Scotland Malawi Mental Health Education Project

Thank you for expressing your interest in volunteering for the Scotland Malawi Mental Health Education Project (SMMHEP). This handout has information about Malawi, SMMHEP and an outline of what your time in Malawi might involve.

Malawi The Republic of Malawi is in southeast Africa. It is bordered by Zambia to the northwest, Tanzania to the northeast, and Mozambique on the east, south and west. It is separated from Tanzania and Mozambique by Lake Malawi. Malawi has a land area the size of Portugal, with a population of about 17 million, three times that of Scotland. The capital is Lilongwe and the second largest city is Blantyre, where you will be based. The country is affectionately known as "The Warm Heart of Africa". Malawi has a largely agricultural economy: its main crops are maize and tobacco. It is a poor country: in 2013, the World Bank identified over 50% of the population as being below the poverty line. The average income is $200 - 300 per year. The currency is the Malawian Kwacha (MWK). At the time of writing, the exchange rate is about 1000 MWK to the pound. The average life expectancy at birth is 55 years. However, some people live into extreme old age. The infant mortality rate is high and it is estimated that ~12% of the adult population has HIV/AIDS. The official languages are Chichewa and English and the major religions Christianity (80%) and Islam (13%). There are at least 10 different ethnic groups, of which the Chewa is the largest. The link between Scotland and Malawi dates from 1859 when David Livingston travelled from Blantyre, Lanarkshire bringing Christianity and medicine to the local population. It was a British colony until a revolution in 1964. More recently, Malawi has had a democratic, multi-party government, currently under the leadership of President Peter Mutharika.

[Type here] 1 SMMHEP Potential Volunteer Information Updated August 2016 Psychiatry in Malawi Malawi is divided into 28 administrative districts, most of which have a hospital and community health services. Mentally disordered people are likely to be seen initially by primary care health workers, in peripheral clinics. People who cannot be treated at this level may be seen by a Clinical Officer or psychiatric nurse based in a District Hospital. Seriously unwell or complex cases may be referred on to Zomba Mental Hospital (ZMH) in Zomba, the old colonial capital, or to Queen Elizabeth Central Hospital (Queens), the main teaching hospital, in Blantyre. Mental health services in Malawi are seriously underdeveloped. There is little treatment for minor mental disorders. Almost all patients from rural areas will see traditional healers before and whilst being treated by the medical services. Some may see witch doctors. Queens treats outpatients and provides a liaison service for the medical and surgical wards. Inpatient psychiatric treatment is largely carried out at the only government mental hospital, ZMH. It has around 150 beds and treats all ages and diagnoses. It is staffed by psychiatric nurses and Clinical Officers with specialist training in mental health. The hospital has an OT service, but no psychology or social work service. There is also an ECT service, which can be lifesaving for patients with severe depression or puerperal psychosis. There is also a small inpatient unit in Lilongwe and a non- government charitable mental hospital (St. John of God) in the north of Malawi. St John of God has recently opened an inpatient unit in Lilongwe. When patients present to the hospital or clinic, often brought in by the police or relatives, they may have florid psychiatric symptoms. Their presenting complaints include trampling the maize, wandering aimlessly, being possessed, being bewitched etc. The patients seen by the mental health services, have the full range of major mental disorders, including delirium, and some minor ones, such as anxiety states and conversion disorders. Self-harm is a rare presenting phenomenon. Alcohol problems are common. The use of chamba (marihuana) is common, but not other illicit drugs. Patients with delirium and other neuropsychiatric complications of HIV and other infectious diseases commonly present to the clinic.

[Type here] 2 SMMHEP Potential Volunteer Information Updated August 2016 The range of treatments is limited and supplies of medication are variable. The most consistently available medications are chlorpromazine, haloperidol, carbamazepine, diazepam, fluoxetine and amitriptyline. Antiretroviral drugs are widely available, but there are adherence problems. There is one psychologist based in Blantyre who offers psychological treatments and supervises the postgraduate psychiatry trainees. Psychiatric staffing is limited. Mental health services are largely provided by Clinical Officers, who have completed BSc courses with specialist training in psychiatry. There are also psychiatric nurses. There are currently no Malawian consultant psychiatrists practicing in the country. SMMHEP is supporting the training of three postgraduate trainee psychiatrists: having completed two years of training in Malawi, they are currently based in Cape Town. By training medical students, we hope to ensure that all Malawian doctors have a better understanding of mental disorders and will be able to recognize them and refer patients appropriately.

SMMHEP The Scotland Malawi Mental Health Education Project (SMMHEP) aims to provide sustainable support for psychiatric teaching and training for health care professionals in Malawi. The project has enjoyed close links with individuals and institutions in Malawi since 2006 and became a registered Scottish charity in 2008. The principal activities of the project are: delivery of undergraduate medical teaching, support for ECT equipment and training, and support for postgraduate training in Psychiatry. SMMHEP has recently completed two three-year projects, funded by the Scottish Government. The first involved training primary health care workers in District health clinics. This was a 'training the trainers' model designed to be sustainable without further SMHEP input. The second was the development of e-learning modules for use by medical students, and post-graduate psychiatric trainees and psychiatric nurses. To support these activities, SMMHEP is also involved in developing a Malawi Mental Health Handbook.

[Type here] 3 SMMHEP Potential Volunteer Information Updated August 2016 In addition to the Scottish Government, SMMHEP receives support from the Royal College of Psychiatrists, National Health Service Education for Scotland (NES), Tropical Health Education Trust (THET) and local postgraduate deaneries and tutors. SMMHEP is managed by its Board of Trustees. You may want to become involved with this work on your return. The ethos of the project is to respond to local needs identified by local staff. We want to support Malawian psychiatry in Malawi rather than imposing a Scottish model. In the long term we hope that, through supporting undergraduate and postgraduate training, the project will make itself redundant.

The College of Medicine The College of Medicine (CoM) was established in 1991 as a constituent college within the University of Malawi (UNIMA). It is the only medical school in Malawi. The CoM has gradually grown from an intake of 10-15 students per year and a handful of Malawian faculty members, to an intake of 60-80 students/year and 110 faculty members, of whom approximately 67% are Malawians. The psychiatry course is taught in English and is an internationally recognized medical qualification. The CoM also has a postgraduate psychiatry course, the M.Med. which is funded by the Scottish Government; this is a four-year course, split between Malawi and Cape Town. Two trainees have recently completed the course and we hope that a third will do so in September 2017. A new postgraduate programme has just started, again funded by the Scottish Government, It currently has two trainees and two more will be recruited The undergraduate teaching is split between the CoM and Queen Elizabeth Central Hospital in Blantyre and Zomba Mental Hospital in Zomba. The Head of Department is currently Dr Stefan Holzer, a London- trained psychiatrist. Dr George Stewart, a Peace Corps volunteer, is a lecturer in the Department until the summer of 2018

Volunteering with SMMHEP

[Type here] 4 SMMHEP Potential Volunteer Information Updated August 2016 SMMHEP supports two types of volunteer:  Short-term volunteers, who go to Malawi for 3-6 weeks, to help with undergraduate teaching. They are not registered with the Malawi Medical Council and are, thus, unable to do direct clinical work.  Long-term volunteers, who go for periods of 3 months to a year, to help with in-patient and out-patient clinical services and undergraduate and postgraduate teaching. They also help with training Clinical Officers and psychiatric nurses. They must be registered with the Malawi Medical Council.

Your role in the College of Medicine You may be asked to teach in either Blantyre or Zomba. Dr Holzer directs the teaching programme. You will be expected to work under his direction and to discuss with him any requests for leave and personal teaching issues or difficulties you may encounter.

Short-term volunteers:

Whilst SMMHEP encourages you to use your leisure time to see the country, please bear in mind that the teaching programme is dependent on volunteers to be consistently at work during the week.

If you want to take a day off to go travelling, please seek Dr Holzer’s agreement and ensure that your work can be covered by your colleagues.

Longer-term volunteers:

For longer-term volunteers, arrangements for taking time off again must be agreed with the Head of Department. In principle, volunteers would be expected to take a similar proportion of leave, pro rata, that they would take in any period working for the NHS or other health service.

[Type here] 5 SMMHEP Potential Volunteer Information Updated August 2016 The Undergraduate Teaching Programme 1.Indicative time-table

August-October 1 week Child & Adolescent Psychiatry & Learning Disability

6 weeks General psychiatry lectures, PBL & clinical teaching,

November- 6 weeks General psychiatry December lectures, PBL & clinical teaching, January-March 1 week Child & Adolescent Psychiatry & Learning Disability

6 weeks General psychiatry lectures, PBL & clinical teaching, March - April 6 weeks General psychiatry lectures, PBL & clinical teaching,

The students divide into two for Child & Adolescent and Learning Disability teaching, half being taught in September and half in January. Otherwise a quarter of the students attend each of the four teaching attachments.

2. Undergraduate Teaching The Child & Adolescent and Learning Disability teaching is carried out over one week. It is classroom based, using lectures, discussion and videos.

The general psychiatry teaching is done over five weeks. The exam is held in the sixth week. The medical students come together in the College of Medicine for lectures throughout the teaching block. However, they are divided into two groups for clinical teaching, one based in Zomba Mental Hospital and the other in Queen Elizabeth Hospital,

[Type here] 6 SMMHEP Potential Volunteer Information Updated August 2016 Blantyre. The groups swap over half way through the teaching block. You will be attached to one of the groups and will be doing Problem Based Learning, tutorials and case-based teaching with them, in both Queens and ZMH. You will also be doing lectures throughout the teaching block. The lectures cover the whole range of psychiatry, except for Child & Adolescent Psychiatry and Intellectual Disability. They also cover epilepsy, because this is often treated by mental health services in Malawi. Professor Bandawe, who is responsible for clinical psychology teaching at the CoM, and other psychology teachers, usually give the lectures on psychotherapy and cultural aspects of mental health. SMMHEP has a bank of power-point presentations, prepared by previous volunteers and covering all the lecture topics. You can adapt them to suit your needs for any lectures you give.

3. Medical Student Assessments There are two forms of assessment: continuous assessment and examination. Continuous assessment is by a written long case and by the student’s logbook, in which you will mark his or her attendance, participation, and case presentations. The examination is both written and oral; you will help set and mark it, during week six of the teaching block.

The Postgraduate teaching programme The COM’s M.Med programme consists of seminars and clinical training. It is a 4 year course, half of which is in Malawi, based at Queens and ZMH, and half in South Africa, based in Cape Town. Volunteers, both short- and long-term, are involved in case- conferences and may give seminars to the trainees during the Malawi leg of their training.

[Type here] 7 SMMHEP Potential Volunteer Information Updated August 2016 There are currently three postgraduate trainees; two of them have recently passed their higher psychiatry exams (Master of Medicine (MMed) degree). A new batch of trainees as started to be recruited into the forthcoming postgraduate training programme in 2017.

Research You may wish to carry out a research project during your time in Malawi or to write an account of the teaching programme or other aspects of the volunteering experience. Indeed, we at SMMHEP would encourage and support this. You will be expected to discuss any project with the Head of Department and get his or her agreement. In addition, if you wish to carry out any research involving patients or their records, you must get the agreement of the College of Medicine Medical Ethics Committee (COMREC) and the relevant clinicians. Be aware that the processing of applications to COMREC can take some time and should be submitted at least three months in advance of the planned project in order to ensure that you have the necessary permissions. If you submit any papers or posters arising out of your work in Malawi, please discuss the appropriate attribution of authorship with the Head of Department. In addition please be sure to acknowledge the support of SMMHEP and the Scottish Government. Any papers or posters or blogs arising out of your work with SMMHEP will have to be reviewed by the SMMHEP Trustees prior to publication or submission for publication.

Accommodation SMMHEP volunteers occupy a comfortable 3 bedroomed self- catering accommodation in Blantyre at a guest house belonging to the College of Medicine. The guest house is located a 5-minute walk from the College and Queen Elizabeth Central Hospital. The house has security and housekeeping services. The Head of Department, Stefan Holzer and his partner, Lucy Ashton, live in Blantyre, close to the College of Medicine, and are available for support and advice.

[Type here] 8 SMMHEP Potential Volunteer Information Updated August 2016 You will do your own shopping and cooking; these are usually communal activities. There is help with cleaning and laundry, but you will also be expected to contribute to the general care of the house. Towels and bed linen are provided and WiFi is available via a dongle. Blantyre is subject to frequent power cuts, so a head torch is essential and it is wise to keep your electronic equipment fully charged. Our accommodation is only for the use of volunteers while they are volunteering. Unfortunately, we cannot support the use of the accommodation outside the volunteering period: it makes housekeeping services too complex. There is other reasonably-priced accommodation in Blantyre if you wish a partner to join you (e.g. Pedro’s Lodge and Kabula Lodge).

Transport Volunteering will involve driving, so you should have a valid driving licence. Though you can walk to work in Blantyre, driving is often more practicable. SMMHEP has 2 cars available for volunteers. Both have manual transmission and are very mature. They are only available for work and activities of daily living. You should, of course pay for any fuel that you use for leisure purposes. If you need a car to go away at weekends, you can hire one easily in Blantyre.

Partners A number of volunteers have asked to take their partners with them. This has proved to be difficult at times, and we have decided that the project cannot normally support partners. You should seek the National Coordinator’s agreement if you want to have friends and partners staying for short periods. SMMHEP accommodation is normally for volunteers only. If you do want your partner to accompany you, we suggest that you make use of alternative accommodation, such as the lodges mentioned above. The Bradt Guide to Malawi or Tripadvisor are useful sources of information about alternative accommodation and the National Coordinator would be happy to advise you.

[Type here] 9 SMMHEP Potential Volunteer Information Updated August 2016 Leisure You will be glad to know that it’s not all hard work and no fun! There are a number of easy trips from Blantyre or Zomba. We can recommend Responsible Safaris in the complex behind Mandala House, on Mandala Road, to help organize most trips ([email protected]) Safaris: From Blantyre it is 2-3 hours drive to Liwonde National Park (Mvuu Camp or Lodge) or 1.5 hours drive to Majete Game Reserve (Thwale Camp or Mzulumadzi Lodge). At Mvuu, you are likely to see hippos, antelope, zebra, elephants and many bird species. In Majete, you may also see lions. You need to book in advance from the travel tour operators in Blantyre. Michiru: This is a nature reserve only 30 minutes drive from Blantyre, with lovely walks and wildlife. Mount Mulanje: Mount Mulanje is Malawi’s highest mountain; the massif is, on average, 2000m above sea level and you can get to the plateau in about 3 hours. It is a relatively strenuous walk. On the plateau you can lodge in basic, bothy-style accommodation: mattresses and blankets are available but you may wish to bring your own sleeping bag. Guides and porters are available at the base of the mountain; they will carry your bags up and cottages for an overnight stay. Take a small rucksack for your bottles of water and snacks. Cedar wood items are available for sale at the base, including walking sticks. Lake Malawi/ Domwe Island: Lake Malawi is beautiful and about a three-hour drive from Blantyre. You can stay in one of the well-kept lodges situated at the edge of the Lake in Chembe Village. You can go by boat to the beautiful Domwe Island, where you can lie on the beach, snorkel or kayak. Lodges are also available on the island or you could camp. There are staff who can help you, if you so desire, to buy fish from fishermen and cook it. All you have to do is bring in your own potatoes, rice or pasta. There is no fee for this service but a

[Type here] 10 SMMHEP Potential Volunteer Information Updated August 2016 tip is usually greatly appreciated. Souvenirs are also available to buy; but don’t forget, you’ll need to barter to get a good bargain. Bookings should be done in advance at local tour operators. Zomba plateau: This plateau is accessible via road or footpath from Zomba town. Accommodation is available in a basic cabin, a forest lodge or the more luxurious Ku Chawe Inn. There are many lovely walks around this area and because of the elevation it tends to be cooler. There are also interesting birds and mammals, including leopards. Tea plantations: There are at least two tea plantations to visit near Blantyre, Satemwa is particularly popular. They are great for bird enthusiasts, tea and coffee drinkers and hedonists. Their houses accommodate large numbers of people and have staff to cook food for you. They are set in beautiful countryside with natural swimming pools.

Trainees: getting permission to volunteer 1. Discuss this with your educational/clinical supervisor 2. If you decide to go ahead make contact with the national or regional coordinator. 3. You will need to obtain permission from your training programme director, postgraduate dean, and medical director as soon as possible. Your regional volunteer coordinator will provide you with information on how to seek these permissions from the relevant region. It is wise to start these negotiations before being finally accepted by SMMHEP

All volunteers: preparing to go Once you have signified interest 1. You should submit an application form, together with a brief CV and the names of 2 referees to the National Coordinator. 2. If selected, you will get up to date information about preparing for your visit. This will include advice about travel, visas, money

[Type here] 11 SMMHEP Potential Volunteer Information Updated August 2016 etc, in addition to health advice, and advice about insurance and driving. 2. You will receive detailed information about SMMHEP accommodation and about the practicalities of living in Blantyre 3. A certain amount of driving is necessary for both work and leisure, so make sure you have a valid driving licence. 4. At present the project is able to reimburse expenses up to a maximum of £500 only towards your expenses. (Currently at a rate of £100/week of your stay, up to £500). This includes travel and health prophylaxis. In addition, we will reimburse any fuel and care hire costs incurred for work purposes. 5. On your return, you will be expected to feedback your experiences to the national coordinator. This will go towards your portfolio and help SMMHEP write a letter of appreciation for you, should you need one.

Contacts

Name/Role Contact Details National Co-ordinator

Madeline Osborn [email protected] West of Scotland

Judith Halford [email protected] Aberdeen region (Grampian) [email protected] Carol Robertson East Scotland (Lothian) Rob Stewart [email protected]

Dundee/Perth region (Tayside)

David Hayward d [email protected]

[Type here] 12 SMMHEP Potential Volunteer Information Updated August 2016 England Jen Ahrens [email protected]

Revised Jun 2017

[Type here] 13 SMMHEP Potential Volunteer Information Updated August 2016