First Report - September 2005
Moni nonse (Hello all),
Welcome to the story of my experience working here in Malawi
under the umbrella of the new Royal College of Psychiatrists
Specialist Registrar volunteer Scheme. I hope that this journal
will encourage others to arrange time out from higher training in
order to learn and work in a low income country.
Like many others, I spent my medical student elective in the
developing world (Nepal in my case) and had always hankered after
returning at a time when I would have some useful skills and
experience to offer. However, the treadmill of SHO posts and the
pressure of exams meant that that dream seemed to be slowly fading
under the approaching shadow of consultant responsibility.
A move to the
Manchester SpR scheme opened up my horizons again. I became
increasingly aware of the growing interest in psychiatric research
based in, and relevant to, developing countries. I received an
enthusiastic response in the Manchester University Department of
Psychiatry to my tentative enquiries about undertaking some
research abroad. Thus, via a year long process (the details of
which I will return to in my next posting), and with financial and
emotional support from a great many people, I found myself stepping
out into the heat and dust of Blantyre airport to begin a volunteer
year as Honorary Lecturer in Psychiatry at Malawi’s Medical School,
The College of Medicine.
I've been here for a month now and am settling in to life
in what is a beautiful, welcoming, and perplexing country. I had
arranged accommodation and a vehicle on a preliminary visit so was
able to quickly get down to some work. Part of my time here will be
spent conducting a research study investigating the association
between maternal mental health and infant nutrition in the context
of the HIV/AIDS epidemic. For this I will travel down to Thyolo, a
small town set amongst the iridescent green of the tea estates 25
miles south of Blantyre. Medicine sans Frontiers (MSF) are based
here and have integrated their HIV programme into government
provision to good effect. At present, however, the idea that a
robust and sustainable country-wide programme of anti-retroviral
treatment is anywhere close, is fanciful. In an example of the
daily struggle that the health service faces, at Queen's Central
Hospital in Blantyre (the main government teaching hospital) the
antibiotics needed to treat pneumonia and meningitis run out last
week. The reasons for this are complex but the situation has left
my medical colleagues increasingly dispirited. It will be
interesting to see how the situation is resolved.
What about psychiatry? I spend 2 days a week up at Zomba
Mental Hospital (a 300- bedded government institution) working
alongside the optimistic and dedicated Chief Government
Psychiatrist Dr Felix Kauye (as he is the ONLY psychiatrist in
Malawi, the title Chief is perhaps a little superfluous). I look
after 2 acute wards - Male 1 and Female B. Each has up to 50
patients, although, for me, it is not as tough as it sounds. The
hospital is largely nurse-led (there was no doctor for many years)
and my role during ward rounds is to review the 10 or so patients
who are either failing to improve or ready for discharge.
Medication decisions are not too tough - Chlorpromazine or
Modecate. There is a wee dash of Haloperidol available and, at
present the antidepressant of choice is fluoxetine. Why? Because
we've run out of Amitryptiline.
I get a strong sense that the culture of care here is one of
respect and understanding, but staff and resource constraints mean
that chemical restraint and seclusion are used more than the nurses
would wish. Felix is particularly concerned about the use of ECT.
It is given un-modified and for a wider range of indications than
might be wise. Diagnostic skills are an area that Felix and I feel
can be improved with a stronger medical presence. The ward rounds
serve as an opportunity for us to teach the clinical officer
students who attend Z.M.H. for 4 weeks in their final year.
Clinical officers are school leavers who have 3 years of general
medical and surgical training and provide much of the non-nursing
medical care in Malawi, as there are simply so few doctors.
In terms of my own personal adjustment, I am getting used
to early rising and have even been known to have a Chichewa lesson
at 8 am. I have a great teacher Dick who is trying to help me
through the maze of noun classes, suffixes, prefixes and even
infixes, that make up this infuriating language. I can at least
introduce myself now as "dokotala wa anthu wa ovutika mmaganizo" (a
doctor for people with thinking problems). I have a ready-made
social life amongst the other volunteer doctors here and have even
met the most important man in Malawi - the manager of the Carlsberg
brewery! (Carlsberg is the
biggest single manufacturing employer in the country
(probably)).
I feel sure that this is going to be a great year and I plan to
share some of my thoughts and impressions on this page over the
coming months. I will also give some explanation of how I organised
the trip so that anyone interested might get some ideas about where
to start. One early step would be to read the information on the
International Affairs pages to learn how the college can support
your efforts.
Dr Robert Stewart,
| Main corridor |
Zomba mental health hospital entrance |
Laundry drying |
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Second Report - November 2005
Hi,
I now have been in
Malawi for almost 2 months so I thought it was time for an update
on how I am getting along.
Well, everything is going just fine. Most importantly, and
enjoyably, I am forming warm friendships and working relationships
with Felix (the Malawian psychiatrist) and Eric (the Malawian
psychologist). Together we are getting down to the process of
translating the various questionnaires needed for the research
study. It is remarkable how many different ways there are to
translate the same, seemingly simple, question. There are some
other teething problems with the study but I am confident it will
work out in the end.
I am also getting more confident on my ward rounds at Zomba
Mental Hospital, although it often feels more like bravado! I
justify my decisions only on the basis that it can't be worse than
having no psychiatrist input at all. There are certainly signs that
conditions at Z.M.H. will improve over the coming years. The
government are putting some money into building new wards, and an
energetic Dutch engineer has raised funding for the building of an
Occupational Therapy department and a sports field (the latter
funded by Johann Cruyff). If you are interested, there is a website
describing these projects - http://www.malawitogether.net/.
The ideal, of course, would be to bulldoze the whole place and
build small units in each town and develop the community services.
The model for this would be the St John of God service based in
Mzuzu, the main town of the northern region (an area known as the
"Switzerland of Africa" as it spans from the lake to the mountains,
and has some pretty unpredictable weather). About a month ago, I
visited the service (run by a Catholic charity) and admit to having
had a lump in my throat comparing the atmosphere in the homely
purpose-built unit to that at Z.M.H. Of course, it is well funded
and can attract and retain motivated staff, but it is great for
Malawi to have such an inspirational example of what can be done.
They do not have any psychiatrists but the experienced clinical
officers seem to do a pretty good job.
If you
are considering spending a year in an out of programme SpR training
placement, working in a country like Malawi, then one of the issues
is money. Few developing country jobs are going to be able to offer
much in the way of a salary but there seem to be a range of sources
of potential funding. I was looking, in part, for funding of a
research study, so I trawled through the list of charitable
foundations that offer small project grants (available on the
website: http://www.rdinfo.org.uk/). There
were many options but, for me, a depressing list of expired
deadlines (Lesson 1: it is never too early to start organising).
Having adjusted my personal ethical spectacles, I approached drug
reps and wrote to the companies, telling myself that the ends
justified the means. It was worth it; I received a generous
contribution from one company (Astra Zeneca) although the rest were
less forthcoming.
With my departure nearing I resorted to the time-honoured
sponsored cycle ride and, with the prompt of a leaflet explaining
my objectives, many friends, family, work colleagues and complete
strangers, came forth with donations for which I am very grateful.
Producing a "flyer" also had the benefit of spreading awareness of
the mental health needs in Malawi. The Royal College were also
supportive; under the SpR volunteer scheme they funded me with £500
given on the condition that I could demonstrate that the year,
although self organised, was appropriately structured and
supervised.
Despite these varied contributions, this year is still going to
cost me a significant amount and this prospect may put some people
off undertaking a similar trip. If it is at all feasible though,
just consider how many years ahead you will have on a fat
consultant salary when, as CPA meeting merges into CPA meeting, you
will be able to drift back into the warmth of a red-dust tropical
sunset. Definitely worth it.
Once you have made the decision to go, I would suggest
contacting any local consultants or lecturers who might have an
interest in developing world psychiatry, or who might have useful
contacts. Contacting the authors of research that interests you is
also an option. At an early stage it is sensible to discuss your
ideas with the training scheme coordinator. I was allowed to come
abroad as "Out of Programme Experience" which means that my
employer superannuation contributions continue to be paid. Getting
training accreditation for the year is a matter of writing to the
college in advance and making a case. You may, of course, not wish
to get it accredited. Extending SpR training for as long as
possible is, as we all know, a desirable goal.
I am writing
this sitting in the garden of the French Cultural Centre here in
Blantyre, listening to the music of Wambali, the "godfather" of
Malawian jazz. This may seem odd to some of you. I understand that
the media in the UK is full of articles highlighting the impending
famine in Malawi, and my mum said she was finding it hard to square
this with my phone conversations with her describing meals out,
trips to the lake etc. I am sure she is right to be perplexed, and
not a day goes by when I do not struggle with the contrast myself
(particularly when pushing my trolley between the groaning shelves
in Shoprite, the Blantyre equivalent of Tesco's).
One thought comes to mind. The audience here is almost entirely
made up of Malawians. They are the middle class, many of whom are
involved in the businesses that must grow in order to expand the
Malawian economy. Whether that wealth trickles down to the
overwhelming majority who live a marginal rural existence depends
on the policies of President Bingu and the actions of foreign
donors/advisors. I understand that investment in irrigation will be
one potential route out of the bitter cycle of annual crop failure
and starvation, as, at present, it is woefully underdeveloped.
Malawi has plenty of water but it is in the wrong place. It may
work, though I always think how difficult any sort of change must
be when you are pervasively poor, tired and hungry.
On a happier note, here are a few mental images of Malawi:
Clifton, the gardener's joyful, high-pitched and tuneless singing
as he sweeps the lawn for the nth time; the intense concentration
on the faces of men as they gather speed on overloaded unstable
bicycles, carrying loads of wood and charcoal into town; the
hyper-mobile, hyper-sexual hip-shaking moves of the dancers at last
Friday's Oliver Mtukudzi concert; and the proud unimpressed gaze
from the baby wrapped tight in the chitenje on his mother's back,
as I secretly stick out my tongue at him.
I have also added a few more photos of the hospital.
| Building new wards |
Male ward outdoor area |
Plenty of Chlorpromazine! |
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Third Report - December
2005
Hello again,
Back in October, on a ward round at Zomba Mental Hospital,
I faced a dilemma. Across from me, staring emptily down to the
floor, sat Mary (not real name). The notes described her as being
about 50 years old - precise ages seem to have less meaning in
Malawi - and she was clearly severely depressed. She had been on
female ward B for 3 weeks but, despite 40mg of fluoxetine/day, she
remained as flat and withdrawn as on admission. Her cousin, who was
acting as her "guardian" (helping her with food and hygiene) was
finding it increasingly difficult to encourage her to eat, and Mary
(not real name) repeatedly expressed choking worry and guilt about
how her family were coping without her.
With that nagging sense of needing to "do something", and,
feeling that the severity of Mary's illness needed a predominantly
biological approach, I considered my options. I could persist with
fluoxetine, switch to amitriptyline, or prescribe ECT. I decided on
a switch of antidepressant but quickly recalled that there was no
amitriptyline available. When the nursing sister reminded me that
the fluoxetine was also finished, I realised that there were no
antidepressants in the whole hospital, and that the only option was
ECT. However, as I mentioned in an earlier letter, ECT is given
here "unmodified", without anaesthetic or even sedation. Could I
really send Mary to have a treatment that would be frightening and
potentially dangerous? I have always remembered my brief ethics
teaching at medical school and, when faced with difficult
decisions, have fallen back on the axiom "primum non nocere" -
above all do no harm. Would I be breaking this rule? In the end,
after weighing up these concerns against Mary's clear suffering and
taking into account both my certainty in the diagnosis (a rare
experience here) and the lack of any alternative, I wrote "ECT x 4"
and signed my name. Thankfully, this time, she suffered no major
problems and recovered well.
The antidepressant situation has now improved - an
effect of having Felix Kauye here as the government psychiatrist,
able to bring authority to requests and decisions. ECT, however,
remains a troublesome issue. In the many years during which the
nursing staff (and the sole clinical officer) worked with
commitment and compassion but without medical supervision, ECT came
to be used as a sedative for difficult-to-manage patients.
Unfortunately, attempts to change this practice face a difficulty;
namely, in the nurses eyes, it "works". There is no doubt that,
after a few doses of ECT, previously aggressively psychotic,
elated, and potentially violent young men, become calm and
manageable. Whether that is a result of the ECT, the concomitant
antipsychotic medication, or just time, is largely irrelevant in
the view of the nursing staff who see a clear change and feel safer
because of it. It is worth remembering that there are 4 trained
staff for up to 50 acutely ill patients, working in a run-down
environment without Acuphase or a PICU on the end of the phone. It
is also not so long ago that ECT was being used in the UK in much
the same way. My father trained in psychiatry in the West of
Scotland in the late 50's and used to tell the story of admitting a
floridly psychotic patient on a Friday and being encouraged to have
him "better" for the consultant ward round on Monday by giving
shocks daily over the weekend! Slowly things will change here.
Felix is determined to alter the culture surrounding ECT, and we
have the funding to ensure that the treatment is at least given
with an anaesthetic administered by staff from the nearby general
hospital.
What else has been happening? Well, my Malawi Television
(TVM) career goes from strength to strength! I have had 3
appearances to date. Back on October 10th, World Mental Health Day
coincided with Malawi's Mothers Day (which warrants its own bank
holiday here). As my research is focussed on maternal mental
health, this seemed like too good an opportunity to miss. My
colleague Eric, by virtue of being the only clinical psychologist
in Malawi, often gets asked to appear on TV to comment on
health-related news items and he was able to use his contacts to
secure a slot on the TVM "Breakfast Show". Dragging myself out of
bed at 6 am, I joined him on the very flimsy-looking set where,
with the programme's version of Mr Motivator barely cooled off, I
was under the glare of the hot studio lights giving a rather
startled interview. More recently, I appeared on a panel discussion
about human rights as they apply to people living with psychiatric
illness. It was broadcast as prime time evening viewing, which
perhaps gives you a clue as to the state of TV Malawi's schedules!
However, I hope that it is all part of the glacial process of
pushing psychiatry/psychology up the health agenda.
One of the most enjoyable aspects of working here is the
variety. No two days are the same, whether in terms of the work, or
as a consequence of the quirky little Malawian occurrences that
bring a smile or a shake of the head.
Regarding work, I was involved in caring for a young traveller
who stumbled into the country psychotic and vulnerable. Negotiating
repatriation with his very helpful embassy, and his not-so-helpful
insurance company, was an interesting and testing experience. I
have spent a few weekends with Eric and Felix travelling around the
country giving presentations to staff in district hospitals. As the
talks have been in Chichewa, my role has largely been that of
driver and drinks boy. Seeing a white doctor struggling with a
couple of crates of Coke and Fanta is always a source of great
amusement to the audience. In a hangover from colonial times (and
as a symptom of current economic inequalities) "muzungus" - whites
- aren't really expected to be fetching and carrying.
These talks have been a great way of seeing parts of the
country that I would never have otherwise visited. One trip
involved a bumpy drive down an un-tarred road to Nsanje in the
lower Shire valley. This is the poor and isolated district that you
may have seen recently on the news or in the papers. Here the
impending nationwide famine has already tightened its grip.
Following the arrival of anxiously awaited rains and the almost
instant greening of the landscape, it is sometimes difficult to
square the lush appearance of the countryside with the severity of
the food shortages; it is the ghost of last season's failed harvest
that is haunting the mud tracks and straw huts of rural Malawi.
Again, trying to end on a happy note (and inadvertently
reflecting the bitter contrast between my life here and that of the
hungry), I am looking forward to a family Christmas back in
Scotland. I am in need of a rest but I hear it is a wee bit chilly.
I am sure that I will be keen to get back here in January when my
research study starts in earnest.
In my next letter, I plan to write about the ups and downs of
undertaking research as part of a volunteer year in a developing
country. Many thanks to those people who have emailed me and
expressed an interest in arranging a similar year abroad. Anyone
else interested, please feel free to get in touch.
(The stunning photos of this stunning country were taken by my
travel photographer friend, Ian Cumming. Thanks Ian.)
Christmas yabwino!
Robert
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Fourth Report - January 2006
Lero, ndachita kafukufuku (Today, I did research).
Since returning from a much-needed holiday back home in the UK,
the data collection for my research study has finally begun.
Although I am now very busy, it is a great relief to have started.
In the days prior to Christmas, as I wrestled (metaphorically) with
the ethics committee, it seemed as though it would never really
happen. I am conducting two studies investigating whether there is
an association between maternal depression and poor infant
nutrition in Malawi. There is good evidence for such a link in Asia
(see Patel V et al, BMJ, 2004;328:820-823 for a review of the
studies in this fascinating area) and some similar work is being
done in Ethiopia and South Africa. I am working at 2 sites - one
based in a measles vaccination clinic in the tea-growing area of
Thyolo, and the other in Moyo House, a malnutrition unit in
Blantyre.
At the first site, Thyolo District Hospital, I have
employed 2 nurses to interview mums and weigh and measure the
babies. They are both wonderful. Doreen is very experienced and is
a great organiser, able to pick out eligible participants from the
scrum of mothers bringing their children to be immunised. Sophie is
younger and, with a smile as wide as her hips, calms and cajoles
the babies as they are stretched out on the measuring board to
record their lengths.
Of course, conducting
psychiatric research in another culture and language poses numerous
questions and difficulties, both ethical and practical. Even for my
small project, I have had to struggle with the dilemma of how to
employ fieldworkers without removing them from clinical service
provision. Thankfully, my study is short and Doreen and Sophie are
working for me whilst they take annual leave. This issue of local
"brain-drain" is certainly a problem. Government wages are low, and
I have learned that there is a temptation when doing research to
just pay as much as needed to ensure that the study gets done,
without taking a wider view of the impact on the local health
service.
A
practical difficulty for an outsider undertaking research in a
country like Malawi is, of course, the language barrier. I cannot
administer the interviews myself and am employing Malawians to do
so. The question therefore arises - what do I actually do? The
answer - I hand out drinks and try and keep people cheerful! My
barman duties extend not only to the mums, to whom we give a bottle
of Fanta whilst they wait to be seen, but also the staff in the
clinic who are being helpful and accommodating, despite the
temporary disruption to their routine that the study has
brought.
We are recording the heights and weights of the mothers as a
rough indicator of their own physical health, and I also help out
with this. I have become adept at measuring a mum one-handed whilst
holding her baby with the other - a risky operation as the
"chitenje" nappies aren't very waterproof. I have learned to take a
spare shirt with me to work! Lifting the plump cheerful babies is a
joy but also a painful contrast to doing the same procedure at the
other study site, the malnutrition unit, Moyo House. Here the
children are heartbreakingly light, and feel as fragile as their
own grip on life. About 20% of them are orphans and about 50% are
HIV positive.
You may have seen Moyo on the 10 o'clock news just before
Christmas; we had a visit from Ewan Macgregor in his role as UNICEF
Ambassador. Many of the mothers (or other carers) of these infants
come from the overcrowded townships around Blantyre. Life there is
harsh, and social and family structures have fractured under the
pressures of urban migration and poverty. Unsurprisingly, we are
finding high rates of depression amongst these women. They each
have a story, often of broken marriage or teenage pregnancy, but
Precious (name and details changed) made a particular impression.
Stunted and wiry, with a lined weary face beneath unkempt hair, she
came to be interviewed with one child cocooned in a dirty chitenje
on her back and one under each arm (a fourth she had left in her
bed area). 2 were her own - twins - and the others orphans from her
neighbourhood. All had been admitted severely malnourished and 3
were HIV positive (through the cruel lottery of mother-to-child
transmission of the virus, one of the twins is negative, the other
positive). She struggles on in a daze of stoical determination but,
like so many others, is being pushed downstream in an inexorable
flood of disease and disadvantage.
This is my first experience of conducting research and it has
been a steep learning curve. However, it has certainly added
another dimension to my year here in Malawi. I sense that working
fulltime on the wards at Zomba Mental Hospital would have been very
draining, and to anyone hoping to spend a similar year as a
volunteer SpR, I would certainly recommend trying to mix clinical
activity with teaching, research, or service development.
The rains are starting
to fall in earnest now, sustaining the maize that now stands at
head height on every free patch of land in Blantyre, before
funnelling down the roads, breaking up the tarmac and cutting deep
axle-twisting channels in the dirt tracks. Hopes are high for the
harvest but it is still over 2 months away and nothing is certain.
A nation has its fingers crossed.
Best wishes for now. Feel free to get in touch.
Robert
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Fifth Report - August 2006
Home.
Real beer, regular electricity and chocolate
that doesn’t taste of sand. Channel 4 News, broadband internet and
cars with 2 working headlights.
Oh… and traffic jams, Big Brother and
drizzle.
A year goes by very fast. For anyone who has
not read my previous letters on this site, that year has been spent
working as an SpR volunteer in Malawi, undertaking a stimulating
mix of research, teaching and clinical work. It has been a while
since my last report, and I hope that many of you will have read Dr
Leonie Boeing’s description of her visit out to Malawi for 6 weeks
in February/March in which she enthusiastically documents her
experience of teaching the undergraduate psychiatry unit.
As she rightly pointed out, I had asked her to
take up the pen as I was feeling under the screw of research data
collection! In fact, the research element of the last year went off
far better than I could ever have hoped. There is no question that
conducting what is a rather obsessional activity in an environment
where the pressures of clinical responsibility and day-to-day
financial necessity can be overwhelming for staff, was at times
tough and frustrating. However, I got through it in no small part
because of regular and supportive supervision (via email and
fortnightly telephone contact) from my supervisors Professor
Francis Creed and Dr Atif Rahman. I strongly recommend that
anyone conducting research as part of a similar SpR placement
should insist on such hands-on supervisor involvement. I was also
lucky enough to have in-the-flesh support from Dr James Bunn in
Blantyre who, although not a psychiatrist, gave me incalculable
wise counsel and cheerful encouragement.
I had the pleasure of attending and presenting
at the conference of the African Society of Psychiatrists and
Allied Professionals in Addis Ababa in May. It was really
encouraging to see the drive that exists to improve the
understanding and treatment of mental illness in the Africa, and
inspiring to see the situation in countries such as Kenya and
Ethiopia and imagine where Malawian psychiatry could be in 10 years
time.
At present, however, things are still hard. Dr
Felix Kauye remains the only psychiatrist and there is no realistic
prospect of his being joined by trained colleagues for many years
to come (although there is clear enthusiasm being shown by one
junior doctor and a number of medical students). And, of course, it
is not just psychiatrists that are needed but psychologists,
nurses, clinical officers and occupational therapists. Training for
staff in district hospitals and rural clinics is an urgent priority
as is political and community involvement to start to reduce the
stigma experienced by those living with mental illness. One abiding
memory from my clinical work at Zomba Mental Hospital is of a young
man who was bound so tightly by his neighbours (fearful of his
psychotically driven behaviour) that he was left with serious
neurological damage, limiting his use of both hands, and
compounding his difficulty in returning to a useful and rewarding
life outside of hospital.
However, I was also struck by some aspects of
the care of the mentally ill in Malawi that we would be wise to
bear in mind in our services in the UK. In particular the healing
space, both physical and temporal, available to people admitted
acutely psychotic to Zomba Mental Hospital compares favourably with
the lack of access to fresh air and outdoor areas in many newly
built acute units here. Just a thought.
So where from now? Well, over to you! It has
not been without its frustrations, and I probably could have worked
harder in some areas, but spending time out from SpR training to
work in a developing country cannot be recommended enough. And I
sense a growing momentum behind efforts to make the process easier
for anyone contemplating such a move. The support of Joanna Carroll
in the College Board of International Affairs has been very
welcome, and I am sure she will be happy to advise and encourage
others wanting to utilise the provisions of the SpR Volunteer
Scheme.
Finally, I must again thank all those people
who supported my Malawi experience and contributed financially to
the research study. I believe I spent your money wisely! But,
again, my overwhelming thanks and admiration goes out to Felix
Kauye who is quietly improving the lives of the mentally ill in
Malawi. There is a clear moral imperative for UK psychiatrists (and
the organisations within which we practice) to support colleagues
in developing countries - such as Felix - whilst they work to build
indigenous and sustainable services. I hoped that my minor
contribution will encourage others to do just that.
Robert
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