Electives overseas

Africa...

Conjures up images of wild, open, barren land and mud huts.
Parts of it are like that, but it can also be incredibly beautiful with its burnt orange sunsets, noisy minivans, patterned cloths and bustling markets. 

I chose to visit Malawi and found the people genuinely warm and welcoming. In general they were fun, honest people who looked on a sometimes challenging life with a mix of optimism and resignation.

Blantyre at dusk...

When to go and objectives...

I spent my last summer holiday as a student on elective (our official elective is only 6 weeks and I wanted the chance to go to more than one interesting destination). I had always wanted to visit Africa and was keen to see how healthcare in a developing country would compare to the UK. My main concern in choosing a developing country for my elective was that I did not want to be unsupervised and "practising" on patients in an unethical way but I did want to have the opportunity to get hands-on experience. A tricky balance.  I was glad I had not gone earlier in my course - I would have learnt less and been far less useful.

Where I went...

I organised the placement myself through the University of Malawi (a LOT cheaper than using an elective company) and was allocated to Obstetrics & Gynaecology at one of the country's main government hospitals - Queen Elizabeth Central Hospital, Blantyre (or "Queens" to the locals).

I was shown around the library and even given my own email address and access to the IT facilities which was unexpected. The team made me welcome from the start and I shadowed various members of staff including nurses, clinical officers and registrars plus attended ward rounds, clinics and theatre. My fears of being asked to crack on with a c-section solo were unfounded - in reality, the department was well supported and staffed most of the time and so I actually had no concerns with being asked to act above my level of competence. However not all my friends working in district hospitals had the same experience - some were left to conduct ward rounds and on-calls alone as if they were a qualified doctor with full prescribing powers. Of course, having the power to give someone a drug out there is not always relevant as shortages are frequent. Even at the main central hospital where I was based it was common to run out of basic drugs and so patients' families were sent on errands to try to source them. 

Empty shelves at the city chemists...

When I tried to buy dexamethasone for the labour ward there was ONE vial in the entire of Blantyre.

The hospital grounds are well maintained but the infrastructure needs some TLC. As I was leaving one of the wings was being upgraded but even the areas that have been recently built with international help could do with better planning. There are rooms set aside for facilities that don't exist - in my view a waste of space and money when some wards have patients on mattresses on the floor due to lack of beds.

I spent some time in the Emergency Department too where there was a cracking US consultant who was great at teaching and passing on practical skills and also enthusiastic about flagging interesting cases to students and other staff. It was a fast paced and challenging environment and I heard that there were some terrible RTAs that presented. Patients often turn up in the back of a truck as there is no reliable ambulance service and people cannot afford other private means of transport. Practical procedures there are unavoidable so great if you want to be a real member of the team.   

There were many challenges:

• Seeing patients die from eclampsia.
• C-sections that proved complex and resulted in hysterectomy.
• Pregnant women with meningitis and malaria
• Lack of privacy - intimate examinations often carried out in full view of the entire team (this could be 12 people) without drawing curtains
• No theatre one day because key staff had gone for interviews and there was nobody available to cover.
• Late presentations of treatable disease because of the lack of access to effective primary care.
• Sinks but no hand washing... aaaargh!

But I was impressed by:

• Dedicated midwives, working long hours for less than $10 a day. Not a terrible wage in context but they could have left to work abroad and chose to stay where they would be needed.
• Staff persevering with malfunctioning equipment and faced with acute shortages of key drugs.
• Patients who were dignified and rarely complained - this gave me an interesting insight into womens' health in a different cultural context but I was also aware that there was under-reporting of pain as a result.
• Staff make the best of everything and one of the main things I learned was an appreciation for clinical evaluation without reliance on imaging and creativity with limited kit. Surgeons managed with one size of gloves and three suture types. 
• Caring relatives. Patients bring their own chitembe or sarongs that they use as sheets - the hospital doesn't provide any. In stark contrast to the UK relatives set up camp in hospital grounds in order to provide care and meals for the patient. So, whilst other aspects are clearly lacking, care and attention for the patient is evident.

TOP TIPS FOR BLANTYRE

Kabula Lodge - lovely place but not safe to walk to and from town even in the day as tourists are known to reside there and have been targeted frequently (sometimes violently) in recent months. (Yep, one was me). You will need to factor in taxis to your budget for staying there. I was told that sometimes you are followed from ATMs after taking out money so always get a pre booked taxi home again.

Doogles - loud but friendly. The staff are great fun and they will store your bag for you if you go away at weekends. Not great for meeting long term visitors as people tend to be more transitory here.

Vege Delight - best place to eat even if you aren't a vegetarian! quirky food and friendly owner. 

Heritage Cafe - near QECH and Beit Cure just off the roundabout. Great buffet lunch and super cheap.

National Bank had a bureau for foreign exchange - great rates August 2012 and friendly staff who even changed a small amount of currency for me when I ran short on my last day. Highly recommended.

Don't let the crime put you off - in general Malawi is a very safe place and theft is culturally completely unacceptable but with the huge contrast in wealth tourists will always be a potential target. You could just as easily be mugged at home.  Just be sure to minimise what valuables you carry and take taxis after dark. Blantyre is not a very pretty city but it has character and I loved the markets. At the weekends it is easy to get away and see other brilliant areas of the country just never get public minibuses after dark  - the roads are dangerous enough in day and potentially lethal at night given the potholes, lack of working headlights and no seatbelts. Do get minibuses in the day - its fun and a great insight into everyday Malawian life - try to grab the second row on the right, the seats are fixed and wont tip you off and avoid the backseat as this is often where they squish 7 people...

Outside of the hospital I explored the country and tried out horse riding in Zomba, kayaking at Lake Malawi and trekking in Mulanje. 

An intense but rewarding trip to a lovely country with warm people. 

So if you are thinking of going, buy your plane 

ticket early (££££ ouch), learn some 

of the local language if you can and

 consider bringing supplies for the 

hospital as they will be appreciated.