Working in Malawi as a Physiotherapist

JOSEPHINE KINSELLA DipPhys ~ I I S C P nlCSP Ph!\iotherdpisi. SI Miclirdl's Housc. Dublin

Key words: Malawi. propranime to help the disabled. low cost appliances. rural clinics. treatnient of children with brain damage. physiotherapy in Malawi. some personal thoughts. Summary: The author describes the organisation she work! for in Malawi and the work she was involved in as a physiotherapist in a devcloping country. There is a description of the current state of physiotherapy in Malawi and plans and hopes for the profession. The article concludes with sonle personal thoughts on the author's time in Malawi. Biography: Josephine Kinsella qualified from the Dublin School of Physiotherapy and Trinity College Dublin in 1981., She worked at, Waterford Regional Hospital and then with the Western Care Association, an organisation for the mentally handicapped in County Mayo. Ireland, before going on to Malawi in 1986 for two years as a VSO volunteer. She now works for St Micheal's House. an orpanisation for the mentally handicapped in Dublin.

Introduction MALAWI is a developing country in South East Africa, known as Nyasaland until it became independent in 1964. The country is mainly agricultural, producing tobacco, sugar, tea, cotton, groundnuts and macedamia nuts. The population of approximately seven million people live mainly in the rural areas and support themselves by subsistence farming.

Malawi Against Polio (MAP) was formed in 1977 by a group of concerned doctors, churchmen and others who hoped to set up a programme to help the many thousands of polio victims across the country. They planned to follow the successful methods pioneered in Uganda by Professor Ronald Huckstep in the 1960s and early 1970s.

Professor Huckstep visited Malawi in 1978 and following his visit the plan of action for setting up a nationwide rehabilitation programme was set in motion. Workshops were set up in each of the country's three main centres of population, each manufacturing a range of calipers, crutches and walking aids. Based on Professor Huckstep's designs, these appliances were all simple and inexpensive devices which could be made by people with a minimum of technical skills. Later, wheelchairs and hand-propelled tricycles were also manufactured at these workshops.

Medical teams~from each of the centres travelled to district and mission hospitals throughout the country to meet disabled people in each area and arrange help for them. Despite the name Malawi Against Polio, people suffering from other forms of physical disabilities have always made up a large percentage of MAP'S patients - about 60% are affected by conditions other than polio.

Lilongwe Polio Unit I 'went to Malawi in February 1986 to work as a volunteer

physiotherapist wi th MAP. I was based in Lilongwe (the country's capital). MAP Lilongwe, as the centre where I worked is generally known, operates from part of the old general hospital where there are workshops for making the appliances, an office and a small ward wi th 11 beds where patients and their families stay when waiting for treatment or for repairs to their appliances. Operations and physio- therapy treatments are carried out at Kamuzu Central Hospital (the new general hospital) t w o miles away.

The centre's catchment area for patients is an area about 300 km northhouth by 200 k m east/west and at the end of 1987 approximately 5,000 patients were on record, half being polio victims and half wi th other conditions.

With such a large area to cover, holding regular clinics throughout the region is an important part of the service.

Fitting new calipers and clogs for a child at a rural clinic while mother looks on Learning to walk after tendon releases to strengthen legs deformed by polio

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Above: The proud new owner shows off a hand-propelled tricycle made at the Lilongwe workshop while two other patients, a relative and the maker of the tricycle look on

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Right: Measuring new appliances for a young polio patient at a rural clinic * , , -

Staff go out to 28 district and mission hospitals to hold clinics every two months. At these clinics they see people referred by the local health personnel or people who have heard about MAP from other sources such as their church, friends and neighbours, or the traditional authorities; and regular patients who come when they need new appliances or repairs to their existing ones.

The patients needing specific physiotherapy treatment, mainly the young children with cerebral palsy, are asked to come in to Lilongwe and stay at the centre for a period of daily physiotherapy treatment; others needing simpler assistance such as the changing of corrective plaster of Paris casts on children with club feet, and the measuring or repairing of appliances, can be dealt wi th at the rural clinic.

The main part of my work was with the many babies and young children suffering from neurological problems or developmental delay. The major causes of brain damage in babies and young children in Malawi are birth trauma and severe convulsions due to diseases such as malaria, meningitis and measles. Children who are neurologically normal can be very delayed in their development due to poor nutrition, frequent illness or in some cases simple lack of stimulation.

When mothers are asked to bring their children to the centre at Lilongwe for a period of daily physiotherapy treatment, it is a big effort for them to leave their other children at home and travel to the capital with a handicapped child. In Malawi as in most African countries the women do most of the farm work as well as the housework and bringing up the children. I t is very important that staff time is spent teaching the mothers how to handle and work wi th their children a t home as when they go away after treatment it may be many months before they are seen again.

The women are usually enthusiastic, and once they under- stand what to do they are not at all inhibited or nervous of doing the wrong thing. Having a group of mothers together for a treatment session really helps as the more experienced mothers assist and encourage the newcomers.

The equipment used with these children is kept to a minimum. Some simple toys have been collected over the years, and rather than trying to get expensive foam wedges and rolls for each patient to take home we teach the mothers to use their own bodies instead of this equipment. They position the children on their laps instead of using a wedge, or over one leg instead of using a roll. If a child is unable to sit, a wooden corner seat may be provided at home; and for those learning to walk, wooden trolleys and rollators can be made.

Results of treatment are mixed, and because it must be on-going for most of the children’s lives a lot of the mothers stop attending after a while and one can only speculate as to the reason why. For some it is because they expected an immediate cure and did not get it, for others the effort involved in coming for treatment may have become too much, and for others, more positively, the patient may have improved to such a state that the mother was happy with her child‘s condition and saw no reason to keep coming back.

Physiotherapy in Malawi Physiotherapy is a new profession in Malawi and at present

a physiotherapy service is provided at only six centres in the country. There are five qualified Malawians and about ten expatriates working as physiotherapists in the country. There is no physiotherapy training school or training scheme for helpers. Physiotherapists have to train abroad and the people working as helpers are usually State enrolled nurses who have been seconded to the department and receive on-the- job training from the physiotherapists.

It will be some time before the plan to have physio- therapists in all the district and mission hospitals becomes the reality but despite this the Malawian therapists are optimistic about physiotherapy as a profession in their country. In the short term they are hoping that more physio- therapists will be recruited from overseas to expand the service into the districts and that more school-leavers will

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be enabled to go abroad to train as physiotherapists. In the ionger term it is hoped that a physiotherapy school will be started in the country followed by a training course for physiotherapy helpers. Indeed, so far-thinking is this group of Malawians, that they are already investigating the possibility of forming a Society of their own.

Some Thoughts on being a Physiotherapist and Volunteer in Malawi

Working as a physiotherapist and volunteer in Malawi has been a mixture of all sorts of experiences. There have been the rewarding times when a patient who came in our door crawling on all fours eventually went out again walking, even if it was with the help of crutches and calipers; and the depressing times when I have had to tell someone that there is nothing we can do for them. There have been the frustrat- ing times when I felt like a complete outsider and the gulf between what I had learned about the people of Malawi and what I needed to know to be effective in the field of rehabilitation was as wide as Lake Malawi itself.

Being a volunteer is not all about work, of course. There were great opportunities to travel around what is a beautiful, friendly and easy-going country, to learn a little of a very different culture and language, and also strangely enough to see my own country and culture wi th the benefit of a clearer vision that distance brings.

ACKNOWLEDGMENTS

M y thanks are due to Mrs Sylvia Kambelamatore RPT DipManagement, superintendent physiotherapist in charge of physiotherapy services in Malawi; to the Malawi Against Polio head office in Blantyre for allowing me access to its filing cabinet; and to my former colleagues in Lilongwe for their help, patience and support during my time with them.

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Fitting new appliances at the MAP clinic at Nkhotakota Districi Hospital

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A little boy whose legs are paralysed and deformed by polio - crawling is his only means of mobility

Mothers at work with their handicapped children in the physiotherapy department of Kamuzu Central Hospital, Lilongwe

Some healthy local children posing for a photograph at the lake shore

REFERENCE

Huckstep, R L (1970). Poliomyelitis. A guide for developing countries - lncluding appliances and rehabilitarion for the disabled. Published by The English Language Society and Churchill Livingstone, Edinburgh.

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