In 2013 I spent six weeks in a hospital in Nkhoma, Malawi. The hospital was in a beautiful rural village at the bottom of a mountain with limited resources, financed by Church of Central

Africa Presbyterian (CCAP). It had a handful of wards: general male, general female, paediatric, labour and two theatres. You could walk through the whole hospital in three minutes. Staffed by one senior physician and one senior surgeon from the US and Holland respectively. The nurses were all

Malawian and could speak English, but almost all the patients only spoke Chichewa. I was there over Rosh Hashana, Yom Kippur and Succot which was an interesting experience as there were unsurprisingly no Jews in Nkhoma.

Traditional healers

Malawian culture places ample emphasis on traditional healers. There is no primary health care, general practitioners don’t exist. However, many patients will seek a traditional healer as a first port of call. It has a significant impact on healthcare because it results in many patients presenting with late stage diseases after the traditional healer failed to cure them for a period of time. Moreover, patients often trust traditional healers more than conventional healthcare, which can make management complex.

Limited resources

Investigations were not always readily available. Blood tests were often very limited if they didn’t have the money that week to pay for reagents required to run the tests. Chest x rays were sometimes not possible if there was no running water to develop the films. This meant having to triage the patients who most needed the tests.

Language barrier

Although I learnt some terms in Chichewa, the local language, most of the time I was taking histories and examining patients either with the aid of a nurse translating, or using solely non verbal communication. This made consultations both challenging and at times amusing when trying to portray vomiting or diarrhoea through the art of acting.

Tropical disease

Tropical diseases were prevalent, but not as much as I thought originally. I learnt a reasonable amount about diagnosis and treatment of these diseases, e.g. schistosomiasis, but I learnt a lot more about the common diseases that one sees in the UK, e.g. heart failure and pneumonia.

Because patients presented late, clinical signs were more readily detected and the number of patients with organomegaly doesn’t compare to that which you see in the UK.

Religious beliefs

I was surprised to learn about the impact of religious beliefs. The local community were devout Christians and the Chaplain played a key role as part of the medical team. Many patients were either terminal, dying, or died in hospital. The chaplain was always called to see the patients and family to help explain, reassure or comfort them, making a huge difference to the patient, the family and the general atmosphere on the wards. It was interesting to discuss the similarities and differences with the Chaplain from a Christian and Jewish perspective on science, modern medicine and death. The patients trusted the Chaplain more than the medical team. He played such a crucial role in comforting the patients but also in explaining conditions to patients bridging the gap between their traditional religious beliefs and our modern understanding of science and medicine 

Patient with breast cancer.

Three weeks into my elective, I saw a 52 year old female on the acute medical ward. She had presented with a cough and shortness of breath. I took a history from her with Catherine, one of the nurses, translating for me. After the history, I thought a simple pneumonia was the most likely explanation for her symptoms. Other infectious diseases would have to be on my differential as well, e.g. TB. As usual I proceeded to examine the patient, not expecting to find anything remarkable aside from maybe some respiratory signs. When it came to exposing the patient’s chest, I was shocked. On her right breast was a horrible fungating breast cancer.

Although I am uncertain as to whether or not I drastically changed my facial expression to express my shock, I doubt I was able to stop myself from reacting to it as I was totally unprepared. The patient did not seem to mind the cancerous growth spread across engulfing her breast. She simply said it’s been there for while. I completed the rest of the examination and heard some crepitations in her right lower base. She did in fact have a pneumonia as well as the fungating breast cancer.

This case had an impact on me in terms of understanding why patients seek medical care. This patient had a fungating breast cancer for at least a year yet she didn’t seek medical care until she contracted a pneumonia. This puzzled me. A woman in the UK would not wait for a breast cancer to grow through the skin, she would more often feel a lump earlier on and seek medical attention. People in the UK are educated, formerly or indirectly, about breast cancer. In schools, on television, or adverts on the tube, women know about breast cancer and are aware of what signs to look out for. Moreover, there is a national screening programme for it. This is diametrically contrasted with women in Malawi. There is little health education, formal or indirect, and there is no breast screening program. This patient did not know she had breast cancer because she did not know what breast cancer was or that it even existed. It did not bother her, she continued life with it. Ultimately her breast cancer did not disable her. As a mother, culturally her duty was to take care of the children, manage the home and cook the food. She was able to continue to do this until she developed a pneumonia. Although shortness of breath is seemingly a mild symptom relative to the gravity of a long standing invasive breast cancer, it was nonetheless more disabling for this patient. Patients in Malawi do not seek help because they are concerned about certain symptoms, they seek help if those symptoms are disabling because if they cannot work or fulfil their expected duty at home, they do not earn money, they cannot afford food and they starve. They do not go to hospital if there is merely pain, blood or deformities. They go to hospital if anything disables them, if it physically impairs their function.

This reminded me of the importance of public health education and screening programmes. People need to know about diseases so they can seek help before these diseases become untreatable. This patient’s prognosis was negligible. There’s no medical or surgical treatment available to her that will prevent her cancer from killing her in the near future. If either she sought medical advice when she first noticed a lump, or if there was a breast screening program in place, it would be a different story, one with a better ending.

Rosh Hashana, Yom Kippur, Succot

I knew before going that there was no Jewish community in Malawi, not even a Chabad, which was surprising. I therefore realised it was essential to bring a mascot, a religious item of sorts, to serve as a constant reminder my roots and religious Jewish persuasions. So I decided to be practical and brought with me a bulky, awkward to pack, space occupying Shofar. Despite the presence of my shofar, this was the first Rosh Hashana I had which did not feel like Rosh Hashana. I managed to find apples in the local market. Not really an M&S selection, not really golden or delicious. But there were four apples to choose from – apples bizarrely cost more than grapefruits in Malawi. I chose the two least bruised apples, some honey from Mzuzu. Very grainy. Bit too bitty. Semisatisfied with my apples and Mzuzu honey, I showered and donned my white shirt for the New Year, before struggling to explain the significance of eating honey on apples without sounding like a weirdo to the other medical students and volunteer doctors from around the world. Although Rosh Hashana wasn’t what it usually was for me, I invited a Malaysian and Dutch medical student round to my house to show them how it’s really done. Yom Kippur sadly also lacked the atmosphere which I take for granted at home. However, it was interesting to discuss with everyone, including the Chaplain the concept of a day of atonement, introspection and self reflection. And it was an experience breaking the fast for the first time on Malawian gin, something I will not  ever voluntarily be doing again. As for Succot, the best I could do was find a large lemon and some willow from the garden.

There was, however, one small aspect about being in Nkhoma which I found connected me to my Judaism unexpectedly. There were oftenpower cuts which limited us to candle light and restricted gas cooking. This meant on Shabbat, towards the evening there was an atmosphere that reminded of me Bnei Akiva camp where everyone sits around a table with no phones, no tvs, no computers and talks as it gets darker and Shabbat comes to an end. The abundance of candles available also made Havdala very easy and accessible.

Thanks to the JMA for all the support and enabling me to have a fantastic elective in Malawi!

Julian Gertner
UCL