Medical school interviews start

At my medical school they have started interviewing for 2015 and there are lots of anxious looking sixth formers all waiting for their turn to go in. It is really weird to think that this time last year it was me nervously waiting for my interview and now I am almost at the end of my first term. I can remember feeling really scared as it was my first interview and it was an MMI which is really hard to prepare for. I thought it went really badly as I messed up a couple of the stations, but I still managed to get an offer so I can’t have done too badly.

If you’ve got an MMI coming up then read this article in The Guardian which has some tips from admissions tutors to help prepare for this type of interview and you can also find lots of advice for the day itself in this book. Just click on the orange words to go to the links. Good luck!

Interview with Dr Robert Newman, MD, MPH, Director of the Global Malaria Programme, World Health Organisation

Recently I asked Dr. Robert Newman, MD, MPH, Director of the Global Malaria Programme at the World Health Organisation, a few questions about malaria.

This is what he said:

Me: Drug and insecticide resistance, lack of global funding, and poor testing and treatment facilities in many infected areas are some of the obstacles to eradicating malaria, but which one gives you most cause for concern?

Robert Newman: While all of these issues are concerning, the greatest threat to continued success in the control and elimination of malaria is financial rather than biological. While there has been a massive increase in international funding for malaria, from less than 200 million USD annually to nearly 2 billion USD today, that total still falls far short of the more 5 billion USD annually that are required to scale up life-saving malaria interventions.

That said, parasite resistance to antimalarial medicines, and mosquito resistance to insecticides are also major threats to success. In the past, the spread of resistance to chloroquine in Africa was responsible for major increases in child mortality on the continent. We now have resistance to artemisinins that has emerged in the greater Mekong Subregion. For the time being, this is restricted to four countries (Cambodia, Myanmar, Thailand, and Viet Nam) but given population movements in Asia and the world, the geographic scope of the problem could widen quickly.

Insecticide resistance has been detected in 64 of the 99 countries with ongoing malaria transmission. This affects all classes of insecticides that are used in malaria vector control, and has had the worst impact on the pyrethroids, which are the only class used on insecticide-treated nets. While vector control tools remain effective in most settings, this issue needs to be addressed urgently to prevent a global resurgence of the disease.

WHO has released global plans on the management of these two biological threats (The Global Plan for Artemisinin Resistance Containment and the Global Plan for Insecticide Resistance Management). If adequate funding were available, both challenges could be fully addressed.

Me: I read recently that the UK has pledged £1 billion over the next 3 years for the Global Fund, which is really good news for the fight against malaria. What do you think is the most positive news in the fight against malaria today?

Robert Newman: The most positive news today is the steady decline in malaria cases and deaths that have occurred over the past decade. The unprecedented scale up of life-saving malaria interventions, including long-lasting insecticidal nets, indoor residual spraying, diagnostic testing, and effective antimalarial treatment (especially with artemisinin-based combination therapies or ACTs as they are known) has resulted in an estimated 26% decline in malaria mortality rates globally, and a 33% decline in the WHO African region.

Malaria interventions saved an estimated 1.1 million lives over the past decade; this is a tremendous achievement. But the gains are fragile, and history shows us just how quickly malaria can resurge if funding is decreased or stopped. A decade of progress can be undone in one or two malaria transmission seasons.

Me: Do you think you will see a world without malaria in your lifetime?

Robert Newman: I do believe that I will see a world without malaria in my lifetime, but this requires a few assumptions to be met:

a) that I have a long life (as I think global malaria eradication is probably 40 years away)

b) that political and financial commitment to control, eliminate, and ultimately eradicate malaria continues

c) that innovative tools continue to be developed that allow us to stay ahead of the mosquito and the parasite, and

d) that overall development continues, especially in Africa.

I am optimistic that these assumptions will be met, and I believe that human beings are capable of amazing things when we dedicate ourselves to solving a challenge and then work together to get there.

I’d like to thank Dr Newman for his generous time in answering these questions for me. I first met Dr. Newman when I went to the APPMG at Westminster to give a presentation about malaria for World Malaria Day in April. This is what he said afterwards: ‘I very much enjoyed meeting you… during the All-Party Parliamentary Malaria Group meeting earlier this year, and I was so impressed with what you said, and the way you delivered it.’

You can read my presentation on the APPMG website here, and read what the other speakers said here.

Interview with my Great-Auntie Joan, a nurse

Recently I’ve been looking at different medical schools, so I asked my great-auntie Joan about her experiences at Barts in London, where she trained to be a nurse in the 1950s.

Me: Who or what inspired you to go into nursing?

Joan: I wanted to do something practical and worthwhile -the pay for my first month’s work was just over £7, so it was not for the money!

Me: What was it like to study at Barts?

Joan: It was good to be in central London, where I had friends who lived and worked, but it was hard work. We worked on the wards or theatres for a 48 hour week but with time off during the day for study and recreation. The facilities for study were good for their time but the work was much more practical then, than it is now. On the other hand one learns and understands much more by actually doing something fo patients rather than reading about it – even if the actual ‘hands-on’ work is, at times, rather grim.

Me: What have been your most challenging and rewarding experiences during your career?

Joan: One of the most challenging things was having to deal with a man in Casualty, who had fallen through a roof dragging a barrel of tar all over him. The training for my Girl Guide Laundress badge was the most useful for getting tar off his face, hands and hair!  He needed some medical help, too.
Another was a girl on her honeymoon, who came into Casualty and was transferred to the ward with a tracheostomy (quite rare in those days) and in an Oxygen tent. I was specialing her for a whole Easter week-end and everyone thought she was going to die – until to our surprise she aborted twins and walked out a week later!

Me: If you were just starting out now, would you still think that nursing is a good career choice?

Joan: NO! I think the country will be so poor/third world soon that patient’s relatives will be bringing in food and sleeping under the beds!

I’d like to thank my great-aunt for taking the time to answer my questions. She is a great inspiration!

Interview with Chris Richardson-Wright of Malaria No More

Chris Richardson-Wright works for Malaria No More and he has kindly answered my questions about their work to combat malaria.

Me: I know that you have partnerships in Ghana, Botswana and Namibia which are already helping to protect over ten million people from malaria, are you planning on expanding into other African countries, like Malawi?

Malaria No More: Malaria No More UK invests in countries and programmes according to the extent of a country’s malaria burden and our ability to make a sizeable impact. To date, this has led to investments in: Ghana, where 100% of the population is at risk of malaria; Botswana and Namibia, where a comparatively smaller malaria burden has enabled them to adopt ambitious strategies towards malaria elimination. An example of one of our recent projects in Namibia can be found here and with the help of the Global Fund we’re rolling out the pilot scheme across the country. Whilst we are currently investing in malaria control programmes on the ground in Ghana, Botswana and Namibia – where we have been able to use our funding to leverage a significant impact – our advocacy and communications support extends across Africa and beyond. Our efforts have, for example, helped to secure an increase in UK aid support for malaria, with the government committed to spending up to £500 million per year on malaria by 2014. We have also been successful in advocating with DFID for this funding to be directed at those countries hardest hit by the malaria epidemic – including Uganda, Rwanda & Ethiopia. Go here for more information on where UK aid is being spent on malaria. 

Me: There is a focus on mosquito nets for the prevention of malaria, but in reality people can still become infected when they are not sleeping under their net. How likely is it that there will be a vaccine available in the future?

Malaria No More: Vaccines are seen as the most effective – and often cheapest – means to stop the spread of disease. Scientists around the world are working on the development of a vaccine against malaria and there are promising developments on a weekly basis. However, the malaria parasites have proven to be remarkably adaptable. They change their characteristics as antibodies are developed, making it hard to find a vaccine.

Currently there is no vaccine that has been approved for use, although there are trials of a malaria vaccine happening at present in Africa. It will be some years before a vaccine is available to help prevent the spread of malaria among all those vulnerable to the disease. In the meantime, we need to concentrate on providing prevention, testing and treatment.

It is worth noting that although a vaccine would be a great solution, we do have the tools to achieve country-level elimination of malaria without vaccines, and bed nets remain one of our most effective weapons.

Me: How close are we to achieving the global goal of near zero deaths from malaria by 2015?

Malaria No More: The target of near zero malaria deaths by 2015 was set by the Roll Back Malaria Partnership in 2008, we have the knowledge and tools to make this vision a reality. Increased international support and strong African leadership have enabled tremendous progress with malaria deaths reduced by almost 10% between 2008 and 2009. However, we are still a long way from achieving this goal and increased and sustained support will be critical over the next few years. Current international funding in 2011 amounts to just one third of the anticipated need. Although it looks increasingly likely that the target may be beyond us, it has provided a brilliant aim for the global malaria campaign to rally around and has helped launch initiatives that otherwise may not have come into effect. Funding decisions made over the next few years could determine whether we continue to see a decline in malaria cases, or whether we see a resurgence in the disease, so we have to make sure that we keep up the pressure and the effort to fight the disease.

Interview with Professor Neil Kennedy

Professor Neil Kennedy is Professor of Paediatric medicine at Queen Elizabeth Central Hospital and Malawi College of Medicine in Blantyre, Malawi. He and his family lived over the road from me and my family for 4 years, and he has very kindly answered my questions for this blog.

Me: What’s a typical day like for you?

Professor Kennedy: Long!

0700 – 0800: Office and emails.

0800 – 0900: department handover meeting. We hear what’s gone on the night before, discuss difficult cases

0900 – 1200: ward rounds or clinic work. Here, that means seeing perhaps 40-50 children some mornings. We always have students with us when we work on the wards, so I do a lot of teaching – medical education is an apprenticeship. Most of my clinical work is in general paediatrics, but I have a specialist interest in paediatric cardiology (I run the only kids’ heart clinic in Malawi) and in child protection work.

1200 -1330: lunch (on occasions) or more usually some sort of meeting – a journal club or a university committee

1330 – going home time: varies a lot between teaching, working on research, administrative duties (I’m head of the dept), writing grant proposals or seeing specific sick children.

Me: What’s the biggest challenge that you face at the moment?

Professor Kennedy: Lack of time to do all that needs doing. Government is often out of cash for basic treatments.

Me: What is the most rewarding part of your work?

Professor Kennedy: The amazing variety and the opportunity to make a difference in the lives of the children we see and the wider community. Last week, I met the President as she opened our new centre for abused children. I got a phone call from a mum in Northern Malawi to thank me for getting her child sent to India for life-changing heart surgery. I worked with a donor to gain funds to train another 8 specialist paediatricians for Malawi (we only have 16 now – just over one per 500,000 children!)

I would like to thank Professor Kennedy for his interesting answers to my questions. I hope he inspires you as much as he has inspired me to become a doctor.

Interview with Dr Sue Heyes

Dr Sue Heyes is a British doctor, who spent a year working in the diabetes clinic in Queen Elizabeth Central Hospital, Blantyre, Malawi. I was lucky enough to spend time shadowing her last summer, and she has kindly allowed me to interview her for my blog.

Me: What was the biggest challenge that you faced working in Malawi?

Dr Heyes: The biggest challenge that I faced working in Malawi was two fold really. One was having so few reliable clinical tests available to help in diagnosing patients.  The other was not having enough basic drugs available to treat the commonest illnesses.

Regarding the clinical tests available, the hospital had lots of fairly up-to-date machines for performing tests, but they often didn’t work because they needed a new part which was unavailable, or the reagents were out of stock for the blood and microbiology testing.  For example, for a few weeks there were no tests available for diagnosing HIV so that meant that patients could not be started on their HIV drugs because it was essential to have a positive test result before starting treatment.  Also, we not infrequently ran out of processing chemicals so that X rays could not be developed so no X rays.  Most of the time there were not the reagents for the machine which checked for electrolytes (a test of kidney function) so there were no results or more commonly they just could not be relied on…  The test results for TB often got lost and had to be repeated several times before a result was available…… Getting lymph node biopsies done and getting a result,  to distinguish between TB and lymphoma, was so difficult to organise….The MRI scanner needed a spare part so was not in use for a few weeks while they waited for the part to arrive and the machine to be repaired… I could go on and on, but you can imagine how difficult this made things.  In the UK, we rely on test results so much in making our diagnoses, so in Malawi I had to relearn my clincical skills and start to rely on them for diagnosis.

Regarding drug supplies there did not seem to be a problem with supply of drugs for TB or HIV treatment.  However there were severe shortages of almost all other drugs.  Twice during my year in Malawi we had no long-acting Insulin  (the commonest treatment for Insulin treated diabetes ) available for several weeks.  There was no good alternative available.  Some people were given quick acting Insulin as an alternative but there is a much greater risk of low blood sugar levels with this and consequently, sometimes death.

In addition, we sometimes for a few weeks, did not have the antibiotics needed to treat the commonest bacterial infections, eg bacterial meningitis, pneumonia, non-typhoid salmonella and even malaria.  These are very common in patients with HIV and will often cause death in these patients whose immune systems are so damaged. 
One of the worst things, though, was the lack of available painkillers, both  mild and strong ones. Mostly the only painkiller available in the short term was paracetamol.  Good painkillers were available for patients who had a confirmed terminal illness through Tyanjane, but generally on the wards there were very few available.  I ended up having my own supply of painkillers which I gave out on the wards as necessary. To me it is bad enough that we did not have the right drugs to treat the patients with, but it seems unacceptable that we were not at least able to keep our patients comfortable and allow them to die as comfortable a death as possible.

Me: In the UK everyone thinks of AIDS or malaria when you mention Africa, do you think diabetes gets forgotten about, and how could awareness be improved?

Dr Heyes: I do think that Diabetes gets forgotten about when thinking about Africa. I believe that over the next 20 years, it is going to become a huge public health issue, as an increasing cause of illness and death.  It is obviously important to raise awareness of diabetes, both its prevention,diagnosis  and treatment available, in Malawi.  However, having seen the scourge of HIV at first hand, I can completely understand the priority given to HIV awareness in Malawi at the moment when health care resources are so scarce.  HIV predominantly affects young adults in the age 20 to 40 age group who tend to have young children and families to look after where as most people with Diabetes tend to be in an older age group, so again, much as I, as a diabetes specialist, would love to see Diabetes having a higher profile, I can understand why HIV takes priority.

Interestingly, it is now known that some of the drugs used to treat HIV increase the risk of  developing  Diabetes, so therefore actually increasing education about the prevention of HIV, would also impact to some degree, the incidence of diabetes in the developing world in the future!

Me: What was your most rewarding experience working in Malawi?

Dr Heyes: Regarding rewarding experiences in Malawi, there are two which stand out in my mind.

One was looking after a young man with HIV and paraplegia (loss of any power and sensation in his legs and lower back).  He and his 2 younger brothers had been orphans for many years (probably due to HIV) and R was the breadwinner while his brothers finished their schooling.  They were all very bright boys and the youngest brother wanted to go to medical school to train as a doctor.  R was looked after in hospital by his middle brother M who had left school but was unable to get a job because he was caring for R.  Over a few weeks it became apparent that there was no hope that R would ever recover from the dreadful pressure sores he had developed on his bottom and hips (because he had no feeling below the waist).  I was able to help M to come to accept that his brother could not get better and was going to die and I was responsible for his care when he died peacefully in hospital, with his family understanding that this was  inevitable.

Subsequently, I was very pleased to learn that M had been successful in getting a job as a translator at QECH (the hospital where I was working) which hopefully will be his first step on the employment ladder and means that M is now able to financially support his family.

The other rewarding thing about my time at QECH (Queen Elizabeth’s Central Hospital, Blantyre) was the development of a diabetes foot clinic which had open access for any diabetic patients with foot problems, in the out patient department which ran weekly .  This is the only diabetic foot clinic in Malawi and had not existed before 2012.  We were able to offer education regarding the prevention of foot ulcers in diabetics, as well as providing good  multi -disciplinary treatment for pateints with ulcers, to help the ulcers to heal and to prevent subsequent amputation which is an all too common consequence of foot ulcers in sub-saharan Africa.  During my time there, the Orthotics department made their first pressure-relieving insoles to be worn in shoes, to off-load pressure areas in a patient who had had recurrent foot ulcers over many years.  And it was wonderful to see some of the ulcers that I had treated actually heal and not need those amputations (from which there is such a high mortality in Sub saharan Africa).

I would like to thank Dr Heyes for taking the time to answer my questions in such depth.