DGMH is a district hospital situated 1000m above sea level, which was founded by Dr Robert Laws over 100 years ago. This location was chosen because of the low numbers of mosquitoes in the cooler climate of the mountains and therefore the decreased prevalence of Malaria. Today this remains true; however, the hospital's geography means that a significant proportion of the hospital budget is spent on fuel and maintenance for the 4x4 ambulances which travel arduous and mountainous routes to serve the remote and isolated villages that depend on the hospital for medical care. Despite this issue, I learned that DGMH serves a population of almost 100,000 over an enormous area of Northern Malawi and supervises numerous rural health clinics. Staffing the hospital are Dr Lyn Dowds from Northern Ireland, and a team of two Clinical Officers, Three Medical Assistants and several nurses and midwives. The responsibility for many of the day to day chores of the hospital, including changing beds and feeding the patients, is handled by 'guardians' who are the friends and relatives of the patients. The guardians live together in a small community near the hospital and help each other to support the patients, all, of course, as volunteers.
For both patients, staff and guardians, the day begins at 7am with prayers in Timbuka before a handover in English. Coming from a secular workplace, this opportunity to pray together with my colleagues was one which I embraced. It was encouraging and refreshing to have the opportunity to combine my faith and my work and to unite with the staff and patients in our common beliefs.
Following prayers I joined the ward rounds of the four departments: Male, Female, Paediatrics and Maternity. I decided to try and split my time relatively evenly between these departments, in the hope that I would have as broad an experience as possible. Unlike in the UK (where a question is only asked of the medical student as a test), at DGMH I found that that my opinions could lead to clinical changes, and my findings influenced further investigations and treatment. This motivated me to read up about every patient to ensure that my knowledge was reliable, up-to-date and robust. My intimate and regular involvement with patient care was more like my future FY job, than any previous placement. The result was that I cared deeply about the patients and reflected on them long after leaving the hospital, often coming back the next day with new ideas or questions. In this way, each patient became a learning tool, a concept which has been preached at lectures but which is now a reality of my medical practice.
Some Memorable Patients and Events
Looking back over my time at DGMH, there are, of course, certain patients who stand out and whose stories reflect some of the issues facing a rural, resource poor hospital. While I saw and helped in the treatment and cure of many patients, it is sadly the ones whose care was not so successful which stick most in my mind. One 8 year old girl with severe burns on both legs presented to the hospital almost a month after an accident because her family had first tried the traditional healer, and then neglected the child. We were managing her with daily change of dressings with a view to transferring her for skin grafts, but unfortunately her poor nutritional state meant that she was unfit for the difficult transfer, or for an anaesthetic while she had her dressings changed. I will not forget the girl screaming as her dressings were changed or my exasperated disappointment when she developed a concurrent infection and died. Wound care, and bed sores are a major issue and the nursing staff often lack the training needed to pro-actively manage these issues which ultimately kill patients. Nutrition is another killer at DGMH since often the patients cannot afford nutritious food, often having eaten meat perhaps once in the last year. The necessity of basic care which we take for granted in the UK, was sadly demonstrated to me by unfortunate cases such as that 8 year old girl.
Oddly, some of my first significant contributions to DGMH did not depend a great deal on my medical knowledge or training. On my first day at the hospital, a biomedical engineering student and I were asked to attempt to fix the broken X-ray machine. Using some problem solving ability, and admittedly a manual, we were successful! I could only imagine the reaction of a UK radiologist if he were to find two young students reaching under his equipment with hammers and screwdrivers!
Later in the week, I expressed my desire to help with other such projects and soon found myself enlisted to assist in reorganising and cataloguing the store room. This gave me an invaluable insight into the resource issues facing a hospital such as DGMH: walls of specific donated drugs which cannot be used before their expiry dates; very few or none of other key drugs such as NSAIDs, ACE inhibitors, beta blockers; and mountains of donated surgical equipment of no use to a rural hospital. This experience highlights that while of course the hospital need medical donations, it is critical that the donations match the need of the hospital. In this way, the impact of our generosity can be maximised. Moreover, there is a perception that if medical equipment is unwanted or unused in the UK, it will be wanted in the developing world. From my experience in the store room, and from my conversations with staff, it is clear that this is not the case and that they are striving for the same standards of care as we deliver in the UK. Thus if it is not good enough for the UK, it may well not be good enough for Africa.
One other way I was able to help the hospital was by conducting an audit of the use of oxygen therapy over the previous month. This was a particularly interesting study to conduct in a culture where many patients believe that oxygen therapy kills patients, making the false association between a sick patents need of oxygen and the chance of them dying.
On Reflection
There is no doubt in my mind following this elective, that I will be a better clinician for having completed it. My knowledge was pushed and often relied upon forcing me to be my best. The culmination of this was me successfully leading my first resus attempt on a neonate – an experience which will forever live in my mind. I was certainly exposed to numerous diseases and clinical situations which are alien to UK practice and gained invaluable experience in these conditions. Moreover, I feel I was able to make a positive impact upon the DGMH. I regularly made contributions to the weekly teaching, and following my audit of oxygen usage, there was a noticeable increase in patients receiving therapy. I would like to think that my overall impact on the hospital will be positive and lasting if only in a small way. I am extremely grateful to EMMS for helping me to make this placement possible and for contributing to some of the defining experiences of my medical training and of my life.
To summarise what I have learned about medicine in rural Africa, I would say that my lasting impression is that the issues we imagine to be most prevalent, such as limited resources, are not those which most effect quality of care. While it is true that it was extremely frustrating to be denied a diagnosis by limited investigations, this problem was completely overshadowed by the issues of transport, communication, and staff training which I have mentioned above. Ironically these issues may be the most difficult to correct and require a long term vision, with ongoing input and support.
