Dr Sue Heyes is a British doctor, who spent a year working in the diabetes clinic in Queen Elizabeth Central Hospital, Blantyre, Malawi. I was lucky enough to spend time shadowing her last summer, and she has kindly allowed me to interview her for my blog.
Me: What was the biggest challenge that you faced working in Malawi?
Dr Heyes: The biggest challenge that I faced working in Malawi was two fold really. One was having so few reliable clinical tests available to help in diagnosing patients. The other was not having enough basic drugs available to treat the commonest illnesses.
Regarding the clinical tests available, the hospital had lots of fairly up-to-date machines for performing tests, but they often didn’t work because they needed a new part which was unavailable, or the reagents were out of stock for the blood and microbiology testing. For example, for a few weeks there were no tests available for diagnosing HIV so that meant that patients could not be started on their HIV drugs because it was essential to have a positive test result before starting treatment. Also, we not infrequently ran out of processing chemicals so that X rays could not be developed so no X rays. Most of the time there were not the reagents for the machine which checked for electrolytes (a test of kidney function) so there were no results or more commonly they just could not be relied on… The test results for TB often got lost and had to be repeated several times before a result was available…… Getting lymph node biopsies done and getting a result, to distinguish between TB and lymphoma, was so difficult to organise….The MRI scanner needed a spare part so was not in use for a few weeks while they waited for the part to arrive and the machine to be repaired… I could go on and on, but you can imagine how difficult this made things. In the UK, we rely on test results so much in making our diagnoses, so in Malawi I had to relearn my clincical skills and start to rely on them for diagnosis.
Regarding drug supplies there did not seem to be a problem with supply of drugs for TB or HIV treatment. However there were severe shortages of almost all other drugs. Twice during my year in Malawi we had no long-acting Insulin (the commonest treatment for Insulin treated diabetes ) available for several weeks. There was no good alternative available. Some people were given quick acting Insulin as an alternative but there is a much greater risk of low blood sugar levels with this and consequently, sometimes death.
In addition, we sometimes for a few weeks, did not have the antibiotics needed to treat the commonest bacterial infections, eg bacterial meningitis, pneumonia, non-typhoid salmonella and even malaria. These are very common in patients with HIV and will often cause death in these patients whose immune systems are so damaged.
One of the worst things, though, was the lack of available painkillers, both mild and strong ones. Mostly the only painkiller available in the short term was paracetamol. Good painkillers were available for patients who had a confirmed terminal illness through Tyanjane, but generally on the wards there were very few available. I ended up having my own supply of painkillers which I gave out on the wards as necessary. To me it is bad enough that we did not have the right drugs to treat the patients with, but it seems unacceptable that we were not at least able to keep our patients comfortable and allow them to die as comfortable a death as possible.
Me: In the UK everyone thinks of AIDS or malaria when you mention Africa, do you think diabetes gets forgotten about, and how could awareness be improved?
Dr Heyes: I do think that Diabetes gets forgotten about when thinking about Africa. I believe that over the next 20 years, it is going to become a huge public health issue, as an increasing cause of illness and death. It is obviously important to raise awareness of diabetes, both its prevention,diagnosis and treatment available, in Malawi. However, having seen the scourge of HIV at first hand, I can completely understand the priority given to HIV awareness in Malawi at the moment when health care resources are so scarce. HIV predominantly affects young adults in the age 20 to 40 age group who tend to have young children and families to look after where as most people with Diabetes tend to be in an older age group, so again, much as I, as a diabetes specialist, would love to see Diabetes having a higher profile, I can understand why HIV takes priority.
Interestingly, it is now known that some of the drugs used to treat HIV increase the risk of developing Diabetes, so therefore actually increasing education about the prevention of HIV, would also impact to some degree, the incidence of diabetes in the developing world in the future!
Me: What was your most rewarding experience working in Malawi?
Dr Heyes: Regarding rewarding experiences in Malawi, there are two which stand out in my mind.
One was looking after a young man with HIV and paraplegia (loss of any power and sensation in his legs and lower back). He and his 2 younger brothers had been orphans for many years (probably due to HIV) and R was the breadwinner while his brothers finished their schooling. They were all very bright boys and the youngest brother wanted to go to medical school to train as a doctor. R was looked after in hospital by his middle brother M who had left school but was unable to get a job because he was caring for R. Over a few weeks it became apparent that there was no hope that R would ever recover from the dreadful pressure sores he had developed on his bottom and hips (because he had no feeling below the waist). I was able to help M to come to accept that his brother could not get better and was going to die and I was responsible for his care when he died peacefully in hospital, with his family understanding that this was inevitable.
Subsequently, I was very pleased to learn that M had been successful in getting a job as a translator at QECH (the hospital where I was working) which hopefully will be his first step on the employment ladder and means that M is now able to financially support his family.
The other rewarding thing about my time at QECH (Queen Elizabeth’s Central Hospital, Blantyre) was the development of a diabetes foot clinic which had open access for any diabetic patients with foot problems, in the out patient department which ran weekly . This is the only diabetic foot clinic in Malawi and had not existed before 2012. We were able to offer education regarding the prevention of foot ulcers in diabetics, as well as providing good multi -disciplinary treatment for pateints with ulcers, to help the ulcers to heal and to prevent subsequent amputation which is an all too common consequence of foot ulcers in sub-saharan Africa. During my time there, the Orthotics department made their first pressure-relieving insoles to be worn in shoes, to off-load pressure areas in a patient who had had recurrent foot ulcers over many years. And it was wonderful to see some of the ulcers that I had treated actually heal and not need those amputations (from which there is such a high mortality in Sub saharan Africa).
I would like to thank Dr Heyes for taking the time to answer my questions in such depth.