Malawi Again:
Greetings from Malawi, again.
Many of you know that I am back in Africa. Some of you are aware that I was here last year for a few
months and for others this note may come as a surprise. For those of you new to the list, I try to send
updates from the field when I am working in developing countries.
Last year I worked with Dr. Arturo Muyco, a 78 year old general surgeon and the only general surgeon at
the Lilongwe Central Hospital (LCH) in the capital of Malawi, Lilongwe. (LCH is the only government
tertiary care/level 1-type trauma center in the north and central part of the country with 600 beds and a
census usually approaching 1,000 patients) After hearing that Arturo had been by himself since I left last
February, guilt along with the desire to work again in Malawi prompted me to return. (Plus the fact that
Lake Malawi is one of the great tourist attractions in Africa and I had failed to see it last year.)
For those of you who do not know or perhaps don’t remember, Malawi is a southern African country
surrounded by Mozambique, Zambia and Tanzania. It has a population of 11 million, an HIV prevalence
rate of 15% and a per capita GDP of US$190. Of note is the fact that the average life expectancy has
dropped from almost 50 in the early 1980s to about 37 now.
I’ve now been in Lilongwe a little over a week and I am amazed at how little things have changed and
realized how quickly the year has passed. I’m settled into my old hotel, the Riverside, (the Ministry of
Health is picking up the tab for that), rented another Toyota and went back to work immediately. Arturo,
finally feeling comfortable enough to leave town actually picked me up at the airport on Sunday and was
on a plane with his wife to Johannesburg the next day; his first time away from Malawi in over a year.
Monday was my first full day in Malawi and in addition to doing a full list of cases, included a prostatectomy,
we had emergencies all night and I was up to 3 a.m. It’s a great way to get over jet lag. In the time that I’ve
been here we’ve had 5 cases of sigmoid volvulus, two requiring resections and three we were able to just
pexy. (Sorry for the medical language for the non-medical types.) What’s so amazing is that this is a case I
think I saw only once during my entire medical school and residency training. Arturo and the clinical
officers are in the process of collecting much of the data on these cases for the past few years and are
planning to write up their experience.
We have also had quite a few incarcerated hernias; most have not required a resection. Fortunately we
haven’t had much in the way of operative trauma, though the general surgery emergencies have kept us
busy. We have seen a few cases of peritonitis that people here feel may be from TB or possibly CMV. We
even had a case of Fournier’s gangrene. For the non-medicos, I’m not even going to explain, suffice it to
say you don’t ever want it. For elective cases we are doing one prostate per operating day (Monday,
Wednesday and Friday) and it certainly would have been nice to have an EEA stapler when I closed a
Hartman’s, but the two layer anastamosis was nice. We have about 5 cases of esophageal cancer waiting
on the wards that we are evaluating for possible resection. Most are probably non-resectable, though I
think one distal lesion may be operable.
The anesthesia department if anything has gotten stronger since last year. There is a German woman
who runs things and gets some outside funding from the German Government. Turn over time in the OR
is pretty quick and last Friday evening we were able to do three cases: a sigmoid volvulus, an incarcerated
hernia and perforated appendicitis in about two and a half hours. Everyone did a tremendous job.
Unfortunately that is where the good news ends. The urologist, Dr. Essam has gone and there is no
replacement; Dr. Williams the ENT specialist also left. The clinical officers and I are comfortable with doing
prostatectomies, but I’m not about to start doing cystectomies for the many patients with bladder tumors.
There is also a major staffing problem in the hospital. We have four interns and two clinical officers
(Chimwemwe and Nelson). One resident was supposed to show up last week but never did. There had
been another clinical officer who was excellent, I had worked extensively with him last year and he had
stayed on, but he was recently hired away by Doctors Without Borders to help on one of their projects. I
can’t fault Henry, they were certainly offering much more money than he could earn at LCH. It is a shame
that with all the money that is pouring into Malawi, about US$ 150,000,000 (one hundred and fifty million
dollars) earmarked for HIV/AIDS, very little of it is going to curative medicine. We can’t even get face
shields for the OR, though I’m sure if we ask, we could get condoms for the entire staff. It’s really quite
upsetting.
This problem is also rampant with the nurses, many of whom are leaving in droves. I thought it was bad
last year when we had one nurse for a ward of 70 or so patients, but now many of the wards are going
without any nurses for days at a time. It’s so bad, that on Sunday we got a call from a nurse on another
ward that she had made rounds on her own on the women’s ward and had discovered a patient
transferred from a Mission hospital who had eviscerated after a c-section. We can’t quite figure out how
she made it to the fourth floor without anyone on our team knowing about it (also given the fact that the
elevators no longer work), but luckily the nurse found her and called us. The case by the way was a
mess. She has disseminated Kaposi’s and had already eviscerated once before and was repaired and
when they did that at the other hospital they had caught the small bowel, so she also had a small bowel
fistula. We were able to resect to normal tissue and close with retentions but certainly her long term
prognosis is grim.
But anyway, about the NGOs hiring away hospital staff, they only comparison I can make is to the times
that I’ve been in humanitarian crisis situations and the NGOs all complain about the journalists who pay
inflated prices for drivers and translators and the NGOs complain about the effect on the local economy.
Well guys, the same thing is happening here.
We will see what we can do, maybe write up some proposals and try to get some funding, but it doesn’t
look very promising also given the fact that the hospital administrator is ineffective as is the ministry of
health and also given the exceedingly high level of corruption throughout the country, it seems unlikely
that this problem will be solved anytime soon. Things are so bad that I have been hearing from people
about the possibility of having to shut down LCH. It’s hard to imagine what will happen to the patients, I
guess they will go to the Mission hospitals, but the whole situation is terrible.
On a more pleasant note, I have seen many people I met last year and it’s great to see the staff at the
hospital again. I must say, the feeling of returning to work in a third world country is probably greater than
the feeling of showing up the first time. I was really pleased by the warm reception I received when I got
back. The guilt thing again was setting in when I got an email from one of the doctors I had met in
Nasiriyah asking me if I had any plans of returning to Iraq. I haven’t been able to answer him yet.
My plans for the moment are to be here for a total of seven weeks and I am hoping this time to see the
Lake and maybe get to Zambia to the South Luangua Game Reserve (supposedly one of the best in
Africa). I’ll be back in the States on March 1. After that I’m hoping to get a program off the ground in
Nicaragua working with the Organization of American States. The plan will be to provide surgeons in rural
landmine affected areas to work with local docs, be a resource if there is a demining accident, do some
trauma training and also do and teach essential surgery. We have already received preliminary funding
from the US State Department to go ahead and are looking to finalize things a bit more.
I hope everyone had a Happy New Year and that 2004 is going well. Those in the Northeast US, try to
keep warm.
All the best,
Adam
So, since the last update things got worse, then got better then got really bad and now are better. First
off, Chimwemwe, one of the two clinical officers left for the city of Blantyre to start a Master of Public Health
program. That left only me and Nelson. Dr. Muyco was not back at the hospital because he was waiting
for his contract to be renewed by the Ministry. So I began discharging all of the elective cases and that got
our census down to a more manageable 125 patients. Things were busy enough only doing the
emergencies and the cancer cases.
Luckily Dr. Muyco started working again on Monday (although he’s still waiting for a contract) and we even
got a new resident Carlos, (he just finished his rotating intern year) and things were looking better. We
had a bunch of cases scheduled for Monday and then things got really bad. There was some sort of water
main break and the water was cut off to the hospital for over 24 hours. We had to cancel our cases, no
water, no sterilizing the equipment, no operating. During the evening we had a trauma case that needed
to be operated on and had to transport him to “bottom hospital” a smaller facility that is mostly obstetrics.
We removed a shattered kidney and then transported him back up to LCH. No water in the central hospital,
pretty bad for a country that is one third covered by a lake and it’s the middle of the rainy season.
Luckily the water came back working and we were able to operate. We did 17 cases on Wednesday
starting from 9 am and finishing just before 5 pm. I’ve done a total of 69 cases so far, including 11 cases
of sigmoid volvulus (where the large intestine twists on itself).
I apologize for all the medical terms that I used in the last update and in order to make these updates more
comprehensible to the medically illiterate the purely medical parts will be in italics.
Over the past few weeks the obstruction cases keep coming. I’ve now operated on 11 cases of sigmoid
volvulus. One difficulty has been with a variant of sigmoid volvulus where the ileum wraps around the
sigmoid and forms a knot, ileosigmoid knotting in the literature. Last year I thankfully only saw one of
these cases but this year I’ve already had five. The last one was a total nightmare. A woman, 6 months
pregnant with the worst case of necrotic ileum and sigmoid I had see to date. We had to resect and do a
temporary closure in order to get her off the table and stabilized in the ICU. It was not a pleasant way to
spend a Sunday.
Yesterday was a great day; I did a partoidectomy, a thyroidectomy, a silo for a child with gastroschesis, an
ex-lap for a patient with an internal hernia secondary to post-op adhesions, and a resection of a large
ovarian cystic mass.
I’ve done quite a few incarcerated hernias and we’ve done a bit of peds stuff including an anoplasty for a
low imperforate anus a few colostomy closures for Hirschprung’s patients and the excision of laryngeal
warts with one child requiring a trach. We have a child with a Wilm’s tumor scheduled for tomorrow. The
Fournier’s patient is doing very well and the ICU continues to do a great job in taking care of the
obstruction cases.
The other night, however, was particularly depressing as we had three obstruction cases and all were
very, very sick. All five beds in the ICU were full with intubated patients and so at midnight I had to make
the decision to not operate on two of the patients. We hydrated them overnight and operated the next
day. One had a midgut volvulus which required a resection and the other had post-op adhesions that also
required a small bowel resection, but to my delight both have done well and tolerated the delay and the
surgery. Basically is proves that the patients who make it alive to receive care have already proved their
ability to survive. But I really have to give a great deal of credit to the folks in the ICU, without them we
would certainly lose many more patients.
In addition to the obstruction cases, we’re hoping to do a few esophagetomies, they appear to be possibly
resectable but all have gone home to look for blood. Patients have to provide their own donors. We have
7 in the process of being worked up, hopefully they will return and we will have space in the ICU.
One interesting difference here is that the phrase “left AMA -, against medical advice” is not used when
patients leave. Plus they don’t sign out, they just go, but I frequently hear that the patient, “absconded.”
One afternoon we had a two day old infant present to the casualty (E.R.) with an omphalocele. She was
stable and the membrane was intact. I spoke with Arturo and his said he paints the membranes with
mecurichrome and the children usually do well and just develop a hernia. Well, when I got back to the
hospital to examine the child I couldn’t find him and was told by one of he casualty clinical officers that the
parents had “absconded” with the child. It was similar to the patient whom one of the clinical officers
thought needed a lower extremity fasciotomy, but when I came to review him, he was gone.
One theatre day we did a decortication and repaired a massive epigastric hernia. We were then going to
just do a gastrostomy feeding tube for a patient with unresectable esophageal CA, when we got a transfer
from one of the district hospitals. The patient had presented there with a ruptured uterus and had
undergone a hysterectomy, unfortunately the ureters where both tied off in the process. Luckily Arturo
was around, and he and I reimplanted the ureters and fixed the bladder injury.
So, apart from the hospital situation, many queried what the rest of Lilongwe was like. The city of Lilongwe
is relatively spread out, but not at all big. There is an old town with a few shops, a supermarket and about
4 restaurants and a busy market. The main roads are better this year than last and that’s because there
has been relatively little rain. Although potholes are developing as the rainy season continues with some
really heavy downpours. It gets a little dicey at times because there is no shoulder and basically the roads
tend to become narrower and narrower as the rains wear away the edges of blacktop. Aside from some
rainy days, the temperature has been in the upper 70s to 80s. For those of you in colder climes, I am
sorry.
This isn’t a walking town; you really have to have a car to get around as things are spread out. However,
most of the locals either walk the long distances, or take minibuses which are vans crammed full of
people. There is not the urban squalor which is so typical of many big third world cities, here there are
abundant trees and things are relatively green. Grounds crews tend to the areas in the few traffic circles
which are used instead of traffic lights. (There are only two traffic lights in the city.) The population here is
reportedly about 450,000, but it really feels much smaller.
One amazing thing about this place is the sky; during the day the sky is a vivid blue while at night the view
is incredibly clear. When I look up and see the vast cottony white clouds that drift across the sky or
partially cover the moon it really does look like an African sky.
There is a small expatriate community and I bump into many of them at either the Shoprite (the large
supermarket) or at Foodworths (a smaller gourmet supermarket) located between the old city and the new
part (City Center) where most of the embassies are located.
As for living here, things are very relaxed. Outside of work, I’ve been invited to a few dinner parties
including one with the new US Ambassador. There are a few pubs (the Shack and Goodfellas - Harry’s bar
which closed last month just reopened) and two night/reggae clubs (Legends and Chez Ntemba) which are
frequented by expats and well-to-do Malawians. There is a volleyball league on Wednesday nights at the
Shack where most of the young expat community shows up. Otherwise it’s pretty quite.
As for other projects, Arturo and I met with the WHO representative here and are planning to approach him
for funding to restart a program to training the police and fire department as “first responders.” The
Ministry of Health cancelled the program after only one class had been trained in November due to lack of
funding. We are hoping to train four more classes of 25 students and be finished and have a public
demonstration by the graduates on April 7th which is World Health Day, and trauma is this year’s theme.
We are also planning to approach UNDP in order to see about getting funding for short stays for surgeons
to work at LCH through the United Nations Volunteers program.
In late February, a team from the US Army European Command is going to be visiting and they will be
looking to do an assessment of projects here in Malawi. They had funded the construction of a new
building for an ICU and a new emergency department. The project was started after the Embassy
bombings in Nairobi and Dar. The plan was to have a new trauma unit and ICU. Both areas are now
completed but they are not being used because of a lack of equipment. We are going to see if anything
can be done about this.
Otherwise I’m making plans to go to Zambia from Feb 13-15 to visit the South Luangwa Game Park. On
February 24, I’m giving a talk on Iraq to the medical community here in Lilongwe and will head back to New
York on March 1.
Best regards to all,
Adam
Things have “normalized” a bit since the last update. Dr. Muyco is back full time, an Egyptian urologist just
started today, Chimwemwe is back from his introductory classes in public health (the program is for two
weeks every three months for two years) so we have two full time clinical officers, and Carlos our new
registrar is getting up to speed. The emergency cases have slowed down a bit; although Arturo and I did a
nasty case of a sigmoid/cecal volvulus the other day at 4 a.m. My final tally of cases for the seven weeks
is 107.
Some of the trauma cases have included an 18 year old run over by a tractor with a pelvic fracture, a guy
who was hit playing soccer and had a shattered kidney, a guy who fell from a tree with a bad liver injury, a
few kids with splenic injuries, and a couple of stab and panga (machete-like tool) injuries. I’ve also had to
do two burr holes (decompress the skull for a severe head injury) in the last few weeks, one on a four year
old. The obstruction cases for the past two weeks have also mainly been incarcerated inguinal hernias. I’
ve operated on 4 in the past two weeks.
By the way, I’ve also learned some interesting facts about Malawi in the past few weeks. Besides being
one of the 10 poorest countries, it has one of the lowest doctor to patient ratios at about 1 to 40,000. In
terms of funding, however, Malawi is scheduled to receive US$400 million over the next four for HIV/AIDS.
We are still looking for funds to improve the curative side of health care, but donors don’t seem too
interested at the moment.
As for things outside the hospital, I got to go to the lake one Sunday. That was great, sitting out by the
pool at the Le Meridian Livingstonia hotel, over-looking the water. I didn’t go swimming in the lake partially
because the pool was so nice and partially because of the risk of schisticomiasis. Schisto is a parasitic
disease which is transmitted to humans through small worms from snails and is found in fresh water in
many places throughout the world. There is a medication which can treat it, but if left untreated it can
cause severe medical problems including liver failure from portal hypertension (blocking a main blood
vessel to the liver) or irritation of the bladder leading to bladder cancer. This is a reason for the many
cases of bladder cancer that we see here, many in patients only in their twenties or thirties. Sometimes we
can resect the tumors, most of the time they present too late. But, needless to say, the lake was beautiful
and it was great to escape for a day.
I also had the opportunity to get away for four days to go to Zambia. I was excited because it was the first
time I had ever been to a country that’s name began with a “Z.” I traveled there with seven medical
students who are rotating through LCH for the month. They are fourth year students from the University of
Pittsburgh. We left early Thursday morning and returned late Sunday afternoon. It was great having the
four days away from the hospital. We stayed at a camp on the Luangwa River with hippos right out front.
We went on four safari drives, three during the day and one at night. Even though it’s currently the rainy
season and we were not supposed to see many animals we saw quite a bit, including hippos, crocs,
elephants, giraffes, zebras, baboons, water buffalo, impalas and other antelopes, and a few lions. During
the night drive, where they use a spot light to find animals, we followed a lioness and saw her kill an impala.
Of course when I got back to work on Monday everybody keep telling me how much I was missed because
on that Saturday there was a big mini-bus accident with a number of patients needing to go to the OR and
things were pretty crazy. Unfortunately Arturo was by himself.
We are in the process of looking for other people to come out here and help. We have approached the
United Nations and the U.S. embassy to try to get funding for short term stays for American surgeons. If
we can get something going I would plan to come back for two months again later in the year. Arturo was
also recently spotlighted in the February issue of General Surgery News and about 10 surgeons have
expressed interest in coming out the LCH. If any one is interested the article can be accessed at www.
generalsurgerynews.com.
Arturo and I met with the Minister of Health the other day; he presented me with a letter thanking me for my
assistance to the people of Malawi (Appendix III). We also discussed the possibility of having surgeons
come out for short term stays and he stated that the Ministry was in the process of getting an apartment
ready for such a program.
This will be the last update for a while as I will be back in New York on Monday. I will try to send out
updates from Nicaragua. I am scheduled to be there from April 13 to May 8. It should be interesting to see
the differences in medicine between Africa and Central America. The plan will include a short stay in
Managua and then two stays in remote landmine affected areas where I’ll be available for any demining
accidents. I will also be teaching first aid and trauma care and helping out with essential surgery for the
local population. The plan is to set this up through the Organization of American States and try to get it as
a fully functioning program with surgeons from the states going for a few months at a time. If anyone is
interested in hearing more details, just give me a shout.
Take care and best to all,