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{( speakerName('A') )} {( convertTime(1810) )}
So hello everyone, and welcome to our next episode of Clinical Conversations provided by the Royal College of Physicians Edinburgh Trainee and Members' Committee. My name is Anda Bularga. I'm a T&MC member. Today we have an interesting and a very informative discussion touching on different aspects of health care and medical training in Malawi. I am delighted to introduce our guests Dr. Michael McKenzie and Dr. Isaac Chirwa, both working in the capital city of Lilongwe, Malawi. Dr. MacKenzie is an infectious disease consultant who trained in Edinburgh. And Dr. Isaac Chirwa is a consultant endocrinologist who did part of his medical training in Scotland. Together with Doctors MacKenzie and Chirwa, today we're going to touch on several topics talking about health care and training between Scotland and Malawi. At the RCPE, we work closely with our international community and we are a member of the Scotland Malawi Partnership. Our international development group has been exploring and developing links with academic and healthcare institute supporting postgraduate training in Malawi. Welcome both and thank you very much for your time today. So at the start of this podcast I would be very grateful if you could give us a further introduction yourselves and describe your training and work experience both in Scotland and Malawi.
{( speakerName('B') )} {( convertTime(76882) )}
So I'm Isaac Chirwa, working in Malawi in Lilongwe. I had what we called sandwich undergraduate training. So I did part of my undergraduate medical training at the University of Cape Town and after three years I got back to Malawi and finished my MBBS degree at the College of Medicine Investor Malawi. And after that I did internship, or housemanship as it's called in other countries. And that usually would take about 18 months. And then I started working as a registered medical officer. Then I trekked out of the country after about three or four years of work and went to the UK where I did my SHO training and then became a registrar and then go back to Malawi after a couple of years. Currently I'm working as a physician with subspecialties in diabetes and endocrine.
{( speakerName('A') )} {( convertTime(130114) )}
What about yourself, Dr. MacKenzie?
{( speakerName('C') )} {( convertTime(131926) )}
Yeah, thanks very much. And my training um, in some ways is pretty familiar to I guess trainees maybe in Scotland and the UK at the moment. I did undergraduate medicine up in Aberdeen and then I also did what Isaac did, the Senior House officer training, junior and senior House officer training in that system. And after some years I did a very sort of familiar training programme in south and eastern Scotland and infectious diseases and general internal medicine. But at various intervals I've come down in between the training post, I guess to practise in different parts of Africa. That's been a big part of my career. Also just practising medicine in Africa, most recently in Malawi for the last couple of years. I think we were discussing the training path is often quite long. But I've had a mixture of trainings, with the traditional one in the UK through the medical specialty system, and also some kind of real life training in different parts of sub Saharan Africa, most recently in Malawi.
{( speakerName('A') )} {( convertTime(192346) )}
That's very interesting. And just out of interest, what made you both, do you want to have that kind of experience, broad experience yourself in the UK, Doctor Chirwa, and in Africa, Doctor MacKenzie?
{( speakerName('B') )} {( convertTime(203220) )}
I think for me, during my time when you finish your undergrad training it was specifically clear which route you to follow to go through specialist training. There are other opportunities, but it is very limited. And during that time most of our friends had opportunity through the Paediatric department of the College of Medicine to get connections through the UK and get trained there. And that looked like the easier option, wasn't easy in the end, so it looked like the route I could follow to go through my club and then get a job in the NHS and then proceed with my training. There were other options, but that looked a bit more what could have been achieved that time. And also it was just I wanted to get a feel of my consultant then, when I was working as a medical officer. He was somebody who had worked in UK to consult in levo. And so he was like my mentor. So it was very easy to follow his footsteps.
{( speakerName('A') )} {( convertTime(268102) )}
How did you find the transition process, Doctor Chirwa?
{( speakerName('B') )} {( convertTime(274790) )}
Interesting, it was quite a big difference in terms of what was expected and actually just the pathology, the change in the pathology. I mean, during that time, HIV/AIDS was a big thing here. It was, but not such a big thing. So the change in pathology was one big thing. And the character itself, and Mike might agree to that. There is some degree of respect which you offer to your seniors here, which is not the case in the UK. There's some degree of camaraderie which is again, to adapt to that culture. It took a while, but yes, after a couple of months it sort of settle in.
{( speakerName('A') )} {( convertTime(318090) )}
What about you? Do you MacKenzie, what made you want to have that experience in Africa?
{( speakerName('C') )} {( convertTime(323150) )}
I can see that Isaac and I somehow moved in opposite directions a little bit and then we've turned around and we're in the same place now. But I guess my motivations were two things really. I guess medical school for me had its ups and downs, but out of interest, really, I became more interested in the immune system. And then through that, really the sort of infectious diseases angle Isaac mentioned, HIV/AIDS, and I remember getting not a lecture, but a kind of talk in medical school, I think maybe from someone from MSF talking about, and this is around the sort of the millennium about HIV/AIDS and what a sort of interesting disease that was. And the other thing that I became aware of was really the burden of disease. And I felt that to go to sub Saharan Africa as we could from around that time treat HIV/AIDS effectively, it was kind of a quintessential experience as a doctor. So it felt like something that would really be of great utility. So it was really interesting then wanting to make oneself useful. A doctor is always useful I think. But what I could see was there was a really big need in the early 2000, mid-2000s and that kind of drove me to work in Zambia and South Africa particularly, and to start building up my experience.
{( speakerName('A') )} {( convertTime(402870) )}
Thank you, that's very interesting. And I guess a bit later in this podcast we'll touch a bit about the health conditions and the burden of diseases in Africa and Malawi. Quite interested. You both spoke a bit about training. What about if we think about medical training in Malawi? So if we take someone who's just finished medical school, is there a specific path similar to what we have here in the UK to become a physician, to kind of have a career path in the medical specialty? What is the training path in Malawi?
{( speakerName('B') )} {( convertTime(433070) )}
These things have changed in the medical school in Malawi and I might take another question to that. So currently we only have one medical school in Malawi. I think
{( speakerName('A') )} {( convertTime(598118) )}
Very interesting. Yes. And what about postgraduate examinations? Is there still kind of an examination process after medical school at the end of the fellowship you're describing?
{( speakerName('B') )} {( convertTime(609698) )}
Yeah. So there are two main exams. So there is the Part 1 exam after two years, because it's the prospect of a training programme for four years. But you'd have to pass your Part 1 exam to proceed to the third year of your training. So there is an exam at year two, which is a part one, and then there's the ultimate exam at year four. That's the end of the Master's programme or the fellowship programme. With regards to the Master's programme, there is also the yearly annual review of competence, which is done just like it used to happen in the RCP training. I wonder if it's still happening in NHS.
{( speakerName('A') )} {( convertTime(649370) )}
Yes, those words ring a bell.
{( speakerName('B') )} {( convertTime(653290) )}
We still have that for the fellowship. While for the Masters in Medicine, they have the exam at tier two and the final exam at tier four, which one has to pass to finish the training.
{( speakerName('A') )} {( convertTime(664570) )}
Basically, the training path that you describe will take someone from their internship. So similar to what we have in terms of foundation training to becoming a specialist in the area that they choose. What about undergraduate training? So we touched a bit on that. When you said there is one medical school in the country. What about accessing that, can anyone apply? Is there the access for all people who want to become doctors?
{( speakerName('B') )} {( convertTime(690846) )}
So it depends on which level you start. But there's a one year pre-med. Once one passes the pre-med, then they go to a five year MBBS programme. Again, as I say, that is offered by currently one medical school. That medical school is initially just a medical school, but now it is amalgamated with the nursing school to form a University of Health Sciences. So everyone would apply according to how they scored at final year high school exams. So at the end of the final year of high school, the university will call for applications and then the candidates would apply and then candidates will be selected into the programme. So everyone has access, but as you might understand, you could have thousands who want to enrol, but you can only take how many the university can accommodate. And because of that, now, we have seen quite a significant number of medical graduates in Malawi who have been trained outside the country. So they train and they come back home and then do the practise.
{( speakerName('A') )} {( convertTime(751930) )}
Interesting.
{( speakerName('C') )} {( convertTime(752764) )}
So I was wondering if I could, Anda, if I could maybe add a bit of perspective in terms of those undergraduate and postgraduate trainings. Would that be okay?
{( speakerName('A') )} {( convertTime(760660) )}
Yes, of course, please.
{( speakerName('C') )} {( convertTime(762210) )}
Yeah, so, I mean, I guess the medical school undergraduate training is, I think, particularly important because, per head of population, Malawi has one of the lowest numbers of doctors in the world. It's pretty low in the number of actual MBBS or MBChBs in the country. The medical school, the one, is such an important institution and I guess for trainees and consultants and other people listening to this, if you walk into the medical school environment, the lecture rooms, and the hospitals, in some ways it is really quite a familiar environment. In the morning, at the main central hospital in Lilongwe, the medical students attend the morning handover, something, for instance, like the Acute Medical Unit handover, where the night shift staff present their cases and the medical consultants will sit there and ask certain questions. And, some people call it a grilling. Some people say that's inquisitive inquiry, which helps to- but you would find yourself, I think, I found myself when I entered that environment, in a very sort of familiar environment. And the specialists like Isaac and the colleagues that do that work have a lot of clinical experience and they've had the trainings in South Africa, UK or various different places. And it really is, I find it a very high quality training environment. And after the night shift, junior doctors present their patients, the medical students will present the case that they've clark. And it's very much in the tradition that many of us have been brought up in. So it's such a big job to do to sort of supply the good doctors which will help the healthcare system in Malawi. I think from our discussions, I think maybe even Isaac's own personal journey in terms of postgraduate training and work. I think what I would say is that Isaac and maybe his peers that I've met have often been sort of pioneers in terms of having to find a route to become a specialist, as it were. I think that's been quite challenging and I think that the other significant thing is really that these training pathways for postgraduate medical specialists that Isaac has been mentioning. As I understand it, Isaac, are quite new and I know yourself and some of your colleagues have been quite important in setting these train pathways up. So these things are new and they're fantastic developments. And the trainees that I've met in the first couple of years are very enthusiastic and I think it's a great development. So things are changing in the positive direction, thanks to the work of Isaac and his peers.
{( speakerName('A') )} {( convertTime(919590) )}
Very interesting. And that lead is leading to my next question, which is going to be your involvement in training and education. And from what you're saying, sounds like you have a crucial involvement in setting up, also providing that training together with your day to day work.
{( speakerName('B') )} {( convertTime(938704) )}
Yeah, exactly. As Mike says, that for science is correct. Like the fellowship we are talking about, this is probably and then the MMed programme is a couple of years. So up until about four or five years ago, people were sent to Cape Town or to Johannesberg for their specialist training. So most of us now are those who have been to South Africa and other parts of the world. And the crop of the local specialist in internal medicine probably just studied, I think, maybe a year or two years ago. You can't run away from being a trainer because the numbers are very few, so you'd have to be involved in training. So currently, both Mike and myself are part of the faculty of the fellowship, which is at Kamuzu Central, and we have a slot where we teach and coach the students. So it's part of the job, you can't do that, you don't have the privilege to stay away from it.
{( speakerName('A') )} {( convertTime(1000828) )}
You're sharing your experience and basically building the next generation of doctors in Malawi.
{( speakerName('B') )} {( convertTime(1006002) )}
Yeah, exactly.
{( speakerName('A') )} {( convertTime(1007116) )}
So thank you very much both for giving us this very interesting overview on the main aspect of training in Malawi. Good insights for us, but also comparison to the system we have in the UK. I'd be interested to know a bit more about your working life and your experiences of practising medicine. So I would be just grateful if you could both tell me a bit more about your day to day work within your specialty. What does it look like?
{( speakerName('C') )} {( convertTime(1034480) )}
Work for me in the hospital starts again with sort of way of working that will be quite familiar to many people listening. It's ward round in the morning and typically there's hand over like I described, which incorporates medical students and junior doctors and presenting cases to consultants. And then it's really into ward rounds and hospitals that I've been working in the Kamuzu Central Hospital, the major hospital in Lilongwe. And the Anglou hospital, which is just outside, typically there isn't sort of subspecialty wards, there tends to be general medical or general internal medicine wards. And so really, usually, it can be quite a long ward round with a really mixed set of presentations and pathologies. And actually when we sort of look at sort of audits of the type of things that are treated in the medical ward, what I've seen is really kind of even split in Lilongwe, at least of infectious diseases and noncommunicable diseases, which kind of works relatively well for me. And so I feel that the training that in a large part was facilitated through RCPE was particularly quite useful, at least in learning about the diseases. And then you get obviously some learning in the job in medicine, so getting more experience with some of the type of conditions that are less prevalent in incident in the UK. So there's still a lot of HIV/AIDS, there's plenty of TB and there's plenty, plenty of malaria in the wards in the right times of year, there are no doubts. And there are bacterial infections which are so common, both community and hospital-acquired infections presenting to medical wards. But the lab capacity is quite a challenge. So microbiology services are things like blood culture are harder to find. So you have to use a bit of more clinical guesswork, really, to try and address those issues at times. While we always try to get microbiology samples and get hard investigations to help us. So there's plenty of infection. And for people who work in clinical infectious diseases, there's plenty of that. There are parasitic diseases, and there are different presentations which are often quite florid. For people, my sort of cousins who are working in infectious diseases and microbiology, there's plenty of work to do, but that would be more in terms of establishing really good microbiology lab services, that's a high demand. In terms of going round the hospital, general internal medicine presentations, there's an awful lot in the city, certainly of diseases such as diseases related to hypertension. So there are hypertensive emergencies, plenty of them. There are strokes. There's a lot of problem with diabetes, which I'm sure Isaac will kind of give an overview on. So there's plenty of variety in the wards. Of course, Malawi, like all other parts of the world, has had this particular disease called COVID-19, which is certainly shaded my experience in Malawi, or certainly influenced it, and we'll maybe touch upon, I'm sure, at another time. But plenty of variety, plenty of clinical signs on the wards. So a fantastic learning and professional experience with bigger challenges in terms of a smaller menu of tests and treatments that you can offer. So in some ways familiar, some ways unfamiliar.
{( speakerName('A') )} {( convertTime(1255266) )}
And in terms of that lack of test or access to tests, is that really a lack of resources or training to run those, or a combination?
{( speakerName('C') )} {( convertTime(1264242) )}
Yeah, I mean, I focus on microbiology. So when we think about PCR, which people have become very, at least familiar with PCR tests, PCRs can detect infections. So those PCR tests are available for common diseases which include COVID-19, HIV, and the GeneXpert platform for detecting TB. But in terms of doing tests like blood culture, urine culture, culture of various different things which can guide our treatments, those things require a lot of investment and training and skill. So those things are a bit more challenging. They are there in a couple of places which are very good laboratories but they are more limited. And I think Isaac may touch upon maybe some of the other key, kind of indicated and kind of bichemistry investigations and how challenging it is to sometimes access reliable testing on that front.
{( speakerName('A') )} {( convertTime(1313860) )}
What about you, Dr Chirwa? What is your day to day working life?
{( speakerName('B') )} {( convertTime(1318000) )}
Thanks Mike, for highlighting those. So I have some slight advantages, in that I'm flexible in the way I work. I run a practise, which has a couple of specialists, and I also travel outside Lilongwe to some rural places 35 miles away, which basically caters for the rural population. I did that for quite a couple of years, about five, six years. So I'll be three days at my facility. And two other days I'll be at these, which are secondary care hospitals run by Best organisation. One of these is where Mike had been as well. That one is quite common in the rural Lilongwe. So my number would usually be a word round. You get a handover from colleagues and then you do a ward round and then if it's a clinic day, some clinics, if you do some presentation somewhere then you go and do that presentation somewhere, mainly in the afternoons. And of course the days will be anywhere between 10 to 12 hours, depending on how busy it has been. So our wards are just a general medical ward. There's only one specialty, subspecialty, which has a different ward, and that's TB. So there will be TB ward and then there will be a general medical ward. Everything else is in there. Yes. So that one, again, you'd get the handover from the colleagues who work overnight, they hand over all the cases and then you do ward round with colleagues who are taking over in the morning. Then after that you do your clinics in the afternoons. Again, if there's any slot for you to be involved in some teaching, then you'd always fit it in there. So usually that's often times a day. And of course you work on a weekend as well, if the rota demands. And the weekends are predominantly a bit of wards and some scheduled clinics, basically. But I just wanted to also to touch a bit on issue of support service for patient care, basically investigative services. They are significantly limited and the major thing is resources: lab, advanced radiology, things like histopathology, biochemistry - they are limited predominantly because of resources. There are some staff who have been trained through a couple of college years and universities in the country. But I think it's investment in the necessary equipment, which is part of the things as a growth in their care is looking at setting up. And also number two is that they test themselves in our context. So it's not just setting up the service. If, for example, you'd want to do a culture, the test itself would also translate into being expensive. So it's not just the set up, but also funding of the actual thing of the test. So these are things which we need to invest into so that it can support the numerous pathologies. We are very rich in the pathologies, but we need to learn more about them and then try to be guided in appropriate treatment. So resources, it's a major thing.
{( speakerName('A') )} {( convertTime(1512664) )}
What about the healthcare system then? How do you, you describe, so, kind of what you'd call tertiary or in-hospital healthcare and secondary, so out-patient clinic-based? Where does primary care come into that? How is it organised in Malawi?
{( speakerName('B') )} {( convertTime(1527522) )}
Yeah, I'll try to explain it a bit. So the healthcare system in Malawi is a person in three main arms. The majority is public health care services. And then you have faith based organisations, Muslim association. As well as the Muslim associations, other faith, and these have their hospitals. Now, there's an arrangement between these faith-based organisations. They're mainly secondary care facilities and there's an arrangement with the government. So they're usually in hard to reach places, because the history goes back to when the missionaries, some of them from Scotland, who came to Malawi and settled in the northern part of Malawi in the rural areas. So usually when the missionaries came in, they would start the school in the hospital. So that took up from there. So we have faith-based hospitals which are very good facilities, most of them in the rural areas. And there's a special agreement with the government that staff in those places are paid for by the government. And the government helps with other services, but the [unclear] is run by faith-based organisations. So these are secondary care facilities. And then there are the private facilities, which are very, very, very few in terms of the healthcare in Malawi. Most of them are just simple clinics. Now the set up in terms of the healthcare, now as such, combining all these, you have what is called the primary healthcare facilities, which are basically what you call health centres. And then these can offer up to certain level of care. And then in other places, you move from there to a rural hospital. Now a rural hospital will be able to do things like some minor surgeries. And then from a rural hospital you move on to a district hospital, which is now a second care facility. In these second care facilities, you don't have specialists. Specialists, they come from specialist facilities to visit. So they are visiting specialists. So you have visiting specialist clinics, visiting specialist days of surgery, etc, etc. But there are plans now to get into this place is what I call family medicine physicians. Then from secondary care centres you get tertiary hospitals. And there are four main tertiary hospitals in Malawi in each of the four critical regions. So one in the north, and the south, in the centre, and in the eastern region. And these are tertiary centres, so where you have almost everything being done. And so people are referred from secondary care centres to these tertiary care centres, depending on which geographical part of the country the secondary care centre is.
{( speakerName('A') )} {( convertTime(1688452) )}
So rural healthcare. You mentioned a bit about that. Have you both had experience of working in a rural healthcare setting? What's the main challenge in facing rural healthcare in Malawi?
{( speakerName('B') )} {( convertTime(1702302) )}
Yes, personally, I've had during my medical school training. And as I say, I've been doing that for the last few years. I mean, the challenge is a lot. You have infrastructure challenges, both on the patients' side as well as the caregivers' side. And these include patients accessing health from where they are geographically to where the health facility is. There could be infrastructure challenges. You have health seeking behaviour and attitude which can impede your cultural aspects on the patients' side. And then at the facility, then you have the infrastructure itself, you have the supporting aspects you're saying, and you have human resources. In rural hospitals, it's a big problem because people prefer to stay in the cities rather than to be in the rural hospital. So you would see that some of the rural facilities are really basically to their bare bones in terms of human resource. And these are big challenges and I think there's a lot of things we need to look into as how to attract people to serve in their rural areas.
{( speakerName('A') )} {( convertTime(1770210) )}
What about you Dr. MacKenzie? Have you had experience of working in a rural setting?
{( speakerName('C') )} {( convertTime(1776010) )}
I have. I think that it strikes me, what Isaac is saying. I'm sure there's a parallel and similar debate going on, for instance, in Scotland, in the rural parts, about how to address human resource issues there. My rural experience, actually, I've worked mainly in the last couple of years in Lilongwe, which is the capital city. A few years back, I worked in Zambia, and I don't know, Zambia is a neighbour. Malawi is sandwiched between Mozambique, Tanzania, and Zambia, and the central to eastern part of Africa, really. And Zambia and Malawi, I don't know if Isaac would agree, but there's something like Scotland and Ireland. There are very, kind of, cousinly type arrangements where they have similar cultures and arrangements. And I worked in quite a rural part there. And it can start with some of the faith-based health organisations as well as the government organisations. During a visit to a village which may be 20, 40, or 50 kilometres away from a tarmac road or further, and it may be starting in a thatched dwelling and seeing people with any kind of problem and deciding and advising who should come to town and who should be treated simply. It can start with vitamin therapy. There is nutritional problems and I worked a little bit with the World Food Programme. From that, I know that under-nutrition is a big problem and that can cause stunting and can cause mental and physical problems for people achieving the potential, and the lack of vitamins is a real thing. It can go from something like that to some very under-resourced facilities in small towns, even sometimes in the cities, in certain contexts, one can feel, in the capital city, quite under resourced. The thing to note is, of course, that some of the services are free and provided by the government, but some cost money, and basically you can be quite under-resourced even in urban environments. So you can go from very, very basic care trying to look at nutrition, through to complex presentations and trying to get people with hypertensive bleeds through long roads from the northern region to the neurosurgeon in Lilongwe. And having that very interesting interface between a physician and a neurosurgeon and trying to figure out what the best thing to do is to sort of salvage quite a difficult situation. There's a huge spectrum of presentations, and in this part of the world, it's a fantastic experience. Sometimes you can help and sometimes you can't, like anywhere. Sometimes it can be just some vitamins which can help, sometimes it can be something much more complex and trying to problem solve and to get people to go across vast distances to the best available resource.
{( speakerName('A') )} {( convertTime(1946370) )}
Very, very interesting. I find very interesting that also what you were saying earlier about patients' health behaviours and disease perception, which is a very interesting topic in itself. But on that note, you're describing complex cases and a lot of pathology, different pathology. So if we were to summarise, what are the prevalent health conditions amongst the Malawi population at the moment? And have you both observed, from your experience and knowledge, a growing burden of noncommunicable illnesses?
{( speakerName('B') )} {( convertTime(1978962) )}
Yeah, I think if we take it as a whole, then usually we talk of HIV/AIDS, respiratory tract infections, we have the TBs, the pneumonias, malaria, diarrhoea disease, and maternal related problems. But if you zero down on medicine, internal medicine as such, then I think we have the infectious diseases, the HIV, the TB, the diarrhoea, etc. But yeah, I agree with what Mike said. We are seeing a very significant decrease in noncommunicable diseases, as such that our programmes now are changing. There wasn't much attention being given to noncommunicable diseases until some years back because it wasn't the burden at all. But now that there have been changes, that in some HIV/AIDS facilities, they are co-managing, so they have protocols covering both NCDs and HIV, so that if somebody comes in HIV clinic, they always screen for NCDs. And that's standard practise. And because we know of HIV-positive individuals living longer now than could be exposed to possible complications of the medications, basically, just like how it changes as you live longer. So the transition, to somebody like me, I remember years back when I was in medical school, and our specialist thing when they're taking us through hypertension and diabetes clinic, and you probably just have a couple of patients attending, but I remember you could not go through your diabetes clinic in a day. So the clinics have to be split because of this overwhelming, overwhelming number of people. So the changes been stated, but overwhelming, and that has put a huge burden on our health care. And again, that comes back to what Michael said, that business has a big need for supportive services. For example, we need a bit more physiotherapists now because we're seeing more strokes. We need more speech therapists, things which were not there before.
{( speakerName('A') )} {( convertTime(2106020) )}
So that comes, all the training challenges that we discussed earlier as well.
{( speakerName('B') )} {( convertTime(2111000) )}
Exactly, exactly.
{( speakerName('A') )} {( convertTime(2112770) )}
Thank you. Thank you very much.
{( speakerName('C') )} {( convertTime(2114444) )}
In terms of what I've seen, I guess the major context is that, I believe Malawi is around 20 million in population. 80% of the population is rural. Specialists, and I think this is probably true in Scotland, the UK, Europe and beyond, is that most of this what you call specialists, I work in infectious diseases, Isaac in diabetes and endocrine. We're practising in cities, and so we will see plenty of noncommunicable diseases. In my ward, it's around 50/50 in terms of acute medical presentation, if you put it like that, inpatient medicine, and then the hospitals that I work in, and it's a fantastic experience. We can do quite a lot for both infectious diseases and noncommunicable diseases, but I think probably there's quite a different disease profile in the rural parts and problems of nutrition. Specialties, other colleges, in fact, all colleges, obstetric health is a huge issue in Malawi. More so than it would be in Scotland or the UK. Paediatric, maternal and child health, these are things which take, rightly, a lot of resource and a lot of attention from the Ministry of Health because they're such big issues. And Malawi doesn't have, for instance, the elderly population that Scotland would have, which is causing obviously a lot of challenges to the healthcare system. The overall population context, Malawi is quite different to the Scottish and, say, the Edinburgh population challenge. But the one thing I think is the same, obviously, with working in clinical medicine, you get to meet the people. And what I would say, to counterbalance all the troubles, is that the Malawian people are, as advertised, extremely pleasant and humorous and warm people. So there's huge population and clinical challenges, but you can have fun.
{( speakerName('A') )} {( convertTime(2221352) )}
Well, you've definitely shared some great experiences and I'm m very intrigued. Thank you very much, both of you, for sharing your very valuable experience with us and giving us some important insights into both training and working in Malawi. As you suggested earlier, I'm looking forward to our next episode, which is going to be on the experience of COVID-19 pandemic in Malawi. Thank you very much for your time and we'll see you soon.