On the ground in Malawi by Mick James

We left Malawi on 20th March after seven weeks of visiting villages and many hours spent in all four Central Hospital Emergency Departments. Covid19 was just really coming into the public consciousness, but it was still really someone else’s problem, just as it was here when we first heard about it.

In the hospitals the mood changed over our seven weeks with Covid19 becoming an agenda item and being talked about as a certainty by the lead clinicians. The front-line staff were too professional to be in denial, but they were realistic and they were visibly nervous. In one department a senior professional told us they had 12 nurses, 2 clinicians and a locum to cover Emergency Medicine 24/7. Given the expectation that >25% of staff would be ill at any one time they were realistic about their ability to deal with large patient numbers.

Front-line staff were quietly thankful Malawi had no testing (and hence no cases) as it gave them a breathing space to create some kind of a plan. This plan was being driven by the limited staff, spaces and resources already available in the system as they sought to cope with what they saw coming.

The clinicians were most concerned about the practicalities. How would they isolate cases? Where were the spare wards? Where would they find spare nurses to run a ward and not be part of the rest of the hospital? Where would they find spare equipment? There were less than 20 ventilators in the country at the time.

They were also trying to figure out how to deal with the practicalities of the scrum at the Emergency Department door – with outpatients, guardians (Malawian patients normally bring two or three along to feed the patient), trauma and emergency patients all mixed together, and lengthy triage times meaning infection could spread quickly among the already sick. Even getting money for signage to direct those with a cough and temperature was hard.

In the villages understanding of Covid19 lags behind the urban areas. Traditionally communication is driven through meetings. Village Head Men meetings; school meetings; church groups; communal song and dance. All passing on information in a sociable and open forum. Covid19 will force a re-think to the communication strategy. WhatsApp is already circulating myths; avocado and lemon are not cures; and countering these with flyers, free texts, radio, data free corona sites will all help. Right now our Community Youth Group contacts tell us there is little understanding in the villages and subsistence farmers, already in food crisis, are not well placed to isolate.