Malawi Ulendo

Clinical Digest16 A retrospective

2011-12-30T03:06:00.000-08:00

It feels strange writing this blog now and thinking back at the time I first set foot in a hospital in Malawi during this placement. Trying to link it all and witness this incredible journey and the transformations it has brought both to my personal and professional life. Trying to think about the impact it has had on the people of Malawi, and beyond if any. Trying to think of other ways I could have done it. Trying to summarise what the Malawian health care system is really all about and what the future has in store for it. Ultimately trying to work out if my presence here has overall been beneficial or not. I might not be able to answer that yet, because for the retrospectoscope to work best, time needs to elapse. Right now my subjectivity and sentimentality about leaving soon will no doubt introduce a certain bias. But lets try anyway.

Lilongwe- 6weeks

When I look back, this was one of the most fascinating times in my entire medical career. It spelt a complete new start, clean sheets, the beginning of an era. The mix of uncertainty and excitement was almost toxic, yet I’ll admit, somewhat intoxicating too. I’m sure that this wouldn’t constitute most people’s fix but for me, there was a certain thrill about deciphering the meaning of all of it then that kept me going. I found myself in areas I had not ventured into for months if not years, like the urology theatre or the labour ward. I found myself doing circumcisions and Caesarian sections. I found myself finding operations I would rarely see in the UK suddenly becoming routine, like limb amputations on young adults, sequestrectomies and bone drillings. I found myself in a maze of new pathology, using an almost entirely new medical vocabulary, approaching management from a totally new perspective. I was making a choice to unlearn some of the rigid set ways of doing things as I used to back home so I could integrate into this new system. It was intense and challenging but it was with one safety I would soon leave to enter the wild world beyond: consultant supervision.

Ntcheu- 1 year minus 6 weeks

My first day at work in Ntcheu. Surreal. A week’s orientation visit during my in-country training did hardly anything to lessen the shock. I was now an official employee about to work alongside everyone rather than a mere observer. I had to get to grips as quickly as I possibly could with all the intricacies of this new world so I could start operating within it. Lilongwe I found out was a very far cry from it. It gave me a good flavour of the Malawian health care, but had very little in common with the district setting. I would soon be reminding everyone about this so they don’t get misled by their placements in central hospitals that this is the standard of care most Malawians are receiving.

Ntcheu, my new workplace, opened my eyes to many challenges and led me to develop new skills to tackle them. For the first time ever, I would become a departmental manager, a data collector, a policy maker, a networker, an inventory maker and a procurer. I began working alongside maintenance to repair, improve and create equipment we needed. I became an advocate for improved sterility standards, almost in the style of the notorious infection control nurses I used to scorn at in the UK. I learned how to talk, present and teach in a completely new way, one which would make sense to Malawian students. I did all the usual things too, like ward rounds, theatres, clinics but developed a completely different approach to fit in with this entirely alien setting. I realised the need to balance efficiency with practicality. Never has the expression “more haste less speed” seemed more true. I slowed down, became more flexible but made sure to maintain my standards in the context of the hospital. I had to accept certain failures, but only if I could use them to change things so they wouldn’t happen again. Teaching by example became a very important philosophy of mine. I wish I could have done so without ever losing my cool at the heights of my frustration (which I won’t hide), but then that would be claiming to have cracked one of the most complex challenges of Malawi within a single year. In all truth, a lifetime might be too short.
Ntcheu, because of all these things, was my first in depth insight into the Malawian way of doing things, which would help me adapt my style to fit in better with the healthcare system, thereby enhancing my impact on it. Ntcheu, no longer so alien anymore, reshaped me for the better. Ntcheu prepared me for the journey ahead.

Blantyre – 1 year

This was in a way my graduation into the higher strata of tropical orthopaedics. Whatever little I had seen in Lilongwe seemed a long way back, and whatever I’d done in Ntcheu was a long way from this level I would be diving into. The learning curve was vertical, exponential, dizzying to say the least. My 2 hour lunch breaks were shrunk to minutes. My evenings of leisurely reading and work preparations were to make way for some of the most hectic calls I’ve ever done and assiduous reading about new operations and approaches. My very much self motivated presentations about topics of my choice to general clinicians and nurses were alchemised into specific lectures to medical students, trainee orthopaedic clinical officers and other doctors. My research imperative was cranked right up. With internet at work, no matter how intermittent and temperamental it might have been, I was able to get much more done in much less time. In addition to this Blantyre was also a city where I would be able to run projects on a different scale, with readier access to partners and resources. Hence I got the tricycle project going, thanks largely to your very generous support. I also got specialised splints made for traction patients, again with the help of sponsors from home. And above all, I got things moving like I could never have done in Ntcheu for the one biggest project of all: the editing (and future printing) of the Orthopaedic Resource Book. Right now, I am engrossed so much in this project everything else suddenly seems to have been put on hold. It is by far the biggest undertaking I have ever dealt with and its completion here or back in the UK will be my single biggest legacy to Malawi, in the name of my VSO placement.

All my time in Queen’s has also consisted of the bread of butter of orthopaedics naturally and on a scale that puts a lot of my previous work placements to shame. My operative logbook has benefitted from no less than 300 new cases, a lot of them being ones I would not have been able to perform before arriving in Malawi. I have received some of the best supervision ever from truly dedicated consultants here, both permanent (Dr Bates & Prof Mkandawire) and visiting, adding further to the wealth of that experience. My calls have brought me face to face with many socio-economic realities of Malawi: the political riots, the poverty that resulted in many patients presenting late with inadequate primary care, the fallen down houses and walls during the rains, the extra-ordinary motor vehicle accidents, to name a few. I became very much a frontline trauma doctor with a new sense of cool I will always be grateful to Queen’s for. My ward and clinic duties have assumed a higher level of responsibility which should see me evolve much more smoothly into registrar training once I get back to the UK. Beyond teaching, this notching up of my seniority has earned me the honour of presenting at some fairly high level fora such as the COSECSA (College of Surgery of East Central and Southern Africa) and Surgical Association of Malawi annual meeting, as well as the AO training for the Malawi Orthopaedic Association annual meeting.

I conclude this clinical digest feature today (having as yet failed to produce one on the complexities involved in dealing with convicted patients in Malawi) on an exceptionally high note. My 2 years in Malawi, and particularly my year in Queen’s haven’t completely gone unnoticed by my colleagues. Thus today I had the nicest sending off I have ever received from any workplace. The whole department gathered to say thanks for my work done and to wish me well in my future pursuits. It felt like a real tribute,indeed an epitaph to look back on, when doubts may arise about whether I made a difference or not. I know at least, I’ve touched my colleagues and, through them, I can be pretty sure, my working environment too. But above all, let me say this: it me who has benefitted the most from this incredibly rewarding time I’ve spent in Malawi. I’ll be a new person, a new doctor when I get back home.
Thus, today’s final review of Malawi signals more a new beginning to me than a conclusion...

TOP 10 MALAWI

2011-12-25T05:04:00.000-08:00

Slowest internet connection ever today... photos will have to wait a bit!Happy Christmas to ya'all!
(chronological)
Lilongwe 6weeks
My arrival in Malawi. Simply awesome. No time I look back upon compares with this period in terms of the pace of learning new skills, insights, ideas and expectations for the 2 year period here. The feeling of awe and excitement of being in this strange new country without knowing exactly how it’s going to pan out is one that can only be experienced, not described. Stranger in a strange land, with one difference. A very willing stranger.

Everest night out with Dutch students
This episode never made it as a feature on my blog, probably because I was too dazed for too long afterwards to write it up. Now is the time for it to receive its rightful accolade. For anyone who remembers the Carlisle church flat, one will remember how it’s the amazing parties it hosted (Knocking on heaven’s door, Heaven&Hell and Trilogy) that raised it to the legend status it still now boasts in our collective memories. For Ntcheu, it will certainly be the Everest nights out that will occupy that space. To be honest, it was probably a Friday night like most others in the Everest night club in Ntcheu. But somehow, it combined so many elements which, when mixed, gave the perfect cocktail. First ingredient of course was the novelty. Novelty always dies out, but then it was still fresh and exicting. Then came the build up. All good parties have a prelude. That night out had been orchestrated for a good few days and everyone discussing it at work that morning. Last but not least, the company. It’s rare for all your buddies to be around at the same time in Ntcheu. At least 1 person usually has a wedding, funeral, family trip of some sort or other thing going on in the home villages that they have to leave Ntcheu to attend. That night everyone was there. And what more, we had visitors. Special visitors. Everyone loves visitors in Ntcheu and the rest of Malawi too. 2 wickedly friendly medical students from Holland was one rare treat for the local crowd at Everest and it certainly got everyone one partying like there’d be no tomorrow that day. For my part, I was totally absorbed in the vagaries of this new culture and was quickly substituting one form of dancing (salsa) for a new one (local stylee)!
This one goes out to Craill and Nicorr!

Nyika trip with Janet (bike ride)
When you find out a few months later that the trip you’ve just been on actually features in the “Rough Guide to the planet- 1000 things you should do before you die”, you simply lick your index finger and draw a tick in the air! Nyika, Rough Guide or not, was the trip of a lifetime. The journey (but then again very much the destination also) was what made it. My first steps into the wild north were simply amazing. The different sceneries, villages, climate and people, not mention the fact that Janet was over for her first visit made for a holiday spirit that’s hard to match from our existing repertoire. To top that up with a ride on one of the highest, most idyllic plateaux of Malawi (often compared with the rolling hills of Scotland) on mountain bikes that worked elevated it to one of the top rungs surely of this retrospective blog today. When I dream of escapes from reality, Nyika lives on as that place I once visited that I would happily never want to come back from.

SAafrica
Okay, this one is not truly Malawi, but it encompasses a lot of Malawi and it would most certainly not have happened had I not been in Malawi at the time: Ayoba time in South Africa. Journey beat destination again. The start of it all was not surprisingly at Everest night club for that legendary launch concert (Black eyed peas, Shakira, K’naan). The spirit then just got better and better by the day. By the time I was on that epic bus journey, I was already in the zone. Then came the border crossings through Mozambique, Zimbabwe and Beitbridge in SA. Awaiting on the other side was the best football company ever- me bro Su, cousin Randhir and other friends and family. Roughing it in Jozie before a smooth finish at Cape Town was simply amazing. The utter football party spirit that reigned supreme is only possible for a world cup I think. But South Africa as a whole was a treasure I had not expected it to be. To say that it has whet my appetite for further exploration would be an understatement.

Lake of stars (both)
The 2 blogs already dedicated to this event attest to the sheer grandeur it boasts in my mind. Hence, I shan’t go on much more about it, but to say that this festival is not just the best I’ve been to in Malawi but certainly in the world too. I might not have done Glastonbury yet but this mixture of good people, good acts, good weather and a simply magical backdrop is definitely gonna be hard to beat.

Thyolo walk with Matt and Bex
Aloha Matt ndi Bex! Guys you simply treated us to one of our best walks ever in that post-apocalyptic period we were treading at the time. ZK! The lush green carpets of Thyolo tea estates were revealed to us in a way simply not given to outsiders. What with Mulanje lurking majestically, yet discreetly in the distance. Our passport into the estate was Matt who must have had the coolest VSO placement working there. No nook nor cranny seemed unknown to him and with him as guide, we were in for a treat. Out of this world!

Kamba
Now this one is an insider affair. It’s the bottlestore par excellence of Blantyre. It is a shack to be honest. But it is the closest thing to a good old old-man’s-pub Malawi can offer in my wide experience! Your local crowd in there ain’t the usual yobos and trouble-makers but a rather elite group of men (even in such a place the women haven’t made it yet) from different walks of life with a somewhat intellectual slant. The name “Silvergrey” kind of gives it away when I look back. This is the sort of place you have to be taken along to by an insider as otherwise you would simply walk on by, without ever being tempted to go in. The Friday night post-work sessions I’ve enjoyed in there with my mate Chris, topped up by the full on Malawian-style pool rounds, will live on sweetly in my memories.

Mulanje (the Lujeri trip)
This one again has it fair share of dedicated entries to its name. Its omnipotence in the Malawi skyline is on a par with the place it occupies in my consciousness. The one trip that remains most etched in my memory of it has to be the utter physical challenge we undertook on a short weekend to get up in and down in 2 days while bagging the highest point in Malawi- Sapitwa (literally “don’t go there”). That was the May trip to wish farewell to our Norwegian friend, Tor, great companion of ours in this Malawian journey. Little did we know that in his pre-retirement period, his legs were very much still at work like a Klipspringer one might say, in remembrance of this rare sighting we made during that hike. The combination of sceneries from the Lujeri tea estates, through the mountainsides, plateau and peak will be my live equivalent of the Shire in “Lord of the Rings”!

Monkey bay surprise boat trip
And this one will go down as my live equivalent of the beach scene from “The Beach”. Having decided to divert from the classic tourist trail that invariably ends in Cape Maclear, not out of choice so much as out of vehicle incapacity, we found ourselves taking the path down Monkey Bay with both Janet’s and my parents for a bit of discovery. To arrive just on time for the impromptu boat ride that was leaving the backpackers where we were putting up at was pure and serendipitous luck! Nothing could possibly have been a better welcome than this after a long and sweaty car journey, considering food and booze were to be found onboard too! My excitement would be manifested as manic backflips and rooftop dives from this party boat, but there was definitely something for everyone. Both Purcell and Doorgakant progenitors I’m certain will testify to this with the incredible lakeside landscapes, close up sightings of Pied Kingfishers and Fish Eagles and pristine waters on offer!

Boadzulu island trip
Back to the lake for this latest top-tenner of our Malawi sojourn. This was a truly personalised and magnificent send off from our friend Neville Bevis, director of the Open Arms Orphan Care that he runs with great passion. How our paths met typifies the way the greatest travel friendships start, that is a chance encounter. We were picked up by him some 4 years ago on our first trip to Malawi as we were walking back at dusk to our lodge located next to a township. He thought this unsuitable for us to do given the number of recent muggings of foreigners in that area. We exchanged ideas during that brief encounter and they must have been good ones since we have kept on exchanging them since. Our year in Blantyre really brought us closer to him and his Malawian partner, Enipher. To wish us goodbye in style, he invited us for a trip aboard his catamaran to an island off the Mangochi part of the lake, Boadzulu. To sum up how amazing this was, try and conjure up images of pelicans and terns, a cliff-side colony of cormorants, beautiful clear waters that felt warm as you swam through them and just stretching out in the breeze with a drink to savour this fabulous environment. Contentment in Malawi cannot be said to be complete without a last tribute trip to the lake. That one will certainly live up to the occasion.

Cross cutting themes (to use a perfect VSO jargon):
Meeting people and expanding world view
Today’s blog even surprised me when I read it back, as I noticed how intricately linked it was to the people we’ve met here. One can safely conclude that without the human factor, much of the above list wouldn’t have made it to the top ten. And likewise, with a good human vibe, rather dull moments can be transformed into memorable ones. The people we have included so far have been mostly fellow foreigners like us, with something in common, be it our desire to learn this culture in Malawi better, to work on restoring some balance in the world or indeed, a shared love for birds and animals. But what I don’t want to leave out just because we don’t go on trips with them are the unique and amazing people of Malawi. This sounds cliché and I won’t dwell too much on it for fear of reinforcing that cliché with more cliché words, but I have come across a form of friendliness here that I’ve never seen before. Although some of it has undoubtedly been out of self-interest (associate with the “rich” and you’ll get something), I am quite confident that most of the time, this welcoming attitude was genuine and truly selfless. Malawians have taught me lessons in humility, generosity and joie de vivre I will never let myself be distracted from again. Poverty, as has been proven here, is no obstacle to the achievement of these core human values.

Birds, animals, wildlife at so close range
A cursory glance at my blog so far would have given it away without me having to dedicate a special section to it today. Suffice to say that I have graduated from a Planet Earth documentary fan to a real field admirer of wildlife through Malawi. My appreciation of the delicate balance required to maintain such beautiful biodiversity has really been refined over here. The constant confrontation between the (allegedly) highest member of this ecosystem and the other members is clear to see. Developing a true love and knowledge of birds and mammals and fish and trees has brought me into an intimate relationship with the world where the concept of respect can stand out supreme. Respect surely can have wider applications.

...And that’s not even mentioning the joys of Zomba, Chilwa, Majete, Liwonde, Gongonya village week in Madzanje, the Blantyre arts festival and fantastic times with loads of other friends for life: Klaas and Gerdien, Sajir, Hanna and Raz, Helen and Mike, Marieke, Liora, the Bates etc.

Clinical Digest15 Cutting

2011-11-26T11:41:00.001-08:00

The blog Not Made in China produced the desired response (largely due to its controversial nature). The controversy was without a doubt about Gaddafi and I deliberately did it and I'm glad I engaged some minds in debate. So I'll start with a little disclaimer to clarify my thoughts on him. I'm no starry eyed fan of no ageing dictator who's held on to power for far too log (even 10 years is too long for me), with an appalling record on human rights. But lets face it there is no leader white, black, yellow or brown worldwide that can claim a clean record. Western leaders often get praises for the good they've achieved (such and such peace deal or economic prowess) instead of being forever damned for their records on arms trade, secrecy, covert human rights abuses, economic subjugation of the world etc. So make no mistake about it (Bushism!), Gaddafi is no angel but he's one guy who has stood up against the unjust global power system. He's literally torn the UN constitution in a statement that's been mocked by those it blamed for maintaining such a fake global democracy. He has pulled Africa together across tribal divisions more than any other living person and formed the albeit flawed African Union. And if even Mandela sees him as a friend (he was a major international driver in the overhaul of apartheid in SA while Western leaders were still pontificating on such and such legal loophole!), lets place credit where it is due. Cause if we can give it to the likes of Thatcher, Bush, Churchill (not exactly famous for his racial ideas), Mitterand and the rest where they're deemed to have been successful without provoking such controversy, then I think we can grant Gaddafi his claim to fame..

Cutting!

Is it right to come to Africa for cutting? This is an oft-bandied about expression from home, referring to the benefits of doing elective or other work abroad when you’re a trainee surgeon. It usually goes:
- “I don’t know what the interview panel will think about the experience I gained abroad, given it’s a different system.”
- “Don’t worry about it! You’ll have loads of “cutting” and they’ll be well impressed.”

Thus as a trainee surgeon, one embarks on this mission to get cutting as much as possible so that they can go back with an extensive logbook to prove their diligence away from home. Befitting my general cynicism on the over-competitive UK training system, I came here with a much tempered sense of necessity to acquire this cutting experience, unless of course, it formed a natural part of my work. Cutting, especially unsupervised, for the sake of cutting in an environment where adequate safeguards might not be in place is akin to human experimentation. Thus, despite doing some rather cutting edge cutting (involving unfamiliar territory like urology, gynaecology and general surgery in addition to orthopaedics) in my very first weeks of induction in Lilongwe, my logbook numbers dwindled significantly while in Ntcheu. In fact all I was cutting was the numbers! But that was fine then and I got a chance instead to deepen my understanding of other areas of management, which frankly I would have missed out on by coming straight to Queen’s. These include the technical aspects of conservative treatment and above all the insight into wider aspects of organisation such as procurement, maintenance, theatre safety, data management, networking etc.

But now I’m at Queen’s, the nature of my job has been radically transformed. There are designated people for all of the above tasks, who need very little input from me and the need for my skills is very much at the service level, the shop floor, the wards and theatres. And let’s not forget the classes, as the academic department staffing required to meet the needs of the ever-growing student population at the adjoining medical college is very much stretched to its very limits. And every visiting doctor automatically gets a timetable of lectures as part of the package. Mine has recently been expanded that little bit more, with the arrival of the TOCOs (Trainee Orthopaedic Clinical Officers), such that the only free half-day slot left in my weekly schedule, that of Friday afternoon has now been filled! But then again, I love teaching. As Martin Luther King Jr. said "the function of education is to teach oneself to think intensively and to think critically"...

But let me cut the chase and come to the point again, that is cutting. That’s what I do at least 3 days a week now and on occasion 4 or even all 5. Let me tell you that I’ve never done so much operating (to use the official term for cutting) in my life before, let alone so much new operating. My learning curve is near-vertical now and my brain is quickly replacing old cells (probably devoted to such past idlings of my mind as French literature or German speaking- sorry continentals, nothing personal!) with new ones packed with pictures of approaches, exposures and metal implants not to mention the long paragraphs that describe them! I’m quickly tackling operations like forearm and ankle platings, intramedullary nailings of femurs and tibias and external fixations, not to mention skin grafting and soft tissue procedures like tendon repairs with greater degrees of independence. To have leapt to that level in such a short time is quite phenomenal and not without its challenges (an all-encompassing term here in Malawi which I’ll tackle bit by bit now). Well the first challenge is really that: is that surgeon competent enough to do all these new cases? Well the simple answer is no! But then there’s challenge number two, how do we provide an essential service when there’s not enough hands on the ground to provide it? Should we use people with some but not full training and crash course them into doing the job? To that, considering that’s what I’m undergoing, I’ll have to answer yes, with the proviso that the trainee is responsible enough to recognise their limitations and do their homework rigorously. That’s what happens naturally back home, and that’s what the stringent UK selection process (when not marred in favouritism and nationality biases) endeavours to achieve. And that’s why no trainee surgeon will be allowed to operate unsupervised until they’re consultant level pretty much. And that introduces the third challenge which is supervision. I’ve already said that every member is stretched almost to the point of having their limbs dismembered here. Hence a surgeon might feel the pressure to do most of the operating themselves, so that they can get all the cases done rather than painstakingly take trainees slowly through the processes. Thankfully that’s not what happens at Queen’s and for that reason alone, it deserves a 5 star grading as a surgical training institution. What’s more, it constantly receives visiting surgeons from various schools of surgical thinking (German, Dutch, English, rest of the world) and each one has a different way of doing things. This, when one doesn’t get confused instead, imparts an overall diversity which absolutely enhances understanding, probably better than having 10 supervisors who all have to follow the same approaches back home. So the issue of unsafe operating is taken care of by the system I think, but the problem remains that there are very few trainees coming through. Lack of competition and the pressure to produce more surgeons to cope with the ever increasing demand makes it very difficult to turn applicants down let alone fail them during training. Yet again, Queen’s has a very impressive academic record, and at least the graduates that have entered into surgical training (as opposed to pen-pushing jobs of DHO for which they are not qualified) are in my opinion, of the right ilk. The question is how do I, and the like of me fit into that system, especially the likes of me with a real hunger for cutting?! Are we depriving the local trainees of adding up their own numbers or are we providing much needed competition so they can up their game. I’m lucky to have come into Queen’s at a time when the number of local trainee is very low, hence there is enough work to keep everyone busy. But this is bound to change with time, at the rate at which the College of Medicine is churning out new graduates, and with all the DHO posts already taken up.

So, to cut a long story short, my point is that coming here for cutting is an ethical dilemma the visiting trainee has to address thoroughly in advance, lest they slip into human experimentation and disrupt rather than benefit a system.

Just like cutting in surgery, the role of volunteers in all lines of work needs equal consideration before rushing to the conclusion that being a volunteer is, de facto, a good thing that benefits a poor country. There are many challenges in all areas (culture, language, expectations, let alone technical ones specific to the subject) that might make the work of a volunteer ineffective, if not even negative. The standard of personal responsibility and social awareness of many volunteers (especially VSO as we get training in these areas before coming here) works as a natural check that’s often enough to mitigate against such adverse outcomes. But these days, there is a certain romance associated with working abroad (especially in Africa) and people embark upon such missions either for adventure, to meet a challenge or simply get a job/ experience with the job opportunities suffering back home. I warn against volunteering on these grounds. Doing a paid job is another thing. The main motivation in volunteering should be that of bringing positive change to the place and people. Should one feel they’re not achieving that, then they should change what they’re doing or step away rather than continuing for the other reasons. Especially relevant in this context are the very short term exchanges that abound in health care where people come here on glamorous (all inclusive) grants for 6-12 weeks and expect to change things in that time. I think these brief visits should be exclusively for observational/ research purposes and the volunteers ought to be briefed in advance that this will be their role (unless undertaken by experts, especially ones with experience in Africa, providing consultation). Their work has to be supervised and they should assist rather than take over things.

That is my 2-ish years’ worth on the subject and I’m certainly still learning the system more than I’m running it. I might have got it wrong in my analysis but these are my thoughts heretofore and that’s pretty much the only place I can record them.

Cut!

NOT MADE IN CHINA: MIXED MEDIA

2011-11-08T04:31:00.000-08:00

Not a blog really. Not an essay. Maybe I’m putting it down here as a record of a creation on Malawian soil. Which will remain on Malawian soil (? indefinitely).

Not Made In China (J&A Doorgakant, October 2011) - made with china mostly and from [Made in China] materials:
• cardboard panel (broken ceiling board) [origin unsure]
• oil paint [Processed in Malawi- Chinese chemicals]
• contact adhesive [Made in India]
• broken china cups and plate [Made in China]
• broken orange glass plate [Made in China]
• paintbrush [Made in China] bristles which came out during the painting

Not Made In China came about as a bud of an idea of mine at least 4 years ago, in the heat of the Beijing Olympics. At the time I joined the massive street protests in London when the torch-bearing parade was intercepted by Free Tibet activists (under my very own stare). I was fuming in those days about the oppressive Beijing government and its abject violation of Tibetan people’s rights. I still am but my sentiment has evolved.

I always believe that one’s opinions ought to be dynamic, without this necessarily weakening the value of them- i.e. one should be entitled to hold a strong view on an issue, even if the very next week that view switches to a diametrically opposite one, held with an equal intensity. The crucial element in validating such opinion change is reason, often in the form of newly-acquired knowledge or similar knowledge acquired from a new angle. Without this, we wallow in the realm of the arbitrary without much more than personal bias informing our judgements. To expose one to maximum new knowledge is one way of ensuring continuous opinion change, the degree of which generally becomes subtler and subtler with time, i.e. tends towards refinement. It is the reasonable evolution of opinion.

One very effective way, possibly the most, in exposing one to new knowledge or angles thereof is travelling. Travelling to Malawi has opened my eyes and mind in ways I could not have anticipated 2 years ago. It has given me a new understanding of the world, challenged many pre-conceptions of mine and taken apart so many over-simplified beliefs I held with great assurance. I found myself suddenly reading different newspapers and magazine, watching news from different broadcasting corporations, talking to people with completely different views of the world to the one I’d become accustomed to hear among my group of friends back home. These views were challenging but they provided a great insight into the process of opinion making. What we think is so largely influenced by what media we are exposed to. It’s inescapable and that is the reason why governments around the world spend so much money and political leverage on media-control. What I used to see as a great all-rounded source of information on the world, The Guardian newspaper, suddenly seemed like nothing but one of the less biased but still biased papers, where the boldness to tell things as they truly are is still largely lacking. People like to read what they believe. So in the market-dominated society, even a paper like the Guardian will respond to the interests of its government (propaganda) and its audience: the ‘left’. But this concept of the Western ‘left’, which I used to view as the forward-thinking solution to many things, is what I’ve come to challenge radically since arriving in Malawi. This ‘left’ might well think very differently from the conservative ‘right’ but they’re still closer to the latter than to a balanced view of the world. A more balanced view of the world requires adequate discussion of global issues, past and present, a constant debate on how the world is governed and indeed a greater call for justice. Selective campaigning on issues that would seem to benefit oneself too (such as the attack of the western ‘left’ on China; and the one on capitalism only once the banks began to collapse and their prosperity bubble burst) may seem as nothing but mere enlightened self interest to me! If the same debates were accompanied by a true call to question of the western governance style, its economic system, while not simply dismissing the damage caused by slavery and colonialism as a regrettable mistake of past rulers, then these campaigns might seem to stem from a true aspiration for the global good. Unless one argues from this premise, one cannot expect anyone from outside to support their views. This is not to say that there aren’t good campaigns from the West. Indeed most good ones do come from there but they sadly are not enough and are too often stifled by politics.

Hence the paradigm shift when I came to executing this evolved version of ‘Not Made In China’. I might have been banging on about the evils of the Chinese government 4 years ago, but now I’ve come to realise: the evils of government are universal. Where else to analyse evils of government better than in sub-saharan Africa, I might ask? So the government of Malawi (and many others) is anti-progress and guilty of misappropriation of funds, based on the majority of sources (including lefty ones) in England. What about the UK’s role in this? What are they doing to empower poor countries they stripped off any dignity and wealth in the days of colonialism and slave trade? Maintaining trade barriers, political and military threat and a continued pressure to promote British interests while holding on to their illicitly acquired land there (hence the great attack on Mugabe even in the Guardian)??? The French are no better, with their record in Ivory Coast and West Africa and their famed colonial pact, which is literally the signing away of all economic autonomy for the sake of independence! The Germans meanwhile still pretty much own Namibia and natural resources are still largely being extracted for a pittance, hence the Belgian love for the Congo (DRC) and the Dutch one for South Africa. Inamongst all this the Americans are busy with their mission of thought control, particularly important now that China is making inroads into African development. It won’t be as easy as taking down Patrice Lumumba or dislodging Kwame Nkhruma anymore I guess. But maybe it will be, as we saw recently with the assassination of Gaddafi. This guy’s record on African development is remarkable and unprecedented. All that seems to have come out of western media about this legendary pan-Africanist (lefty sources indeed) is the fact that he is a warmonger who had no qualms on attacking his own people. I dare say that till any country gets its own house in order and truly comes clean, then the authority to interfere abroad is absolutely impermissible. As long as the US keeps on sponsoring the war on Islam through Israel and its new blank cheque, anti-terrorism, then it should have no say whatsoever on global, let alone Arab politics. This is why my rage against China has been tempered so much in the 2 years I’ve been in Malawi. China certainly has a more liberal aid programme within Africa, with hardly any of those Western strings attached. The quality of the development may be poorer but it’s also not claiming to be better than what it is. The job creation opportunities might not be the same with Chinese labour being largely imported for these contracts but the job is done. What China does not do is tell everyone how to behave or else... Because China knows it’s not in any position to pontificate on government behaviour. So why pretend? The west want to keep on pretending they have the key to global harmony through one over-simplified concept of democracy which they are intent on imposing forcefully onto all. Yet that dream is best achieved through economic empowerment and not interference. This is precisely what Africa is not getting from them...

PS: The box has finally landed (12 weeks since the order!)

A certain tolerance of (gross) imperfection

2011-10-17T04:18:00.000-07:00

There is an anecdote recently from work that encompassed so many aspects of this feature so Malawian that I really have to elevate it to the status of case study. It is about a phenomenon that us foreigners find so hard to understand and accept. It drives us up the wall, it’s probably responsible for the majority of instances where we lose it with Malawians (and then repent shamefully for weeks!) and it certainly provides an incredible insight into the Malawian psyche, let alone socio-economic reality. It is the way imperfect results, systems, jobs you name it, are so coolly tolerated here. This will without a doubt sound like a litany of criticisms of the Malawian way of doing things. Indeed I was first to have this reaction when I landed here. But really I’ve moved from that stance to be closer to understanding what it really tells us. It tells us a lot about Malawi, the country and the people for sure, but it also tells us about ourselves quite a deal. For if tolerance of imperfection makes us flinch so much, then it somewhat suggests that we are more inclined to the opposite... and in that I read intolerance!

The story is that of a box! A box I tried to get the hospital maintenance department to make in order to enable us to run a nurse-less clinic. Indeed the situation in terms of nurse staffing is so dire at Queen’s that we run all our clinics ourselves as clinicians. Also our orthopaedic ward staffing has recently been culled such that there is now a single nurse for up to 70 patients on nights. So I devised a compartmentalised box which would contain all the materials (gloves, dressing, slings etc) we need in clinic and all the ward nurses would have to do is to keep it stocked up in between clinics. So I drew up a model of the box in the question and handed over to the maintenance big guy as I would have done in Ntcheu. To my surprise he directed me to the main guy for the specific section: carpenter. I automatically assumed that this must be a big enough unit to deal with quite a volume of work. So I gave the model to the chief carpenter and got the assurance that this is a very simple job indeed which shouldn’t take more than a couple of days to complete. So 2 days later, I drop in on my way to the clinic and can’t find the box. I find the subordinate carpenter instead who informs me the chief carpenter is on a bigger job and has delegated this job to him. But he had decided not to make a start on it until he got a chance to check on specifics with me. Fair enough! So I went through the very basic features of this simple box and got told to come back at the start of the following week. It turns out I was very busy that next week, so I gave the carpenter ample time to do the job well. Come Thursday, clinic day, I stumble by the department again and find no signs of my box yet. The subordinate, it turns out has gone off sick. Can’t help it, so I ask the chief carpenter to reassume responsibility of the job if the other doesn’t come back soon. Next week I go there to enquire and still find no progress on the box. The chief carpenter is not around, he’s gone off on another more important job again. Fair enough, the corridor connecting the surgical annexe to the main hospital has caved in! It started as a crack in the wall and before we knew it, the wall was on the ground with a big chunk of floor attached to it! So that’s another week at least before chief carpenter gets back to ‘little jobs’ again. As for his subordinate, he’s not back yet. I’ve seen it so often here and it saddens me. Young perfectly able-bodied men and women, look smilingly at you one day full of life and the next day they’re in the throes of a terminal illness, out of which many don’t make it. There’s a lot of serious infections that go round but I don’t agree that they should claim such a big death toll. Poverty among low grade health staff is really heartbreaking and results in life being, to put it bluntly, devalued. So I gave my carpenter man, now working all by himself, another 2 weeks instead of one to get back to the task. So the next time I go there, I have an OMG moment when I see him actually displaying the work he’s done. He’s come up with a list of materials that he will need to make the box and is waiting for me to provide the cash. And I find out about this 4weeks from handing the job in! So I ask why is this not covered by the departmental budget and he tells me he assumed I wanted it done quicker to save going through the procurement process. That’s when I find out that this guy is working without tools essentially. Every new job has to go through an inconvenient approval process, including the very nails he needs. Thankfully the list of things we need for my box are internally stocked and can be procured within a week. So next week, I drop in, you know the next bit... to check on the progress with the box. We now have the wood cut up in the component pieces and enough nails to connect them, but something else is missing. A hammer! If I had one I assure you I would have hit my own head with it! The carpenter shows me the one he’s using, which is the equivalent of a fork without prongs essentially. There’s a handle attached to a headless hammer that’s only got the nail-pulling end still on. He must have had this for years without being replaced and he still uses it to hit big things. But nailing I’m afraid can’t be done lest we want a fingerless carpenter to stick to the theme! I’m assured though that there is one that been ordered a while ago and which has been approved for external sourcing finally. Another week I say, that’s okay I’m busy anyway. So next week, (...), and I finally find a hammer next to the nails and cut up wood blocks and can only express my puzzledness to the carpenter as to why the hammer hasn’t driven the nails into the wooden blocks yet! And I’m told that he wanted to check everything with me first before ‘committing’. This isn’t amputation surgery, but I guess that when he’s handling material that’s so difficult to acquire as in this case, he wants to treat it as if it was. And indeed, upon checking, I find out my cursory initial explanation had been misunderstood, but there was no need for him to ask for clarifications then as he would have forgotten it anyway by now. This happens a lot here, for that precise reason: predictable unforeseen reasons! So one more week I delay and go back to find my man. Hallelujah, I see a box! But is has no lid. Why? He didn’t realise I wanted it so I could keep the box locked when not in use, even though it was on the drawing. So another week goes by and predictably, there’s a finished box with lid and even a lock , which I haven’t had to wait another week for. I reach out for it and realise it’s not ready yet. No! It’s yet to have the final touch applied. Polishing and lacquer. But hey, a large piece of sandpaper only cost about 25Kwacha (10p) and he can’t get it procured fast-track. So this time, I fish for the cash from my pocket and say get it when he’s in town. Next week, I find the box in the same state it was the week before. I’m told there is no sandpaper in town! I can’t believe it. But I just remembered I had some at home. This I bring to him the next day, but it’s not the right one and not big enough. So next week when I find him, no progress still! I’m baffled, not sure what the next move is. So I just leave things to move at the default pace of external procurement. Luck has it though that I had to go to town that week and in the shop where I wanted to buy paint, I find sand paper also on sale. Can you believe it? So I race back to Mr Carpenter and hand him by new found treasure. Why he couldn’t find it is a slight mystery but the following reasons are likely to be contributory. Currently a lot of shops are out of some stock or other because of the acute fuel shortage and his shop, probably the only one he’s allowed to procure from for the hospital doesn’t have it. Because initiative is not rewarded and he doesn’t dare to bypass the authority of the hospital even though I gave him the money (read job insecurity despite pathetic wages), he simply assumes the same situation applies across town. He’s probably been told that by the shop guys anyway. The frequency of stock shortage and malfunction (of equipment/ system) has over the years slowly eaten away at that vital human attribute called initiative. It is (sometimes rightfully) perceived as a waste of time, which could be better spent elsewhere. It is used by some to get on with personal errands that they would otherwise not have time to get done. Do you know that most Malawians I’ve worked with hardly ever take any holiday? They are entitled to it but because of their pathetic wages, often prefer working them so they can earn some locum money- and don’t be fooled into believing this is the same overinflated locum wages as replacement staff get in UK. This locum is a fraction of their normal wages. Each time I hear expats call Malawians lazy, I feel like suggesting to them to drop their wages to a measly £200 a month and do away with holidays for an indefinite period! Circumstances force a different work ethic within which opportunities are created to avoid burn out simply, e.g. a looser adherence to punctuality, extended lunch hours, time off for training and the all-notorious allowance culture. I’m under no urge to adopt these ‘mental-state-sustainability’ measures for I, like most expats, am only here for a couple of years and can work myself to the limit in this time. If I were told to continue at this rate for longer, I would certainly burn out.

So even as we speak (10 weeks on), the box case ain’t closed yet, as the final stage of lacquering is still underway. But the shift of perspective it has engendered is quite apt, since I’ve literally had to think outside the box to even begin to comprehend the complexity of issues at hand here. Is there a part of it even I’m responsible for? I for all I stand: the Mauritian- African, Indian and muzungu all at once, the aid worker, the idealist, the perfectionist, each aspect coming with its own threat of interference. When so many external influences as we see in Africa more than anywhere else in the world come in conflict, one can see progress might be hampered rather than enhanced in the end. To simply bandy concepts like Dead Aid, neo-colonialism, slave trade legacy, economic and cultural invasion, global village, China in Africa and the state of international trade rules in one line is exceedingly inadequate. But for sake of illustration, it does the trick, that is to start thinking that all might not be due to the Malawian personality, including that of its leaders. Very importantly too, there’s a lesson, we, from the West, can learn from here- to be more patient, relaxed and tolerant of human imperfection. The right way is always somewhere in between.

The world is like the human body, where each part is linked and crucial to the functioning of the whole. It has been so since the beginning of times, way before anyone coined the term global village. The little toe going black is often not due to the toe having done anything wrong itself- it was dependent on blood flow to it being adequate...

Lake of Stars 2011

2011-10-03T10:51:00.000-07:00

I am aware that most of my latest entries have borne a reference to a similar period from last year. In fact I can predict that if I stayed here once more year, the same would hold true for next year’s entries around this time. Yet this in no way makes me reluctant to write about them again for fear of repetition. This time of year is momentous for me in Malawi and each year it represents a climax, with very different elements to it. The work climax that recently was has properly made way for the post-climactic chill which could find no better embodiment than this certain festival known as the Lake of Stars.This year’s event was an entire journey starting as a post-nightshift blues on a typical sequence of public transport modalities (taxi, minibus, matola). Having worked from 7.30am the day before to noon the same day, clearing up an unexpected theatre list, I was ready for a major showdown. So was Janet, equally saturated with work over the last few weeks. Despite having had to cover the last 20 or so Km in the back of a pick-up truck in pitch black darkness, and then get accused by the driver and some drunk conductor of damaging one the windows, once we reached the place, it was like someone had reset the time to start from scratch in our minds. Within seconds, we were captured by the spirit of the festival. This remained so for the next 48hours where every minute was simply unique. Now I don’t go on describing festivals from the UK with such exuberance, despite probably being more excited about some of the main acts on show. But when you have sun, sand, a cool lake and funky laid-back people in abundance, it almost doesn’t matter what music is on offer for you to have fun. Now imagine the prospect of still having great music with all these ingredients! Could you blame me for banging on about it?!Now for the geeky bit- my favourite acts this year. Take note.From Malawi, all the regular crowd pullers were there: Maskal, Lucius Banda, Theo Thompson, Dan Lu and Black Missionaries. But it’s the new discoveries that always stand out and this year it’s a band called Mafilika that really dazzled me, not just for their talent, but for the fact that this talent was in the genre so rarely heard around here which is ROCK! Yes Mafilika rocked and indeed reassured me that somewhere in everyone, there is a dormant rocker waiting to be awoken. Another beautiful discovery was of the 79year old acoustic artist called Giddes Chamalanda, who simply eased me through a somewhat dreary mid-Saturday state of exhaustion before the major line up. His original take on classic and original rock blues was just great. My excitement at seeing the main Malawian singer I was waiting for, Maskal, was unfortunately tainted by a slight incident in which I got pick-pocketed of my phone. But that doesn’t lessen the quality of his performance, hyped by an impressive advertising build up from his sponsor distributing free T-shirts and all.And that brings me to the next band I wanna talk about: The Very Best! Not the very best name for a band by far, but the elements that made it up were fantastic, namely a Swedish DJ, an English rapper and a Malawian hip-hop singer, all complete with dance troupe. Again the publicity from free T-shirts flung into the crowd worked quite well. But above all the music was very original, and you must believe me because I am very partial with this genre.As for the international line up, this is the bit I get most excited about, because you hardly get such a diverse mix of origins in a UK festival (even though I’ve never been to Womad- so hold me back on that one). Here there must have been a good 10 countries represented, each with a special twist to their music. Rwanda was represented by Sophie, playing a string instrument called Inanga, Namibia by a troubadour reminiscent of Tracy Chapman, by the name of Shishani and Kenya by a most energetic designer/singer called Liz Ogumbo. England was definitely there in the bodies of Mercury Award winners of this year: The Foals, which is probably the longest uninterrupted metal rendition Malawi has ever heard in its history. The fact that I didn’t exactly connect with them straight away is quite telling about how distanced I’ve grown from this style in my time here. However I was reminded there about how much I do miss it. Again from England we had soul queen Beverley Knight, whom I’d never really attached any memorable songs to before... until last night of course. She was just brilliant. It makes such a difference seeing what they call a Diva performing in front of you, as compared to hearing it from a tape or disc. I now admit there is an incredible talent in getting a human voice to do such things. There were also acts from the US and France that I missed.Now for what I considered the cream of the International line up, an international band in itself, who alone would have justified my cross-countrying all that way to the festival: Freshlyground. This was in many ways a new discovery because I only got listening to them in the build-up to the festival, apart from a few faint snippets I’d had from other people’s musical selection before. The band is from South Africa and they literally took me back there in the tantalisingly electric spirit of the world cup. The musical scene I discovered there had significantly marked me and I’ve been sampling more and more music from that country. Last night’s addition will remain on the playlist for a while to come now. The band is real encounter of artists and instruments, not least of which is the amazing voice of the main singer. The guitarist, a Mozambican, particularly stood out for me and gave that final eclectic quality to the band. So look out for them if the name is new.To wrap up, I’ll just have to mention one last artist, who is not a singer in the precise use of the term, but without a doubt an expert lyricist. Lake of Stars like all good festivals had more than just music on show and the guy I’m gonna talk to you about added an incredible sense of brilliance to the poetry scene this year and he goes by the name Q Malewezi. His style is his own creation and defies any attempt at classification, however intent I might be at rounding him up with the slammers. I do insist, probably more than for the set of musicians I’ve described above, that you go and look him up! And better still watch him perform (Blantyre Arts Festival next week).So that was the Lake of Stars in a more of a watermelon- than a nut-shell! But this event is so exciting that one can’t help recounting it other than with the most elaborate descriptions. And I assure you, even so, I’ve missed out loads more.Sophie wih Inanga

Local instruments

Freshlyground

Iwes

Hattrick!!!

Enter Chilldom

2011-09-29T17:27:00.000-07:00

You can plan a nice long relaxing weekend up Mulanje mountain with plenty of time to recover or you can tag it on to the end of an epic conference at least 6 hours away, while being the official team medic for an expedition of 18 women! Guess which one I chose! It was certainly not for the 18 women that I did it, let that be clear, as really I would rather be with 18 loud and smelly Mauritian men, if only for their ability to get up and go promptly. But I did it the way I did mainly because it had long since been planned and it was only in the very end that I got double booked with the conference (the dates couldn’t be conveyed further in advance).

Just a quick note on the conference even though it was probably the highlight of my research interest for this year. The reason is that I’ve already told you most about this project in my last entry about Lilongwe. The latter was essentially a dress rehearsal for the more dedicated platform that it was targeted to- MOA: the Malawi Orthopaedic Association annual gathering. This is again an event you’ll have heard about to length in an entry almost exactly a year ago and indeed this year also things weren’t that different. One difference though was that I was invited to join the faculty on the AO (Arbeitsgemeinschaft für Osteosynthesefragen!) training day, which was a huge priviledge and responsibility. This is the first part of the yearly meeting and it really is the perfect opportunity to get those CPD (continuous professional development) points in orthopaedics across to our OCOs. The second day, I was awarded the key note address after the original speaker couldn’t make it. This was again a great opportunity to enhance the impact of my research project. I undertook a pilot project into an improved data collection system that would work for the districts, with the hope of reducing duplication of work and registering more accurate data to inform planning and prioritising within the speciality nationally. Big words I know but when you have the health PS among your audience, you really got to seize your chance with both hands. And this I certainly did by promoting my other big project at the moment which is the publication of a multi-author manual to common orthopaedic problems in Malawi. Unfortunately, at that point my heretofore very successful conference came to a premature end. I had to excuse myself to attend to that other commitment I had made ages ago!

So, after a 7 hour transfer, including car, minibus and legs, I reached my lodge in Mulanje ready for the next days’ adventure. I made the acquaintance of my 18 strong woman team that night for a medical briefing and ground testing. The girls had actually come as part of a “responsible tourism” initiative to raise money for a financial project supporting microloans for the less well-to-do. What’s most laudable about the way they’ve organised it is that they’ve included a trip to the actual place in their itinerary. They were certainly a great laugh to hike with, and maybe also good that they didn’t push me anywhere near my physical limit, as that might have slightly impaired my medical faculties. Thankfully, those weren’t called into action much, save a few sprains and a nosebleed that I was one of the only ones not to have witnessed! The route itself was the old classic to the hut adjacent to the summit Sapitwa. The latter we had to skip to accommodate the team’s pace. Thereafter the route changed to incorporate brand new territory for me in the form of the Scorpion path, West peak and the Milk run. 3 days, 2 nights in total and a total body meltdown after those last few months of intense build up to the conference.

PUBLIC TRANSPORT 4
No big trip in Malawi is complete without a new insight into the idiosyncracies of its transport system. This time it was the return trip from Mulanje to Blantyre that provided the new wisdom. It is a poorly understood paradox as to why minibuses seem so reluctant to depart from the depot, yet turn into land speed record contenders once they get going. You’d think, ‘they’re full to the brim when they leave and surely will pick up people as their exiting passengers make way for new ones. Why the rush then?!’ Well competition as you probably imagined is the key. But why this particular route and particular time? That’s where my insight came. Around 5-6pm is when a lot of tea/sugar estate workers commute back home. This means they’re scattered along the route and their journeys are usually short ones. Thus if one minibus stays ahead of another throughout the trip, they get to pick most of these short distance travellers and take the lion’s share of the booty. Once one’s minibus is overtaken, one notices an immediate escalation in tension as reflected by the speed. Unscrupulous tactics are adopted by the one in front to prevent loss of their advantage- lane straddling, indicators to indicate ‘not safe to overtake’, blocking exits at stops etc. Overtaking becomes an all-enveloping obsession for the one behind and the slightest mistake made by the rival can be fatal to him. Sadly this metaphor so suited for the race strategy described above, often ends up also being true in the literal sense!

I should have felt refreshed to resume work in the best of shapes after this escapade, but this was so brief that it merely served as a sore reminder that Janet and I are due a more proper holiday very soon to beat this recent drawl of work-dominate-life routine!!! The lake of Stars (my second and Janet’s first) fortuitously is just round the corner now. Maybe that’s what we need to kickstart our long awaited descent into chilldom! Highlights guaranteed to follow...

Team posing with Jacaranda

Porters celebrating West Peak

Dramatic Mulanje

Outside Lichenya before final descent

Glorious Mulanje

Lilongwe meets Blantyre

2011-08-29T05:27:00.000-07:00

6 months on from my arrival in Blantyre, my outlook on the city has changed tremendously- almost to the point where I wish I could go back and edit that first entry, in which I thankfully predicted that this would be the case. Some things are still the same though, for example the extreme gap between wealth and poverty that’s in-your-face. Well the thing that got me thinking about this again was a trip to Lilongwe this week where I experienced some déjà-vus of the time of my original arrival there some year and a half ago. I found myself taking the same routes to the hospital from the same guesthouse where I was living then. I was presenting at a conference for the Surgical Association of Malawi this time, where I also joined the faculty of COSECSA for a day teaching orthopaedics. There, I met a lot of the same people I’d met 18months ago, like Dr Muyco, Sven and the Lilongwe OCOs. As a treat, Steve Mannion was also there, organising the orthopaedic training training day, as well as moderating some of the sessions for the conference. All in all, it was a pretty intense week, with an equally intense build up to it, where the presentations and research for it was being undertaken (hence the paucity of blog entries- there’s always a reason!) As you can imagine, once all this hard work was unloaded, I switched straight into “off-work” mode and took the opportunity to maximise my time with Steve and Sven.Nostalgia and anticlimax weren’t long to kick in. I felt the sweet vibes of my first time in Lilongwe, its sweet mix of the terrifying unknown and an all-capturing titillation of the senses. I really felt at home in this city, Lilongwe. It is indeed one of my favourite cities in the world. It is a vast expanse of green with distinct areas strangely numbered in the order in which they were built, as opposed to their geographic location. But that adds to the quirky charm of it. It does not feel the need to be defined by an outsider. It has its own character. Unlike Blantyre, it is the administrative hub of the country. It boasts a different spectrum of the commercialism that somewhat defines Blantyre. For Lilongwe, it manifests itself more in the form of posh hotels, springing up all the time and good eateries- essential exigencies for the host of expats and diplomats released on its streets daily from the country’s major airport. As a result or not, Lilongwe also feels a notch more peaceful. In other words, the constant banging of undisciplined bottle stores and bars with outside speakers doesn’t follow you into every nook and cranny as it does in Blantyre. What better way of demonstrating that than by the greater presence of birds all over Lilongwe. And yes, that is now one of my chief delights in visiting the city. Not that Blantyre doesn’t have them, but in comparison to Lilongwe, that’s a mere fraction. And to exacerbate the difference in greenness further, Lilongwe also boasts a wildlife sanctuary in the very heart of the city. I won’t go on any further lest I be called a tree hugger!

So that’s how it felt being back in the capital, home of the VSO office and guesthouse- my first bases in Malawi. But of course, times have changed and contrary to expectations, my affinity for Blantyre has also grown greatly in my time there. I might not have become immune to its riot of decibels but I certainly have got a feel for the character of the city. And this I owe in large part to one thing I never had at first in Lilongwe- companionship. With Janet here and both of us equipped with bikes, we’ve stroked the asphalt of most streets within a mile radius of our house at least and many more beyond. We’ve come to meet people very different to the stereotypical arrogant rich I’d at first got fixated on. These lot exist in every place in the world, Lilongwe as much as Blantyre as much as Manchester, Port Louis and Bombay! Thankfully they exist less in places like Ntcheu and I guess I’d forgotten what it’s like living alongside them until I got to Blantyre. But now I’m used to them again, I can easily blank them from my field of vision and focus back on the joys of being here: satisfaction from work, culinary discoveries courtesy of Blantyre market and the local spice haunts and the great new joys of gardening. And then also I ask “what more do I need when you’re an hour or less away from such classics as Mulanje, Majete, Thyolo and Zomba plateau?”

It's gonna be hard to leave...

Lilongwe's just too cool!

COSECSA faculty and audience

Tree hugging!

Mousebird

Blantyre insolites... and surrounds

2011-08-29T05:11:00.000-07:00

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Tricycles and wheelchairs Update3

2011-08-08T08:35:00.000-07:00

The suspense on MF is officially over. Her rather delayed delivery was a reflection of some realities particular to Malawi and indeed of the various mechanisms that exist to get around them. MF, now a 40yr old woman, lost the use of both her legs well in her childhood to that terrible disease called Poliomyelitis. She has learnt to get about since by shuffling on her hands and knees. She didn’t actually appear on the radar of MAP (Malawi Against Physical Disability) until 1.5 years ago quite incidentally after a routine admission to hospital. Now many of you will have wondered why Malawi Against Physical Disability uses the acronym MAP instead of MAPD! Well the reason is that MAP was actually an accurate initialisation of its original name Malawi Against Polio, but then had to be rebranded when the disease (thankfully) became quasi-extinct in the early 2000s.

To get back to our unexpected delay in delivery of the tricycle, this is what happened. The tricycle was actually ready more than 2 months ago. We then tried to get hold of the ‘client’, as they are known in MAP, whose waiting list the patient was selected from. Since most people don’t have a postal address in Malawi, they have to be located through their village or if they are in a big town, by a prominent reference point- e.g. “Ntcheu Boma, behind Petroda”. Sometimes, they use a well-to-do neighbour’s address. This is a service that often applies to mobile phones too, when the client does not have a handset of their own. Our first attempt at tracking MF was unsuccessful and we assumed that she must have moved away. So we sent a volunteer from her neighbourhood to investigate and after a while, he got back to us triumphantly having pinned her down. We probably had got her whereabouts misspelt and got misled as a result. This also isn’t uncommon here, where names are often spelt as they sound. With some sounds being so similar, two completely different locations can end up being spelt the same, or even worse spelt as the other! (Just consider these town names for a second and judge for yourself: Lilangwe and Lilongwe; Bua and Mua; Lunzu and Lundu). If that wasn’t enough, occasionally, the client themselves give us a wrong address, for a number of reasons (embarrassment, social issues at home, no fixed abode etc).

Another interesting little hurdle that further complicated matters was the fact that our volunteer was initially chased away. Our volunteer is part of an outreach network that allows MAP as an organisation to provide services to even the most far flung haunts in the land. Now strangers are not always welcome in villages, often because they may have had some bitter past experiences from fraudsters. Thus when our man first came to the village, he was perceived as a crook who would run away with the tricycle and sell it once it got made for MF. It was not until a few months later, when they heard about other people in nearby villages benefitting from our volunteers’ efforts, that they finally called him back and welcomed him.

I have to say that to have eventually managed in imparting to MF her designated mobility aid is a success story of sorts. Now this 40 year old formerly housebound maker of snacks can finally take her delights herself to the selling stalls at the market or elsewhere. Her specialties are the famed deep fried doughballs called Mandasi (to which I’m sadly addicted) and coated fish called Kanyenya. So if you ever find yourself buying one of these near Lunzu, make sure you look around to see if you find a tricycle parked nearby!
Look up MF’s first spin on her new bike on my latest videoblog: coming up soon

With Alex and Sally (from MAP) at MAP

Girl Power

Empowered!

Blantyre Insolites... and surrounds

2011-07-31T07:44:00.000-07:00

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Palibe Chonena!

Clinical Digest14

2011-07-31T07:02:00.001-07:00

Gunshots

It has been another extraordinary period on the clinical front at Queen’s since the last update. On the one hand, there’ve been hair-raising moments like the recent unrest on the streets of Blantyre (remember 20July). On the other hand, there’s been a recent overnight escalation in my level of responsibility at the hospital. Both my orthopaedic consultants have been on leave simultaneously, leaving me to coordinate the entire orthopaedic department, with the assistance of a visiting surgeon from Holland, Jan Paul Frolke and Christopher (the chief OCO). Being the one making all executive decisions in the department I have to say is not something I’ve been called up to the task for before. Yet the challenge of it all generated enough motivation and energy required for this new role. I managed to reshuffle my duties to include more ward rounds, while making sure theatre lists kept running as normal. This felt like self defence from predators at times, with everyone around seeming to have their sights on this potentially vacant slot, desperately poised to make a go at it anytime. Thus more than once I had to fend off these predators and claim my territory!

How fateful that the majorest alert that I will have experienced in Malawi had to occur precisely during that period: The anti-government protests on the 20th of July!! I actually considered myself really lucky on that very day not to be on call, thinking I would plan the trauma list the next day to deal with the repercussions. It was a grave assumption to make that things would revert to normal by then. Instead of picking up the pieces from the day before (a total of 1 patient, who ended up under plastics instead of orthopaedics), I amassed a total of 3 severe gunshot injuries freshly from the aftershocks that were still happening in pockets of Blantyre the next day. It was a formidable experience to be on the frontline operating on these cases till early hours of the morning. Closest thing to MSF ever happened to me. LIVE gunshots! I remind one here of this strange phenomenon of the bizarre medical arousal which is a natural pill against losing it all in the heat of extreme moments in the medical/surgical profession.

The first case got sorted with the help of Dr Frolke who was still in the hospital at the time- an open elbow fracture with massive soft tissue destruction, including the ulnar nerve. We fixed it primarily with a tension band wiring technique and prayed for our plastic surgeon to work his magic on providing soft tissue cover subsequently.

The second case was a shattered wrist, with a through and through wound, in which the bullet somehow managed to skirt the median nerve and most tendons. The ulnar was not so lucky once again, but the damage done was surprising little considering the bullet that caused this injury. The wrist only needed a major debridement, after which it had enough soft tissue cover to hopefully deal by secondary intention. Of course, the possibility of any reconstruction of the joint itself could not be entertained for this patient within the resource setting of Malawi, but luckily most of the damage to the bone did not involve the joint.

The final case was what kept me on my toes till autopilot had to kick in. I kind of inherited this patient from the surgeons with a diagnosis of a comminuted open fracture of the proximal humerus. Since the wound was all dressed up in a bulky bandage to control the haemorrhage, I elected to do my examination in theatre. That is when I discovered the one tiny bit of information that was left out in the referral: that the entry wound of the bullet was actually through the chest while it was the exit wound that lay around shoulder! Partly owing to the delays encountered in getting operations done out of hours in Queen’s (some kind of a systematic deterrent to operate on anything but the most serious of all cases after 5pm),the patient had also managed to lose a significant amount of blood by the time he appeared on the operating table. Here I was expanding my initial plan for this patient to include a chest drain insertion, fluid and blood resuscitation in addition to the shoulder wound debridement. The latter was a typical example of the bag of bones description we reserve for the most severely comminuted fractures in the orthopaedic world. Unfortunately for the victim, his ‘bag’ was also in tatters and he would be another case on our esteemed plastic surgeon’s list for the next week.

That was a day in the life as Ortho reg in Queen’s. The remaining days found me mostly operating on forearm and ankle fractures, both fresh and non/mal-unions. The coincidence of finding so many similar pathologies in that short time provided the perfect opportunity for me to develop my surgical technique to the point where I feel quite confident to tackle these independently now (which I ended up doing twice). I owe a lot this to the very clever supervision from our visiting surgeon, Jan Paul Frolke and Christopher as well as to the encouragement from another visiting surgeon from across the road at Beit CURE orthopaedic hospital. It is incredible how much one can achieve from just having the right combination of factors in place at the right time. Some of these factors, which a priori might appear to be obstacles, indeed prove to be the catalysts in the learning process. Maybe that’s a lesson in Orthopaedics that resonates with my mountaineering vibes... There’s no such thing as bad weather; only inappropriate clothing!

The uses of linea

2011-07-18T12:21:00.000-07:00

First of all, a little definition of linea.

Linea: n.,inv. The ultimate example of recycled material. Made from the soft (side) part of used car tyres . The rubber is stripped into long threads, with incredible tensile strength and flexibility. These strips can be further split by separating them in the middle.

1. Rope. The higher the strength required the thicker the linea. Note: Linea can also be combined, by weaving or tying, to increase its strength.

2. Hanging flower baskets. Tied into a netting to contain a soil-filled coir bowl. Note: Linea makes an amazingly slip-resistant knot (a bit like Vicryl for surgeons out there!)

3. Reinforced packaging. Multiple linea strips can be combined to wrap around newspaper and whatever parcel, where bubblewrap is not available.

4. Fastener. This one really needs to be discussed by sub-section:

Transport
4a- To tie an endless list of things (from firewood to crates of beer) to the luggage rack of a bicycle taxi.
4b- To fasten together bamboo sticks into a portable chicken cage.
4c- To tie bundles together so they can be better balanced onto heads (sticks, leaves, reeds etc)

Round the garden
4d- To tie reeds and branches together into a fence.
4e- To tie tomato plants to stakes (as in our wonderful garden).
4f- To tie fine twigs into an outdoor broom.

In the market
4g- To attach items onto boards for display.
4h- To tie and reinforce bales, sacks and bags (of cotton, tobacco, potatoes, clothes etc).

Miscellaneous
4i- To lock doors and windows, when the key (or handle) has been misplaced!
4j- To fasten poles together (into scaffolds, roofs or animal pens).

5. Seats. Can be used to fashion both the back and the bottom support!

6. Football. When the air-filled variety can’t be afforded. The elasticity of linea lends itself well to this particular use (especially when combined with (smuggled) condoms, I’m told!)

7. Shock absorber. Perfect at the bottom of ‘fragile’ boxes. The thin strips should be used here, and laid down so they coil up on themselves.

8. Security barrier. Very useful in little shacks selling groceries in villages. It has the advantage, over metallic grilles, of being rust resistant and very cheap.

9. In the bikeshop. To mend bicycle punctures. In desperate situations, the leak is tied instead of patched. Also ideal to pad handle bars.

10. Art nouveau/ Recycl-art!

PS1: If you’re now wondering what happens to the tread bit of the tyre that doesn’t go into linea manufacture, rest assured, it doesn’t go to waste either. In actual fact, it makes great soles/flip flops.

PS2: Feel free to add to the list. The above sample is by no means exhaustive!!!

LINEA!

Held together by linea

You name it!!!

Linea-aided display

Nothing too heavy for linea

1 car, 2 weeks, 5 holiday-makers, 6 flats

2011-06-29T12:43:00.000-07:00

A timely visit by my mum and Janet’s mum and dad has brought a badly needed break from the relentless grind of work at Queen’s this month. As expected, work peaked to somewhat a climax before their arrival, just to make sure everything got sorted out. Then again, it was impossible to take the full 2 weeks’ stretch off at once. So we had a 4 day work intermission sandwiched in between. Thus the parents had a good chance to see Blantyre as well and get a better flavour of normal life here (as opposed to the resort-hopping tourist version). Since they’re parents, we thought they wouldn’t mind! But even in these 2 weeks less 4 days, the distance covered in miles and experiences has been enough to pack a holiday diary to the brim for them.

Malawi, despite being dwarfed by its neighbours, has more to offer than can be covered in just 2 years I believe. Rather than be lured back to the same established spots, we thus aim for a combination formula with new as well as old terrains. Rather than be lured also by the established mode of transport required for these epic holidays (a 4x4), we opted instead for a Toyota Gaia (took me a week to get the spelling right and find it on the internet) 7seater, which fitted our budget nicely and was better placed to meet our space requirements than the Rav4, which as the name suggests is only good for no more than 4 passengers. Rather than be lured finally by longer stays in fewer spots, we chose the converse (shorter stays in more spots) hoping to get more bang for our buck for our visitors (hope they agree upon reading this)!

New terrain1: Nkhotakota
After a night at a backpacker’s in Lilongwe (surprisingly quiet, rustic and convenient in fact) just to acclimatise our newcomers a bit, the adventure could now begin.
This wonderful sounding place, which was formerly one of the busiest seats of the slave trade in Malawi, is now a peaceful district fringed by one of the largest forest areas of Malawi and one of the most tranquil sections of the Lake Malawi. Having freshly picked our Gaia the day before after a cursory inspection which was unremarkable, we embarked happily on our first long distance stretch. Hardly half way through, purely incidentally, I noticed something amiss with the way the car was parked as we came back from a leg-stretch-stop by a road side market. Our first flat tyre had declared itself. Thankfully (3-fold), the tyre was not completely flat yet, there was a garage within 300 yards of us and right next to it was a tyre-fitter! Thus we got fixed within the hour and got going again. The 10Km approach to our resort in the Bua Forest Reserve was going to be our test for knowing if this car could cope with the planned itinerary. For most of it, the car actually did stand up. The last 3 Km however proved a little trickier than anticipated (we were guaranteed by the car owner and resort manager that even a saloon could get down this route- but I guess they had a 1 person saloon with no luggage in mind). Our Gaia was completely loaded and had less ground clearance than a mini. So the rocky sections required us to unload all passengers and get them walking. That wasn’t too painful. The car rattled for a bit from what we thought was a yanked bit of the exhaust but the problem self-resolved, so we never thought again of it.
Bua Forest lodge was idyllic to say the least. A perfect start amidst vast expanses of green, and amazing sunsets. A walk in the woods the next morning, spiced up by the sight of some mammoth crocs, got us ready for the next instalment- Nkhotakota Pottery Lodge (NPL). But first, our surprise finding had to be sorted out- flat tyre no.2. Luckily for us, the lodge manager was out on an errand that morning and managed to get it repaired before we were all packed and ready to go.
NPL was the perfect way to introduce our visitors to the lake (which they excruciatingly resisted dipping into). While Janet and I camped, they enjoyed amazing lakeside chalets with the best wake-up views you can possibly find around here.

New Terrain 2: Mua
Well fed and refreshed from that spot the next morning, we attacked our second long distance drive to a hillside village by the name of Mua. Mua needs no introduction to most of Malawi’s Christian community as it was one of the first sites of activity of the ancient “white fathers”. It has been the hub of the Catholic denomination ever since and has been kept pristine with incredibly beautiful gardens, an amazing church, a peaceful and colourful way of life (full of a capella singing and meditation) and a fascinating array of art. We toured the cultural museum there with its dozens of frescoes and were simply charmed.

New Terrain 3: Monkey Bay
Another overnight stop in a fantastic location, and we were energised for the next leg. Having ditched the testing roads to our established resort of Cape Maclear, we diverted towards Monkey Bay instead. What a fascinating discovery this was for us, let alone for the fascinating sceneries leading to it, teeming with birdlife as I’ve never experienced before outside a park (long-tailed glossy starling, brown-headed parrot, long-crested eagle, glossy ibis, ?African hawk-eagle, grey lourie, little bee eater, brown-hooded kingfisher etc). Monkey Bay had far fewer places on offer than Cape Mac, but to have found a better spot for us would have been difficult. Trading comfort somewhat for style, we got basic rooms in a relatively deserted backpackers right on the lake, safely shielded from the hectic drone of the town less than a kilometre away. Our arrival coincided perfectly with a boat trip that was happening that day and we got ourselves one pretty unique experience of the lake! The bird life, once in location kept accruing and I was totally in my element.
As we got back from our boat trip, we came across nasty little discovery 3- another flat tyre. Luckily we got it fixed in town not far away, while taking in the daily local life to the tune of a green (Carlsberg lager)!

Old terrain 1: Liwonde National Park
Somewhat reluctantly saying goodbye to this newly-discovered paradise on earth, we set sail for Liwonde. No other place probably holds a greater pull on me in Malawi these days than this place, largely owing to its amazing birdlife. But this time around, the tourists were treated to another little gem... or a rather big one: ELEPHANTS! It’s not every day you get to see elephants in Malawi’s parks, especially if you’re on a boat and not land safari and you’re told that none has been sighted for at least a week there. But having that box ticked so quickly on my tourists’ list, I could now relax!

Old terrain 2: Blantyre
Being deterred from staying at Liwonde by the prohibitively expensive lodge there, we headed straight to Blantyre that same day. That was another epic drive taking us right through to late evening. Crash start back at work for another hectic week of operating, on-calling, lecturing and examining. Meanwhile, the parents had a little self-styled insight into the normal working life we lead here. That didn’t stop Phillip (Janet’s dad) from going on a deathly ride to Limbe on the bike, that even we haven’t dared to do yet!

Old terrain 3: Mulanje
Again this one has been done to death on my blog, but suffice to say that it cannot be omitted from a tourist itinerary in Malawi. If you happen to have been taken around Malawi before and not seen this rooftop wonderment, then please ask for your money back. Mulanje also formed the seat of our 4th flat tyre, a front wheel this time. We realised by now flats must be very common in Malawi (especially ones with nails!) as there are tyre fitters pretty much everywhere.

New terrain 4: Blantyre (different angle)
The week in Blantyre was also accompanied by a certain training routine as, coming back from Mulanje (where I did not attempt any significant hiking for once), I would join the 3 peaks of Blantyre odyssey that Saturday. 45 Km. 3 peaks: Michiru, Ndirande and Soche and dozens of little villages in between. 25 odd people started, with about 15 finishing. Phillip joined me at first in a highly laudable attempt at crossing the finish line, but the soaring heat of that day proved too much for him, having had less than 2 weeks to acclimatise. He did remarkably well to complete more than half the route, at a ridiculous pace set by the group, which was faster than I’d ever gone before. I myself barely managed to finish, even after having swerved off the main peak to get Phillip back safely. The spectacle of the entire trek was phenomenal though and presented an entirely new Blantyre to us.

Old terrain 4: Zomba plateau/ Ntcheu/ Lilongwe
This was a redo of our epic bike ride from a few weeks back, but with the added luxury of cushioned seats and motorised wheels this time. What a difference that made! We stayed at the top next to a trout farm in a magnificent wooden cabin fit for the gods! I have to stop saying “amazing” now lest you stop believing me, but this place was one fairy tale of a one.

Our drive down the next day added the final 2 tyre punctures or punctuations by now to our journey. The first one was while driving down from the plateau along a narrow high held winding road. Thankfully, we kept control of the car. There was no magic tyre fixing possible this time, the tyre in question having through its 3rd failure, which was a burst this time! So we got the spare tyre out and decided to run it to the end. We dashed through Ntcheu for a little trip down memory lane. Then we had to alter our plans of breaking our journey at Dedza, in case we got another flat the next day which would leave our guests stranded away from the airport. What a prescient decision that was, as hardly after leaving Dedza pottery for a final shop, did I start to feel the car wobbling about on the M1. I thought “this time it’s the whole wheel balancing or something major gone wrong”. But hey lo! what did we find? Our 6th and final puncture! The big difference this time was the setting. It was very dark as we had to extend our original route. There was no civilisation in sight. The road was a busy highway travelled by trucks and speeding motorists AND we had already used our spare tyre. Our tyre had to be fixed somehow or we’d have to resort to something else. That’s precisely what we had to do when after 1.5 hours of waiting for some street youths to take our tyre away for fixing. When they came back with it still flat and with a useless valve on top of that, which they had tried to sort out with melting plastic! All this time, we have a consortium of village kids who’d gathered by the roadside to stare at this rare and amazing scene- stranded muzungus! Thus they kept chirruping away in Chichinglish for the entire length of time, giggling and heckling at us, having nothing better to do. By then, I thought “desperate gotten ails by desperate appliance are healed!” and called for help. This didn’t come until 1.5 hours later, by which time we’d managed to push the car just enough to be out of earshot our little persecutors and the indistinct hard shoulder of the road. Meanwhile our self-appointed tyre fitters hadn’t gone to rest over our case and had brought a 10+ tonner from nobody knows where to tow us away. At about the same time thankfully, our two rescue vehicles also appeared almost simultaneously (the VSO emergency vehicle and our car renter’s [John] own support crew). What followed was pure delight. In our trance-like state of exhaustion, we looked on, like at a scene from the A-team! John, like Hannibal, got his man working on the tyres and the battery (made flat by our hazard lights) like clockwork. The VSO tow bar turned out not to be compatible with our vehicle and the 10+ tonner got promptly dismissed. The car was up and running within 20 minutes, with 2 spare tyres this time and we drove on to Lilongwe escorted by our 2 rescue vehicles. The human lesson from this was suitably heart-warming after such an adventure. All throughout the agonising wait along the cold and exposed ‘motorway’, the Malawian entourage that had gathered around us were ensuring our safety and seeing to it we got to our destination somehow. Whatever little token of appreciation they expected in return does nothing to diminish the brilliant warmth of their nature. This was one destination we couldn’t have taken our visitors to in any direct way but they saw it for themselves: THE WARM HEART OF AFRICA!

Tricycles and Wheelchairs Update 2

2011-06-29T12:41:00.000-07:00

Unreassuringly quiet as it has been on this front since my last update, the tricycle project wheels are now confidently back in motion. The logistics of course are what has proved the greatest spanner in the wheels with this... as for most things in Malawi. And when you haven’t got wheels (the motorised type!) and have to do all the chasing over the phone yourself, in the midst of an insanely hectic timetable(of an orthopaedic reg at Queen’s), well the brakes can easily get stuck! Thankfully, with the right amount of motivation and moral support, lubrication can be applied to loosen this grounding friction. With another 2 tricycles now doing good service on the streets of Ntcheu and now also Blantyre, I’m glad to announce we’re up and running again!

Since the success of the first 2 tricycles in Ntcheu, the word has gone out on the streets and attracted a number of new candidates of their own accord to the project. This revealed a fact to me-that demand for mobility aids has been there for a long time but people have just learnt to live (somewhat painfully) with their disabilities due to lack of money and government assistance to acquire one. Once the opportunity appeared to get a tricycle, we didn’t have to wait for new casualties to arrive but had enough long term disabled ones to pick from. Thanks to the assistance from my Ntcheu-based link, Mr Mittawa, the initial technical assessment and measurements are done before I get there. This greatly facilitates the order chain so that all I have to do is meet the new candidate and assess their suitability for our mobility aid. Mr Mittawa works as rehabilitation technician at the district hospital and is, I hope, going to keep things running once I’ve left.
The first new recipient of a tricycle is Chisomo Madyaudzu, a charming 23 yr old boy who is perfectly able-bodied save his legs. He was born with a very mild form of cerebral palsy, with minimal impact on his mental faculties. Thus he has not let disability get in the way of his life too much and went through vocational training to become a tailor. Owing to his physical impairment, he has always been based at home, with limited business opportunities. What a tricycle can achieve for him is probably the best it can achieve for anyone, that is empower them to move from a home-based hidden existence to a main street business where they can thrive. One can say that Chisomo is the lucky one, since he came to our attention first, ahead of all the new ones now who are on our waiting list. This is because his mother is a staff at our hospital and, no sooner had she caught sight of the previous shipment of our first 2 tricycles than she set out on a mission to find out how her son one could obtain one too. Just reward for being proactive I say. Chisomo has unfortunately had to wait more than 2 months to lay his hands on the tricycle though, owing to lack of transport to get the bike transferred to Ntcheu. We do have a Ntcheu vehicle that comes to Blantyre now and again but coordinating these visits with the collection of our tricycle is the same on the scale of difficulty as getting a bus from the depot on time and reach your destination without one delay or another!

Which is why I thought it was time now to widen the net a bit and turn to my own backyard for new clients. So our second beneficiary is a Blantyrite and it’s a SHE this time. I have tried as much as possible to be impartial with the allocation of tricycles but since Blantyre already had a long waiting for them and many of them are ladies, I thought I’d pick the first lady on the list. I don’t think that can be termed unfair given the relatively poorer chances of access to health care services that this gender enjoys in Malawi. Considering how statistically speaking empowering a woman can be so much more (cost) effective than empowering a man (given the male scourge of alcoholism and irresponsibility with money), that again quelled my discomfort pertaining to this bias. In fact it made me even wonder whether I should limit my field of activity exclusively to women and let the slow trickle in the system take care of the men! But I don’t think that’s fair either. So JD will my first Blantyre beneficiary and I shall revert to the natural order of the list, combining Blantyre and Ntcheu. More to come on that one in the next update...

Chisomo before

transferring

Being measured up by Mr Mittawa

Tricycle delivered through Mr Phiri- District Nursing Officer

Family meeting Chisomo (family form a major part of my sponsoring network)

Happy. Smiling. Empowered.

Clinical Digest 13

2011-06-29T12:37:00.000-07:00

To nail or not to nail...

My area of interest within developing world orthopaedics has slowly but solidly, while in Malawi, become the femoral shaft fracture. Quite understandable given the implications this condition holds here. From my audit of inpatient orthopaedic diagnoses in Ntcheu, I established that this was the commonest one on the adult male and female wards, even commoner than the neck of femur fracture. The same held true on the paediatric ward, ahead of infectious affectations of the bones, joints and soft tissues combined. Given that, of the adults, it tends to affect the younger age group, who are working and economically active, the socio-economic impact is also quite significant. This is compounded by the resultant consequence of impairing the very ability to work of this age group if a less than optimal outcome is achieved following treatment. The history of the management of femoral shaft fractures is quite fascinating indeed, as it reveals many insights into the divergent nature of scientific research (between first and third world). As for the biomechanics and principles of treatment, they are equally fascinating in their own rights. I can certainly comment on the operative and non-operative management of this condition for Malawi. The way this relates to global trends is very interesting.

The management of femoral shaft fractures in developed economies is usually guided by the very latest technology, without being hampered much by cost considerations. The degree of excellence in terms of accuracy of reduction, time to return to normal function and infection rates, to name a few outcomes, could be argued to have come very close to the best it will ever be. The level of research conducted into femoral fractures, and for that matter most medical problems, in most journals tends thus to focus on subtle improvements in one or more outcomes. These improvements, unfortunately, hold little if any relevance to environments where even management approaches from 50 years back or more still pose logistic, financial and other challenges. Apart from helping the district level clinician from understanding the physiology of fracture healing or the properties of metalware they will never get to use, this research is of minimal benefit to them. There is a real paucity of contemporary research into the management of conditions in resource-limited environments. Low resource approaches used in the past often hold serious implementation challenges, given the non-availability of many components they used to employ. These, since the methods have been abandoned, are often no longer widely produced. This in turn, has had the direct effect of boosting up their prices, making them no longer economically favourable. When treating people in a district hospital, which is the typical health care setting for most Malawians, one has to recognise these problems

The gold standard for treating femoral shaft fractures in modern western health settings is through the acute insertion of a locking intra-medullary nail. This can be offered to some but not all people in our central hospitals in Malawi. The majority of our femoral nails however are unlocked (K-nails), thereby offering poor control of rotation, and then also, they represent less than 30% of our patients. Our K-nails, although available, are far from ideal and the only way to keep operating at times is wicked improvisation. To illustrate this, consider a recent case we did where we needed a 38x10 size nail. We had no nails of such a size and to get the diameter had to combine two 8nails. Now if we had two 38zx8 nails, then that would have been job done. But things aren’t that straight forward here as we had only size 42x8 nails and ended sawing 4cm off the combined metallic nails for about half an hour! The rest (majority) are treated like in the district. A large number of our nailings are done for non-unions, after conservative treatment has failed. This (conservative) is the standard treatment for the district and that usually means skeletal traction, typically via a tibial pin.

When I was in the district I observed the management of this fracture closely. Rather than deplore the lack of intramedullary nails and specialists who can insert them, I believe they should focus their energy on finding ways of improving the outcome with the tools they had. The lack of academic presence in the district and the rather poor rewards for the thankless task achieved by the orthopaedic clinicians there mean than little if any effort is spent on finding improvements. I certainly can think of many low-cost, widely available measures that can be employed to improve outcomes like rotational deformity, speed of recovery, length of stay, knee stiffness and pin site infection. All that is required is the dedication of the clinician and their will to spare some time at the beginning to implement these measures. As the nails hopefully become more streamline in the central hospitals, maybe we can start then to work on their implementation in the districts. By that time, also one would hope there’d be enough doctors or senior OCOs in Malawi to undertake this task there.

Are we there yet (Part II)?

2011-05-17T04:21:00.001-07:00

Here is an early untested theory on memory! In the early days following an event, the brain has a tendency to focus on the hardships endured more than the joys derived in the process. Yet as time passes by, these painful memories slowly start subsiding to leave place for an overall positive recall of the activity. This, need should there be to clarify, holds tru-est for long hard slogs more than your ordinary walks-in-the-park-type activities. And should you want to consult my wife, my sense of planning has lately been rather skewed in the direction of the former. Having survived Mulanje barely (and the limping week to, at and back from work that ensued), the plan was to take the new bike out for a test. Janet’s new bike that is. The best bike I think we’ve ever laid our hands (and feet) on. So nothing should really been too much of a push for it. Of course, my handicap for the trip would be to ride a standard Malawian bike with all the friction that can possibly be generated from its moving parts. Having happily used it around Blantyre I thought that the overall added difficulty wouldn’t be too much for me to take. So I thought of a nice return trip to a place not so near but not so far either: Zomba. How I came to that distance assessment is something neither me nor Janet ever questioned. We simply assumed that it looked closer than Mulanje on the map and Mulanje is 50 something from Blantyre. Since the unit of distance here is the Kilometer, our estimate was that Zomba was less than 50Km from Blantyre. That’s a doddle really in our books. Having been known to do 20 a day to work and back in the UK, 50 over a whole day can’t be that bad. Here’s how this trip differed from this arbitrarily selected UK reference point. The weather in the UK might be sh*** but it is cool and doesn’t sap you of your will to live like a midday Malawian sun. Secondly, the average terrain is somewhat more level in a British city like Manchester than the endless undulations encountered between Blantyre and Zomba. Lastly, and most significantly, the unit of measurement I used inadvertently was 50 Km when, in reality, it turned out to be 50miles! So the whole trip was more like 75 odd Km each way. Try and explain that to the loyal wife who slogged some 20 hours’ of mountain walking for you one weekend ago!

Back to my theory on memory. So, there is its classic application: Hills, in particular undulations along a route which is flat on average! Yes, as you proceed one way from point A to B, you remember the hills (read hardship) mostly and think that the overall gradient was an uphill one to your destination. Hence the return trip should be much easier, being by default downhill! But here’s the catch. On the way to point B, you forgot to factor in the bits of the trip that felt easy (the bits after the hills that is, when you’d relax your legs a little). These easy bits of course became hills on the way back. Since the hills take longer to get through than the flats and descents, the overall impression from point B to A again becomes one of uphill. Thus I conclude that man has a preferential memory for pain in the short term than for pain-free goings on. And this pain gradually gets converted into a sense of achievement which is perceived as a positive memory long term!

Back to Zomba. It will certainly live up to be one of our most enduring memories of Malawi. Formerly the colonial capital of Malawi, it boasts some amazing architecture including the lodge where we stayed. Fringed by a superb plateau, its scenic potential is also very close to Mulanje’s and Nyika’s. While Mulanje is the wildest and Nyika the smoothest, Zomba wins the lot as the greenest. For those who dare not take the potato path as we did up the 700-800m up, there’s even a road that takes you there. (Small insight into the origin of that name- it was and is still used as the crossing route by farmers between the potato growing plains in the Domasi valley east of Zomba to Zomba market where they can be sold.) And don’t worry if you don’t have a car. The business of organising taxi ferries up the plateau is thriving in town. If you happen to need a taxi on the way down alone, then the economics are largely swayed in your favour as there are enough taxis that have only been hired one way and up. So they’re empty on the way down and will only take a couple of hundred Kwachas. Considering, they’re on neutral gear most of the way, they couldn’t realistically hike the price up any higher to cover their fuel cost! Beyond the adventure, the scenes and the streetwis-dom, Zomba was our bank holiday escape Janet and I to mark (somewhat belatedly) our 6th year of being together. That’s got to make a place memorable.

Zomba Plateau

Lush Greenery

Beauty & the Beast (or other way round!)

Are we there yet (Part I)?

2011-05-17T03:37:00.001-07:00

There are few places in Malawi laden with more meaning for me that this one colossus. Dominator of the skies from Kilimanjaro to the Cape, it is a place where the soul roams free, away from all the overwhelming chaos and din of lower lying areas. The only noise here is that of Nature. It is my one favourite recluse and yet I haven’t paid it real justice yet. Mulanje- Malawi’s island in the sky. Malawi’s jewel of biodiversity and also its most mysterious corner, imbued with more legends and myths than any other single place. The immensity of it naturally lends itself to such fancies but let’s face it, any mountain of such a scale will have its casualties. There exist enough plausible causes to not have to attribute any to spirits and the like. Perhaps one benefit of that is that the mountain is avoided by many, thereby keeping it more pristine. Unfortunately, of those who do actually tread there are a number of unwanted individuals- namely loggers and poachers. I would refrain from calling them vandals, considering the factors that do lead them to such desperate means of survival. It certainly is no mean feat to try and come up this mountain to scrape a living. One often risks their own lives, be it from forest scouts or the leopards they hunt, let alone the harsh conditions that prevail up there. Mulanje boasts the honour of supporting the largest number of Malawi’s national tree – the beautifully scented Mulanje cedar. This is a tree that’s incredibly difficult to grow by man’s hands. Sadly, every passing year sees its numbers dwindling scarily given its propensity for making curios and other artefacts for one time visitors who largely haven’t got a clue. Even more alarming is when the wood is not even chopped but lit by arsonists to scare animals as part of their traditional hunting method. This leaves vast areas of the plateau reduced to cedar graveyards.

But despite these sad details about the vulnerability of Mulanje, it remains one of the most ecologically fascinating areas of Malawi. Whether you approach it with your gaze facing down with a microscope or facing up with a telescope, there are gems to be found everyone. I already listed my repertoire of birds on this plateau. Land animals do also reside here, except that they have (rightly) become very elusive from man. Our last venture out there brought us close to klipspringers. There are also loads of rock hyraxes and fewer leopards that prey on them. The most diverse aspect of the flanks and plateau however has got to be its vegetation. There are no two times of the year when you can expect to find exactly the same things emerging from the ground. The famous pan-seasonal delights are undoubtedly the sunflowers. They exist in so many varieties (in size, colour, shape, density, you name it) and are so abundant one can almost feel a sense of security about their survival. Among the more seasonal features are the protea flower, red hot pokers, vibrant purple Mulanje irises, glorious aloes and dizzying vellozias, which can hang from any rock no matter what the gradient, and their amazing lilies.

Of course, I’m reminding you of Mulanje here because I’ve only just reminded myself of it not so long ago. My friend Tor (Norwegian surgeon from Lilongwe) wanted to organise a farewell trip prior to leaving Malawi. We formed a team of 8 (5 Norwegians, a Belgian girl and Janet & I) and decided to approach it from a different starting point to the one I’ve always used before. Our chosen path was the Lujeri one, which starts from a beautiful lush green tea estate that seems to have no limit and is flanked by natural forests as you begin your ascent. At first, I planned to stagger the whole thing over 3 days giving us enough time to ramble and recuperate. At the last minute though, this had to be shortened to 2 days, as both Janet and I had to be back at work. So we made slight adjustments to our plan, so that we (and our Belgian friend) could come down earlier than the rest of the group. Instead of saying: “let’s scrap the peak” though, as in retrospect one would hope we had done, we thought: “let’s start earlier on the peak than we planned”. Of course, that adjustment did nothing to reduce the overall distance covered and only added the pressure of time to our schedule. Having clocked an amazing 8 hours’ walk the day before, with a 6am start, we started our second day with a 5am start! 5 hours later, after having elatedly conquered the height of Malawi at 3001m (Sapitwa Peak), we began to contemplate the route ahead. My team (Janet and the Belgian girl) were already somewhat drained by that stage and I could already anticipate a return journey to the tune of “are we there yet’s”! As it is in Malawi, number guessing is as accurate a science as cloud figure guessing! Thus we were told anything between 3 hours and 7 hours. Erring on the side of caution, we allowed for the higher limit and estimated that we would make it to the bottom and across to the bus depot in time for the last bus to Blantyre. And how precise that turned out to be! Once at the bottom, we managed, within minutes, to get a ‘matola’, but in the local style. That is, while thinking even we couldn’t fit in the back of that pick up with all our bags, we managed to gather 5 more passengers along the way. If you dared to breathe too deeply you might just tip over the side! Back at the depot, we hardly had time to get a soft drink before the last Blantyre bus came along and was ready to go... In fact it was a Limbe bus (the small commercial town 3-4 Km from Blantyre). But then, we learnt a little trick of the trade here. If you negotiate an arrangement with the driver from the start, you can top up your fare by a couple of hundred Kwachas and get him to drop you off further. Of course that only works with the last bus of the day. And for us that was ideal. We snoozed all along and in the end got the driver to take a route that delivered us on to our very doorstep. After a day of trying to make it up to Janet for the somewhat extreme planning, I could finally answer “we’re there now”!
Lujeri Valley

Our team

Before Sapitwa (seen in the back from the plateau)

On Sapitwa

Mulanje Iris

Clinical Digest 12

2011-04-18T07:57:00.000-07:00

Back after a long absence. This has paradoxically been the most exciting period of clinical activity in Malawi. Moving from low rumbling Ntcheu to the epicentre of trauma in Blantyre, while joining the on-call registrar rota, has come with a predictable surge in medical/surgical drama. Not a single week goes by in Queen’s when I don’t think, “well I could make a ‘case report’ out of that”! The somewhat perverse sense of medical excitement(perverse because it directly means that someone’s tragedy contributes to the doctor’s direct pleasure- although I have got over that one, through my “survival in a fast and stressful environment” doctrine) is satisfyingly tempered by the widely diverse range of my duties here: weekly teaching of 3rd year medical students and trainee ortho clinical officers, examining, course facilitation, clinics, drafting of a reference manual, outreach clinics to Ntcheu and Thyolo and other more epidemiological interests in these 2 locations. To say that I’ve got my work cut out for a year is quite an understatement!

The two ER-style dramas that have formed the highlight so far of my 2months in Queen’s have both been a direct consequence of the surprisingly intense second wave of the rainy season, while I’ve been on call. The soubriquet of trauma-magnet has indeed followed me to this corner of the world! The proof is that my 3rd on call was the quietest I’ve ever had. Hold on, that can’t be! That on call happened to be one I had effectively swapped and the “swappee” turned out to be a scene from a horror movie scene- assaults, lacerations and open fractures needing theatre attention for all night.

Land-slide wall
So here I am, slightly nervous that this is going to be my first proper call in more than a year and having not yet worked the system out fully. I pre-empt disaster by doing a systematic round of all relevant clinical areas to pick up the cases that might be referred to me during the night. Satisfied to have cleared all that up before 11pm, I yawn a final goodbye to my orthopaedic ward sister, who tells me “Hang on. Don’t go far!”. As anyone who has ever done a medical call knows, that statement is usually paraphrased as “Don’t even think of going anywhere cosy tonight!”. Just outside town, a multiple casualty has occurred, where a number of people who were standing by a wall suddenly had its whole weight collapsing on them! 2 ladies were severely injured, one of them pregnant. I find the non-pregnant one collapsed on the surgical ward without a pulse, being attended to by the intern on call. No bleeding visible anywhere, but a ghostly appearance. Pallor is a clinical sign that is certainly easily detectable on black skin, despite certain doubts I’ve heard to that effect. One feel of her pelvis and you got the diagnosis: Fractured Pelvis. But before that, the bit which is the real challenge here, is the ATLS resuscitation protocol- your ABCDEs. A challenge since ATLS was written with your western high adrenaline tertiary trauma unit in mind, not an under-resourced African hospital, where more than half of your assistants have never even heard of ATLS! As it was, my patient’s blood pressure was in her boots, with no accessible peripheral veins in her arms. Thus, aptly I decide to go for the area around her boots indeed and do my first unsupervised saphenous cut down. As much as is feasibly possible, I secure it and manage to administer just the amount of fluid and blood required to revive her. But as soon as she gets back to the ward (she was taken to theatre recovery for that), some “clever-clogs” decides to hang her fluid bag from the same drip stand as is normally used for the arm line. To no-one’s surprise, the line is too short and ends up simply yanking my cannula out!!! By that time, she has a recordable blood pressure though and gets an arm line inserted. The rest is standard open book pelvic fracture management- sling around the waist and legs, maintain BP (stable, therefore no need for ExFix in the middle of the night [which would incidentally have been my first one too!]) and wait for the morning to plan her definite fixation.

The pregnant lady, given the mechanism, also ended up with a pelvic fracture. However her clinical picture was entirely different, with pain being her main complaint. Everything else was stable and the reason for this stunning difference lay in the Xray pictures- whereas the first one was probably facing the wall as it fell on her and had her pelvis effectively opened up from the symphysis, the second one must have either been hit by the side or had the weight of the wall somewhat dampened by something else, sustaining a bilateral pubic ramus fracture instead without any posterior element, hence maintaining the integrity of that polo mint structure overall. That budding fetus in there must be relieved things didn’t happen the other way round!

About mini-buses
Remember that flash storm I once experienced at the start of my placement? Well I do remember thinking to myself that day “I’m glad this isn’t in the middle of the night and that the road is clear”. Such was not the luck of the casualties I admitted on that second ever call in Queen’s, when I was advised not to go far! A minibus effectively got sandwiched between a hauler truck behind and a car in front in what I remember to be the biggest downpour of the season. Impossible to attribute the blame to any party in particular here, but in spite of the commonness of reckless driving in this place, I think even the most meticulous driver could have found this unavoidable that night. The only safe option would have been not to go out. Those who made it alive (not sure how many but there were deaths on the scene), were barely hanging on. With full ATLS awareness in mind, the team on call (2 registrars, 2 interns and 2 nurses), used a multiple casualty approach, treating the most severe injury first, then the others. We split in 2 teams and managed to stabilise the 2 most unstable patients, both with clinically unstable pelvis fractures. Before I could even measure the vitals on my patient, the other team’s patient was already being wheeled to theatre, where I eventually joined them. I was effectively the senior orthopod for that night, since my consultant’s phone went unanswered on at least 10 occasions. The patient ended up needing multiple debridements, elevation of a depressed skull fracture (by the general surgeons thankfully) and an arm amputation. She then went to ICU intubated. It would have been a miracle if she survived and she didn’t. The second one also had multiple serious wounds that needed debriding, including open fractures of her forearm. Her outcome was more positive. As I got to the 3rd patient, whose main injury was a closed tibial fracture, the latter had evolved into a nice ballooning compartment syndrome. Now the dilemma arose about how I was going to do this case for the first time ever unsupervised. I’ve read a lot about it but this is a condition I’ve always tried to get involved in but never saw one while being on duty. So, assisted by the general surgical consultant, himself somewhat rusty on his orthopaedics, upper GI being his thing, I went on to translate book to limb for the first time. In that medically perverse fashion, I will admit to you that the opening up of a fascia which is in compartment syndrome must be one of the most satisfying feelings in surgery that I know of! It just bulges out and you can see the pressure offloading at once. And it’s a limb saved, potentially a life! Next big question then arose: do I fix him in the middle of the night, as indicated by the grade of his injury (Gustilo I) or do I plaster his leg with these massive open wounds? So I decide to go for the ExFix option and taught myself how to use this new kit that I’ve never used in the process. As it all held together straight when I tightened the final screw, I heaved one sigh of relief only surgeons can understand the meaning of! The last patient wasn’t mine and had mostly maxillofacial injuries, with a minor head injury. An on-call spent almost entirely in theatre and indeed a highly rewarding one. The way I downed that Coke I managed to lay my hands on at the end of that shift would be a serious contender for the next Coke advert without a doubt!

The rest
I wish I had enough space and time to document the rest in its full scope here. But since I have to actually DO the rest, I won’t spend much time DESCRIBING it. In brief it’s a mixture of trauma and elective work that I’ve not encountered much before. The trauma work is incredibly fascinating, with a lot of them presenting late and being non- or mal-unions. The tools we’re using are ones that are not so common in the UK anymore, e.g. K-nails and even then, improvisation is the key. Like just last week, we needed a 10x38mm nail and had nothing near it. So we combined two 8x42mm and then spent half an hour trimming it to 38mm! The elective work, for its part, is simply out of this world. Spinal surgery with the Prof- TB decompressions, laminectomies, fusions, pedicle screw stabilisations. A whole repertoire of terms that were hitherto very unfamiliar to my work vocabulary, let alone the spectrum of diagnoses involved- neurofibroma of the cord, syringomyelia, monofocal fibrodysplasia and even the first case of post op malignant hyperthermia I’ve ever seen.

This is the cutting edge of orthopaedics in the third world I think and I’m really thrilled to be involved in it. The learning curve is phenomenal but the sense of fulfilment even more so...

Bird’s Eye View

2011-04-11T15:25:00.001-07:00

At least 2 weeks' worth. Longer but shorter blogs seem to be the norm with this city life!

With Saj visiting, I got to see Malawi from a new perspective altogether. This was in no small measure helped by the (temporarily) upgraded mode of transport, in the form of a rattly converted army Land Rover “Defender”. Luxury nonetheless for me! Our itinerary comprised a mix of unchartered territory as well as familiar stomping grounds of mine. Having a visitor around really gives me an excuse to go and explore the place I’m in better, while allowing me to see familiar things differently from the way I normally would.

The first few days were really a warm up to get into shape for the meaty stuff ahead. On day 1, we went up Soche, the mountain literally in my backyard, for a bit of joint lubrication and muscle awakening. We decided to enlist the help of a local who might be able to guide us up. As it was, we met a group of boys near the base and one of them volunteered to accompany us. Another candidate (who seemed more familiar with the surroundings) had to be turned down because we had absolutely no way of communicating to him! We shot up a fairly well defined path until we reached this overgrown grassy maze, where one could only guess the next bit from lines of flattened (slippery) grass. Only at this point did our “guide” actually reveal to us that this was the first time he himself was going up! From there, effectively there were 3 guides (Saj, me and this guy) while Janet opted for the safer option of sitting down for a nice view! We think we made it to the top, but there’s no way to verify!

Next, we enjoyed a couple of days at work in Queen’s before our next bit of exercise. This was a basic but informative insight into the health system here for Saj. It was also a time to tease out any car rental difficulties- which were aplenty! On Wednesday, we did our second mountain ascent inamidst the lush tea plantations of Satemwa estate in Thyolo, interspersed with banana and maize fields. We acquired a bike from colleagues out there to make the number up to 2. These were gonna be put to the test the very next day in Majete game reserve. Unfortunately it came to our attention that one of the bikes (mine) did not take too well to being squashed in the back with 2 suitcases and camping material, not to mention a hell of a bumpy ride. Thus once set to go, first the gears went dead, which took us the best part of an hour to “fix”. Then hardly 2 miles along the dirt road, I found myself attempting to define a new cycling stunt without much success- the single pedal ride, the other one having come loose and joined the gravel! After being rescued from heat exhaustion by Saj who cycled back to the Defender to come and fetch me, we headed straight into our first game drive. The catch was pretty good: eland, sable antelope, impalas, nyalas, water buffalos, water bucks, baboons etc. A cool starlit night set us up for a different circuit in the morning to see if we could abolish the elephant jinx. And how we did! 2 separate herds, one just off the track and a second literally within arse-slapping distance by a waterhole (full of hippos itself)! Zebras and an impressive bull nyala crowned this last drive and we were headed back to Blantyre ahead of the biggie. Carb-loading was in order that night, ahead of tomorrow’s plan.

Mulanje! The legendary massif believed to have inspired Tolkien in the Lord of the Rings was to host us for 3days and 2nights. An average of 6-7 hours’ walking per day, taking in 2 paths (Skyline and Otto’s), 2 huts (Chisepo and Thuchila) and 1 peak (Nandalanda) left us deliriously content in the end. The weather dealt us some pretty authentic plateau variations between intense rain, sun and fog. Our peak ambition in fact got thwarted on the 2nd day due to the rain, only to be revived on our final day before a timely descent ahead of the rain and dense fog which would have made the enterprise impossible again. Nandalanda was an epic though. Not to be climbed wet, unless you like water slides very much and your life a little less. The scrambling turned out to a pure rock climb in the end, where I even had to ditch the boots to enhance my grip! To complement the physical exertion of the expedition in style, Mulanje was the seat of a formidable biodiversity, which our expert guide (Comestar be his name) helped decipher for us. We kindled a certain fascination for bird spotting and came to recognise some incredible beauties like the Livingstone’s Turaco (Lourie), various Sunbirds, Shrikes, Bulbuls, Bishops and a even majestic Lanner Falcon at the base. Short of seeing mammals, we saw loads of leopard and hyrax pooh. Interestingly the latter’s fur was the distinguishing feature of the former’s pooh!

A long dirt road cross country drive brought us to Zomba town, where we did little but recharge our batteries. The next day (Tuesday) we took the world’s bumpiest dirt road to a less visited gem of biodiversity which is Lake Chilwa. The lake is actually shallow enough to be puntable for most of it. We dragged a couple of bikes on our boat to take onto the small island of Chisi. On sea as on land, we saw ever more birds, with a newly discovered thirst- Egrets and Herons of all sorts, Burchell’s Coucal, mjore Bishops etc. The island had only one dirt path, which we followed almost till its end (about 5Km). Yet on the way back, I (leading) came across a bifurcation and took the wrong lane. Thinking there could only be 1 road, I carried on, assuming I would join the main track. 45 min later, I found myself stranded on this other port from the one we alighted on. Our punter was back at the original one as agreed! Saj, who had been followed all along by a swarm of excited kids, got pointed in the right direction by them at the fateful junction. Hence we made separate ways to main land, but all the same in a more memorable way... an hour apart. In that time, Saj befriended with an English-speaking local, whom, together with my herculean return-punter, we took for lunch. Back in Zomba, we stocked up around its bustling market renowned for the best fruit in Malawi. We then went on to meet Caleb in Domasi for the night, where we were welcomed by a typically timed power cut. Still it made the peace of the place even more astounding.

Liwonde national park was our next stop and our most thorough delectation of bird life up to now. A legendary boat safari gave us no less than 25 new birds to remember, which I won’t even list this time! Or maybe I should try- Masked and brown throated weavers, Diccops, Fish eagles, Kingfishers (Malachite, Pied, Striped, Woodland), Spur-winged geese, Open billed Storks, White breasted Cormorants, a Martial Eagle, Boehm’s Bee eater, Lilac breasted rollers, Wire-tailed swallows, Striped Wagtails, African Jacanas, White-faced Ducks to name a few... Crocs were also a common sighting there and we got very close to some indeed. We had lunch at this cultural village (Njobvu) on the outskirts of the Shire river, which Saj will remember as his best of the whole trip.

Not ready to stop yet for the day, we set sail for Mangochi, along the shores of Lake Malawi. The road trip was now retuned to a drone of pure indulgent relaxation. By the way, we saw another fascinating rare bird then- the Southern Ground Hornbill (or Tukey Buzzard). After a pretty social night (another word for long awaited session!), we woke up reenergised for a bit of lake based activity. Thus Saj decided to recreate a past adventure of ours, which I was glad to have come out alive of! With a displaced sense of confidence, he lures me aboard this enormous kayak, without any safety jackets and glides effortlessly with the wind. Only when we have to turn around do we realise that this was not gonna be the same as the ride out. Knowing all too well how easy it is to capsize these shells, I finally put the oars down after our 5th or so failed attempt at overcoming the wind. Of course, I’m on another beach altogether now, separated from the starting point by a good mile of rock crossing. Quite a rewarding rock climb that proved to be, if I can see one positive side to this rather treacherous crossing. The owner of the place didn’t seem the least bothered when I told her what had happened and simply sent two of her Malawian employees to the rescue. The speed with which they rode the boat back against the wind was a real blow to our physical pride! Thereafter it was back to relaxation as previously agreed with a nice swim and a bike ride into a Baobab laden countryside, where we also recognised some of those recent avian discoveries of ours.

The Lake dream then followed a natural ascent into pure escape mood as we drove off to Cape Maclear. Admittedly more cliché than anywhere else in Malawi, once you’re there, you simply don’t care anymore and just enjoy it. This spot is also the ideal platform for snorkelling with Cichlid fish around the rocks of a nearby island. We made the most of this opportunity, encountering another typical cliché in the process- that of being duped by beach boys! Despite not having our formerly agreed sunset trip included in the ride, the very fact of coming into close contact with this wonderworld of Darwinian evolution was enough to keep up elated till the next morning. Interestingly, fish was on the menu that night! Not the Cichlid type though...

The remaining days were now strictly reserved for recuperation, given my failure to actually just lounge at the lake doing nothing as planned but opting for more physical exertion instead. We took a couple of backpackers with us out of Cape Maclear and ended up getting stuck in a sand bank before a small stream crossing. Such events really lack the drama and despair one might feel if it happened in Europe. Because here, within seconds, people just appear out of nowhere to assist (with the expectation of a good tip). When you have twenty strong pairs of biceps it usually doesn’t take more than 2 minutes to move even a 3 ton Defender! Thence we went very much uphill to Dedza (incidentally bagging a Sooty Falcon in our bird tally), where we checked into a very Malawian haunt for a very nice flavour of Malawian life for Saj. Top on the scoreboard for that night was the food. The downers were too funny to be troubled by for any length of time. Firstly we tried to get someone to tune the TV in our room to some news. We ended up being the ones teaching him how to do it. Once we did that, we realised the whole place had only one dish, such that what we would be watching would also be on other people’s screens. Not surprisingly, I had the world news on. At 1.30am, I realised at least someone had been more engrossed in world events than me that night as my next door neighbour (who crashed in around 11pm with a whole group of people) started to pray out loud for peace in the world and an end to all natural calamities. Hmmmmmm!!!! The one night I find a nice hotel without a bottlestore nearby with loud music to ruin the peace, I have a middle of the night sermon instead! Nothing against the actual prayer, but why out loud at this time of night? There’s something about the Malawian way of preaching one can only understand by being here.

Since we were in Dedza, we felt obliged to go and explore the UNESCO world heritage site of ancient rock art in the nearby hills the next day. Only mildly enthused by what we saw on artistic merit, what entertained us more was the new wave of charcoal drawings by kids on some of the rocks, as well as painted church messages. Meanwhile there was not a single hint of anyone doing anything to protect this site of global significance. Minimally perturbed, we embarked on the final leg, which was the Lilongwe trip to the airport. What a finale it turned out that was! An apocalyptic downpour caught us while we were in the market and cast such fascinating atmosphere to it all. The climax had to be the wooden strut bridge crossing in the end over gushing waters to get to the fruit and veg side of the market. We spent our last night with a friend of mine in his amazing guesthouse. Just what our lazy bones needed before a mega-holiday’s conclusion.

Saj’s last trip was to the airport, while I remained with a final leg to Blantyre. How our ancient Defender lasted all these days, without the slightest problem was on my mind, when the vehicle suddenly began trembling. As the amplitude kept increasing I pulled over and guess what? I had my first flat tyre. Hardly 3 hours after dropping Saj off. What timing! True to Malawi, a previous film repeats itself for me as, out of nowhere, self-proclaimed mechanics rush to the rescue...

Blantyre from Soche

Off to Majete. Man & Defender!

Nandalanda my beauty...

From Mulanje

The Chilwa island vibe

Hello~!

Ground Hornbill

Cichlids

Rock Art?

Final Crossing

Broken down Blantyre

2011-03-22T09:25:00.000-07:00

Some themes are recurrent in Malawi and right now it’s a déjà vu of Ntcheu’s period of gloom. Except that it appears to be even worse, despite it being the ‘fast-moving’ city of Malawi. When we first landed here, we were staying at a friend’s house on the fringe of the posh quarters. Thus we were shielded from the bitter reality to which more ordinary Blantyre residents are accustomed. Now we’ve moved into an “average” neighbourhood, we’re finding out for ourselves what this entails. 3-4 times weekly water shortages (in the midst a very wet rainy season) and about the same frequency of power cuts (hydroelectric for most of it) appear to be the norm simply. It’s not that we’ve moved into a poor area or anything. That would be the townships strewn around the city. We’re still in a relatively affluent part of town, out of necessity (proximity to work and town for non-car owners, safety, peace), just not one of the posh parts. Of course we’re finding ways of getting around these (like writing blogs when power’s out, or having power naps). We’re just surprised by the differences in facilities that exist from one postcode to another. Of course the posher the area the less frequently these inconveniences arise. This is in exchange for higher utility bills per unit consumption apparently. But there are some other parts which are far from being posh where similar priviledges also exist. I’ve tried to grapple with that for a while now and I’m told it’s only because when you live in a less wealthy quarter, your area consumes less out of hardship/austerity and the ones who can afford the facilities can do so for longer before the area’s quota is eaten up. The alternative explanation has been one linked in a direction of inverse proportionality with the distance from a prominent politician/civil servant’s house. Another unfortunate feature that hasn’t changed much since Ntcheu, you might have guessed by now, is.. correct! The noise! Having had a 2 week honeymoon in Hanna’s house, albeit makeshift, we’ve now moved up on a hill, where it appears that every night the music from bars at least 1Km away get windswept up to our living room. And we can usually tell which direction the wind is blowing based on this alone! My ability to survive this for another year (not tested yet!) is entirely dependent on the quality of this noise. Whereas in Ntcheu the music tended to drift downwards, hence transmitting the bass beat mostly, here the windswept melodies tend to have a more ‘voice-like’ waveform. Not to imply that it is not distracting in its own rights, but just that little bit less. What doesn’t upset me in the least, on the other hand is the Muezzin from the nearby mosques, which is simply music to my ears...

So it’s been 6 weeks since we moved to Blantyre, and 4 weeks in our present house. The fact that I’m only updating this on here now is an indication of how hectic things have been since the move. This move alone was an epic, involving an intra-city move for all our loose luggage as well as a return trip to Ntcheu (3 hours each way) to pick up our furniture... all in the same day. But, with it, came a clearer definition of our respective roles at work. In stark contrast with Ntcheu where I was a bit of my own boss, setting up my routine of activities in order to meet my placement objectives, in an established unit like Queen’s, things are already in place and I kind of have to work my objectives around them. Despite this there is a lot of leeway and I have been able to integrate some of my extra VSO objectives in my schedule, very much centred on upgrading the standard of care in the districts. Apart from work, which is rapidly filling virtual blogs on a daily basis in my mind here, the other perks of moving to Blantyre have also started to become manifest. None of them are really about the upgrade of our standard of living to match the place, and indeed we have been trying as much as possible to uphold our Ntcheu tempo. Every visit to Ntcheu in fact is a massive perk from living in Blantyre, simply because it turns out it’s still not too far and the return visits abound with social interactions, where everyone I know there welcomes me back, as if I’ve been sorely missed for years. It’s a testimony to how positive a time I actually had over there, which I sometimes failed to acknowledge. But back to Blantyre, the exploration on foot and minibus of its various nooks and crannies have proved to be a real discovery. Perhaps more ground could have been covered by car, but that tends to then take you away from the city you live in. Feet, on the other hand (funny English twist- similar to left is the right way!), have opened up a meshwork of footpaths and shortcuts, with their vantage points and chance encounters, which I couldn’t have dreamt to discover from behind wheels. And smells too, but then these are balanced by an equally ubiquitous scattering of scents. With the rainy season animating this soil and atmosphere with an ant-like drone of natural activity, the results surround us in every way. Besides the incredibly lush vegetation and undergrowth that makes you feel like you’re in some kind of a hobbit-land at times, the temptation to respond to invitations from the close up world residing within is irresistible. The relentless buzz of insect life, bird life and funny-indescript-creature life that operate herein are all but fascinating. My personal chart topper happened last week, when we got drawn out of the house by what we thought was a horny cat announcing their readiness to mate atop the compound walls. To my utter joy and surprise, it turned out to be an amazing hornbill instead, perched on one of our trees.

In tune with this theme of green, another prominent perk of our last weeks has been the slow conversion of vegetable garden and flower patch to some new colours and flavours. Hardly a fortnight on and we can already see the buds creeping in from under their thatch bed. No fertilisers. “No nothing” as they say here! Except for some good old compost and those magic rays that irrigate it with energy when it’s not the rain quenching its thirst.

It’s becoming clear that the tone of my appreciation of Blantyre is evolving fast towards the positive end of the spectrum. This was predictable in truth. Anyone leaving a simple place where they had set home and worked hard to establish themselves, approaches a new, more developed place with a good dose of cynicism. There are certainly elements of it that maintain my cynicism, like the pretentiousness of some social groups and their casual disdain for the ‘simple folk’. Yet I’ve now fairly confidently established that these groups are thankfully a minority. The other hazards of the crowded city have also not gone unnoticed, like the crazy driving, especially from minibuses that goes on here. I almost got shoved in a water-logged ditch by a 4x4 that simply drove on the other day, but now I’ve learned that the simplest to avoid these unpleasant interactions is to just walk in a different way. Let the danger pass, avoid confrontation and then proceed! But this few-bad-seeds flavour is very soon overcome by the general sweetness of most people here. I’m really starting to see how this affable charm of Malawian people pervades across the whole land, spanning village and city alike.

This brings me to a concluding anecdote, which is Janet’s current favourite dullness-breaker. Having shunned the high spec techno bars for a quiet after-work week washer on Friday, I approached my colleague for him to take me to one of the local pubs. Now what I had in mind was itself quite a busy, happening place, frequently mostly by Malawians. But my friend thought that maybe a more traditional drinking place might be better. So we ended up in this small block by a market place, with a succession of tiny little pubs. The one we walked in was aptly called ‘the sitting room’. And it was exactly that! You have a line of 4-5 chairs on either side, such that you were always facing someone. Hence conversation flowed freely. The people were so welcoming and interested in us (not in a nosy way) that we overstayed our planned 1 hour by at least another 2. A few drinks and games of pool later, we decided to make our way back. As we pulled up the hill to my house, the vehicle suddenly puffed to a stop. Classic empty tank scenario! Quite interestingly, people tend to fill up by small amounts frequently here instead of getting a full tank once in a while- which given the unpredictability of fuel pumps is quite a sensible thing to do. So there we go, Janet and I are outside the house and our friend needs to get back somehow. Not the least upset, he sets off on what would be at least a 2 mile walk in that direction to fetch the gas. I stop him and call my usual taxi driver (Bekelesi) instead, who promises to be there within 5 mins. Sure enough a vehicle appears in that time, with 2 other people inside. I chant my appreciation out drunkenly to him “Ah Bekelesi, always so reliable!” and negotiate a price for the small fuel errand. Thankfully I got on to a bargaining exchange with him which delays proceedings slightly. By the time we’re finished and agreed on a price, hey lo! round the corner appears an identical vehicle with just the driver. Before I even have time to turn my head to find out who that might be, the first vehicle had vanished in a smoke. The real Bekelesi was here for us and Janet was writhing on the floor with laughter pains. My bemused friend quite relievedly invokes God for sparing him a nasty denouement of one of the best nights in Blantyre.

Lessons learnt: 1. Have a system for recognising your driver even in the dark. Lesson 2. Know his number plate by heart! Lesson 3. Make sure you have enough fuel when heading out at night!

In the House

Improvised outdoor cooking

Minibusing it

Hornbill in the garden

Limbe Market

Tricycles and Wheelchairs Update 1

2011-02-28T05:31:00.000-08:00

There we have it! It’s less than 2 months since the appeal for donations went up on here and already we have 2 tricycles doing good service around the streets of Ntcheu. Two people have had a life sentence of confinement and dependence removed thanks to this latest agent of empowerment. Their stories are remarkable and I give you a small close up of each one here. But before I do that, I should like to thank everyone at home for all their generous contributions. Without these, none of these patients would have had this unique chance to see their lives so suddenly imbued with hope again.

Case1: GC is a 60 year old man who grew up with a congenital condition causing all his limbs to be short and disproportionate. Over the years he developed contractures of both his legs, resulting in impaired mobility. How that deteriorated after he had the fall that led him to come into hospital under my care! He broke his femur and despite it healing in the end, his mobility and especially his confidence suffered a blow. His job as a goat seller at the market took a turn for the worse as a result and he himself came up to me to plead for help towards a mobility aid. Any difficulties I was having in selecting suitable candidates for the project were at once solved and I referred him to the rehabilitation technician of our hospital to be measured. I promptly delivered these to the office in Blantyre and within a month the tricycle was ready. I was already a Blantyre resident by then but I hadn’t lost all my links with Ntcheu. So I called the hospital transport manager to ask if there was any vehicle going from Blantyre to Ntcheu soon. By some stroke of fate, the same truck that delivered Janet and I into Blantyre with all our boxes, was back on another errand that same day. Since I had 2 tricycles to deliver together, again all my worries about uniting the patients with their long awaited tricycles were solved. A week later, I went to hand them over to GC (and BK, presented below). Not without some ceremony which is customary and expected with this kind of thing, the handover was done with the blessings of the DMO, DHO and administrator of Ntcheu DH. As GC wheeled off in his new transporter, you could sense that a whole new chapter had opened up in his life. One where he would regain some of that lost independence and resume remunerated work. Nothing more than that serene smile of gratitude on his face could convey it better...
Before
After
That Smile!
With DHO
With DMO

Case2: BK was a victim in so many ways. Born also with a slight abnormality affecting his physiognomy and leading to premature cataracts, he became the target of mockery and abuse from other people. Aged only 18, he was thus assaulted in Blantyre while I was still in Ntcheu and suffered panga knife cuts all over his lower limbs. These went through many of his tendons and nerves and healed very poorly. He was eventually referred over to his home district of Ntcheu from Blantyre to have rehabilitation. His legs had become almost completely dysfunctional by then, being complicated by infection and neurological deficits. With all his life ahead of him, consigning him to a fate of lifelong dependence and immobility seemed incredibly unfair. Thankfully his hands were spared. So, once the project got set up, I had no doubts who would be one of the first beneficiaries and I made sure I got all his contact details. He got measured in the same way as GC and had his bike made in the same batch. This was delivered to him 2 days after GC got his under the auspice of the entire orthopaedic department this time in the Ntcheu DH courtyard. His brother accompanied him and the new pride of being able to live a dignified life was the greatest gift of thanks anyone would want in return of this gift of mobility and independence to BK.
Before
After
With our amazing orthopaedic team

Check out the first donations on youtube to see the difference you can/have made to these patients’ lives:
http://www.youtube.com/watch?v=YOmHayuJbzk
http://www.youtube.com/watch?v=dfLLSDorkLo

About the project:
The bikes do take a little while to get used to. So the patients have to be reviewed by the rehab tech at first to make sure they are using it properly and safely. That is why the Ntcheu project works so well, as we have our own resident rehab tech there, Mr Mittawa. He has been extremely useful in getting the project set up and will remain as a link person there for future patient selection and work up. The bikes also will need some maintenance over their lifetime and they are made so that the cost of this repair is down to a minimum, using the same parts as the cheapest bikes around. If well maintained, they should last a good 20 years or more. The best thing about this project is that it employs Malawians to build the bikes locally and also supports the organisation which runs the workshops, called Malawi Against Physical Disability. This organisation is really transparent and has enormous potential to come to help to disabled people across the land. The only thing limiting them is lack of funds. By receiving more orders for their workshops, they are able to assist more disabled Malawians, who would otherwise just have to live with their disabilities. So far we have 2 tricycles. There are 2 more orders underway. And depending on how much more money I raise, we’ll have even more people being given this unique chance of some life changing improvement.

The mean machines!

Being shipped to home county- Ntcheu

Please keep your contributions coming. All you need to do is email me on ashtindoorgakant@yahoo.co.uk for details of my bank account (maybe paypal soon).

Early days in Blantyre

2011-02-22T02:35:00.000-08:00

3 years ago, when I left Blantyre after 3 weeks at CURE hospital to go back to London, I was overwhelmed by the great sense of human coldness and general sterility I experienced upon arrival. I was longing for more of that great human warmth and colourfulness characteristic of the Malawians I’d met in Blantyre. This, by all accounts, is mostly the same to date. But to get an idea of how much more so it must have been in Ntcheu, consider the fact that upon landing in Blantyre for the first time as one of its residents, as opposed to a mere passer-by, I felt almost as I did when I left Blantyre for London. I suddenly felt immersed in a big cold city full of superiority-complexed people, dodgy dealers, excessive security and smoke. Of course, all that is relative, since when compared to your Mayfair and Brixton quarters of London, Blantyre, despite all its superciliousness relative to Ntcheu, would still represent a saintly opposite! And of course, the initial feeling of antipathy towards it gradually softens as I start to discover that the city is nevertheless diverse and that I still have the choice to make my lifestyle not so different from what it was in Ntcheu. Every big city has this corruptive potential, some more than others, but ultimately, it only corrupts you as much as you are willing to let yourself be corrupted.

Blantyre cradles many extremes at once. On the one hand, you get a sea of anonymous Malawians, flocking to the city in search of any work they can find to get themselves out of poverty and be able to support their relatives back where they came from. These people walk everywhere, eat only the cheapest available food, sleep in the most basic settings, usually some distance outside the city itself and are essentially indistinguishable from the rural inhabitants. Interestingly, the phenomenon of urban drift does not appear to be anywhere near its counterparts of Asia, where there is a real congestion as a result. Townships around here are relatively small.

On the other hand, you find another group of people who are only ever known to walk when it involves moving from a 4x4 into a building, or back! They are made up of Malawi’s emerging upper middle/ upper class, the asian community of wealthy tradespeople and muzungus. At first I was surprised to find so many rich Malawians, but the more I thought about it the less surprised I became. If so much money is actually said to be injected into this country’s economy and the poverty level, essential services and infrastructure remain so stagnant (based on many old timers’ accounts I’ve heard and my own comparison between 2008 and now), the money must be going somewhere! This is not a generalisation, just a reflection of the surprisingly high number. These people live in exclusive areas in and around the city, guarded by electric fences and armed security. They frequent the numerous posh establishments around and shop in your high end supermarkets. They establish that stark contrast for which the city is famous.

In this dangerous juxtaposition of extremes, one finds another trait for which Blantyre is famous- crime, namely break-ins! Whether an extreme in scaremongering among the wealthy, desperate to safeguard that wealth, or a real extreme in the crime rate, I haven’t had a chance to establish yet and hope not to establish it by personal experience either. But its influence is ubiquitous. Enhanced security is everywhere ranging from broken glass embedded in the walls to electric barbed wire! Another peculiar manifestation of it that no one can fail to notice is the daily parade of armoured guards with angry barking dogs, which one security company likes to exhibit.

There is a middle ground though and it’s made up people who are neither rich nor poor, but are generally trying to get by. It is also fairly substantial which is reassuring. It includes salaried Malawians, students, and many lowly paid NGO workers (like VSO!) as well as members of the above –mentioned wealthy groups who decide not to behave like venerable super-humans. The middle ground, of course, sits uncomfortably between the rich, eager to lure them closer, and the poor, eager to humble them. Those who are in it by choice, probably abide to the latter category, whereas those who fought to get into it in the first place probably want to ascend further to get into the former category. Janet and I for one (two!), will probably try as much as possible to live the low impact life we’ve got accustomed to in Ntcheu, but still won’t alienate ourselves from a good bunch of people who might have opted for the more comfortable cosinesses of expat life. The factors determining lifestyle here are complex and there are plenty of good intentioned people living quite a plush existence.

Janet and my arrival in the big city has been accompanied by 2 crises incidentally, which are linked to the lifestyle choices referred to above. Firstly, one on a national scale, is the fuel crisis (Petrol/Diesel Palibe) which reached its dizzy heights just before we arrived. This had the strange ability, for once, of uniting the rich and less rich (and also poor, when you add in thirsty minibuses) under the same roof with the same desperation for a commodity. One might point out that the rich end of the spectrum were the more desperate, having grown so much more dependent on the stuff to ‘fuel’ their fancy lifestyle. Minibus passengers, if forced to, would probably be able to leg a few miles home if no transport was available. This crisis, apart from blurring the contrast between rich and poor, also throws some important questions about the state of this country. The effects of oil dependency can really be observed at close range and it certainly is worrying. As any ‘disaster’ it hits the poor first and hardest but knowing how the rest of the world is also so addicted to that liquid, one wonders what it might look like if suddenly in Europe or North America, people and industry and public services and trade suddenly got made to scrounge around for the last remaining drop of fuel in town for three weeks on end. This is what is happening at the moment here, and no one is spared. The queues outside fuel pumps are endless, the chaos bewildering- with everyone squeezing in best they can, straddling central reservations and even the opposite lane-, and the traffic unbearable. Janet and I, seeing this, are so glad we resisted the temptation to buy a car here. Beyond this relatively minor inconvenience, all services are also suffering. Supplies in the hospitals are at an all time low. Staff are being forced to adapt their timetables around fuel availability. Patient referrals from district to central hospitals for higher levels of care, are being paralysed, resulting in deaths at times. Meanwhile the 10-20 gas guzzler motorcades of certain individuals don’t seem to be suffering in the least!

We're actually in the wrong lane here and the 4x4 below is straddling back to the correct one. The line of cars is the fuel queue, not parked vehicles.

"FUEL PALIBE"- No Fuel!

The second crisis, one on a more personal level, is our pains with housing. This again has revealed some insights which forcefully tempered our precipitous attitude towards moving into a space of our own. Of course we wouldn’t have had the luxury to do that, were it not for the amazing hospitality of Hanna, fellow VSO volunteer, who literally welcomed us in like old friends. All this time, we believed that we would be moving in houses similar to some of our fellow expats, thinking without actually questioning it, that this was the norm. It’s only once we were told that we would receive a limited budget towards our accommodation, that we realised how exclusive these areas were. Yet there are many alternative options around, which are much less expensive. Sadly we don’t get many expats wanting to live there, opting for the posher areas where other expats live. It results in a strange segregation almost where expats have little chance of interacting with ordinary Malawians other than at work or their house employees. Our situation is unique in that we are the ones doing our house hunting instead of VSO placing us in a house (since my transfer to Blantyre halfway through my placement was a situation quite unfamiliar to them). Of course, I’ve wondered why the VSO houses have tended to be in the posher parts of town and the reason for it seems to be down to the fact the houses are actually provided by the college of medicine, which is a well-paying partner of VSO. So their employees (VSOs) are placed in their houses and VSO ends up paying, although ideally they should. In light of the difficulties in finding suitable accommodation for volunteers, and the constant pressure from the latter’s concern about security being inadequate elsewhere, the simplest (and sometimes cheaper) option for VSO has been to go with the posh houses. They try and cut the costs by encouraging people to share. Couples are given a special status (which is likely to change soon, with necessary budgetary tightening) whereby they are entitled to a house by themselves. Sadly none of those are available for us at the moment, not least helped by the fact that the ‘partner’ in my case is no rich college of medicine, but rather a poor relation called Queen Elizabeth Central Hospital! All this tedious delay however (2 weeks in a spare room with half opened boxes) has had a positive effect nonetheless. It has enabled us to understand the system better and make our quest for more suitable accommodation- within our means and in line with our desire to keep it simple and around ordinary Malawians. The light is finally starting to appear at the end of that tunnel we feel...

Of course it’s still very early days here and I will probably come back over my first impressions of this city. It feels so complex in its dynamics. Yet at times, things are also deceivingly so downright simple. Things will change and numerous new discoveries will be made for sure. After a year in Ntcheu, I don’t think I even scratched the surface. Blantyre is potentially more intricate. So I’ll keep my senses and observations acutely tuned to take in the most that one year can aspire to. But at face value, for now, to a new-comer this is what it has felt like. More to come.

The sound of Ntcheu (Part2)

2011-02-07T12:13:00.000-08:00

Today is the 7th of February. 1 year day for day since I’ve been in Malawi. Momentous date indeed. Especially since today also marks the day when I conclude my stint in Ntcheu to settle in the ‘Big City’ which is Blantyre. One thing you can be sure about is that I didn’t leave quietly! I left in true Ntcheu style. With a bang! A party that brought me in line very much with my earlier woes about the place. It will be clear after you read the preliminary notes that I wrote in advance about Ntcheu, how much I’ve grown accustomed to this one sensory stimulus.That’s what I imagined my leaving Ntcheu would sound like:

I won’t miss it. I’ll miss the place, the wonderful people, the amazing friendships, the good times, the fabulous countryside and so many things, let there be no doubt about that. But I won’t miss the sound of Ntcheu. Maybe I didn’t elaborate enough on that one!(?) But beyond the crazy fanfare of dog/hyaena howls, pounding rain drops on my tin roof and Uncle B’s sickening floor beat, Ntcheu was also the seat of unregulated noise in every context imaginable. And to my utter surprise, hardly anybody complained. Only the hardest hit (e.g. my friend who runs a guesthouse right behind Uncle B) saw the disturbance it was causing. Not a single person thought it might interfere with learning and concentration for example. And so, it went on. For some, it was a statement of status. The louder your speaker, the wealthier you are. The louder your shop’s music, the more attractive is your shop. It attracted more customers in that simple way. Thus, on our one mile long shopping street, you’d find no less than 20 nicely cranked up music systems, competing for who could blare out the loudest noise, hardly a few metres from each other. They invariably had a system inferior to the speakers (placed outside the shop by the way), which would magnify everything including background fuzz, to decibels that would wake a deaf man up! As this cacophony is taking place, one would be ill advised to stand right in front of a speaker, lest they end up with ringing ears for the rest of the week. Yet, to my bafflement, there is usually some guy happily sat on/next to/ in front of it, inflicting some irreversible damage to his eardrums. Occasionally you’ll find a dancer, inebriated far too early during the day, volunteering some of his moves for some attention.

Move away from this commercial noise, which essentially lasts only during shop opening hours, you get the night club feature which has no official finish time... at least not in practice. There is an interesting order to this disorder when you look deeper. The epicentre of chaos regularly changes location. My singling out Uncle B was highly misleading. I probably chose it for it funny sounding name and for the fact that it was my first presumed culprit. Then I found out that on any given night, there would tend to be one club that dominated the sound scene. And each time, it was the same speakers that would lie behind the chaos. This, I later discovered, was a set that got hired out in rotation, so only one club could have them on any given night. Whatever the mode of distribution though, the effects of it can be felt miles away. This is not helped by the town plan of Ntcheu- if such a concept can be applied. The bars that spew out this noise all face a valley where the hospital and most of its staff residences are located. I’m sure the wind also mostly blows in that direction! There are nights when it feels literally like someone is having a rave outside my room (Janet, queen of noise tolerance, will even confirm this for me!)

Then also is the one ultimate thing that no Malawian will raise their voice about- Religion. Of course, the sense of mutual tolerance of each other’s religion is highly amazing and commendable, but whether that justifies a church amplifying its sermons such that the entire town has to listen to it, I don’t know. This is what Ntcheu Catholic church is famous for. Much more prominent than the other churches, who also have powerful speakers indoors that can be heard till the end of whichever dirt path they lie on, this one boasts exceptionally powerful speakers (and members- whose money must have gone towards them) that sit right outside the church. Thus everyone in Ntcheu wakes up no later than 7am on a Sunday, to hear not only the singing but also the speeches and frenzied collections from this one church.
And the list goes on. Music really plays everywhere here and as loud as one’s system will allow. It plays outside our morning handovers in the hospital in the form of health education chants by some 50 shrill female voices. It plays in my orthopaedic office, even during consultations. It plays in theatre all the time. It plays on the wards from patients who do not need to check with others if it’s alright with them. It even plays next to the library. It plays in buses such that you could not possibly answer your phone with a chance of hearing what the caller had to say, assuming you heard it ring in the first place. It plays in almost every house, including mine (even though my ex-flatmate very soon minimised it). It plays in every shop and every bottlestore as I said. You can even hear it all the way up Ntcheu Telephone Mast mountain, coming from a particularly notorious “beer garden” at the foot!

One might think, especially knowing my historical aversion to noise, that this is somewhat exaggerate. But trust me, I have become a hell of a lot more tolerant to noise, and this time it really IS bad. The only way to disprove that is by experiencing it!

So that is how I thought I would be leaving Ntcheu. But Ntcheu has been my home for a year. Ntcheu has been the first African town to take me in as its resident- not just a tourist. Ntcheu has developed me in ways that couldn’t possibly have occurred anywhere else. Ntcheu has turned me into the doctor of my dreams, but beyond that also into a gardener, a bird spotter, a re-born footballer, a ‘famous’ pool player, a dancer, an explorer, a boundless foodie and so many other things. So whatever challenges it might have laid in my path, Ntcheu has become a part of me. And, in fact, more so for these very challenges. I’m so glad I had the chance to share that with Janet even if it was only for the couple of months which she spent mostly here, while awaiting confirmation of her lecturing post at the College of Medicine in Blantyre. The Ntcheu experience is so authentic it couldn’t be described merely in words even to someone who’d be living only a couple of hours away. Ntcheu is a landmark along the landscape of our lives, the freshest of them all. I really will miss it as a whole, with or without its music. The proof: today, as we were driving down in our removals van, I caught myself asking the driver why he didn’t have any music on. A few months ago, I would have been secretly praying as we got on that van that the CD player was broken!
Farewell Ntcheu. Blantyre ahoy...

My Beautiful Ntcheu dwelling

Party House getting ready!

Dj'ing is serious business here!

Tricycles and wheelchairs

2011-01-17T06:05:00.000-08:00

INVITATION TO WILLING SPONSORS

Dear friends and family,
I won’t pretend that this is not yet another fundraising initiative from me but I can assure you this time it has a different flavour. The difference is that there is no Oxfam nor even VSO attached to the end of it in a way that makes you wonder how your money has been spent. This time round, it’s going to fund my own work here, which you’ll see the direct results of, and whose player on the ground (me!) you already know and trust (I hope!).

So what is it I’m trying to milk you for? Well it is an idea that has taken about a year to come to fruition but which I see as one of the most concrete ways of improving livelihoods here. As you know, effectively Orthopaedics is more about saving livelihoods than about saving lives and with the challenges arising from limited resources, at times I wonder how much I can assist patients with my bare hands alone (and brains arguably). But with a tiny bit of investment, my input can really stretch a long way further. And that particularly investment is towards purchasing bicycle wheelchairs (tricycles) for people with both legs paralysed or amputated. Effectively, once they have been afflicted by the above conditions, they are often reduced to a fully dependent status. Unless they have a supportive family with the means to assist them, they can be truly marginalised with little means to sustain a living. Having a bicycle wheelchair empowers them almost like a new pair of legs might do. It gives them the means to mobilise further distances and engage in remunerated work (you often see them conducting small businesses around markets). Above all it also frees them from the confinement that comes with having no legs and resorting to using the heels of your palms to get about.

As I said, it took me about a year to suss out the logistics of having them made for the patients. In brief, there are only a few centres that build them as they need to be made to measure. They cost 400000Kwacha each, which is somewhere in the region of £160. It might seem like an expensive bicycle but it’s professionally made and is essentially an orthotic device which would cost at least 1 extra zero in the UK. So here’s my business plan. For any of you who have always been interested in assisting with development work but never trusted that their money would be put to good use, here is your chance. Any amount is welcome. What I’ll do is just give you my bank account details for the transfer. Then I’ll pool the money donated together and retrieve it here to purchase the bicycle. Any excess money will be used towards new patients, whom I’m always finding, or at providing badly needed wheelchairs for the hospital. I have 3 patients in mind to start with for now.

If you’re interested in this charity venture, please email me and I shall forward you my bank account details. Please spread the word to potential donors. I look forward to your assistance towards this project.

Yours thankfully (Zikomo Kwambiri)
Ashtin
ashtindoorgakant@yahoo.co.uk

Before

The Bicycle Wheelchair (tricycle)

After

Clinical Digest11

2011-01-12T04:12:00.001-08:00

One might not have got the real flavour of African medicine through my blog yet. That is because (grudgingly) most of that stuff belongs to the sphere of the general clinicians, more strikingly for the infectious diseases guys! That doesn’t mean that I haven’t seen these textbook conditions which I would never dream of seeing in the UK, like rabies (with its Oh so distinctive hydrophobic characteristic) or tetanus (with your pathognomonic risus sardonicus) or measles (Koplik spots- but then I had it myself in Mauritius!), not to mention the vast array of HIV related illnesses (Kaposi’s sarcoma, high pressure CSF of Crypto meningitis, PCP etc). But two cases in the last 2 months have certainly added the exotic flavour to my Orthopaedic caseload too. Not that I want in any way to rejoice about the suffering of the afflicted patients, but one can’t help but marvel at the science of medicine when manifested in such classic cases.

C4 transection
Granted you’re going to see that in the UK too. But most of the time, the patient will have been dashed off to an ICU unit and rigged up to countless tubes and machines far and safe from your regular ward SHO! As a result you (ie me, the SHO) have hardly had a chance to really observe the striking physiological effects of such an injury and the speed at which they progress. This is now the third case I’ve seen already here. It’s quite common in fact, owing to a certain hazard called the “Matola”. This is the open back pick-up truck I’ve referred to already, in which people cram in the back, most sitting on the edge holding on to hardly anything. That combined with the terrains for which these vehicles are reserved (far flung village rocky dirt roads where there is no road access for better vehicles) is a recipe for disaster. After a sudden bump, the patients tend to be jolted right up in the air, often landing on their heads. Those who make it alive rarely present without a crack somewhere. When the break is in the cervical spine and involving the cord, one is left to praying for the best. What with the lackadaisical approach to ATLS and C-spine immobilisation prevailing in this place! The pattern of this neurology is so fascinatingly typical though that it could easily be the equivalent of an anatomy textbook condensed in one clinical presentation. You can map out the level of transaction to the exact dermatome. In this last case you could do so even without laying hands on him. A simple eyeball would tell you that his thoracic respiratory muscles had been knocked out of action. He was reduced to diaphragmatic breathing, of which unfortunately he would very soon tire. Sadly there are no remedies to this diagnosis here. You just hope that some neurology, at least the respiratory control, will return. Any attempt at transferring the patient acutely often only means changing the place of death and, more worryingly, adding to the patient’s distress through cumbersome ambulance journeys. Even if you happen to come off your matola right next door to the spinal orthopaedic hub of QECH in Blantyre, and for that matter in Europe, your chances of survival are still pretty slim. The only difference is that in Malawi, the rapid decline is for all to see, with ITU reserved for only the few cases with a theoretically better chance of survival. Recognising this early is really a knack the tropical doctor must needs master.

Congenital Hypophosphatasia
I admit it. I never even heard of it before coming here. That’s because this condition belongs to the weird and wonderful repertoire of metabolic bone diseases, that, unless you’re running up to an exam or the like, you would never willingly inflict upon your brain. To be more precise, the condition can be specifically attributed to the group of Vitamin D resistance syndromes. Wow! Completely unprepared for it, I got called one morning to review this 1year boy with a bizarre clinical presentation and even ‘bizarre-r’ looking Xray! The difficulty here is that everyone is somewhat expecting this “muzungu orthopaedic specialist” to come up with a spot diagnosis as he must have read about it before! But there I was as perplexed as them if not more. The child had a classic presentation of long bone fractures with minimal trauma and generally didn’t like being handled. The Xrays, I found out as I revealed them to the superior beings that inhabit CURE hospital, was quasi-diagnostic of the condition. It is so rare in fact most of you (medical readers) will never encounter one in your lives. Even google images failed to conjure up any decent pics for comparison. Once again, the treatment for this kind of condition is extremely limited here. Even at Queen’s Hospital (QECH) where the child got referred, the prospect of lifelong phosphate/Vit D replacement is extremely challenging without a family who can assist financially. The usual outcome unfortunately is a gradual decline into terminal renal failure.

So here again, I end up ending on a hopeless note regarding my patient’s outcome. However, in perspective, most conditions we see are common and treatable. We, as medics, have a natural tendency to get excited about rare conditions... I guess to counter the boredom that might arise from applying your 1000th plaster for a wrist fractured in exactly the same way. What can be frustrating is when even the simple stuff gets mismanaged. The danger then is to identify one single person/factor in the entire system to blame. But when the system is fraught with such severe deficiencies of staff and resources, one might instead remember all the cases that are actually being well treated by that person/factor and work on improving the system rather. From that premise however arises the conundrum that some staff feel completely exempt from blame as a result and take liberties with patients’ health. Who and how do you blame? Or should you blame? If you don’t (something or someone), how do you identify the fault? That really is the challenge that working here as a volunteer doc exposes you to. More than the pathology and surgery of medicine, you’re learning things far beyond these borders. And by one year, I can say that is also quite a rewarding experience.

New Horizons

2011-01-12T04:08:00.001-08:00

...Phew! Almost a month since last blog. I guess that tells another story in its own rights- my internet connection here!

Reflections on an old year
It feels almost surreal to think about it. The recent year switch actually symbolised close to a full year of my placement here. 11 months by the time this blog will be up. It moves me to tears almost. So intense. So fascinating. So real... It has transformed me in the deepest of ways and this has surely not been without the mistakes and challenges which forced that learning curve very much down the hard way! I’m confident that I’m coming out at the other end of this chronological divide stronger, cooler and wiser in my humanitarian vision.

So what has this journey, which is yet to be half completed, consisted of? Allow me this nostalgic retrospective exercise for symbolism’s sake. February 2010, the 7th, the day it all started. A mind boggling crash course into this country’s diverse facets before being thrust down the deep end for a taste of the real thing. To be honest, my dive was somewhat cushioned by a month of central hospital “settling in”. The immersion into Ntcheu’s myriad sensations felt none the less absolutely dazzling! There was the initial period of unlimited enthusiasm at changing everything in the hospital, soon tempered to the confines of the orthopaedic department. That itself gradually got further refined and narrowed in its scope. In May, Janet paid her first visit after 3months of sage separation and we celebrated in style by hitting on one the best road trips in my life, going up north through the highlands to Nyika plateau and cruising back along the lakeshore road. By June, things had started flowing a bit smoother, with connections being made within Ntcheu and wider into the cities, where senior Orthopaedic support is known to dwell. I was finding my depth and could now let my hair down a bit (that amazing amount that rests atop my head!). Fortune obviously had it that the world cup was happening at that very time. The first one ever to be hosted on African soil and one to which I actually had tickets (thanks Su)! And what a trip that was too- 30+ hours each way aboard a cochlea-challenging bus through Mozambique and Zimbabwe. Jo’burg then Cape Town followed in the full frenzy of possibly the most electric of all sports gatherings to exist. Truly, truly a landmark of my African escapade, not to mention my entire life! The work in Ntcheu then resumed with the same momentum it had before the interruption. I was collecting data for the Malawi Ortho Assoc’s AGM. This was given a special boost by the visit of the super-ortho-doc Steve Mannion and his team Feet First, who visited Ntcheu and whom I later joined on a full-on surgical week in Rumphi. My insight into the Malawi health care was also deepening as a result and I already had my sights on VSO’s next doctors’ peer support (for which Klaas and I had been designated as main organisers at the last one in May, courtesy of Marieke). Just before the AGM came another biggie, which somehow never got its due spectacle on this blog, partly out of a desire to preserve its full independent sanctity, and partly because it would have eaten up at least 10 blogs’ worth, which was impossible with the AGM around the corner. I’m talking of the Mauritian instalment of Janet and my wedding in August. Back in Malawi things picked up extremely fast with the AGM first and the VSO national conference/doctors’ peer support next. I found myself very involved at the AGM in September, presenting two papers while also helping with coordination of the whole event. The short lapse before the national conference saw the amazing Lake of Stars music festival and a brilliant leaving party that surely put Ntcheu on the map and on the musical repertoire of a sizeable bunch of VSOs (look up the Ntcheu song in the slam section for clarifications- the tune is that of Alicia’s Empire State of the Mind!). An intense build up to the national conference and peer support it certainly was, with meetings and phone calls and internet sessions happening at an unprecedented rate. All that while work was also proceeding at full steam, putting into practice all the newly gained wisdom from our orthopaedic meeting. My stress level, not in the least helped by the escalation of loud music from Ntcheu’s nightclubs to honour the summer peak in alcohol consumption, at that time distracted me from my intended mission in some ways and I found myself back pedalling very quickly. A perfectly timed retreat into the heart of Malawian culture helped to readjust my system. This was the most intimate contact I’d made thus far with the real Malawian folk as I spent a week sleeping in a hut on a reed mat and eating the local food daily in Gongonya village. All this while having my evenings cradled amidst quiet starlit reveries under limitless clear skies. Back on track, my mind was now set on the next major transition in my Malawi experience- that of welcoming aboard that so-far solitary journey of mine a new person- Janet. What a reunion it was! It’s been so marvellous and intense at the same time that I cannot find words to express it in this blog. Not without its challenges as expected, this new journey of two has been rightly set to the tune of an exciting year and a bit ahead. All the excitement of Christmas and New Year was somewhat consumed in the mutual “settling in”- Janet’s first and my second. And here we are in the new year with new hopes, new insights and new ambitions for this kaleidoscope of experiences that be the Malawian reality...

What better way to confirm that we are indeed in a new year than with this latest spate of joint madness! We were busy chopping up a panful of basil leaves freshly harvested from our bountiful kitchen garden and garlic to make our own pesto (which costs an arm and a leg here) when hey lo! from nowhere appears a drunken bat, executing the most bizarre pitches and yaws. The microbiologist in me and the one next to me took less than a second to figure out the threat that dwelled aloft. No-one forgets rabies when they’ve seen a case of it and no-one knowing that would take the slightest risk when faced with a potential threat of it. But then the question arose- how do you tackle a potentially rabid bat darting at full speed in your living room with all escape routes securely closed? Next thing Janet (still in the kitchen) sees, after we isolate the bat in the living room, is me emerging from our room covered from head to toe in heavy duty water proofs, save for my face. I’m on a mission to set the bat free with the minimum fuss. But my face feels vulnerable, exposed in the face of this challenge. Suddenly Thandizo, my guard, [who cavalierly offered to readily pounce on the flying mammal to put it (and us) out of our miseries but then revised his proposition seeing me in my new garb], points out us that there in my living room resided a crash helmet left by my recent flatmate. The rest is a scene that could well have come out of a spoof of the X-files: this helmeted strangely attired alien with a huge flattened cardboard box in his hand engaged in a frantic mission to ground an enemy a hundredth his size!! This he finally does after ten or so attempts and, in a final act of elation, concludes the mission with a firm sweep to the concussed victim which sends it flying onto the outside. And that is how we are marking the first days of this exciting year. We promise to bring many more of those to you... Just give us time. Happy New Year everyone and thanks for your enduring support.

Ntcheu Market

Handy juxtaposition of services!!!

X-files...

Clinical Digest10

2010-12-13T03:42:00.000-08:00

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.

A week less ordinary

2010-11-22T04:01:00.000-08:00

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!

National Conference/ Peer Support

2010-11-22T03:44:00.001-08:00

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!

Sleepless in Ntcheu

2010-11-22T03:40:00.000-08:00

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!

Lake of Stars

2010-10-22T03:04:00.000-07:00

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

Broken Down Ntcheu

2010-10-22T02:41:00.000-07:00

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?

Little Things so Malawian

2010-10-10T11:46:00.000-07:00

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

Clinical Digest9/ Public Transport3

2010-09-27T13:46:00.000-07:00

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

2010-09-18T14:42:00.000-07:00

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

2010-09-04T07:48:00.001-07:00

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!

Ntcheu Social Football Club

2010-08-11T05:00:00.000-07:00

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!

Preparing for Madam

2010-08-09T08:36:00.000-07:00

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!)

Clinical Digest8

2010-07-21T07:59:00.000-07:00

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.

Clinical Digest7

2010-07-08T03:41:00.000-07:00

7/7/10
Mannion,Me,James,Danni,Clive,Bernie

Maybe the date should have alerted me that today would be a disaster. I nonetheless approached this rare highlight of my Ntcheu orthopaedic calendar with the utmost enthusiasm and hope. The reason for such excitement was a long awaited visit from the illustrious travelling Orthopod, Mr Steve Mannion and his highly committed team from the Feet First project, Bernie, Danni, Clive and James. Mr Mannion, aptly surnamed “superdoctor” by Lord Winston for the BBC, is usually based in North West of England, operating at the Blackpool Infirmary. Despite such proximity to my UK abode, our paths never crossed while I was there. We always seemed to miss each other. Not surprising when you consider his typical timetable, which is a sequential intercalation of 2weeks in the UK and 2weeks in some other part of the world, mending limbs and restoring vital functions! This routine sees him visiting Malawi up to four times a year, where he was one of the founders of the club foot programme. So, when I found out he was coming, I linked up to try and organise a surgical visit over at Ntcheu. This request was positively received and I went on from there to meticulously build an appropriate operating list for him. The task was no easy one, considering all the logistical hurdles this posed. Firstly, as at every district hospital maybe in Africa, maternity has first pickings on theatre space allocation. Therefore, I had to make arrangements, with the help of the DHO, for all maternity emergencies to be directed to our neighbouring district hospital on that day. I also had to make regular announcements at our handover meetings to remind everyone of this eventuality. Furthermore, I had to make sure that transport would be available for these transfers and that the transport officer was also at the ready. The job of ensuring anaesthetic and nursing cover for theatre on the day became a plea at times, where instead of (rightly) assuming that these people would simply turn up on time as they are meant to on any day, I had to entreat them do so like they were doing me a favour. But it’s best to play the game. So I did and it bore its fruit. Meanwhile, I put a paper request around all the potential points of recruitment for interesting cases, including our orthopaedic and outpatient departments as well as the physio outreach programme. This yielded 4 cases, 3 minor and one major to be done. With some kind of sixth sense, I at first told all the patients to come in 2days before the planned day. Then somehow, I got dissuaded from this by my colleague, who reassuringly told me that admitting them on the eve would be adequate. Little did I know that the eve would be a public holiday. What that effectively did was to completely sabotage the list. Only one patient turned up on the op date and, to make matters worse, it had been breastfed already, thereby delaying the only operation of the day! Fortuitously, that same morning there turned up a potential second case, a new one which presented in our clinic. All excited by this luck, we started preparing for the op. The patient, an old man with recurrent Dupuytren’s contractures, told us he’d go and lock up his bike and make his way to theatre thereafter. Again, as tends to happen a lot in Malawian hospitals, and escaping my all-too-informed vigilance, the patient simply did a runner! Did we scare him!? Did he just not want to have the operation anymore and live on with his rather debilitating deformity? Whatever the reason, our second case never materialised. So we did one single case, a tiny one indeed, a correction of a polysyndactyly at the fifth toe of a 7 month old tot. It was a great teaching case nevertheless, not just surgically but also from a nursing and general theatre planning perspective. Bernie, a senior theatre sister by profession, did a reckie of the entire department and came up with some pretty sound recommendations. The maintenance of sterility suddenly doesn’t seem like such a ludicrous concept anymore. Meanwhile Danni, a radiographer, had a productive session in our radiology department, providing that essential support this group of staff rarely gets here. Clive, ODP by trade, was our jack of all trades keeping the list on its feet (so to speak) and making sure all our equipment was there. James, baby doc just hatched out of med school, added a breath of fresh air, good humour and keen hands and feet to assist us with setting up the patient. He miraculously got a cannula in a 7months old’s hand, first time. Shot! Looking back, I realised that we managed to turn a seemingly disappointing start into a truly rewarding half-day. The time freed up allowed us to go around the wards, and for me to receive some feedback about patient management in the district context. It also allowed for a couple of highly useful presentations on specific management of a number of conditions I’m dealing with all the time here- skin grafting for wounds, femoral fractures, neck of femur fractures etc. Above all, it provided a real insight into the typical Malawian working style and patient attitude, which, if ignored in any enterprise like today’s, can leave you feeling pretty bitter and dejected. None of us did though, since, knowingly, we planned for the worst case scenario anyway. Today, certainly, was far from that! To brighten things up even more, I inherited a mouth-watering selection of surgical tools to supplement the rusty ones in our Ntcheu kit and hopefully open up new operating frontiers in the near future. What more could I ask for?!

Bafana Bafana Fever

2010-07-02T05:34:00.000-07:00

Bafana Bafana Forever
Me & Kuduzela!!
Malawi has been the platform of yet another experience of a lifetime. It may have involved days of mile munching aboard a freezing-alt-sweaty bus, but it paid off in the end. I’ve seen, felt, heard (oh yeah!) and, above all, lived the South African World Cup as it was happening in South Africa. One item ticked off my own personal bucket list. In fact, my latest trip allowed for a few more items on that same list to be fulfilled, the first one being unquestionably cross country coaching from Malawi to SA.
I reached Johannesburg first, with a freaking sense of insecurity, what with all the scaremongering that goes on about this legendary city of crime. Despite it being daytime, the lonely 5 minute walk from the coach station to my taxi point felt like days, and the very prospect of bargaining with the taxi driver over his largely inflated price, like a death wish. But the air soon dissipated once I settled in and found myself sat next to a fellow human being, scraping a living out life. I was met at the other end by a chance host, the very acquaintance of whom I made less than 3 weeks previously. Of course, I knew of him well before but only met him by chance in Ntcheu as he came over to visit his wife on the eve of the world cup. He (Sandress Musuku) was the former DHO (District Health Officer) at Ntcheu District Hospital. We staged an impromptu celebration at the local club and he extended an invitation for me to join him in Jo’burg. Being a VSO volunteer, I could hardly dismiss such an offer. That gesture though was more than mere coincidence- it symbolised one of the truly unmistakable attributes of Malawians: their generosity. Whatever little they have, they will want to share it. There is absolutely no status boasting involved (we actually shared a tiny university all-in-one room) but it fills them with enormous satisfaction to have been of assistance to someone, anyone. Going to my latest read (30hours each way by bus does get me through a good few pages), The Shadow of the Sun- Ryszard Kapuscinski, I found parallels with his description of life for ordinary “Africans” (a term I use sparingly, all too aware how a Malawian is different from a Kenyan, from a Ugandan, from an Egyptian, Libyan, Malian and Mauritian etc), whereby interdependence is second nature. Survival under hardship depends very much on this unspoken social contract. But my host was no hardship-stricken Malawian. He was simply carrying forward the evolutionary trait that his people have acquired over generations, a trait that possibly unifies most central Africans. Having already saved me a little fortune, Sandress went on to treat me to some exceptional good times in Jo’burg. I was only able to meet my bro, Suraj, briefly there, considering he had tickets for games which I didn’t, but we caught up in style later on. Jo’burg, on the whole, was very short, albeit intense. It, doubtless, served to instil that first drop of the Ayoba in me (something like ecstatic fun in Zulu), but it is Cape Town that would see it develop to its full-blown grandeur! The connection to my second stop was by way of a no-frills airline (a treat in comparison to its European counterparts) at 6am. The airport turned out to be so far from Jo’burg city (no difference from European counterparts) that I only caught my flight by the skin of my teeth. Once on the plane, I couldn’t help being struck, almost guiltily, by its passenger demographics- almost all-white-, in sharp contrast to my very recent coach ride- almost all-black. This is one very typical facet of life in Africa that I still struggle to come to terms with sometimes.
Two hours (of deep sleep) later, I landed in Cape Town. Clueless really about what to expect (I hadn’t done my homework), somewhat underwhelmed, I was almost questioning whether it was really worth trekking all this extra distance just for a game. Within a couple hours, I found out it was more than just a football game. Way more. It was to be an escape, Ayoba!, of epic proportions. Flanked by juicy mountains and oceans, the very sight of which causes me to melt with desire, Cape Town boasts to be a gem of natural conservation. In less than 4 days there, I conquered the summits of two most subliminal peaks I’d been dreaming to ascend, Table Mountain (bucket list item) and Lion’s Head. The former actually forms a feature known as the twelve apostles when viewed from the sea- quite spectacular really. We also visited the point where the Indian Ocean joins the Atlantic, Cape Point in a national park where you could find ostriches and baboons roaming freely, and stopped by a penguin beach further along. Lion's Head
The grand TABLE
On top of that, Cape Town set the scene for a most unique family reunion, regrouping cousins from Germany, Mauritius and England as well as a long lost friend, Kushroo, whom I reconnected with in Cape Town itself. The city has a cosmopolitan mix of cultures, ranging from Xhosa tribal to Malay (Indonesian actually) to Israeli to a bit of everything, with a strong Dutch and German influence from its significant white population, making it a really colourful and rich city in many ways. Add to that the football fever that reigned supreme, you’d get all the ingredients necessary for the perfect city break. And it was.
A global reunion
SA beat France in public
It began in the most Wow-ing style with the live game of the South African Bafana Bafanas against France, being projected live on giant screen along the waterfront. I’ve never seen such an electric display of football frenzy before. Despite only having the remotest chance of qualifying at that stage, the yellow sea of South Africans didn’t let that get in the way of a good show, only heightened by the ever-sounding Vuvuzelas! Love it or hate it, the added decibels do transform an audience, literally. But if you love it, like I did, then the added spectator joy can only be measured on the Celsius fever grade!! As of now, it became almost a rule to watch all the games on public giant screens, except, of course, for the one we’d be watching at palpable distance from the players LIVE IN GREENPOINT STADIUM: Cameroun vs Netherlands! I will, no doubt, fail to convey the atmosphere of such an event in words for you, but just let it be known that watching a live game at a world cup, especially when it is the first one staged on African soil while I’m based there, is another of these experiences of a lifetime that I’ve now drawn a big tick next to! Seeing the Dutch orange invasion at close hand alone, especially when it undulates along a Hola! (Mexican wave), was worth making the displacement from Malawi for. And the flags, including those of so many countries having not even qualified, including Mauritius’, brought with them a sense of international unity I’ve not witnessed elsewhere. Indeed, forgive my callousness to my English readers, even the Germans were happily sharing jokes and drinks and hugs with us on the streets and pubs after the game. The way stadium floor would come alive even as the ball came close to 18yard box, let alone when it crossed the goal line, is a feeling that could only be matched by the splitting roar of the Vuvuzelas accompanying it in the air. In other words, you had to be there to begin to fathom what it was like!
Thus, one week of dizzying football fever has left its indelible mark on my African passage. One month if you include the ripples emitted throughout Africa, not least Malawi. Its presence for me has been omnipresent, from Malawi, through Mozambique and Zimbabwe to its core, South Africa. By way of illustration, I was even able to verify the scores of the matches I’d missed while on the coach with the immigration officer who recognised me on the way back in Mozambique. Only a week left to go, and already you can feel a vibration in the air, an anticipation of a greater African celebration. This time, it is African in the wider sense. The excitement of the entire African continent behind their sole representative left, Ghana, is, in one word, captivating. Okay two: addictive! Go on Black Stars!

No comparison

2010-06-29T04:48:00.000-07:00

Travelling african style
Any pretension I may have held about being hardcore in my travelling, based on previous journeys, has been turned on its head after my latest flirtation with the African road. “African” I say without fear of over-generalising as the latest epic took 4 countries in its stride: Malawi, Mozambique, Zimbabwe and South Africa. 30 hours each way to use the typical term for distance measurement here, and that comprises a generous chunk for the sole purpose of negotiating border bureaucracies- or should I say idiosyncrasies! For those of you who still perceive distance in kilometres, then the grand figure of 1500 each way would be a rough ballpark figure!
Unwittingly, I started the journey with a self-inflicted hangover following England’s disappointing game with Algeria the night before. At 8.30am in Blantyre, a strange combination of moths (taking cover from the daylight), flies (trapped inside the bus and trying to escape), mosquitoes (from the nearby ditch) and butterflies (in my tummy, in apprehension of this unknown factor ahead) marked the start of this trip. An hour and a half later, after all procrastinations were done with, we were finally en route. I got a nice seat at the front and was pleased to have a friendly neighbour. Hardly 10minutes into the ride came my first and most dreaded challenge- the bus music/noise. Pure wailing Malawian gospel, absolutely identical, even the videos, which were being projected on a screen at the front. Unfortunately, changing seats so that I would be farther away from the epicentre of this cacophony was not an option, since each seat was specially endowed with its own speakers, with no individual volume or ‘off’ switch. Competitive inhibition was the only solution as of now, meaning that I would have to rely on my personal music to be blasted loud enough by my earphones to override the surrounding music. Every now and again, even through this, I could hear the bus noise and even worse, a certain high pitched beeping which could go on for an indeterminate length of time. At first I thought the sound system was defective, as is often the case in Malawi and that I would simply have to brace myself and suffer. But then I found out this was a speeding alarm, which indicated to the driver that he was going over 110 Kmph. Despite liking the idea in its concept, I was all too aware that, to the Malawian driver, such a deterrent would be as useful as Chambo steak to an edentulous! Noise encourages Malawians on the contrary! But prolonged exposure to an insult can ultimately condition one to it, and insofar as I can be conditioned to noise, I was. I sat at the back nonetheless on the way back, swapping toilet for beep, but still had a nice neighbour!

In Mozambique
Another unexpected inconvenience along the way turned out to be a mal-functioning AC or one cranked up sadistiscally by the driver, on pretence that it would keep him awake. I couldn’t argue with that one! This kept the entire bus shiveringly awake on the way down. On the way back though, probably from the aforementioned overuse, AC did not function at all and sweaty came to replace cold and dry. All the same, the latter was more comfortable as one can always open the air hatches.
Our first border crossing would be that between Malawi and Mozambique at the Mwanza/Tete immigration point. That was the scene for one great big- and expensive- surprise to me. My Mauritian passport would be categorically declined. Indeed I ought to consider myself lucky not to have ended up behind bars, as having two passports is considered illegal here. So I was forced to go on my British passport, which attracted the plump sum of ~$25 each way. Might not seem so much, but in the context of VSO wages, you will see that the cumulative effect of those payments (4 times in total only for transit visas) amounted to roughly what I had saved by opting for the road instead of simply flying down to South Africa. All this for that glamorous passport which I had to wait 12 years to get in England and which I’ve never had to use in Europe! To think that the Mauritian passport used to be my worst nightmare whenever it came to travelling in Europe, thanks to the ultimo of travel deterrents- Schengen Visa- , and now it’s that same passport I wish I had entered Malawi with! Too late. But I’ll be philosophical about it. I might have lost out in this situation (from oversight mostly) but in all fairness, I don’t think any European/Muzungu is in the right to moan about being imposed this charge. Not even at the slowness of processing the visa in actual fact. My bitter experience in Europe has had one single positive effect, which is to give me the opportunity to compare the way an African is treated by the usual European immigration system with the converse scenario. To get a Schengen visa in the past, I had normally to apply to the country’s embassy which I would be visiting first, at least a month in advance. This would have to be done over the phone at the premium rate of £1-£1.50 per minute, each call lasting around 2ominutes. During this call, it would be highly advisable for you to have your detailed agenda at the ready, where you have minimised any commitments for the ensuing month, as the time and date you are allocated are purely random. If you happen to be busy on the date given to you, then you have to keep the call ticking till a more acceptable one is offered you. Once you have the appointment, you have to also make the travel to the single place in England or Scotland (even though they can turn you down if you’re based in England, albeit next to the Scottish border) where they process these visas, early enough in the morning, so as not to miss your chance. There are usually loads of people there on the same desperate mission as you. I remember once queuing outside the French consulate in London from 5am, only to get to the counter at 10am. Once you’ve tackled this appointment hurdle, comes the more thorny issue- the right documents. Not only do you have to produce a return ticket (with no guarantee of even being allowed to travel) but you need a formal invitation letter from the town hall office of your host, or a hotel reservation. This invitation letter usually takes your host about a month to process, at least 2 trips to that office and 30Euro at least. Consider yourself lucky to have got those, you also need a travel insurance, a letter from your employer (job contracts don’t count) and proof of finances (bank statements don’t count). Financially, excluding your plane ticket, the whole process can set you back £150-£250. Damn that £1 Ryanair fare! Meanwhile, in Mozambique/Zimbabwe/Malawi, despite the greater threat historically posed by a European on these soils, it took us less than 1 hour to have the whole lot done and an upfront payment of $20- $30 (~£15- £20). On one occasion, it did take 2 hours but that’s because the English traveller ahead of me was visibly infuriated by the process and decided to get confrontational with the immigration officer. Consequently, everyone with a foreign passport was punished.
Border crossings constituted one dreary, heart-sinking moment of the bus journey. Each crossing required a visit to both countries’ immigration offices to have your passport stamped. Leaving was usually swifter than entering a country, naturally! Except, of course, if one of your fellow passengers decided to overstay his keep in the exiting country. Dealing with this situation is very crafty. Bribes are eminently du jour and they are not negotiated in any direct way at all. There’s no asking price here. The offender simply leaves a note in a page in his passport. The officer actively searches the passport for it, and if discontent with the amount presented, grumpily hands the passport back. A few minutes later, the offender, after having scrounged for some extra dosh, presents the cash in a similar way, and this strange bargain can go on a number of times until the passport is finally cleared or singularly dismissed. Somehow, in the latter case, the offending individual then simply vanishes into ether and the bus decides to leave him/her behind. Next thing you know, maybe 5Km or even 50Km into the next country, the person will reappear at some road junction and hop back on the bus. This s/he might not be allowed to do, in which case they will appear at the final station, again inexplicably, and collect their luggage there! The most remarkable example for me was a woman who sneaked past the Zimbabwe/South Africa border with her baby and was refused back on the bus, but somehow beat us to it at the terminus!
My experience of the borders was nowhere near as exciting but worth a mention. When leaving Malawi, one is allowed a maximum of Mk3000 and I had around 6000. So I had to spend the excess (in fact more like the whole lot) on wooden artefacts around there, only to find myself burdened with this extra weight, which I intended to leave with the Mauritian connection in South Africa.
One way bridge
Going through Mozambique, an additional delay declared itself, in the form of a single lane crossing across what is apparently the longest bridge in Africa- not the widest that’s sure! If you happen to be that first person to be held back after a batch has been let through, then I’m afraid you might as well take a little nap or get your Sudoku out. They rotate hourly here!
We're in Zim
In Zimbabwe, the immigration officers were exceptionally efficient and, on a personal basis, not adverse to foreigners at all. However, the intimidating presence of Robert Mugabe was distinctly manifest in the picture frame hanging behind them on the wall. That man decided that British travellers ought to pay the same numerical amount as others (Europeans/ Americans) except that the amount would be in pounds rather than dollars! Once again, I shot myself in the foot by using my British passport. There was also a strange incident of a stranded bag hanging on a tree outside the immigration office, that left all of us somewhat insecure. The bag -lady’s handbag- looked like it might have been left there deliberately, possibly to lure curious fingers hence, warranting an arrest, or, heaven forbid, waiting to tick down to a boom! At the South African border, my luggage got searched along with a number of other passengers’. Interestingly, I was made to go and register my wooden curios, while the guy next to me had all varieties of fish and vegetables stuffed neatly between his trousers and shirts and sailed through! The way back across the borders blended into a fuzzy dream for me, having exhausted myself to the limit in South Africa. All I remember was that the Mozambican immigration guy recognised me as the ‘Mauritius one’ and, on the other side, I (unethically!) used my status of (male) doctor needing to get back to work, to speed my baggage check through so I didn’t have to wait for all the luggage on the bus to be individually checked until we got to mine. This is what normally constitutes the longest delay in the whole return trip and I was in no mood for it. Malawians are renowned for their ability to shop till the last mm2, for absolute nothings most of the time, when travelling back (a bit like Mauritians used to do in the past/?still). I made a list of such improbable items crowding the interior of the bus and racks: large crisp packets, large pop bottles, oranges, bags, oil, biscuits etc.. I decided to alight here rather and make my own way back on Malawian public transport. This, I delayed till the next morning as a very important appointment was also waiting for me in Mwanza just as I cleared customs- the Germany v England game.
More on the South African world cup next....

About Malawi

2010-06-15T02:27:00.000-07:00

The anticlimax set in rather quickly following Janet’s departure 3 weeks ago, her last week culminating in a crowning finale as we got to watch Lucius Banda in concert (second time for me) right next door to Ntcheu, i.e. his home town Balaka! This was made even more symbolic by the fact that most of our roadtrip had been animated almost entirely by him singing on the only player we had in the car- a cassette player, with the only cassettes available to buy here being local Malawian or Zambian music. It would be unfair to isolate lack of choice as the reason for listening to him though, as he is really good. Interestingly, he is also running for president it seems. Unfortunately, his party aren’t really showing much of an interest, while the current president has brutally sidelined him in response to a song on his latest album, where he indulges in a rather defamatory soliloquy on the president’s unpopular politics. Hence not only does the album get banned from airing on Malawian radio, but the entire artist’s work. To his relief, that doesn’t stop him being played all day (and night) all over Malawi on CD (...and tape)!
That sets the scene nicely for me to talk a little about politics for the first time here. Yes, it takes less than a week here to crack that one, but has taken 4 months to put in words. We have what is officially a democratically elected president in multi-party style election. Except that around the time of the elections, he, Bingu wa Mutharika, has quasi-monopoly of the media and the country’s resources. He is in his second term now, and won the last elections in December with an overwhelming majority. Since then, he has imposed himself in somewhat more of a dominant style and has been pushing for some changes that never really seemed to have any public consent. For one he is planning on changing the Malawian flag to one that suits his own eccentric taste- a move that will cost a small fortune to the economy, without any economic benefit as far as anyone can see it. Rumour has it the flags are already here in containers, while awaiting for the final bill to be passed. Secondly, as in many African countries, the president tends to affirm his authority by displaying pictures of him looking imposing in every office in every town. He is also on billboards everywhere boasting about some achievement or other. Whether this serves as a reminder to everyone that he is there watching you or mere propaganda I can’t tell. But what I can predict is that soon these pictures (must number thousands) will all have to be taken down and replaced with new ones, because, he has just been awarded some dubious professorship in China. He now boasts the title of Prof in front of the already present, Ngwazi Right Honorable President Dr... Ngwazi in fact being an appellation the former leader/dictator Dr Hastings Banda used to connect himself more to his people. Bingu now likes to compare himself with this still very popular past leader (remembered by many guide books for banning long hair for men, or skirts for women, or worse even the song Cecilia from S&G!). Bingu, of course, is also famous for the latest gay marriage saga that even made it to the European news. In a 180 move, highly likely to have been motivated by a strong pressure from the UN chief, Bingu pardoned the gay couple, who a week later had been sentenced to the severest possible term- 14 years IHL. The ensuing week, he declared publicly that for such “evil acts”, the law rightly punishes but God forgives! Speaking of marriage, Bingu too made the news this year at the grand age of 75, when he decided to get engaged on Valentine’s day and remarried in April. He hosted a royal banquet, paid by the state of course, with more than 5000 guests, and turned up in a flashing new Limo. All the papers had messages for each of the two events posted in them for the happy couple, most of them being from government offices and parastatals! The TV channel at that time, played similar reels of repetitive messages as much as they did actual programmes. Meanwhile, special glossy magazines were printed and distributed to remind people (in case they lived under a massive rock that only allowed glossy mags in) of that holy union. Let me not get too carried away with this bleak analysis because I might get expelled from the country soon. In his defence though, from talking to a few Malawian friends, a lot of positive changes have been made since Bingu’s arrival (“his predecessor was essentially a shameless thief who would even circulate counterfeit money in the country”), especially the quality of the roads. But when you ride a motorcade of 15 shiny 4x4s everytime you travel, if you’re not in your state-purchased private jet, you want your ride to be a smooth one!
Besides politics, one other item that’s featured prominently on the agenda here has been football. Of course there’s the world cup, but personally, I’ve also managed to join the hospital team lately and am finally back to weekly matches. Last time I was doing that goes back to more than 10 years ago and it feels great. As for the world cup, I shall save that for the next time, when I have fresh news from the hosting nation itself. Pepani!

Roadtrip / honeymoon

2010-06-03T03:16:00.000-07:00

This week we took to the Malawian roads. This was also the first time I got to properly drive around Malawi (omitting that sedate and carpeted drive from when I picked Janet up from the airport). This time we had an altogether different mix of terrain, landscape and weather. I think this must be the longest drive I’ve ever done in my life, taking in at least a half of Malawi’s vertical diameter and combining high alpine plateaux with basking lakeshore escapes! Each day in this last week has been so rich in stimuli, interactions and discoveries that an individual page is what’s really needed for each. We shall endeavour to relate them to you each as a paragraph instead, which is going to be no mean feat.

Lilongwe Market
This will surely qualify as the first leg of our epic odyssey, even though Lilongwe was only intended as a practical stopover before springing up North. The decision to go and explore the market came almost naturally as we finished our overwhelming supermarket raid to stock up for the journey and felt in need of an antidote. Even though I’d already explored this market twice before, I never tire of going back there to be completely captured by the buzz of human activity and the profusion of colours, smells and sights. A kick to the senses really. From the meticulously stacked displays of fruits and vegetables at one end to completely dispersed messes of clothes and paraphernalia, we meandered along countless aisles, which revealed the true expanse of this deceivingly enormous market. The skill of bargaining quickly turns into an art here, and to any poker enthusiast I strongly recommend a visit sometime. Not even getting your shoes shined comes without some element of it! Having negotiated that little exchange, we proceeded to a systematic exploration of the specialist sections of the market and that took us along the traditional medicine quarters (be aware that taking photos on the sly might set you back a good few Kwachas!), the food “pavilion” where not a single part of an animal gets wasted except for bone maybe (by that of course I mean the inedible cortical part, not the marrow!.. and then again, I stare at my necklace pendant wondering which bone went into making it!), the tailoring&repairs, the kitchenware, the hardware and the megaphone-animated flea market style clothes areas. The market is such a beautifully organised mess that it is bound to lure you back any time you’re in Lilongwe. All the more so if you have a sense of adventure and decide to cross the flimsily erected paying bridges across the river that divides it in two (surprisingly it was not us getting paid for risking our lives on it but the astute architects of these totally uninspiring pontoons).

Donija Nkhoma

On Sunday, we did our first drive section to a community project called the Donija Nkhoma village. Thanks to my expert co-pilot, we experienced our first emotional moment when, at 110Km remaining to the destination, I was informed it was only 11Km away. Imagine my joy (read heartsink¬) after I discovered the stranded zero! Donija Project is essentially a close up look into the way traditional Malawian communities are organised, by staying and eating with them in their houses in the village. We had a fascinating guided tour around the different nuclei of the village to see how all these things come together- the nsima, the mudbrick or wooden houses, the ingenuous water supply and the wicker pens for cattle and corn. We also visited a fishpool constructed by the villagers miles away from the nearest lake, and learnt about the role of cattle as dowry! We were treated to a true delight of a traditional dance, where the women could best be described as yodelling, while the chief dancer gyrated and shook in his soft-drink-bottle-metal-cap-studded outfit at a speed my eyes could not fix. The sound was an eclectic bojangle beat.

Vwaza Marsh

After a very comfortable hospitality with some VSO friends in Rumphi (amazing food, courtesy of Marianne!), Vwaza was our next stop and first taste of a nature reserve. The road north form Rumphi becomes a dirt road for 100s of miles further, and really tested the car and Ash! The car resembled a pile of red dust by the end of this portion of the route and amazingly still has all its bits attached (which goes for us too!). Its original blue also proved to be the perfect lure for the millions of Tse-Tse flies colonising the marsh, which would come tick-ticking loudly at the windows in desperation for some human blood. Hence all windows up in the stifling afternoon heat while we attempted a mini-drive safari of the place.
Vwaza is a marsh surrounding a lake, where we stayed in a wooden hut on sticks, overlooking the lake. We were treated to the amazing sites of the park and got within arse-slapping distance of elephants (which Ash was very suspicious of their potential as man squashers [thanks to Janet’s white bait of a shirt!], though luckily we escaped unscathed). Also on the tick list numbered an entire herd of impalas, bushbucks, kudus, baboons, hippos and so many birds I couldn’t begin to name them (but there was a wicked Ibis couple in there).
A cook was at our service that evening, who conjured up some wonders out of our very sophisticated tinned offerings. As the night, its silence and crazy sounds closed in around us, we enjoyed the delight that be our candle-lit hut in total outside darkness and the sweet hiss of Malawi Gin with sprite.

Nyika Plateau- nature walk
Nyika rightly deserves the title of our ‘piece de resistance’ for this trip. It was, after all, the ultimate destination around which we constructed this sumptuous itinerary. Nyika is Malawi’s first and largest National Park, most parts of which are still inaccessible today, but to the most diligent and researched explorer. The motor-able route up put our dare-devil off-roading in Vwaza to shame, with the car threatening to skid off the road at least twice and forcing a maximum speed of 40Kmph on us.

Once you get to the plateau, you are immediately enveloped by a magical feeling of escaping to another world. In all truth, for Ash, it strictly represented the first time since in Malawi, where he felt altogether free from noise (Vwaza was a close contender, except that, of all days, ours was when the village gathered for a very rare mourning ritual on the edge of the park). In Nyika however, there prevails that silence which magnifies every other natural sound to its absolute sweetest (little wood insects, rustling leaves, water streaming etc). The setting is one akin to the highlands of Scotland, with one slight difference: inamongst the bracken (and seasonal orchids), there’d lay a herd of zebras (my favourite) or bucks or Roan antelopes staring at you with that quizzical face that says “friend or foe?!”. We managed to get close to the animals (including an elusive scrub hare just for Ash) on the first afternoon with the help of a local (black) guide by the name of White. It was an absolute treat to be able to not just see but also learn about so many species of animals, birds (herons, buzzards, bustards, cisticolas etc) and plants in one single day. And that made our day. Or maybe was it the delicious concoction created by our dedicated chalet keeper-cum-chef, Moses, who performed what can only be described as alchemy on the sweaty ingredients we’d be dragging along from Lilongwe. In this season, at this altitude (2000m), even in Malawi it gets pretty chilly. What better way to feel smug then than by a local firewood fireside with some more of that Malawian gin and real tonic before hitting a perfectly manicured bed...

Nyika Plateau- cycle ride/ village walk
Day 2 up Nyika was pedal powered along a myriad of paths and viewpoints onto vistas of the order only gleaned at on 'Planet Earth' or the like on TV. My position as the pack leader entitled me to the honour of approaching the animals first along the trip, often seconds only before they would rush back t o “security”, away from my trailing bike partners. White was again very useful in his local insight, even though that did not suffice to bring out the elands for us. Having exhausted ourselves to smithereens, we opted for the lazy stroll in the afternoon, which took us to the well kept secret that be the workers’ village on the plateau. That proved to be a great cultural extra (which we’re always keen on here) and also such excitements as crossing a derelict wooden bridge and balancing our bodyweights on some felled pine trunks near our chalet. This you need to picture as an amazing cabin warmed by an enormous central hearth and almost fully wood fuelled, including hot water (delight!)! Large windows let in plenty of light and gave us views out into the dense conifers to the back and into the small valley with its dams in front of us. As you guessed, dinner was consumed by the warm fireside, as prepared by Moses, and this time he managed to make us some bread and a perfect stir fry out of the fresh ingredients he sampled from a high up garden.
For two days, Nyika produced what would be best described as a little piece of heaven for us.

Nkhata Bay
From alpine silence and cool to humid lake-bound bustle, the transition could not have been starker. But then again a Malawian road trip wouldn’t be complete without including at least one stop at the lake. As it is clear to me by now, each bit of the lake has got its own personal character and charm. Far from the tranquil repose of Mangochi, or the posh resort of Cape Mcclear, Nkhata bay’s distinct appeal lies in its cliff-perched villas flanked by lush green wilderness. Once you’ve eliminated the thought that crocodiles might lurk somewhere in that water, it becomes one of the best for snorkelling haunts I’ve seen so far. You can really get close to those cyclet fish (which are unique for the propensity at evolution and rapid selection) and swim long distances without having to worry about tides or currents. If you’re lucky you’ll find a parked boat which you can climb and dive from... Simply ecstatic!

Senga Bay
In search of a more sandy version of the Lakeshore, the next day found us trekking another 350Km or so to Senga Bay, which is otherwise known as the capital’s swimming pool. This is where all these executives and short stay tourists rush to for a quick chance to immerse into Malawi’s biggest gem. However, partly owing to my state of sheer exhaustion and partly from a less than optimal choice of lakeside to stay at, Senga Bay will probably not remain etched in our hearts and minds as the preceding 6 days will. As for tranquillity, it certainly surpassed our expectations and we were glad to have a peaceful last night of a truly amazing holiday, recapping and recharging our batteries.

Lilongwe to Ntcheu- Public Transport2
Taking hitch hikers en route had become customary for us by now and the last leg of our journey was no exception. It was a reluctant reminder to us that our time of enjoying this luxury (lift offering) was also coming close to an end. The keys of the hired car would be handed over soon and we would become the ones either hitching or screeching and squeezing aboard a bus back to Ntcheu. This was precisely what happened after we managed to dodge past the horde of would-be porters to our bus. There we sat relieved that the bus was already full and ready to depart. Or so we thought. I was sat on the engine box at the front (my backside being guarded from smothering to an ash [!!] merely by an aptly placed wet towel from the morning’s swim!) and Janet on the steps. In the next 10 minutes the bus managed to fit another 10 or so passengers and within 10 miles of Lilongwe, it made this unexpected stop, where one person boarded together with their life’s belongings, followed, to our disbelief, by another, and another... until a miraculous 15 other passengers (less kids) found a space to stand somewhere aboard this bus. I don’t know how we managed to breathe after that. I think that if a preacher had joined us at this time, I would have stood up and preached back something about existentialism or some unintelligible metaphysical subject just to get it off my chest. Thankfully, the drive was quick, the music not deafening (thanks to my premier position next to the driver, hence controls) and the sun-setting scenery over the mountains of Dedza and Ntcheu an absolute treat for at least two exhausted contemplators.

1st week in Ntcheu... together

2010-05-24T02:07:00.000-07:00

Today I will add a twist to this latest entry as I have in my company a guest appearance by the name of Janeti! She will hopefully confirm such concepts as the “sound of Ntcheu” and “public transport” for you here but also provide a very fresh insight into life and work in Ntcheu, with her original views.
So here I am, and I has perfectly become we again, which is just great! We are sitting here together eating Lilongwe strawberries from today’s tour around the city’s market, in the best room in the VSO guesthouse. We’re preparing for our epic trip to the North which starts tomorrow, after a lot of organising from the well connected and diligent husband. So to take things backwards first, perhaps you all might like to know the other half of the Doorgakant’s impressions of Malawi...
It’s fairly impossible to know where to start, and even when you do start you can only make crazy generalisations anyway, so I’ll keep to the facts- I arrived in Lilongwe after a long but smooth flight via Addis Ababa, most of which I slept through after hauling an unfeasible amount of luggage down to London and then optimistically turning up with it all at Heathrow, only to be relieved of a significant portion of it at the gate (thanks Saj!), allowing the plane to actually take-off. It seems I’m not yet Mauritian enough to be able to get all I intend on a plane!

The happiest and most brilliant bit yet then came being reunited with the husband in the airport- you can all picture him there I’m sure, standing out in his brown felt hat! You’ll all be pleased to know that he’s the same as ever- full of energy, life and enthusiasm, but with one significant change, which I’ll leave you to ponder...and challenge you to spot on proceeding photos. (something quite bizarre, that I can’t explain- he puts it down to the washout of accumulated e-numbers and oestrogenated tap water from the UK!)

Back then to Ntcheu after reuniting my tastebuds with Nsima. It’s a long town based around a main road. I’ve seen the infamous Uncle B’s, I’ve climbed up the Mt. Ntcheu telephone mast (battling [psychological] heatstroke), heard the dog chorus, admitted that ‘yes’ there is quite a lot of noise pollution in Ntcheu, tasted the homemade marmalade, and loved meeting some of the great people already mentioned in this blog.
Briefly, to stop this being a complete epic (there are other things to do than write blogs on a Saturday night!) I’ve enjoyed seeing a little of how the lab works in the hospital, after very kindly being allowed to spend most of last week shadowing the work there. There is a main multidisciplinary lab for malaria films, FBC, some biochemical tests (depending on reagent availability- also less U&Es) CD4 counts, and then a micro lab which mainly can deal with CSFs and TB smears. One of the main challenges has been dealing with Dr Ashtin’s varied output ranging from specimens in contravention of the lab acceptance policy, to trying to get samosas through the door (also against the rules of the labarotory). In only 4 days it’s really opened my eyes to the realities of work here, and I’ve also been very impressed by the standard of the staff. I’ve also made media, which is something never really done in labs in the UK now, so a good education for me. I could write very much more, and will talk very much more, but for now back to this blog’s real author.

In case you’re already conducting an internet search to find out which newspaper or TV programme my illustrious wife has appeared on, let me clarify that by media she meant this funny plastic dish full of microbes, which gets microbiologists all excited for some reason! Never made my life easier as an orthopod because the next thing is usually a diatribe of Latin and Chinese to tell us that we need to use the antibiotics we were intending to use anyway. In any case, Ntcheu only has 3 or 4 on offer!
Also to get back to the Samosa event, let me just add that after spending your lunch hour doing your second operation of the day (the first one having been a killer in its own rights), namely a hydrocoelectomy turned Orchidectomy because the booking clinician had no clue about testicles, the very thought of even thinking of sharing the only bit of food you could lay your hands on before rushing back to theatre ought to be met with better gratitude... even if the offering was made on the threshold of a microbiology lab! At least it was not inside the lab, next to the dissected testicle!
Anyway, you’ve heard it from a second source now, Ntcheu rocks, but Ntcheu also needs a certain level of decibel tolerance and Ngoni-style energy. This is the local tribe around here, who really deserve a good few paragraphs of their own. Let’s just say for now that late night partying and heavy drinking aren’t exactly alien to them. It’s really been great having the wife around to see what’s going on in the hospital too. It surely wasn’t easy to spring into the same familiarity with it all as I have developed in at least 3 months, in less than a week, but she’s done pretty well indeed. She even knows more than me about what tests can be done here now and is able to give me insider information on how to find out when they’re available!
I won’t dwell too long on this first duo-blog because there’s a big trip ahead of us, which stills needs quite a lot of fine tuning doing on the organisation. One of the good things about being in Malawi though is that last minute planning tends to be the norm. Somehow or the other things just work out... I hear Bob Marley’s lyrics... but is it me musing or is it the Lilongwe Uncle B launched for the night!?

Clinical Digest 6

2010-05-12T03:51:00.000-07:00

Another 3 weeks gone in the hospital and so many new surgical adventures to recount. The nature of operating has not exactly changed, in that it is still mostly salvage surgery, but a few items have been added to the repertory. One of them is split skin grafting. Since I got to Ntcheu I kept hearing that we had the kit for it but I was yet to put it to the test. I judiciously chose a small case to be my first one. The surgery was uneventful, although remarkably slow, owing to some issues with positioning and kit. The knife in question is a donation from a very enterprising Dutch doctor who pioneered this new model based on its resemblance to the “Schick” razor and even uses the blades for it. Only drawback is that it only allows you to harvest tiny grafts which you then knit together on the wound. As it is, the wound on our patient in question was right over his Tendo Achilles and the anaesthetist was not happy doing him prone. So I kind of got him supine with a figure of 4 crossleg, which made the actual job of the final stitching tediously slow. It’s a question of time now to find out if it takes or not.
My level of amputation has also progressed and I now count a below elbow amputation in my logbook. One must wonder whether all this is really necessary or whether we could just debride radically and wait. Well that’s precisely what we were doing at first and discovered we were being too conservative and had to take patients back. Just to contradict this pattern, then came a case of a grossly septic leg which we were very close to performing a through knee amputation on but had to hold back as the patient refused surgery at the last minute. What ensued was rather enlightening. To my consternation, this leg which I had, by now, consigned to an irrevocably doomed fate, started to get better with stringent wound care alone. That threw me back to the original question of “to chop or not to chop”. I guess that there will always be cases, especially here, which behave differently from the norm. The actual protocol of practice however, should, I believe, be based on the average (which time and experience will aid my clinical judgement of) rather than special cases. And indeed, that below elbow amputation was another special case, which I thought was amputated high enough. Yet it gave me reason to worry that it was still infected, ie I hadn’t gone high enough. Thankfully, aggressive wound care sufficed.
By the way, you will have also noticed that we are consenting our patients, but the process is a far cry from our 4 pages of carbon-copy material plus all the other forms in England. The form here resembles more like an 8th of an A4 page with the following signed statement: “ I hereby consent to have an operation on any part of my body as deemed necessary by the surgeon,” or something similar!
The degree of sepsis encountered here is something of a completely different order to that found in the UK. Whether this is explained by the virulence of the pathogens or toxins (as in the few snakebites I’ve already dealt with) or by the time it takes to get to the hospital, or even by the time it takes from admission to get to theatre, or by the stubborn stoicity of the people who have faith it will get better by itself, if not with the assistance of the greatly revered witch doctor (whose involvement is often recognised by the tell-tale abrasion scars on the skin), I can’t really tell for sure, but it is likely to be a combination of many if not all of the above. The management of such sepsis is a real challenge and necessitates intervention on a number of different levels.
My latest case in theatre was a surprise last minute one I only picked up the day before and planned for the end of the 3rd week: an index finger drop. The patient had been severely panga-knifed, sustaining bilateral Tendo Achilles divisions as well as multiple scalp and bilateral forearm wounds. Poor chap (19yr), he looked like he’d just come out of a sarcophagus, with all the bandages around his body! (He was approached by some ruffians who wanted a mobile phone from him, which he didn’t have. So he ended up paying for it in the form of these unwarranted lacerations). The hand on the non-operated hand was afflicted by an ulnar nerve palsy beyond repair. The other hand needed an extensor tendon exploration and repair, which I had only ever assisted in them in the UK but never done one alone. Technically though, there was no reason why I shouldn’t be able to do it. So I approached this case, made more complex from the fact that he had two potential wounds on the dorsum of his hand/wrist where the tendon could have been divided, not to mention the fact that he was almost a week from the time of injury (hence starting to retract). I was quite pleased when I finally freed both lacerated ends of the tendon, although I only had a flimsy silk suture to reapproximate it. My first independent case of reconstructive surgery, provided the best booster at the end of this 3 week stretch I could ever wish for. And now also, my interest in hands has been properly rekindled.
Besides operating in the main theatre, minor theatre has also provided its fair share of excitement in the recent weeks. I embarked upon a poster teaching session forced by some of the practices I had witnessed earlier by the student staff. Hence we drew posters on safe administration of local anaesthetic and the differences between common lumps and bumps (a description which caused hours on end of giggling here). The rules behind the dosing of LA and its limits were completely alien to this staff group who had been administering them liberally for months if not years already. Being low resourced is not an excuse for letting your standards down on such an easy-to-implement concept. As for the lumps and bumps question, we now have a readily accessible chart to differentiate between them. This is been a welcome addition to the trauma room, where hopefully lipomas will now be diagnosed only when they are actually lipomas and not cysts or nodes or pseudoaneurysms anymore! As a real coincidence, that same day, we received a serendipitous casemix to examine in our clinical area: a real lipoma (which was enormous and I only just managed to excise under LA), a ganglion, a scalp sebaceous cyst, a skin tag, a histiocytoma and a pyogenic granuloma! What were the chances of that? What I found with the style of the teaching is that it is very participatory and depending on how it works, I can surely see myself exploring a wealth of topics during the year to come. Next one is already lined up- aseptic handling and sterility. The microbiologist in me, not to mention the one attached to me, could faint at the way some instruments and specimens are handled here!!

Aphiri

2010-05-03T05:57:00.001-07:00

That’s Chichewa for mountains. That was also the fortuitous nickname I earned at the ART course from the Malawian candidates. Pretty fateful, since, now the rainy season is pretty much behind us, more and more unsuspecting people are being dragged up these breathtaking heights with me. The last time was Zomba with Caleb, Corrie (a VSO from Holland), and Claire and Nicole (CNN for simplicity- visiting Dutch medical students, who are a real laugh by the way). This weekend was the second ascent of “Mount Ntcheu Telecom Mast” as I shall name it, for want of an official name. My victim, for the second time in a row, was Caleb and his unpreparedness for this expedition was obvious from his power shirt and the NASA-mission-looking DocMarten type shoes he was wearing (only slightly worse than the ones that crawled up Zomba plateau in - so I thought he’d manage)! In the interest of variation, we chose an alternative descent route, which is what made this time around more memorable. Of course, the ascent involved the same toil of sweaty gradients and tall grass, with inescapable reminders of snakes lurking amidst the thick canopy. After losing his body weight in sweat and CO2 and demanding almost the same amount of time in rest as in actual walking, Caleb unbelievably made it to the top. Once we started our descent, the functional uselessness of those very shoes became apparent. The arch-less insoles, smooth as a baby’s ass caused his whole foot to keep sliding on the downward slope, with his great toe constantly abutting against the tough inside. Oh did it hurt...and slow us down. We were now taking longer for what ought to have been the faster leg. And how things weren’t helped by the fact that, unbeknown to us, this alternative route was some 7-8Km longer than the ascent route!! We found ourselves contouring the foot of the mountain towards another town some 7Km from Ntcheu. (I know of an old hiking partner who’ll spot a few similarities with some big hills once in Scotland!) We were on the flat now with the sun right above our heads, still clueless about the remaining distance to the main road. Our attempts at gauging it from the locals in our broken Chichewa attracted answers ranging from ½ Km to “forever”. So we thought it might be wise to hail a passing vehicle and cut short Caleb’s blatant suffering by now. The first vehicle was an ambulance driving too fast to be safe, which didn’t stop even though I was signalling quite desperately that I am a doctor!!! By the way, ambulances in here are mostly used for staff as opposed to patient transport. We passed on the second option, a pick up truck, with some 30 people sardined in the back, screaming some songs; alcohol-fuelled and football-related we concluded (some things are the same anywhere in the world). We finally met with better luck with our third vehicle, if luck it can be called. It was a relic of a 4x4 with the back loaded up to the top with sacks of potato, atop of which were some 6 opportunistic travellers like us, as well as a bike. Considering the rocki-ness of this dirt road and the local driving style (which is one of my main sources of work in the hospital!), we thought we’d negotiate a place in the front. There was already a passenger there and at a push (literally) it would accommodate another one. Its door was not closing and had to be held closed with some old tyre strips (the favourite strapping material in Malawi). Somehow we set off with 3passengers and a driver in the front, the far-side passenger (myself) hanging on fiercely against the door which my bum was pushing open, with my hand at the top straining feverishly to close the gap! It turned out we were only 3Km away, but given the state he was in, even that would have been too much for Caleb to leg. Thence we caught our final minibus ride home to Ntcheu, in search of food and more food. As it is, getting on a minibus is not something I take too lightly, given its high contribution to the Malawian trauma statistics. The driver is normally subjected to a breath test by me (both ways it stinks, but the alcohol-imbued one a bit more) and the tyres inspected for the adequacy of the treads. Today, despite bypassing all of these checks, it felt like the safest ride home that I’ve ever had....

Written upon Caleb Muchungu's request: VSO Volunteer at Domasi- and slowly becoming a seasoned mountaineer.

D-day -10

2010-04-29T08:52:00.001-07:00

This is one is for my lovely wife, akazi kokongola Janeti!! Today is exactly 10days before she comes down for her first visit and it will also represent a symbolic 3months since I've been in country.
I might have made scant mention of our long-distance relationship till now but it's been a really important aspect of this experience of mine. Janet's support is largely responsible for me remaining upbeat through it all up till now. So a big thanks to you here Janet and I look forward to welcoming you soon to this great adventure/work/personal development...

A Zombie in Zomba

2010-04-26T08:33:00.000-07:00

Caleb and I
Okay.. this time I won’t mention the lake! Too late! I went up to the mountains instead. Zomba plateau to be precise and immediately after heading down to Blantyre first on the Friday and waking up super early the next morning for my lift to the base town- hence the zombie state! The route to Blantyre was in honour of my educational meeting at CURE hospital for the complex cases discussion from Ntcheu. I almost didn’t make it because, en route, my minibus hit some pretty severe weather in the form of a flash storm, where we had a gobsmacking downpour of hail with a visibility of less than 5m, and streets being flooded on both sides. That didn’t stop our driver from keeping going, nor did my constant shouts and pleas from right behind him!
Flash Storm
Zomba is this picturesque mountain city, the old capital of Malawi in fact before Banda relocated it to Lilongwe, with limitless vistas onto the fields around and further onto the lake. The route to the top was essentially a road with few shortcuts off the beaten track. My intention to do the whole thing along a potato path obviously went wrong somewhere, but did nothing to curb my enthusiasm about rising up in altitude. At some 1800m in height, the air feels somewhat fresher and the heart lighter. I really enjoyed being back in that element as evidenced by the pictures. The temptation was there to stay in a hut at the top but unfortunately they had a rallye the same day and all accommodation was booked. So we decided to go back down and in the end that move paid off. I stayed at my mate Caleb’s house in a nearby place called Domasi and it was just the most fitting escape for me, as concerns the nightly drumbeat cadence of Ntcheu. There, I stayed on the veranda, fenced by a fine metal mesh, which kept the mozzies away. It was quite frankly like being under the stars, and what more, without disco noise but the natural roosting and humming and click-clicking of the myriad creatures around. Caleb was in top form and is currently working with the Malawian Institute of Education to enable them to produce some educational videos etc. His interest and knowledge in African current affairs is astounding and these insights are even available in electronic format on the web. Just type in Caleb Muchungu and you’ll be exposed to some real African views rather than the typical whitewashed one we often get.
From Zomba.. with awe
After my fix of altitude and silent night, I made my way back to Ntcheu on the minibus, which was another great incursion into the world of African transport. In other words, never run a tight schedule if that is your chosen mode of locomotion. It waits at every station to try and collect that one extra passenger at the detriment of the available bum space in the already packed vehicle. It slows down at the sight of every potential passenger along the way, to reaccelerate to some wild speeds I wouldn’t do on a British motorway, once it’s figured out that person actually prefers walking to being a passenger of theirs! It then always gets halted at road blocks, where policemen eagerly scan the vehicle for the slightest flaw to impose some fine. And that negotiating can take up to 30min easily. But the fun lies in the witnessing of all this crazy rigmarole and the ample opportunities for conversation with Malawians. Not only is it a great way to get to know the culture better but it’s also an opportunity for you to be an accessible muzungu as opposed to the convential image of a 4x4 barricaded white face in a segregated shopping complex car park, where they sell cheese, chocolate, pizzas and the like. The minibus, in a figurative way, allows people to see there are also tourists/expats who eat nsima and usipa (the local tiny fish from Lake Malawi which I had the priviledge to eat, as prepared by a local Malawian friend of mine according to a traditional recipe- truly succulent I thought.. although my other friends didn’t seem to agree so much). I think I am now starting to see beyond my Bradt guide... and for myself. Oooh Malawi!

Clinical Digest5

2010-04-18T11:35:00.003-07:00

If, by now, you are starting to expect some clinical stories from my new front, you’re right. For I’ve been in Ntcheu for 3 weeks already and have not sent any reports yet. That is partly because I was busy assimilating it all, and working on the contrast there exists between here and Lilongwe, sorely aware of the extreme contrast even this state-of-the-art centre presents next to the UK.
However it has not felt like a gloomy debut at all. There are so many facets of working in this environment that would make Lilongwe blush with envious shame, let alone the UK. For one the people working here are all approachable, all eager to help and all extremely welcoming. Despite there being a significant deficit in knowledge and skills, largely attributable to the resource-stretched training reality here, the affinity to learn on the job is remarkable in so many clinicians. The latter group comprises in order of seniority student medical assistants, student clinical officers, medical assistants, clinical officers, specialist clinical officer, medical interns and doctors.
The clinical highlight of my first week was really ward rounds and clinics, with little theatre work, besides assisting (mostly C-sections and a hernia). Orthopaedically, we did do one knee arthrotomy and washout for the management of a septic knee joint. I also saw some interesting cases of gross mal-union [a harsh reality of ORIF (metal implant)-deprived settings] and deep burns turned necrotic.
The second week saw me finally getting to the knife, performing salvage operations mostly. First of all, I did a below knee amputation (BKA) on a 3yr old for a necrotic snake bite wound on an ankle which had turned completely septic. My main concern about her management came intra-operatively when I discovered some suspicious looking fatty tissue as far up as the knee. I was not prepared to escalate to my first through-knee amputation though, with no guarantee that even that level would be adequate. So a careful decision was made to wait and see how the BKA alone would fare. By the day 10 mark post-op, I have to admit that, to my surprise, encouraging signs of healing were showing. The next operation came in the form of multiple disarticulations required on a man with severe septic eschars on his dominant hand from a burn injury. I did it under a wrist block (my first ever), which was somewhat helped by his HIV associated peripheral neuropathy anyway. In the end, after more tissue had to be resected than originally intended, he was left the best semblance of a hand that he will ever get. Time will only tell if that will survive or he will end up losing even that rudimentary pincer grip we have tried to preserve.
The second week also saw some colourful moments in minor theatre, which is essentially a treatment area, where most wound management is done. Most of it by junior clinicians, often unsupervised. The result of this state of affairs revealed itself to me in a pretty hairy manner, as I unintentionally found myself taking over a few times (at lunchtime as it typically happens) from struggling clinicians, completely out of depths. Firstly there was an excision of a dorsal wrist ganglion misdiagnosed as the universal lipoma! An unmounted blade was the instrument of choice for plane dissection and a big question mark on the clinician’s face, the method of choice to dissecting it out! Another case was the excision of an actual lipoma (correct diagnosis for once, even though they were unable to distinguish it clinically from a pseudo-aneurysm), over the radial artery territory. It came out very satisfactorily as a whole and so was the ultimate state of the radial artery. Finally, the scariest bail out of all was for a “lipoma” dangerously close to the femoral artery which the clinician was blindly pecking away at. This is a case I would of course have chosen to do under GA/Spinal in majors. But here I was using a tiny incision, to limit the damage done and resect as much of a pus filled lymph node (?TB) as was actually possible. The femoral lived on... by a very close margin!
Week two ended on an especially convened clinical meeting, at my request (excepting the timing), on the Saturday morning. This is a quality control exercise which is very laudable in its concept, the effectiveness of which remains to be seen. It should normally be conducted monthly but often months can go by without one. Most pertinently, it is a hospital-wide clinician reunion, where issues are raised by everyone on their own or their department’s behalf. The size of the institution in Ntcheu is really what allows for such an exceptionally democratic and wide-ranging meeting to take place. We discussed myriad issues relating to hospital organisation and the dichotomy between volunteers and locals was again starkly drawn out. Whereas we were banging on about issues of accountability, initiative and quality control, many of the points raised by the locals pertained to remuneration, satellite TV subscriptions and free diagnostic kits! Thankfully, the chair, a local Malawian doctor, was very impartial and did pick out priority issues for the main agenda and left “social” ones to be discussed as AOBs (any other business). I left with an overall satisfied feeling and a great urge to put our resolutions into practice.
Last week (week3), was when things really started to come together a bit more neatly. This was in part helped by competing operators being away at a training (ETAT- emergency triage assessment and treatment of under-5s). I therefore managed to get into theatre a bit more and to get to grips with the booking process and how to expedite work. My two main operations were both on hands for, you guessed it, necrotic wounds. With a slight difference, the first one was not a burn wound but a infection secondary to a foreign body. It’s worth remembering that tetanus is a real danger here and can kill pretty quickly too. This patient was not such a case but his middle finger needed amputating. With poorly functioning tourniquets and less-than-optimal lighting, ligation of tiny bleeders can be one serious challenge here. We had to leave the stump to heal by secondary intention and it will be quite a new experience to see the natural progression of such management on the ward in days to come. The second operation was almost a carbon-copy of the previous multiple disarticulation mentioned. This guy was not as lucky though and was left with only his thumb, which itself is unlikely to survive. We’ll be preparing for a definite below elbow amputation next week, rather than allow the infection to spread more proximally. The wards meanwhile, were being populated with an increasing number of people on traction for a number of different diagnoses. We had tibial skeletal traction for a couple of femoral shaft fractures (treated with skin traction in children), skin traction for femoral neck fractures and an amazing case of 900/900 traction through the tibia in a 60 yr old man with a femoral fracture but bilateral knee and hip contractures and shortening, secondary to multiple bony epiphysiodeses. What I particularly enjoyed was giving instructions to the elderly patients in skin traction regarding, regular exercises to avoid DVTs, as low molecular weight heparins are something of a distant dream in Ntcheu. The week was concluded by an educational visit to CURE hospital in Blantyre, which proved to be so useful and insightful that I’m going to be making of this a regular occurrence, with huge benefits for my patients.