Providence reaches across globe to strengthen Malawian health care system

January 2024

When talking about her work in Malawi, Dr. Anna McDonald sometimes shares the story about a box of sutures that saved 28 lives.

McDonald fills her luggage with medical supplies every year when she makes the trip from Seattle, where she is a faculty member with the Swedish First Hill Family Medicine Residency program, part of Providence St. Joseph Health, to a 400-bed hospital in Mangochi, Malawi. She has been collaborating since 2015 with colleagues in the southeastern African nation to develop and run its first family medicine training program.

Drs. Anna McDonald and Emmanuel Mkolokosa use a point-of-care ultrasound at the bedside at the hospital in Mangochi, Malawi, where Mkolokosa is head of pediatrics. McDonald, a Seattle-based physician, collaborates with colleagues at the hospital to offer training in family medicine. Her work is supported by Providence St. Joseph Health.

In 2021, the day after she arrived, two colleagues from the Mangochi hospital told her the facility that serves a rural population of about 1.5 million was out of sutures, so patients in need of lifesaving surgeries were being sent elsewhere. She grabbed three boxes of surgical thread from her unpacked suitcase and handed them over.

"That same night, 14 women had emergency C-sections," McDonald says. "That's 14 women and 14 babies whose lives were saved by one box of sutures."

Bidirectional learning
Hand-carrying basic medical supplies into a country of 20 million people with fewer than 1,000 physicians is a small part of Providence's commitment to Malawi.

The centerpiece is helping to fund what amounts to a full-time faculty position at Malawi's Kamuzu University of Health Sciences, the nation's only medical school. McDonald splits that faculty post with Dr. Jacob Nettleton, another Seattle-based family practitioner. Both spend one semester a year in Mangochi teaching medical students and health care leaders.

The pair also serve as clinical directors of a bidirectional education program for doctors in training from Providence and Malawi. Providence sends up to 14 U.S. residents to Mangochi every year for four-week stays to learn how doctors there provide care in a low-resource setting and to offer mentorship to local medical students and other clinicians on principles of family medicine. Providence also sponsors up to three Malawian clinicians annually for a family medicine rotation in Seattle.

McDonald calls the two-way learning aspect of Providence's Malawi program "critically important." She believes care providers from both sides of the Atlantic gain insight from the exposure to radically different care settings.

"I've said many times that I will take U.S. residents to Malawi on the condition that the Malawian trainees get to come here," she says. "If one of those things falls apart, the whole thing falls apart. We're not going to do a unidirectional program."

Supportive partnership
The U.S. Agency for International Development reports that Malawi has made dramatic gains in health in the last two decades. Its advances include reducing infant mortality by more than half and the number of AIDS deaths by 73%.

Still, with only one medical school, about 30 hospitals and a ratio of two physicians per 100,000 residents, the need for an improved health care infrastructure in Malawi remains evident.

Since 2017 Providence has partnered to strengthen Malawi's health care system with Kamuzu University of Health Sciences, the Swedish First Hill Family Medicine Residency program and the nonprofit Seed Global Health.

Carrie Schonwald, director of global programs for Providence, explains that the overall goal of the system's global efforts is to promote equity and resiliency in health care.

A visiting U.S. resident takes a rest with the pediatrics team after morning rounds at the hospital in Mangochi, Malawi. Providence St. Joseph Health sends up to 14 residents to the hospital in southeastern Africa every year as part of a bidirectional education program. The system also co-sponsors a family medicine rotation in Seattle for up to three Malawian clinicians.

"The real work of global health is, first of all, to support community-driven initiatives and goals and, second of all, to do it in a way that builds out sustainability and capacity," Schonwald adds. "Locally driven clinical training falls into that category, but only if it is meeting an identified need and done well."

As part of ensuring that its global assistance programs promote sustainability and eschew dependency, Providence is one of the signatories of the Brocher Declaration. Among other things, that pledge commits organizations to respect the culture and empower communities in the host country.

Hands-off assistance
In Malawi, Providence providers get to see the challenges and resourcefulness of their counterparts in a nation where the average annual salary is $640.

While on the rotation, the Providence caregivers mentor and train on Providence's holistic approach to family medicine, but they don't provide hands-on patient care since they lack Malawian medical licensing.

McDonald explains that the entire program is based on principles of decolonization and equity. "What I say to every resident before they come to Malawi is, 'Imagine if a Malawian physician were fresh off the plane and walked into Swedish Hospital and just started laying their hands on patients, that would never happen, right?'" McDonald notes. "Expat status does not make someone an expert."

Even though their exposure to Malawian health care is hands-off, Providence clinicians report that the experience deepens their understanding of some aspects of care, such as tropical disease management, and strengthens their delivery skills for underserved populations.

From learners to leaders
The Malawian physicians who come to Seattle get a six-week immersion in family medicine at Swedish. They also take part in a global health leadership program through the University of Washington and they become co-presenters at the annual American Academy of Family Physicians' Global Family Medicine Forum.

McDonald says one of her main points of pride in the exchange program is that several of the 10 Malawians who have done Seattle rotations have moved into leadership roles in the family medicine department at Kamuzu University. "It's just awesome to watch them go from first-year residents to now running and directing the department," she says.

McDonald collaborated with colleagues in Malawi to start the postgraduate family medicine training program at Kamuzu University in 2015, just seven years after Malawi's Ministry of Health recognized family medicine as a discipline.

She says her work in Malawi is "a huge lesson in gratitude and humility."

"I just can't say enough about how much I have learned and how much I've grown as a clinician, as an educator, as a human being," she adds. "When you just see the incredible resilience and ingenuity and persistence of my Malawian colleagues who work in these incredibly difficult circumstances and yet keep showing up to work every day, it's just completely humbling."

Following founders' path
Providence's assistance to Malawi, under the umbrella of Providence Global Programs, goes beyond educational exchanges and hand-carrying basic supplies across the divide.

The system also has provided five handheld point-of-care ultrasound machines to the Mangochi hospital and funded training on how to operate the devices for a core group who can in turn train others.

In addition, during the COVID pandemic when the caregiver exchange was put on hold, Providence redirected its funding to the building of a medical skills simulation lab in Malawi to train clinicians on lifesaving techniques. Since 2021, the system also has worked with Catholic Relief Services to improve water, hygiene and sanitation across Malawi.

Schonwald says of Providence's work in Malawi and in other parts of the globe: "Our true mission and our calling in this incredible organization is to follow the footsteps of the Sisters of Providence and St. Joseph to serve beyond borders, to serve alongside communities, to partner deeply in community-led initiatives, and to do that always with the idea in mind of decolonization, not to further the inequities that systems have developed to perpetuate for a very, very long time."


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