LINKS case study competition

below is a copy of the essay we wrote to win first prize! it hasnt copied well unfortunately but maybe you get the idea!

xxx

LINKS case study competition

Medicine in Malawi - Enhanced Electives in Developing Countries
Neil Merrylees, Jon Dowell (Staff) Rebecca Acquah (Student) Dundee Medical School, UK
Dan Namarika Director of Medicine, Kamuzu Central Hospital, Lilongwe, Malawi
Introduction
Medical student electives are a memorable learning experience and approximately 40% are spent in a developing country. With around 8000 students a year from the UK alone participating in medical electives this equates with 500 years of student time annually. Students often have laudable motivation but are rarely helped to learn or contribute most effectively whilst away.
We have sought to create an ethical trade elective experience specifically to challenge the existing ‘health tourism’ norm. Academic publication is pending and we are now seeking publicity for the concept to encourage dissemination. Start up funding from the Scottish Government International Development Fund and NHS Education for Scotland has been secured along with support from Dundee Medical School.
Methodology
We have established a program of placements for senior medical students in Lilongwe through a twinning arrangement with Dundee University, Malawi College of Medicine (COM) and Kamuzu Central Hospital, Lilongwe (KCH). The normal six week elective has been extended to four months for selected students at Dundee Medical School. Students must demonstrate suitability through participation in an international health module (or significant previous developing country experience), a sound academic and health record, appropriate understanding of the programme aims, participation in tropical medicine training, cultural/safety briefings and fundraising for KCH (£500 each).
The aim is to provide an exceptional learning opportunity for students but, crucially, also clear benefits for their Malawian counterparts and host hospital. Overall the approach aims to be sustainable as a form of ‘educational trade’. Hence:
• Student contribution to patient care is improved by arranging extended placements, throughout the year, based in one clinical area.
• Learning and supervision is coordinated by a senior clinical tutor for both elective and local health care students together.
• Practical support with educational resources and medical equipment is provided by project/student fundraising.
There is scope for a number of other health service connections to expand as a result of this project, especially the high profile of student fundraising activities and prospect of ‘twinning’ of an NHS trust with a specific hospital overseas. This could be replicated at many centres.
Activities
The first cohort of students is currently in Malawi, something which has been three years in the planning. To date we have:
• Secured £60 000 start up funding (NHS Education Scotland and the Scottish Government International Development Fund)
• Established formal support (via a memorandum of understanding) with KCH, Dundee Medical School and Malawi College of Medicine (CoM)
• Selected and prepared the first two Dundee student cohorts. (7 in first, 8 in second)
• Benefited from two pairs of Malawian students visiting Dundee for 6 week electives.
• Supported anaesthetic Clinical Officer training in KCH via financial support for courses, books and equipment.
• Funded a visit by two medical physics technicians to KCH
• Sent 2008/9 cohort of students to KCH. These students are now established participants in providing care and promoting educational meetings for staff in the medical wards. Typically our students:
o Share responsibility for a bay of 4 patients with local junior clinical staff.
o Learn about conditions they rarely encounter, do procedures and take responsibility rarely available in the UK.
o Encourage (by their presence, provision of equipment and attitude) an enhanced program of clinical meetings at which both they and local staff (clinical officers and interns) benefit from training provided by local consultant staff.
• Agreed how the first years support funding (£5000) will be spent to provide enhanced basic equipment for the ward area.
• We are considering how start up funds can best be used to support a planned expansion of CoM via the creation of a new campus in KCH. This will enable support increased medical training in Malawi.
Outcomes
The first year of this scheme will transfer approximately £10 000 of resource to KCH and students will spend a further £12 000 in Malawi. Dundee Medical School benefits from a course offering innovative and exceptional opportunities (Program is heavily oversubscribed). Specific achievements of the program to date are:
1) Motivation for both staff and students in Malawi and UK.
2) Equipment has been provided (projector and laptop for continuing medical education) and will shortly be ordered locally for medical department (e.g. Patient trolleys, sphygmomanometers, oxygen concentrators etc.).
3) First audit in KCH looking at outcomes of admissions of patients on HAART (HIV treatment)
6) Change of attitude and sense of accountability in patient management imparted to Clinical Officer (CO) Students
7) CO students learnt how to use powerpoint and lead case presentations
8) Bedside teaching: Dundee students teach local students on examinations, procedures, and specific western diseases like stroke. They receive specialist HIV and tropical disease training, for instance, managing acutely toxic patients with sepsis or malaria.
9) Exchange students report increased awareness of health care provision in a different country and many new clinical experiences.
Challenges
To establish a sustainable trade we must prove there is sufficient educational benefit to persuade those funding medical education that resources should follow students to centres overseas which demonstrate an enthusiasm and ability to provide excellent clinical education for UK students.
To make a significant difference this process requires publicity. There is a clear demand from UK students for more ‘ethical electives’. An alternative model may well help this process.
There are associated risks. Forming partnerships requires time, effort and some resources. Culture shock causes distress and problems with excessive responsibility, culturally inappropriate behaviours, and personal risks (HIV, RTA) can arise. Unrealistic expectations may be created.
Conclusions
In summary, although electives are a popular and successful aspect of undergraduate medical courses we suggest they can be improved and negative effects minimised using a fair trade ethos within a formal institutional link. Though currently small scale we believe this concept has great potential and is now ready for increased publicity.

photos

hopefully you will be able to view some of my pictures by clicking on the links below, or cutting and pasting into the address bar....Granny -get fiona to help you!!

xmas and new year
http://www.facebook.com/album.php?aid=12333&l=4cd53&id=289400653


nkhata bay - malawi
http://www.facebook.com/album.php?aid=12327&l=2dc1f&id=289400653

Camels and Safari
http://www.facebook.com/album.php?aid=12329&l=dcebb&id=289400653

holidays part 3 - dar to zanzibar and back

We hadn’t heard many positive things in relation to Dar Es Salaam, and were warned about the heat and humidity and so we had tried to plan to go elsewhere but money and laziness I guess made us stay there for about 6 days in total. We were to be there over Christmas, and thanks to my lovely family and their donations we had planned to stay somewhere a little nice so we could enjoy our first Christmas together. Howevere our first shot at $40 dollars a night was not that great – with unfriendly staff, twin beds and the noisiest air conditioner you can imagine..not to mention the breakfast! Euch. So we headed to the popular back packers hostel where we were met by a similar room, but the friendliest staff you could ask for so we were happy.

Dar turned out to be a very friendly welcoming city…but yes it was hot and humid and the air conditioning was definitely necessary! Everywhere we walked we got ‘ jambo’, ‘habari’, ‘mambo’, ‘karibu’. People were genuinely interested in us, and we met people from all different backgrounds. We were staying in a predominantly Indian area, next to Mosque Street so it was quite fascinating just wandering around.

Christmas morning started off badly with me waking up 2am with projectile vomiting after eating a Chinese prawn dish a few hours previous! Anyway my lovely hubby, thankfully decided against the idea of taking pictures, and helped me with my situation, cleaned it up and we went to sleep to awake feeling perfect Christmas morning. We opened our two presents – an obama kanga for me and a Tanzanian football strip for Jose both kindly given to us from Annie and Gid in Arusha. The Obama kanga which has a big picture of himself between to maps – both of Africa, and America nowhere to be seen, was later to give us many laughs on Zanzibars beaches. The place to be on Christmas day was Coco beach, a surprisingly beautiful beach with white sand and blue waters. We arrived in time for lunch, traditional roast meat, and soon the beach was filling up with it seemed the whole of Dar! Huge families came down, and the children paddled and played in the sand while the adults enjoyed drinks and snacks. It was quite a scene seeing the whole stretch of beach crammed with people, and a different way to spend Christmas!

A very good friend from Uni had planned a long time back to come and join me over new year in Zanzibar. She was due to arrive on boxing day evening, so we were to head to the island first thing next morning. A couple of hours before we left to pick her up, a call comes through of a very worried sounding lyndsey who was stuck in Nairobi airport after her flight had apparently been cancelled. Not a good start to her very short holiday! Anyway she was put up in a lovely hotel and arrived the next morning, before we all got on a boat to paradise.

And paradise is the only word…. The whitest sand and sea that is nothing short of turquoise in colour, with picturesque dhow’s sailing past the glowing red sun – we knew we would be happy here. Stone town was a very pretty little place, with old weathered buildings, with tiny streets in between. The people here were absolutely beautiful, from all over the world originally now living side by side and producing gorgeous kids who were all very friendly, singing songs along the old crumbling streets. The only advice we were given about eating in Stone town, from everyone we asked was this street food bazaar. It is normally set in a garden, beside the ocean, but unfortunately it was closed for refurbishment, so for us it was along a side street. It consists of stall after stall of very cheap street food – from every kind of sea food you can imagine to meat kebabs, to different kind of bread and bhaji type things and fruit and salad on top! The problem was how to choose! I went for some sea food – lobster and prawn kebabs, with coconut bread and salad. It was nothing short of delicious and it all cost a couple of pounds! It was only a pity that we couldn’t go back for more!

Time was a big constraint so after one night and a morning of wandering the streets and getting a feel for the town we headed an hour north to Nungwe – the beach! My measly words trying to describe the beauty of this place could never do it justice, I will put a link to photos which I am afraid will also not do but will give you an idea and maybe the thought that you can go and see it for yourself. We had four days here, and a beach holiday is not something I have ever done, but I was surprised at how content I was to lie and read day after day! We enjoyed a good healthy breakfast every morning, headed to the beach, read some book, had a mid morning refreshing juice, read a bit more, enjoyed lunch, went for a swim/played volleyball, watched the sunset, had a shower and got ready for a delicious dinner followed by cocktails/drinks in a local beach bar. Bliss!

We did have a bit of excitement the morning we decided to swim when the tide was out and unfortunately Lyndsey got stung by a sea urchin which by the way looks to be a very painful event…I thought she was going to faint. Any Mr Fine from the diving shop came to our rescue and did his magic with some water and papaya juice as an antiseptic, and she was soon on the mend..although it was a couple of days before she could walk properly again! There were a group of Masai men (and women, but we did not see them so often) who were in Zanzibar for the high season, trying to sell curios to make money to take back to their boma’s. They were all very friendly and often came to chat to us on the beach, and we also met them in the evening and played pool or something equally western! They seemed to be a very happy people, and we had fascinating conversations about their way of life and their views on life. We were aware that it must be very strange for them coming to this place with girls in bikinis, people playing sports on the beach, sailing in fancy boats, drinking plenty alcohol etc, when compared to their life back home. We had asked one of them how he liked it and he told us it was far too busy here and he loved going back to the boma where he could spend all day sitting and listening to his radio! Another man, when we asked him if he was married, told us he was saving up – he had 2 cows and he needed 25! He had a long way to go! They did performances of their famous ‘jumping’ dance in the evenings at hotels, and we figured this must be how they made their money as they rarely tried to actually sell us their curios, instead just wanting to chat!

New years eve was spent first with an amazing buffet of sea food spread which was delicious and then we headed for the beach bar called Cholo’s. We had coincidentally met with a South African guy that Jose had befriended in Malawi and so we spent the evening with him Tshepo and Tsabi his south African friend, and Patrick a Namibian dude we picked up along the way. The banter was great – lots of dancing, including round a fire..and on top of boats and tables. It will definitely be a new year to remember!

Unfortunately, our holiday was then coming to an end. Farewells were said to Lyndsey, and we started the long bus journey back to Malawi. I think what will stick in our minds the most, is the friendliness and liveliness of the Tanzanian people. I am sure one day we will be back, and maybe if they opportunity arises, me and Jose I think would be happy to settle their for a few years…lets see! For us, it was also so nice to spend some good quality time together on our first proper holiday!

holidays part 2

It may have been due to the amazing hospitality, gorgeous house and tasty food but as soon as we arrived in Arusha, we felt completely at home and strangely enough the conversation often came to the discussion of Arusha being a place to live in the future. We were lucky enough to stay with old family friends, Annie who has been based in Tanzania for many years now, and Gideon her Tanzanian husband who is a doctor and runs his own (very impressive) clinic. Arusha’s climate is perfect if you don’t like it too hot and humid, we were there in the hottest time of year and still sleeping with a duvet, whilst during the day we were still able to obtain a tan! Days started with a laid back breakfast out on the veranda, with local Tanzanian coffee and fresh fruits..yes it was luxury! My mum had ventured from Scotland to – creating the first meeting between husband Jose and mother (I think it went well), so we spent our days wandering the markets or exploring town. It was her first time in Africa, so it was fun showing her the ways of life there, and trying different foods etc.

We spent one day on safari in Tarangire National Park, with an excellent loud Tanzanian guide called Willie. We didn’t venture to the more touristy safari parks to avoid being stuck in queues behind other jeeps, and so were not expecting to see any big cats, and I was even beginning to think we would be lucky to se anything – the way people were talking. The Park was absolutely beautiful, and there were not many people around. About only 1 minute into the drive…I spotted our first animal of the day – a zebra, and from then on it was animals galore. I couldn’t believe it – they were everywhere! We saw giraffes just a few feet from the road, we watched a herd of elephants crossing the road around us – including a 1 week old very curious little elephant, we saw baboons, waterbuck, impalas, ostrich, warthog and more! Just before lunch we had headed towards a marshland where there was lots of water, and the view was spectacular. There were a herd of elephants a kilometre or so away and willie suggested we go along for a couple of miles just in case any other animals had come to drink. We got to the elephants who were creating a bit of a stir, so stopped the jeep and suddenly willie announced – ‘ladies and gentleman, I promised you and know I have delivered…..a lion!’ at which point Jose jumped down inside the car and hid behind me!! The lioness was lolling high up in a tree, observing the elephants from afar. She looked so thirsty and was probably desperate to get to the water but the rowdy elephants were a danger to her. This was definitely the highlight of the trip – and once Jose had assessed the situation, he also found it to be amazing. We were also very lucky to see a family of wild dogs – which are very rare to see, in fact our Tanzanian friends had not seen one in their 20 years of regular safaris! They were right by the road, and resting under some bushes. Two of them were very small, and playing like puppies. It was hard to believe that these animals kill in one of the most verocious ways, they looked so cuddly!

Another day was spent riding camels – a project that our friend Annie had set up. The camels had been left some time ago by a ? South African who needed to leave in a hurry, and so these camels had been looked after by a group of Masai. We trecked for half a day and then had a lovely lunch at the camp. It is possible to camp there or even take the camels for a 7 day hike! My bum was sore after 2 hours! The camels were very funny to look at and they all had their own little personalities, one being very noisy and grumpy, stopping to eat all the time and drooling stinking saliva everywhere. Jose’s camel was very docile and was snuggling under my arm while we walked and he was always the first to do as he was told! Mine was pregnant.

After the camels we were privileged to visit a Masai boma. I was a bit shocked by it all, and probably didn’t appreciate the good points of the visit as much as I could of as I found it hard to look past all the childrens dirty faces with flys in their eyes and the young boy with a huge hydrocephalus who had only seeked out a traditional medicinalist. We saw their tiny houses with bed in the kitchen area, and chickens too so the smoke was unbearable even for us being in their for 2 minutes. In the centre of the camp was the animal pen, with thorns around the edges to prevent lions entering. We had a chat to some of the women and children and they could not understand how a black man – Jose could not speak Swahili, and then found it hilarious that we could possibly be married as we were different colours. They kept just pointing at both our skins – it was very funny and they were all very sweet with gorgeous kids. We were later to meet several masai, trying to make a living in the high season in Zanzibar…total different way of life.

The international tribunal for Rwanda is in Arusha, and has been ongoing for 7 years now. While we were there we heard that 3 of the big shots were having their final judgement, so although not a normal holiday activity we thought it would be interesting to witness. After a confusion with the UN security about Jose and I wearing flipflops and therefore not allowed in followed by mother and Annie having polite words we got to the viewing room. I don’t think I have ever been in a court before, we all had to put on headsets and choose our choice of language. The document containing all the evidence was 4000 pages long so they did a quick summary in about half an hour. The incidents and events they talked about were absolutely chilling and the accused sat there straight faced all the way through. 2 of them were given 3 life sentences each, and the other was proved not guilty. These men were part of those who planned and ordered the genocide, not the ones who actually did the killings. Those people are being tried in Rwanda and are in local Rwandan jails. These big men, as they are being tried by the UN, need to be kept under certain level of condition and therefore get to choose which country they serve their sentences.. It was a very interesting piece of history to witness, even if it made me feel sick inside hearing it. On the bus back from Tanzania we watched a film called Something inApril about Rwanda and it actually mentions Bagasora – the man we saw. For those of you who haven’t seen it watch that and Hotel Rwanda.

Gideon was brought up in Western kiliminjaro and so we were lucky enough to go and stay in their tiny little ‘weekend’ house at the bottom of this great landmark. Jose and I were camping,so after setting the tent up, we had a lovely meal of rice and coconut beans, and a few G and T’s as the sun set behind the mountain. We slept early, enjoyed camping and got up to see the sunrise and an amazing view of Kili. Jose was amazed by it, as we all were, and took loads of pics, I went back to bed and slept more. The next day we headed up the hill to the edge of the National Park, and again got stunning views.

I could talk more and more about this Arusha experience, even just the food – from traditional roast meat (the best chicken I think I have ever had), to Ethiopian to full Christmas dinner etc etc…life was good! Then it was time to move on.. We said our goodbyes and boarded a coach for the bustling and humid city Dar Es Salaam.

holidays part 1 - Malawi to Arusha

So I know you guys all think I have come out here on an extended holiday and yes, I would much rather be here than home, we get the odd long weekend, and even the normal weekends we can go to a beach, on safari, climb mountains to name just a few so I guess I shouldn’t complain but it has also been really hard work out here! IT had been a while since I had had a week off…around 11 months actually so I was definitely ready to take some time and see some more of Africa!

Jose had arrived a couple f weeks previously and we did find it tough as I had to leave him in the house bored every day while I went to work..so time away together was on the cards! We started by heading 6 hours north to Nkhata bay, a beautiful site on the Lake, and stayed in an awesome backpackers lodge place – set on a steep hillside with huts and camping sites available. It was relaxing to say the least, we swam, canoed, ate and drank for 2 days…meeting some interesting people along the way. A man called King David took us on his boat for a trip of fish eagle feeding – it was called Condaleeza Rice and had a wing span of about 2 metres and you could feel the wind from her wings as she passed us, cliff jumping, and playing games on the beach. As usual the highlight was the kids…who all came to see us on the beach, where we spent ages throwing them off our shoulders into the Lake…they could all swim like little fishies.

We didn’t really fancy leaving this little corner of paradise on the Lake, but we had much more exciting things ahead so we started a long journey from there to Arusha…northern Tanzania – roughly 2000km from Nkhata bay! A few scary minibuses and a night bus later we were at the Tanzanian border, where Jose was lucky to pass for free, whilst I needed to part with $50.. Unfortunately, a group of boys who wante to change our money at the border – and nearly got us that way, but we were quick..then took us to a bus to get to Mbeya – charged us double the prize and put us on a bus where the driver was driving seriously dangerously. Jose was not comfortable so we got off and on to another one for half the prize…that’s the problem when in a new country – it takes a while to suss out whats the going rate etc.. anyway safety first I guess!

Mbeya is the largest town in south western Tanzania and is set high up in the mountains so has a very cool climate…in fact we found it really cold! It was a beautiful setting though with good views all around and this is where we first met the friendliness of the Tanzanian people – they were so keen to chat with us and show us around the town. The town wasn’t really set up for tourists and so there wasn’t a whole lot to do but we occupied ourselves for 2 days with wandering the market, trying out different restaurants and playing snooker with some local guys..

Then it was time to move on, next in our journey was an 16 hour bus journey direct to Arusha, which I told myself was going to be 24 hours as we had heard many horror stories about break downs etc.. Luckily ours went to plan and when we arrived after 18 hours I was quite pleased! Tanzania we discovered is beautiful to travel through on buses, we went up and over a huge stunning mountain range ( nearly died in the process…the buses were in convoy racing over these hair pin bends with cliff drops on one side..we saw several overturned lorries on the way none of which seemed to slow down the drivers!), we went through a National Park and saw elephants right by the roadside, and passed through many small very African villages.

About midnight, we pulled up to a deserted dark Arusha bus station, where bless him, Gideon, our Tanzanian friend and host to be for next 2 weeks was dutifully waiting. He had been there a while though, and his (safari like) jeep had run his battery down with im listening to music, so a little push and we were off. It wasn’t long before we realised exactly why he needed a jeep to get around..Tanzania’s roads aren’t as well developed as Malawi’s, and we had to scale a rough potholed road to reach his house..we would soon get used to being thrown around in the back of a car!

Tony's Story

February of last year, a boy came into this world, uneventfully actually, to a family of 2 older brothers and sisters. Although he didn’t know it yet, he has been born into the 3^rd poorest country of the world - Malawi. His young parents owned a small plot of land on which they farmed maize, earning them enough to get by.

Shortly after his birth, his mum became more and more unwell, and was diagnosed with HIV. She attended a group session to learn about antiretrovirals and was given an appointment to come in to start these. Unfortunately, she died before this day came. Tony was by now 2 months old, and left with no wife Tony’s father felt unable to cope and sent the children to live with their grandmother, sold the farm and left for the city to make some money. Tony never saw his father again, and his grandmother never received any support for looking after the children.

She cared for the children as best she could, but finding money for food, clothes and healthcare - the basic needs of a child was difficult, and they often went short. Tony, was especially vulnerable due to the fact that he needed formula milk, expensive to buy and hard to prepare. By 10 months old he weighed 5 kg – a weight at which it is possible to be born at.

The week after Christmas, he developed diarrhoea and vomiting, and a rash on his groin which gradually spread over his whole body, sparing his face. After waiting a few days to see if he would recover, his grandmother eventually took him to see a traditional medicinalist, the cheapest ‘consultation’ around. He was prescribed a white paste which his grandmother dutifully painted on his whole body day and night… soon his skin broke out into a red raw rash, and opportunistic fungal and bacterial organisms likely took hold. His condition worsened and worsened until he stopped eating and crying, and she then took him to the nearest health centre who referred them to Kamuzu Central Hospital with a large paediatric department.

At the clinic, in his condition, an IV line should have been set up and at a minimum some fluids and antibiotics started before being admitted. Instead he was sent to the ward and started on oxygen, and left, presumably to be seen later. This is where I came in. I was in the treatment room, inserting various IV line for kids in the ward, and being lunchtime, I appeared to be the only ‘member of staff’ around. This baby caught my eye, as it appeared not to be breathing ( I had resuscitated one the day before, so my eyes were possibly more adept to checking!). I went to the patient and indeed it was having apnoeic episodes (episodes of not breathing). Knowing the baby needs help to breathe, I quickly make a decision whether to start on my own or go and find help…the second was more sensible as I am really not qualified to resuscitate a horrendously malnourished, dehydrated, for child so I ran to all the wards but could not find a soul. I then ran back and bag and masked the baby, gladly noticing that the heart rate picked up beautifully when he was ventilated – a good sign. After about a minute, maybe too, I again left the baby and went to the secretary to call someone at which point I found a senior consultant who was not at all pleased at my dragging her to see the baby. She assisted me in getting IV access whilst still ventilating the child and told me to run some fluids and see if the baby picks up. She told me it was very poor prognosis and left.

By this time, an intern (fresh out of medical school) was also helping me, and after about 20 minutes of resuscitation, we began asking ourselves what are we doing for the child besides fluids? So we eventually did what we should have done at the beginning and checked the blood glucose, discovering it was hypoglycaemic. I have always been told giving glucose in hypoglycaemia is a very satisfactory thing, and indeed it was, the baby came round and was breathing spontaneously with a good heart rate.

It was now safer to leave the child for short spaces of time so I went to find one of the Baylor Doctors. Baylor is an institution linked to a medical school in the U.S which is here to treat HIV infected children. They have access to more advanced resources than the hospital, and the children seem to get a very high standard of care. It does however create a situation where the HIV infected children are receiving better care and surviving very serious HIV related diseases, whilst non infected kids die of malaria or diarrhoea which could sometimes be caused by a lack of staff or resources.

Dr Gordon came to my assistance and reviewed the child, and we developed a management plan, and started the child on expensive antifungal and antibacterial creams, as well as systemic therapy not usually available on the ward. Luckily there was a bed on the high dependency unit and after a lot of persuasion whilst trying not to get angry/upset, the nurses eventually accepted him in and it was time for me to go home.

The next morning, I was told that Tony had passed away a few hours after I left. Every death I have witnessed so far has affected me in some way, and I hope I will always be that way, but some seem to get you more than others, the previous day I had performed CPR on a 5 day old baby, and yes it was hard, but Tony got me in a different way. Maybe because of the state he arrived in, maybe because I was able to get more of a background story from the grandmother, or maybe just that he was obviously a pure fighter..having got so far with so much against him. This boy made me think what if?

What if… I had not been first on the scene?
What if… the consultant had not been so busy and frustrated with her work?
What if… there had been more staff in HDU to actually monitor the child during the night?
What if… the person who had admitted him had managed him properly from the start?
What if… his grandmother had taken him to the central hospital in the first place?
What if… his tiny body had not been covered in some unknown white paste?
What if… he had been given a good nutritional diet from the start?
What if…his mum had been diagnosed before pregnancy?

What if…he had not been born in Malawi?

*names have been changed to respect confidentiality.

*some (unimportant) parts of this story have been made up.