Plumes of red dust are kicked into the air as an ambulance rumbles along a pockmarked dirt road.

Below Mount Mulanje people are working in the fields hoping for a better crop than the year past. In Malawi, hunger is only ever one bad harvest away.

For the last 20 minutes, there have been no road signs or obvious markers until nurse Annie Kaseka spots a child by the roadside ushering them towards Margaret Makhunya's home.

Margaret is one of many vulnerable patients being looked after by palliative care staff at Mulanje Mission Hospital (MMH), a project supported, in part, by a group of Scottish missionaries.

The hospital was founded by the Church of Scotland and has a history which can be traced back to those who followed in the footsteps of explorer and medic David Livingstone.

For the last 175 years, Scottish charity EMMS International has been working to improve health in some of the poorest countries in the world.

Today, they are involved in a palliative care project at three hospitals in Malawi.

Annie steps out of the ambulance and into the searing midday sun, shielding her eyes as she catches sight of Margaret walking towards her barefoot.

"I can see a great change," Annie says.

"Before she was crawling and now she is standing up and walking by herself. That feels good."

The 24-year-old has Kaposi's sarcoma, a common cancer in Malawi that usually affects the skin and mouth.

When Annie last visited, the mother-of-two was in severe pain and unable to move her leg, let alone walk.

Following chemotherapy and pain relief, she now walks slowly back to her front door to join her mother under the shade of their straw-roofed home.

As Annie and Margaret chat, Limbikani examines the case notes.

"In Margaret's case, she is improving so we are very happy," he said.

"Where the hospital cannot do anything, palliative care should be able to help.

"We take her through the difficult times."

The World Health Organisation estimates six million people die from cancer around the world with little or no pain relief every year.

In Malawi, the palliative care needs are even greater because of the scale of HIV, with a UNAIDS Gap Report showing Malawi's HIV prevalence as one of the highest in the world.

That is why, as medical director Ruth Shakespeare explains, the Mulanje Mission Hospital has been pioneering in palliative care for over a decade.

"If you really want to build up a full service in the whole country, then you need to have much more access to training," Ruth says, walking around the hospital grounds she has called home for the last five years.

"Palliative care can be about anything, from providing a mattress to someone who is now bed-bound and hasn't got one in the community. It can be about providing foodstuffs, it can be about providing a wheelchair so they can go out.

"It is mostly about looking after people in their own homes.

"A lot of the diseases we are talking about are very, very painful diseases to be suffering. So pain control is an enormous part of it."

A project being match-funded by the UK Government - Malawian Education and Training for HIV and Other Diseases (METHOD) - aims to grow palliative care across Malawi and provide degree-level training near Blantyre for nurses and clinical officers, avoiding the previous difficulties of travelling to Uganda.

Margaret is no longer in intense pain but is still unable to work in the fields and grow crops to feed her family, with no benefits systems in place to help her.

Fortified porridge is asked for and a prescription is written. Then, the conversation and laughter flows. Time is not timed.

"It is a human right to be without pain." says Edinburgh's Cathy Ratcliff, director of international programmes at EMMS International.

"The thing about palliative care is that it is holistic and goes beyond the patient," she adds. "It is looking after families before and after the death.

"It is about giving them back a pleasant life and making sure they can be clean and nicely dressed so they can sit outside and watch their children play."

As the ambulance travels back to the hospital to a waiting queue of patients, Annie smiles content with Margaret's dramatic improvement.

"By caring for them, you see them improving and you get encouraged," she says.

"The family can tell you what the patient cannot explain.

"They feel worthy for you to visit them."

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