Life as a GP in Malawi —the warm heart of Africa

Dr Martina Collins writes about her experiences as a volunteer GP in the African country of Malawi, where her daily struggles with a lack of resources were offset by a real sense of making a difference to people's lives.

Trying to persuade a mother to get herself and her underweight baby tested for HIV, deciding if a nasty-looking cellulitis is bad enough to warrant some of the limited supply of flucloxacillin, treating the 20th child with malaria that day... these are all part of a day’s work for a GP in Malawi.

As third-year registrars on the Cork and south-east training schemes, we were lucky enough to be offered the opportunity to work in a primary care setting in Malawi, with the Billy Riordan Memorial Clinic. This was arranged as an educational attachment through the South East Training Programme and was a first for GP training in Ireland.
Tropical diseases

The post offered first-hand experience of the diagnosis and treatment of tropical diseases while promoting an understanding of the art of medicine in a developing country within a different cultural setting. While initial feelings were those of excitement tempered by apprehension, we now look back on our four-month stints as the highlight of our careers to date.

The ‘warm heart of Africa’ was the phrase initially coined to promote Malawi abroad. After spending some time in the country, however, you realise how apt this actually is. It is one of the smallest countries in Africa, but what it lacks in size, it makes up for in spirit. The people are warm, friendly and inspiring and the landscape is beautiful.

Lacking the major game parks and tourist attractions of neighbouring countries means its beauty is unspoiled. Tourists are a novelty and, for the most part, are welcomed and well treated.

Behind the beauty and joie de vivre, however, lie some pretty sobering statistics. One of the poorest countries in the world, Malawi has a population of almost 14 million in a country 1.5 times the size of Ireland.
Great courage

People there have a life expectancy of just 43 years and there is an estimated HIV prevalence of 14 per cent. While working in the clinic, it was difficult to forget these facts. They were offset, however, by the locals’ great courage in the face of adversity.
The Billy Riordan Memorial Clinic is located in the village of Cape Maclear or ‘The Cape’, as it is fondly known. This is a village of about 6,000 people on the shores of Lake Malawi. The clinic was set up by Mags Riordan, a Dingle native whose son Billy was tragically drowned aged 25 at Cape Maclear.
Fallen in love

Billy had been to visit Malawi a number of times and had fallen in love with the area. The clinic began seeing its first patients in 2004, and the work it has done since its inception is a more-than-fitting tribute to his memory.

The clinic is run by a team consisting of two resident medical staff complemented by an ever-changing group of volunteer doctors, nurses, physiotherapists and administrators. Dr Jeanette van Os from Holland and Catherine Ginnell, a nurse from Westmeath are the resident staff.

They are very committed individuals. At times, they have to work without any extra volunteer staff and are responsible for the clinical aspects of running the clinic. The majority of volunteers tend to be Irish because of the strong Irish connection, but there are also volunteers from the UK, from Holland and from further afield.
Communal breakfast.

A typical working day in Malawi started with communal breakfast, during which any issues that had arisen on-call overnight would be discussed. Following this, we had a short walk to the clinic. As this happened to be in the same direction as one of the local schools, there was never a shortage of helpers to carry our bags, hold our hands or hitch a piggy back!

On arrival at the clinic, most of the morning’s patients would already be waiting. Following the usual round of ‘Mwadzuka bwanji’ (good morning in Chichewa, the local dialect), which was generally greeted with laughter at our pronunciation, we got stuck into work.

Clinic ran from 8am to 12pm and from 2pm to 4pm. Conditions typically encountered in a day’s work included malaria, dysentery, bilharzia and HIV-related illnesses. This was in addition to the typical coughs, colds, aches and pains encountered in any GP surgery throughout the world.

Consultations were carried out via interpreters. As time progressed, however, we found ourselves learning more and more Chichewa as the interpreters were only too delighted to teach. The clinic is very much primary healthcare-orientated, although Dr van Os also provides some obstetric services. Of huge importance, a free anti-retroviral (ARV) therapy service has just been started and HIV testing will start soon. Prior to this, those on ARVs had to travel to the next village to get their medication.
The clinic also has 12 in-patient beds, which are used for short-stay admissions, for example for those requiring IV fluids, antibiotics or quinine or children requiring observation. The hospital beds and tables in these wards have come courtesy of the amalgamation of Cashel and Clonmel hospitals. The doctor’s desk even had a helpful list of Cashel NCHD bleep numbers, should one feel homesick!

Patient numbers were variable, depending on whether or not it was peak malaria season. The time between morning and evening clinics was spent reviewing any patients that were admitted and returning to the volunteer accommodation, or ‘The Gap’, as it was known, for lunch.

After-hours emergencies were dealt with in a small treatment room at The Gap with transfer to the clinic by ambulance if necessary. Because the clinic has no access to diagnostics or surgery, anyone requiring these is transported via ambulance to the next town of Monkey Bay (roads and weather permitting). However, services at Monkey Bay are also very limited.
Limited equipment

Professionally and personally, the Malawi experience was fantastic. Although the work seems daunting at the start, you quickly settle in and it is rewarding to see how much can be done for people with very limited drugs and equipment.

Some of the highlights are the job satisfaction and camaraderie at the clinic, not to mention the patients, who never seem to complain and are always in good spirits. For anyone who has come through the Irish hospital system, where ‘teamwork’ is a phrase often used but seldom practised, working in the clinic is like a breath of fresh air. Nurses canulate, doctors change dressings. If it’s busy, everyone chips in to get the job done.

Furthermore, those who like the gruesome side of medicine will not be disappointed. There are numerous abscesses to be incised and drained and cockroaches to be extracted from ears. There is also a chance to see at first hand conditions only previously read about in textbooks, from leprosy to snake bites to African medicine.
Some downsides

Of course, there are some downsides to the job. At times, the lack of access to diagnostics and basic medications can be very frustrating. Also, depending on the number of medical staff, the on-call can be frequent, although generally quiet. Needless to say, the most difficult thing to become accustomed to is seeing children die.

Because working at the clinic requires living in close proximity with fellow volunteers, people generally become firm friends following the experience. There is never a shortage of banter, especially if there happens to be English volunteers around and there are plenty of people with whom to have the craic. After-work activities can range from swimming and volleyball to getting thrashed in soccer by the locals. There is also snorkelling, kayaking and a dive school for the more adventurous types.
Picturesque and popular

Cape Maclear is very picturesque and a popular backpacker destination. There are lodges, restaurants and a bar or two, so there is no excuse to be bored. Local brews and Carlsberg (or ‘Greens’, as it is known) are the beverages of choice.

Indeed, the Malawi experience in some ways reflects the Carlsberg slogan. It is ‘probably’ the best spot in the world to visit if you want to work in a developing country, meet new people and embrace a challenge.

At the moment, the clinic is increasing the services it provides. In addition to expanding its feeding programme for undernourished children, the previously-mentioned ARV Clinic is in operation. Mags is also in the process of building a new school in the area.

As one can imagine, the workload is also increasing and Dr van Os would always welcome a pair of helping hands for any length of time. Unlike larger NGOs, it accepts volunteers for short stints, and if there is a partner who wants to volunteer also (even in a non-medical role), they can often be accommodated. Because the clinic is well established with protocols in place to aid in its smooth running, it is relatively easy to slot in and get stuck in over a short space of time.
Ideal starting point

For anyone who has ever considered working in Africa, this is the ideal starting point – whether it is for a few weeks or months. Some paediatrics or emergency department experience would be helpful, but not essential. The most valuable skills would be sound clinical acumen, adaptability, an easy-going personality and a sense of adventure.

As the time comes to leave the clinic, people invariably regret not being able to stay longer. As it says in the guidebook, “You are bound to leave a part of your own heart in the ‘warm heart of Africa’.”
We certainly did.

To volunteer at the clinic in Malwai or to support the project, contact Mags Riordan at the Billy Malawi Project at magsriordan@esatclear.ie.