TORONTO - Working in the continent hardest hit by HIV-AIDS, Dr. Michael Schull sees glimmers of hope amid the often bleak realities of the epidemic.
Schull, his wife, Dr. Josee Sarrazin, and their three children began their year-long relocation from Canada to Malawi in July. The married doctors are helping lead efforts to train health-care workers in the African country in the ongoing fight against HIV-AIDS and other illnesses.
Schull said the situation in Malawi remains very serious with respect to HIV, with prevalence rates around 15 per cent in the adult population, but the country has done "a commendable job" in improving access to antiretrovirals. About 40 per cent of people requiring the medication for AIDS are on it, an "incredible improvement" compared to five years ago, he said.
"What we've also begun to see is really quite remarkable is mortality or death rates across the population are starting to decline, and we think that's a reflection of improved access to medication for AIDS," Schull said in a phone interview from Zomba, Malawi.
"It is still a very serious situation, but it's one where there's been tremendous progress over the last three years, and I think it's safe to say that people are feeling much more optimistic than they were a few years ago."
Recently released figures by the World Health Organization and UNAIDS estimate the number of new HIV infections has declined each year by about 17 per cent from 2001 to 2008. While about four million people were receiving AIDS drugs at the end of last year -- compared with three million in 2007 -- an additional five million people need treatment and aren't receiving it.
Despite the improvements in Malawi, Schull said they still haven't reached everyone. His concern is there's a real risk funds necessary to continue to ramp up access to AIDS treatment and services isn't guaranteed.
"The problem is people might take the success of the last few years to mean we don't need to provide so much money anymore," he said.
"The reality is, the success just means, 'We could do this, we could reach those people,' but there are a heck of a lot more that still need to be reached."
Schull, an emergency room physician at Sunnybrook Health Sciences Centre in Toronto, is on the board of directors of Dignitas International, a medical humanitarian organization which works to increase access to life-saving HIV-AIDS-related prevention and treatment.
An estimated 930,000 adults and children are living with HIV in Malawi, where more than 500,000 children have been orphaned due to AIDS.
Dignitas offers clinical support to the Ministry of Health in treating HIV patients in Zomba, and has a research program focused on continually improving services being provided.
Schull is a senior research fellow leading a pilot project on innovations to integrate HIV care with other primary care in rural health centres.
It will involve training about 12 people who will in turn train nearly 300 staffers across Zomba district working in small health centres. Training will focus on simplifying the work of front-line clinicians making diagnoses.
It will also centre on how to more effectively communicate with patients and developing administration skills to better run health centres. That includes stock-keeping so there are fewer occasions where health centres run out of medicine.
Schull said there are constantly issues with ensuring medications are available. Diagnostic aides, HIV test kits and the ability to diagnosis tuberculosis and malaria varies tremendously between health centres, he added.
"One of the things that this guideline is designed to do, and the training, is to help staff figure out what to do when, let's say, the recommended drug is not available, what would be an alternative? Or if a particular test kit is not available what should one do?"
"The training is designed to try to help staff cope with what here is unfortunately just a reality -- that supply of medications is never perfect."
Schull said his goal would be that when he's left, the project will be running smoothly, and that they will have established a core infrastructure.
"That really means staff that can support ongoing research to make the services that we're providing ever better, and that I can feel that the project really has contributed to making the lives of nurses and clinicians who are working here easier and the care that they provide a bit better for patients."
Sarrazin, a radiologist at Sunnybrook specializing in abdominal radiology, has been training technicians at hospitals in Zomba and Blantyre in doing ultrasounds using a miniature, portable machine brought from Canada.
An ultrasound technician will be spending six weeks in Malawi starting in January going between the two centres, and radiology staffers at Sunnybrook have gathered books to be shipped to technicians to start a library, she said.
Sarrazin said the most striking thing she's seen is the lack of therapeutic options.
"I've encountered several patients with clearly treatable disease medically or surgically and here they were basically declared palliative cases, whereas back home they would definitely be treated," she said. "When you put that in perspective of a country where the average life expectancy is 44 years old, most of the patients I see are in their 20s, early 30s and there's no treatment.
"That has been quite difficult to witness actually and it's quite eye-opening and sometimes difficult to tolerate, to be honest."
Following previous stints in international medicine, Schull said what distinguishes his current experience in Malawi is that he's sharing it with Sarrazin and their children -- Camille, 11, Gabriel, 9, and Juliette, 6.
"They're seeing as much about what's wonderful here as they are about problems here," he said of the children.
"They're also learning to cope with phones that don't work so well, and electricity blackouts that occur almost daily, and bugs in the house they've never seen before," he added. "I think it's fun."
