I spent my 8-week elective at Mulanje Mission Hospital (MMH) in the south of Malawi. Having previously spent time in sub-Saharan Africa I was keen to return, and hoped that some aspects of the culture I had learnt in neighbouring Mozambique would be transferrable, with the advantage of English being an official language.
Primary Health Care (PHC)
I spent the first two weeks of my placement with the primary care team, and soon became aware of my need to learn more of the local language (Chichewa). However, I managed to quickly pick up a few of the basics, and was able to help register mothers for antenatal care, administer contraceptive injections and vaccinations, and weigh children.
The department also undertakes a large amount of health-education, particularly with the women in the district. At the start of every clinic one of the nurses gives a short presentation on a topic such as hygiene, HIV-testing, vaccinations, or understanding the different food groups. The team have even written a “family-planning song” to communicate the advantages of spacing children and contraceptive methods available!
I also spent time with the palliative care team, visiting a peripheral clinic near the Mozambican border. As well as bringing home the impact of un-treated HIV infection, this was also the first time I witnessed the extent to which the health system is under-resourced. The nurse running the clinic had forgotten to communicate to the hospital which drugs she needed us to bring, so we arrived to find out they had run out of paracetamol. A long discussion ensued about whether we could borrow some from another part of the clinic, who would sign for it and what would happen if the ministry of health did a spot check - all for a tub of Panadol. Finally it was sorted, and we were able to start handing out paracetamol and indomethacin, and administering vincristine, but I couldn't help thinking of the opiates, chemotherapy drugs and radiotherapy that we would use in the west.
Paediatrics
Following my time in primary care, I spent 2 weeks in the paediatric department. While there are a few things that are the same the world over (we had one toddler who was admitted having swallowed a key), there was a huge amount that was different to working in the UK. The first thing I noticed was that most of the children were admitted with infections – malaria, diarrhoea, pneumonia and meningitis. While the majority of these were successfully treated, during my 2 week placement we had 6 deaths, most (if not all) of which would not have died in the UK. The death of a child is always difficult to cope with, but I found it even more so when it felt as though it could have been prevented.
Another striking difference was again the resources available – the ICU consisted of a few beds with access to oxygen, and the “incubators” in nursery were “the cots next to the radiator”. While we were able to order simple investigations, such as full blood counts, blood films, and x-rays, there was plenty that wasn't possible, including checking electrolytes or doing blood cultures. On one occasion we made a diagnosis of haemophilia on a purely clinical basis!
General Medicine
I spent the remainder of my placement split between the male ward and the female ward. As my Chichewa improved I was able to review existing patients by myself, although my history taking was unfortunately limited to closed questions about particular symptoms.
Towards the end of my time at MMH, a number of the clinical officers left to pursue further training in Blantyre, and I was asked to look after male ward. Although I initially found this slightly intimidating, as I gained confidence I enjoyed conducting my own ward rounds and making decisions. However, I always found that there were enough people to help if I ever felt out of my depth, and several times I asked one of the doctors to review a patient with me if they were particularly sick, or if I wasn't sure of the best course of action.
While I saw many patients during this time, there are two that particularly stick with me. The first was an elderly gentleman, admitted with severe pneumonia. I reviewed him with one of the doctors, and we started him on oxygen, IV fluids and antibiotics. By the end of the day, he was looking much better, the next morning he was sitting up and talking, and in a few days he was home. It was a real reminder that sometimes, all that's needed are the basics.
The following week we admitted a 22-year old with diarrhoea and abdominal pain, who was looking equally unwell. Again, I discussed him with one of the doctors and we started him on oxygen, fluids and antibiotics. The next day, he was looking even worse, and we requested an ultrasound scan, which was suggestive of typhoid. Throughout this year I have been taught the importance of recognising sick patients, and early referrals to intensive care; however, in this setting, all we could do was continue current management and watch him get sicker. He died later that day: sometimes, the basics aren't enough.
In terms of my future career, I am still uncertain as to whether I will decide to work for a time in a resource-poor setting. However, I feel that I now have a much clearer understanding of the reality of what such work entails. I also feel more confident about starting work next year, and feel that I have benefited hugely form being given the opportunity to manage both acutely ill patients and more routine cases, while feeling supported by those around me. I would enthusiastically recommend MMH to any future elective students looking for a placement that will stretch them out of their comfort zone, whilst providing good support and teaching.
