Abstract
When we tell people about how we left our jobs as GPs in London to work in Africa, the most common reply we hear is ‘I've always wanted to do that!’ And that is exactly how we felt before we took the plunge.
We had wanted to work overseas ever since we qualified. We knew that we wanted to work with an organization that was founded on the principles of sustainable development and felt that a longer term placement would be more beneficial to the people we were working with and ourselves. Initial enquiries when we were junior doctors led us to realize that the major overseas development agencies preferred more experience than we had at that time, and we were encouraged to apply on completion of our GP training.
And so, it came to be that we spent a year in Malawi with Voluntary Service Overseas (VSO), an international development charity whose goals and philosophies are closely aligned to our own. VSO aims to fight poverty through volunteers working in partnership with local colleagues to share skills. VSO supports the idea that knowledge is the most powerful tool, people are the best agents of change and lasting progress is only possible by working together.
Setting the scene…
Malawi is famously known as the ‘Warm Heart of Africa’. However, ‘warm’ is perhaps an understatement in relation to the area of Malawi where we were working, which is affectionately referred to as the ‘armpit’ of the country, with temperatures soaring to 50°C for large parts of the year.
Malawi is ranked 153 of 169 countries in the human development index (HDI), a measure of development that combines indicators of life expectancy, educational attainment and income. There are 1.6 doctors per 100 000 population and human immunodeficiency virus (HIV) prevalence in rural areas is estimated at 16%.
Trinity Hospital, where we were based, is a 200 bed mission hospital located in one of the most isolated parts of the country. The hospital serves some 150 000 of the local population, including numerous Mozambicans who settled in the area after the protracted civil war that raged in their own country throughout the 1980s. The hospital is a referral facility for health centres in the area. We were several hours' drive on a dirt track to the nearest tarmac road and a further hour from there to a specialist referral hospital.
Prior to our arrival, there had been no doctors at Trinity for over 2 years — medical care was provided principally by clinical officers (COs) and nurses at one quarter of the recommended staffing levels. This is not particularly unusual; COs are commonly found throughout Africa. They are clinicians trained to manage common medical conditions and to perform some surgical and obstetric procedures, such as caesarean sections.
Our first day set the tone for how different things were going to be from UK general practice. Firstly, there was the man with a scrotum the size of a watermelon. Then, the woman who had undergone a caesarean section — but no one could recall if she had also been sterilized! After this, there was the man with central chest pain who was given albendazole for a presumed diagnosis of worms (?), and finally, the 30-year-old woman with three children in tow, coming for HIV staging. And that was before a break for morning tea and cassava! After lunch, there was the small matter of a disciplinary meeting regarding the Matron who had been found lying in the hospital gutter smelling of alcohol and with empty pethidine syringes in his hand. All in a day's work.
But after our baptism of fire, we settled into the swing of things. No primary care for us though that department was being managed by two excellent nurses so it was decided our clinical commitments would be on the wards and outpatient departments. We tried to explain that we were more used to tree hugging and hand holding than crocodile bites and cerebral malaria, but our cries fell on deaf ears.
In order to combine ‘gap filling’ with skill sharing, we divided our time between teaching ward rounds for the trainee COs, outpatient and HIV clinics and developing an inter disciplinary continuing professional development (CPD) programme. We had to get to grips with the basics of HIV and tropical medicine fairly quickly, with the mainstay of cases being malaria, tuberculosis (TB), malnutrition and HIV-related conditions, alongside common infections with which we were more familiar (albeit at lesser degrees of severity), such as pneumonia and gastroenteritis.
We also took on managerial responsibilities that could sometimes be more daunting than the clinical work; for the first time, in our careers, we were considered to be ‘the bosses’. As part of the hospital management team, we were involved in staff disciplinary procedures and grievances, issues of clinical governance and resource allocation. These were areas that we would not have had the opportunity to be involved in at the current stage of our careers in the UK.
What did we learn?
There were many things we learnt and experienced outside of work. Living in a rural area with basic amenities was a refreshing change from the hurly burly of life in central London. So much so, that we have now relocated to Norfolk! We developed resilience and our relationship has undoubtedly become stronger as a result of our time in Malawi.
Our colleagues and the patients inspired us every day. Despite the harsh environment, lack of resources and critical shortage of staff, our colleagues showed phenomenal resilience and commitment to clinical care. We often reflected that we learnt more from them than we felt able to give back ourselves, with particular reference to our colleague Mr John Wanda, the Chief Clinical Officer at Trinity. His dedication and calmness in the face of adversity are something we think back to when faced with a ‘busy’ day in UK general practice.
We saw people who lived in abject poverty and witnessed their daily struggle to survive without the benefit of a social welfare system. Yet, we also saw the strength of their communities and resolve to care for each other. The only question we now have is: when will we go back?