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

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!

Hospital Transport

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!