Malawi: Australian doctor Rosyln Brooks

Dr Roslyn Brooks, photo taken while working in Sri Lanka, 2009. © Petra Thomson / MSF

Roslyn Brooks is a doctor from Cooma in New South Wales. She is currently working with Médecins Sans Frontières in Malawi, in one of the organisation’s biggest HIV/AIDS program. This is Roslyn’s fifth field placement with Médecins Sans Frontières, having previously worked in Thailand, Nepal, Sudan and Sri Lanka.

6 September
Hello from Chiradzulu, where it is cool and overcast this morning after a hot, dry, dusty and very smoky week. The clouds and cooler air that blew in last night were very welcome, although the air is still full of smoke as people continue to dig and clear their fields, burning weeds and stubble. I am afraid the smoke haze will continue through the dry season now until the rains begin in November. We will have a lot of much hotter and dry weather before then so I am making the most of any cool spells. There are lots of mangoes in the market now, they are excellent and very cheap (equivalent to about 10 Australian cents).
 
We have a new pharmacist, Natasha, or Tash, who is another Aussie. She has done one field placement with Médecins Sans Frontières before in Jordan, but has spent many years with other NGOs in Micronesia and other places, including Africa, so she has lots of the right kind of experience. She is full of enthusiasm and is already using some local language, determined to learn more.
Tash is very keen to get stuck into the big task of getting our pharmacy under control. However she has a very sensible attitude of spending the first weeks observing, finding out what is going on, and getting the trust and support of her national staff before trying to make changes - gradually. I think she is a real winner!
 
I have had a good week, and am starting to feel that I am building a good relationship with the clinical officers and also getting to know more of the nurses and counsellors who make up the teams of national staff working in the health centres.

I visited three health centres this week, and working alongside the clinical officers and nurses, I felt I was not only more familiar with the medical problems and treatment protocols for HIV, but I am becoming able to provide some useful input on complicated cases. It is good not to feel so ignorant as I did at first! It is impressive to see how quick and efficient they are at the work. I guess the main thing I can contribute at present is thinking outside the basic protocols with more complicated clinical cases, confusing drug side effects etc, and having a broader overall clinical perspective. Plus just encouragement, support and reinforcement of all they are doing right!

While most of the patients we see returning to the health centres for their checkups and supply of antiretroviral treatment look well and happy, there are lots of tragic stories too. I am doing an audit of the patients from each health centre who died during the past month. One child was six years old and weighed only 10 kg when he was first seen. His parents had died, probably of AIDS, and he was cared for by a relative. He had anaemia, diarrhoea, malaria, liver disease as well as severe malnutrition and had arrived too late for medical care. Very likely, he had other infections like tuberculosis, but died after being admitted to hospital, before a full assessment could be made. So many children here are born already infected with HIV because their mothers are infected. If they are not treated with antiretroviral drugs they will probably die of severe infections and malnutrition (from chronic diarrhoea and sicknesses) before they are five. Even on treatment, they are faced with a lifetime of taking medicine that has unpleasant side effects; and the treatment is likely to become ineffective after ten years or so due to the virus developing drug resistance.

Other drugs can be substituted but with long term treatment eventually the options are exhausted, and the virus will multiply, destroying the person's immunity, until they succumb to infection or cancer. It is for this reason that the prevention of mother to child transmission of the virus is so important, and this is a significant aspect of the program.

11 September
Not much new this week, things have continued much as before for me, with daily visits to the health centres and afternoons in the office. It is sometimes frustrating not to be doing direct patient care and clinical consultations myself, but I am supporting the clinical officers in their roles, which I consider the most important aspect of my whole job, and will keep working on this.
The weather is getting hotter with clear sunny days, but today again a cold wind and cloud cover, a nice change. The air is a pall of smoke most mornings now as burning off increases; it clears a little during the day but is always noticeable. If only the farmers would mulch their weeds and leaves!
 
Yesterday at Mbulumbuzi health centre, we saw one ten year old boy with an infected, oozing fungal rash on his face. It looked really sore and he seemed very miserable. Luckily it can be treated quite easily and should clear up completely. But as most of the children we see who are in the program look well, I was a bit surprised at this neglected looking rash. Sure enough it turned out he had missed coming to the clinic for a couple of years after starting in the program (for what reason I do not know) so had not been on preventive drugs or having regular checks to pick up infections, rashes etc early. I guess his parents only thought about bringing him back when he got sick. It underlined how effective the program is when people are seen every three months for a medical check, counselling to encourage adherence to their treatment, and of course the prophylactic (preventive) antibiotics and antiretroviral drugs.

Sometimes people stop coming when they are well, so part of the initial counselling emphasises the importance of regular checks and taking medication even when well. I still feel happy when I see so many cheerful healthy kids and adults turning up with big smiles. The kids aged from five to 15 usually have counselling on the same day as their three monthly medical check, and often come along to see the clinical officer with the balloons or lollies they have been given, and with big grins. The counselling is done so well and in such a supportive way, stressing that with ongoing treatment they can lead normal lives - school, further education, work, marriage, family. It seems that the availability of good treatment is reducing the sense of stigma and despair associated with HIV infection here, and many HIV positive people are indeed living normal lives.
 
Last Sunday I walked along a small dirt back road for about an hour, and at various points was followed by mobs of giggling cheeky children who thought it a great joke to see me tramping along. They have very limited English and it becomes rather tedious to be asked 50 times 'what is your name? where are you going?' especially as most of them can ask the question but not understand the answer - I am not sure if most of them even know what 'where are you going?' means.

In Chiradzulu there are some who pester every white expat with the chant - 'give me my money' - these I ignore completely, but unless feeling very tired and fragile I try to reply to every one of the hundreds of 'what is your name?'s with a smile. As one expat commented 'there is not so much for kids to do in Chiradzulu, so any foreigner is a diversion'.

Well whatever else I might or might not be able to contribute here I can claim to have been a source of fun for a few local children!