“Thirty three” cried Anthony, the clinical officer leading the 6:45 a.m. prayer meeting. It was my first day at
Malamulo. The number referred to a specific hymn in the books that Dr. Santos had passed around.
There were five of us and the others all sang. As everything was in Chechewa, the local language, and
the fact that I’m Jewish, I kept quiet. After the first hymn ended Dr. Santos loudly chose, “One hundred.”
Everyone turned to the appropriate page and sang.
At this point, and now please don’t get me wrong, I truly mean no disrespect, but I couldn’t help
remembering the old joke about the guy who arrives in prison and hears other inmates yelling out different
numbers and then everyone laughing. When he asks his cellmate what the numbers mean, the guy says,
“We have all been here so long that we have memorized all the jokes so when someone wants to tell a joke
all they have to do is yell out the number and we all know what joke he is referring too.” So the new inmate
decides to try and yells out a number. “Twenty two!” he says, but no one responds. His cellmate turns to
him and mumbles, “I guess some people just don’t know how to tell a joke.” Well that’s the feeling I had. I’m
sure that after we finished with hymn 100 if I had called for hymn 22, the response would have been
something like, “Oh, we don’t sing that one.”
Anyway, that was my first introduction to Malamulo Seventh Day Adventist (SDA) Hospital. Dr. Beteta
Santos or just Dr. Beteta as everyone goes by their first name (I am known as Dr. Adam or sometimes Dr.
Adams) is an internist and the medical director of the hospital here in very rural southern Malawi. She and
her husband Leo are both originally from Mexico. She went to medical school there and practiced for a
number of years. Afterwards both she and Leo went to Guyana in South America for six years. They have
been working at Malamulo for two years and are planning to stay for a total of six. Leo is an engineer and
helps keep the place running.
The hospital is part of a larger mission that originally began as a leper colony in 1902. The hospital was
founded in 1915 and a clinical officer training school and nursing school with a current combined student
body of about 300 began in 1936. There are also primary and secondary schools and a publishing house.
At present the hospital has approximately 325 beds though the census is relatively light.
I arrived on a Sunday and Dr. Beteta and Leo met me at the bus station in Blantyre, the major city about
an hour’s drive to the north. This time I took a real luxury bus. There were reclining seats, air conditioning
and a stewardess who served bottles of Coke and small snacks. The movie was Mrs. Doubtfire and a
Lionel Ritchie tape kept playing in the background. The four hours went by quickly. Afterwards we drove
to the hospital and I was dropped off at the guest house. Dinner was on the table waiting for me.
At 6:30 the next morning Dr. Beteta met me and I accompanied her to the hospital. It is actually a very nice
place. Yes, I do qualify that statement with the fact that it’s a mission hospital in one of the world’s poorest
countries and probably wouldn’t be up to JACHO standards. However, all in all one would be pleasantly
surprised, especially in light of the conditions at the Lilongwe Central Hospital, which by the way, has been
renamed the Kamuzu Central Hospital (KCH) after the first Malawian president-for-life, Dr. Kamuzu
Hastings Banda. In fact, many things have been renamed “Kamuzu” including the Kamuzu International
Airport outside of Lilongwe.
The reason for the sudden change in names is that the new president, Bingu wa Mutharika ordered it. It
will be interesting to see what happens because it was the previous president Bakili Muluzi who changed
the names the first time and Bingu was supposed to be his hand picked successor. Luckily at this point,
Malawian politics are very stable – for an African country.
So, Malamulo SDA Hospital, by contrast to KCH has long cool hallways which are like covered paths with
red brick walls that are large open archways. It’s rather Mediterranean and invokes the image of old
Roman aqueducts. The grounds are well maintained and everything is green. The general ward rooms
are large with relatively few beds (8 to 10) and substantial nursing stations; and there is a paying patient
annex with semi-private and private rooms. The operating suite is excellent with two well sized operating
rooms and a minor procedure room complete with flexible endoscopy equipment. My hat’s off to Dr. Gilbert
Burnham for his design. One problem, however, is the lack of running water. To scrub for cases we have
water from buckets ladled on to ours hands. But the scrub sinks are first rate!
By the way, for those of you that don’t know, Dr. Gilbert Burnham is head of Refugee Health at Johns
Hopkins and one of my former professors. He spent 14 years in Malamulo and is credited with having the
vision to vastly improve the hospital and the medical training school for clinical officers, medical assistants
and nurses. I have met many people here who fondly remember Dr. Burnham and there is even a
Burnham Hall at the Medical College. The students are currently on their Christmas break but I have been
assured that there will be students to teach come January. Also of note is that as an internist, Dr.
Burnham did well over 500 caesarian sections and when I was at Hopkins he gave me some good advice
about working in Africa. He told me that one thing he learned from all the cases he operated on was that
“It is important to start with a blood pressure.” It may seem like very simplistic advice, but working here in
Africa it is actually quite relevant.
Now for our daily schedule we meet every morning at 6:45 a.m. to have a prayer session and then review
the admissions from the previous night. As a matter of fact prayer is a pretty big thing here. In addition to
the morning prayers, we pray before each operation and before we drive into town to the medical clinic in
Limbe. I guess I shouldn’t be surprised; it is after all a mission hospital. And let’s face it, I can’t see the
harm. I’m not sure it helps keep the wound infection rate down but maybe we should do a study.
In an effort to increase revenue to support the hospital a medical clinic was established in Limbe, the sister
city to Blantyre (the city north of the hospital). Patients are charged approximately US$ 4 for a
consultation and there is an in-house lab. Wednesday’s are my days to be at the clinic. The first session
was a bit slow, only four surgical patients showed but I had eight consultations the second week.
Wednesdays are also my day to check and send email. We don’t have internet access at the hospital -
not every part of the world has joined the World Wide Web.
It is nice going to Limbe and not solely because I can check email. The drive leaving Malamulo is stunning
as the mission is located in the heart of the tea growing region. These tea estates as they are called
cover vast tracts of land and driving out in the morning I was shocked to see what looked like emerald
carpets up and down the hillsides. My first impression was of a manicured golf course or even a giant
shag rug. On more careful inspection one actually sees small bushes of a uniform height of two to three
feet. I was puzzled until we rounded a bend and I saw more than a dozen men and women spread out in
rows along a field with large wicker baskets strapped to their backs. These were the tea pickers.
Watching them one can scarcely follow their hands as they feverishly pick only the uppermost leaves and
toss the tea over their shoulders and into their baskets. They collect the tea and effectively prune the
bushes. At intervals workers gather by the roadside to empty their baskets into sacks which are weighed
and then piled into waiting trucks. The entire scene seemed reminiscent of what cotton fields must have
been like in the late 19th century. Rows of workers strung out over a field filling sacs or baskets - being
paid by the pound.
Heading back to Malamulo in the afternoon I was awed by the colors. The deep greens of the trees and
the tea, the mountain silhouettes (Mulanje) off in the distance with shades of blue and grey draped with the
white of mist and fog. Women selling mangos and bananas squatting in front of small shacks wearing
brightly colored dresses and wrap around skits, some of the patterns reminding me of Hermes scarves. As
we turn off the main highway at Thyolo teenage boys run to the car windows and try to entice us with bright
yellow corn grilled to a golden brown. The twisting turning road then head back through more tea fields
occasionally affording views of the Shire River making its way down to the Zambezi. The drive to and from
Limbe is a wonderful way to begin and end the day.
As for things in Malamulo, the accommodations/guest house is quite nice. There is a caretaker/cook,
Jesiman, who looks after the place and cooks my meals. The food is pretty good, even if it is vegetarian.
The only problem is that water is rather intermittent so I’ve had to bathe using buckets of water. Electricity
has been on most of the time though outages are not infrequent.
The weather here has been fine, not to rub it in for those of you in the Northeast and Europe. But it’s
been in the upper 70s to low 80s every day and although it’s the rainy season it usually only rains for an
hour or so each day. The locals have begun planting maize (corn) and the stalks are about a foot high.
Sleeping with a fan at night is quite comfortable. The rainy season does intensify the mosquito problem but
it is aided by sleeping under a net, wearing long sleeve shirts and pants in the evening and using repellant.
My first week was a bit complicated due to a registration problem with the Malawi Medical Council. While I
was working in Lilongwe the council was aware of my presence and I had a temporary status.
Unfortunately, this was not transferable to Malamulo. The trouble really began after a notice appeared in
the Nation (a newspaper) announcing a visiting American general surgeon at Malamulo. The hospital
administrator was contacted and told that as I was not officially registered; I could not legally touch
patients. I halted my clinical work and immediately forwarded copies of my medical license, medical school,
residency and board certification diplomas along with copies of letters of appreciation from Dr. Muyco, the
Director of Lilongwe Central Hospital, and the Malawian Minister of Health. It took a few days, but once
they received the documents and US$ 200 I was allowed to practice legally, again.
So, what’s it like being the only surgeon at a mission hospital in Africa? Well, for starters being here at
Malamulo is probably not typical. First off, the facilities are much nicer than other places. In fact it is well
known that at one time Malamulo was the best hospital in Malawi. In fact in years past it was also the most
active and I’m told that they did the most surgery. However, things have changed. The cases are also
different from what I’ve experience before. It is more of an elective caseload. So far no trauma and only a
single sigmoid volvulus; although the season for that really begins in mid-January. Also we are relatively
close (one hour) to one of the major tertiary referral centers at Queen Elizabeth Hospital in Blantyre. This,
however, is a relatively recent change as the road from the mission to Thyolo, a town half way to Blantyre,
was paved a little over two years ago. The drive used to take about four hours and was impassible during
parts of the rainy season.
Clinically I am still constantly amazed (one would think that I would be used to it by now) at the differences
in practicing medicine here in Africa. I know I shouldn’t be shocked but I guess it’s the way my thought
process works here. What I mean is that when I hear about a patient having a fever I immediately think
about malaria; enlarged lymph nodes are probably TB; abdominal pain – typhoid; obstruction – sigmoid
volvulus or worms. For the non-medical types these are basically the diseases in U.S. medical school that
one sees as footnotes. Also the diagnostic tools we rely on so heavily back home are almost never
available here. Here I’m lucky if I can get a hematocrit, even luckier if I can get electrolytes. Forget the
liver function tests and other not-even-so esoteric things. I can’t actually remember ever seeing
coagulation studies. There is an ultrasound machine at the clinic, but not at the hospital. Here it really is
the history and physical exam which help you to make a diagnosis.
One must also constantly try to determine the best management options for patients who present with
advanced stages of disease or who have had other therapies performed, either by traditional healers or
other physicians. For example, a woman presented with right breast pain and palpable axillary lymph
nodes. Two weeks previously she had had the nodes biopsied but the results were not going to be back
for another six weeks. When I asked if she had had a mammogram, she said, “No.” She also complained
about right sided back pain. So I recommended a mammogram and a chest x-ray. Of course she returned
with the CXR which was normal and an ultrasound which didn’t shown any lesion (I had not felt one on
exam). She didn’t get the mammogram because it was too expensive. (Mammography is only performed at
Mwiawathu, the private hospital in Blantyre. The cost is about US$ 60, and then one has to take the films
to the only radiologist in town who charges US$ 20 for interpretation.) So for this patient, the plan is to
have her go to the histopathology lab and try to get the results of her biopsy back quicker. It does make
things difficult.
But fortunately I have been operating. Not as much as I initially anticipated, but given my licensing
problems and the holiday season it is to be expected; I have really only had three OR days. So far I’ve
done: a prostatectomy for BPH, resection of a very large cystic hygroma in a seventeen year old, a
mesosigmodopexy for sigmoid volvulus, an appendectomy, some skin grafts, a couple ganglion cyst
excisions, and a feeding tube. The surgical clinical officer, Mr. Banda, also taught me how to plate a tibial
fracture. It was interesting to see his technique in which a sterile drill bit was secured in a power drill which
a circulating nurse controlled. The nurse then drilled the holes in the bone for the screws. (Most people
usually get a sterile plastic bag and the surgeon does the drilling, but hey, whatever works, right?)
I’m hoping that as things progress I will be able to book more cases as the OR staff is very eager to work
and very helpful. However, since there hasn’t been a surgeon here for some time we need to get the
referrals up and running again. Hopefully this will happen well before I leave and especially before another
surgeon who is scheduled to arrive in January appears.
One other issue is that Malamulo charges patients for their care. There is a sliding scale for general ward,
semi-private and private with charges varying with each category. The overnight charge for the general
ward is 10 kwacha, about ten cents US, but some people can’t even afford that. But basically by doing big
cases for the patients in the private ward, I am also helping the hospital generate money which will be used
to keep the place running.
We have had about 10-15 surgical patients in-house and each day I see about twenty patients between
the ones in-house and new out-patient consults so I think my skills are being used. For the non-surgeons,
just because a surgeon is not in the operating room doesn’t mean he is not dealing with surgical issues,
remember, not every patient needs an operation. Even if, “a chance to cut is a chance to cure.”
A good deal of my work has also been to educate the staff in how to care for the patients and how to
improve conditions. One of my first tasks was to encourage people working in the operating room to wear
eye protection. On my first day when I asked if there were any visors I was told, yes, but as they were
disposable and they were not being used. I showed the OR staff that I bring my own disposable
mask/visors with me and I reuse them for many cases. So it was agreed to distribute the visors and reuse
them as well.
I’ve also instituted a weekly lecture following the morning prayers and handover on Thursdays. The
clinical officers and medical assistants picked the topics: breast, prostate, obstruction, ano/rectal, upper GI
and gallstones. So far it’s going well. I try to give them a way of approaching problems that is useful for
Malawi and then explain to them the way things are done in places with more resources such as the
States. The differences were really highlighted during the breast lecture. In Malawi, the workup basically
stops after history and physical exam. There is usually no mammography, fine needle or stereotactic core
biopsy, radiation or even chemotherapy. One can aspirate cysts, do an ultrasound, but if there is a mass
you need to operate and you may get the pathology back in a few months. There is also Tamoxifen, if the
patient can afford it.
As for some differences in operating here, first off there is no electro-cautery. There is a machine, but it’s
broken. Sutures are a bit of a problem. There was actually a better selection in Lilongwe, but that’s fine. I
just look at what’s available; no vicryl, fine, dexon. No 3-0, fine 2-0. It’s not always ideal, and I certainly
know what I would like to have, but hey, this is Africa and you do what you can. And usually everything
works out OK. At least I haven’t had a problem yet. Though when all the power cut out for about 15
minutes in the middle of excising the cystic hygroma, that…was suboptimal.
We have had a few gynecologic cases and one thing I regret is that I did not take more advantage of the
GYN consultants when I was last at KCH. I am going to try to scrub in on a few c-sections. The other thing
I need to do is to brush up on my orthopaedics. I’ve done a bit but certainly not enough. Too often in the
past I’ve been lazy and relied on clinical officers with more experience.
So overall things are fine, but I think that I will plan to head up to Lilongwe for a month or so after I finish
here the end of January. I really enjoy the trauma and emergency cases more that the elective stuff. Also,
I want to give a hand to Dr. Muyco who is back to his old tricks of operating three days a week even though
he underwent heart bypass surgery in July. He is really amazing. In addition it will be easier to get things
going on the SHARP project from Lilongwe. (and there’s also Harry’s Bar and volleyball)
Happy New Year to all,
Adam
A number of you have written asking if I was planning to head to Southeast Asia to help with the aftermath
of the tsunami. For a number of reason the answer is no. It’s not that I don’t wish to go and help; however,
firstly, I have given my word to the folks here at Malamulo that I would stay until the end of January. As it is
they are practically begging me to stay longer, some say I should stay for a year, others say five years.
Secondly, I don’t think there is much work for a surgeon in Indonesia. My understanding is that many of the
people drowned or were killed by falling houses and debris. Although I do remember reading about the
tsunami that hit Papua New Guinea a few years back and seem to recall that there were a significant
number of orthopaedic injuries with broken bones and such. The main issues, however, will be water and
sanitation, infectious diseases, and malnutrition. I also don’t want to forget the mental health aspect.
These people probably need psychiatrists and therapists more than they need surgeons. The last reason,
however, is that even though I have some feelers out, I wasn’t asked. If an aid group asked, I probably
would have gone.
So in light of the terrible conditions throughout the Indian Ocean, all is well in the land-locked country of
Malawi. For those of you who think that all I do here is suffer in horrible conditions and work at the hospital,
I just want to assure you that that is not the case. For Christmas Eve I enjoyed a very nice time at the
home of Dr. Leo Vigna and his wife “Chicki.” Leo is a general surgeon and Chicki is an anesthesiologist.
They are both originally from Argentina but spent 12 years at an Adventist mission hospital in Nepal. He’s
got some great stories about doing surgery there and at one point was almost competing with the folks at
Malamulo for USAID funding.
The Vignas moved to Malawi seven years ago and at first worked at the Blantyre Adventist Hospital but are
now at the Mwaiwathu Private Hospital in Blantyre. I met Leo at the surgery conference in Harare and he
was the one who informed me about the need for a surgeon at Malamulo. And by the way, Leo is the only
surgeon that I know who currently does Laparoscopic Cholecystectomies in Malawi. In fact, some might
think that Leo practices in an entirely different country. He’s interested in doing some gastric bypasses for
morbidly obese patients and he recently started doing liposuction (no joke) and charges by the pound
(joke).
On a more serious note, Leo is part of a group of doctors who are looking into getting a radiation oncology
center started in Malawi. It seems that Malawi just recently joined the International Atomic Energy Agency
(IAEA) and will now be able to import the necessary materials and equipment. There is a preliminary
meeting next week that I am also planning to attend.
It is amazing that even in a country as poor as Malawi there is a small group of relatively well off people
who either go abroad to South Africa, Europe or the States for their medical care; or they go to Mwaiwathu,
the private hospital. Mwaiwathu is a nice little facility that looks like it belongs somewhere in rural America.
There are 65 beds, nice ORs and an ICU. However, I’m told that their CT scanner is currently out of order,
as is the one at Queen’s (the government hospital), but there is still a scanner at Blatyre Adventist
Hospital. So at least there is still one working CT scan for a country with a population of 11 million.
Anyway, I joined Dr. Beteta, her husband Leo and their son, Harvey at the Vigna’s house for a wonderful
Christmas Eve dinner. I informed them that it was quite the contrast from the traditional New York Jewish
Christmas Eve which usually entails Chinese food and a movie.
The following day, Dr. Beteta called me early in the morning to ask if I wanted to join the family at Saturday
church service. I have learned that Seventh Day Adventists go to church on Saturday, the seventh day. It
was interesting. The service was in English with translation into Chichewa.
One other thing of note was a large tree near the church which I’m told is a “Livingstone Tree,” as in “Dr.
Livingston, I presume.” The great explorer/missionary supposedly rested under the tree. Now this would be
more remarkable except for the fact that just about every town in Malawi has a “Livingstone Tree.” It’s kind
of like the “Washington slept here” signs which dot the Northeast United States.
As Christmas and Boxing Day fell on a weekend this year, the following Monday and Tuesday were public
holidays. So with the hospital basically closed on December 27th and 28th, I ended up joining the Santos
family and we went to “the Lake.” We drove about 5 hours, roughly 300 kilometers to an area just north of
the town of Mangochi where there are a number of “resorts.” We joined up with a group of Filipino doctors
and their kids (about 21 in all) and spent two days and one night at “Sun ‘n’ Sand,” a not-too-bad but
rather run down Malawian “Club Med.” We stayed in large walk-in tents set up on platforms with a roof,
furnished with chairs out front, two twin beds, an end table and a lamp. All in all, not bad for US$13 a
person.
Back at the hospital there was a very nice end of the year party on December 30th. The entire hospital
staff gathered in a main dining hall. There were speeches, an awards ceremony, some games, and then
they handed out snacks of popcorn, cake and drinks. It was the first party I had ever been to which was
BYOC or “bring your own cup” as they served the drinks out of coolers, but didn’t provide any cups.
Luckily I was able to get a bottle of coke. (I hadn’t brought my own cup.) The best part, however, was that
everyone got an end of the year gift. The gift was a t-shirt, polo shirt or sweater with a Harley-Davidson
logo. The story is that these garments were part of a donation from a group in the U.S. that sent over two
40 foot containers of goods. One container had powdered milk, the other had battery powered
toothbrushes: 2,000 boxes with 48 toothbrushes in each. The clothing was also part of that shipment.
Now this whole donation thing always strikes me as a bit misguided. Yes, I think it’s great that some people
in Malawi can now get free battery powered toothbrushes, however, given the cost of shipping this stuff
over and the fact that the government allocates basically US$1 per person per year on health care, there
might, just might be a better use of the money that it cost to get the good over here. But, that’s a whole
different issue. I really should just say thanks for the toothbrush.
Anyway, my hospital gift was a bright orange t-shirt with “Classic” Harley-Davidson on the front and a
picture of Pike’s Peak on the back. It’s been rather interesting to see all the staff wearing their Harley
shirts around the place. It’s not quite Sturgis, but surprisingly made me think about Kuwait City. The
reason being that when I was there in May 2003 one of my colleagues had us running to the Harley-
Davidson store looking for gear for some of the more helpful folks up in Baghdad. It’s amazing what can
help grease the wheels in some settings.
Now for New Year’s Eve, one of the Filipino doctors has a party at his house in Blantyre. It was very
relaxed with lots of food. I also got to watch about a half hour of CNN. It’s was the only tsunami coverage I’
ve seen. As the internet at the hospital was not working and having no television or radio at the guest
house; I am a bit isolated.
As far as surgery goes, we have had a few more cases: another prostatectomy, some hernias, some
orthopeadic cases and a few emergencies. We also had a very sad case of a 14 year old girl with a huge
mass growing around her left eye. She had originally been treated at the government hospital but they
said they could no longer offer her any treatment. I sent her home at the beginning of the holidays and we
are now waiting for her to return to the hospital to try and do a palliative procedure.
The whole HIV/AIDS issue is also a bit different in these patients as opposed to the one’s I’ve taken care of
in Lilongwe. One thing which has come up is that some patients withhold the information that they are HIV
positive or that they are taking HIV medications, ARVs (anti-retrovirals). This is especially concerning with
patients with perianal diseases or other infected wounds in that surgery is the last thing you want to do in
many of these cases. Another thing is that we’ve had a number of patients when asked about medical
problem say they have diabetes. When we check their blood sugar it’s completely normal, and then we find
out that they are taking ARVs. Somehow, diabetes has become some sort of euphemism for have HIV. It’s
rather strange.
On a more positive note, awareness of HIV is certainly growing. Many patients now also show up and ask
to know their CD4 count, or request to begin taking ARVs.
Well, this Saturday is another holiday, John Chilembwe Day and so Monday is a public holiday. The plan
is to head into Blantyre for the weekend and also attend the wedding of one of the registrars from
Lilongwe, Carlos Varella. I’ve never been to a Malawian wedding so it should be interesting. I’m curious to
know how many cows he had to pay for the bride. A friend of mine got his wife for only one cow; amazingly
it’s been a few years and he still hasn’t paid up.
On Sunday the plan is to spend the night in Zomba, the old capital city, and then on Monday visit Liwonde
Park for a river boat ride to see hippos and elephants. After that it’s back to Malamulo. Next week I will
begin some formal teaching for the medical assistant and clinical officer students. I’ve decided to give
them a version of the trauma program that was so successful in Nicaragua.
I will probably be at Malamulo for another week or so and then the plan is to head up to Lilongwe for about
a month. After that, possibly up to Tanzania and maybe Kilimanjaro. As for when I’ll be back in the States; I’
m not certain at the moment. I’ve got a flight scheduled for March 9th, but that could always change.
And for those of you who voiced concern about my comment of maybe having to get a real job, fear not, it’
s certainly not imminent. (Sorry Mom)
All the best,
Adam
In May 2003, an Iraqi physician in Nasiriyah told me that "during the invasion, my patients could not get
chemotherapy." I empathized with him, but at the same time thought about Malawi. I had just recently
returned from three months at the Lilongwe Central Hospital where, on a daily basis, we faced many
cancer patients and the complete lack of both chemo and radiation therapy. I was a bit taken aback by the
Iraqi doctor’s comments; but I did realize that Iraq and Malawi were two vastly different situations; so I kept
my thoughts to myself.
But it did amaze me. There was Malawi, a country of 11 million people without the ability to provide proper
oncologic (cancer) therapy for the thousands of patients each year who develop cancer. We operated on
the ones that we could, mainly for palliation, and the rest just went home to die. A lucky (and relatively
wealthy) few went to Zimbabwe or South Africa for chemo or radiation therapy.
For this reason it was exciting to be in the boardroom at the Mwaiwathu Hospital last Wednesday evening.
Sixteen of us were seated around the conference table and represented a variety of interests. Attendees
included Aleki Banda, who was formerly both the Minster of Health and Minister of Agriculture and who is
currently a Member of Parliament (some of you may also remember that I helped operate on him after he
was injured in a car accident a few years ago); a prominent local lawyer; an architect; the President and
Vice President of the Lions Club of Blantyre; and the head of a large local bank. From the medical side
there was a representative of the Ministry of Health; representatives from the Malawi College of Medicine
including; an internist, a pediatric oncologist, three OB/GYNs, a pathologist; and for surgeons, Dr. Leo
Vigna (who is the driving force behind the project) and me.
The meeting was to initiate the establishment of a non-profit trust to create and run a national cancer
center. The trust will not be a government run institution. The plan is to build a facility in Blantyre and
charge those patients who can afford to pay and provide free treatment for those that can not. Once the
trust is formed plans will proceed to build a facility, procure the necessary equipment, and begin training a
staff.
In discussing the issues involved, we realized that one possible source of funding will be the United
National Global Fund for HIV/AIDS. Currently half of all cancers in Malawi are HIV related and with an
estimated 900,000 HIV positive persons in Malawi the number of patients that will need radiation for cure or
palliation is enormous. Data suggests that almost 30% of HIV positive patients will ultimately die of a
malignancy, including Kaposi’s sarcoma, cervical cancer or Non-Hodgkin’s lymphoma; many of these
cancers can be treated with radiation; unfortunately in Malawi many of these patients are just sent home to
die a slow and painful death.
The plan is to have the legal documents for the trust drawn up and then meet again in three weeks to
appoint the trustees and establish working sub-committees. We are also looking to possibly pair up with an
oncology program in the States or Europe as there will be a need to train oncologists, physicists and other
technicians.
It will be interesting to see where this leads.
On the surgery front, last Thursday I assisted Dr. Vigna in operating on a 24 year old guy who had been
involved in a serious car accident last year and ended up in the Intensive Care Unit at another hospital. He
had been kept on a ventilator for a long time and the result was a stricture (narrowing) of his trachea
(windpipe) and severe difficulty breathing. This is a well known and feared complication of intubation and
while prevention is the best option, the only way to treat it once it occurs is to cut out the diseased part of
the trachea and then sew the remaining ends together. It may sound like a pretty simple operation but it is
actually a fairly complex case. When Leo asked if I was available to help, I immediately agreed. It’s one of
those cases I really can’t imagine doing with only a scrub nurse as an assistant.
Anyway, the case was a success. For the non-docs I apologize for the following but it’s just too difficult to
describe in English. The lesion was fairly high, extending from just below the cricoid for about 3
centimeters. We started with a cervical incision under local and then did a partial sternotomy for more
exposure. Once we cut the distal end of the trachea we were able to use an ET tube and relax a bit. After
resecting the diseased portion is was a bit unsettling to stare at the empty space where there is no trachea
and with the neck hyper-extended. As always, the trick is to do the anastamosis with minimal tension.
There are a few tricks to gain length including freeing the inferior pulmonary ligament or mobilizing the
right hilum. Another option would have been to incise the hyoid and bring the entire larynx down, that
supposedly gains you 2 centimeters if you need it. Lucky we were able to get the ends reapproximated with
minimal difficulty. We ended by placing two big nylon stitches into his chin and securing them to his chest
wall. We extubated him post-op and currently he is doing well. Oh and for those of you that are curious,
anesthesia was excellent, the only problem was that since the anesthesia machine is broken someone had
to hand bag the patient the entire time he was intubated; but it worked. And again, I couldn’t imagine doing
something like that alone, but Leo does his esophageal resections by himself, the same for Dr. Muyco, it’s
really amazing.
Meanwhile, back at the mission hospital, all is well. We’ve has some interesting cases, but by no means
anywhere near the volume that I saw in Lilongwe. In fact, in the six weeks that I’ve been here I’ve only been
called into the hospital three times at night, never to operate, and never after 10 p.m.
The trauma presentation went very well, although I must say it was quite a bit different from the program in
Nicaragua in that I didn’t have the benefit of the two fine translators, Melba and Susan to laugh with.
And so how was the wedding? I’m sure someone is curious to know it went. Well…, a Malawian wedding; it
has a certain ring to it. I thought it would be interesting, and maybe even fun. I can certainly comment on
the interesting part. Part of me wasn’t actually surprised. I had been warned to bring plenty of small bills, a
stack of 10 and 20 Kwacha notes (exchange rate: 115 Malawian Kwacha = US$ 1); and the fact that the
entire Malamulo College of Medicine staff was included on an invitation should also have been a give
away. But hey, it was for Carlos the registrar I had worked with last February in Lilongwe, and besides
some of the folks from KCH were coming down, including Arturo and Amy Muyco.
The invitation stated that things were to begin on Saturday at 2 p.m. at the Limbe Cathedral. Well, Dr.
Muyco and I got there a bit after 2, expecting things to be getting underway, but it was quite; too quite.
After waiting around for 10 minutes we saw a copy of the program and of course things were to begin at 3
p.m. So we waited. The folks from KCH arrived; a few operating room nurses and Ivan, the Russian UN
volunteer surgeon. At 2:45 the groom arrived in a white Mercedes; at 3:15 the bride. The ceremony began
at 3:30; not bad by African time standards.
Overall the ceremony was quite the experience of sights and sounds and…smells. The Cathedral is the
largest in Malawi and was built in 1928. It’s fairly typical in design and probably holds about 500 plus
people. The interior colors were an interesting choice of light purple/blue offset with dark yellow/orange.
Off to the left was the choir from the church secondary school, to the right were a dozen men dressed in
leopard skin hats and kilts, one even carrying a hide shield (they would intermittently join the singing or
give out loud shouts.). As for the music, although I realize that catholic services are no longer conducted in
Latin, and I did expect things to be in Chichewa, I didn’t expect the singing to have an African/reggae beat
complete with accompanying drums. Other sounds came from the two year old boy sitting right behind me
who cooed, babbled, cried, screamed and otherwise made some type of noise for the entirety of the
service. As for smells, just to complete the picture; let’s just say I don’t think the man that sat next to me
has ever met a bar of soap.
But it was fine. The service ended a little after 5 p.m. and then we went to the reception hall, held at the
trade convention center, a popular wedding venue. Inside there were a few tables in the front and then
rows and rows of seats, approximately 500 or 600. Now on the invitation it said that the reception began at
6 so I figured it would be a wait, and in this I was not disappointed. Things didn’t get started until 8 p.m.
The bridesmaids and groomsmen entered down the center aisle with a band playing music with an African
beat. Then the bride and groom arrived. Then the real fun began. There was an Emcee. And he began to
call up groups of people. Friends of Carlos, friends of Amanda, all men, all women, people who work with
Carlos, people who work with Amanda and on and on. Now when these groups were called up they were
supposed to toss money into baskets that had been placed in the front. The whole thing had a bit of a
telethon/game show feeling. The reason to bring the small bills is that you are expected to toss some cash
every time you go up. They actually have a group of women who act as cashiers and they keep a tally of
the take. I also learned later that the Emcee gets 10% of what is collected. Now all this happens and is
actually in addition to the gift you are supposed to give the bride and groom. And in return, the guests
get…maybe a small piece of cake and a drink, maybe.
Luckily for me Dr. Vigna was also invited. I say lucky for me, because he left around 9 p.m. and I escaped
with him. I’m told that the thing usually goes on until the early morning hours. But by the time we left I was
hungry and running out of small change. I had also been throwing US$ 1 bills into the mix. I figured it would
give the counters something different to contend with.
So, Malawian wedding: been there, done that. No need to go back. Oh, and I never did find out how many
cows she cost.
Anyway, the plan is still to head up to Lilongwe in a week or so to work at KCH and get things going on the
SHARP project.
Best to all,
Adam
Although a fair amount has happened since the last update, the most significant item is my decision to go
in mid-March to Indonesia with the International Rescue Committee (IRC). The IRC is a large American
humanitarian organization that is doing post-Tsunami relief work around Banda Aceh. I will be joining them
for two months as a health manager. This will not be a surgical position but will entail helping with the
reconstruction of the health sector and training local health care workers. If I can get email access, I will
continue with the updates.
As for the past five weeks, I left Malamulo on January 25th and took a bus through Mozambique and
Zimbabwe to Durban, South Africa. I decided that before going to Lilongwe to help out at the Kamuzu
Central Hospital (KCH) I would buy a car. Having spoken to a number of people I was advised that my best
bet would be to take a bus to Durban, buy one of the used Japanese imports and then drive it back to
Malawi. It sounded simple enough. So, I decided to give it a go. Well…let’s just say on paper it’s a pretty
simple process. In actuality I got a whole education in buying and importing used cars, dealing with the
African economy and bureaucracy, but did get to go on an interesting 1,800 mile road trip through South
Africa, Zimbabwe and Mozambique. Some of the highlights were spending a night in Kruger National Park
and then spending the next night in my car at the Zimbabwe border because the computers for the
customs authority were down. All in all I did, however, manage to buy a very nice Toyota Caldina which is a
sporty station wagon, fully loaded with CD player and air conditioning. Would I do it all again? I’m not sure.
Was it worth it? Well, kinda. It probably cost me about as much if not more than buying a car in Malawi,
plus all the aggravation and frustration would have been avoided, but in retrospect I’m sorta glad I did it. I
am planning to keep the car here in Malawi for when I return. I may in the future decide to sell it and as it’s
a really nice car probably get all of my money back. By the way, if anyone wants, just send me an email
and I will forward the whole story once it’s written.