Two weeks ago I returned to Malawi - almost two years to the day since departing for tsunami stricken
Indonesia in March 2005. Aside from Madonna having put Malawi on the map; not much has changed.
Fortunately for the Malawians, Dr. Muyco (the Filipino general surgeon who arrived at the Kamuzu Central
Hospital (KCH) twenty three years ago) is still here and operating like a fiend. Incredibly he is maintaining a
pace that to me still seems super-human. That is until Monday when the hospital administration announced
that daily overtime pay (locums) would no longer be provided for operating room nurses. The result is an
immediate cessation of elective procedures.
Thing had been going fairly well; relatively full schedules were being completed on Mondays, Wednesdays
and Fridays for general surgery and urology cases. Currently there are four operating rooms; four general
surgeons (six if you include me and a NYU surgical resident here for a rotation); two urologists; plenty of
clinical officers, interns and students; anesthesia; but only two operating room nurses. The result is that we
can now only do emergency operations. I spent yesterday discharging patients either back to district
hospitals, or with instructions to return to KCH in two months when hopefully conditions would improve.
This crisis is again an example of the limited resources in countries like Malawi and the brain-drain in which
qualified health care personnel are lacking to care for the health needs of millions of people.
Basically, this is an issue of resource management. Malawi is an incredibly poor country, with a population of
12 million, most of who subsist on less than a dollar a day. The government annual per capita expenditure on
health care is 5, yes, that 5 US dollars per person per year. Not a heck of a lot of money. As I’m sure you all
know tertiary care and surgery is relatively expensive. Yes, we could argue that the guy whose incarcerated
hernia I fix will be able to go back to work and be a productive member of society, but with five bucks a head,
there are a lot of other folks who are going to get nothing, and that’s in a country with a very high childhood
mortality rate, people dying of malaria, diarrhea and other (by Western standards) easily preventable or
treatable conditions.
So what do you do? What’s the answer? Honestly, I’m not sure. I think, however, it has to be a local decision.
Not one for a “gringo” like me to make – certainly. On the other-hand, that doesn’t mean I can’t help. I’m
planning to continue teaching, making rounds and I’ll be on call for six of the next ten days. At least that will
give the other general surgeons who are here a bit of a break, and allow Dr. Madinda (a United National
Volunteer general surgeon from Tanzania) to take his first vacation in almost a year.
One of the nicest things about being back has been the outpourings by the hospital staff expressing such
delight that I’m back - of course that is followed by the admonition that I should stay for longer than the two
months I am planning.
For those of you who don’t know, or remember, this is my fourth time in Malawi. Initially I came here in
December 2002 when I got word that there was only one general surgeon at the 1000 bed central hospital
which provided services for approximately five million people. That first time I work with Dr.Muyco, the second
time I was pretty much on my own. Two years ago, my third time, I spent almost two months at the Malamulo
Seventh Day Adventist Hospital and then a month at KCH, but by then the UN volunteers had arrived; things
were a bit more manageable.
So, what else has changed here in two years? Surprisingly little. Harry’s bar is still in the same location,
volleyball is still played every Wednesday at the Shack, there are a few new buildings, and three new traffic
lights. Basically time here stands still. The other unchanged item is the large number of patients, the poor
conditions of the hospital, and the fantastic ability of the local staff to take care of so many patients in such a
trying environment. As always, I’m amazed.
Last weekend, I was able to escape for a few days and see the north of the country. I visited the Central
Hospital in Mzuzu; it was completed in 2000 by the Taiwanese and is staffed with Taiwanese physicians and
surgeons. Friday morning I made rounds with Dr. Fan, a cardiothoracic surgeon who I had met previously
and who has been in Mzuzu for three years. As with KCH, they were doing lots of trauma, sigmoid volvulus,
and prostatectomies.
Best to all and I’ll be in touch.
Adam
Malawi 2007 Update #2
It is an often mistaken belief that crocodiles are the most dangerous animals and that hippopotami are cute
docile creatures. The reality is that more people die every year from attacks by hippos than from crocodiles –
at least that’s what I’ve been told. Actually though, a few nights ago the distinction didn’t really matter. I was
on call and heading to the hospital at night to operate on a woman we were presuming had a midgut volvulus
(twisting of the small intestines) – she did as I ultimately found out at 3 am; there was however, a delay.
The delay was caused by a guy who was transfer in from Deza District Hospital (about an hour south of
Lilongwe.) The story is he was out in a river or marsh cutting reeds and a croc took a bite of his right leg. His
lower extremity wasn’t totally amputated, but looked like it had been used as a toothpick. Given the extent of
the injury and the long time before he arrived at KCH our only option was to amputate. He is currently doing
well.
So there I was thinking things like this just wouldn’t happen in New York. First of all, its rare enough to have a
case of midgut volvulus in an adult – although it could happen and I remember doing one case as a resident
– but a crocodile bite; never. Unless of course someone got into the crocodile tank at the zoo, but the
likelihood of that, well, not worth considering. I was though sort of reminded of the time shortly after I arrived
in San Antonio for residency and was called to see a guy in the Emergency Department with what was billed
as a Rodeo Clown injury. Many injuries are often related to the local environment.
Anyway, I digress. So the crocodile victim is having his leg amputated and I’m waiting to operate on the
woman with the volvulus when I’m told there is another trauma patient that just arrived from Kasungu District
Hospital (about an hour north of Lilongwe.) So, I go to casualty and take a look. The story is he was riding a
bike and was attacked by a hippo. Yes, as in hippopotamus; and it wasn’t pretty.
He was relatively stable, breathing, and talking which was somewhat of a surprise. The reason being that his
most striking injury was an open fracture of his skull (left frontal region) with brain protruding; he also had an
injury to his right hand and right thigh. We took him to theatre and examined all of his wounds more closely.
The head wound was irrigated and debrided and I was able to get the large piece of skull back in place and
close the scalp over it. The hand injury consisted of an open fracture-dislocation of the 5th finger. The finger
was amputated and the wound debrided. The thigh injury was rather interesting (again an example of why
you never want to be an interesting patient.) There were a series of six small holes which I presume were
from a bite. Initially it looked like all we would have to do was debride the edges. However, on closer
inspection the holes extended all the way to the bone (there was no fracture on x-ray) and the muscles
underneath were torn and bulging and I had to connect the dots and open the whole thigh, open the fascia,
and irrigate and debride thoroughly. It was quite a case. After that we operated on the woman with the midgut
volvulus. Currently everyone is doing well. (I’ve also posted some pictures on the blog at: http://360.yahoo.
com/adamkushner )
So, I guess these cases aren’t surprising given that I’m in Africa but I must admit they are not daily
occurrences – we had a very lively discussion the next day at our morning conference – although not as
spirited I’m told as the discussion a few weeks ago dealing with a hyena attack.
Otherwise, all is well. The operating rooms are still not functioning normally and there is a bit of tension in the
air, but we are still able to do the emergencies.
The other day I also visited Dowa District Hospital (an hour and a half northwest of Lilongwe). As a bit of
background, Malawi has fairly good health facility coverage for a country which is so poor. There are local
health centers in many villages (with varying quality) and a series of 28 district hospital and 4 central
hospitals (KCH, Mzuzu, Zomba and Queen Elizabeth in Blantyre). There are also 14 mission hospitals
throughout the country. One of the things that started at KCH a few years back after the UN volunteer
surgeons arrived (and Dr. Muyco as no longer by himself) was to make routine visits to the district hospitals.
For the central region where KCH is the referral hospital the districts include: Nkotakota, Kasungu, Ntschisi,
Dowa, Salima, Mchinji, Dedza, and Ntcheu. They along with three mission hospitals (Likuni, St. Gabriel’s and
Nkhoma) form the referral network for approximately 5 million people. In terms of surgery, the district
hospitals usually have a district health officer and clinical officers who can do c-sections and some smaller
general surgery cases, but most major surgical cases are referred. Using generous estimates of 500
operative cases a year per district hospital, 1500 per mission hospital, and 10,000 for KCH, that translates in
a rate of 370 operations per 100,000 population. That is in contrast to the figures from the US which are
about 8,200/ 100,000 (and only include major operations unlike the Malawi estimate.) That begs the
question, why are there so many more procedures in the US, and what’s happening or not happening in
Malawi? But those are questions for another day.
In terms of my visit to Dowa, it was great. With the district health officer, saw about 20 clinic patients, made
ward rounds, and then operated on four patients. We did an inguinal hernia repair, an epigastic hernia
repair, a scalp cyst removal, and drainage of a large chest well abscess. It was nice to do some teaching. It is
hoped that as the district visits continue the clinical offers will gain the necessary skills to do more of the
smaller cases and relieve the burden on the central hospital.
Apart from working at the hospital, I was able to escape for a weekend and visit friends in Blantyre. It was an
adventure. If I had forgotten that I was in Africa; I was smacked awake. I had decided to take the luxury bus
from Lilongwe to Blantyre – leaving Sunday morning and returning Monday morning. Well, the luxury bus was
broken so the bus company sent a not so luxury bus that instead of leaving at 7 a.m. left at 9:30. After about
an hour on the road the bus broke down. We waited almost three hours until mechanics arrived and fixed the
bus. We then continued south. After another two hours the bus broke down again. We had to wait another 3
hours before another bus came and picked us up. The advertised four hour trip took almost 12 hours. I
arrived at 6 pm. But it was fine. I stayed with the Vigna’s (Leo and Chicki) – I’ve mentioned them before: he’s
a surgeon, she’s an anesthesiologist. They are both from Argentina, worked for 12 years in Nepal, and have
now been in Malawi for almost 10 years.
Leo is also spearheading the effort to build a cancer center in Malawi. After two years of hard work there was
an official launch in February that the Malawian president attended. Malawi has also been accepted into the
International Atomic Energy Agency (IAEA) which was a first step in obtaining radiation therapy for cancer
patients in Malawi. There is no radiation therapy and limited chemotherapy in Malawi and as the machines in
Zimbabwe and Zambia are no longer functioning patients if they are to receive any care must go to either
Tanzania or South Africa. If anyone is interested in helping with this project, or has a spare US$ 7 million to
help get it going, don’t hesitate to give me a shout and I’ll get you in touch with Leo.
Anyway, the visit was great, except that during dinner we got a call that a patient had arrived with a gunshot
wound to the abdomen and right leg with a possible femoral artery injury. As Leo rushed off to the hospital, I
couldn’t just sit by. We operated until 2 am, and the patient did well.
As we were up so late I decided that instead of taking the 7:30 a.m. bus, I would take my time and get the one
leaving at 4:30 p.m. I was assured that all would be fine – and was even given a discount for my troubles the
previous day, along with an apology. Well, the lesson I later realized was, “Fool me once, shame on you. Fool
me twice shame on me.” Of course after about two and a half hours the bus broke down, we waited hours for
a mechanic who finally arrived and was unable to fix the bus. Luckily there was a woman on board from the
NGO Action Against Hunger and I was able to grab a ride when they sent a car out for her. I arrive back in
Lilongwe well after 2 a.m. Ah, Africa. It’s always an adventure.
Well, that it for now.
Best to all,
Adam