Greetings from Edinburgh. Rob has given me his spot on the website so I can give another perspective on volunteering in Psychiatry in Malawi (nothing to do with him working all hours on the final push of data collection for his study and therefore having no time to update his dairy entry I’m sure!) I’ve just returned to Scotland after spending six weeks in Blantyre and Zomba helping out with the fourth year medical student teaching at the Malawi College of Medicine. I bumped into my old SHO buddy Rob at last years College Annual Meeting in Edinburgh, and as he fleeced me for sponsorship for his fund raising cycle ride, he told me of his Malawi plans.  Felix Kauye, Malawi’s Chief (and only!) psychiatrist was also in town, and as we enjoyed an uncharacteristically sunny evening in Edinburgh my serendipitous plans for a trip to Africa took shape. 

 

 

My SpR tutor and postgraduate Dean could not have been more supportive, and with the Royal College actively encouraging such ventures, making the trip during my SpR training was very straightforward.  I used a combination of study-leave, annual-leave and unpaid leave to make up the full six weeks, and with a mention in meeting minutes circulated by the Scottish Division prompting local donations, I travelled out with a suitcase full of teaching materials. At national level the Royal College also donated general textbooks in psychiatry for the medical students that were delivered just in time for the teaching block. In previous years the students have had very limited access to psychiatry teaching, and indeed have never had clinical experience in psychiatry at undergraduate level. Given the extremely limited access to psychiatric care, the lack of public (and professional) education about mental health issues, and high rates of psychiatric sequelae of infectious diseases so common in Malawi, the need for general medics to be aware of psychiatric issues is paramount. So we had our brief for the teaching block: orientate Malawi’s next generation of medical graduates to the main psychiatric conditions (especially acute confusion and its safe management), bring some interest and humanity into the subject, and possibly even get a couple of the students hooked on psychiatry as a career. 

 

A great side-effect of the trip was that it foreshortened my Scottish winter, and I gladly exchanged dark nights for Malawi’s rainy season. The skies would open in torrential style every couple of days washing away roadsides, maize crops and occasionally the electricity supply, so life's comforts and communications could become a little uncertain. The positive side of all this water was the wonderful green that dominated every view. In Blantyre the houses were surrounded by blossoming aloe vera trees and other exotics, and every available corner of ground was head high with maize. You'd hardly know you were in a city of over two hundred thousand people, with the majority of the population hidden away in shanty towns on the outskirts of the city. Malawi really needed a good rainy season as the aftermath of last years poor harvest were all too horribly evident at the local nutrition clinch at Moyo House (you might have see the TV coverage of Ewan McGregor’s UNESCO trip there a few of months ago). Rob’s research on infant nutrition and maternal depression is based at the clinic and he spent his days measuring hungry babies too weak to cry while their dazed mothers gazed on. Given how very, very little these women had, they still found a smile and time to help out with the research. Our other flatmate, an infectious diseases consultant would come home from work with tales of two patients in each bed, plus two underneath, erratic supplies of antibiotics and trying to run a diabetes clinic with no insulin.

 

My own work started with a surprise announcement that I'd be doing over 16 lectures instead of the planned three. Having been fully absorbed in the world of child and adolescent psychiatry as an SpR for the last three years, I spent much of the first three weeks making up power-points and revising everything from narcolepsy to paraphilias (a process made more than tolerable as I wrote the lectures on a sunny veranda, kept company by Malawi’s two fattest cats).

 

The language of tuition at the College is English and the medical students were bright and interested in learning, so there were plenty of great questions and a chance to build up interest as the teaching block progressed.

 

 

There were also two psychiatrists visiting from Norway helping with the teaching as part of a five-year commitment their local health board has given to support medical teaching in Malawi. I enjoyed some very dynamic joint lectures with one of the Norwegians who’d worked everywhere from Cambodia to Vienna. Felix Kauye was superb in orientating us to psychiatry in Malawi and keeping us right on how to tactfully approach transcultural issues with the students. He's a St Andrew's Medical graduate and is tackling the weighty challenges of reforming psychiatry in Malawi with good humour and quiet determination. During the three weeks of classroom-based teaching the students worked particularly well with teaching videos, case examples and small group work, although I’m pleased to report that they (usually!) stayed awake during the pretty intensive lecture programme. We then decamped to Zomba (an stunningly beautiful hours drive to the north of Blantyre) for two weeks of clinical attachment at Zomba Mental Hospital. First impressions of ZMH are very striking. Some of the conditions are very poor, with stark Nightingale wards for sixty plus patients, extremely basic toilet facilities, and scarily high patient-nurse ratios (at the weekend there are usually only one or two nurses on duty for 250 acute patients, not to the mention the kids and the rehab wards).  The teaching was tutorial based with time spent with patients on the wards, practising case presentations and academic ward rounds. The warm welcome from nursing staff and patients helped me overcome my initial anxiety about being the only doctor at these clinical ward rounds, which turned out to be an invaluable insight for me into psychiatry in Malawi and allowed professionals from all disciplines access to the teaching (as well as helping Felix out with his mountainous clinical commitments during the extra busy time of the teaching block). Everyone showed endless patience helping me with translation and cultural issues which, I hope, made the wards rounds feel more like an exchange of information and expertise rather than three hour didactic marathons. By the end of the two weeks the ethos of prompt discharge and rehabilitation as necessary, combined with the kind and patient approach of staff and open green spaces on the wards, went some way towards offsetting the seclusion rooms and extremely limited medication options. Thankfully new wards are being built next to the old buildings (one of which actually fell down last year!). There’s further reason for optimism despite the massive challenges as Felix is pushing on with reform of the Malawian mental Health Act, a multidisciplinary learning centre at ZMH and epilepsy education programmes in the community, amongst many, many other things.

 

 

By the end of the teaching block, MCQ and oral exams complete, I’m delighted to say that a couple of the students are thinking of psychiatry as a career and the feedback from students (which happily did not go un-noticed by the Medical College authorities) was very encouraging. Possibly the ad hoc cinema we created at the medical college using the lap top and data projector, showing A Beautiful Mind and One Flew Over the Cuckoos Nest with beers and snacks had played it's part.

 

I’d always hoped to volunteer abroad but personal circumstances preclude the one - two year commitment demanded by most agencies, so it’s been a great opportunity to make a trip on a briefer timescale. Malawi will need extra support with psychiatric teaching for the foreseeable future so a group of interested psychiatrists in Scotland, with the support of the Scottish Executive, are making plans to support psychiatrists at SpR and consultant grade make two- five weeks trips on a more regular basis. To have the opportunity to directly support Malawi’s own College of medicine and Felix Kauye seemed a straight forward way to support Malawi’s own efforts, as I can safely say that the longer I stayed in Malawi the more confused I became about issues of aid, NGO’s and the huge complexities that represent beautiful Africa.   I’ve over-stepped the word count quite considerably, so I won’t have time to tell you about the elephants and hippos, or the dazzling sunbirds, or the sea kayaking at sunset on Lake Malawi, or the shared laughs with patients on Ward M2, or the amazing smiles from locals walking endless distances by the side of potholed roads…. I’ll leave that for Rob’s next entry as his year in Malawi comes to a close.

 

Best wishes, Leonie Boeing.