Since July 2016, I have lived and worked in Malawi as part of the Global Health Service Partnership, a joint program of the Peace Corps, the President’s Emergency Plan for AIDS Relief (PEPFAR), and Seed Global Health. GHSP aims to improve clinical education, expand the base of physician and nursing educators, and build healthcare capacity in five countries, Malawi, Uganda, Tanzania, Swaziland, and Liberia, that face critical shortages of healthcare providers. I’m visiting faculty at Kamuzu College of Nursing, University of Malawi (KCN Blantyre Campus), where my brief is to expand research capacity.

So what does it mean to “expand research capacity”? That means I supervise 32 masters’ degree candidates in their research dissertations, am an instructor for doctoral students, am working with faculty on their research, and am developing joint studies.  It also means working in collaboration with colleagues at the College of Medicine and other research institutions to promote and support the development of research that addresses the needs of the Malawi people.

For example, many of the masters students are currently collecting data for their dissertation at district hospitals or other remote centres in the country. Data collection sounds so clean and easy, but it isn’t, interviews don’t always go as one hoped and records can be missing. In order to help students address challenges early in the collection process, I’ve been trying to review their data and find ways to mitigate issues that arise. The best way to do this, in my opinion, is to visit the student at his/her research site to understand the context and then troubleshoot together to find solutions.  

Last week, my work brought me from Blantyre, the principle city of the Southern Region, to Mzuzu, the main city of the Northern Region, over 400 miles and a 10 hour drive away. The Northern region has less population density, lower HIV rates, and higher median years of education than the more populated Central and Southern regions (Malawi DHS 2015-2016).

After hours and hours of driving through sere, dusty, crowded towns punctuated by hills denuded of trees, the land began to rise, and the temperature dropped. The burnt dry landscape yielded to tall green pines, granite domes, and the sparsely populated spaces of the North. At times, I had cognitive dissonance – am I driving to Yosemite or to Mzuzu – then turned a corner to see a troupe of monkeys sunning themselves on the shoulder of the road, reminding me that I was still in Africa. 

Though I was staying in the city of Mzuzu in Mzimba district, I had to drive south for 1.5-2 hours to meet the graduate student at the main hospital in the southern part of Mzimba where she was gathering data on outcomes for women with severe primary post partum hemorrhage (PPH). This was a retrospective study where we are examining 4 years worth of labour and delivery records to determine the number of women with PPH and their outcomes based on various factors. Simply put, did women that experienced severe PPH live or die and what factors may have led to survivorship vs. death. She was still collecting records, but found issues with missing data on women that had been transferred to that main hospital from an outlying facility. Records hadn’t been sent with the women. The implications of missing records this are dire, if monitoring data hadn’t been sent with women coming from outlying areas, it could impose critical delays in appropriate diagnosis and care on top of existing delays in care due to transport. So now we will consider the role of missing records when analyzing the odds of death from PPH.

The next day, I met with staff on the pediatric ward at Mzuzu Central Hospital (MCH). There are four central hospitals in Malawi, each one a regional referral centre. MCH is a newer facility as compared to Queen Elizabeth Central Hospital (QECH), the referral hospital for Southern region, where I am based.  Similar to QECH, the Mzuzu facility consists of a series of separate brick wards connected by covered walkways, but it is smaller, quieter, cleaner, and in much better physical shape than its Southern counterpart.  I met with the ward matron, several pediatric nurses and the medical officer to discuss some research practice improvement initiatives. The head matron noted that there are perhaps 200 children in the region that are known to have Sickle Cell Disease (SCD). These children suffer from painful, debilitating SCD crises, requiring frequent readmissions to MCH, sometimes on a monthly basis. The head matron wants to stop the cycle of frequent readmissions. We discussed chronic disease models for children, considering that HIV and diabetes both centre on improving family knowledge of disease, enhanced management, and psychosocial support for children and families.

I shared the literature I had on SCD cases Malawi, and schemes for management of SCD from  Kenya, Tanzania, and Uganda so we can consider what might work in Malawi.  MCH has a good records system, which we will use to gather initial statistics on the number of children with SCD, number of admissions per year for SCD, and SCD admissions as a percent of total paediatric admissions.  We are considering funding sources that would potentially support the SCD clinic as an example of increasing staff capacity to deliver non-communicable chronic disease care.

On Friday, I met with Mrs. Phiri, a senior lecturer in Nursing at Mzuzu University, to engage her in the SCD clinic effort at MCH. Mrs. Phiri presented some wonderful research on adolescents with diabetes at our recent interdisciplinary Paediatric and Child Health Association of Malawi Conference. She is interested in collaborating with the MCH staff on this as she has worked with them previously. Her understanding of the challenges in chronic disease management will be an invaluable contribution. And we are bringing in a palliative care nurse to work with families and staff to use a pain rating system, and pain medication to see if it might bring down to time from crisis onset to hospital and reduce morbidity during the transport period. We discussed possible outcomes we might see if this initiative is successful. My GHSP colleagues in Mzuzu, Julie and Casey, are based at Mzuzu University and will also follow up with faculty and hospital staff on this effort.

So, will I lead this work, be a co-PI if we get funds to compare admissions and length of stay pre and post roll out of the SCD initiative? No. I am bringing together the relevant parties in Mzuzu to discuss ideas, to provide literature, to make suggestions on practice design and possible funding sources -to help them realize their goals. But it is the staff, particularly our highly motivated paediatric Matron, that has started this process, leads it, and is owning this initiative every step of the way.

My role is to facilitate increased nursing and medical research by and for Malawians. Yes, it can be frustrating as I would love to have my own projects but Malawians should be able to set their own research agenda rather than follow the priorities set by external aid agencies or foreign researchers and my hope of that this kind of encouragement will expand number and the quality of Malawian initiated nursing research.

Many of the readers may be asking at this point – where is the part where we read about the horrible conditions and terrible sacrifices you’ve made to do this work?  But this isn’t about that; I chose to be here. 

Seeing the masters students evolve in their practice, collaborating with the excellent child health Faculty at KCN in Blantyre, assisting the MCH paediatric ward staff in setting their own research priorities, is rewarding. I’ve learned hard lessons about my own limitations and then pushed myself to try to overcome those limits to be a better researcher, teacher, and nurse. For every bad day, frustrating experience, or sacrifice made, I’ve been gifted in return by connections to great people and opportunities for personal and professional growth. I don’t know what the future will bring but this experience has allowed me to be more able to take on whatever lies ahead.