malawiupdate2005

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.

Anyway, at the moment I am in Lilongwe, the capital of Malawi . It is a city with a population of
approximately 400,000. I have rejoined the surgery department at KCH (a hospital with 970 beds) and for
those of you who received this updates in previous years, things are both very different and similar. The
main difference is that there are now other surgeons. Last year when I worked here it was only Dr. Muyco,
and then he went on vacation and left me alone for about 3 weeks. Now there is Dr. Madinda (from
Tanzania), Dr. Hanano (from Germany), and Dr. Ivan (from Russia). Plus there are two urologists: Dr.
Kamara (from Sierra Leone) and Dr. Maher (from Egypt). The surgical department has been organized
into three units. Unit I: Drs. Muyco and Ivan. Unit II: Drs. Hanano and Madinda. Unit III: Drs. Kamara and
Maher. I have joined Unit I and work mainly with Dr. Muyco. It’s amazing how much easier rounding on the
patient is when you only have to see a third of them. The wards are still overcrowded and there are still
more cases to do than operating time, but at least there are a sufficient number of consultant surgeons.

One problem, which had been ongoing, is the chronic lack of nurses. Previously one way to deal with the
problem was to have nurses do extra shifts: locums. Usually the nurses would volunteer for these shifts,
occasionally they were mandated to do this. However, there is a major uproar about the practice, mainly
because of the issue of salary. The current pay for doing a 12 hour shift is 600 Kwacha, about US$5.50;
and it’s the same for days, evenings or weekends. The nurses are refusing to work for so little. This has
translated into a shortage of nurses in the operating theatre and instead of being able to run three rooms,
we are limited to only one or maybe two. With three units all trying to do their cases it becomes rather
difficult and a schedule has been developed to allocate theater time. It is uncertain when this crisis will end
as the Ministry of Health has offered minimally more money but the hospital staff is so far refusing the
accept the new terms. By the way, this is also affecting the work schedule of the clinical officers, registrars
and interns who under the ruling of the Malawi Medical Council are only required to work a maximum of 4
calls a month. We will see what happens.

This problem is also causing a lot of headaches at the Ministry of Health at a time when things are rather
uncertain. For those of you familiar with Malawi, the Principle Secretary for Health, Dr. Pendame and a few
other high ranking people were recently replaced amid various unsubstantiated rumors. It seems likely,
however, that the changes are the result of the new Malawian President, Bingu Mutharika’s desire to clean
house. Many other ministries are facing similar changes as well. In fact things have gotten so bad between
Bingu and the previous President, Bakili Muluzi, that Bingu left his party, the UDF, and is planning to start
his own.

Despite all the problems, however, not everything at the hospital is bad. We have been able to do the
traumatic and more urgent cases, even if the smaller cases such as skin grafts, hernias and even some
resections for cancer have had to be delayed. Next week we will try to do an esophagectomy for cancer.
Hopefully we will get the theater time.

My role in the department has changed quite a bit from last year. Instead of being on call every day and
operating almost everyday, I’ve been able to spend more time teaching students and interns; I help out on
rounds, and have had a chance to go on district visits. I will only have seven calls during the four weeks in
Lilongwe and although I am not operating anywhere near as much as last year, I did get a chance to do a
thyroidectomy, a few hernias, an exploration for multiple stab wounds to the abdomen, an amputation, a
debridement for Fournier’s gangrene and a tracheostomy. I also repaired a recurrent hernia for a young
guy I met at the Mwanza border post when I reentered Malawi with my car.

At the border post there were about a dozen or more young guys who ran up to the car with offers of
assisting with customs clearance. One of the unsuccessful kids began asking me questions and when he
heard I was a surgeon told me about his hernia repair at Malamulo two years ago and how it has come
back. I told him that if he could get to Lilongwe either I or one of the other surgeons would repair it. Well,
Harold and his father (the deputy immigrations officer at the Mwanza border post), showed up 10 days
later at KCH. Luckily, I was able to book him and repair his hernia. We used a plug and patch which had
been brought over by Dr. Gemer, a surgeon who lives in New York and came out to KCH last summer and
stayed for 5 months. Dr. Gemer was one of the surgeons who had seen the profile of Dr. Muyco in General
Surgery News last March.

Some of the other cases we’ve seen have included a crocodile bite to the chest, a guy whose face was
eaten by a jackal, some sigmoid volvulus cases, multiple incarcerated hernias and a young guy who was
fighting over a girl in a bar and was stabbed in the chest. Dr. Muyco saw him initially in the casualty (ER)
and was able to get a chest tube in him. We were able to stabilize him and get him to the ICU, but he
continued to bleed and so Dr. Madinda ended up doing a thoractomy. The patient was very lucky; he had
a small laceration to the heart which was repaired.

Another consequence of having more consultant surgeons is that every Tuesday, Wednesday and
Thursday a team of one general surgeon and one urologist goes to a different district hospital. There are
eight district hospitals in the central region and so each facility is visited approximately once every three
weeks. This program has been going on for about six months now and is met with varying interest
depending upon the hospital.

I went to Salima one day and Nkhotakota the next. It was quite eye opening. Salima is about 100
kilometers east of Lilongwe , very close to the lake. When we arrived there were about 35 patients waiting
for our review. The purpose of the visits is supposedly to improve the quality of surgical care in the
districts and help instruct the people working there how to perform simple cases. Well, it isn’t really going
too well in Salima. Most of the cases we saw were very simple things that didn’t need a consultant to see,
let alone the three of us who had gone. The worst part was that after seeing the patients and rounding in
the ward we were told that the anesthesiologist would not be available until about 1:30 p.m. We decided
not to wait around for the two and a half hours and instead went into the town to have lunch. We returned
and ended up doing two hernias and a hydrocele; both simple cases that the clinical officers should be
able to handle. All in all it was a very unsatisfying visit. Of course in the operating room I did note that no
one was wearing eye protection and that they did not use the “hands free” technique of passing scalpels
only in basins.

The next day we drove to Nhkotakota. We left Lilongwe at 9 a.m. and drove over 200 kilometers on roads
which gradually became worse and worse. Our speed decreased as villages became smaller and more
infrequent. Nhkotakota is situated on the shore of Lake Malawi and has the inglorious distinction of having
been one of the largest slave markets during the 1800’s. One source I read estimated that at the height of
the trade over 20,000 slaves passed through the town annually. Today it is a sleepy place with a small
market and a few dozen worn and neglected one-storey buildings.

We arrived a little after 11 a.m. and went straight to the hospital; drove up to the clinical area and I
immediately thought about how this place made KCH look good. Here patients were lined up or sitting
outside the wards; a boy of 12 or 13 years, probably with some psychiatric problems, paraded around
naked.

We were directed to a room which was the office of the chief medical officer. We began to see patients. It
was uncomfortably hot and dark; the heavy cloth drapes were pulled shut and a single low voltage light
bulb cast shadows onto the faded aqua-green colored walls. At one point, a young man lay on the exam
table waiting patiently for our pronouncement. He had an inoperable liver tumor; there was nothing we
could offer him; he would need to go home to die. Dr. Madinda, Dr. Kamara and I all sat looking at each
other, no one spoke; the air was oppressive and depressing. I thought about Heart of Darkness the book
on which the movie Apocalypse Now is based. My thoughts were not on the war or the jungle or the
characters, but on the journey to an increasingly primitive environment. In Nhkotakota we had journeyed to
what seemed like the most primitive of medical facilities in Malawi ; a place which was so primitive it was
difficult to function.

The rest of our visit was uneventful. After the clinic ended we wanted to operate on a patient, but the
operating theater staff had left and locked the doors; there was no one else with the key. We decided to
go for lunch and then return to operate. The first restaurant we went to was in a lovely location on the lake
shore. We asked to see the menu but were informed that there was no food. We left the workers playing
pool as loud music blared and sought out a restaurant on the other end of town that we were assured had
food.

We were rewarded; there was food available, but only chicken and chips. We ordered and waited. After 15
minutes we were informed that they had run out of gas and so could not prepare our meal; we paid for our
Cokes and returned to the hospital. The OR staff never returned and the patient was nowhere to be
found. We waited for over an hour for the hospital accountant to return so that we could collect the money
for petrol. We finally left, again feeling very unsatisfied.

Again, as previously, I have been upset by the lack of protection and especially eye wear for the staff in
the operating theater. As part of my efforts to continue with SHARP, I contacted the Executive Director of
JHPIEGO. JHPIEGO is an organization that is affiliated with Johns Hopkins and one of their areas of
interest is Infection Prevention (IP). They have an office in Malawi and according to their website have
done a fair amount of work in developing training courses and improving things in Malawian hospitals. I
sent the email and didn’t hear a response.

However, last Friday, after I had changed into my scrubs and was heading into the OR, the operating
theatre matron asked why I wasn’t at the meeting with the hospital Director. “What meeting?” I asked.
“The one with the hospital Director because of the email you sent to the States complaining about the
malpractice in the hospital.” “Huh?”

Well, there was a big misunderstanding and jumping to conclusions. My email had been forwarded to the
JHPIEGO Malawi office and the IP person had come to the hospital and had asked to meet with Dr.
Kushner and the hospital administration to see if there were areas where we could collaborate. The first
part of the meeting consisted of convincing the head nursing matron that I had not sent the email as a
criticism but rather as an observation and was attempting to get some help to deal with the issues. Luckily
all went well and we have decided to identify the needs in the hospital, use the JHPIEGO training materials,
set up in-service training for operating room personnel and also attempt to approach the National Aids
Commission to get funding for equipment. Basically it was total buy-in on what I had wanted to develop
with SHARP but with the hospital and JHPIEGO taking over much of it. The next issue will be to get things
going and submit a proposal to JHPIEGO whereby hopefully I can get some funding to assist with the
training. That would allow me to return to Malawi, work on the project and also assist in the department of
surgery. Hopefully this will work.

So, that’s basically the latest from Africa . I have to admit that I am having more fun here than at the
mission hospital, although I did get a chance to get back to Blantyre and spend a lovely weekend with Dr.
Vigna and his family. I also had to collect my things from Malamulo, including a wooden hippo that was a
going away present from everyone at the hospital. It was a very nice and unexpected gesture. The only
problem is that it weights literally about 15 lbs. I will certainly have to ship it back to the States by surface
mail. It’s way too heavy to take with me on a plane.

As a final note as well, the Oncology project is progressing nicely. There was another meeting which
unfortunately I could not attend, but trustees were elected and by-laws are in the process of being
finalized. Once that is done plans are proceeding to develop the best type of facility and begin the
process of raising funds. I will let people know what develops as I hear the news.

Hope everyone is well,