I realise I haven’t managed to enter details of my clinical work for quite a while on here. That was not purely out of fear of alienating my non-medical audience (as I’m told the medical jargon does interest the wider public too- hence the popularity of medical sitcoms!), but also due to the intensity of my life at and outside work recently. Hence I’ve been saving up the stories to deliver them in one package...
Man off the street
This case provided so many windows into the realities of working in the Malawian health care setting that I wish I had encountered it earlier and set the picture for you much right then on that subject. The man was a 60 odd year old who had been on our wards for some time under the general clinicians with some poorly healing leg wounds. Unfortunately he also suffers from an undiagnosed psychiatric illness. As a result he has also been abandoned by his family and community and ended up in the hospital without a guardian. This usually is a non-starter here. The patient has no one to assist him with self-care as the staff manning the ward are usually too busy to add that job to their list. Hence these patients invariably suffer from some form of neglect. As it is this man, quite reasonably I believe, decided that nothing was being done for him at the hospital and took his own discharge. Having nowhere to go and with severely impaired mobility, he ended up abandoned near the main road around the hospital. Apparently he’d lay there for about a month before he first came to my attention. It was a Friday night and I was heading out for a drink when I saw this man with horrible looking dressings around both his feet, full of mud and completely tattered leaving the inside partly exposed. His wounds were so bad his leg bones were actually visible. That is bad news in any orthopaedic book I know! Thus I decided to get him into hospital and work him up for a debridement at least until we can stabilise him for bilateral above knee amputations, which is the only thing that could save his life. That’s when the whole can of worms opened up. Firstly there was no one willing to carry him 100 yards to the hospital on the streets, because let’s face it, no one wants to assist a mad man like that here! I eventually paid some guys to take him in. Once in the hospital more obstacles would crop up. The admitting clinician for one did not feel like handling him alone and in the end I had to assist her with the initial clean up and change of dressing until 8pm. That was a gut-tester in its own rights and revealed an important fact to me- that maggots residing in his bandages had potentially saved his life! I don’t know how beneficial the other bugs in there would have been though. Having somewhat cleaned him, I starved him for the next day thinking someone would echo my thoughts that this guy needs an operation urgently. To my surprise that was far from being the case. Having decided to come in on a Saturday just for that, I had to first face up to a spate of pathetic mockery, where this naive muzungu had believed he could save this man’s life who deserved to die just because he’s mad and does not have a guardian!! When I refused to laugh, it became clear I wanted an anaesthetist to work this man up (He was not a diabetic and had normal bloods- hence confirming that the state his legs were in was in large part due to neglect). Further neglect would claim his life and I was not prepared to allow for that. Thereafter it was a whole barrage of excuses that simply got laid in front of me so we can’t go ahead with the operation. Ranging from medico-legal concerns about consent through social issues about his post-op care (which I had thought about and addressed by planning to refer him to our mental hospital post op and then organising a wheelchair for him) to the non-availability of suxamethionium in our anaesthetic department (it’s like having no blades in a surgical department or no plaster in the orthopaedic department- which, sadly, is also known to happen up here!), the reasons kept piling up. In truth, the main reason was that no one was interested in this mad man (me or the patient?!). So, having concluded that it might be weeks if not months before anyone decides to assist me with this patient, who will inevitably conclude once more that there is no point in him staying in hospital, I referred him to Blantyre for some more specialised people to handle his care. It turns out then that just on the day that the defaulting anaesthetist from Ntcheu rethought his position on this case and congratulated me for rescuing the poor man before the rainy season (which would have wiped him out like a fly), I visited the ward he ended up in Blantyre... only to find that the resistance to assist a guardian-less psychiatric patient was no different there than it is in Ntcheu. The legs were back to almost their original state of decay with little care being administered to him and the plan was just to send him back to Ntcheu without the amputations. For what may I ask if not to die a peaceful death?! I’m afraid not while I’m there.
Amputations
Speaking of amputations, I’ve also dealt with a small series here which have very much enlightened my practice. We’re talking of low-resource settings here and everything you do has to be adapted to this. So when you do your bone cut in a below knee amputation, you have to make sure you have enough Giggli wires to get you through it all. Because if you don’t, for example because the wires have snapped (common problem), then you don’t have an electric saw to finish it off. And this is what happened in my first case. The bone was rock solid and my only tool left after my 3 Giggli wires succumbed to heat exhaustion was a blunt osteotome! So I ended up doing a closure under tension and hoped for the best. Close monitoring allowed me to anticipate a breakdown of his wound, and I took him for a revision before that happened. Thankfully the case was salvaged. So on my next case, I had extra wires and very sharp osteotomes on board and proceeded without much difficulty. Then I also learned that by holding the wires straighter (with upward pull) rather than in an acute curve around the bone, the heat generated was less and the wires didn’t break. Having an assistant pouring cold water slowly on it also helped. As for the osteotomes, they helped in dealing with the fibula issue, which I always used to cut in one stage proximally, with the inherent danger of disturbing the neurovascular bundle in that fairly blind method. What of course turned out to be better was to do a safer osteotomy distally, take the leg off (sorry for that graphic wording but that is exactly what it is!) and then shorten the fibula in a second stage. It’s a bit unfortunate that I’m refining my practice in this way, since any hope of supervision in a district setting is unrealistic. Some people would argue that these patients should be left alone instead, but the outcome of that would be near-certain death from spreading sepsis as the central hospitals could not cope with such referrals if all districts were to send every amputation to them. In most cases also they are straightforward and uncomplicated and the recent series only illustrates some difficulties that sometimes arise. Just in the same way as most Caesarian sections are dead easy, until the massively bleeding one comes along and everybody then gets agitated and starts asking why we’re not sending them all to a central hospital to be dealt with. The answer is that, in practice, and with our resources, this is simply not possible and some complications have to be accepted to be able to continue to provide for the wider majority of cases that go without (this is called the theory of innocent shields of threat in philosophical bioethics parlance).
I did one final amputation in that time which will add to my bad series and again I don’t think this reflects on the general quality of amputations at the district setting. It does however highlight one management misjudgement of mine, which was not to be aggressive enough from the start. My patient was a forty year old diabetic man with a gangrenous septic little toe. His leg however was more severely infected as evidence by his Xrays which showed osteomyelitic changes as proximal as his midfoot. For some reason (partly mixed with influence from other clinicians), I opted for a ray amputation and loads of antibiotics to try and save his leg. That proved to be the wrong choice as he immediately developed a wound infection. I then thought that I wouldn’t wait any time and bring the amputation level proximal and do a Syme’s for him. That again was not proximal enough and unfortunately, he ended up developing gas gangrene (classic soft tissue crepitations). This time, I put my gloves down and decided to refer him straight away to the central hospital for a higher level amputation and better diabetic control (since all we had left was out of date Glibenclamide). I found out later he had an above knee amputation, which was healing well. Strangely, some 10 days post op, he went into a diabetic coma and succumbed to that. I can’t help wondering whether that could have been helped by an earlier referral.
The rest of my surgical work has been a mix of skin grafting, soft tissue work and even an open reduction internal fixation. The skin graft was for a long standing burn wound which was not healing with simple wound care on the ward and which I was referred late. I did a combination of split skin and morsellised skin grafts (similar to pinch grafting in principle but with the donor site further from the wound, where an elliptical full-thickness skin is excised, defatted and chopped in morsels which are then just laid on the recipient site). The main advantage is the donor site which heals much quicker than the split skin (which also with poor equipment can end up much thicker than intended). The soft tissue case was a polysyndactily of the 5th toe, where the importance of careful surgical planning was demonstrated at its best. I was lucky to do this with my clinical officer colleague who could hopefully retain this as a learning point. We identified the dominant toe and all its components that needed excising from a pre-op Xray, which I insisted on having in theatre (often it’s left on the ward). The incision was a S-shaped flap which closed beautifully. The final case, the ORIF, was a tension band wiring for a shattered patella. With no Xrays and a single K-wire which had to be cut and used twice, we ended up cutting through one side of the patella- but by protecting the leg in a backslab post op, and advising protected weight bearing, we managed to maintain the reduction and restore his extensor mechanism.
I feel that I may not be operating as much as I would initially have liked to in Ntcheu. However, with the extent of ward clinical as well as organisational work I am involved in, which arguably is much more important that operating in a district setting, I am quite happy with the extent of this surgical work and its coverage. Every new case provides a learning opportunity to me in this unsupervised setting and by applying my own safety criteria stringently to each case on its own merits, I have the reassurance that I am not going beyond my capabilities.
13 December 2010
22 November 2010
A week less ordinary
5 days and 5 nights in Gongonya village (T/A Kwataine)
I’ve toyed with the idea of “sleeping rough” during my placement here in Malawi since I’ve arrived really. I thought that would be one way of getting closer to the traditional way of life of the people I meet everyday in the hospital and also to better understand some dynamics. For the first few months, I couldn’t even entertain the idea with the rainy season still in full force. After that, I got myself into a routine of work and travelling/meeting people, essential for my early integration, which left me with hardly any time for such ventures. Knowing that the national conference would be a real climax in my agenda here, I finally thought that if I don’t do it in the anticlimax period, before the rainy season reappears and more importantly before Janet arrives, then I might never get to do it. So I hit the iron!
The experience was a unique self-styled escape into a world far removed from the conventional tourist or expat worker trail of Malawi. My expectations were mostly based on 2 previous cultural village visits, but even those were heavily geared at tourists with plenty of extras. This time round, I would taste the real thing- or as close to it as I may ever get. Thanks to Patrick, a great friend at work who works as a HSA (health surveillance assistant) at Madzanje village, I got my keep organised there. Patrick, in that genuine self-offering way typical of most Malawians, decided to join me on my mission and shunned his own comfy bed in town for this. The adventure was partly what lured him but also the opportunity to develop our friendship. Malawians, I have found, will really go to great lengths for this.
The plan was to commute to and back from work in the way the villagers themselves do. That meant mostly matola rides in the evenings, whereas in the mornings, it was essentially a chance affair. Since the time we set off was the peak time, all public transport was too full to stop. We’d end up hitching lifts or trying our luck with any vehicle with a spare seat (for which they charge). It seems that my muzungu status helped at least one tiny beat, not in getting me a lift from the passing cars, but in getting a big bus to stop on two occasions at this roadside lay-by which they normally give a wide berth to, leaving such petty duties for the minibuses. From the main road to our village, we would cover another 2.5Km on foot- a perfect daily constitutional as it were. The first time to the village and the time when leaving didn’t feel quite like this though, more like a full work-out rather, since I had my full week’s luggage with me as well. True to my villager emulation, I ended up carrying it on my head, and indeed that proved to be the most efficient way of going about it. Also one day, Patrick and I cheated, partly for the fun of it, since Henry, my flatmate, offered to lend us his motorbike. Given Patrick’s gregarious elation at this mode of transport, I discreetly declined a repeat offer the next day. The transport experience alone was enough to paint a picture for me of what difficulties the local villager might experience getting to the district hospital when ill. Madzanje, from which it takes a maximum of 3hours to get to the hospital, should really be considered nearby, when you consider such places as Kasinje, which are up to a 100Km away.
Nelly & Agogo- my super hosts
Let me now describe the actual village. I should point out first that I began by telling a few people at work where I was going on Monday, since they were all intrigued why I was carrying a travel bag to work. After noting their puzzled, somewhat disgusted, reactions at being told that I was going to swap my own comfortable house for such basic conditions, I decided not advertise it anymore. When one has to work so hard to get away from such an existence, it becomes quite understandable why they would never do such a thing voluntarily. But I really wanted to experience this way of living at least once properly. And in fact it’s not as bad as it’s made out to be. My hut was essentially a mud brick two-bedder with a thatched roof (very leaky, which is why I chose to do this before the rainy season) and my room a furniture-less rectangle with a concave mud floor on which rested my mat. The only challenge was hanging my mozzie net from was the roof beam and I reached it by way of saccadic jumps while stretched spread eagle against the wall. My rock climbing skills have come in handy like that a few times already! Once you’re used to lying on a hard surface, you just don’t think about it. After all some 80-90% of all Malawians do it. The only difficulty is lying sideways as the bony prominences of your pelvis do get sore after a while. But the thing about back pain, well I don’t know if it’s true! The concavity of the floor (from erosion) made sure I lay in the same spot every night! Patrick, who initially shared the same room, had to relocate in the other room (our dining area) the next night. The concave floor simply meant we would be converging to one same spot on the floor- a bit too close for comfort if you ask me...
Mat & Net!
The other proclaimed deterrent for staying in a village proved also not to be a big issue for me- the food. Essentially I had Nsima every night, with a green vegetable dish (sometimes cooked with a delicious groundnut sauce) and a tomato-based relish (lerish here!). On the first 3 nights, the latter would comprise dried local fish, with eyes still on, as its main ingredient. I have to admit that it took quite some hesitation before my taking the plunge, but once I did it turned out to be quite tasty. I reckon that as zungus, we tend to be put off from these foods purely from the sight and smell of them in the markets, looking quite untidy, with flies around. But that doesn’t mean it’s not cleaned properly before cooking. In fact it’s partly boiled and that softens the meat and gets rid of the smell. The last 2 nights were nonetheless somewhat easier for my own diet, with beans being brought in to replace the fish. The most memorable part of that food experience had to be the freshness of it all. Almost all of it was made from local ingredients (except for the fish) either cultivated the same day or dried and preserved beforehand. It has unwittingly turned me into a real Malawian food fan.
Patrick about to eat all my dinner
Regarding, hmmm, the more basic facilities, I have to say that the absence of a toilet with a septic tank was not an inconvenience I even noticed. Considering the amount of hassle I have with keeping the one I have at home working properly, with frequent water shortages, a defective flush mechanism and leakages, this hole in the ground was clean, not overly smelly and piece of cake to maintain! As for washing, again since I’m so used to having bucket showers by now, I even underwent an upgrade from my routine by staying there. My hosts were so obliging they made sure I had hot water in the mornings to wash. When you’re out in the crisp morning air, before the day heats up, few things come close to those 5minutes of bliss behind a reed enclosure splashing tepid water over your body! The day ahead seemed like the least of details to tackle.
The rest of my agenda in the village was made up of a number of encounters to allow me to peer closer into the village way of life. Among other things, I discovered the morning beer call of sowing/harvest time, the Nsima chain, the village headman’s quarters and, more impressively, the Traditional Authority for the entire region! Right now is the rainy season preamble, where all the farmers are frantically preparing their lands for the big downpour, so they can get the best harvest in a few months. This is a survival necessity in this part of the world- to the point that I have even had to discharge patients well before they were ready to go home because they and their guardians could not afford to desert their land, their food basket. With this routine comes the inevitable need for distraction in the evenings. Hence the morning beer call. Since there are no designated pubs as such here, different houses take turns in providing the evening refreshment, namely a home brew called “Masese”- not very different from Chibuku I would guess. I was not allowed to go and check by Patrick, who insisted he had my best interest at heart! The one big difference with drinking in town there was the fact that more than half of the participants were in fact women. Obviously since they are the ones who’ve toiled the hardest all day clearing these fields! I especially keep this heart-warming image of two giggling 50-odd-year-old women stumbling past my hut one night singing Waka Waka without a care in the world. Exhausted. Happy. That strangely reminded me of my own university days with my buddies after a weekend session!
I think I must have seen every part of the Nsima chain and as I understand it, it goes like this: Maize harvest, drying of corn cobs, plucking of kernels, soaking of kernels in water in big vats, drying out of the soaked kernels on mats, grinding (either by laborious pounding in a mortar or if one can afford it, at one the numerous maize meals scattered across the village) and a final round of drying again. If one only recognised the labour that went into making every single scoop of that most Malawian of all dishes, I think one might appreciate it a bit more!
As for the village headman, I actually met him on the night the drunken women lilted past my house. He had not been spared a similar fate, having been at it most day too. He was in a most jovial mood when meeting me, which I found incredibly welcoming. He even appeared to be the more grateful out of us two and he was effectively my host! Oh Malawi, what a warm heart you have! The traditional hierarchy of authority in Malawi and many other African countries, I believe, starts from small units, which coalesce gradually until one large block is formed. The final division then tends to be tribal or national. In Malawi we have the following steps: village headman, group village headman, sub-traditional authority, traditional authority(T/A) and finally chief (usually one of the T/As). This is separate from the political hierarchy comprising MPs and the rest. Chiefs however are somewhat politically appointed too and there is an inevitable marriage of politics and tradition.
On my last day, I managed to rub shoulders with the traditional authority for the area, T/A Kwataine. That was an honour and a half when you consider his status around the place. Meeting the man felt deceivingly like meeting my next door neighbour. Not to my surprise, he welcomed me with a most comforting familiarity and showed me all the way round his quarters. I was particularly impressed to be in the company of a kindred spirit in terms of environmental preservation (he grows many indigenous trees around his compound and encourages the same around the region he controls). His other project, which he would compel me to mention here were to know I was blogging, is the health centre he’s building near his house. Effectively a multidisciplinary clinic with capacity to deal with general medical conditions as well as labour and deliveries. Quite laudable really.
Green Chief
All good things naturally have to come to an end. And to mark my village sojourn’s one, I decided to share some of that joy with my friends from Ntcheu. With the all-obliging Patrick again, we lined up a group of 10 Ngoni dancers to delight us with a traditional performance. The fact that everyone joined in is testimony enough to its success. The whole dance was complemented by a fabulous meal, the best one of my week, i.e. a combination of my favourite choices from the week gone.
Ngoni Warriors
To say merely that it’s been a great week would miss all the other things it’s been- cultural discovery, personal adventure, new friendships, new insights, new standards etc. I have certainly got over my anticlimax feeling pretty successfully through it. What I can’t promise though is that another anticlimax from that very week itself is what’s gonna set in next!
I’ve toyed with the idea of “sleeping rough” during my placement here in Malawi since I’ve arrived really. I thought that would be one way of getting closer to the traditional way of life of the people I meet everyday in the hospital and also to better understand some dynamics. For the first few months, I couldn’t even entertain the idea with the rainy season still in full force. After that, I got myself into a routine of work and travelling/meeting people, essential for my early integration, which left me with hardly any time for such ventures. Knowing that the national conference would be a real climax in my agenda here, I finally thought that if I don’t do it in the anticlimax period, before the rainy season reappears and more importantly before Janet arrives, then I might never get to do it. So I hit the iron!
The experience was a unique self-styled escape into a world far removed from the conventional tourist or expat worker trail of Malawi. My expectations were mostly based on 2 previous cultural village visits, but even those were heavily geared at tourists with plenty of extras. This time round, I would taste the real thing- or as close to it as I may ever get. Thanks to Patrick, a great friend at work who works as a HSA (health surveillance assistant) at Madzanje village, I got my keep organised there. Patrick, in that genuine self-offering way typical of most Malawians, decided to join me on my mission and shunned his own comfy bed in town for this. The adventure was partly what lured him but also the opportunity to develop our friendship. Malawians, I have found, will really go to great lengths for this.
The plan was to commute to and back from work in the way the villagers themselves do. That meant mostly matola rides in the evenings, whereas in the mornings, it was essentially a chance affair. Since the time we set off was the peak time, all public transport was too full to stop. We’d end up hitching lifts or trying our luck with any vehicle with a spare seat (for which they charge). It seems that my muzungu status helped at least one tiny beat, not in getting me a lift from the passing cars, but in getting a big bus to stop on two occasions at this roadside lay-by which they normally give a wide berth to, leaving such petty duties for the minibuses. From the main road to our village, we would cover another 2.5Km on foot- a perfect daily constitutional as it were. The first time to the village and the time when leaving didn’t feel quite like this though, more like a full work-out rather, since I had my full week’s luggage with me as well. True to my villager emulation, I ended up carrying it on my head, and indeed that proved to be the most efficient way of going about it. Also one day, Patrick and I cheated, partly for the fun of it, since Henry, my flatmate, offered to lend us his motorbike. Given Patrick’s gregarious elation at this mode of transport, I discreetly declined a repeat offer the next day. The transport experience alone was enough to paint a picture for me of what difficulties the local villager might experience getting to the district hospital when ill. Madzanje, from which it takes a maximum of 3hours to get to the hospital, should really be considered nearby, when you consider such places as Kasinje, which are up to a 100Km away.
Nelly & Agogo- my super hostsLet me now describe the actual village. I should point out first that I began by telling a few people at work where I was going on Monday, since they were all intrigued why I was carrying a travel bag to work. After noting their puzzled, somewhat disgusted, reactions at being told that I was going to swap my own comfortable house for such basic conditions, I decided not advertise it anymore. When one has to work so hard to get away from such an existence, it becomes quite understandable why they would never do such a thing voluntarily. But I really wanted to experience this way of living at least once properly. And in fact it’s not as bad as it’s made out to be. My hut was essentially a mud brick two-bedder with a thatched roof (very leaky, which is why I chose to do this before the rainy season) and my room a furniture-less rectangle with a concave mud floor on which rested my mat. The only challenge was hanging my mozzie net from was the roof beam and I reached it by way of saccadic jumps while stretched spread eagle against the wall. My rock climbing skills have come in handy like that a few times already! Once you’re used to lying on a hard surface, you just don’t think about it. After all some 80-90% of all Malawians do it. The only difficulty is lying sideways as the bony prominences of your pelvis do get sore after a while. But the thing about back pain, well I don’t know if it’s true! The concavity of the floor (from erosion) made sure I lay in the same spot every night! Patrick, who initially shared the same room, had to relocate in the other room (our dining area) the next night. The concave floor simply meant we would be converging to one same spot on the floor- a bit too close for comfort if you ask me...
Mat & Net!The other proclaimed deterrent for staying in a village proved also not to be a big issue for me- the food. Essentially I had Nsima every night, with a green vegetable dish (sometimes cooked with a delicious groundnut sauce) and a tomato-based relish (lerish here!). On the first 3 nights, the latter would comprise dried local fish, with eyes still on, as its main ingredient. I have to admit that it took quite some hesitation before my taking the plunge, but once I did it turned out to be quite tasty. I reckon that as zungus, we tend to be put off from these foods purely from the sight and smell of them in the markets, looking quite untidy, with flies around. But that doesn’t mean it’s not cleaned properly before cooking. In fact it’s partly boiled and that softens the meat and gets rid of the smell. The last 2 nights were nonetheless somewhat easier for my own diet, with beans being brought in to replace the fish. The most memorable part of that food experience had to be the freshness of it all. Almost all of it was made from local ingredients (except for the fish) either cultivated the same day or dried and preserved beforehand. It has unwittingly turned me into a real Malawian food fan.
Patrick about to eat all my dinnerRegarding, hmmm, the more basic facilities, I have to say that the absence of a toilet with a septic tank was not an inconvenience I even noticed. Considering the amount of hassle I have with keeping the one I have at home working properly, with frequent water shortages, a defective flush mechanism and leakages, this hole in the ground was clean, not overly smelly and piece of cake to maintain! As for washing, again since I’m so used to having bucket showers by now, I even underwent an upgrade from my routine by staying there. My hosts were so obliging they made sure I had hot water in the mornings to wash. When you’re out in the crisp morning air, before the day heats up, few things come close to those 5minutes of bliss behind a reed enclosure splashing tepid water over your body! The day ahead seemed like the least of details to tackle.
The rest of my agenda in the village was made up of a number of encounters to allow me to peer closer into the village way of life. Among other things, I discovered the morning beer call of sowing/harvest time, the Nsima chain, the village headman’s quarters and, more impressively, the Traditional Authority for the entire region! Right now is the rainy season preamble, where all the farmers are frantically preparing their lands for the big downpour, so they can get the best harvest in a few months. This is a survival necessity in this part of the world- to the point that I have even had to discharge patients well before they were ready to go home because they and their guardians could not afford to desert their land, their food basket. With this routine comes the inevitable need for distraction in the evenings. Hence the morning beer call. Since there are no designated pubs as such here, different houses take turns in providing the evening refreshment, namely a home brew called “Masese”- not very different from Chibuku I would guess. I was not allowed to go and check by Patrick, who insisted he had my best interest at heart! The one big difference with drinking in town there was the fact that more than half of the participants were in fact women. Obviously since they are the ones who’ve toiled the hardest all day clearing these fields! I especially keep this heart-warming image of two giggling 50-odd-year-old women stumbling past my hut one night singing Waka Waka without a care in the world. Exhausted. Happy. That strangely reminded me of my own university days with my buddies after a weekend session!
I think I must have seen every part of the Nsima chain and as I understand it, it goes like this: Maize harvest, drying of corn cobs, plucking of kernels, soaking of kernels in water in big vats, drying out of the soaked kernels on mats, grinding (either by laborious pounding in a mortar or if one can afford it, at one the numerous maize meals scattered across the village) and a final round of drying again. If one only recognised the labour that went into making every single scoop of that most Malawian of all dishes, I think one might appreciate it a bit more!
As for the village headman, I actually met him on the night the drunken women lilted past my house. He had not been spared a similar fate, having been at it most day too. He was in a most jovial mood when meeting me, which I found incredibly welcoming. He even appeared to be the more grateful out of us two and he was effectively my host! Oh Malawi, what a warm heart you have! The traditional hierarchy of authority in Malawi and many other African countries, I believe, starts from small units, which coalesce gradually until one large block is formed. The final division then tends to be tribal or national. In Malawi we have the following steps: village headman, group village headman, sub-traditional authority, traditional authority(T/A) and finally chief (usually one of the T/As). This is separate from the political hierarchy comprising MPs and the rest. Chiefs however are somewhat politically appointed too and there is an inevitable marriage of politics and tradition.
On my last day, I managed to rub shoulders with the traditional authority for the area, T/A Kwataine. That was an honour and a half when you consider his status around the place. Meeting the man felt deceivingly like meeting my next door neighbour. Not to my surprise, he welcomed me with a most comforting familiarity and showed me all the way round his quarters. I was particularly impressed to be in the company of a kindred spirit in terms of environmental preservation (he grows many indigenous trees around his compound and encourages the same around the region he controls). His other project, which he would compel me to mention here were to know I was blogging, is the health centre he’s building near his house. Effectively a multidisciplinary clinic with capacity to deal with general medical conditions as well as labour and deliveries. Quite laudable really.
Green ChiefAll good things naturally have to come to an end. And to mark my village sojourn’s one, I decided to share some of that joy with my friends from Ntcheu. With the all-obliging Patrick again, we lined up a group of 10 Ngoni dancers to delight us with a traditional performance. The fact that everyone joined in is testimony enough to its success. The whole dance was complemented by a fabulous meal, the best one of my week, i.e. a combination of my favourite choices from the week gone.
Ngoni WarriorsTo say merely that it’s been a great week would miss all the other things it’s been- cultural discovery, personal adventure, new friendships, new insights, new standards etc. I have certainly got over my anticlimax feeling pretty successfully through it. What I can’t promise though is that another anticlimax from that very week itself is what’s gonna set in next!
National Conference/ Peer Support
The next few paragraphs would really have sounded like a déjà-vu of a previous blog (Africa a la VSO), were it not for the fact that this time round, it was my mates and myself organising it! What a completely different experience that makes it all of a sudden. All these fun things, for example, that I took for granted in March, now revealed the hard work that went into them. All in all, it is still fun but a different kind of fun- one with greater longevity. But then also one with a steeper anticlimax- state that I’m in right now. Just to clarify things a bit, I got myself (expectedly for most of you who know me) into a rep seat for the volunteers at the last conference. Since then, I’ve been keeping quite busy outside work really sorting things out between VSO and the volunteers. The culmination of this role really, as I already anticipated, came with the organisation of the national conference. True, I won’t take the biggest credit for it. That, by far, should go to my hardworking city-based mates- Hazel, Ruth and Misja. Of course nothing goes plain sailingly in these matters, as a mere 3weeks before the scheduled date, we got a email from the central office telling us we might have to pull the plug on the whole thing. How do you react to such a shocker after you’ve spent the last two months chasing quotes around like a headless chicken and squeezing business discussions into every social gathering where there was a slightest chance of meeting another rep? But we persevered and made amendments to the programme to allow it to go ahead. The end result, with hindsight, at least in my opinion, couldn’t have worked out better. We had the assistance of a super-motivated team from the programme office, including our interim country director, Anne Wuijits. We included talks and presentations ranging from social volunteer-to-volunteer booster sessions to proper development-centred discussions. I even got to do a talk on environmental issues relevant to volunteers based in Africa. This was in-keeping with the new global strategy for VSO, which our revised agenda had to reflect. Beside all this business talk going on all day, we also got treated to some pretty top-act quiz, as orchestrated by our own Bwana Joel (bwana= chief!). And just to put the cherry on the cake, I even found two spots where to rock-climb in the early mornings (without hangover by the way!). The first one was this brilliant quarry with the longest sweetest traverse I’ve tackled in ages. It got so hot in there though that by 8am it was already too scorching to even breathe. That’s why the second spot had the effect of an El Dorado. It was actually just that in every way. Quaint little volcanic island about 2Km from the shore, which you got to by way of a pedalo (and back from using your own propeller power, if you’re called Ashtin or Klaas!), littered with ascents and traverses of all grades. My overexcitement is manifested, even now, by the deep scratches on all but 4 on my finger pulps from the severe friction with this voracious rock. I was being quietly deceived by a placid looking water with cyclet fish circling around in a bliss-like state.
Facilitating
Taking the plunge!
Rock is back...
The second major difference between this conference and the last lay in the fact that this time round, the end of the conference coincided with the start of another- the peer support. Klaas and I were the main organisers for this one and it took one great big bead of sweat off both our foreheads to keep things flowing as they did. I will probably look back at it as one of my medical achievements while here in Malawi. The peer support is really the main forum for doctors to pick each other’s brains about issues being faced at work and make a collective effort at troubleshooting them. A great opportunity to commiserate above all, but which this year we decided also to transform into something more than a rant- a set of recommendations. Thus we sat down and dissected each of our grievances in turn, trying to look for possible reasons to explain things and then formulating practical suggestions as to who should be made to address them and how. We are eventually going to make this into a consultation document, which hopefully will inform wider medical forums and ultimately land on a government desk sometime... Another greatly welcome innovation at the peer support was a number of joint sessions with the nurse and laboratory VSO groups. This was really an opportunity to explore new ways of working together and making a greater impact in our work. It’s difficult to make such serious work related sessions sound as glamorous as, say, a Lake of Stars festival, but, in our own modest way, we did also manage to throw in some good quality entertainment. This was largely aided by Klaas’s very own natural talent for turning seemingly irrelevant details into an all absorbing canvas of fascinating facts, as evidenced by his medical quiz and an incredible take on the intricacies of the Chichewa language! And this time, he didn’t even have his guitar at hand!
The music of my latest week of organising-meet-fun-meet-delirious-satisfaction will ring for a while to come in my own mind though. Once the anticlimax is over that is!
Facilitating
Taking the plunge!
Rock is back...The second major difference between this conference and the last lay in the fact that this time round, the end of the conference coincided with the start of another- the peer support. Klaas and I were the main organisers for this one and it took one great big bead of sweat off both our foreheads to keep things flowing as they did. I will probably look back at it as one of my medical achievements while here in Malawi. The peer support is really the main forum for doctors to pick each other’s brains about issues being faced at work and make a collective effort at troubleshooting them. A great opportunity to commiserate above all, but which this year we decided also to transform into something more than a rant- a set of recommendations. Thus we sat down and dissected each of our grievances in turn, trying to look for possible reasons to explain things and then formulating practical suggestions as to who should be made to address them and how. We are eventually going to make this into a consultation document, which hopefully will inform wider medical forums and ultimately land on a government desk sometime... Another greatly welcome innovation at the peer support was a number of joint sessions with the nurse and laboratory VSO groups. This was really an opportunity to explore new ways of working together and making a greater impact in our work. It’s difficult to make such serious work related sessions sound as glamorous as, say, a Lake of Stars festival, but, in our own modest way, we did also manage to throw in some good quality entertainment. This was largely aided by Klaas’s very own natural talent for turning seemingly irrelevant details into an all absorbing canvas of fascinating facts, as evidenced by his medical quiz and an incredible take on the intricacies of the Chichewa language! And this time, he didn’t even have his guitar at hand!
The music of my latest week of organising-meet-fun-meet-delirious-satisfaction will ring for a while to come in my own mind though. Once the anticlimax is over that is!
Sleepless in Ntcheu
Lately has been a particularly busy and stressful time, with me getting involved in organising VSO national conference and a doctors’ professional peer gathering, not to mention numerous projects coming to fruition at work. And the most valuable commodity for me during that phase? Without a doubt a good night’s sleep during which to recuperate!
Of course, I don’t want another blog to draw pity onto myself, but the combination of elements that contributed to my recent wide-eyed restlessness are quite informative in their own rights. The first element will obviously come as no surprise to you- the sound of Ntcheu. This, however, is not all from the main road bottlestores for once. They also include a number of social gatherings, including one of the volunteers’ leaving do, for which a deejay was hired to play in the garden. The party incidentally formed the climax of my composing skills, where a certain R&B song (Empire State of the Mind- Alicia Keys/ aka New York) was converted to the beat of Ntcheu. The next round involved gathering all the guests of the garden party at my place for a group singing session- with troubadour Klaas expertly commanding that guitar-, which we finally performed live for our departing volunteer in the garden!
With the nightclub beats having become a regular occurrence lately, owing to the hot season attracting more thirsty customers, my sleep was unlikely to improve. What with the heat making matters worse! Fortunately I acquired a fan, which partly helped to address the issue. Once I got over those first two obstacles (noise and heat), I would brace myself for a sound slumber until the morning. But here an unforeseen nuisance manifested itself. The Udzudzu... Any guess as to what that might be? Just try imagining the sound of the word by humming it a bit. Get it? Well it’s the pain that be the mosquito! Somehow, for days on end, a few of them managed to infiltrate my net as I was sleeping. As I would be woken up at 4am or something to relieve some violent bout of itching, the task of eliminating these intruders would prove harder than I imagined. Shaking the net, inverting and brushing it and even crushing it into a tight ball were to no avail. Finally on day4, having concluded I had merely been imagining things or resigned myself to the fact that my problem might be bedbugs rather than mosquitoes, I decided to “Doom” the net and go to sleep in the living room. What a cruel satisfaction overcame me when I finally turned up in the morning to find no less than 5 mosquitoes sprawled all over my bedsheets- DEAD!!!!!! Since then they have not dared make further appearances. The expression pain in the a... shall aptly be renamed Mosquito in the net in my vocabulary henceforth!
Of course, I don’t want another blog to draw pity onto myself, but the combination of elements that contributed to my recent wide-eyed restlessness are quite informative in their own rights. The first element will obviously come as no surprise to you- the sound of Ntcheu. This, however, is not all from the main road bottlestores for once. They also include a number of social gatherings, including one of the volunteers’ leaving do, for which a deejay was hired to play in the garden. The party incidentally formed the climax of my composing skills, where a certain R&B song (Empire State of the Mind- Alicia Keys/ aka New York) was converted to the beat of Ntcheu. The next round involved gathering all the guests of the garden party at my place for a group singing session- with troubadour Klaas expertly commanding that guitar-, which we finally performed live for our departing volunteer in the garden!
With the nightclub beats having become a regular occurrence lately, owing to the hot season attracting more thirsty customers, my sleep was unlikely to improve. What with the heat making matters worse! Fortunately I acquired a fan, which partly helped to address the issue. Once I got over those first two obstacles (noise and heat), I would brace myself for a sound slumber until the morning. But here an unforeseen nuisance manifested itself. The Udzudzu... Any guess as to what that might be? Just try imagining the sound of the word by humming it a bit. Get it? Well it’s the pain that be the mosquito! Somehow, for days on end, a few of them managed to infiltrate my net as I was sleeping. As I would be woken up at 4am or something to relieve some violent bout of itching, the task of eliminating these intruders would prove harder than I imagined. Shaking the net, inverting and brushing it and even crushing it into a tight ball were to no avail. Finally on day4, having concluded I had merely been imagining things or resigned myself to the fact that my problem might be bedbugs rather than mosquitoes, I decided to “Doom” the net and go to sleep in the living room. What a cruel satisfaction overcame me when I finally turned up in the morning to find no less than 5 mosquitoes sprawled all over my bedsheets- DEAD!!!!!! Since then they have not dared make further appearances. The expression pain in the a... shall aptly be renamed Mosquito in the net in my vocabulary henceforth!
22 October 2010
Lake of Stars
I wonder how many blogs from Malawi are presently bearing the same title as mine. I don’t wish to make mine long, for want of avoiding cliche but I couldn’t not mention it. Lake of Stars is probably the muzungu highlight of the year in Malawi. It is a music and art festival that takes place in the breathtaking setting of the Mangochi lakeshore. It is a 2-3 day escape, where you meet all your best friends, get irrevocably wasted, swim in the lake all day, watch new acts from Malawi and abroad and sleep rough in a tent, only to resume the same routine the next day... and if you’re made of that more resilient stuff, yet another day after that! It’s a convenient way to reset one’s clock here in Malawi. And that’s what I did.
Campsite
With Shiraz
I came to this festival slightly underwhelmed as inferred from my intro. Consequently, I left absolutely fulfilled, thrilled, tantalised! The strictly muzungu slash priviledged Malawian entourage did little to spoil that. I found the escape I sought in the acts on offer. They had spoken word, theatre and even nice paintings to complement the music. The line up on that front was exceptional. My being downbeat from the outset was largely attributable to my unfounded expectation of unending gospel or rap music that’s so mainstream in Malawi. Yet what came out at the lake was of a completely different order. Besides the international acts, which I list for my keen music-researching lot, even the Malawian music was highly original. Look out for Dan Lu and Peter Mawanga. Even the one gospel act I saw almost moved me to tears. It was a band of under-priviledged orphans from a school called Jacaranda and they honestly sung like real pros.
Jacaranda- the band
Worthy of mention is a particular protest concert that was set not far from the festival venue by the two main contemporary Malawian performers. They were apparently not made good enough offers. Instead, both Lucius Banda and the Black Missionaries played away and gathered their own crowds.
The most impressive numbers overall included the Zimbabwean enfant prodige Oliver Mtukudzi. He treated us to a real delight of jazz fused with regional beats on his first big show after coming back from an injury. Then there was Ivorian Aly Keita, who played an impressive xylophone held on delicately shaped claypots. The visual impact of an act like that one really potentiates the joys administered to one’s sense of sound. On that same note (okay not literally in musical parlance) there was a drumming band from Burundi, who performed on a level I don’t think can be achieved outside of African soil. If the drum could be made an electric instrument, then that would be one way. The electricity is what the music would generate, not consume! Mark down South African Nomfusi also, who produced some magical moments out there for us, not least for her Pata Pata version, which got me stomping way too early! We also had some brilliant British artists by the names of Tinashe (can’t help being a bit narcissic about that name being such a close anagram of mine), African Boy (UK via Nigeria- again awesome) and wait for it... The Noisettes. Oh dear! If I ever expected some glamour at that festival I never expected it to be on that scale. Maybe I was biased because I was desperate to find one thing the British did better than the Dutch who beat us shamefully at a football challenge, but even without that reason, I reckon they are one of the coolest live acts I’ve seen. Nothing pretentious, nothing absurdly fashion orientated or sexualised for that matter, but pure original movement in keeping with a love for the music. Yes, I loved it and I’ve ordered my CD of the full album already. The festival has achieved its one main objective (after money)... it has generated new fans.
Burundi Drummers
Aly Keita
Campsite
With ShirazI came to this festival slightly underwhelmed as inferred from my intro. Consequently, I left absolutely fulfilled, thrilled, tantalised! The strictly muzungu slash priviledged Malawian entourage did little to spoil that. I found the escape I sought in the acts on offer. They had spoken word, theatre and even nice paintings to complement the music. The line up on that front was exceptional. My being downbeat from the outset was largely attributable to my unfounded expectation of unending gospel or rap music that’s so mainstream in Malawi. Yet what came out at the lake was of a completely different order. Besides the international acts, which I list for my keen music-researching lot, even the Malawian music was highly original. Look out for Dan Lu and Peter Mawanga. Even the one gospel act I saw almost moved me to tears. It was a band of under-priviledged orphans from a school called Jacaranda and they honestly sung like real pros.
Jacaranda- the bandWorthy of mention is a particular protest concert that was set not far from the festival venue by the two main contemporary Malawian performers. They were apparently not made good enough offers. Instead, both Lucius Banda and the Black Missionaries played away and gathered their own crowds.
The most impressive numbers overall included the Zimbabwean enfant prodige Oliver Mtukudzi. He treated us to a real delight of jazz fused with regional beats on his first big show after coming back from an injury. Then there was Ivorian Aly Keita, who played an impressive xylophone held on delicately shaped claypots. The visual impact of an act like that one really potentiates the joys administered to one’s sense of sound. On that same note (okay not literally in musical parlance) there was a drumming band from Burundi, who performed on a level I don’t think can be achieved outside of African soil. If the drum could be made an electric instrument, then that would be one way. The electricity is what the music would generate, not consume! Mark down South African Nomfusi also, who produced some magical moments out there for us, not least for her Pata Pata version, which got me stomping way too early! We also had some brilliant British artists by the names of Tinashe (can’t help being a bit narcissic about that name being such a close anagram of mine), African Boy (UK via Nigeria- again awesome) and wait for it... The Noisettes. Oh dear! If I ever expected some glamour at that festival I never expected it to be on that scale. Maybe I was biased because I was desperate to find one thing the British did better than the Dutch who beat us shamefully at a football challenge, but even without that reason, I reckon they are one of the coolest live acts I’ve seen. Nothing pretentious, nothing absurdly fashion orientated or sexualised for that matter, but pure original movement in keeping with a love for the music. Yes, I loved it and I’ve ordered my CD of the full album already. The festival has achieved its one main objective (after money)... it has generated new fans.
Burundi Drummers
Aly Keita
Broken Down Ntcheu
I used to think for months that things weren’t as bad as one might have expected in my rural part of Africa in terms of utilities. In fact the weekly or bi-weekly 2hour power cuts have almost become an integral part of my routine, which I see as a sign of austerity. I even plan my meals around it. Same goes for the water cuts, which have the added bonus of instilling some discipline in me. Nothing’s for granted. I plan my bucket fills in such a way that neither the filter nor the spare pail ever runs dry. Meanwhile bottles of filtered water are being filled daily to avert a sudden unannounced stoppage. And also there’s always a spare supply for that most unwelcome situation when there’s no water after I’ve come back from a big footie game! So... all along the supply may have been erratic but cope-able.
Broken Down House
Jacaranda- the tree
Lately though, that routine has taken a sudden twist from austere to desperate! For some reason best known to the water board, only our cluster of 8-10 houses in the whole of Ntcheu has been put on load-sharing scheme. What that translates into, in practical terms, is no running water during any of the essential hours of day. If we’re lucky, we’ll get some water at lunch, which will have provide for all our accumulated washing- that is of pots, clothes and bodies. Otherwise our only chance is during the ungodly hours of 3-6am. Since my night guard actually seizes this opportunity to water the plants, we have a situation whereby my plants are getting better watered than myself! And this has been going on for close to 4 weeks. Soon I fear no-one will want to get within a 10m radius of me for my bodily odours. Thankfully, I have strategic friends in the regions where water is still flowing like it’s coming from a biblical fountain, who will grant me some charity showers.
Moving from that most nagging of inconveniences, I opted to apply myself to work and not get overly bitter- but also from lack of choice, with the number of projects I have on the go. Having invested a third of my monthly salary on the purchase of a shiny new dongle to browse the internet at my leisure in my own time, I decided to make some headway on my work in the evenings after that necessary cuppa and shower (however I manage to procure it!). Yet when I try plugging in, I get one of two messages- “there is no network” or “your connection has been terminated”! Why??? I couldn’t begin to speculate! Yet some 3-4 weeks ago, things started off really nicely with my new gadget, where some of you will even remember skype calls courtesy of the dongle. So now the only time I have to complete my email based assignments is in between those ward round and operating hours in the hospital, that is at lunch time, or after work. Highly exhausting I can tell you, especially when the midday heat crushes you to a compulsion for having a siesta. As a result, I’m also not being able to find the time to storm the water board office with my grievances because that would take up my lunch hour! Things are starting to sound like conspiracy already!
And indeed it must be, when you combine my two predicaments with the situation at work that’s currently prevailing. In line with the Malawian government’s highly efficient supply chain and integrity among the directorship of the medical stores (who are absolutely not stealing any medical supplies to sell at inflated prices in their own little private businesses), our hospital has been without some of the most indispensable materials for any healthcare-providing establishment to continue to operate. Yet we are somehow scraping along. I always liked to use the following example to illustrate the ludicrousness of dogged capitalism to people: there are three items that one is guaranteed to find in the farthest severest places on Earth- that is Coca-Cola, Beer and Paracetamol (as if those were the three most essential requirements for human survival!). This month, I believe, even capitalism has been challenged in our hospital! In addition to Paracetamol, the following items have also gone OS (out of stock!): all but 2 or 3 antibiotics, plaster tape, traction tape, plaster of Paris (now back IS), Xray reagents, latex examination gloves, cleaning alcohol/iodine solutions, facemasks to name but the orthopaedic side of things. I wouldn’t like to think what the other departments are enduring, but I’m sure it’s heartbreaking.
To stay on a great subject matter, since it’s been mentioned, I shall digress slightly to give you an update on the headlines here. Do you remember the saga regarding the new flag? Well it is now in full deployment across the whole country, having bypassed any sensible consultation worthy of consideration. And you know what? It’s even illegal to be seen flying the old flag anymore. What’s worse is that the cost of acquiring the new flag has to be borne by the actual requester. As if that was not enough financial squabbling, another all-time favourite ubiquitous display item has now undergone a subtle modification. Instead of reading His Excellency Ngwazi Dr BWM under his grimacing effigy, the text now has to read His Excellency Ngwazi Professor BWM! All because some eastern Chinese university has recognised him as deserving of the honour for his economic achievements! And what a one that will be when, just like with the flag, every office in the country will have to pay for a new portrait to be hung on their walls, or else be subjected to a fine and, more damaging even, political alienation. What a circus! It is said that the long awaited Nsanje inland port will be inaugurated this weekend. That will be a major achievement for Malawi’s trade and international links. But that’s only if it does not find itself thwarted by some jealous Mozambican government too eager to cash in on their neighbours. But praise be given where it be due! For this, well done HENPBWM!
New Flag
I now conclude by pleading you not to feel too sorry for me, as, let’s face it, it could still be worse. Ntcheu, for all intents and purposes, is broken down, but life goes on. Food gets on the plate- warm-, showers are had some way or the other and the mood is generally upbeat (especially from Uncle B after 10pm!). Did I mention to you also that by some strange twist of logic, our electricity supply has been remarkably good in the last 4weeks? In fact I shouldn’t tempt fate, as even as I write this (no kidding), there’s been 2 brief blackouts, which can only be a hint that the customary 2hour one isn’t far away. But then I guess, I am having the real African experience I sought out here- unlike my city dwelling friends, with their barricaded houses and hot showers! I simply wouldn’t trade...
anyone for mango archery?
Broken Down House
Jacaranda- the treeLately though, that routine has taken a sudden twist from austere to desperate! For some reason best known to the water board, only our cluster of 8-10 houses in the whole of Ntcheu has been put on load-sharing scheme. What that translates into, in practical terms, is no running water during any of the essential hours of day. If we’re lucky, we’ll get some water at lunch, which will have provide for all our accumulated washing- that is of pots, clothes and bodies. Otherwise our only chance is during the ungodly hours of 3-6am. Since my night guard actually seizes this opportunity to water the plants, we have a situation whereby my plants are getting better watered than myself! And this has been going on for close to 4 weeks. Soon I fear no-one will want to get within a 10m radius of me for my bodily odours. Thankfully, I have strategic friends in the regions where water is still flowing like it’s coming from a biblical fountain, who will grant me some charity showers.
Moving from that most nagging of inconveniences, I opted to apply myself to work and not get overly bitter- but also from lack of choice, with the number of projects I have on the go. Having invested a third of my monthly salary on the purchase of a shiny new dongle to browse the internet at my leisure in my own time, I decided to make some headway on my work in the evenings after that necessary cuppa and shower (however I manage to procure it!). Yet when I try plugging in, I get one of two messages- “there is no network” or “your connection has been terminated”! Why??? I couldn’t begin to speculate! Yet some 3-4 weeks ago, things started off really nicely with my new gadget, where some of you will even remember skype calls courtesy of the dongle. So now the only time I have to complete my email based assignments is in between those ward round and operating hours in the hospital, that is at lunch time, or after work. Highly exhausting I can tell you, especially when the midday heat crushes you to a compulsion for having a siesta. As a result, I’m also not being able to find the time to storm the water board office with my grievances because that would take up my lunch hour! Things are starting to sound like conspiracy already!
And indeed it must be, when you combine my two predicaments with the situation at work that’s currently prevailing. In line with the Malawian government’s highly efficient supply chain and integrity among the directorship of the medical stores (who are absolutely not stealing any medical supplies to sell at inflated prices in their own little private businesses), our hospital has been without some of the most indispensable materials for any healthcare-providing establishment to continue to operate. Yet we are somehow scraping along. I always liked to use the following example to illustrate the ludicrousness of dogged capitalism to people: there are three items that one is guaranteed to find in the farthest severest places on Earth- that is Coca-Cola, Beer and Paracetamol (as if those were the three most essential requirements for human survival!). This month, I believe, even capitalism has been challenged in our hospital! In addition to Paracetamol, the following items have also gone OS (out of stock!): all but 2 or 3 antibiotics, plaster tape, traction tape, plaster of Paris (now back IS), Xray reagents, latex examination gloves, cleaning alcohol/iodine solutions, facemasks to name but the orthopaedic side of things. I wouldn’t like to think what the other departments are enduring, but I’m sure it’s heartbreaking.
To stay on a great subject matter, since it’s been mentioned, I shall digress slightly to give you an update on the headlines here. Do you remember the saga regarding the new flag? Well it is now in full deployment across the whole country, having bypassed any sensible consultation worthy of consideration. And you know what? It’s even illegal to be seen flying the old flag anymore. What’s worse is that the cost of acquiring the new flag has to be borne by the actual requester. As if that was not enough financial squabbling, another all-time favourite ubiquitous display item has now undergone a subtle modification. Instead of reading His Excellency Ngwazi Dr BWM under his grimacing effigy, the text now has to read His Excellency Ngwazi Professor BWM! All because some eastern Chinese university has recognised him as deserving of the honour for his economic achievements! And what a one that will be when, just like with the flag, every office in the country will have to pay for a new portrait to be hung on their walls, or else be subjected to a fine and, more damaging even, political alienation. What a circus! It is said that the long awaited Nsanje inland port will be inaugurated this weekend. That will be a major achievement for Malawi’s trade and international links. But that’s only if it does not find itself thwarted by some jealous Mozambican government too eager to cash in on their neighbours. But praise be given where it be due! For this, well done HENPBWM!
New FlagI now conclude by pleading you not to feel too sorry for me, as, let’s face it, it could still be worse. Ntcheu, for all intents and purposes, is broken down, but life goes on. Food gets on the plate- warm-, showers are had some way or the other and the mood is generally upbeat (especially from Uncle B after 10pm!). Did I mention to you also that by some strange twist of logic, our electricity supply has been remarkably good in the last 4weeks? In fact I shouldn’t tempt fate, as even as I write this (no kidding), there’s been 2 brief blackouts, which can only be a hint that the customary 2hour one isn’t far away. But then I guess, I am having the real African experience I sought out here- unlike my city dwelling friends, with their barricaded houses and hot showers! I simply wouldn’t trade...
anyone for mango archery?
10 October 2010
Little Things so Malawian
I can’t think of a single story to focus this one on. So I shall regale you with my favourite ones of late.
Public Transport...again!
As if by some rare coincidence, there I was using public transport again in Malawi! This time I was heading to Senga Bay as an invited doctor at the peer meeting of the VSO Health Prevention team. The overall journey was split between a sneaky lift from Marieke traveling to Lilongwe starting at 5am, an uneventful minibus journey to the town of Salima and a most unconventional matola (open back pick up truck) ride for the last 25Km where no other form of public transport exists. I was courteously fetched from the minibus depot by an obliging “matola agent” and reluctantly climbed aboard this least favourite mode of transportation of mine. I was carrying my usual backpack and a wheelie suitcase (with broken wheels). I left the suitcase in the luggage corner of the matola and waited for it to fill up. By then I had already been on the road some 5hours and began dozing off. As our final passenger was finally clambering aboard, I suddenly felt the vehicle jerk forward at full speed, almost catapulting that dear man out on the dirt path. No sooner had it bolted forward than the matola then also stopped abruptly. It occurred to me then that the driver was attempting a runner from a policeman who’d noticed he was not licensed to drive this vehicle. Amidst all this confusion, another matola then just appeared in front of us. Without sparing a thought, we all dashed towards it to secure a decent and safe corner for our bums. Happy to have made it, I sat half-dozing off again. Ten minutes later, I turned round and suddenly realised- my suitcase was no longer with me! In my torpor, I’d run off without it. I exclaimed this to the “conductor” who, by the way, was stood at the back of this pickup barely holding on to another standing friend of his and a passenger. Within a second, he got the driver to stop, jumped out and made me follow him to the other side of the road. There, right there where we stopped, as if it had been placed by a magic hand, happened to be an empty matola, all but idle. We negotiated a quick ride back to the set-off point, which necessitated a fuel refill (from a canister that simply appeared!) and a serious push from 10 strong men to get it started. We found the driver at the police station, who told us he’d left the bag with someone at the starting point. We rushed there, only to find out that the next driver, seeing that we hadn’t come back for the bag, had set off in my original direction again to try and catch up with me! So we inevitably crossed each other at some point. At that point, my conductor friend, myself and another willing benefactor had to find another matola to get my destination. We managed to hail down this bigger truck, which was absolutely packed to the brim, spilling from all sides. You wouldn’t think it could accommodate even an extra chicken on board. Yet all 3 of us got in there somehow. I had strictly the amount of floor space to fit a pair of size10 shoes, my conductor friend had to squeeze his body against a sponge mattress while holding on to a passenger, and the 3rd guy, well, he just sat atop the driver’s cabin! Once in Senga Bay, we went straight to where the driver was meant to have left my bag, and guess what? He’d set off in the other direction again, meaning we’d intersected one more time! Thankfully he wasn’t going far and soon turned around to bring the said bag! Oh, could I believe it! Everything was still in there, intact! Of course, all involved parties were expecting a (thoroughly deserved) tip from me and when I asked how much would be reasonable, I was shocked how low they wanted. I remunerated them fairly and made sure they realised what a special people they are. Malawians. The magnificent people of the warm heart of Africa!
Seconds before- the bag in front's mine!
Mbewa
The next day would see another epic cross country drive to get us to a birthday party in Blantyre. Well, one little fact about these road trips is that along the way, there’re usually boys selling all sorts of delicacies to travellers. Among the most special items are little cooked birds, and –wait for it- mice! Yes 5 of them, boiled, with all the hair on, and squeezed between 2 little sticks. Since we were going to a barbeque (Braai here), one of us had the brilliant idea of bringing a little surprise meat for our hosts. Our present was of course duly laughed at and left to rot in a corner. Unsuspectingly, as we were getting ready to go out, one of the guests spotted the mice and decided to request a bid from everyone present for him to eat one. By the time we realised he was serious and not really drunk, the bidding price had been brought down by a competitor, and before we knew it, none other than birthday girl herself stepped in and said she’d do it for even cheaper. We have videos to prove the act that followed. On it you can see some of us turning our heads away unable to face this spectacle. But there she was digging her gnashers in this hairy crispy beast, tail and head -with teeth- included. She finished it in 3 mouthfuls and you could hear the crunching from the other end of the veranda. To me she had accomplished a landmark achievement. She had proved that even muzungus can eat that most avoided of all foods in Malawi: Mbewa (Chichewa for mice). Maximum respect!
A shuffle
Well if it seemed that there were not enough snakes to eat up all the mice along the road to Blantyre, things looked slightly different in Ntcheu! Maybe I forgot to mention that I came across one such friendly little companion outside my very own house a few months ago. 20cm long, all black and unmistakable! I remember running to the gate, forgetting to push the house door shut as I darted off. To date, I ask myself whether it got in somehow, but I prefer to entertain the thought that it was actually leaving the house when I saw it, heading to its own home! Since then, well, that little phobia has been partly tamed in my mind and I sometimes even get curios about what they look like, especially when patients come it with all those bites. Today, Trish and I decided to venture up ‘Mount Ntcheu Telephone Mast’ –which shall now be know by its official name: Kirkirenje (a local twist on Kirk’s range!)- in the scorching sun. We set off early enough to avoid the worst of the rays and added a few scenic detours to the route. On this new territory I casually joked about the possibility of encountering our own Mamba or something. It was not some two hours later, towards the end that I suddenly heard a shuffle in front of me and saw only the posterior half of it disappear in a flash to the right. My walking stick had almost skewered a snake. I have no idea how long it was, but it had a chunky brown tail. Somewhat wobbly legged I got back home not sure if excited or terrified would describe my emotional state better. I’ll decide on that one on my next hike...
The scenic route
Public Transport...again!
As if by some rare coincidence, there I was using public transport again in Malawi! This time I was heading to Senga Bay as an invited doctor at the peer meeting of the VSO Health Prevention team. The overall journey was split between a sneaky lift from Marieke traveling to Lilongwe starting at 5am, an uneventful minibus journey to the town of Salima and a most unconventional matola (open back pick up truck) ride for the last 25Km where no other form of public transport exists. I was courteously fetched from the minibus depot by an obliging “matola agent” and reluctantly climbed aboard this least favourite mode of transportation of mine. I was carrying my usual backpack and a wheelie suitcase (with broken wheels). I left the suitcase in the luggage corner of the matola and waited for it to fill up. By then I had already been on the road some 5hours and began dozing off. As our final passenger was finally clambering aboard, I suddenly felt the vehicle jerk forward at full speed, almost catapulting that dear man out on the dirt path. No sooner had it bolted forward than the matola then also stopped abruptly. It occurred to me then that the driver was attempting a runner from a policeman who’d noticed he was not licensed to drive this vehicle. Amidst all this confusion, another matola then just appeared in front of us. Without sparing a thought, we all dashed towards it to secure a decent and safe corner for our bums. Happy to have made it, I sat half-dozing off again. Ten minutes later, I turned round and suddenly realised- my suitcase was no longer with me! In my torpor, I’d run off without it. I exclaimed this to the “conductor” who, by the way, was stood at the back of this pickup barely holding on to another standing friend of his and a passenger. Within a second, he got the driver to stop, jumped out and made me follow him to the other side of the road. There, right there where we stopped, as if it had been placed by a magic hand, happened to be an empty matola, all but idle. We negotiated a quick ride back to the set-off point, which necessitated a fuel refill (from a canister that simply appeared!) and a serious push from 10 strong men to get it started. We found the driver at the police station, who told us he’d left the bag with someone at the starting point. We rushed there, only to find out that the next driver, seeing that we hadn’t come back for the bag, had set off in my original direction again to try and catch up with me! So we inevitably crossed each other at some point. At that point, my conductor friend, myself and another willing benefactor had to find another matola to get my destination. We managed to hail down this bigger truck, which was absolutely packed to the brim, spilling from all sides. You wouldn’t think it could accommodate even an extra chicken on board. Yet all 3 of us got in there somehow. I had strictly the amount of floor space to fit a pair of size10 shoes, my conductor friend had to squeeze his body against a sponge mattress while holding on to a passenger, and the 3rd guy, well, he just sat atop the driver’s cabin! Once in Senga Bay, we went straight to where the driver was meant to have left my bag, and guess what? He’d set off in the other direction again, meaning we’d intersected one more time! Thankfully he wasn’t going far and soon turned around to bring the said bag! Oh, could I believe it! Everything was still in there, intact! Of course, all involved parties were expecting a (thoroughly deserved) tip from me and when I asked how much would be reasonable, I was shocked how low they wanted. I remunerated them fairly and made sure they realised what a special people they are. Malawians. The magnificent people of the warm heart of Africa!
Seconds before- the bag in front's mine!Mbewa
The next day would see another epic cross country drive to get us to a birthday party in Blantyre. Well, one little fact about these road trips is that along the way, there’re usually boys selling all sorts of delicacies to travellers. Among the most special items are little cooked birds, and –wait for it- mice! Yes 5 of them, boiled, with all the hair on, and squeezed between 2 little sticks. Since we were going to a barbeque (Braai here), one of us had the brilliant idea of bringing a little surprise meat for our hosts. Our present was of course duly laughed at and left to rot in a corner. Unsuspectingly, as we were getting ready to go out, one of the guests spotted the mice and decided to request a bid from everyone present for him to eat one. By the time we realised he was serious and not really drunk, the bidding price had been brought down by a competitor, and before we knew it, none other than birthday girl herself stepped in and said she’d do it for even cheaper. We have videos to prove the act that followed. On it you can see some of us turning our heads away unable to face this spectacle. But there she was digging her gnashers in this hairy crispy beast, tail and head -with teeth- included. She finished it in 3 mouthfuls and you could hear the crunching from the other end of the veranda. To me she had accomplished a landmark achievement. She had proved that even muzungus can eat that most avoided of all foods in Malawi: Mbewa (Chichewa for mice). Maximum respect!
A shuffle
Well if it seemed that there were not enough snakes to eat up all the mice along the road to Blantyre, things looked slightly different in Ntcheu! Maybe I forgot to mention that I came across one such friendly little companion outside my very own house a few months ago. 20cm long, all black and unmistakable! I remember running to the gate, forgetting to push the house door shut as I darted off. To date, I ask myself whether it got in somehow, but I prefer to entertain the thought that it was actually leaving the house when I saw it, heading to its own home! Since then, well, that little phobia has been partly tamed in my mind and I sometimes even get curios about what they look like, especially when patients come it with all those bites. Today, Trish and I decided to venture up ‘Mount Ntcheu Telephone Mast’ –which shall now be know by its official name: Kirkirenje (a local twist on Kirk’s range!)- in the scorching sun. We set off early enough to avoid the worst of the rays and added a few scenic detours to the route. On this new territory I casually joked about the possibility of encountering our own Mamba or something. It was not some two hours later, towards the end that I suddenly heard a shuffle in front of me and saw only the posterior half of it disappear in a flash to the right. My walking stick had almost skewered a snake. I have no idea how long it was, but it had a chunky brown tail. Somewhat wobbly legged I got back home not sure if excited or terrified would describe my emotional state better. I’ll decide on that one on my next hike...
The scenic route
27 September 2010
Clinical Digest9/ Public Transport3
Malawi Orthopaedic Association AGM
Where do I start this one? This giant. This landmark of my activities in Malawi, which is in part the reason behind my paucity of blogging lately. It being safely behind me, successfully closed, I feel that a chapter is now ended in my Malawian medical mission. It should be possible now to tackle the next one.
“So what!” you’ll be thinking. An AGM is an AGM... just like any other. Boring. Full of protocols. Too long usually etc., etc. But let us remind ourselves that this is Malawi and the very fact of being able to hold a non-business AGM, let alone for a medical syndicate is a little miracle of sorts. Orthopaedics, in Malawi, boasts this honour. We are the only specialty with an executive committee, a Malawian consultant as patron and an AGM, which is now in its 19th round. This is a rare feat, only made possible through the unrelenting support of some donors, which is partly sad and partly encouraging. Encouraging firstly in that the donor support has been sustained all these years, bearing testimony to the value and success of the work achieved. But sad too in that it still has to be a donor that supports us and not the government through an allocated budget. This consequently does not fare well for the longevity of this event, since our principal donor, a retired American surgeon, now well in his 80s, doesn’t yet have a replacement. But for all that, this year, we spent an amazing 3days by the Lake Malawi reviewing the progress made in Orthopaedics in the last year.
This was indeed the meeting for me. After 8months in country, 6 of which have been spent in Ntcheu, it provided the perfect platform for presenting my work and, above all, the perfect audience for making my recommendations to. The bulk of my non-clinical attention in Ntcheu so far has been on improving the system for providing care to patient. This has been a combination of 1) simple modifications such as the one to our file keeping and Xray requesting systems; 2) hardware modifications and equipment acquisition to allow us to do more; and 3) more challenging surveillance stuff like monitoring our activity through audits. The latter, in an environment where data recording is not routine and patients are extremely difficult to track down, was a conundrum that I’m yet to find a reliable solution to. Meanwhile, by placing registers on wards for the staff to fill in, but which I ultimately filled most of, we compiled enough data to formulate admission statistics for each ward and pick out general treatment issues (methods, delays, complications). This brain-racking number crunching paid off as we were finally able to quantify what we were doing, and address our deficiencies/successes better. The best part of it though was the so-called phenomenon my erudite fellow VSO Klaas wisely found the name for: the Hawthorne Effect. Once a problem is spotted, the change to solve it is almost instantaneous. It used to apply to human subjects in experiments, but its wider relevance was clearly visible in our data collecting period. Delays to treatment were getting naturally reduced, while refinements to our methods were being constantly fed in. In the end we got two studies out of one (1. admission data, 2. specific management of one type of fracture) and I think this is the first time we have such data from a district level. It put Ntcheu on Malawi’s orthopaedic map for sure. But it also highlighted one interesting realisation for me. We’re so used to hearing presentations about how to manage our cases this way and that way from visiting surgeons/lecturers who are based in central hospitals and abroad. When I came here, I always held a bit of a cynical view of flying-in-for-a-week professors professing this and that mode of (low cost or low tech) treatment for the rural settings of the 3rd world, without having ever lived there. I was somewhat surprised to find that this also applied within Malawi, where what’s practiced in a central hospital can sometimes be so far removed from the districts that teaching the district officers about it becomes completely irrelevant. Of course, if the central hospital consultants had more time to spend in the rural setting, they would gain enough insight to inform them on what is pertinent to and feasible at a district level (since none of them are Malawian-trained). Yet the only time they ever have to spend in the district is a brief clinic to see saved complicated cases and occasionally operating lists on these patients. The great bit missing, for me, is a real understanding of how the hospital’s orthopaedic department actually works on a day to day basis and more importantly maybe, of how limited resources can be- such that even a “low cost” initiative might not be practical here. In a sense, I’m in a really unique position as an orthopaedic clinician with that insider knowledge.
Among the other perks of my lakeside weekend were the joys of sitting on the judging panel for the best paper presented (safely disqualifying me!) and doubling as returning officer for the new committee member elections. Sadly swimming featured low on those perks, since the agenda was so packed there was only early dawn and early evening to indulge in that. But still I was fulfilled. I was content to have made my first big step in the orthopaedic panorama of Malawi.
Matola Joy
The rest is just the usual circus I’m getting worryingly used to now. I still had to negotiate that last issue of transport back to my base. To have secured a hospital transport to the lake had been a true blessing, bearing in mind even the music was soft and that we were only 4 in the car. Unfortunately, the driver had to be released, such that come Sunday, there was no one to pick us back up. Having lost my Ntcheu colleagues, I decided to find my own way back home, accompanied by an all-but-useless friend, who was zonked beyond recognition from the previous night’s excesses and who now resorted to sleepwalking behind me essentially! Soon I was to discover that, on Sundays, in the remote backwaters of Malawi, there are hardly any buses running and the only remaining form of public transport is the god-feared Matola! Having safely avoided it for months now, I was left with only two other options: walking home or staying over here another night. None of them held any appeal to me, so I jumped aboard, clinging on to dear life! That I did surely for some 15Km in an open back pick-up travelling at 100-120Kmph. Thank God we didn’t have to go off road at any point! Thank God also for that phone call that came just before I was about to take the next matola, from my stranded colleague who, God bless him (I mean it), had been searching for a vehicle for both himself and me. So I stayed put at my stop and eventually got picked up by another “hospital transport” as we know it all too well: a 6 person 4x4 essentially, now having to fit 9 people, and bursting at the seams with bags and bags of fish and allsorts that the passengers managed to lay their hands on while at the lake! Yum Yum! How I slept through most of the journey is a mystery. But then there was one final leg of road to tackle from the point we got dropped off as our vehicle veered off to its own destination. At that stage a 30min minibus drive was all that was left to cover. Never have I been more elated to board that minibus in my entire time in Malawi. It stops at every village and even in between and typically plays the loudest gospel that the human ear can cope with. Yet yesterday, I felt no pain anymore while immersed in it. I guess I’d become comfortably numb...
An Incredible Red Moon
Where do I start this one? This giant. This landmark of my activities in Malawi, which is in part the reason behind my paucity of blogging lately. It being safely behind me, successfully closed, I feel that a chapter is now ended in my Malawian medical mission. It should be possible now to tackle the next one.
“So what!” you’ll be thinking. An AGM is an AGM... just like any other. Boring. Full of protocols. Too long usually etc., etc. But let us remind ourselves that this is Malawi and the very fact of being able to hold a non-business AGM, let alone for a medical syndicate is a little miracle of sorts. Orthopaedics, in Malawi, boasts this honour. We are the only specialty with an executive committee, a Malawian consultant as patron and an AGM, which is now in its 19th round. This is a rare feat, only made possible through the unrelenting support of some donors, which is partly sad and partly encouraging. Encouraging firstly in that the donor support has been sustained all these years, bearing testimony to the value and success of the work achieved. But sad too in that it still has to be a donor that supports us and not the government through an allocated budget. This consequently does not fare well for the longevity of this event, since our principal donor, a retired American surgeon, now well in his 80s, doesn’t yet have a replacement. But for all that, this year, we spent an amazing 3days by the Lake Malawi reviewing the progress made in Orthopaedics in the last year.
This was indeed the meeting for me. After 8months in country, 6 of which have been spent in Ntcheu, it provided the perfect platform for presenting my work and, above all, the perfect audience for making my recommendations to. The bulk of my non-clinical attention in Ntcheu so far has been on improving the system for providing care to patient. This has been a combination of 1) simple modifications such as the one to our file keeping and Xray requesting systems; 2) hardware modifications and equipment acquisition to allow us to do more; and 3) more challenging surveillance stuff like monitoring our activity through audits. The latter, in an environment where data recording is not routine and patients are extremely difficult to track down, was a conundrum that I’m yet to find a reliable solution to. Meanwhile, by placing registers on wards for the staff to fill in, but which I ultimately filled most of, we compiled enough data to formulate admission statistics for each ward and pick out general treatment issues (methods, delays, complications). This brain-racking number crunching paid off as we were finally able to quantify what we were doing, and address our deficiencies/successes better. The best part of it though was the so-called phenomenon my erudite fellow VSO Klaas wisely found the name for: the Hawthorne Effect. Once a problem is spotted, the change to solve it is almost instantaneous. It used to apply to human subjects in experiments, but its wider relevance was clearly visible in our data collecting period. Delays to treatment were getting naturally reduced, while refinements to our methods were being constantly fed in. In the end we got two studies out of one (1. admission data, 2. specific management of one type of fracture) and I think this is the first time we have such data from a district level. It put Ntcheu on Malawi’s orthopaedic map for sure. But it also highlighted one interesting realisation for me. We’re so used to hearing presentations about how to manage our cases this way and that way from visiting surgeons/lecturers who are based in central hospitals and abroad. When I came here, I always held a bit of a cynical view of flying-in-for-a-week professors professing this and that mode of (low cost or low tech) treatment for the rural settings of the 3rd world, without having ever lived there. I was somewhat surprised to find that this also applied within Malawi, where what’s practiced in a central hospital can sometimes be so far removed from the districts that teaching the district officers about it becomes completely irrelevant. Of course, if the central hospital consultants had more time to spend in the rural setting, they would gain enough insight to inform them on what is pertinent to and feasible at a district level (since none of them are Malawian-trained). Yet the only time they ever have to spend in the district is a brief clinic to see saved complicated cases and occasionally operating lists on these patients. The great bit missing, for me, is a real understanding of how the hospital’s orthopaedic department actually works on a day to day basis and more importantly maybe, of how limited resources can be- such that even a “low cost” initiative might not be practical here. In a sense, I’m in a really unique position as an orthopaedic clinician with that insider knowledge.
Among the other perks of my lakeside weekend were the joys of sitting on the judging panel for the best paper presented (safely disqualifying me!) and doubling as returning officer for the new committee member elections. Sadly swimming featured low on those perks, since the agenda was so packed there was only early dawn and early evening to indulge in that. But still I was fulfilled. I was content to have made my first big step in the orthopaedic panorama of Malawi.
Matola JoyThe rest is just the usual circus I’m getting worryingly used to now. I still had to negotiate that last issue of transport back to my base. To have secured a hospital transport to the lake had been a true blessing, bearing in mind even the music was soft and that we were only 4 in the car. Unfortunately, the driver had to be released, such that come Sunday, there was no one to pick us back up. Having lost my Ntcheu colleagues, I decided to find my own way back home, accompanied by an all-but-useless friend, who was zonked beyond recognition from the previous night’s excesses and who now resorted to sleepwalking behind me essentially! Soon I was to discover that, on Sundays, in the remote backwaters of Malawi, there are hardly any buses running and the only remaining form of public transport is the god-feared Matola! Having safely avoided it for months now, I was left with only two other options: walking home or staying over here another night. None of them held any appeal to me, so I jumped aboard, clinging on to dear life! That I did surely for some 15Km in an open back pick-up travelling at 100-120Kmph. Thank God we didn’t have to go off road at any point! Thank God also for that phone call that came just before I was about to take the next matola, from my stranded colleague who, God bless him (I mean it), had been searching for a vehicle for both himself and me. So I stayed put at my stop and eventually got picked up by another “hospital transport” as we know it all too well: a 6 person 4x4 essentially, now having to fit 9 people, and bursting at the seams with bags and bags of fish and allsorts that the passengers managed to lay their hands on while at the lake! Yum Yum! How I slept through most of the journey is a mystery. But then there was one final leg of road to tackle from the point we got dropped off as our vehicle veered off to its own destination. At that stage a 30min minibus drive was all that was left to cover. Never have I been more elated to board that minibus in my entire time in Malawi. It stops at every village and even in between and typically plays the loudest gospel that the human ear can cope with. Yet yesterday, I felt no pain anymore while immersed in it. I guess I’d become comfortably numb...
An Incredible Red Moon
18 September 2010
Uses of a Chitenje/ Calico cloth
Definition: Piece of cloth, usually decorated, designed to be wrapped around a woman’s waist. It’s often worn around a dress, skirt or trousers which the woman is already wearing inside.
How many uses can you put to a rectangular piece of fabric, the most ubiquitous item by far in Malawi (? stroke Africa)?
1. Baby carrier - first and foremost
2. Leg hider (my favourite quote: “legs are to Malawian men what boobs are to English men”)
3. Leg warmer (in winter it’s c-c-c-old!)
4. Body warmer (worn around torso)
5. Head gear
6. Purse (corner tied in a knot with money in)
7. Cleaning cloth (for those kids’ uncontrollable secretions)
8. Bed liner (including examination beds in those busy clinics)
9. Pressure bandage/ Tourniquet (all essential casualty first aid)
10. Hanging traction weights (i.e. bricks)
11. Bench liner before sitting
12. Carrying goods (tied at the corners to make a kind of bag)
13. Securing goods (e.g. bowls full of fruit/veg carried on women’s head)
14. Head cushion (for carrying heavy water buckets/stick bundles on their heads)
15. Fashion accessory
16. Political propaganda (Presidents' faces and party logos- I even saw one of Osama Bin Laden!!!)
17. Commemoration of important events (NGOs issue many of these ones)
18. Curtains or screens
19. Mats
20. Winnow
21. Water filter
22. Tourist souvenir (guess the tourist!!)
Of course I will have left out loads of uses. The floor is now yours to add more ingenuous suggestions!
4 September 2010
Hospital Transport
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I always thought that, whenever given the chance, I would readily swap public transport for an alternative, any alternative. That was indeed until this week, when I realised the full meaning of hitching a ride along a hospital vehicle. It was a perfectly legitimate behaviour from me as well, since I was on hospital business. Just to set the scene quickly here, let me explain to you what hospital transport is actually used for. There are two types of vehicles. One is your familiar chauffeur driven car for the hospital executives, when they need to go to meetings or other official (and sometimes private) business. The same vehicle also picks them up from home in the morning and drops them back in the evening- irrespective of the walking distance: 3 minutes, if I crawl, in the case of Ntcheu. It is a status-laden priviledge that comes with an otherwise poorly rewarded job and I guess the guys don’t see why they should pass it up. The second type of vehicle is your patient transport/ hospital business one. It runs whenever there is a need to deliver or pick equipment for the hospital and when patients need to be transferred to tertiary referral centres (Lilongwe and Blantyre). The way it normally works is that a trip is scheduled for such and such official business. The word is out straight away that there’s a vehicle going that side. The transport manager checks his list for patients needing transferring ‘that side’ and contacts the ward to send the patient/s along. In reality, it takes a little more coaxing from the referring clinician (me) to make sure the vehicle doesn’t leave without the patient. As the 4x4 fills up with its destined cargo, you have a number of hospital staff tagging along for a free ride and filling up the last remaining places.
It soon became clear that by giving a wide berth to public transport in favour of hospital transport (twice) this week, I was actually jumping from the pan into the fire. The obvious appeal of avoiding the long painful wait in a bus depot for the bus to fill up is quickly overcome by a string of new inconveniences. The decibel level, for one, is on a par with the public transport counterpart. I keep asking myself: Am I the only one in this country who reacts to loud (gospel – remember Michael Bolton? He’s still alive and kicking in here, along with Celine Dion, Mariah Carey and their local equivalents who all sing the exact same tune, with slight variations in the lyrics- and rap) music being played for 3 hours on end while I’m trying to snooze/read/work during a journey? Of course, if it could be drowned by my own music through earphones, things might improve a little, but I’m talking decibels that are refractory to such remedial action! As for the waiting, there’s how it goes- apparent time saved versus real time saved (or not).
The first of my two journeys was aboard the executive type vehicle to go the capital for the collection of a shipment that had arrived at the central post office. I had ordered some orthopaedic equipment from India, through a competitive grant I had secured from my NGO. That was one of my early successes some five months back, and the fact that it only turned up now says a lot about the hurdles involved in the procurement process- dealing with London office, multiple invoice changes to meet their standards, dodgy pricing mistakes, ship freight and now customs. The arrangement was to set off early with the DMO, 7am at the hospital gate with the aim of coming back early or at least allow plenty of time in the event customs proved to be difficult. At 7.15, I saw the driver come in unhurriedly and only then set off to go and pick up the DMO. When he came back at around 7.45, the DHO and another person were also in the vehicle. They had some business in Lilongwe too. We finally set off and reached Lilongwe around 10.15. Since we had more than 1 businesses to attend to, ours was naturally left last on the list. We first went to the ministry of health building, which actually is a well hidden gem in the Lilongwe architectural landscape. It sits along with the other ministries along ‘Capital Hill’ and is one of the numerous legacies of this country’s most famous and revered politician, Hastings Kamuzu Banda. It has become almost normal for me to expect to hear his name mentioned in connection with any development I see in this country. We eventually made it to the post office at around 11.15. My dreaded interaction with customs went smoother than I could ever have imagined. We managed to convince them that hospital equipment counted among items exempt from whatever hefty duty. It’s only later on that I realised there had been some butter doused on those palms behind the counter, that obviously took place in fast and discreet Chichewa. Once we got past the official businesses, the next stage was to sort out any personal business that could only be done in Lilongwe, since we were already there and had no chance of getting back in time for work. That’s when it got tricky as everyone had business in different parts of town, which gets very congested with traffic around that time- and I’m told the reason for this is that most people get in their cars to drive home for lunch. That partly explains the 2-3hour lunch break all of a sudden: 30-60min for transport, 30-60min for cooking, 30-60min for eating! It can’t save much money considering the price of fuel here, compared with the dirt cheap cost of a (simple) meal. By the time we’d sorted the mobile phone contract of my colleague out (around 4.30pm), the vehicle had managed a tyre puncture, which further accrued the delay in departing. Just as we thought that was it then, the team decided to stop at a supermarket for some special supplies not available in Ntcheu and just as we’d done that and got ready to go, someone decided we ought to stop in another part of town to buy something else. Thankfully we all figured out that would be perfunctory since the shop would already be closed by now. Thence we made our way to Ntcheu, getting there at the grand hour of 8pm, me half deaf and completely battered, but happy nonetheless to have come back with the goods I set out to collect!
As if that were not a lesson enough, the very next day, I joined the second type of vehicle to go that other city, Blantyre, again on hospital business. What I didn’t know was that I would have to share this vehicle with no fewer than 10 patients/guardians all referred to QECH hospital. One was semi-conscious and lying on a mattress laid down in the back. People were huddled against each other until the last pocket of air was filled. In addition to that, there was their luggage and the transfusion box, which gets filled every Friday. Some people had to be left behind for pure lack of space. You’ll be pleased to hear I secured a seat in the front, squeezed only by another staff member heading south. Once in Blantyre, we unloaded the patients and I made arrangements with the driver to meet up later on so I can go and obtain some more orthopaedic supplies from the stockists there. By the time I’d finished my business in CURE, QECH and the medical stores (nothing useful in stock by the way), it was already around 5pm and my driver had acquired 2 more passengers (including my colleague, whom I had handed over the ward jobs to in the morning thinking he was around!) Again, just as I thought it was time to go, so I could return to Ntcheu in one piece, we incurred delay after delay. We first picked up a parcel from an ex-hospital staff for their relatives in Ntcheu, then went to collect the blood transfusion box, then went to pick up a staff member and all her luggage to move back to Ntcheu and... the straw that broke the camel’s back... we had more patients to pick. The ones from last week, who simply had no means of getting back to Ntcheu of their own. It’s a saddening example indeed of how often people miss out on essential medical care, for the simple reason that they cannot afford transport. The glimmer of hope that I saw in that patient’s eyes as she approached the vehicle, enquiring if we were the Ntcheu transport for her and her convalescing son was, in itself, a thesis on the hardships endured by the poor class of Malawi. I don’t know how long she’d been waiting there for and even worse, I don’t how long more her friends whom we couldn’t fit in the vehicle will have more to wait. Only after that did we manage to unequivocally set off for Ntcheu. It was sunset already and I was shattered and desperate to reach home in the shortest possible time. But as a final dent into my barely standing bodily frame, that also was notbe and the reason being that our driver happened to have some sight impairment. He was completely blinded by on-coming vehicles and would slow his vehicle down to 40Kmph or less everytime one went by. Furthermore, the front seat, despite being away from the sweaty patient crowd in the back, had 1 significant drawback which possibly made it even sweatier. It sat right atop the overworked engine which was radiating constantly like a burning stove. The 2 hour drive back thus took a solid 3 ¼ and I had by then lost all will to live. Thankfully it was Friday night and happiness was just a meal, a shower and a few beers away.
Hop on board!
11 August 2010
Ntcheu Social Football Club
Did I tell you I scored!! Yes I did. And against Dedza too. Ntcheu versus Dedza, when we were one nil down and desperately needed that equaliser to avoid humiliation from our neighbours. That’s the goal I scored. Partly fluke of course, but not all of it! Since then I’ve been elevated to striker status in our boys’ club cum drinking brigade of socialites of Ntcheu. It’s such a treat! Such a unique window into another facet of Malawian life. The single muzungu in the group. The single muzungu in all of our games so far. Maybe that’s part of the reason why I thrive in them. Nobody from the opposing teams seems to know what to expect from this different guy. Is he just gonna be a lame foot dragger lacking their physical endurance, or will he dazzle them with some illustrious technicality? I can’t be my own critique but I’m sure it’s less of any of the above than a pure joy and enthusiasm to be playing football in a team again.
At the last game, I didn’t score. Didn’t really get much of a chance to either. My legs couldn’t run, and worse even, turn as they had built up quite a concentration of lactic acid from the previous night’s excesses and had been sat stiff on a minibus for a couple of hours in the morning, getting to the venue. We were playing away at Mvera against the soldiers at the army barracks. What are the chances of a ‘zungu’ rubbing shoulders with such guys as he goes by his daily routine in Malawi? I got access past the ‘strictly on business’ armed-guard access gate and had an intimate view of the soldiers’ living compounds and training grounds. The game was uneventful, save one disallowed goal for our team, which I served the pass to, and a (goalless) corner that every single spectator made sure they congratulated me on! The camaraderie was overwhelming throughout, in the true spirit of a friendly. Our hosts were overjoyed to have us among them, especially after coming from so far. They staged an exquisite gathering at the soldiers’ mess, sparing no effort to turn it into a fit spectacle for such distinguished guests. We boast a number of figures among our team, who would attract significant respect from the average Malawian: the DEHO (district environmental health officer), the hospital administrator, the district educational officer, a few policemen and myself, a doctor! The soldiers had a full PA system, complete with MC on the mic. In a way we were all relieved when the game was over, as we could switch into full social mode at last. We ate and drank to our hearts’ content. Maybe a bit less to my vegetarian one. Even though I will quite happily cheat at times here, when there’s nothing but chicken on the menu, that day I would stay well away. I was to witness a side of the Malawian diet not usually indicated on restaurant menus. They eat everything from the animal. I mean everything. Okay maybe not the hair and bone (excluding the delicious marrow inside that they make sure to suck well dry!). But there they were digging their gnashers into the fatty piece of cow leg, with the skin still on... and loving it! You could see the knee joint and the foot pads on some of them. Respect! Each to their own. Better than our decadent waste of food in the west anyway I say.
The next item on the menu (if you still dare to follow) is the local brew. It’s sold in a carton with the sign ‘shake shake’ on it. Ominous! Once you open it, your first reaction to its potent vapour will be a tearful turning of the head to catch your breath. The liquid is a murky suspension of fermented corn mash, with some other bits in. It is a truly acquired taste, which I’m yet to know of a ‘zungu’ having acquired. ‘Vomit’ is the usual condescending comparison that they come up with. But then that’s also how I felt the first time I tasted beer in England. That didn’t stop me from going back over and over again till I developed such terms as nectar, hoppy, peachy and herby to refer to it. Everyone drank it, so it had to be good. The same must go for Chibuku I’m sure, if that’s the main beverage on offer as you make your first steps into manhood here. Indeed, a few of my Chibuku-drinking pals would confirm this for me here. The best anecdote is this one from my friend who would occasionally guard his uncle’s bottlestore at the ripe age of 15. He would get some hollow needles from the bushes which he would then stick in the corner of a carton and sip whatever liquid porridge would come out. He passed out on it the first few times until the taste simply became natural and now he doesn’t even bat an eyelid as he downs the stuff. I dare Guinness to match this drink in their slogan “a meal in a drink”!
We stayed on at the barracks way beyond our expected leaving time, secondary to the feeding pressure that our hosts kept exerting on us. We had to stay for the pork and goat braai before we were allowed to leave as dusk was already closing in. Grrrrreat! Now we’d have a bunch of drunken drivers who would be driving in the dark too! Thankfully I went with the least drunk driver and eventually joined the vehicle with the dedicated non-drinking driver as my first driver decided he hadn’t had enough and broke his journey with another sneaky few by a roadside tavern. That is sadly a very real issue in Malawi. Drunk-driving is a common cause of road traffic accidents and deaths. Even the policemen, as in our group, do it liberally and you hardly ever find anyone being stopped for it. Maybe the poorly armed traffic police are afraid of assaults from the disinhibited drunks, I don’t know. But many drivers, including ‘zungus’, simply take advantage of this free ticket to nirvana, while being at their steering wheels. So much for the catchy road safety slogan around here that goes “arrive alive”, which is really funny as Malawians often get their ‘r’ and ‘l’ mixed up and what comes out is one of the three: “allive alive” or “arrive arive” or “allive arive”! Anyway, I reached home alive after a 4 hour drive, punctuated by a highly unfortunate chibuku vomiting incident (imagine the stink: vomit to the power of 2!)
So, in a nutshell, that’s what it’s like hanging with the ‘Socials’. Twice to three times weekly training and maybe once or twice a month we’ll stage a match up with another town, alternating home and away. The whole mixed with food and drinks and pool and many good laughs. To me the spirit of this social club is a true celebration of human affinity for fellow humans. Where there are no cinemas and bowling alleys and beer/food festivals to entertain one every single weekend, gatherings like our do take on that special importance which make football worth playing and life slightly more worth living. You don’t have to drink of course as some more self-restrained members of our crew do!
At the last game, I didn’t score. Didn’t really get much of a chance to either. My legs couldn’t run, and worse even, turn as they had built up quite a concentration of lactic acid from the previous night’s excesses and had been sat stiff on a minibus for a couple of hours in the morning, getting to the venue. We were playing away at Mvera against the soldiers at the army barracks. What are the chances of a ‘zungu’ rubbing shoulders with such guys as he goes by his daily routine in Malawi? I got access past the ‘strictly on business’ armed-guard access gate and had an intimate view of the soldiers’ living compounds and training grounds. The game was uneventful, save one disallowed goal for our team, which I served the pass to, and a (goalless) corner that every single spectator made sure they congratulated me on! The camaraderie was overwhelming throughout, in the true spirit of a friendly. Our hosts were overjoyed to have us among them, especially after coming from so far. They staged an exquisite gathering at the soldiers’ mess, sparing no effort to turn it into a fit spectacle for such distinguished guests. We boast a number of figures among our team, who would attract significant respect from the average Malawian: the DEHO (district environmental health officer), the hospital administrator, the district educational officer, a few policemen and myself, a doctor! The soldiers had a full PA system, complete with MC on the mic. In a way we were all relieved when the game was over, as we could switch into full social mode at last. We ate and drank to our hearts’ content. Maybe a bit less to my vegetarian one. Even though I will quite happily cheat at times here, when there’s nothing but chicken on the menu, that day I would stay well away. I was to witness a side of the Malawian diet not usually indicated on restaurant menus. They eat everything from the animal. I mean everything. Okay maybe not the hair and bone (excluding the delicious marrow inside that they make sure to suck well dry!). But there they were digging their gnashers into the fatty piece of cow leg, with the skin still on... and loving it! You could see the knee joint and the foot pads on some of them. Respect! Each to their own. Better than our decadent waste of food in the west anyway I say.
The next item on the menu (if you still dare to follow) is the local brew. It’s sold in a carton with the sign ‘shake shake’ on it. Ominous! Once you open it, your first reaction to its potent vapour will be a tearful turning of the head to catch your breath. The liquid is a murky suspension of fermented corn mash, with some other bits in. It is a truly acquired taste, which I’m yet to know of a ‘zungu’ having acquired. ‘Vomit’ is the usual condescending comparison that they come up with. But then that’s also how I felt the first time I tasted beer in England. That didn’t stop me from going back over and over again till I developed such terms as nectar, hoppy, peachy and herby to refer to it. Everyone drank it, so it had to be good. The same must go for Chibuku I’m sure, if that’s the main beverage on offer as you make your first steps into manhood here. Indeed, a few of my Chibuku-drinking pals would confirm this for me here. The best anecdote is this one from my friend who would occasionally guard his uncle’s bottlestore at the ripe age of 15. He would get some hollow needles from the bushes which he would then stick in the corner of a carton and sip whatever liquid porridge would come out. He passed out on it the first few times until the taste simply became natural and now he doesn’t even bat an eyelid as he downs the stuff. I dare Guinness to match this drink in their slogan “a meal in a drink”!
We stayed on at the barracks way beyond our expected leaving time, secondary to the feeding pressure that our hosts kept exerting on us. We had to stay for the pork and goat braai before we were allowed to leave as dusk was already closing in. Grrrrreat! Now we’d have a bunch of drunken drivers who would be driving in the dark too! Thankfully I went with the least drunk driver and eventually joined the vehicle with the dedicated non-drinking driver as my first driver decided he hadn’t had enough and broke his journey with another sneaky few by a roadside tavern. That is sadly a very real issue in Malawi. Drunk-driving is a common cause of road traffic accidents and deaths. Even the policemen, as in our group, do it liberally and you hardly ever find anyone being stopped for it. Maybe the poorly armed traffic police are afraid of assaults from the disinhibited drunks, I don’t know. But many drivers, including ‘zungus’, simply take advantage of this free ticket to nirvana, while being at their steering wheels. So much for the catchy road safety slogan around here that goes “arrive alive”, which is really funny as Malawians often get their ‘r’ and ‘l’ mixed up and what comes out is one of the three: “allive alive” or “arrive arive” or “allive arive”! Anyway, I reached home alive after a 4 hour drive, punctuated by a highly unfortunate chibuku vomiting incident (imagine the stink: vomit to the power of 2!)
So, in a nutshell, that’s what it’s like hanging with the ‘Socials’. Twice to three times weekly training and maybe once or twice a month we’ll stage a match up with another town, alternating home and away. The whole mixed with food and drinks and pool and many good laughs. To me the spirit of this social club is a true celebration of human affinity for fellow humans. Where there are no cinemas and bowling alleys and beer/food festivals to entertain one every single weekend, gatherings like our do take on that special importance which make football worth playing and life slightly more worth living. You don’t have to drink of course as some more self-restrained members of our crew do!
9 August 2010
Preparing for Madam
A royal treat
I might have mentioned that Malawians have a somewhat determined way of going about their cleaning. Statement not judgement. It’s an almost impossible ritual to understand for mere zungus like me here. They get up early every morning and sweep the dusty grounds and paths around their house, lifting a dustcloud that could instantly kill a cystic fribotic! This redistributes the soil for a couple of hours at most before it turns back to its former state. They also subject the floors at work to a daily round of energetic mopping, while other modes of basic sanitation are often overlooked (no soap by the taps; theatres cluttered with infection pools; often run out of antiseptic solutions and sterile gloves etc). Furthermore, since bins are hardly ever used/available here, this ritual becomes necessary to prevent a pile up of debris from the patients and visitors.
Lately however, the ritual has been scaled up to unprecedented heights. The rate of mopping has at least doubled. Nooks and crannies that weren’t being reached before are now getting their long awaited scrub. Termite-infested beams are being replaced. Each air vent in the walls is being individually cleaned to a sparkle. On top of that, the whole building and grounds of the hospital are being revamped. Painting here, there and everywhere. Even the potholes have been filled!! And what do we owe this surge of polishing to? Well, it will be one linked to the highly anticipated visit from none other than our brand new first lady! I wonder what the preparations would have been, had it been the president himself showing up here! This visit falls under the umbrella of a wider breast-feeding and maternal health campaign. Not surprising then that only maternity ward gets the full upgrade while other wards, only a superficial one with potential losses to pay for maternity. New sofas, new bed linen, new coat of paint and all just for maternity. I’m not against maternity you know, but what about paeds for example? And the others?!
Ironically, there’s also been a repainting of some signs in the hospital, which boasts a child-friendly policy, whereby no outside drinks are allowed in so mothers can breastfeed freely. There’s a ubiquitous picture of a woman breast-feeding on the hospital walls, which I always found quite amusing as it looked like the woman (man!) had only 1 breast. They attacked this photograph with an unleashed zeal to change it and I thought it was because of my perceived amusement at them. However the real reason came later as I was told that the woman (man!) was not looking at the baby and had to be altered. The fact that she (he!!) had only one breast, for its part, remained unaltered!
So, on Thursday, there was a distinctly palpable sense of excitement in the air in Ntcheu. Nobody wanted to say it but it was there to be read on their faces: “what’s this year’s calendar highlight got in store for me?” Management were getting their knickers all tied up in a twist, not sure what the best way to impress her highness would be. Not less since ministry officials would be spotted a least a week in advance around the hospital grounds doing spot checks and cracking the whip at this and that. So among other things, they asked for all the long-burnt out fluorescent light tubes to be replaced (bearing in mind that Her Highness’ visit would be taking place during broad daylight hours!). All the little bricks that go around the trees in the hospital yard also got dealt a new and tasteless coat of white paint. The original natural appearance was by far more attractive, especially as it did not involve unsightly spillages of white stuff on all these beautiful plants and the grass. The ultimate tribute to this great celebration came in probably the most prestigious form, according to Malawian custom- the issue of new commemorative chitenjis! Everyone is claiming theirs already. Such a cheap easy way to win an electorate- free tshirts and printed rectangular cloths! All style. No substance.
Unfortunately (?thankfully) I was not present when the auspicious event finally materialised on Friday, as I had to dash to Lilongwe before the crack of dawn to deliver a lecture at the physio dept training. But I sought active feedback on the outcome of the visit, slightly deeper than the customary “it went well” Malawian reply! She spent a couple of hours around the village health centres, being entertained to some traditional dances (not exactly breastfeeding related but hey!) and gave some Mk75000 to the best performance. As for the hospital, the visit lasted an impressive half-hour! She spent most of it on the new sofas in maternity ward and paraded around the shiny-floored, brightly-lit corridors only for as long as it took to get there from the main entrance. No pledges were made to upgrade the hospital, obviously since it looked like we were doing extremely well already. I wonder if that’s the reason why politicians here (and worldwide) always seem to think they’re doing a great job. Everything gets sorted to an impressive (hmm misleading) perfection every time they turn up, and as soon as they leave, all the mess, squeezed tight in those cupboards, spills back out in its ugly unsightliness again! I wonder how long it will be till Ntcheu’s natural beat of indifference resumes...
PS: unfortunately no photos for now as I've lost my camera recently. Will try and rectify soon (as I go round "borrowing" from my friends!)
I might have mentioned that Malawians have a somewhat determined way of going about their cleaning. Statement not judgement. It’s an almost impossible ritual to understand for mere zungus like me here. They get up early every morning and sweep the dusty grounds and paths around their house, lifting a dustcloud that could instantly kill a cystic fribotic! This redistributes the soil for a couple of hours at most before it turns back to its former state. They also subject the floors at work to a daily round of energetic mopping, while other modes of basic sanitation are often overlooked (no soap by the taps; theatres cluttered with infection pools; often run out of antiseptic solutions and sterile gloves etc). Furthermore, since bins are hardly ever used/available here, this ritual becomes necessary to prevent a pile up of debris from the patients and visitors.
Lately however, the ritual has been scaled up to unprecedented heights. The rate of mopping has at least doubled. Nooks and crannies that weren’t being reached before are now getting their long awaited scrub. Termite-infested beams are being replaced. Each air vent in the walls is being individually cleaned to a sparkle. On top of that, the whole building and grounds of the hospital are being revamped. Painting here, there and everywhere. Even the potholes have been filled!! And what do we owe this surge of polishing to? Well, it will be one linked to the highly anticipated visit from none other than our brand new first lady! I wonder what the preparations would have been, had it been the president himself showing up here! This visit falls under the umbrella of a wider breast-feeding and maternal health campaign. Not surprising then that only maternity ward gets the full upgrade while other wards, only a superficial one with potential losses to pay for maternity. New sofas, new bed linen, new coat of paint and all just for maternity. I’m not against maternity you know, but what about paeds for example? And the others?!
Ironically, there’s also been a repainting of some signs in the hospital, which boasts a child-friendly policy, whereby no outside drinks are allowed in so mothers can breastfeed freely. There’s a ubiquitous picture of a woman breast-feeding on the hospital walls, which I always found quite amusing as it looked like the woman (man!) had only 1 breast. They attacked this photograph with an unleashed zeal to change it and I thought it was because of my perceived amusement at them. However the real reason came later as I was told that the woman (man!) was not looking at the baby and had to be altered. The fact that she (he!!) had only one breast, for its part, remained unaltered!
So, on Thursday, there was a distinctly palpable sense of excitement in the air in Ntcheu. Nobody wanted to say it but it was there to be read on their faces: “what’s this year’s calendar highlight got in store for me?” Management were getting their knickers all tied up in a twist, not sure what the best way to impress her highness would be. Not less since ministry officials would be spotted a least a week in advance around the hospital grounds doing spot checks and cracking the whip at this and that. So among other things, they asked for all the long-burnt out fluorescent light tubes to be replaced (bearing in mind that Her Highness’ visit would be taking place during broad daylight hours!). All the little bricks that go around the trees in the hospital yard also got dealt a new and tasteless coat of white paint. The original natural appearance was by far more attractive, especially as it did not involve unsightly spillages of white stuff on all these beautiful plants and the grass. The ultimate tribute to this great celebration came in probably the most prestigious form, according to Malawian custom- the issue of new commemorative chitenjis! Everyone is claiming theirs already. Such a cheap easy way to win an electorate- free tshirts and printed rectangular cloths! All style. No substance.
Unfortunately (?thankfully) I was not present when the auspicious event finally materialised on Friday, as I had to dash to Lilongwe before the crack of dawn to deliver a lecture at the physio dept training. But I sought active feedback on the outcome of the visit, slightly deeper than the customary “it went well” Malawian reply! She spent a couple of hours around the village health centres, being entertained to some traditional dances (not exactly breastfeeding related but hey!) and gave some Mk75000 to the best performance. As for the hospital, the visit lasted an impressive half-hour! She spent most of it on the new sofas in maternity ward and paraded around the shiny-floored, brightly-lit corridors only for as long as it took to get there from the main entrance. No pledges were made to upgrade the hospital, obviously since it looked like we were doing extremely well already. I wonder if that’s the reason why politicians here (and worldwide) always seem to think they’re doing a great job. Everything gets sorted to an impressive (hmm misleading) perfection every time they turn up, and as soon as they leave, all the mess, squeezed tight in those cupboards, spills back out in its ugly unsightliness again! I wonder how long it will be till Ntcheu’s natural beat of indifference resumes...
PS: unfortunately no photos for now as I've lost my camera recently. Will try and rectify soon (as I go round "borrowing" from my friends!)
21 July 2010
Clinical Digest8
Orthopaedics in Malawi
My non-medical audience might just want to turn away for this one. But if medical jargon’s your thing, then please stay on! The week just gone has seen an escalation of my orthopaedic activity like none since I arrived in Malawi. I organised an exchange week at another district hospital up North, Rumphi, to coincide with another (more fruitful) surgical visit by Steve Mannion and the Feet First team (Bernie, Danni, Clive and James as well as Steve's wife, Mercy). Having beat them to the place, I had an entire morning to shadow the OCO (orthopaedic clinical officer) on his Monday clinic and ward round. Then I got given a full tour of the relevant departments, such as Xray, minor theatre, physio and the appliances workshop. That proved to be one of the most useful parts of my exchange, by putting a better perspective on things in the Malawian health care system and also questioning some of the assumptions I came to while in Ntcheu. I now know that a lot of our deficiencies which I had formerly attributed to stretched resources aren’t necessarily so: there is at least another district hospital, with the same resources, which is managing to function in these areas. Of course it’s not like UK, but it struck me as a fantastically well run department, given the available resources. The main one of these unfortunately is unique to Rumphi and that is the OCO himself, Mr Mwalanda. Along with a non-clinical assistant alone, he manages to get through more than both OCOs at Ntcheu can do. Still I believe (and hope) that, given the right motivation and organisation, we too can match this productivity even after I’ve left. My job is to find ways of instilling this great drive that, of his own admission, has led Steve Mannion to choose Rumphi as his main operating base in Malawi, into Ntcheu.
So the real medical onslaught began as soon as he, Steve M, landed there on Monday afternoon and tackled a clinic of some 30 collected complex cases to try and devise a feasible theatre list over the next 2 days. Being able to talk through the diagnostic process and management rationale with him allowed me to take on board concepts and skills that I’d only partially assimilated till now (try and explain the intricate relations between hindfoot and midfoot biomechanics to a pre-SpR Orthopod and you’ll get an idea of the level of masochism involved in learning it for oneself!)At the end, it was rather dumbfounding how we managed to get through so many cases in one afternoon, but we did. Among this small crowd featured a number of club foot deformities, genu varuses and valguses (including a case of both in the same patient- windswept knees) and poly/syndactilies not to mention complications such as contractures, sequestrae and post septic joints. This all built up two full day lists of about 14 patients, which matched our scheduled impeccably. As expected though, once we got down to the list, a number of cancellations had occurred for various reasons ranging from malaria to not-unlike-Ntcheu absconding! We were still left with 10 patients and 14 cases in total, ample opportunity for on-the-job learning.
To summarise the mind-numbing learning curve that ensued over the course the following days, I am now hoping to export the following operations to Ntcheu, since they require no expensive or specialist hardware... other than an osteotome and a button (yes!.. to secure the tension in club foot correction):
high tibial osteotomies for selected genu varuses, soft tissue releases for neglected club feet, release of syndactyly using at least 2 methods and, at least theoretically, morsellised skin grafts. So, all excitement it is going to be for the next few weeks back home! All the more so with the new donated kit that’s waiting to be tested out.
To cap off my week in style, I spent the final day of my educational break from Ntcheu back in Lilongwe, where I followed Mr Mannion around on a tour of pretty much all the orthopaedic services for the central/northern regions of Malawi. I got a real in-depth insight into the planning of this crucial aspect of health care in Malawi, where disability and trauma often tend to be given secondary importance, with maternal and neonatal care and HIV enjoying most of the worldwide support and funding. That is largely due to the priority these areas have been given through the millennium development goals, which I am not contesting. However the social and economic impact of neglected orthopaedic affectations, with the incredible number of road traffic and industrial accidents, congenital abnormalities and paediatric fractures and burns, cannot and should be ignored. And indeed, I found out there are a few organisations with the sole aim of addressing these problems in Malawi: MAP- Malawi against physical disability; CBM; and of course Mannion’s own charity Feet First. In addition to these are of course the orthopaedic departments at KCH (Lilongwe’s Kamuzu Central Hospital), the 500miles prosthetic centre and the aptly-named Dae Yang (pronounced Die Young!) Luke Mission Hospital, doing their own invaluable work, albeit with limited staff and resources. Unwittingly I got myself a nice little assignment from this field trip, which is to mediate the next meeting of the Malawian Orthopaedic Association, which regroups all these partners, in September with another UK-based organisation, WOC (World Orthopaedic Concern). With all this on my plate, I think it’s time I took leave of you and set myself to some serious groundwork.
My non-medical audience might just want to turn away for this one. But if medical jargon’s your thing, then please stay on! The week just gone has seen an escalation of my orthopaedic activity like none since I arrived in Malawi. I organised an exchange week at another district hospital up North, Rumphi, to coincide with another (more fruitful) surgical visit by Steve Mannion and the Feet First team (Bernie, Danni, Clive and James as well as Steve's wife, Mercy). Having beat them to the place, I had an entire morning to shadow the OCO (orthopaedic clinical officer) on his Monday clinic and ward round. Then I got given a full tour of the relevant departments, such as Xray, minor theatre, physio and the appliances workshop. That proved to be one of the most useful parts of my exchange, by putting a better perspective on things in the Malawian health care system and also questioning some of the assumptions I came to while in Ntcheu. I now know that a lot of our deficiencies which I had formerly attributed to stretched resources aren’t necessarily so: there is at least another district hospital, with the same resources, which is managing to function in these areas. Of course it’s not like UK, but it struck me as a fantastically well run department, given the available resources. The main one of these unfortunately is unique to Rumphi and that is the OCO himself, Mr Mwalanda. Along with a non-clinical assistant alone, he manages to get through more than both OCOs at Ntcheu can do. Still I believe (and hope) that, given the right motivation and organisation, we too can match this productivity even after I’ve left. My job is to find ways of instilling this great drive that, of his own admission, has led Steve Mannion to choose Rumphi as his main operating base in Malawi, into Ntcheu.
So the real medical onslaught began as soon as he, Steve M, landed there on Monday afternoon and tackled a clinic of some 30 collected complex cases to try and devise a feasible theatre list over the next 2 days. Being able to talk through the diagnostic process and management rationale with him allowed me to take on board concepts and skills that I’d only partially assimilated till now (try and explain the intricate relations between hindfoot and midfoot biomechanics to a pre-SpR Orthopod and you’ll get an idea of the level of masochism involved in learning it for oneself!)At the end, it was rather dumbfounding how we managed to get through so many cases in one afternoon, but we did. Among this small crowd featured a number of club foot deformities, genu varuses and valguses (including a case of both in the same patient- windswept knees) and poly/syndactilies not to mention complications such as contractures, sequestrae and post septic joints. This all built up two full day lists of about 14 patients, which matched our scheduled impeccably. As expected though, once we got down to the list, a number of cancellations had occurred for various reasons ranging from malaria to not-unlike-Ntcheu absconding! We were still left with 10 patients and 14 cases in total, ample opportunity for on-the-job learning.
To summarise the mind-numbing learning curve that ensued over the course the following days, I am now hoping to export the following operations to Ntcheu, since they require no expensive or specialist hardware... other than an osteotome and a button (yes!.. to secure the tension in club foot correction):
high tibial osteotomies for selected genu varuses, soft tissue releases for neglected club feet, release of syndactyly using at least 2 methods and, at least theoretically, morsellised skin grafts. So, all excitement it is going to be for the next few weeks back home! All the more so with the new donated kit that’s waiting to be tested out.
To cap off my week in style, I spent the final day of my educational break from Ntcheu back in Lilongwe, where I followed Mr Mannion around on a tour of pretty much all the orthopaedic services for the central/northern regions of Malawi. I got a real in-depth insight into the planning of this crucial aspect of health care in Malawi, where disability and trauma often tend to be given secondary importance, with maternal and neonatal care and HIV enjoying most of the worldwide support and funding. That is largely due to the priority these areas have been given through the millennium development goals, which I am not contesting. However the social and economic impact of neglected orthopaedic affectations, with the incredible number of road traffic and industrial accidents, congenital abnormalities and paediatric fractures and burns, cannot and should be ignored. And indeed, I found out there are a few organisations with the sole aim of addressing these problems in Malawi: MAP- Malawi against physical disability; CBM; and of course Mannion’s own charity Feet First. In addition to these are of course the orthopaedic departments at KCH (Lilongwe’s Kamuzu Central Hospital), the 500miles prosthetic centre and the aptly-named Dae Yang (pronounced Die Young!) Luke Mission Hospital, doing their own invaluable work, albeit with limited staff and resources. Unwittingly I got myself a nice little assignment from this field trip, which is to mediate the next meeting of the Malawian Orthopaedic Association, which regroups all these partners, in September with another UK-based organisation, WOC (World Orthopaedic Concern). With all this on my plate, I think it’s time I took leave of you and set myself to some serious groundwork.
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