent working in Malawi and how it's really possible to achieve anything useful in a poverty stricken country that is ravaged by AIDS. I usually reply that the teaching you deliver is just as important, and probably longer lasting, than the clinical practice. If you too are curious please join me now on my round in the men's ward of a government hospital. It is February: rainy season and hungry season. We are aiming to see 56 patients sharing 32 beds; three quarters of these patients have HIV. Our team comprises a clinical officer, a house officer, a medical student, and a messenger. The few nurses are too busy to join us. We have three hours.
The first call is to the diarrhoea side room, a sobering array of wasted bodies and sunken eyes. The floor is wet with poorly mopped spills from bed pans. Most of these men meet the criteria for newly available antiretrovirals from the Global Fund to Fight AIDS, Tuberculosis and Malaria. We fan out among the patients and go into information overdrive. “Go and have an HIV test in the room across the yard. If it is positive you can register for strong HIV drugs. If you don't have a test you can't get the treatment.” We wash our hands in a bowl, but there is no soap or towel.
The first bay on the main ward is reserved for patients with meningitis, strokes, or paraplegia. The team spreads out ahead, preparing cases for me to review. We crouch on the floor to assess coma scores, and I crawl half under a bed with the house officer to show him the sensory level of a man with paraplegia. Urine seeps from the mattress on to our knees. The clinical officer falls behind to demonstrate a cerebrospinal fluid tap to the student. The house officer asks me about a sixth nerve palsy in a thin comatose man in a yellow T shirt in bed 7. He needs a computed tomography scan; we can't get one. I check my watch: over an hour gone.
Relatives are leaning in through the windows, anxious, listening, watching, commenting. One calls across, asking me to treat his cough, and I tell him where to find the clinic. As we pass the nurse on her drug round, a man from the other half of the ward pulls at my coat sleeve: “Mundithandize” (“Help me”). I feel under pressure and distracted, and the nurse tells him that we are not his doctors and that someone will see him later.
We regroup and begin on the second bay: bacteraemias, ascites, pneumonias, tuberculosis, jaundice. The team spreads out, and I work my way along the beds. We question, examine, take diagnostic aspirates, scrutinise x ray pictures at the window, and discuss management decisions. We can usefully do a lot here. We are planning treatment for a man with tuberculosis ascites when the sound of keening erupts at the windows—the man in bed 7 has died. Another patient is tapping my shoulder and demanding that I help with his stomach pains. I can't concentrate amid the wailing, and I ask the nurse to get the body taken to the morgue. We shake off the shoulder tapper, the messenger leaves with seven sets of notes to register patients for tuberculosis treatment, and the student accompanies four men through the rain to the HIV testing room.
In 35 minutes the food trolley will arrive, relatives will flood in, and further progress will become impossible. But we hasten through several cases of chronic cough in the last bay and are seeing the final patient as the ward doors open. I am very grubby, mentally weary, and physically drained but also, dare I confess it, rather smug. We did well. We worked as a team and saw all our patients, learnt useful clinical skills, and made good decisions. I issue a closing pep talk and turn to leave.
Passing the noisy relatives, I feel an insistent tug on my coat hem. Not again! I whip round, suddenly angry and impatient to get out. It is one of the patients on the floor in the second bay. Can he not see how hard we have worked? I don't bother to conceal my irritation and speak in clumsy Chichewa: “I have already heard your problem. What do you want now?” He looks up at me earnestly. “Nothing, doctor. You look tired. I think you can share my beans.” He pushes his watery hospital meal on its plastic plate across the concrete floor towards me. I am humbled, deflated, and touched. Who now is teaching the lessons? This sick and wasted subsistence farmer, with his unassuming kindness and generosity, has reminded me in just five seconds why I came to Malawi in the first place, as well as how I should be practising medicine wherever I am, be it in Africa or Britain. If our clinical targets and efficiency crowd out what our patients can teach us about humanity, we are missing the most important lessons of all.
This subsistence farmer has reminded me in just five seconds why I came to Malawi