Malawi Update 1:
Greetings from Malawi!
Last June, while still a surgery resident in San Antonio, I went to a conference on landmine injuries. One
lecture was given by Dr. Steven Mannion, a former British Army orthopaedic surgeon, who had recently
returned from an assessment in Afghanistan. He spoke about cluster bombs and the conditions at a Kabul
medical school; he also mentioned that his current job was as one of the only three orthopaedic surgeons in
the African country of Malawi, a nation with a population of 12 million. During his presentation he mentioned
that the annual per capita health care expenditure by the Afghani government was US$3. He followed up by
saying that Malawi was even worse with an estimated US$1 per person per year. I was immediately intrigued.
During the break I spoke to Steve and asked him if there was a need for general surgeons in Malawi. He said,
“Absolutely,” and agreed to speak with Dr. Arturo Muyco, Chief of Surgery at the Lilongwe Central Hospital
(LCH), the only referral center for the five million people living in central Malawi. Steve and I traded emails in
June and I agreed to contact him after I sat for my boards in October.
In late November I received an email stating that there was now a crisis at LCH. Things had gone from really
bad to even worse. He related that where previously two general surgeons had worked in the hospital; one had
just left, and now only Dr. Muyco was covering. I was also informed that Dr. Muyco was 77 years old. They
wanted to know if I was still interested in working in Malawi. This time it was my turn to respond, “Absolutely,”
and well, two weeks later, here I am.
As a bit of background for those who don’t know (I certainly didn’t). Malawi is a southern African country and is
often referred to as, “The Warm Heart of Africa.” The country was originally under British rule and called
Nyasaland until the mid-1960s when Dr. Kamuzu Hastings Banda took control. He ruled as a dictator until 1994
after which time there were popular elections and the current president, Bakili Muluzi, was elected. The current
president has already served two terms and the constitution limits another term; however, in that wonderful
African tradition - he is now seeking a third term. There were some demonstrations in the south a few weeks
ago, but currently everything is very quiet. That of course may change depending upon how this third term
issue goes.
During Dr. Banda’s time, he is credited with trying to keep much of the population out of the cities, saying that it
would only lead to poverty. Cynics say it is also easier to limit organized opposition that way. The result,
however, is that the majority of people (85%) live in the country-side. Poverty is terrible, however, as this is an
agrarian based society many people grow their own crops and there is a definite lack of the urban poverty and
squalor so common in many third world cities.
There is no real industrial base in Malawi and the main exports are tea and tobacco. Obviously falling prices
and a decrease in cigarette smoking doesn’t directly help these people. Just for the record the annual per
capita GDP for Malawi is US$ 190 (2000).
To make matters worse, there has also been a reported food shortage and famine. From what I’ve been told
the issue with the famine appears partially to be a distribution problem. There was reportedly a government
surplus of food supplies which was sold to neighboring countries and then was not available at the time of
crisis. Steve was telling me he first noticed a problem last February (2002) just before the harvest in April. He
started to see many panga injuries to people’s fingers and hands and an increased number of amputations.
Pangas are a type of machete. The number of cases rose to around six or more a day and the patients where
not the usual thugs one would expect to see, but malnourished and very poor older males. It seems that the
villagers were starving and raiding their neighbor’s food supplies; the panga wounds were their punishment.
This phenomenon has now stopped; however, we are again nearing the end of the planting season so it will be
interesting to see what happens in February.
As for me, finding food hasn’t been a problem. (Oh, but thanks to everyone who recommended I bring Power
Bars, they did come in handy when I was taken with a bout of gastroenterititis for a few days and didn’t leave my
room).
In terms of my situation, I arrived in Lilongwe, the Malawian capital, around 1 p.m. on Friday December 13,
2003, and was met by Steve and his girlfriend Mercy and we immediately left for the southern town of Zomba. In
Zomba we met up with Nadir, a Palestinian anesthesiologist who had recently moved from Lilongwe. We had a
great dinner of Zimbabwean T-bone steaks and Carlsberg beers. We stayed that night at the Le Meridien
Kuchawa resort hotel high atop the Zomba Plateau with a spectacular view overlooking the plains.
The next day we drove to Blantyre, “the economic capital” of Malawi. Like Lilongwe it has a population of about
400,000, is spread out, and fairly clean. We went shopping at the local Shoprite supermarket. And I kid you
not, it was a well, I mean well stocked supermarket. We got T-bones, French wine, hot dogs, Heinz beans,
fruits, potato chips, and other goodies and then headed south for the town of Mulanje at the base of Mount
Mulanje, the highest mountain in the region reaching just over 3000 meters (9000 feet).
The plan was to climb the lower part of Mount Mulanje and stay overnight at the Chamba Hut. We hired two
young local porters to carry our supplies and the five of us: Steve, Mercy, Lori (a friend of Mercy’s), Nadir and I,
started up the trail. Under most circumstances, except for recently flying 7,000 miles and the very steep climb
for the first three hours, the hike would have been fine. However, the fact that we started at 5 p.m., and that it
got dark at 7:30, and then the pouring rain which began at 9:30, made for a less than pleasurable experience.
Steve, the two local girls and one porter went on ahead and started cooking dinner. Nadir and I struggled up
the mountain. Along the way I thought to myself that there must be a joke in this somewhere, “One night in the
pouring rain a Jewish surgeon and a Palestinian anesthesiologist climb a mountain in Africa….” At 10 p.m. we
finally reached the cabin. The T-bones were excellent. The next day we painfully hiked back down the trail and
spent the night in Blantyre. On Monday we drove back to Lilongwe.
The Malawian countryside is lush and beautiful. Many people sell fruit and vegetables along the side of the
road. After a while I almost got used to the large numbers of women carrying large bundles or baskets on their
head. It’s funny, but it really looks like Africa. I am not sure what I expected, but the scenery here is different; it
is African.
As for the medical scene in Lilongwe, it’s interesting to say the least. In some ways it’s much better than I
imagined. In some ways, it’s what I thought. LCH is a 600 bed hospital, however, the director said the other
day there was a census of about 1000 patients. It’s what I’ve seen before; open wards with eight to ten beds,
sometime two patients to a bed, often people sleeping on the floor, and families waiting and eating in the
hallways. There are also the chronic wounds, soiled bandages, and flies.
The hospital has four floors divided into Wards A and B, and a pediatric department. I’ve been concentrating on
the surgical patients in Wards IA, IB, 4A, 4B and pediatrics. Dr Muyco was away in Johannesburg, South Africa
for a few weeks while his wife was ill; he is now back and we have started operating with a full schedule.
Dr.Muyco does an incredible job as the only surgeon at LCH. He is originally from the Philippines and was
trained in the U.S. He came to Malawi 19 years ago to retire after a full career in the Philippines and has work
at LCH ever since. As far as other staff, there is one surgery registrar; he had four years of medical school
training, a one year internship and one year of clinical surgery. There is also a senior clinical officer and five
clinical house officers equivalent to interns. The registrar and the senior clinical officer take second call and
had been operating independently while Dr. Muyco was away. They are pretty good at repairing hernias and
doing bowel resections by themselves. This is a good thing given that we see at least one strangulated hernia
per day and most arrive late and need a resection. Trauma is also a major problem here and clinical diagnosis
is a major part of the work up. There is one ultrasound machine during the day, but it is not available at night.
There is no CT scan in Lilongwe (though there are two in Blantyre).
A big problem is the lack of adequate nursing care on the general ward. I’ve been trying to do some major
teaching because it seems that patients in shock (blood pressures in the 80’s) are frequently being sent by the
clinical officers directly to the general wards. Not surprisingly these patients often die on arrival to the ward. I’
ve now seen it happen twice in one week. Now I don’t know if these patients are salvageable, however, things
need to be tightened up.
Starting Monday (December 23rd) I will take call. I have emphasized to the clinical officers that I want to be
called about every admission; we will see what happens. When Dr. Muyco and I made rounds this afternoon, a
nurse took me to see one of the new admissions; he was reportedly vomiting blood, had esophageal varicies,
and was gasping for breath. I walk into the room and not surprisingly, the patient was already dead. No vital
signs had been recorded in the paperwork. When I questioned the clinical officer he said he knew the patient
was pale and had a weak pulse and needed blood. Again, I don’t know if this patient could have been saved,
but we need to do better with stabilization and resuscitation.
One nice thing about LCH is the four bed intensive care unit (ICU). At the moment all four beds are occupied.
The Taiwanese Embassy donated some equipment the other day, so there are now two additional ventilators.
Of note as well, the US embassy donated US$ 250,000 which is being used to create a new emergency
department and trauma unit. (This project began in the wake of the bombings in Nairobi and Dar es Salaam
with US Department of Defense funds.) The trauma unit will be able to accommodate 15 beds. Of course there
are also the issues of equipping stock the unit and finding qualified people to work there.
Another problem is that the only urologist also recently left LCH. Dr. Muyco and I are now left to care for the 40
plus urology patients in addition to the 50 plus general surgery patients. The other day I scrubbed on a
prostatectomy; it doesn’t look too difficult. Hopefully I’ll soon be doing these cases with the clinical officers; we’
ve got almost a dozen patients waiting to have this procedure.
The case load is pretty unbelievable. As this is the only referral hospital for two thirds of the country many of
the complex cases are referred here. On Friday we did 18 cases by 4 p.m., not too bad with only three
operating rooms running. (We would have had difficulty doing that in San Antonio.) The cases ranged from
simple incision and drainage of abscesses and lipomas, to pediatric hernias, incarcerated umbilical hernias, a V-
P shunt in an infant, a prostatectomy, and an ex-lap for trauma. We cancelled a possible resection of a Wilm’s
tumor because the pt was not fully worked up. LCH is also pretty much the only place for pediatric surgery and
they do a lot for imperforate anus (we have two patients waiting), Hirschprung’s, and the like.
On Monday, general surgery has two room and we have posted about a dozen cases. We will be doing a few
prostatectomies, a massive submandibular mass, a few hernias, a skin graft for a burn, and some I&Ds (I may
have found a place with more pus than San Antonio, but it may be a tie).
One question I’m sure many are asking is what about HIV? Well, it is a problem. But I haven’t changed my
procedures too much. I’m double gloving; we closely watch all sharps, and I make sure to use proper eye
protection. As for equipment, we have electrocautery, suction and a limited supply of vicryl, silk, and nylon
sutures.
There are of course some glaring differences in the way medicine is practiced here. This goes way beyond the
lack of a CT scanner. I saw a woman with an advanced breast cancer with a large fungating mass. The
resident said she was scheduled for a mastectomy. I agreed, but asked him if he knew what the board answer
was back in the States. He did not. I told him that it was pre-operative chemotherapy and radiation, then a
mastectomy. Well, they don’t have chemo or radiation therapy in Malawi, so mastectomy it is, oh and it also
takes about 3 months to get pathology results here. Really 3 months.
On a closing almost humorous note, the other day Dr. Muyco and I rounded on a patient and while reading the
operative note saw that it mentioned a cecal tumor with seeding in the peritoneum consistent with
carcinomatosis. We could not find anyone who had scrubbed on the case, but on questioning the patient he
said he had not been feeling well for a few months and that he had had persistent fevers. Dr. Muyco felt that
this might actually be a case of abdominal tuberculosis with a mass in the intestine. I said that I guess that could
be possible, although I had never seen a case and wouldn’t have thought about that specific diagnosis. We
brought the case up with the registrar who agreed with Dr. Muyco and stated matter of factly, “Well, common
things being common.” I just laughed thinking that the diagnosis of abdominal TB was considered common.
But then again this being Africa, when you hear hoof beats… it might just be a zebra.
Happy New Year and best to all!
Malawi Update 2
Three liters of pus. And the smell. Those of you that have smelled it know, those of you that haven’t, can’t
even imagine. Saturday while I was on call, we had a patient present to the hospital. He was 35 years old and
had had ten days of abdominal pain. His abdomen was distended and tender, the x-ray looked like fluid or
ascites, a tap showed pus. We explored him and found a perforated Meckel’s diverticulum, multiple abscesses
and a necrotic looking cecum. I was operating with the registrar and he just wanted to ligate the Meckel’s.
Instead we did a right hemicolectomy and an ileostomy. He’s now doing fine out on the general ward.
It really has been amazing over the last few weeks. I know they say things always present at a later stage in the
Third World, but this is ridiculous. We had a woman present with a massive thyroid goiter, about the size of
football. An old man presented with a strangulated hernia after three days of pain, we had to resect some small
bowel. Another guy presented with basically his entire small bowel in his scrotum. We had to resect a good
portion of small bowel but left him with his ileocecal valve and enough small intestine to survive.
The cases have been great from a surgical point of view, but have also been some of the most challenging that
I have ever seen. We had a woman with horrendous post-operative adhesions. In addition she was a Jehova’
s witness. I scrubbed in late on the case (there was a problem getting gloves) and the registrar had gotten into
some bleeding. Luckily I was able to stop the bleeding and teach the registrar some new techniques.
Over a three day period we had three cases of midgut volvulus (twisting of the small intestine) without a
malrotation. I had never seen a single case before, but it’s apparently quite common here. We were able to
lyse the adhesions in two, but one was necrotic and we had to do a small bowel resection.
Other cases have included a throacotomy and decorticiation for a patient who was transferred from a district
hospital late after a stab wound and a chest tube failed to drain him adequately and expand his lung, a bunch
of mastectomies for large fungating breast cancers, two perforated duodenal ulcers, one that presented after
three days, was resuscitated but arrested on the table. We got him back with some adrenaline (epi for those
from the US) and chest compressions. He also had a few liters of pus in his abdomen; we did a quick Graham
Patch, abdominal irrigation, and got him to the ICU.
I also did my first prostatectomy. It really wasn’t too difficult. The guy has done great and has gone home.
They do it transvesicularly here (through the bladder). I had never seen it done that way, but it seems to work
well. We had some problems because they had run out of three-way Foley’s, but we managed with two regular
catheters, one for irrigation and one for drainage.
As for running out of supplies, there is currently no gauze in the hospital. Yes, that right, no gauze. I was
rounding on Saturday and the nurse did not want me to remove the soiled dressings because she said there
was no more gauze. I had to do a little teaching. We also have no formalin for biopsy specimens, so most
cases requiring a biopsy have been put on hold.
Luckily for the moment we haven’t had too much operative trauma. We managed a renal injury and a liver
injury conservatively, both have done well. We had a nasty Panga injury to a guy’s face, it sliced down from his
forehead, through his frontal sinus, across the bridge of his nose and stopped just short of his lip. We took him
to the OR and washed and closed it, he also has done very well. The amazing thing about that case, was that I
saw him in the ER, made the decision to go to the OR, rounded for twenty minutes and by that time he was
already in the OR. Amazingly on some levels this place functions better than some of the hospitals I trained at
in San Antonio. That day I was also going to repair a guy’s tendons in his arm that had been severed by a
Panga, but the ortho guys saw it and did it instead.
This week we did a fair number of pediatric cases. We did a pull through for a child with an imperforate anus, a
right hemicolectomy in a child with a fistula from an ileal perforation that had been initially just repaired
primarily, resected a sacro-coxygeal teratoma and did a right hemicolectomy on a child with a large abdominal
mass that turned out to be in the ascending colon. We are starting to get caught up on the pediatric cases with
only two more imperforate anus babies, a child with a meningeocele, a child that needs a colostomy revised for
prolapse, and a child that needs a V-P shunt. Last weekend I also did a pyloromyotomy on a two month old.
Needless to say the surgical experience has been great. We did a vagotomy and pyloroplasty on Wednesday
along with an open cholecystectomy (there is no laparoscopic surgery here.) There are also a few
esophagectomies in the pike, a large abdominal mass in a 25 year old, a maxillectomy and a few thyroids. That’
s in addition to the routine hernias, I&Ds, node biopsies, mastectomies, and breast biopsies.
On a positive note the Ministry of Health just delivered two new major laparotomy sets, two minor sets, one
craniotomy set, and a bunch of other instruments. Dr. Muyco mentioned that it was the first new equipment he’
s seen since he got there, nineteen years ago and the hospital has only been around for twenty-six years. So
at least we have new instruments. I was getting tired of the hemostats that didn’t really work too well. So just
because there is no gauze and at times only one nurse per-ward (about 75 patients), things could always be
worse.
As far as dealing with deaths and complications, I have instituted a weekly Morbidity and Mortality Conference
instead of just talking about the deaths only once a month. The registrar was at first a little confused, saying,
but we only have about 20 deaths a month. I have tried to tell them that preventable deaths are not acceptable
and that we need to discuss all the deaths and complications to learn what went wrong and how we can improve
in the future. They are slowly starting to understand. We have also organized the clinical officers a little better
into three services (Peds, Male, and Female) and Dr. Muyco and I are making rounds more regularly and often
twice a day.
Anyway, I apologize to those of you who find the above too technical and so for those of you who prefer
Survivor to ER, the rest will be in English.
Some of you wrote me about seeing an article in the New York Times about Vampires in Malawi. I saw it on the
NYT website; there were actually two articles on 12/24 and 12/29. The deal it seems is that there are some
people down in the south of the country, in the places near where I was hiking, that have been doing some
blood letting and the like for supposed satanic purposes. Rumors started flying and then the President of the
country made the matter worse when he made a comment about it and said that, “the government was not
sucking the blood of the people.” Anyway, it was interesting to see the NYT write about the problems in Malawi.
In talking to people here, they feel much of the problem also started with the fact that people often sell their
blood as donors for others that need it for legitimate reasons, but of course that doesn’t sell as many
newspapers.
As for the famine, word on the street is that it really does not exist in Malawi. It is a major problem in Zimbabwe
and Zambia, but not here. Supposedly the UN did an assessment in May and estimated that the country would
be short 650,000 tons of maize. The government then borrowed money from the IMF and the World Bank and
bought 250,000 tons or so and also the WFP brought in 350,000 tons of mostly US grain. The problem is that
the actual short fall is something like 350,000 tons, so now there is a surplus, the price of maize is falling and
the government may be selling excess to other countries. This goes along with the usual corruption and fact
that someone is making serious money off of all this.
The other thing about the third term for the President is that there was a vote in the Parliament to change the
constitution, the prez and his supporters felt they had enough votes to change it, however, they lost by 2 votes,
so now it seems as if it is a dead issue, but this being Africa, we will need to hang tight and see what develops.
It seems the President has become very fond of the perks of his office.
Some of you will be amused to hear that I have ended up in a city that is even slower than San Antonio. For a
capital city, this place is pathetic. The tallest building in the city is only 9 stories. There are a few restaurants
and pubs and one nightclub, if you want to call it that. Through Dr. Muyco I spent Christmas day and New Year’
s Eve with the Philipino/Asian contingent. It was quite fun and it’s certainly been a while since I’ve eaten roast
pig (complete with apple in mouth).
I also met the new political/economic officer from the American Embassy. He came by to look at the trauma
unit. Supposedly they already have the 15 hospital beds, but need to ship them and are looking into funding
for monitors and ventilators and the like.
Dr. Muyco and I are having drinks on Saturday with the Minister of Health to discuss things at the hospital and
on Sunday I’m going to dinner with some of the medical people from the Taiwanese Embassy. The Taiwanese
run a hospital up north in the town of Mzuzu and are also looking to fund Malawians to train as surgeons in
Nairobi or South Africa.
I mentioned to Dr. Muyco that he should look into trying to set up some sort of fellowship for surgeons from the
US or Europe who might be interested in a tropical surgery experience. The Minister of Health was looking into
what could be arranged for four month stints at the hospital.
Anyway, I’ve pretty much settled in. I have a car now, the only problem is that its right hand drive and the roads
are getting worse and worse as the rainy season continues, but it’s great to be able to get around on my own
and get to the hospital when we have a case that needs to go in the middle of the night.
Take care and best to all.
Malawi Update 3.1
So it was Sunday morning at about 11 a.m. I had gotten up early and already made rounds at the hospital -
everyone looked OK, including the guy with the gun shot wound to the left chest. I was sitting outside at Café
Delight, the café-restaurant next door to the 7-11 and noticed a helicopter. It came from the direction of the old
(now military) airport. It was one of those black, important looking helicopters. I wondered what it was doing
and where it was going. You just don’t often see helicopters in Malawi. I just shrugged and continued with my
meal.
About 15 minutes later I got a phone call from Dr. Muyco. He told me that he had just received a message from
a district medical officer at the Kasungo Hospital (a smallish city north of Lilongwe). It turns out that the current
Minister of Agriculture, who was also the former Minister of Health, and it turns out the current number two guy
in the government and a possible front runner to be the next president of Malawi was in a car accident. His
injuries were not life threatening; however, they did include a deep laceration to the palm of his right hand with
disruption of tendon at the level of his fingers - a very difficult injury to repair with an often questionable
outcome. Dr. Muyco told me that the Minister would be arriving by helicopter in about 45 minutes. At least it
solved that mystery.
The next thing I did was call Steve Mannion. Steve was the orthopaedic surgeon who had gotten me to Malawi,
who had subsequently returned to the UK, but who just so happened to have arrived in Lilongwe the previous
evening for a one week visit. I told Steve the story and described the injury (one I would not have been very
excited to treat myself.) Steve agreed to stop by and see the Minister.
Steve and I ended up taking the Minister to the OR. Upon exploring the wound we noted that the tendons were
intact and that he had “just” dislocated the bones in his hand below his index and middle finger. He must have
put his hand out when his car rolled after swerving to avoid a child that had run into the road (the driver of the
car only had a few lacerations, the child died at the scene.) We irrigated out the wound, debrided the dead
tissue, repaired the tendon sheaths and put in a couple of pins to stabilize the joints. Of course there had been
some problems intubating him for anesthesia, so he spent the night in the ICU.
Of course, being a very important person in the Malawi government the President of Malawi wanted to visit him.
Fortunately he did not arrive Sunday evening. He did show up about 11 a.m. on Monday. Dr. Muyco and I did
not get the privilege of meeting him, we were in the OR doing a thyroidectomy for a massive thyroid goiter. Oh,
well, maybe I’ll get to meet him some other time.
Anyway, as for mundane issues, I have sent out two emails: number 3.1 and 3.2. As I know that those without a
medical background probably found my last update a bit difficult to follow, I am writing a medical and a non-
medical version. Please feel free to look at both, but don’t say I didn’t warn you.
I have been living for the past five weeks at the Riverside Hotel, situated not too far from the Lindgazi River,
which runs through Lilongwe. The place is clean and nice, if a bit sterile but a far cry from my backpacking
days. I have my own bathroom and shower and a TV with CNN and a movie channel, which is nice given the
lack of a movie theater in Lilongwe. The hotel has a fairly decent restaurant serving both passable Chinese
and local dishes. The hot and sour soup and the spicy half chicken and chips are probably the best dishes.
The weekly schedule at the hospital is that we have operating days on Monday, Wednesday and Friday.
Emergencies are done when they need to be. If they come in late Tuesday or Thursday and can wait, we do
them the following morning, but it does mess up the schedule.
Everyday we start off with a morning report when the clinical officer who was on call the night before goes over
the admissions and any problems on the wards. This meeting is at 7:30 everyday. Dr. Muyco and I usually
round quickly on the wards at 7:15 to scout out any problems. On Tuesday we have recently begun a morbidity
and mortality conference and on Thursday we have a lecture after the morning report.
After the meetings on Tuesday and Thursday we then make attending rounds. Dr Muyco and I divide the Male
and Female wards and we usually meet up and round together in pediatrics. After lunch we have an outpatient
clinic in the afternoon.
On OR days we usually finish by 6 or so, but of course it depends on the cases and if there are any
emergencies. I’ve been alternating call with Dr. Muyco, but I’ve been on the last three weekends and a bit
during the week, but it hasn’t been too bad. I’ve only had to go into the hospital after midnight on three
occasions; one was for a volvulus, one to do a bowel resection for a strangulated hernia and one for a stab
wound. All the patients have done well.
I previously wrote a little bit about Lilongwe. It’s really not much to look at. Things are pretty spread out and
although there is a reported population of 400,000 it doesn’t feel that way. The roads are narrow and the
potholes are many, but the place is actually pretty green with a lot of open space between two “centers”. It
would really be impossible to walk around, first for distance reasons but also for safety. The hospital is located
about a mile and a half from my hotel.
The city is divided into an old and a new town. The old town has the Shoprite, a few electronics stores, internet
cafes and restaurants such as Ali Baba’s (OK kebabs and pizza), Mama Mia’s (Italian) and the recently opened
chain restaurant, Nando’s (Chicken and chips). I was told that Nando’s are pretty common in Southern Africa
and that the one in Botswana is especially good, who knew? Old town also has Harry’s Bar (good club
sandwich but the cheeseburger tastes like meatloaf) in the Imperial Hotel, the Lilongwe Hotel with a Malawian
band that plays 6 nights a week, and Goodfellas with a few pool tables. There are a few more stores, but really
not much else to speak of.
The new city or capital city is where the embassies, government offices, the central bank, the few large
buildings and the one skyscraper (9 stories) are. A few restaurants are there, but I haven’t eaten in any of
them yet. Like I said, this place is pretty sleepy. There are only two traffic lights in town, in addition to the 4
traffic circles.
A week ago we had cocktails with the former Secretary of Health. He’s an anesthesiologist by training and it
was interesting to get his perspective on health care in Malawi. He is still very involved in the management of
things. Some of the topics we discussed included the decentralization of health care to the districts. By 2004
the districts will be responsible for establishing budgets and plans and then implementing them. It sounds
pretty ambitious and should be interesting to see the results. They are also working on a plan for autonomy for
the hospital with its own board and revenue stream, things will really have to change if this is to happen. We
also talked about the fact that there is little in terms of cancer screening and prevention and the need to
support tertiary care including surgery, in light of the cost of providing such services.
AIDS/HIV is a very big problem in Malawi and a lot of foreign money is going into programs for prevention,
screening and treatment. However, many people still are not being tested and many have not changed their
habits, although the distribution of condoms is up 100% over last year. I heard from one of the clinical officers
that a study done in Blantyre (the other major city in Malawi, located in the south and named for the hometown
of explorer, Dr. Livingston) showed that 80% of patients in the medical ward were HIV positive, it was only about
30% on the surgical ward. We assume the same here in Lilongwe. There is a push to get people tested. In
the past it didn’t seem to really make too much of a difference since there was no treatment, but the Ministry of
Health is beginning to distribute anti-retrovirals to HIV+ individuals.
In terms of things at Lilongwe Central Hospital, what is really amazing is that as bad as things are in the surgical
department, they are much, much worse in medicine. There is only one Egyptian attending for Medicine and a
medical student visiting from Brussels was telling me that every morning they report multiple deaths from the
previous day. He told me that last weekend was especially bad with almost entire rooms being empty on
Monday because so many patients died.
And to think I thought things were really bad in surgery because we had 14 deaths in the month that I’ve been
here. I have conveyed to the clinical officers that although most of the deaths were probably unpreventable,
there were a number where things that could have been done differently and some of these patients should
have lived. Part of the problem is dealing with the other departments and ancillary staff.
I can’t tell you the number of times I hear that patients did not get the required x-rays. The excuses range from
no petrol for the transport car to pick up the x-ray tech at night, to no film, to the tech is sick, to the current one
that there is no developer in the hospital. Well, at least we were able to get gauze for the OR and we now also
have formalin for biopsy specimens.
Last week we had dinner with the medical folks from the Taiwanese embassy. We went to the Italian restaurant
Mama Mia’s. I didn’t realize that Malawi was one of only a few countries to actually recognize Taiwan. I
wondered why the Taiwanese were being so nice. I heard that the Malawians actually addressed the general
assembly of the World Health Organization asking that the Taiwanese be given observer status. They got
blasted by a whole host of nations including the mainland Chinese. But it does explain why the Taiwanese built
a hospital in the north in a town called Mzuzu. They are also staffing the place with Taiwanese doctors. At the
dinner we met a new arrival, Dr. Fang. Turns out he is a cardiothoracic and vascular surgeon and will be in
Malawi for a year. It’s great to have him, but there’s really no need for his specialized services in this country.
Most people die well before they develop coronary artery disease and need a bypass, plus the resources are
just not there. He and a nurse anesthetist came by LCH the next day. They were amazed at how busy we were
compared to Mzuzu and how many more patients we treated and were on the wards. I realized that we really
are the referral hospital for 2/3 of the country.
Another thing that has been interesting to note is the number of people here in Malawi who have or who are
planning to obtain a Masters in Public Health. I always joke that obtaining my MPH was the most painful year of
all my training, from the standpoint that while a surgeon needs to make quick decisions and often acts alone,
public health focuses on whole populations and emphasizes gaining consensus on issues. But as I thought and
subsequently found out, the MPH provided me with the language of the donors and the people in the ministries
and non-governmental organizations who control the finances and agendas for health care delivery in many of
these countries. Right now the trend here is to fund HIV and infectious disease projects; however, we are
looking into doing more work with trauma.
The prevention aspect of trauma can be very valuable in reducing the number of injuries and preventing the
need for expensive specialized care. The surgeon in me also points out that while no AIDS patient will be fully
cured and those with advanced symptoms will never go back to work, the patients that we care for from trauma
or even repair their hernia and resect their intestine will make a full recovery and be able to work and be
productive (the cynic says, yeah, but 30% of these patients in Malawi are HIV positive). In the past I often felt
that maybe the cost of surgery and such services was not justified, however, I am in the process of reevaluating
my thoughts on this seeing the benefits that we have been able to provide to patients.
So, what else is there to do in this town? I’ve been told that on Wednesdays, starting next week, a weekly
volleyball league is resuming at a place called the Shack. Luckily for me it’s right next door to my hotel.
Supposedly this is the place to be and everyone goes.
Last Wednesday things were pretty quite, probably because it was a national holiday. It was John Chelimbwe
day. The day honors a Malawian preacher who lived in the early 1900’s. He was educated in the States and
returned to Malawi, then the British colony Nyasaland and led a movement for freedom from colonial rule. He
led a rebellion and the story is that a local white farmer was decapitated. The reverend gave a sermon that day
with the severed head displayed prominently on the pulpit. He was later arrested and executed. So, now he is
a national hero and his picture is on all the paper money. Gotta love Africa.
Hope all is well with everyone,
Malawi Update 3.2
As far as surgery has gone it has not been a bad few weeks since the last update. We are finally past the
holiday season so we will no longer be losing Wednesday OR days (Christmas, New Years and John Chelimbwe
Day). But the big cases keep coming. We have done a bunch of pedi cases: a cystgastostomy in a 1 year old
with an abdominal mass that turned to be a large cystic lesion coming off the pancreas. We also excised and
repaired a meningeocele, that was interesting, never having done pediatric neurosurgery before. We also had
a 4 month old with an obstruction that turned out to be a gastric and intestinal duplication.
It has been very good to rely on clinical findings, mainly the old history and physical to decide when to operate.
This past week we did have a supply of gauze and formalin, but had no X-ray facilities for the entire week. It did
make the management of stab wounds to the chest a bit difficult, but decreased breath sounds are a pretty
good indicator. Not having x-rays has made the cases of obstruction a bit more a guessing game when we go
to the OR. Without films, we weren’t able to appreciate the bent inner tube sign on the massive sigmoid
volvulus in the 35 year old, but from just looking at his abdomen you knew there was a problem. The sigmoid
had turned 2 ½ times and was black. We did a Hartman’s. The day before I operated on a lady with a 3 day
history of obstruction and she turned out to have a cecal volvulus with a necrotic segment. We did a right
hemi.
A very strange case was the 24 year old male with the lower abdominal mass that had developed over the
previous few months. An ultrasound showed an appendiceal mass and normal bladder. On exploration it was a
large infected urachal cyst. Luckily Dr. Essam, the Egyptian Urologist who recently joined us, was in the OR.
Intra-abdominal was OK, so I just ligated the urachal remnant, irrigated the heck out of the cavity and drained it
and sent a bit of the wall for path.
I’ve also done a bit of trauma surgery on the colon. One was a present from the gynecologists; a TOA where
they got into the sigmoid. I repaired it primarily, but did a diverting loop colostomy - the abdomen was a mess.
She did fine and has gone home. We’ll bring her back in a few weeks, and close her. I also got a 2 a.m. call on
Sunday night about a stab wound to the left flank and abdominal tenderness. He has a large slice in his
descending colon, a through and through in the sigmoid and a hole in the small bowel. All were repaired and
since there was minimal spillage, and he was hemodynamically stable, and the injury occurred only 2 hours
before we were in the belly, I repaired it primarily without a colostomy. He too has done well and was sent
home. As for non-operative trauma, we had a guy show up with a GSW to the left chest. Of course we had no
x-rays when he arrived. I found out about him the next morning. Clinical officers had placed a chest tube and
the following morning, the one liter glass jar was completely filled with blood. We emptied that jar, I ordered an
ultrasound to just rule out tamponade (though he had been stable for a good few hours now) and went to x-ray
to find out if we could get x-rays and a gastrograffin swallow. When we got to radiology, they told us they “had
found some chemicals” and so could do x-rays. We went to get the patient, but in the interim his family had
taken him out of the hospital and gone to a mission hospital 10 miles away. It was unbelievable. The guy did
return, he had films and they showed the tube in good position, but the bullet lying near the midline. We were
fortunately able to get a swallow which showed no extrav and he has done well. Luckily.
The good cases keep coming. This Monday did a big thyroid goiter and a hemi-mandibulectomy for a tumor.
On Wednesday we have a patient with a lower esophageal cancer and a patient who needs a
cholecystectomy. We were going to do a MRM for a breast biopsy that came back as infiltrating ductal, but the
patient has decided to go to South Africa for treatment. I can’t really blame her.
The weekly M&M seems to be going well. I think the clinical officers are taking a bit more care of looking at
problems and taking care of the patients, but there is still a long way to go. One of the results of the first
conference was to write up a protocol for handling head injury patients on the wards. There is limited ICU and
Intermediate care space and often the patients are just left on the ward, with not so good results. Hopefully by
having a protocol and highlighting the problem we can reduce the mortality from these injuries.
We did manage to save a guy who was assaulted. He came in with a GCS of 4. I was already in the hospital
taking care of the Minister of Agriculture and got the guy intubated and admitted to the ICU. He also had a
panga injury to his right wrist and unlike the Minister, his injury was a subtotal amputation which was completed
in the OR. Fortunately he was beginning to wake up the next day. In the past this guy would probably have
gone directly to the ward and died. The next day at morning report I asked the clinical officer who admitted the
guy what were his first thought when the guy came into the ER. I expected to hear A,B,C etc. Of course he
said, “I noticed the lacerations on his head and his wrist. I then had to say “And what was the first thing I said
when I saw the patient?” “He needs an airway.”
I’ve been discussing with some of the more interested clinical officers about writing up some of the cases. I
think articles on midgut volvulus and intestinal TB might be of interest to some of the major journals and I haven’
t been able to find any literature on panga injuries (the ubiquitous machete/knife which is the source of many
injuries in Southern Africa) and it might be of interest for the Journal of Trauma. If the guys get some abstracts
together there might be the possibility to get them to a major conference such as the AAST, ACS or ISS. I’m
sure there would be some way to find the funding. One of the clinical officers has already written up a study he
did last year looking at all the trauma cases over a six month period.
All in all the surgical experience has been wonderful. In four weeks I’ve already done almost 50 “index” cases
and they keep coming. It has also been very challenging. The other night I did a bowel resection for a
strangulated RIH. I did a midline incision and was able to use 2-0 chromic and 3-0 vicryl and I closed with PDS.
I did not repair the hernia, one because it was late at night, two because I had done the bowel resection, but
mostly because I could not get any non-absorbable sutures at that time. Yup. I’m definitely learning a lot, but
not everything I learn will be applicable to that hotel room interview in October.
Take care,
Malawi Update 4
Every once and again you do a case that really makes you feel good, a case in which you really feel that you
accomplished something. Well, yesterday we had such a case.
It was about 5:30 in the evening and we had finished for the day. I stopped by the ER to see if the clinical
officer on call had any new cases and to make sure that he knew about the guy with the incarcerated hernia
that I wanted to operate on that evening after the patient received more IV fluid. When I got to the ER the
phone rang and the clinical officer answered it, he turned to me and said there was a new admission in the
pediatric ward - a child who had fallen. We walked down to the ward.
The child was a three year old girl who had fallen from a height of about 5 feet onto her head. Her mother said
that she was unable to speak after the fall and looking at the child I knew we were in trouble. The girl was not
moving the left side of her body, however, she was uncontrollably twitching (seizing) with the right side of her
face. Her right pupil was dilated and she was looking toward the right. These signs are all indicative of a
severe head injury with increase pressure on the brain and probably the result of an injured artery under the
skull (epidural for the medical types).
I quickly called Dr. Muyco, who luckily was still around. He spoke to the anesthesiologist on call and within 20
minutes we had the child in the OR. We shaved her head, cut open her scalp and drilled three holes into her
skull. The first hole did not show any blood, but the second and third did, confirming our impression of an
epidural hematoma. We evacuated the blood and got the bleeding to stop.
The next morning the girl was sitting up and talking. It was interesting to hear that initially her father did not
want to give consent for the procedure because he felt that surgery on the brain was not possible at LCH. In
some ways I can’t blame him.
Seeing that this girl was taken care of and did so well, I was a bit less upset about some of the other problems
with the hospital. That night I was never able to operate on the guy with the incarcerated hernia because he
did not receive adequate fluid replacement. I finally operated on him the next day. Some of his small intestine
had died, but I was able to resect it and he should do fine.
Otherwise, things are starting to become fairly routine. We did a large case the other day, the resection of the
end of the esophagus for a cancer. In the past week I also did a thyroidectomy, a mastectomy, a
prostatectomy, and a few other ectomies.
On the political front there has been a bit of action this week. The issue about amending the constitution to
allow President Muluzi to run for a third term has resurfaced (seems he really likes being President). In fact, on
Monday there was going to be a vote in Parliament on amending the constitution, that vote has been delayed,
however, there were protests in Blantyre and the police fired guns and tear gas. There were no injuries
reported. Things here in Lilongwe have been calm. No protests or anything like that, though four members of
Parliament who do not support the third term amendment were reportedly beaten up. I’m sure none of this has
made the U.S. newspapers as it doesn’t involve vampires.
It was interesting to note that last week when the Prez visited the hospital he gave every patient in the hospital
50 Kwacha (90 Kwacha = US$ 1) or about 50 cents. Talk about buying votes. And all this was in the face of
the hospital not having enough gauze or chemicals for developing x-rays, ah, politics.
Anyway, that’s all for now. I’m actually not going to be in the hospital next week. I’m going on a road trip of
sorts, but I will send an update when I get back.
Best to all,
Malawi Update 5 (or not guilty in Philly)
To the surprise of some of you, I began this update in the Philadelphia International Airport and am sending it
from the business class lounge in Heathrow. As I wrote in the last update I was not in the hospital during this
past week, I was not even in Malawi, not even in Africa - I was in the States. Why? I came back to testify at a
malpractice trial. The case was from when I was an intern; my first year in residency. A case from 1996.
To make a long story, not so long, I received word a few weeks ago that this case, one which I had hoped to
ignore and it would go away, was actually going to get underway on February 2nd. Needless to say, my
attorney, who did a great job and who by the way looks almost a bit like Richard Gere, felt strongly that my
presence would be beneficial. As I am always up for a road trip and a few additional frequent flyer miles I told
him I would go, but only if the insurance company picked up the tab and I if I could fly business class. They
agreed and I flew from Lilongwe on Sunday 2 Feb and arrived late on Monday in Philly.
The trial lasted four days. The plaintiff’s expert (an internist who admitted that he had never treated a trauma
patient) claimed that because I as the intern did not transfuse the patient (a sixty-five year old lady involved in a
head on collision, who was not wearing a seat belt and sustained multiple rib fractures and a subdural
hematoma) the day before she was made DNR, the day when she was clinically stable with a normal heart rate,
blood pressure and urine output, it was my fault that she died. The fact that the family did not let us intubate
her the next day when she was having problems breathing and that the autopsy report showed that she died of
pneumonia was according to their expert irrelevant. Luckily our sides’ expert witnesses both (two surgeons)
supported my decision not to transfuse. The jury deliberated for about 10 minutes before we were cleared of
any wrong doing.
So needless to say, I got to hang out in Concordville, PA, speak to and see some old friends in Pennsylvania
and collect some supplies to take back to Lilongwe. The donations, included face shields and goggles (few
people at LCH have eye protection), sutures, surgical staplers and some items for cystoscopy. The supplies
came from Taylor Hospital and Crozer-Chester Medical Center. (Thanks again!)
It is amazing to think that the cost of my flight, rental car and hotel for the week so I could testify at a trial for a
case that should never have even seen the inside of a court room was about the same as what the Malawi
government spends on healthcare for about 5,000 people for one year. Once again highlighting the fact that
we’ve got problems in the States. I did note that while I was in Philly, doctors in New Jersey were staging a work
slow down to protest the high cost of malpractice insurance. It will be interesting to see where things go. And
some people wonder why I don’t want to practice in the US.
On a more positive note, when I get back to Lilongwe I will finish writing up a proposal to obtain funding for the
OR. The plan is to approach the Malawi National AIDS Commission which has about US$ 138 million in donated
funds. The proposal will be for a three year program to provide education and protective material for health
care workers at LCH. We are looking to begin a monthly education series and also provide gowns, gloves, eye
protection, linens, drapes, gauze, bandages and suction machines for the ORs to protect the people working
there from HIV. The risk is substantial given that about 500 people work at LCH including the doctors, clinical
officers, nurses and ancillary staff and over 300 people work or rotate through the OR. Last year’s case load in
the OR consisted of 4,000 minor procedures and more than 3,500 major cases. With anywhere from 4 to 10
people in the OR at a time, including anesthesia, nursing and doctors the exposure risk is huge.
Well, once I get settled in I’ll provide another update. Dr. Muyco was planning to line up a bunch of big cases
for next week as my time in Malawi is quickly coming to an end. I’ll be working alone next weekend as Dr. M and
his wife are going to take the opportunity to escape from Lilongwe as it may be his last chance for a while.
Regards to all,
Malawi Update 6
This is the last Malawi update as I am leaving Lilongwe on Monday, February 17. I had only planned to stay for
2 ½ months and it is amazing how quickly the time has gone by. I hope that the updates have been an
enjoyable insight into Malawi.
As for future, I will be heading back to the New York area and…I’ll just have to see what develops. I don’t have
any definite plans at the moment, mainly to recover from the jet-lag, put together a video of the experience and
maybe write up a few articles for publication. Otherwise, if anyone hears of anything interesting…let me know.
Future updates will follow if (when) I end up in some other place.
Best to all,