Saturday, November 22, 2014

On a peak


November 21st
(Beware, this is a long, esoteric blog post that Liam thinks will bore everyone.) 

I am not sure if it is because Malawi is about 60 degrees warmer than Seattle right now and I am thinking of the crisp clear skys and beautiful views over lake Washington but I find my mind wandering to a mental picture of the Olympics on a clear day.  From far off, it looks like you could walk along the ridge summiting peaks, appreciating the effort it took to get to the view but then seeing there is another higher peak ahead with a valley or two in between.    


Today, I am on a peak, I feel full of hope; I am admiring the view. 
I spent the past 2 days in Mangochi.  Mangochi is a 3.5 hour drive north of Blantyre. It is known for being home to the Yao—a large group of predominantly Muslim people, its humidity, proximity to the Southern tip of Lake Malawi where many people vacation, and the site of first district hospital where Family Medicine Physicians will be trained in Malawi.  The purpose of the trip yesterday was to meet with the DHMT (District Health Management Team), discuss the terms of agreement between the College of Medicine and Mangochi District Hospital and sign a Memorandum of understanding.  Regardless of what actually happened during our meeting, the fact that this meeting was happening represents a long story of hard work and dedication. 
Starting in 2011, two Malawian family doctors began laboring to promote the idea that Family Medicine as a speciality can improve health care in Malawi by being clinical leaders in the district hospitals.  These two family doctors have carried enough passion and perseverance to continue the efforts even when it seemed no one was listening.  Today, November 21st 2014 is a day of celebration.  But given there has been so much foundational work done in the last few years, sometimes I feel I am cheating by entering the story of family medicine in Malawi at this pivotal time when the fruits of their hard labor are being revealed.   I would like to take a moment to illustrate the depth of the celebration today. 

Concept #1: 
Starting less than 10 years ago, a movement started in Africa to incorporate Family Doctors into rural hospitals to provide the spectrum of care that is required to meet the needs of the community they are serving.  The concept of the African Family Doctor has been described as “physicians trained to have a body of knowledge, skills and attitudes required for the provision of primary, continuing, comprehensive, personalized and holistic care to individuals, their families and the community”.[1]   An abundance of literature describing the need for FM in Africa is already in circulation. But at the same time there is an acknowledged lack of consensus about how to define FM training in Africa--as the role of the Family Doctor will be very different in setting that have unique needs.  Malawi has been sited in many of the foundational articles that have wrested with this dual realty. 

Concept #2
Within Malawi there is consensus from people in high places about what the role of the family doctor might look like: as a clinician, health manager and team leader who provides consultation to other health workers within the team (in their unique setting) and provides emergency surgical and obstetric care.  From the side of the Ministry of Health, there is motivation to promote Family medicine: if a family doctor can function as a well trained clinician who can treat patients for a wide range of conditions, in a timely and evidenced based manner that health outcomes in Malawi can be improved.  The College of Medicine has articulated that they are invested to support the concept of training physicians in a district setting—for the first time. 


Concept #3
Building a residency curriculum in the US—where FM as a specialty is well established and the spectrum of training requirements are fairly well defined—takes a lot of time and effort.  Building a residency curriculum in Malawi--where the concept of FM is completely foreign and the work of the family doctor has never been piloted—is a herculean task.   And it was only two family doctors who decided to take this task on.  Today—after many meetings, closed doors, set backs and reiterations--Dr Dullie and Dr Makwero’s residency curriculum was accepted by the medical council.   This curriculum defines the role of the Family doctor in Malawi and specifically outlines a robust 4-year curriculum. This accomplishment has been done by only a handful of African nations. 


Concept #4
A curriculum is nothing without residents.  Recruiting Malawian Medical Officers (who have completed medical school and a 18 mo internship and are qualified to practice in Malawi) to take up a role of student again for 4 years, AND move to a rural setting is not easy. 
Finding a district hospital that is willing to incorporate medical residents into a system that has no precedent for this is also not easy. 
Yesterday a memorandum of understanding was signed between this rural hospital in Mangochi.  And in about 3 weeks the first residents will begin their training at this site. 
Recently published an article entitled “Understanding Family Medicine in Africa” describes the complexity of this process that is happening all over Africa.

(Understanding Family Medicine in Africa. Br J Gen Pract. Mar 2013)
The world is watching to see if it can happen in Malawi. 

Concept #5
As of today, Mangochi represents collaboration between a district hospital and the college of medicine that is brand new.  This site has the potential to showcase a profound success. But, it is expected that FM is not going to be easy to implement on the ground.  Already is it clear from the two Family Doctors (who have come through SEED global health and GHSP) that the work to teach through example, to slowly earn the right to be clinical consultants, to slowly work to develop systems that will accommodate FM doctors is very difficult and at times profoundly discouraging.   This trial is likely to take many years and a lot of patience.  Although one can intellectualize that the way to change systems is from the inside, slowly and humbly, much credit should be given to those visiting family doctors who are doing this hard work.

Concept #6
I came here with a notion about how I could help propagate the expansion of FM in Malawi.  Though this notion was shallow and naïve, I now believe strongly that a long term academic partnership between WWAMI and Malawi will be fruitful in the months and years to come.  This strong belief is founded on what is happening as a result of the work of incredible R3s from Swedish who have come to work alongside me (Beth Thompson, Ben Davis, Kannie Chim.) 
Swedish R3s are working full time at Ndirande Health Center in Blantyre.  The goal is that over time this health center will grow from a struggling health center into a well functioning full spectrum district hospital to meet the needs of over 200,000 patient who seek care there.  When this hospital is formed it will be a second model site for training both medical students doing their clerkship in FM and for residency training.  This vision will come to fruition slowly, over months and years.  For now, the work is not well defined, the resources are extremely limited and the relationships between “us” (the white doctors) and them (the clinicians—who are not doctors—who have been running this health center for years) are complicated.  There is limited space, no money for anything, and hundreds of patients everyday.  The conditions are grimy, there is rarely any water and we don’t speak the same language. I ask the resident to go: see patients, take overnight calls, build relationships with the clinicians and nurses, work on the small quality improvement projects we have started (with humility and patience) and keep the long term goal in mind.  They are demonstrating resilience and hard work to an extent that I never imagined possible.  I am not only proud of them but I think that there is potential for Ndirande to be a model site for Malawi and even for other nations in Africa. 
Ben and Beth left two weeks ago, nurses and clinicians enquire about them, they are missed here.  They are missed for their hard work, their willingness to work as part of the team, the teaching and the clinical resources they developed while they were here.  Kannie arrived two weeks ago went to a rural community yesterday, worked with a clinical officer and an eye doctor and evaluated the patients who had been waiting for 6 weeks to receive medical care.  She was on call last night and delivered a baby alongside Malawian nurse midwives with whom she has built a relationship of trust.  Emmy is coming next and is already on the teaching schedule for our new Wednesday afternoon didactic sessions and we have patients returning for care that will have seen Ben and Beth, Kannie and Emmy.  We are part of this team.  We are patient and have big goals. 
None of this would have happened without the foundation built by Dr Martha Makwero and Dr Luckson Dullie.  We would not be here without the risks these two took on to incorporate us into their vision.  But both of these things happened and we are now confidently working together in partnership toward a shared vision that will hopefully change the health system in Malawi and maybe even beyond.


The financial needs are vast.  This vision will not come to fruition without monetary support.  I am realizing that my role here is 1/3rd clinical (at Ndirande), 1/3rd with the college (helping to organizing the medical student clerkship rotations that happen every 6 weeks) and 1/3rd to help with grant writing.  … and at the moment I type this bit about grant writing on this page, the vision of the Olympic Mountain range comes into my mind again.  I picture heading into a valley.  I am not a grant writer.  But I will try.  Dr Martha Makwero—who is a hero of this blog post, my colleague and partner this year, and my friend—has been telling me, in her Malawian accent “you CAN!”  And I have to believe it and keep moving toward the peaks and through the valleys. 




[1] Luckson Dullie MD “Developing Family Medicine presentation, AAFP Global Health Conference 2014

2 comments:

  1. Liam is wrong - I am fascinated, not bored. And so glad to catch up with your news because I haven't checked in for too long. Seattle news: yesterday Genny delivered son #2, Calvin, with a bit of drama because he was in more of a hurry than they realized and arrived at the foot of the stairs at home, about 2 minutes before the firemen. Everyone is well. Love and miss you all.

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  2. Wow! What a breathtaking picture you are painting Elizabeth. So glad for the good work you are doing there!

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