Worlds apart

Pauline Josiya has just had to tell the family of a 10-year-old girl she needs heart surgery – but an operation of that kind is out of reach for poor families such as theirs.

Each day Dr Josiya is forced to reconcile what she knows her patients need with what little support she can give. ‘There’s nothing we can do, except lessen the symptoms, and she’ll be coming to hospital frequently.’

Dr Josiya is a recent graduate of Malawi’s only medical school and is now an ‘intern’ at Mzuzu Central, a government hospital in the north of the country.

During an 18-month internship, resident doctors such as her are often the most senior clinicians on duty at this public hospital serving nearly three million people. More senior doctors tend to work in private hospitals.

‘You have to tell patients: “If we were in a developed country, we would have done this for you but because mostly we don’t have medication or equipment, that’s all we can offer you,”’ she explains.

Dr Josiya describes a recent 24-hour shift when she was responsible for about 120 patients across three wards. She barely ate and had just 90 minutes’ sleep before she was summoned to confirm a patient’s death.

‘You have to be the strong one for the patients there, no matter how you feel. There’s some days that you’re like, “this is too much”. But if I see a very sick patient recovering and going home smiling, that’s very rewarding. And compassion is as important as clinical knowledge: the patient will always remember how you made them feel.’

GP partner Elizabeth Howard has a tie-dye picture of a Malawian village on the wall at the Brighton surgery where she works. It’s a reminder that if medicine can be tough in East Sussex, the challenges in Malawi are a completely different order of magnitude.

Dr Howard and her husband spent three-and-a-half-years in southern Malawi from 2015 when he took a job as a paediatric orthopaedic surgeon at Beit-CURE international hospital in Blantyre.

At the time, Malawi had only a handful of GPs who had completed MRCGP, believes Dr Howard, and just one psychiatrist. WHO data shows Malawi has just 0.54 doctors per 10,000 people, compared with 32.3 in the UK.

Most of Malawi’s rural healthcare relies on ‘clinical officers’, who have generally completed three to four years’ training plus a year’s internship, and who routinely perform life-saving procedures such as caesareans. 

At the village clinic outside Blantyre, which Dr Howard supported, the focus was preventing non-communicable diseases and treating conditions such as diarrhoea and malaria. Anything more serious required people to find the minibus fare to a larger health centre – and hope it had the necessary resources.

Villagers would start queueing outside the clinic from 5am, head torches bobbing in the dark.

The shifts – and the poverty she witnessed – were often overwhelming, says Dr Howard. ‘People die of a stroke because they don’t have their blood pressure treated. It just seems so unnecessary.’

The leading cause of death for men and women in Malawi is HIV/AIDS. Anti-retroviral therapy is available free of charge in the public sector but stigma or the fact some drugs must be taken with food to be effective poses serious challenges.

‘Some of the stories are heartbreaking,’ recalls Dr Howard. ‘Things like power cuts in the middle of surgery and the patient dies on the table because you can’t see them. Or in a busy maternity clinic, where you want to check for pre-eclampsia or hypertension, there’s no blood pressure cuff: it’s gone missing.’

For Dr Howard, the precariousness of it all was summed up perfectly by a Malawian GP on placement in the paediatrics department of a UK hospital. When a child died, it was not the death that shocked the Malawian doctor but the outpouring of grief among staff. ‘It made me realise that, in some countries, children dying isn’t normal,’ she said.

It was while Dr Howard was involved in training medical students in Blantyre that she came across the charity Medic to Medic and started collaborating with them to support student wellbeing. She is now one of its UK trustees.

Founded by UK doctor Kate Mandeville in 2007, the charity sponsors medical students from disadvantaged backgrounds through their training in Malawi, as well as a wide range of other trainee health professionals, from midwives to mental health workers.

More recently, Medic to Medic has extended its support into Uganda and Zambia. 

It pays tuition fees, and provides a laptop, medical books, equipment and welfare support – at a cost of about £1,000 a year per trainee. At any one time, it sponsors between 100 and 120 students and aims to increase that figure to 150 by the end of next year.

Its focus is students who would otherwise be at high risk of dropping out, which was precisely Pauline Josiya’s situation when she was introduced to the charity.

She had long nurtured an ambition to study medicine. In the remote, rural community where she grew up, most villagers relied on traditional medicine: childhood illnesses were usually treated with her grandmother’s ‘concoctions’ foraged from the bush.

‘I’ve seen my mother spend a whole day walking to the hospital because she didn’t have money to board a bus,’ she says, ‘and, anyway, buses and taxis are not readily available.’

After her father died, she relied on a government scholarship to cover her schooling – and the goodwill of an uncle who lived close to her school and agreed to take her in.

Yet, at medical school, a government loan covered only part of her tuition fees and by her third year, despite support from relatives and a church friend, she faced the very real prospect of dropping out. She often went without food.

It was then that she met Tamsin Lillie, the British doctor who has been Medic to Medic’s CEO since 2014. The charity provided financial sponsorship and accommodation for Dr Josiya: Dr Lillie offered her mentorship and friendship.

‘I am where I am now because Tamsin believed I could do it,’ says Dr Josiya. ‘She has been an anchor to me. Medic to Medic made a very great impact on my life.’

Retaining and strengthening homegrown talent in Africa is important for Dr Lillie. She now spends up to nine months a year there: for the rest of the time, she is an urgent-care consultant in Rotorua, New Zealand, putting in long hours to make her work in Africa possible. (She’s aware of the irony that she no longer works in the UK where she did much of her training.)

Dr Lillie is proud of the fact that more than 90 per cent of Medic to Medic alumni have stayed in their home nation. Many other medical graduates leave for countries such as South Africa, not least because of the lack of specialty training in Malawi.

The charity’s focus on disadvantaged students, often from a rural background, resonates with the ‘WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas’. The WHO strongly recommends that health worker education programmes in low- and middle-income countries should enrol such students.

For Dr Josiya, working in northern Malawi, where her mother’s family is from, is a way of ‘giving back to my home’ and ‘bringing hospital closer to the people’.

Yet, even the strongest commitment to medicine and Malawi is not enough to sustain students through medical school. They need moral support, too.

Two years ago, Medic to Medic set up a mentorship programme whereby alumni mentor students, with a strong focus on wellbeing. There are plans now for an independent, out-of-hours helpline for all healthcare trainees, too.

‘Students are used in service provision as well because there’s not enough health workers,’ says Dr Lillie, ‘and they’re often left on their own to do procedures they’ve maybe done or seen only a few times’.

Dr Howard says it’s important to give this its proper name. ‘It’s important to start talking about moral injury, otherwise what happens is people just end up burning out – or absenteeism,’ she says.

‘Malawian medical students all do MB BS, they all know what they should be doing, but if the cupboard is bare when they go for the amoxicillin or insulin, then they have to cope with the fact that someone’s going to die because the equipment or medicine that should be there isn’t in place.’

For Dr Lillie, one experience during a recent visit to Mulanje in southern Malawi embodies so much that is lacking in the Malawian health system.

She and a group of overseas elective students came across a dishevelled man with a head injury lying unconscious in the street, 200m from a hospital. As they started to attend to him, he had a seizure.

‘Nobody was stopping to help him,’ says Dr Lillie. ‘But then Malawi doesn’t have a national ambulance network and there’s a real lack of health education and probably a little bit of fear as well.

‘When we get him to the resus bay at the hospital, there’s one person’s already on a stretcher and it’s staffed by one clinical officer, with a whole queue outside.’

The scale of the challenge takes a heavy emotional toll on Dr Lillie at times. The charity has only one other employee in Malawi, who assesses students’ suitability for sponsorship.

But the need is so compelling Dr Lillie finds it hard to stay away. She’s realistic though about what a small charity can achieve – and presses on.

Medic to Medic has a longstanding elective programme placing international students in a range of different hospitals across Malawi – and now wants to develop opportunities for doctors on sabbatical to get involved in teaching too.

Dr Lillie’s work in Africa does mean that patience can sometimes wear thin when she hears people in New Zealand complaining about work.

It’s the example and courage of health workers such as Dr Josiya who work long hours in the most stressful conditions – and often support dependants with their earnings – that drives her on.

‘The young professionals are incredible people for what they see every day,’ says Dr Lillie, ‘and the fact they still get up every day and want to work’.

And, for the days when the need in Malawi threatens to overwhelm, Dr Josiya herself has a good answer for Dr Lillie: ‘This one medical student will benefit an entire community and care for thousands of patients over a lifetime. The more doctors are being trained, the more lives are saved.’

•  Medic to Medic’s sponsorship programme matches regular donors to an individual healthcare student, providing regular updates on their progress. For more on this and other ways you can support Medic to Medic, from buying African scrubs, to doing an overseas elective, or running a marathon in Malawi, visit medictomedic.org.uk