Report about a mission to Mzuzu, Malawi in November 2024

Interplast-Germany, Section Kurpfalz in cooperation with Wells for Zoë

 

by Dr. Joachim Gröschel
Anesthesiologist
Interplast-Germany e.V.
j.groeschel@web.de

 

At the end of October, we set off on an unusual mission to Malawi. Dr Joachim Gröschel, an Interplast anesthesiologist in Malawi for many years, had a special idea. Mobile ultrasound should fundamentally improve the care of health-centers, central hospitals and clinics in northern Malawi in the future. He was accompanied by Dr Martin Krajewski, an orthopedic surgeon. Martin has been working in Africa for many years, including over a year at Puma Hospital in Tanzania. Also, part of the team was Angelika Möhrer, a nurse from the BG-Klinik in Ludwigshafen with extensive work-experience in East Africa.

 

After countless preparations and numerous emails, WhatsApps and video conferences, the plan for this project was finalized. We were supported by an NGO from Ireland, which has been active in Mzuzu since 2005. Wells for Zoë specializes in building wells, planting trees, educational projects and supporting health centers.

 

In order to better assess the general conditions, we began with 3-hour ultrasound courses. Topics included an introduction to sonography, vascular puncture, an overview of regional anesthesia with ultrasound, lung ultrasound and trauma ultrasound. This was followed by practical exercises on a puncture model and on volunteers. Angelika especially ‘cooked’ the model on site so that it didn’t weigh down our luggage.

 

We were surprised by the high level of participation and the enthusiasm of our colleagues. There were 26 participants at St John of God’s Catholic Hospital, another 18 at Mzuzu Central Hospital and as many as 40 at Chitipa District Hospital in northern Malawi. The lectures were interspersed not only with exercises, but also with interactive quizzes in which the participants took part online using their smartphones. The winner received a bar of chocolate to loud applause. Our feedback form was also completed online, providing interesting insights for further work. See separate report. The certificates of participation, professionally produced by Martin, were also a source of great joy and were proudly used to create final pictures and selfies.

 

It must be said, however, that the requirements of the participants in these pilot events were very heterogeneous. From nurses and physiotherapists who had never used ultrasound before, to doctors and clinical officers who come into contact with it occasionally, to radiographers who deal with it on a daily basis. However, our list of participants will make it possible in future to address participants specifically and make suitable offers.

 

What was certainly new for all colleagues, however, were the many new areas of application that we were able to point out. Abdominal ultrasound and obstetric ultrasound are the most common procedures in Malawi. There seems to be an immense demand for obstetric ultrasound in particular. Another new feature for the participants was the possibility of mobile ultrasound from the company Butterfly, which offers the option of tele-sonography and therefore ultrasound support from experts in Germany and all over the world.
Of course, the question of whether we could leave the equipment in place came up again and again. In both hospitals in Mzuzu only the radiologists use ultrasound and in Chitipa the only device is defective. Often not even the x-ray equipment works there. This time, however, our aim was to determine general interest in the topic, explore the possibility of further specialized workshops and test the necessary conditions.

 

Targeted events are then to be organized next year with further funding. Additional devices could be procured for this purpose. The cost per device is only €4-5,000 . This would allow Interplast ultrasound trainers from Germany to hold a workshop in the first week and then accompany their qualified Malawian colleagues to their workplaces in the second week and hand over the equipment for long-term use. In order not to leave them alone afterwards, they could continue to receive tele-sonographic assistance from a network of international experts in difficult cases.

 

For doctors and clinical officers with their own practices, we came up with the idea of not giving them the ultrasound equipment free of charge. We were told that between 8,000 and 15,000 Kwacha, i.e. between €4 and €7.50, is required for the private liquidation of an obstetric ultrasound. With the help of a loan, the practice owners could afford the equipment and their own initiative could be encouraged. The same would be conceivable for hospitals. Qualification, i.e. participation in appropriate training courses, should be a prerequisite for qualifying for a loan and a device.

 

Incidentally, through our discussions with the medical council in the capital Lilongwe, we were able to find out that Malawi also has a mandatory system of further training. It is not called CME but CPD, Continuing Professional Development. Our lectures were also rewarded with 2 points each.

 

In addition to the sono-lectures, another goal was to determine whether tele-sonography could also be possible in the health-centres of the partner organisation Wells for Zoe. The health workers could be specifically trained to recognize pregnancy complications and pneumonia in children. Also supported by experts using tele-sonography via the internet.

 

Pneumonia (lung inflammation) is the most common cause of death in under-fives worldwide and is easy to diagnose using ultrasound. The widespread practice of administering antibiotics to all children with a cough and fever and causing antibiotic resistance could be replaced by targeted treatment of actual pneumonia. This would make a major contribution to reducing infant mortality.

 

In the case of pregnant women, it is a question of recognizing the most important complications. Simply determining the exact date of birth, which is easy to do, can save lives because women arrive at the hospital’s Mothers House in good time and do not have to be transported by oxcart during labour.

 

The visit to a health centre in Elamuleni south of Mzuzu was somewhat disappointing in this respect, however, as there was no mobile phone reception at all. Instead, we were greeted by hundreds of women and children singing and dancing. Our partner organisation has plans to equip the health centres with mobile internet via Starlink so that an internet connection will hopefully be possible in the future.
The next day, we therefore decided not to visit another health centre, but to test the tele-sonography in Mzuzu with good internet to Germany. On the other side, Angelika was initially available at the accommodation and finally also the gynaecologist Dr Fiona Werland. The tele-sonography worked relatively well, technically and Fiona skillfully explained how to proceed. Only the tablet with the ultrasound image had to be held by a second person between the examiner and the patient, which was a little cumbersome.

 

The Malawian nurse Alepher proved to be a stroke of luck for us. She coordinated all our activities with Wells for Zoë and the hospitals in Mzuzu. As head of the health-centers, we were able to introduce her to ultrasound. What’s more, she was given a crash course, and proved to be talented and very eager to learn. This way we were confident to give her a probe at the end of our stay, which was financed by Wells for Zoë. This will allow us to continue evaluating the practical application until our next mission. Meanwhile, Joachim supported her tele-sonographically from Germany several times after his return home.

 

In addition to numerous discussions with those responsible for health care, Martin was the only one who had time to enjoy the beauty of Malawi by visiting Livingstonia in the mountains. Angelika was confined to bed and the toilet for a few days with severe diarrhoea. So severe that Joachim had to give her several litres of infusion to get her back on her feet.

 

Nevertheless, all our goals were achieved and the conditions for the further promotion of mobile ultrasound in Malawi were created.

 

We would be delighted to receive practical support and good suggestions on how to proceed.