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Blantyre, Malawi: Clinical & Teaching Experiences in the Warm Heart of AfricaThe Medical Needs of Malawi :
The Queen Elizabeth Central Hospital is the largest public tertiary care facility in Malawi, a country of 13 million people. As a government funded hospital, facilities, services (both physician and laboratory), and treatments are rationed out as is most appropriate and utilized to maximal benefit. That being said, QECH is severely under funded, understaffed, and over burdened with the sickest and poorest patients in Malawi. For example, the “Special Care Ward” in pediatrics (for the very sick but not critically ill) has a daily census of greater than 80 patients with 2 to 3 nurses—this is a common reality for nearly all of the surgical, medical, and pediatric wards. Another example is the radiology service where patients routinely wait hours for the very limited staff to image and diagnose disease using plain film x-ray and (when working) computed tomography. Finally, the pathology department (which serves as the only pathology laboratory rendering histological diagnoses for all public hospitals in Malawi) has two staff pathologists, one of whom serves as chairman of the department and the other who also serves as head of the national blood bank.
Because of the generosity of foreign governments in collaboration with local and governmental efforts, some special facilities (i.e., newborn intensive care unit) have recently been added to the hospitals services. However, routine daily clinics of all types that function to triage, investigate, and treat the vast majority of patients is a slow and tedious process.
QECH is located only steps from the University Of Malawi College Of Medicine which is the only medical school in the country. Although this six year program now boasts 60 students per class, the attending physicians within QECH are often faced with 5 to 10 students on a service leaving little opportunity for one-on-one teaching, constructive feedback, and skills assessment.
Post-graduate training and advance continuing medical education for physicians is extremely limited and almost universally requires that those desiring such experiences leave Malawi. This creates an immense problem of “brain drain”. A continuing exchange system with single or multiple institutions could insure Malawian trainees of any type could thrive in the foreign institution and then return to their home institution (UOMCOM) to begin or continue their career.
Opportunities for Physicians from abroad in Malawi:QECH is the largest central hospital and, thus, provides a full range of services to the community and country including pediatrics, internal medicine and specialties, surgery, radiology, clinical laboratory testing (including blood banking), anatomical histopathology, and emergency medicine. Within Blantyre, there are private hospitals and clinics as well as the CURE Orthopedic Hospital and the Lions Eye Hospital (both of which are physically adjacent to QECH). About 1 hour north of Blantyre within the small town of Zomba there is the regional psychiatric hospital. The department heads at QECH and the principal of the College of Medicine are enthusiastic about the prospect of having visiting physicians. This would be of huge benefit to Malawi. The leadership of both of these institutions are extremely talented and efficient individuals whose input into the roles of physician volunteers is required for success. Visiting physicians are asked to work directly with students and patients for clinical care, be involved in teaching at all levels, and possibly foster research relationships as deemed appropriate by the College of Medicine and its Research and Ethics Committee.
Subspecialty facilities and opportunities in Malawi:Because of some small existing programs which provide people power to some services, one of the biggest needs (after simply additional person power) is for talented specialized physicians. For example, pediatrics, under the guidance of Professor Elizabeth Molyneaux, has a continual exchange of young pediatricians from Europe and the UK; however, experts in advance and difficult pediatric diseases are limited to a handful of veteran clinicians. Similarly, specialized surgical teams may visit QECH for short periods of time but are not available year round; therefore, visiting teams of surgeons would greatly increase capacity for both general and complex surgery. During the heaviest teaching months for the department of histopathology (Jan through March), a team of Scottish pathologists (usually 3) and Dan Milner (from BWH) are often present to assist with teaching and service work; however, during the rest of the year, all sub-specialty teaching and clinical service fall upon two pathologists—having even one extra pathologist visiting would increase the service, teaching, and research capacity measurably.
Physicians, nurses and physician assistants of all types would be equally beneficial if they were interested in participating directly with a visiting physician.
Brigham physicians at work in Malawi:Dr. Dan Milner has worked in Malawi since 2000 and is an Honorary Visiting Lecturer at the University Of Malawi College Of Medicine. During his annual visit of 4 to 6 weeks, Dr. Milner is located within both the QECH complex and the UOMCOM complex for his work, teaching, and research. Dr. Johanna Daily (Infectious Disease) and Dr. Rebecca Folkerth (Pathology) have worked and/or visited in Malawi. Dr. Deb Hung (Broad Institute) and Partners in Health has existing relationships with different aspects of Malawian culture and healthcare (PIH site is not located in Blantyre but rather two hours west). Several residents and fellows in several departments at BWH have visited/worked in Malawi prior to or during their training.
Malawi at a glance:Malawi is a politically stable democracy of 13 million people located on the shores of Lake Malawi and surrounded by Tanzania, Zambia, and Mozambique in Southeastern Africa. The people are known for their warm, friendly nature as well as their smiles. Though the people of Malawi are naturally extremely intelligent and resourceful, they tend to be extremely shy and have self-esteem issues stemming from years of political dictatorship which only ended in the mid-1990s; therefore, they need encouragement and positive feedback during personal interactions. Religious affiliations are reported as Christian 79.9%, Muslim 12.8%, other 3%, none 4.3% (1998 census).
Blantyre is located in the southern central region of the country and is approximately 1 hour from Mount Mulanje (excellent non-technical mountain climbing located in the lush tea region), less than 2 hours from Liwonde and Mvuu Camp (a river side safari park with loads of animals including some of the only rhinos in Malawi), and from 1 to 4 hours from a range of other sites including Dedza (pottery) and Mangoche (the lake with resorts and water based activities). Travel within Malawi can be tedious but is possible either via local car hire, buses, or (for the wealthy) short flights.
There are many languages in Malawi including Chichewa 57.2% (official), Chinyanja 12.8%, Chiyao 10.1%, Chitumbuka 9.5%, Chisena 2.7%, Chilomwe 2.4%, Chitonga 1.7%, other 3.6% (1998 census). The common languages of Malawi are predominantly Chichewa (common in Southern Africa) and Chiyao (a bush dialect) in and around Blantyre; however, a British-form school system exists so that all people who attend are given the opportunity to learn English from an early point. This results in every medical person speaking fluent English but, because of the demographic of QECH, most patients will not speak English very fluently.
Travel to and from Malawi is quite easy because there are daily flights from New York, Washington, DC, and Atlanta, Georgia (South African Airways and Delta) into South Africa followed by usually one or two flights a day to Malawi (South African Airways, Air Malawi). Airline travel for economy class tickets ranges from $1500 to $2500 on American carriers for round trip tickets. Travel on American Airlines through London and then on to Johannesburg via British Air is also possible but takes longer and requires usually a 12 hour layover in London (not recommended unless you are a seasoned traveler).
The local currency is the Kwacha which has a current stable exchange rate of K139.90 to 1USD. Fruits, vegetables, eggs, starches (e.g., corn, potatoes, and rice) and common household items (i.e., candles, matches, etc) are extremely cheap in both local markets and stores; however, most Western items (i.e., candy bars, sodas, processed meats, and jars of jam/jelly) are of equivalent or higher prices than compared to the US. Although most Malawians live off about $1.00 to 2.00 US dollars per day, visitors can expect to spend $10 to 20 dollars per day or about $50/week on food (i.e., purchasing food from stores and/or providing food for a household cook to prepare meals).
Accommodations can range from high end hotels (i.e., The Mount Soche Hotel ~ $140/night, Ryals Protea Hotel ~$200/night), to quaint guest houses ($25 – 45/night), to monthly 2-4 person homes usually with staff ($1000 - $2000/month)*.
Malawi has a long rainy season (which is also the high malaria season) beginning in January which runs to early June during which time it rains usually once per day. June, July, and part of August tend to be a bit chilly. September through December is very hot but has some of the most beautiful vegetation.
Diseases that the traveler may encounter included malaria (prophylaxis should be REQUIRED for visitors), tuberculosis, diarrheal diseases (i.e., bacterial, viral, helminthic, and protozoan), HIV (15 to 35% of the population is seropositive depending on cross sectional survey), allergies (both inhaled and contact reactions), schistosomiasis (endemic in the lake region), African sleeping sickness (focally, far outside of Blantyre), infestations (i.e., lice, scabies, Pootsie flies), and accidents (specifically, motor vehicle accidents and hippopotamus bites).
Interested in Malawi?Please contact Dan Milner
