This is a guest post from my friend and colleague Colin Larmour, Consultant Orthodontist and Senior Lecturer, Aberdeen Dental Hospital and Institute. Many thanks to Colin for his great support of the MalDent Project and for compiling this post describing his recent visit to Malawi.
As part of the MalDent Project ‘flying faculty’ program I travelled to Malawi in May to provide introductory clinical orthodontic teaching to the third year BDS students. This group of students are the ‘pioneer’ students at the new Dental School of the Kamuzu University of Health Sciences (KUHeS). My wife Pauline, a Psychiatrist, also made the journey to Malawi to provide clinical teaching in psychiatry at the medical school in Blantyre and Zomba Hospital through the Scotland Malawi Mental Health Education Project (SMMHEP).
In the months preceding our trip I was given a lot of advice from Jeremy in Glasgow about what to expect with a trip to Malawi from both a practical perspective and also in relation to the Dental School set up and the curriculum for the BDS course. I was also in close contact with James Mchenga, the academic lead for Dentistry at KUHeS, and Peter Chimimba, the lead for the MalDent Project in Malawi. This included discussions about the orthodontic curriculum and the content of the introductory programme in orthodontics and exchanges of reading material and learning outcomes for the students.
Following a request from Malawi for some orthodontic instruments, including examination kits and rulers, Christian Burdess from DB orthodontics in West Yorkshire was kind enough to donate the orthodontic instruments requested, as well as lip retractiors and mirrors for orthodontic photographs. Many thanks again to Christian and his team in West Yorkshire for their support of the MalDent Project.
As far as travel arrangments in the COVID era, I had lots of advice from Jeremy who had made a recent trip with Chris Cox and Stuart Bassham. Mandatory vaccination and a negative PCR before arrival were still required. As far as COVID is concerned, having seemingly escaped the virus for more than two years I started to develop symptoms two weeks before we were due to travel. Luckily my symptoms were mild and I stopped testing positive after 8 days. I had a PCR test around day 12 which was also negative so travel plans were still on course…
The journey began on Wednesday 18th May and the first leg of the journey was with British Airways from Aberdeen to London Heathrow, connecting with an overnight flight to Addis Ababa with Ethiopian airlines.
An early morning connecting flight to Chileka airport in Blantyre saw us arrive in the early afternoon on the Thursday, almost 20 hours after leaving Aberdeen. Successful negotiation through the COVID clearance tent, where vaccination and PCR status are checked, and onto passport and visa checking at the border control and then, thankfully, reunited with all our luggage including the dental equipment.
We were staying at the Kabula Lodge, a guest house about five minutes from the city centre, situated in an elevated position with panoramic views of the city and surrounding mountains.
After a couple of days settling in over the weekend I was picked up by a University driver, Richard Jumbe, who brought me for an early morning meeting with James Mchenga and Peter Chimimba at the Kamuzu University of Health Sciences, close to the Queen Elizabeth Hospital.
We were also joined by a new part-time faculty member, Yusuf Maundala. We had a very productive discussion about the orthodontic curriculum and plans for the orthodontic teaching that would be delivered over the next few weeks while I was in Malawi. We also organised the instruments donated by DB orthodontics so that those required over the next few days in Lilongwe with third year BDS students on clinic could travel with James and myself. One of the challenges at present is having the students split over two campuses with the early phase students (foundation year and first and second year BDS) being at present based in Blantyre and the third year BDS students in Lilongwe, while the team await the completion of the building of the new Dental School in Blantyre.
Late morning I left Blantyre and travelled to Lilongwe. This was a very interesting road trip travelling north through Malawi with the road running along the border with Mozambique, reaching Lilongwe around 5 hours later at the Sunbird Capital Hotel in the centre of the city. James was travelling separately with his wife and arrived slightly later. We met for a very pleasant Malawi-style buffet dinner in the hotel, with a chance to catch up around plans for the week ahead.
Early next morning James and myself were picked up by our driver Richard and were taken across the city to the Dental Department at Kamuzu Central Hospital, where we had a short meeting with Jessie Namarika, the Senior Dental Surgeon at the clinic.
Following this we went to the seminar room to meet a group of local general dentists for a CPD session on orthodontics. We had a lively and interactive session which included a presentation on ‘Dental and Occlusal Anomalies’, including intercepting problems in the mixed dentition.
The following day we met the third year BDS students at the Kamuzu Central Hospital for introductory sessions on Orthodontics, including an update on facial growth and occlusal development.
The students were very enthusiastic and keen to make the most of the sessions, with lots of lively discussion and intelligent questions. We were joined for the session by a local dentist, Dr Samonte, who is based at the clinic and is involved with student teaching.
A full day of lectures and a ‘virtual’ new patient assessment session followed, with the students completing two virtual new patient assessments.
All the students were happy to contribute to the discussions around each virtual patient and proved confident enough to present their thoughts on the diagnosis of each malocclusion type and development of a problem list. Fuelled with a tasty snack of Scottish shortbread they still had energy to have a go at a short quiz at the end of the day and left with a spring in their step, feeling that it had been a worthwhile day.
On my last day at Kamuzu Central Hospital in Lilongwe we met the students early for a preparatory tutorial before moving to the clinical areas, where the students carried out orthodontic assessments on each other.
Dr Samonte, a local dentist who has an interest in orthodontics, was also present and the students worked very enthusiastically through the orthodontic assessments before presenting their ‘patients’. In the early afternoon we had a debrief and final session for the students with James and myself so they could feed back and ask questions about all they had been learning that week on their introduction to orthodontics course.
Following final photos and goodbyes we travelled back to Blantyre. The roads were much busier on the return journey and it took us more than an hour to get out of Lilongwe onto the Blantyre road. We arrived back in the early evening after five hours of driving, enjoying a beautiful African sunset on the way.
With a weekend free, Pauline and I went on a camping trip with the local hiking club which allowed us to travel to the Chikala hills to the north east of Blantyre. This involved a couple of hours travel on rough dirt roads through local communities. This overnight trip turned out to be a highlight of our time in Malawi with a hike through the rainforest and an overnight camp on the summit, with views to Mount Mulanje in the south and the Shire valley in the east.
The following week, back in Blantyre on the Monday I had a meeting with James and Yusuf, with further discussions around the orthodontic curriculum for the BDS students going forwards. We were also visited in the afternoon by a retired dentist from the U.S., Dr Clifford Daines, who was in Malawi with his wife as missionaries with the Mormon church.
Dr Daines had brought with him a batch of donated dental instruments which were enthusiastically opened by James and Yusuf.
The following day James and I had organised a CPD day for local dentists. Accordingly a group of nine dentists, based in both private practice and government health clinics, met in the board room in the medical college. We had a good interactive discussion around a presentation on dental and occlusal anomalies, including interception and management of problems in the mixed dentition. Several dentists have an interest in orthodontics and were very enthusiastic and happy to contribute to the day.
Later in the afternoon Wellington Chikuni, one of the local dentists on the Queen Elizabeth Hospital site, gave me a very informative tour of the Dental Clinic.
Several paediatric patients were in the clinical areas having extractions under local anaesthetic and Wellington discussed how this can be difficult, with many very anxious children presenting with toothache and acute dental infection. There is currently very little access to extractions under general anaesthesia and we discussed the potential advantage of introducing inhalation sedation as an option for younger and more anxious patients. Plans were hatched, with both of us agreeing to take a look at options for developing this service in the future.
My final few days in Blantyre were busy with further meetings with James, Yusuf and Peter. I was also given the opportunity to speak to the preclinical first and second year BDS students and it was great to see their enthusiasm as they set out on their studies in Dentistry.
They proved a lively bunch and asked lots of questions about orthodontics, especially after I let them into the secret that it is the best speciality in dentistry!
On my final afternoon I was given the opportunity to accompany James and Yusuf to the Plastic Surgery department at Queen Elizabeth Hospital and attend an educational meeting on maxillofacial trauma, presented by the plastic surgery registrars with clinicians at other hospital sites in Malawi linking in via ‘Zoom’. It was a well attended meeting. James and Yusuf contributed to the discussions with it being apparent how much general dentists and dental therapists are involved in managing facial trauma in Malawi with most being proficient at placement of inter-maxillary fixation.
Our final weekend was spent exploring the Mulanje mountain area south of Blantyre, before saying our goodbyes and heading back to the UK. The return trip was uneventful with a reverse of the outward journey travelling from Blantyre to Addis Ababa and then onto London and finally Aberdeen.
On reflection it was a very stimulating and rewarding trip both personally and professionally. I felt privileged to join the MalDent team and make a small contribution to the on-going journey to improve dental health for the people of Malawi. The enthusiasm of the local team including James and Peter is immense and they are very upbeat about the positive changes in dental health and clinical capacity that are slowly starting to take root in Malawi. They have understandably great pride in their ‘pioneer’ BDS students and new faculty members who are the bright future of dentistry in Malawi.
This is a guest post that has been compiled and edited by Jonathan Miller, Education and Data Analysis Manager at Medical Aid International. It describes the ongoing programme undertaken by Medical Aid International, in partnership with Martha Chipanda, the Oral Health Coordinator at the Malawi Government Ministry of Health. The programme was funded by the Scottish Government through the MalDent Project. It aims to ensure the sustainability of healthcare equipment investment in the region by providing holistic Biomedical Engineering training for students in Malawi.
Contributors: Martha Chipanda, Jonathan Miller, Tim Beacon, and Jeremy Bagg
Our journey starts over 20 years ago when Tim Beacon noticed the desperate need for medical equipment in low- and middle-income countries (LMICs). Tim, being driven and having a can-do attitude, set about utilising his contacts to make a difference. He built Medical Aid International from the ground up to focus on this aim.
Tim has a varied background across a number of different fields including roles as an Operating Department Practitioner, outdoor adventure trainer, running personal development courses, university and military healthcare lecturing, and more. He completed his Post Graduate Diploma in Travel Health at Glasgow School of Medicine and is also the author of The Gap Year Handbook. An Essential Guide to Adventure Travel (available for free download here).
In all of his previous jobs and his life in general, Tim has a history of responding to challenges with vigour and decisive action. When attending meetings addressing the healthcare situation in LMICs as part of his work at Medical Aid International, he noticed the topic of Biomedical Engineering and maintenance arising almost every time. No one seemed to be doing anything about this need, so Tim sought to address it himself.
At first, Medical Aid International partnered with Mercy Ships to deliver an on-the-ground 8-week course in Biomedical Engineering. Whilst this programme was extremely effective, the cost was prohibitively expensive to be rolled out to a wider audience; there were also the practical, logistical issues of getting to people! To create the solution that would be equally useful, but more cost effective, Medical Aid International invested over £150,000 to produce a comprehensive, online Biomedical Engineering Programme which is available in both English and French.
This multi-faceted programme includes a robust online training course, professional grade toolkit, a set of textbooks and a digital library of service manuals. The students are taught through a series of over 70 videos covering a wide range of topics, all tailored to the LMIC environment. Students must answer over 300 multiple choice questions throughout the course to pass, ensuring rigorous learning.
The course is designed for hospital “fixers” and estates managers who already have responsibility for looking after the hospital equipment, and upskills them to be more effective in their roles. By supporting their passion and enthusiasm with practical knowledge and resources, a huge day-to-day impact is achieved.
Research has been conducted into the effectiveness of the programme and found that students rate the course over 9.5/10 for course satisfaction and over 9/10 for course impact. A full data analysis report on the first 50 students that completed the course can be found here.
This brings us to the present day, where we have over 85 students across more than 12 countries with both the English and French versions of the course in use. Our impact in Malawi is particularly significant, a point of pride for us, with 27 students having either completed the programme or currently studying. These students are spread out geographically across the country, from Karonga in the North to Blantyre in the South (not forgetting Lilongwe in the Centre too). We’re proud to have worked with organisations both large and small, from governments to NGOs.
The textbooks and service manuals also allow for future study to further the students’ capabilities. By providing the professional grade toolkit we ensure the students are well resourced and can put into practice their newly acquired skills. Through the provision of this Biomedical Engineering training, the investments into new equipment are protected for the long-term and provide a lasting impact into the future.
Now to the MalDent project. Six students (five dental therapists and one biomedical engineer) across all regions of Malawi were selected to undertake our programme. The students have now all received their toolkits and have started the course. Here are some fantastic pictures of students receiving their toolkits; many thanks to Martha for arranging delivery and taking such great photos!
All six students have been working diligently and have completed the course in just a matter of weeks. We truly believe this hard work will pay off, benefiting the students, the healthcare facilities, and their patients. We will be sending out certificates to each of the students shortly to both congratulate them and celebrate their fantastic achievement. We look forward to hearing about the projects undertaken by our graduates and would like to thank the MalDent project, once again, for making this all possible.
The bespoke LMIC course (which focuses on equipment actually found in LMICs) teaches the students about:
Unit 0: Health and Safety
Unit 1: The Frequency Spectrum
Unit 2: Electrical Safety
Unit 3: Electrocardiogram (ECG)
Unit 4: Defibrillation
Unit 5: Patient Monitoring
Unit 6: Infusion Devices
Unit 7: Premature Baby Incubators (PBIs)
Unit 8: Ultrasound
Unit 9: Surgical Diathermy
Unit 10: Hygiene Guidelines
Unit 11a: Anaesthetics, Oxygen and Suction Devices
Unit 11b: The Operating Department and Sterilisation
Unit 12: First Aid
Unit 13: Train the Trainer
We are real advocates of the “Train the Trainer” approach. By this we mean that we train the students how to become trainers, so they can teach others and share their knowledge. This allows for best practice and benchmark standards to be developed hospital-wide – improving equipment maintenance and patient care.
We look forward to sharing the success stories once the students have been given the opportunity to put their training into practice!
Tim Beacon, CEO of Medical Aid International says:
“It is so wonderful to be working with MalDent on this project. Their long-term strategic vision, that we share, which encompasses this vital area of equipment support is to be highly commended. Giving these engineers the physical resources and foundational knowledge, which can now be built on as they develop their specialisation in dental work, is essential. It has also developed the communication infrastructure between them, which as the drive to develop dental services in Malawi continues, will be extremely beneficial.”
Martha Chipanda, the Oral Health Coordinator at the Malawi Government Ministry of Health says:
“I am very excited to see all of my students succeeding, many thanks to the Scottish Government, University of Glasgow and MalDent Project for the effort they have made to sponsor this program. I will fail in my job if I do not thank the Directorate of Health Technical Support Services (HTSS) Mr. Chimphepo, Ministry of Health Headquarters, for understanding the importance and granting us an opportunity to train dental therapists along with biomedical team in biomedical engineering. This is a development that is going to see our equipment being repaired and taken care of at district level where biomedical engineers are not easily available. It has started to implement our newly launched National Oral Health Policy on the area of infrastructure and equipment. It is my hope that another cohort is on the way to be trained. I am very confident that my team will do a great job on the emergency repairs of our dental equipment. A big congratulations to the students. Tim, Jonathan, Prof. Jeremy you are a blessing.”
Medical Aid International would like to thank the MalDent Project, the University of Glasgow and the Scottish Government for their involvement with this fantastic project.
On Thursday 14 April 2022 the Malawi Government Ministry of Health launched its first National Oral Health Policy. This represented the culmination of two years of work and twenty two meetings of the Oral Health Policy Taskforce, which had been established at the Oral Health Policy Workshop held in Lilongwe in February 2020. It was a big day for all concerned and a significant event on Malawi’s journey to ‘Oral Health for All’
The launch was held at the Sunbird Capital Hotel in Lilongwe – in exactly the same venue as we had convened the initial Oral Health Policy workshop in February 2020.
Whilst the guests were assembling, they were treated to entertainment from the Health Education Band, whose members sang songs which included messages about the importance of good oral health. The following video, which will give readers a feel for the music, was provided by Dr Mwapatsa Mipando, whose role in establishing and delivering the MalDent Project, including the Oral Health Policy development, has been so crucial from the outset.
Thanks to the modern wonder of Zoom, those of us who could not attend the event in person were able to join by videoconference from our bases around the world. Dr Yuka Makino, WHO Technical Officer for Oral Health in Africa, had contacted Chief Dental Officers from a number of other African countries, who joined the launch via Zoom. Thanks are due to the technical team at Kamuzu University of Health Sciences (KUHeS), who set up the Zoom link and made it possible for a further thirty of us to join those who were present in person.
The launch was facilitated by Mr Adrian Chikumbe, who is the Ministry of Health Public Relations Officer. The event started and ended with a prayer .
The first speaker was Dr Janet Kayita, who is the WHO Country Representative in Malawi. Dr Kayita commented that she was impressed with the standard set by the policy and that Malawi’s Oral Health Policy was running ahead of the imminent WHO Global Oral Health Strategy.
The next speaker was Dr Peter Chimimba, who had been invited to provide feedback from the perspective of the MalDent Project.
As Malawian lead for the MalDent Project, Peter has been closely involved with all aspects of its work, including the establishment of the new BDS degree at KUHeS.
Peter explained the critical importance of partnership working …
… and gave a very clear account of how the various components of the MalDent Project interface with one another. The new Oral Health Policy and its embedded Implementation Plan would now provide a blueprint for the way forward.
At the conclusion of his talk, Peter invited Dr Mwapatsa Mipando, Dr James Mchenga, Miss Annie Mwapasa and the first ever cohort of BDS students, now in Year 3, to stand up so that he could introduce them to those present and thank them for all that they are doing to support oral health improvement in Malawi.
Following Dr Chimimba’s talk, there was a speech by the Chair of the Parliamentary Health Committee, Hon. Dr Matthews Ngwale MP. He advocated strongly for research in Oral Health and also stressed the importance of access to appropriate care in rural areas.
The next speaker at the lectern was Dr Jones Masiye, Deputy Director of Curative & Medical Rehabilitation Services, who presented the key elements of the policy. As Co-chair of the Taskforce, Dr Masiye had a detailed knowledge of the policy drafting and its final content. He laid out very clearly the key challenges that the policy addressed:
The Concept Paper, Narrative Review and Situation Analysis undertaken by the Oral Health Policy Taskforce in preparation for writing the policy had identified key priority areas, which then formed the seven pillars on which the strategic direction of the policy was based:
The detailed presentation of the policy by Dr Masiye set the scene for Dr Queen Dube, the Chief of Health Services, to address those present. Dr Dube had spoken previously at a Global Oral Health meeting held during the COP26 summit in November 2021 and once again showed tremendous support for oral health improvement. It was wonderful for the BDS students present to hear this strong endorsement and Dr Dube’s assurance that the Ministry of Health has created posts for them once they graduate. Dr Dube also remarked how important the strong links between KUHeS and the Ministry of Health had been to success of the Oral Health Policy development and how critical that partnership continues to be across all aspects of healthcare in Malawi.
Following Dr Dube’s talk, there was a musical interlude from the wonderful Health Education Band, who you heard in the earlier video clip.
Following the music, the presentation moved to the climax of the event – the launch of the National Oral Health Policy by Hon. Enock Phale MP, Deputy Minister for Health. Regular readers of the blog will know that the Deputy Minister trained as a Dental Therapist and subsequently became the Oral Health Coordinator in the Ministry of Health, before his election to Parliament. It was, therefore, very fitting that he should launch the Oral Health Policy! His speech included a strong commitment to support implementation of the Oral Health Policy and he thanked the Scottish Government for its support of Malawi’s work to improve the oral health of its citizens.
Following the Deputy Minister’s address, attention turned to the ribbon-cutting!
Miss Annie Mwapasa, our MalDent Project Administrator, who has worked tirelessly on all aspects of the MalDent Project, including this launch event, presented the Deputy Minister with a pair of scissors ….
… and the ribbon was cut …
To the sounds of cheering and applause, the National Oral Health Policy was declared officially launched!
After the formalities of the launch had concluded, the delegates present assembled outside for the customary group photograph.
The meeting concluded with opportunities for informal discussion and lunch.
There was significant interest in the policy launch from the national media. You can read here a report from the Malawi News Agency and below is a front page headline in The Nation newspaper:
For those who are interested in reading the Oral Health Policy and the Policy Summary Booklet, these are available below:
This was a significant milestone for the MalDent Project but, more importantly, for the ongoing work within Malawi to improve the oral health of the population. The policy drafting included input from many players and benefitted significantly from the cross-sectoral partnerships involved. It is now important to maintain the momentum by pursuing actively the strategies identified in the policy. As Wilbur Ross once commented:
It’s important to have a sound idea, but the really important thing is the implementation
The foundations are in place, the building blocks are available and it’s now time to work hard towards achieving the goal of ‘Oral Health for All‘ in Malawi.
Now that our charity MalDent Student Aid is fully established, we are embarking on a series of fund-raising events. The Kiltwalk, established by Sir Tom Hunter, is an annual series of events run at different times of the year in Glasgow, Dundee, Edinburgh and Aberdeen. Thousands of walkers from a vast range of charities join these walks to raise money for their respective causes. There is a major additional incentive since Sir Tom Hunter adds 50% to the total raised by each walker, an exceptionally generous act which provides support to a multitude of deserving causes.
We assembled a team from the University of Glasgow Dental School to join 10,000 other participants in the Glasgow Kiltwalk on Sunday 24th April 2022. I was joined by David Conway, his wife Lizanne, Kurt Naudi and Ziad Al-Ani. The event commenced at Glasgow Green, where we were blessed with a beautiful sunny morning and an east-west following wind, conditions which remained with us all the way to the end of the walk at Balloch on Loch Lomond.
The route soon joined the River Clyde, which looked tremendous in the sun, with a backdrop of many of Glasgow’s most famous landmarks, such as the Hydro and the Armadillo.
As the route was about to take us away from the river, we decided on a first group photo opposite Glasgow Science Centre. Ziad is very handy with a camera and an expert on IT. We appointed him as our official photographer for the day and I would like to acknowledge that virtually all of the photos in this post were taken by Ziad. He had come armed with a very fancy selfie stick which also converted into a tripod – it served us well as the day progressed!
Along the route there were a number of pit stops, with toilets available and refreshments. Some of these were provided by participating charities and thanks are due to all the teams of volunteers who helped us on our way with these very welcome watering holes.
We were really enjoying the walk and before we knew where we were we had reached the pit stop at Clydebank Shopping Centre. Here, I had an important phone call to make. My good friend, colleague and Trustee of MalDent Student Aid, Alex Mackay, lives close to the Kiltwalk route between Clydebank and Bowling. Alex had kindly offered to lay on a lunch for us and had suggested I give her a progress report from Clydebank, which was about an hour away from her home. The call was made and final arrangements concluded!
The next section of the walk was through beautiful countryside – stunning blossom, swans nesting and all beneath a bright blue sky.
We reached the landmark white cottage where we were to turn off the official Kiltwalk route, cross the bridge over the canal, and head a short distance to Alex’s house. We received a characteristically warm welcome from Alex and were led out to a sumptuous spread on a table in the back garden. It was an opportunity to rest, re-fuel and enjoy a great conversation, largely focused on our interests and work in Malawi.
We rounded off our lunch with freshly brewed tea and coffee and a group photo, before pulling ourselves away from this very comfortable spot to start the second stage of the walk. Massive thanks to Alex for looking after us so well.
The next leg of the walk took us to Bowling. Just before reaching Bowling Harbour we spotted a houseboat that was sporting a banner for our MalDent Project partners Smileawi, who had also entered a team on the Kiltwalk to raise fund for their fantastic charity.
From Bowling, the route picked up the Bowline, a disused railway viaduct and track with lots of photo opportunities!
By the time we reached Dumbarton, we were beginning to sense that the end was in sight. We remained in good spirits and our legs were holding out well.
This next stretch, along the River Leven, was another very scenic part of the walk, with views to the hills in the distance.
There’s something about a ‘1 Mile To Go’ board that is very cheering! We were among a queue of teams waiting for their picture at this spot – all helping each other by providing a photographer for the other teams in line!
Reaching the finishing line was a fantastic feeling – cheers from the crowd mingling with strains of the Red Hot Chilli Pipers performing in the marquee just ahead of us.
It was time to sit down with a drink on this lovely sunny evening, soak up the atmosphere and proudly display our medals!
For those who are interested in the route and figures, here’s a summary of our team’s Kiltwalk:
If you’d like to see a dynamic representation of our walk, you can view it here.
Finally, our JustGiving page remains operational until 4th May 2022 and is available here.
I’d like to thank all those who have made this fundraiser for MalDent Student Aid possible.
My walking colleagues were fantastic company and really good sports – I hope you’ll join me again next year and that we can put together an even bigger team!
Many thanks to Alex Mackay, not just for a splendid lunch, but also for all the support of our Kiltwalk through your social media channels.
A very big shout out to those who have supported our Just Giving page – at the time of writing we have raised just over £4000.
A special thank you to Martin Aitken & Co, who helped with the set-up of the charity and with its ongoing governance and management. We were proud to include the company logo on our T-shirts.
The Kiltwalk is a massive logistical exercise for the organisers both in the run-up to the event and the day itself. The organisation was first-class and thanks are due to the many official team members and helpers who made it such a memorable occasion.
Finally, huge thanks are due to Sir Tom Hunter, for the original concept of the Kiltwalk and for the amazing 50% top-up that he provides to the donations raised by all the walkers. Our £4000 will become £6000, which will provide significant benefit to those dental students in Malawi who are training to support our long-term MalDent Project ambition of ‘Oral Health for All’.
This is a guest post that has been compiled and edited by Andrew Paterson. It describes a recently completed pilot programme undertaken jointly by Bridge2Aid and Smileawi in partnership with Martha Chipanda, the Oral Health Coordinator at the Malawi Government Ministry of Health. The project aligns closely with the disease prevention component of Malawi’s new National Oral Health Policy, due to be launched on 14th April 2022. The pilot programme was funded by Scottish Government through the MalDent Project, and supports the workstream on communicating messages which promote good oral health.
Contributors: Martha Chipanda, Andrew Paterson, Shaenna Loughnane, Nigel Milne, Victoria Milne, Jeremy Bagg
One of the key challenges in African healthcare is providing appropriate coverage for those living in remote and rural areas, which includes 60-80% of the population in countries like Malawi. These areas are underserved by both health services and health promotion. With the inclusion of oral health into the Malawi Government’s essential package of healthcare, the recent World Health Assembly statements on the importance of oral health, the MalDent Project and the new Malawi Bachelor of Dental Surgery degree programme there is significant momentum to address rural oral health in Malawi.
In 2020-2021, funded by a Scottish Government grant to Smileawi, Northern Malawi dental therapists were upskilled in the relationships between oral health and non-communicable diseases and taught skills to teach rural community volunteers to cascade-train key oral health messages within their remote communities. This course was delivered remotely using tablet computers (mOral Health) and coordinated locally. It was a collaborative effort of the NGOs Bridge2Aid and Smileawi, ProDentalCPD, the Dental Association of Malawi, The Ministry of Health of Malawi, the MalDent Project and the Universities of Glasgow and Dundee.
The next stage was for the therapists themselves to design a programme best suited to training community volunteers who could then cascade the oral health messages widely in their own remote communities. This was resourced by the Scottish Government funded MalDent Project and involved collaboration between Bridge2Aid, Smileawi, the Dental Association of Malawi, The Ministry of Health of Malawi, the Red Cross, the MalDent Project, the University of Glasgow, and the Kamuzu University of Health Sciences. The therapists were coordinated, supported, and managed by Dr Martha Chipanda (National Oral Health Coordinator) and production of teaching materials was facilitated, supported, and edited by Bridge2Aid and Smileawi volunteers.
The area selected for the first cascade training was Mzimba North in Northern Region Malawi. This is the largest District in Malawi with a population of over 600,000 people predominantly based rurally with agriculture being the main work in the area. Crucially some of the therapists who had received our training in 2020-2021 work in Mzimba North. There are many barriers in Mzimba North to access rural areas as the road system is primarily unpaved and the main form of transport is bicycle. Public transport is infrequent and often fails to predictably reach destinations. Many areas are inaccessible in the rainy season. Having well trained oral health promoters available locally is the key to disseminating important oral health messages in this area.
The therapists delivered the training they had designed to Red Cross volunteers from many parts of Mzimba North in a central location over two days, which included empowering the volunteers to present the newly learned key oral health messages. The volunteers received teaching aids to use in their communities, being an oral health flip chart in the predominant local language of the area, Tumbuka and a tooth model and brush to demonstrate effective toothbrushing techniques.
Here are the reflections of some of the key stakeholders in this part of the project:
Martha Chipanda (National Oral Health Coordinator, Malawi):
Training Oral Health Promoters is one of the ways to implement Malawi’s National Oral Health Policy. This pilot programme was focused on the promotion of oral health and prevention of common oral diseases. It tested the concept of cascade training using dental therapists to facilitate the training of non-health volunteers who would have a pivotal role in spreading oral health messages in their communities.
The Smile North therapists were extremely well organised which was important to the smooth running of the programme. Identification of volunteers was important. We targeted volunteers with the help of the Malawi Red Cross Society which enabled coverage of large parts of Mzimba North.
The volunteers were very excited and eager to learn. They actively participated in the programme and showed by their presentations that they were competent to deliver important oral health messages. At the end of the two days ten were successfully trained and hopefully they will play an important role in local oral health promotion. A certificate of attendance was given to the participants.
Feedback from the training therapists has been very positive:
“The programme is good for oral health promotion. The advantage is that it targets everybody, the rural, urban, and semi-urban population. But it is most advantageous to the rural population where oral health information is difficult to access”
“The programme is a mindset changer and a primary preventive measure that is bound to reduce the number of dental and oral conditions in most rural parts of the District. The programme is already gaining publicity within Mzimba North rural areas”
Following the programme, the therapists have also suggested modifications that may improve the programme such as providing some phone support for the community volunteers so that questions can be answered, additional support provided for challenges that may arise and to update the trained volunteers on changing oral health priorities.
This long-awaited programme has given hope and light to Oral Health Promotion and Prevention in the Northern Region. It is the hope that this can be similarly rolled out to other regions in Malawi.
Thumbs up to Bridge2Aid, Smileawi, the MalDent Project, the Malawi Government, the Scottish Government, the Dental Association of Malawi, the University of Glasgow, and the Kamuzu University of Health Sciences who all collaborated to bring about a successful course. There were many others who contributed to the delivery of this course who are too numerous to mention but their input is much appreciated.
Andrew Paterson (University of Glasgow & Bridge2Aid Trustee):
Being involved in the initial training programme to upskill the dental therapists and to teach them teaching skills and then to be further involved in a Malawian led and developed oral health cascade training programme has been, and continues to, be an uplifting experience.
A legion of problems was overcome by close collaboration and teamwork. One of the unexpected benefits of the programme has been that when the stakeholders involved in oral health in Malawi work cohesively and closely together the benefits of those relationships is good for the improvement of oral health.
The decision to provide teaching aids for the community workers in the local language of the area, Tumbuka, makes this form of cascade training particularly relevant and culturally appropriate to the needs of rural communities and will hopefully translate into improved oral health literacy in the area. This fits with the WHO principle of not leaving anyone behind by giving all the opportunity to receive appropriate health messages in a format they understand. That said there were a few uneasy moments after this decision with the realisation that our combined knowledge of Tumbuka amounted to five words. Nevertheless, good communication and a ‘never say never’ problem-solving attitude from all collaborators involved meant the end goal was achieved.
This model of cascade training has benefits not just for oral health but for general health too. The messages speak to the prevention of NCD’s as part of the Sustainable Development Goals agenda. Take for example the messaging around quitting smoking. This messaging may impact on the many adverse effects of smoking more generally such as cancer and heart disease. In rural areas where general health promotion is sparse, oral health promotion offers significant benefits to general health.
This programme is a first step to cascade training for oral health in remote and rural Malawi. Much reflection is required on the lessons learned, problems solved, barriers and benefits of the programme and then it can hopefully be expanded into other Malawian regions with teaching materials in languages like Chichewa to remain relevant to specific localities. This training model may have potential for use in the wider Sub-saharan Africa region but there are many distinct cultural groups and what works for one area may not work for another, so if it were to be used widely then local oversight and collaboration will be imperative to remain culturally appropriate.
Shaenna Loughnane (CEO of Bridge2Aid):
It was fantastic to see the online training course created and delivered last year to the Dental Therapists based in Northern Malawi. However, this course was never designed to stand alone, and was co-created by a partnership of organisations and people passionate about making a real impact on the oral health of remote and rural communities in Malawi.
It has been great for Bridge2Aid to continue to work with similar partners to plan, create and deliver the second part of the programme – training Oral Health Promoters to work in their own communities to prevent oral disease and to share knowledge and behaviours that will have a huge impact on community health.
“Localise”, “capacity building” and “community-led development” are buzzwords in international development and have been around for a few years now. The concepts and values behind these buzz words, and other words such as “partnership”, “prevention” and “power-shift” are at the heart of the recent changes in strategy and programme focus at Bridge2Aid.
However, it is important that we don’t just pay lip-service to these concepts but embed them in all that we do. I truly believe that this programme embodies all these core values and is a real demonstration of what can be achieved if you work together, and ensure your project is led, managed, and delivered locally. It embodies the principles of building capacity for oral health education and aims to continue to spread important oral health messages to the remote and rural communities that so desperately need them.
We now need to ensure that we fully evaluate the programme, and the effect it has on oral health literacy and behaviours in the communities in which these volunteers work to ensure we are having the impact that was intended. This will allow for learning to take place to further develop the programme.
Nigel & Vicky Milne (Founders of Smileawi):
Smileawi has been enormously proud to be involved in this great project. When we first visited Malawi 10 years ago, we had no doubt that any significant improvements in oral health services would need to come from a governmental level and that seemed an impossible dream all those years ago. However, with the MalDent Project and all its different strands we are starting to see positive changes and not least with our friends and colleagues in Smile North. In 2020-2021 with a Scottish Government small grant Smileawi was able to produce and deliver the Oral Health Course to twenty-four dental therapists along with partners Bridge2Aid, the Dental Association of Malawi and Prodental CPD. The collaboration between these different organisations was highly successful and the course was very well received with positive feedback from all the participants.
“I have enjoyed very much the presentations and the knowledge I gained will help to improve oral health service delivery in the community”
“It was well organised and has really improved my teaching skills in imparting oral health messages to different groups of people”
The MalDent Project then stepped in to fund the next part of the process and we watched from afar as the team in Malawi led by Dr Martha Chipanda brought together six dental therapists and ten volunteers. The dental therapists then spent a couple of days teaching the volunteers basic but vital oral health messages and how to best pass these messages on to their communities. The challenges thrown up were mostly to do with financial and physical logistics and it was frustrating not to be there to help. We feel that the autonomy this has brought to this group of dental professionals can be seen as a triumph and our feeling is that they will grow in strength and conviction and with their voices being heard and the momentum they have achieved everything will continue to move in the right direction for oral health services in Malawi.
Jeremy Bagg (MalDent Project & University of Glasgow):
One of the great strengths of the Scottish Government-funded MalDent Project has been the extensive network of partnerships and collaborations it has generated. In retrospect, when the grant application was written, we did not have a full understanding of the scope and scale of what we were proposing. If it hadn’t been for our wonderful team of partners, we’d be way behind by now!
This proof-of-concept programme, examining the effectiveness of training dental therapists to deliver education on oral health to community workers, who can then cascade these messages to the population at large, is a perfect example of our joint working. Smileawi gained a small initial grant which supported work with Bridge2Aid, ProDental CPD and the Dental Association of Malawi to develop e-learning materials for a group of dental therapists in Northern Malawi. These therapists completed the online programme via devices and data purchased with the grant and have now delivered training to community workers (with assistance of the Malawian Red Cross), who in turn have gained experience of training others.
This oral health promotion programme directly supports the key plank of the new National Oral Health Policy (also developed as part of the MalDent Project), which is the importance of a preventive, as opposed to curative, approach to oral and dental disease in Malawi. As we move into the policy implementation phase, the timing is perfect.
On behalf of all at the Kamuzu University of Health Sciences and the University of Glasgow with responsibility for delivering the objectives of the MalDent Project, can I offer a massive vote of thanks to all partners involved. Yewo! Zikomo!
One of the work streams in the MalDent Project that has been most impacted by the COVID pandemic is the completion of the re-equipping of the Dental Department at Kamuzu Central Hospital, which we commenced with our partners Dentaid and Henry Schein in 2018. Since then, many items of donated equipment had been delivered to Dentaid in Southampton for refurbishment and servicing by Stuart Bassham and his team. The shipping container that we purchased with financial support from the RCPSG HOPE Foundation had been loaded and transported across to Malawi last year, ready for Phase 2 of the refurbishment. The one missing part of the jigsaw was a visit by our team to install the equipment.
As travel restrictions began to ease, we were able to plan this last step. On Sunday 13th March I made my way to London Heathrow Airport to meet Stuart and our latest recruit to the MalDent Project, Chris Cox from Henry Schein Dental. This was to be the start of a very busy, successful and memorable working visit to Blantyre and Lilongwe.
Jacqueline James at Dentaid had looked at several options for our travel and, after consultation with Stuart, we decided to take a new route via Addis Ababa with Ethiopian Airlines.
After a very comfortable seven hour overnight flight on an airbus A350 we arrived safely in Addis Ababa.
As you will see from the photo above, Stuart is wearing a boot on his left foot and walking with crutches. He had broken his foot earlier in the year but did not allow this to deter him from travelling to Malawi. It also did not hold him back once the hard work started!
We had a two hour stopover in Addis Ababa and found a lovely coffee shop. I had already realised that Chris was a very keen coffee drinker and a cup of the strong black liquid soon had him smiling after the overnight flight.
Ethiopia is widely believed to be the birthplace of coffee. Apparently Ethiopia is the only place that coffee grew natively. According to a story written down in 1671, coffee was first discovered by a ninth century Ethiopian goat-herder called Kaldi. Allegedly he noticed the energy his goats received from eating the cherries! Whatever the veracity of the legend, we were very grateful for the energising we received that morning!
Our second flight, aboard a Boeing 737 to Chileka Airport in Blantyre, took only four hours.
On arrival at the airport, our first visit was to a large tent, in which our COVID tests and vaccination certificates were checked.
We then headed into the terminal building to purchase our visas and clear immigration. This took a while, and when we were finally through to the baggage reclaim area, I was delighted to see that Peter Chimimba had come to meet us. Our airline baggage tags were checked by security before going through the X-ray scanner:
It was fortunate that Peter was present, because one of the security staff operating the scanner wanted to understand why Chris was bringing in the large tool bag. There was a discussion in Chichewa, which did the trick, but I think we might have struggled to explain had we been on our own!
Once into the airport car park, our bags were loaded into a Toyota Hilux pickup that would be our steed for the duration of our visit.
We also met our driver from the Kamuzu University of Health Sciences, Sibande Balaka, who would become a very trusted and loyal friend during our stay and who is pictured here a few days later at Kamuzu Central Hospital:
After a 20 minute drive we reached the Sunbird Mount Soche Hotel at about 1.45 pm. I was so pleased to see the familiar surroundings and many familiar hotel staff after the COVID-enforced two year absence from Malawi.
We quickly checked in and whilst Chris and Stuart headed to their rooms, I travelled to the KUHeS campus with Sibande for a meeting with Professor Ken Maleta. We discussed some aspects of our work in the area of prevention of dental caries in children, which aims ultimately to establish a Malawian model that is akin to Scotland’s Childsmile programme. I was grateful to Professor Maleta for his valuable advice and guidance, providing suggestions to pursue once back in Scotland.
After the meeting I headed back to the hotel and to the red sofa in the bar where Peter and I have had so many meetings and discussions in the past. We had arranged for Stuart and Chris to meet with Professor Wilson Mandala, Executive Dean of the Academy of Medical Sciences at Malawi University of Science and Technology. In addition to making introductions, we were also keen to update Prof Mandala on the plans for the training of Malawian dental therapists and biomedical engineers in dental equipment maintenance that have recently evolved. Ever since our visit to MUST in 2019, we have been keen to work with staff in its Biomedical Engineering programme on delivery of teaching around dental equipment maintenance. We had a very positive meeting and look forward to further joint working.
Following the meeting with Prof Mandala we enjoyed dinner in the hotel and after a good night’s sleep were up promptly on the Tuesday for meetings at the Blantyre Campus of KUHeS. Our first set of discussions was held with Professor Johnstone Kumwenda, the Dean of Medicine, who has been very supportive of the new BDS programme. After introductions, we briefed Prof Kumwenda about the purpose of our visit and then enjoyed a general discussion about the new course and how things were progressing.
After our meeting with the Dean, we walked across the campus to meet the Acting Vice-Chancellor, Professor Macpherson Mallewa and the Registrar, Mr Stuart Chirambo. We had a very positive set of discussions, after which Stuart, Chris and I were presented with gifts to mark our visit.
For me it was a great pleasure to meet Lucia Msiska, formerly the PA to Dr Mwapatsa Mipando when he was Principal of the University of Malawi College of Medicine, and now supporting the AVC. Lucia played a very important role in the early days of the MalDent Project, before Annie Mwapasa was appointed as our Administrator. Lucia reminded us that exactly four years ago she had been in Glasgow with the CoM delegation that visited, and was part of the team that wrote the successful MalDent Project grant application to the Scottish Government. After the formal meeting we had a chance for a quick catch up, which I really enjoyed.
Our next engagement was with the BDS students in Foundation Year and in BDS 1 and 2. We met them in the same auditorium as the BDS Programme launch had been held in 2019 and it was quite emotional to see the large cohort of budding young dentists as the course gathers momentum.
After introductions by James and Peter, Chris, Stuart and I each took our turn to address the students. It was a great opportunity to update them on the broader aspects of the MalDent Project, including the forthcoming launch of the National Oral Health Policy and the progress being made with the design of the new teaching facility on the Blantyre campus.
In the afternoon we headed across to the Dental Department of the Queen Elizabeth Hospital.
When I had first visited this facility in 2017 it was in a dreadful state. Since then, with funding from the Ministry of Health and KUHeS, a significant amount of refurbishment and re-equipping has been undertaken, bringing about great improvements. However, there were still a number of equipment issues that remained to be addressed and Stuart and Chris soon had the tool kit out and set to work:
Whilst Chris and Stuart were busy, I left them to head back to the KUHeS campus for a meeting with Joyce Gondwe, the Dean of Students and Collins Chiliwawa, the Scholarships Officer. We had a very fruitful discussion about MalDent Student Aidand the Dentist to Dentist scholarships that are being established at KUHeS.
I returned to the Dental Department at the Queen Elizabeth Hospital later in the afternoon, expecting Chris and Stuart still to be working. However, they were at the entrance chatting with staff, having completed all the repairs required:
The next few photographs illustrate some of the improvements that have been made recently to the clinical facilities. First, a panoral radiography set up has been installed:
New dental chairs have been fitted in re-decorated areas of the building and the dividers between each unit have been replaced with new fittings that feature oral health messages:
Here, some of the dental therapists who work in the Department are posing in a surgery that has colourful painted murals:
It was fantastic to see these significant improvements, all of which had taken place outwith the funding from the MalDent Project itself, and which bring tremendous added value to the work being undertaken to improve oral health in Malawi.
We returned to the hotel for dinner and I was delighted that my good friend Nelson Nyoloka, Lecturer in Pharmacy at KUHeS, was able to join us. Nelson had spent the previous year in Glasgow completing his MSc in Clinical Pharmacology, and it was great to see him again and introduce him to Chris and Stuart.
The following morning we were up early for the long drive to Lilongwe. I have now completed this journey on a number of occasions and always enjoy it. For Chris and Stuart, it was their first time on this road, and they both found the variety of views and beautiful countryside fascinating. En route I spotted a private dental clinic in one of the towns and managed to take a photograph as we passed.
We checked into our hotel in Lilongwe and had a light lunch before heading across for a reconnaissance of the work to be undertaken at the Dental Department in Kamuzu Central Hospital. Whilst we were enjoying our lunch there was a very heavy rainstorm, which lasted for a matter of minutes before abating:
On arrival at KCH, and after greeting the team there, we headed straight to the pre-clinical skills facility, since a priority for the visit was to install the second group of six A-dec 4810 phantom heads to complement the six identical simulators we had installed in 2018.
Whilst the existing cabinetry looked in a reasonable state from the outside…
… a quick look inside revealed exactly the same problem we had encountered in 2018 – massive destruction of the composite board by termites, which had reduced much of the internal structure to a brown dust:
It was clear that the structure needed to be removed, so Chris, Stuart and I set about removing the fittings, breaking up the wooden structure and removing it completely
The ‘moth-eaten’ appearance of the wood is clearly evident in this photo…
… as are the piles of termite dust in these photos:
By close of play, covered in dust and wearing sweat-drenched clothes, we were very pleased to have completed this part of the work on our first day in Lilongwe, to allow the hospital carpenters to start building the new cabinetry the following day.
After showers, a decent meal and a good sleep at the hotel, we were up early to head back to KCH. On arrival I enjoyed a chat with Jessie Mlotha-Namarika, the senior dentist at the facility, who I have known since my first visit to Malawi in 2017. Jessie was delighted with some tooth models and teaching materials that Stuart had donated to her on behalf of Dentaid.
Shortly after our arrival, we were joined by the hospital carpenters. Stuart and Chris explained what was required, referring to the structure built in 2018 for the first six simulation units, which provided a template for what we needed. Wood was ordered and once it arrived the carpenters set to work.
A little later, the equipment from the shipping container arrived on a truck…
… and unloading commenced
The chairs were placed in the circulation space in the centre of the building …
… and the six phantom head units lined up outside the pre-clinical skills facility:
The shipping container from which the equipment had been delivered to the Dental Department that morning is now permanently stowed at the Lilongwe campus of KUHeS. It is available to ourselves and all our partners, including Smileawi and Bridge2Aid, as a storage facility and staging post for all our various activities associated with oral health improvement in Malawi.
Just as the truck with the equipment was arriving, I had to leave for a meeting at the Ministry of Health with Dr Jones Masiye, Deputy Director Clinical Services – NCDIs and Mental Health. On arrival I apologised for my ‘working clothes’, before we started our discussions, including the detailed planning for the launch of the National Oral Health Policy, which had just been re-scheduled for 14th April. It was a very valuable meeting.
I returned to Kamuzu Central Hospital, where the carpenters were busy constructing the cabinetry for the phantom head units. In light of the termite issue, the structure was liberally coated with an anti-termite preparation, which should help to preserve it.
These views show the metal manifold from which the compressed air is directed to each of the simulation units
The carpenters were happy to pose with Chris, once their work was done:
We returned to the hotel in the evening and enjoyed a dinner in Vincent’s Restaurant with colleagues from the Ministry of Health. We were honoured that Enock Phale MP, Deputy Minister of Health, was able to join us, along with Martha Chipanda, the Oral Health Coordinator at the Ministry and Jones Masiye, who we had met earlier in the day. Jessie, Peter and James also joined for a truly memorable evening.
Enock Phale and Martha Chipanda had been classmates at the College of Health Sciences when they initially trained as dental therapists. We were able to capture this lovely photo of Enock and Martha (seated) and Jones and Jessie (standing) – all key players in the journey to improve oral health for the citizens of Malawi
On a previous visit to Malawi I had sampled crocodile tail, which I had really enjoyed. On my recommendation, Chris (and I!) chose the crocodile for our main courses and both thoroughly enjoyed it.
This photo was probably our favourite of the trip – the most positive image you could wish for:
When Stuart had been packing the shipping container at Dentaid headquarters, he had included an Oxford hoist, which had previously been used to care for an elderly relative. His intention had been to donate it to the main hospital, but we then realised that it could be used to lift and transport the dental chairs and other weighty items. Anyone who has tried to move dental treatment units will know how heavy and awkward they are. Moreover, the base is designed to be non-slip for stability, making sliding the chair very difficult. We were very grateful for Stuart’s brainwave in packing the hoist, which made our lives much easier.
Mid-morning on the Friday I walked across to the Lilongwe KUHeS campus to meet with the pioneer cohort of dental students, who have now commenced BDS 3. Our extensive discussions were accompanied by refreshments. It was an opportunity for James, Peter and I to update the class about a number of developments underway on the MalDent Project and for the students to air some of their feedback and concerns.
At the conclusion of our meeting, we enjoyed lunch together …
… and then moved to the steps at the front of the building for a photograph.
Grateful thanks are due to Madalitso Kaphamtengo, Administrator at KUHeS, for organising the venue and refreshments.
Following the meeting with the BDS 3 students, I returned to KCH. The trainees were still busy working with Chris and Stuart. At one point they were divided into two teams and each given a chair replacement to complete under the watchful eyes of Chris and Stuart. They were extremely fast learners and this experience bodes well for the Medical Aid International training they are about to commence.
On the Saturday, we returned to KCH to continue working on the equipment. Chipi, one of the therapists from the group of six who had visited the previous day, joined again voluntarily on the Saturday and the following Monday, as he lived locally
On the Saturday evening, as we were enjoying a drink in the bar, Peter recognised an acquaintance of his, Professor Francis Moto, who is Chairman of the KUHeS Council. Formerly Professor Moto was the Malawian High Commissioner to the UK (2005-10) and subsequently Malawi’s first Ambassador in Brazil (2011-15). Peter greeted him and he kindly came across to join us for a fascinating discussion on a wide range of subjects. It was a memorable evening. I was especially interested in the tartan scarf that Professor Moto was holding. It turned out to be the official Malawi tartan – designed at his instigation whilst High Commissioner in the UK!
On Sunday, Chris and Peter were away for the day visiting a charity (the Chinthowa Development Trust) outside Lilongwe – Chris’ family has close involvement with this organisation.
I stayed in the hotel and completed some academic work that required attention. In addition, it was World Oral Health Day 2022, and we were able to publish a series of tweets about the work we were doing in Malawi, including the following three:
On the Sunday evening we were all joined by Dr Mwapatsa Mipando, who had travelled to Lilongwe that day from Blantyre, having only just arrived back from a visit to Zambia. We enjoyed a working dinner together, ahead of a visit on the Monday by Mwapatsa to see the results of the work at the KCH Dental Department.
Whist at the Dental Department, he was able to meet with the BDS 3 group who were waiting to have a lecture in the Conference Room there. It was good to see the tablet computers that we had helped to fund being put to good use by the students.
By this stage, the installation work was largely complete, with small details being attended to before we left. The phantom head unit was transformed into a first class training facility:
In total, six refurbished dental chairs were installed and five existing chairs serviced and repaired…
… and seven chairs were prepared to be transported and installed in district clinics. The therapists who are undergoing the biomedical engineering training will be able to support these installations.
By the end of our visit, we had accumulated a ‘graveyard’ of termite-ravaged cabinetry and scrap equipment which will be disposed of by the local team:
Word got out that it was my 65th birthday on Monday 21st March and I was very touched that the BDS 3 class presented me with a birthday card! The success of the trip itself was a fantastic birthday gift, and it’s an occasion I won’t forget.
On the Monday afternoon, Chris brought the BDS 3 students into the pre-clinical skills unit to run over some of the ‘dos and don’ts’ of using the equipment. Chris previously worked for A-dec before joining Henry Schein, and what he doesn’t know about these simulators isn’t worth knowing – the students were learning from a true expert.
Just before we left KCH for the last time, we had a photo with Chipi, who showed great enthusiasm and aptitude for working on dental equipment – he had rapidly become part of the team.
Chris donated the extensive tool kit to the Department, together with a large bag of spare parts, to support the local team with maintenance moving forward.
After leaving KCH for the last time our driver, Sibande, took us to a local market. Chris and Stuart were keen to buy some artwork and artefacts to take home.
When he returned to the car, Stuart handed me a birthday gift – a beautiful wooden model of a Land Rover Defender. Stuart is a great fan of Land Rovers and knew I share an interest in cars – it was a lovely surprise and will join my collection of Malawian items from earlier trips.
We returned to the hotel to commence our packing and decided, as it was our last night, to have dinner in Vincent’s Restaurant. Chris opted for crocodile yet again and I started with the fantastic mushroom soup they serve.
The next morning we had a leisurely start, leaving the hotel at 11.15am for Kamuzu International Airport.
Our COVID PCR tests had all been negative and we were quickly through the necessary checks.
The flight to Addis Ababa was on time and uneventful. However, we had a six hour stopover before our flight to Heathrow. We settled down in a cafe called ‘Cravings’, next to a power point, and enjoyed a nice meal followed by laptop time using the excellent free airport WiFi.
Whilst we were waiting, we received a message from Chipi, the dental therapist turned biomedical engineer! He wanted us to take a selfie and send to him, which we duly did. His message indicated how much he and his colleagues had learnt and that he would be in contact through WhatsApp with any issues that Chris and Stuart could help to resolve. It was a lovely message and along with the enthusiasm of the six involved has confirmed that the concept of training dental therapists to maintain their own clinical equipment is worthy of examination.
We boarded on time and the overnight flight to London was smooth and punctual.
Once we had cleared immigration and collected our bags, Chris and Stuart headed to the car park to retrieve their vehicles and I headed for central London and the train home from Euston.
This had been a tremendous visit. As always, our Malawian colleagues showed us great warmth and hospitality and our partnership working continues to reap rewards on all fronts. My good friend Peter Chimimba was always on hand to help and guide us, and I was particularly pleased to capture this very happy photo of him with Stuart at breakfast in the hotel.
Big thanks are also due to James Mchenga, Annie Mwapasa and Mwapatsa Mipando for their help in organising our visit and ensuring it ran smoothly. We are also indebted to Sibande Balaka, our driver, who always greeted us with a wide smile and for whom nothing was too much trouble.
Thanks are also due to the many individuals and organisations who donated the equipment in the UK for onward transport to Dentaid and then to Malawi. Many thanks also to Scottish Government International Development and the Royal College of Physicians & Surgeons of Glasgow HOPE Foundation for generous financial support.
Personally, I would also like to thank Andy Evans, Chief Executive Officer of Dentaid, and Patrick Allen, Managing Director of Henry Schein UK, for supporting Stuart and Chris respectively to participate in this visit. Both Stuart and Chris worked tirelessly to extract the maximum benefit from our time in Malawi, utilising their expert knowledge to not only complete the installations, but also provide training, advice and a set of tools so that the local team can maintain the equipment far more effectively moving forward. All of this was achieved with both humility and a great sense of humour. I could not be more impressed or more grateful to them – they deserve the last word and final photo in this post! Zikomo!
During the course of the Maldent Project we have received a large number of donated dental chairs and related items of equipment, including phantom head units, destined for the Dental Departments at Kamuzu Central Hospital in Lilongwe and Queen Elizabeth Hospital in Blantyre. This work stream has been strongly and generously supported, particularly from a technical perspective, by our partners Dentaid and Henry Schein Dental.
In May 2019 we completed Phase 1 of the re-equipping of the Dental Department at KCH and on arrival back in the UK began collecting additional items to allow completion of the work in a second phase. That work is about to begin as the container of equipment dispatched last year has arrived safely in Lilongwe. I will be heading out to Malawi on 13th March with Stuart Bassham from Dentaid and Chris Cox from Henry Schein to complete the installation. In addition to the materials that have already arrived in the container, we will take out a number of additional spares which will support the installation and any maintenance required on the chairs installed previously.
There are many potential pitfalls surrounding medical equipment donations. In one study of 112,040 pieces of equipment, 38.3% of items in developing countries were found to be out of service, with the three main causes of equipment dysfunction being lack of training, health technology management, and infrastructure (Perry L, Malkin R. Effectiveness of medical equipment donations to improve health systems: how much medical equipment is broken in the developing world? Med Biol Eng Comput. Jul 2011;49(7):719-722). One of the common pitfalls, especially for donated pre-used equipment, is a failure to consider in advance the need for ongoing maintenance and repair of the equipment following installation, which requires appropriately trained biomedical engineers. In many sub-Saharan African countries, including Malawi, there is a shortage of trained biomedical engineers. As a result, medical equipment which breaks down often lies idle for extended periods, or is discarded, when a trained and well-resourced engineer could resolve the problem relatively easily.
We have been acutely aware of these challenges since the MalDent Project was established and we included a funding stream to begin addressing this issue with dental facilities in Malawi. The COVID-19 pandemic hindered the start of this element of the project but an exciting and innovative start has now been made on what we are calling the ‘MalDent TechAid‘ programme.
Recently, Stuart Bassham at Dentaid became involved in another global health project with the Social Enterprise Medical Aid International, which is led by Tim Beacon. Medical Aid International’s stated goal is ‘to improve healthcare across the developing world through supplying medical equipment and accessories, training and biomedical support that is context-appropriate, fit for purpose and tailored to the individual project’.
Stuart subsequently introduced Tim to a group of partners we had been assembling to develop on-line training materials in dental equipment maintenance and repair. Patrick Allen, our long-term partner and supporter from Henry Schein, set up a conference call with Stuart, Tim, Tony Royston (Medical Aid International), Jason Spencer (DCI), Aldo Eagle (axiUm) and myself to examine how our shared expertise could be pooled to address the need for enhancing dental equipment maintenance and repair skills in Malawi. The meeting resulted in exciting developments which will likely prove a turning point.
Following introductions and a short summary of the scope of the MalDent Project, Tim delivered a presentation about Medical Aid International and how its work could support and interface with our own ambitions.
His opening slide included a photo of two Malawian engineers at the Beit Cure Hospital in Malawi who have already completed the on-line Medical Aid International training programme.
Tim then described very clearly the various ways in which his organisation approaches the delivery of support for medical equipment procurement, installation and after-care in low-and middle-income countries:
The procurement of equipment appropriate to the environment, and high quality education for engineers and estates teams, are central factors which will also be key to addressing the challenges surrounding dental equipment in Malawi:
One particular slide illustrated a surgeon who, with minimal equipment but some knowledge was able to effect a repair on an operating light. I was delighted to recognise the surgeon as Steve Mannion, an orthopaedic surgeon who is renowned for his work in global surgery, particularly in Malawi, and a fellow member of the Royal College of Physicians & Surgeons of Glasgow Global Health Group:
What was of particular interest to the group was the educational package that Medical Aid International has developed on biomedical engineering for those in low- and middle-income countries:
The training package comprises three components, the first of which includes the supply of a set of tools:
The second component is an on-line training programme. There is an extensive monitoring and student support process delivered by staff at Medical Aid International:
The final component, COVID-19 permitting, is an on-site face-to-face follow-up:
The next slide stimulated a very interesting conversation which has fundamentally altered our approach in terms of the target group for the training:
We had previously only considered the up-skilling of qualified biomedical engineers, by delivering specific training on dental equipment installation, maintenance and repair. However, Tim suggested that we should perhaps consider training a cadre of dental therapists, who would then have additional skills and could provide extended duties in the field. I had never considered this previously, but the more we discussed the concept, the more sense it made. Many of of the equipment challenges arise in parts of Malawi (particularly more rural areas) where there is no access to a biomedical engineer. If there were dental therapists on the ground who had some knowledge and understanding, then they could undertake routine maintenance and attempt repairs themselves when necessary.
After the call, I spoke with Martha Chipanda, the Oral Health Coordinator at the Ministry of Health in Malawi. Martha was very enthusiastic about this concept and, as a result, we have enrolled five dental therapists and one biomedical engineer on the Medical Aid International programme.
In parallel, Stuart, Patrick and Chris Cox, together with their other colleagues at Dentaid and Henry Schein respectively, will design a series of on-line training modules specific to dental equipment, which the six individuals who complete the Medical Aid International course will then undertake as a follow-up programme. The first face-to-face planning meeting has already taken place:
It is very exciting that this part of the MalDent Project is now underway and that we have added another partner to our team in the shape of Medical Aid International. If this proof-of-concept pilot training programme is effective, then we can examine ways in which it can be extended, potentially linking with further- and higher-education institutions in Malawi. It is also clear that there may be applicability to other countries in the region which face similar challenges to Malawi with dental equipment maintenance and repair.
The American New Thought writer Wallace D Wattles (1860-1911) wrote: “It is essential to have good tools, but it is also essential that the tools should be used in the right way”. Our aim is to ensure we do both.
As a result of the impact of the COVID-19 pandemic and associated restrictions, it is now two years since I last visited Malawi. On reflection, we were extremely fortunate to have been able to hold the National Oral Health Policy Workshop in Lilongwe in February 2020, just before the lock downs commenced, as that meeting laid the foundations for establishing the Task Force and our subsequent policy development work.
However, as regular readers of this blog will be aware, we have managed to maintain the momentum of many strands of the MalDent Project despite the challenges of the past two years. In this post, I will provide updates on some more recent events and activities, before providing a taster for what we are planning over the next few months.
1. The National Oral Health Policy
The Task Force that was established in 2020 met every fortnight on-line to develop the policy. A Concept Paper, Literature Review and Situation Analysis were undertaken to inform the subsequent drafting of the policy document itself. The work was presented to the Ministry of Health Technical Working Group on two separate occasions and their feedback taken into account as the final draft was prepared. The Policy was accepted by the Ministry of Health Senior Management Team on 13th December 2021 and has now been officially signed off by the Minister of Health and Secretary for Health
This represents a major milestone for the MalDent Project, as it was one of the key objectives. A formal launch of the Policy is currently being planned and attention now turns to its implementation. Access to the full text of the Policy will be provided to readers following the formal launch.
The MalDent Project team was delighted to hear of the recent appointment of Enock Phale MP as Deputy Minister of Health. As a trained dental therapist and former Coordinator for Oral Health at the Ministry, Enock Phale has been campaigning for improvements to oral health in Malawi for many years and it is very fitting that his recent appointment coincides with the oral health policy launch. We all send warmest congratulations and good wishes in his new role.
2. Phase 2 of equipment upgrade at Kamuzu Central Hospital Dental Department
The pandemic has significantly delayed the installation of the refurbished, donated dental chairs and phantom head units at KCH. However, the loaded container finally left Dentaid’s HQ in Southampton in July 2021…
… and arrived safely in Lilongwe in October:
This is a container that we have purchased with support of the Royal College of Physicians & Surgeons HOPE Foundation so that we can use it as a storage facility for the MalDent Project and for our partner organisations including Smileawi and Bridge2Aid. This particular load included a Dentaid portable dental chair which Smileawi was providing for Edward Hara, a dental therapist with whom they have worked for several years in the Northern Region of Malawi. The chair was picked up and has now been delivered safely to Edward.
Now, the ambition is to arrange a visit to Lilongwe this Spring with colleagues from Dentaid and Henry Schein to install the dental chairs and other equipment in the KCH Dental Department.
3. Publications and presentations
There have been a number of opportunities in recent months to publicise the activities of the MalDent Project. The first was an article in Voice, the quarterly magazine of the Royal College of Physicians & Surgeons of Glasgow.
This was the first in an ongoing series of articles that are to be submitted through the RCPSG Global Health Group covering a range of activities in global health across the five faculties of the College. If you would like to read the article it can be found here.
The second article was a piece we submitted about our new charity, MalDent Student Aid, in Scottish Dental magazine
This article followed an excellent piece in the same edition in which one of our Glasgow BDS students, Katie Read-Challen, provided a summary of the project she undertook for her intercalated BSc in Global Health, which examined the work of Scottish charity Smileawi through the lenses of partnerships, collaboration and sustainability. Nigel and Vicky Milne, who founded Smileawi, were co-authors and you can read the article here.
On Wednesday 20th October 2021, Peter Chimimba and I were delighted to have the opportunity to present a summary of the MalDent Project at the Scotland Malawi Partnership (SMP) Health Forum and 15th Covid-19 Co-ordination meeting. We each produced a short video clip ahead of the meeting which Jade Stein, the fantastic Media and Communications Officer at SMP, edited into a short on-line announcement about the forthcoming presentation:
Unfortunately, on the day of the meeting Peter was having problems in Malawi with internet connectivity. We therefore agreed that I would present the slides and that we would answer questions jointly at the end. This meeting provided a tremendous opportunity for us to speak to a large audience in both Scotland and Malawi and we are very grateful to Stuart Brown, Deputy CEO of the SMP, for all his help and support. A recording of the entire meeting on 20th October can be viewed here and the section on the MalDent Project commences at 1 h:06 mins on the time bar.
A further opportunity arose in conjunction with a three day University of Glasgow COP26 satellite event that I co-organised with my friend and colleague Julian Fisher, who is based at the Charite University in Berlin and who has previously written for the MalDent Project blog. The event was entitled ‘Sustainability in Healthcare and Education – Global Challenges and Solutions’ and we were delighted that Jenny Gilruth MSP, then Scottish Government Minister for Europe and International Development, delivered a pre-recorded welcome message as the meeting opened. Over the course of the three days more than 1500 delegates participated from over 80 countries.
The first two days centred on Global Oral Health, and provided an opportunity for the MalDent Project to illustrate the application of many of the principles embodied in the WHO 2021 Oral Health Resolution that had been accepted at the World Health Assembly in May 2021. In the session on Day 1 entitled ‘Scotland-Malawi partnership working – putting the WHO Oral Health Resolution into Practice’, there were presentations from Dr Mwapatsa Mipando and I …
… from Dr Jones Masiye (Deputy Director of Clinical Services – NCDIs and Mental Health) at the Ministry of Health …
… and from Dr Queen Dube, Chief of Health Services at the Ministry of Health, who spoke about raising the profile of Oral Health as a political priority in Malawi:
This session was followed by a round table discussion entitled ‘Oral health policy development in Malawi and the Region’. The discussion was co-chaired by Dr Benoit Varenne (Oral Health Programme Officer at the World Health Organisation) and Dr Yuka Makino (Technical Officer for Oral Health, WHO Regional Office for Africa), both of whom were also delivering presentations in other sessions of the meeting.
Representatives from Malawi, Rwanda, Zambia and Zimbabwe participated in the facilitated discussion. Noel Kasomekera, based in the NCDI Unit of the Malawi Government Ministry of Health, represented Malawi. Noel has played a major role in the development of the National Oral Health Policy over the past two years and will be a key figure in the implementation phase.
For those interested in reviewing the presentations, all of the recorded content from the three days is available here. The material specific to the MalDent Project is in the first recording from Day 1 with the time stamp 1h:12m:40s to 3h:10m:01s.
4. Looking ahead
Whilst it remains the case that the COVID-19 pandemic is far from over from a global perspective, we hope that moving into 2022 we will be able to regain ground on some of the work packages which have been delayed. There are a number of activities that I hope we will be able to report on during future posts this year:
Progress on moving the new student hub / clinical dental teaching facility on the Blantyre campus of KUHeS from the design into the construction phase.
Undertaking a national child oral health survey in Malawian schools following the WHO Pathfinder model.
First steps in delivering the Implementation Plan following launch of the National Oral Health Policy, including aspects such as task-shifting, in conjunction with Malawian and UK partners.
Establishing educational modules on dental equipment installation, maintenance and repair in conjunction with stakeholders in the charitable, academic and commercial sectors.
Much work has been underway in planning these initiatives throughout the past year and the improved opportunities for travel should now assist with progressing them.
Whilst the availability of Zoom and related platforms has been a lifesaver during the pandemic, together with its very positive impact on carbon footprints through reduced travel, partnership working such as the MalDent Project does benefit from at least some degree of true face-to-face interaction. Having not visited Malawi since February 2020, I have really missed seeing so many of the friends that I have made there. When Peter Chimimba and his wife Frider let me know that they would be visiting family in Leeds over the recent festive season it was just too good an opportunity to miss. Accordingly I travelled down from Glasgow early in the New Year and enjoyed coffee, lunch and a 10 item MalDent Project agenda with Peter:
It was an extremely valuable meeting and we both thoroughly enjoyed the wide-ranging discussions that ensued, without any fear of WiFi dropout or other technical mishaps.
During discussion with the barman, Kenzo Chiumia, it turned out that he also was from Malawi, which stimulated much chat and laughter, particularly when Peter’s wife Frider joined us:
Peter and his wife are now safely back in Malawi and I very much hope that our next meeting will be soon – and in the Warm Heart of Africa!
I am delighted that this guest post has been written by Cleopatra Matanhire, a dentist from Zimbabwe who recently completed a Master’s degree in Global Health at the University of Glasgow.
For her research project, undertaken in part-fulfilment of her master’s degree, Cleopatra undertook a case study of the work underway by the Oral Health Policy Task Force, established by the Ministry of Health in Malawi.
Cleopatra was able to visit Malawi in October 2021, allowing her to attend a meeting of the Ministry of Health Technical Working Group when it considered the draft policy and to meet key personnel from the Ministry, the Dental Association of Malawi and the Kamuzu University of Health Sciences.
This account, based on a diary of Cleopatra’s visit to Malawi, gives a flavour of her experiences as as she visited the ‘Warm Heart of Africa’.
Monday 4 October 2021
After several weeks of the journey to Malawi being postponed, finally it materialises today, the 4th of October 2021. The story of how this happened emanates from a self-initiated introduction that I made to the University of Glasgow (U of G) dental team on my arrival in Glasgow for my MSc Global Health Studies. Even though I was enrolled in a different College, I had hoped to learn as much as I could about the accomplished and renowned work the U of G Dental School was doing in the world, especially in Africa. In my reading, I had come across the MalDent Project in Malawi and Bwiza Childsmile Initiative in Rwanda that U of G was involved in. Little did I know that I would end up doing my Master’s thesis on one of the projects.
Sometime in October 2020 I had a virtual meeting with Professor Jeremy Bagg and Professor Lorna Macpherson at Glasgow Dental School. I informed them of my willingness to learn as much as I could about their work, especially in dental public health. Instantly they asked what I planned to do my dissertation on, which was oral health policy related work, and our worlds aligned. One of the MalDent Project goals was to develop a national oral health policy for Malawi.
This was it, it ticked all the boxes, a dentistry related project, African context and if possible, on oral health policy. I had hit the jackpot!
What followed was months’ worth of preparation, reading, meetings and more familiarization with the MalDent Project. I settled on the title Developing Oral Health Policy in Africa: Case Study of Malawi. All of my project had to be done online as a result of the COVID 19 pandemic, but I sought to go visit Malawi physically and contextualise my research. Which is the purpose of this trip.
As I departed from Harare International Airport I wasn’t sure what to expect. One thing for certain though, I knew I would be intrigued by the journey as all things to do with developing oral health, especially in Africa, get me excited. I was expectant to learn from the hard work the Malawi team had put in. I was fortunate to have been invited as a physical observer to the Oral Health Policy Taskforce meeting with the Technical Working Group (TWG) of the Malawi Ministry of Health, when Draft 11 of the policy was to be considered for sign off. My journey would start in Lilongwe, where the TWG meeting was to take place and then I would proceed to Blantyre. A busy but interesting itinerary was laid out for me by the Malawian team.
Tuesday 5 October 2021
We hit the ground running. I would be in the company of Dr Peter Chimimba (MalDent Project lead in Malawi) and Dr James Mchenga (academic lead at the new dental school). Both James and Peter are Oral and Maxillofacial Surgeons (OMFS), in fact the only two OMFS in Malawi. On the schedule lined up for us in Lilongwe were a tour of Kamuzu Central Hospital, a visit to the Kamuzu University of Health Sciences (KUHeS) Lilongwe campus (formerly known as University of Malawi College of Medicine), a meeting with a Dental Association of Malawi representative and attendance at the Ministry of Health Technical Working Group meeting where the national oral health policy document was being discussed in depth. All this and more were achieved.
The tour of Kamuzu Central Hospital was very interesting. The quality of services rendered by the currently available manpower is impressive. Because for a long time there hasn’t been a dental school in Malawi, dental therapists’ scope of practice goes above and beyond the typical expectation. The therapists man rural health centres and district hospital facilities mostly on their own, undertaking maxillofacial procedures such as cyst enucleations and intermaxillary fixations.
At Kamuzu Central Hospital I was impressed to see Registered General Nurses running the Dental Department’s infection control and equipment sterilization – I was informed they had been requested from the Central Sterile Supply Department (CSSD). This was particularly interesting as Malawi does not have qualified dental nurses or dental surgery assistants but had managed to plug the gap with an appropriate standard. I also had the privilege of meeting Mr Edgar Mthunzi, a dental therapist with further training in general anaesthetics. He was preparing for retirement, but I was rather impressed – never in my mind had I imagined that the local cases that were being conducted under GA were being undertaken with the anaesthetist having a dentistry background. This was a brilliant solution for the context and he had worked in this capacity for many years. In fact, the gentleman had worked with one of my colleagues from Zimbabwe during his training to qualify as an OMFS. I had to have a photo taken with him! I thought of our Dental Therapy students back home in Zimbabwe and how this would be a great example for career diversification and growth within the dentistry profession, if one is willing.
During the trip, James and Peter would share with me their career journey and life stories which were so interesting. Later, that day we met with Dr Wiston Mukiwa, who I had been privileged to interview on-line for my master’s research project. Wiston has been practising for more than four decades. He had the privilege of serving as Principal Secretary in the Ministry of Health and Chief Dental Surgeon of Malawi earlier in his career. I spent the afternoon in the company of the three, as they narrated the journey of Dentistry as a profession in Malawi, from when there were only three dental practitioners to the present day. I was in awe of the accomplishments they had made, including the involvement of private practitioners in the development of the new National Oral Health Policy. The biggest takeaway from the afternoon discussions was that you only need a few dedicated, committed people to do the job. We agreed to work on strengthening collaborations as Regional dental associations and dental schools.
Wednesday 6 October 2021
Today the Ministry of Health meeting was held. Two new policy documents were being discussed – the National Oral Health Policy and the Emergency and Critical Care Strategy. Though we were physically at the Crossroads Hotel in Lilongwe, most of the participants logged in virtually on the Zoom platform. At the meeting I got an opportunity to meet Dr Jones Masiye (Deputy Director Clinical Services – NCDIs and Mental Health) from the Ministry of Health and Dr Martha Chipanda (the newly appointed National Oral Health Coordinator). Dr Dube, the Chief of Health Services and a specialist paediatrician, brought the house to order and led with poise. In fact, what surprised me the most was how well versed she was with both policies and specialties, having clearly reviewed the draft documentation thoroughly. She had an intriguing depth of oral health intersectionality with other health disciplines, referencing relevant previous projects and documentation that had been run within the Ministry of Health, decades prior. She proved to have a wealth of knowledge and offered wise suggestions of what needed to be improved.
I couldn’t help but think, this is what we need in African countries – homegrown, innovative and contextually relevant solutions to the health challenges: eradication of the silo approach and integration of health services.
There were even discussions to incorporate oral health into emergency services. At the hospital the previous day it had been indicated that most of the surgical cases were Road Traffic Accidents (especially with motorbikes being on the rise as public transportation in Malawi), followed by tumours.
Thursday 7 October 2021
Today we travelled to Blantyre by road. James made a great tour guide, helping me discover more about Malawi. He even showed me the area where my mother’s paternal roots and heritage originate from, before migrating to Zimbabwe. This was really a life defining moment, as I always wanted to appreciate the land of my forefathers in Malawi, Ntcheu!
After a 5-hour road trip we arrived in Blantyre. No time was wasted as we went straight to the Queen Elizabeth Hospital. We toured the Dental Department and the rest of Queen Elizabeth Hospital. I had the privilege of seeing Mercy James Paediatric Hospital, a specialty facility that Madonna, in collaboration with various benefactors, built and named in honour of her daughter who she adopted from Malawi.
In there were benefactors close to my global health academic journey: the Beit trust who had sponsored my postgraduate studies at the University of Glasgow and NHS Greater Glasgow and Clyde, who were a frequent find in our studies and whose staff we interacted with a lot.
The highlight of the afternoon was James preparing his theatre list for the following day. I was present for all the case reviews. I was yet again impressed as dental therapy interns that had clerked the patients presented the patients, including differentials and provisional diagnosis, surgical and treatment management plans. What stood out was the early age of presentation of patients with benign and malignant tumors of the maxillofacial region – more than 4 of the cases were patients less than 24 years of age; some were even in their teens. A minority of the cases were trauma cases, the injuries having been sustained in road traffic accidents and assault cases. The staff helped me appreciate that the patients had travelled far and wide to be able to access these particular oral health services.
From the Hospital, we headed to Kamuzu University of Health Sciences Blantyre Campus. A quick tour of the institution helped me realise the outstanding work the Malawi and Glasgow team have been putting in equipping and establishing a world class dental training facility. Even though we had had an extremely busy and exhaustive day, it was productive and ended on an extremely high note!
Friday 8 October 2021
Friday commenced with a debriefing session with Peter and James at KUHES Blantyre Campus for the week’s activities and more. We ended our meet and said our goodbyes to each other and the other MalDent team members.
Aboard the return flight from Blantyre to Lilongwe my official itinerary was complete, with everything done and dusted. It was time to carry out in-depth personal reflections of my visit.
My reflections …
Though it is clear Malawi’s oral health workforce is inadequate, it is highly specialized. In Blantyre at Queen Elizabeth Central Hospital I spent the afternoon yesterday with Dr Mchenga and his team of dental therapy interns attending to the theatre list for the following day. The knowledge the interns had of OMFS was the standard of BDS finalists / interns. They even gave provisional diagnoses and treatment plans.
Prior to that I had been informed that due to the similar challenge of the Oral Healthcare Worker shortage, Dental Therapists are equipped in districts to perform minor surgical procedures such as inter-maxillary fixation, enucleations and the like.
For me, there is an emerging story to be told here. I reflect on home and realise that contrary to Malawi we have a large oral health workforce, but it is now concentrated in the urban areas, whilst the remote parts of the country are unserved. Most recently the BDS program has been restructured to become longer and internship for foreign trained dentists extended. The African region faces a clear shortage of practitioners, but the regulatory authorities continue to tighten training policies and increase the timeline to produce a Practitioner. It made me think, what is the motivation for these decisions? Are the decision makers informed of the situation on the ground? Do they consult oral health experts prior to imposing these decisions? Do they consider the plight of the candidates who take up the training who now have to invest 8-10 years of their time into undergraduate degree training without pay? At present, there already is a massive exodus of health practitioners. Where will we stand in a decade from now on oral health service delivery? In the meantime, the oral disease burden increases and lives are at risk.
Lessons from the visit to Malawi
Oral Healthcare Worker shortage is no excuse for not delivering services. Existent health workforce can be capacitated within the required field. Dental Surgery Assistants are non-existent in Malawi, but Central Hospital Dental Departments have RGNs from CSSDs manning infection control, disinfection and sterilization. Meeting a dental therapist who had pursued further training in anesthetics and worked in house with the OMFS was another revelation – a career path for a dental therapist that I had never thought of.
We need to think again about workforce models, because the traditional norms in developed countries do not work for low- and middle-income countries. In reality, there is now a realisation that they don’t work well for developed countries either, particularly as the need to address sustainability and planetary health has become an urgent imperative. There is an opportunity for countries like Malawi and Zimbabwe to develop and lead the way on new ways of working. I am excited to be part of it!
After a short break on the MalDent blog, we are delighted to be back with a guest post from Chifundo Banda, one of the pioneer cohort of Bachelor of Dental Surgery students at Kamuzu University of Health Sciences (KUHeS).
However, by way of preamble I would like to congratulate Drs James Mchenga and Peter Chimimba on the work they have been doing with colleagues to improve the clinical facilities available at the Dental Department of the Queen Elizabeth Hospital in Blantyre.
These improvements have included installation of some new dental chairs:
and the installation of a digital pan-oral radiography unit:
These enhancements to the infrastructure will be a great benefit to patients as well as to staff and future students and were part of the experience gained by Chifundo and his classmates when they visited recently.
I hope you enjoy Chifundo’s reflection!
My name is Chifundo Banda, a second year Dentistry student at the Kamuzu University of Health Sciences. I totally had no idea of what a Dental Department at a Central hospital looks like. On the 27th of October 2021, I had the privilege to visit the Dental department at Queen Elizabeth Central Hospital in Blantyre, Malawi. I was very eager to see and experience how the setup is like and how it operates. Everyone was excited and we were smartly dressed in our white lab coats, we really looked like Dentists. We were warmly welcomed by our Academic lead, Dr. J. Mchenga. We made a mistake by not arriving on time, and this was our first lesson that as Dentists we should always keep time. We also learnt that we should not just sit anywhere else because we do not know who was previously sitting there to minimize the risk of infection spread.
Our first room to go in is where extractions are done. The room is spacious with about 4 extraction units and it is well ventilated. I realized that the instruments that are used for extractions are kept in silver trays that are fully covered and each is classified according to its use. When one wants to get an instrument, they had to use forceps to minimize contamination. There was also a waste disposal bin and another one for sharps. We were lucky to see a little girl having her tooth extracted by one of the dental therapists. From there, we went to a room where surgeries like oral and maxillofacial surgery are performed. It is the best room that we ever visited; the paintings, equipment and ventilation made it look good. There were two Dental chairs fully equipped and each had a separate radiograph machine mounted on the wall that could easily be used to examine a patient while sited on the chair. It is a convenient room to work in with a patient. The drainage system itself was very perfect. There was a mobile suction machine ready for use in case the one mounted on the chair gets out of use. We were lucky that we had our first hands on experience by sitting on the dental chair, and using some of the things that are on it. While we were still there, we saw a boy with a swelling, probably a tumour on the left mandible who was with his guardians. Our academic lead, welcomed them warmly and they were helped. Every one of us realized that there is more to Dentistry than just teeth.
Our next station was the Dental laboratory for the hospital. I was wondering of what would we would find in the lab. To my surprise, I really confirmed that Dentistry is an art too. This is the lab where we make false teeth (crowns, bridges, veneers) and jaw impressions on our own. Materials like acrylics and plaster of Paris are used, I really liked the lab since I love art. We then entered another room that is under refurbishment. This is the one that will be used for paediatric dentistry when it is complete. Our academic lead told us that he wanted it be painted with beautiful drawings since children like them. We loved the idea.
Pertaining the issue of infection prevention, we were shown another room where all used dental instruments are sterilized using an autoclave and other cleaning machines. In order for a Dentist to make a good diagnosis, there is a need to use supporting equipment like radiographs. It is therefore a privilege that our department has a radiology room since if we depended on that for the whole hospital it would take long to get the results. We were amazed to learn that as part of our training we learn radiology so that we are able to interpret the results on our own. We also entered another room where all other Dental procedures like orthodontics, periodontics and prosthodontics are done. It was also fully equipped, I really felt that I was in a clinic.
Finally, at the entrance there is a plasma that is supposed to convey Dental related education to the people who come to the clinic but that was not the case. It is the therefore our responsibility as Dentists-in-training to come up with something to show up to the community. It was really a wonderful experience that I have ever had in my life and am looking forward to the completion of my degree so that I serve mankind.
As Chifundo and his colleagues look forward to the clinical dentistry components of their BDS course from next February onwards, it is not only the technical aspects of the profession they need to understand, but also the social and environmental context in which they will be serving their fellow Malawians. This latter aspect is a very strong component of all healthcare courses at KUHeS and for that reason students spend time living with a family in a rural area for several days to understand and see at first hand how the social determinants of health play a key role in disease prevention and access to care. This module is called ‘Learning by Living’ and will provide great benefit to dental students as part of their learning to be dentists who are not only ‘globally competent’ but also ‘locally relevant’.
Chifundo and his colleagues have recently completed the ‘Learning by Living’ module as part of their BDS 2 programme of study and we look forward in due course to their reflections on the experience.