Clinical Digest8

Orthopaedics in Malawi
My non-medical audience might just want to turn away for this one. But if medical jargon’s your thing, then please stay on! The week just gone has seen an escalation of my orthopaedic activity like none since I arrived in Malawi. I organised an exchange week at another district hospital up North, Rumphi, to coincide with another (more fruitful) surgical visit by Steve Mannion and the Feet First team (Bernie, Danni, Clive and James as well as Steve's wife, Mercy). Having beat them to the place, I had an entire morning to shadow the OCO (orthopaedic clinical officer) on his Monday clinic and ward round. Then I got given a full tour of the relevant departments, such as Xray, minor theatre, physio and the appliances workshop. That proved to be one of the most useful parts of my exchange, by putting a better perspective on things in the Malawian health care system and also questioning some of the assumptions I came to while in Ntcheu. I now know that a lot of our deficiencies which I had formerly attributed to stretched resources aren’t necessarily so: there is at least another district hospital, with the same resources, which is managing to function in these areas. Of course it’s not like UK, but it struck me as a fantastically well run department, given the available resources. The main one of these unfortunately is unique to Rumphi and that is the OCO himself, Mr Mwalanda. Along with a non-clinical assistant alone, he manages to get through more than both OCOs at Ntcheu can do. Still I believe (and hope) that, given the right motivation and organisation, we too can match this productivity even after I’ve left. My job is to find ways of instilling this great drive that, of his own admission, has led Steve Mannion to choose Rumphi as his main operating base in Malawi, into Ntcheu.
So the real medical onslaught began as soon as he, Steve M, landed there on Monday afternoon and tackled a clinic of some 30 collected complex cases to try and devise a feasible theatre list over the next 2 days. Being able to talk through the diagnostic process and management rationale with him allowed me to take on board concepts and skills that I’d only partially assimilated till now (try and explain the intricate relations between hindfoot and midfoot biomechanics to a pre-SpR Orthopod and you’ll get an idea of the level of masochism involved in learning it for oneself!)At the end, it was rather dumbfounding how we managed to get through so many cases in one afternoon, but we did. Among this small crowd featured a number of club foot deformities, genu varuses and valguses (including a case of both in the same patient- windswept knees) and poly/syndactilies not to mention complications such as contractures, sequestrae and post septic joints. This all built up two full day lists of about 14 patients, which matched our scheduled impeccably. As expected though, once we got down to the list, a number of cancellations had occurred for various reasons ranging from malaria to not-unlike-Ntcheu absconding! We were still left with 10 patients and 14 cases in total, ample opportunity for on-the-job learning.
To summarise the mind-numbing learning curve that ensued over the course the following days, I am now hoping to export the following operations to Ntcheu, since they require no expensive or specialist hardware... other than an osteotome and a button (yes!.. to secure the tension in club foot correction):
high tibial osteotomies for selected genu varuses, soft tissue releases for neglected club feet, release of syndactyly using at least 2 methods and, at least theoretically, morsellised skin grafts. So, all excitement it is going to be for the next few weeks back home! All the more so with the new donated kit that’s waiting to be tested out.
To cap off my week in style, I spent the final day of my educational break from Ntcheu back in Lilongwe, where I followed Mr Mannion around on a tour of pretty much all the orthopaedic services for the central/northern regions of Malawi. I got a real in-depth insight into the planning of this crucial aspect of health care in Malawi, where disability and trauma often tend to be given secondary importance, with maternal and neonatal care and HIV enjoying most of the worldwide support and funding. That is largely due to the priority these areas have been given through the millennium development goals, which I am not contesting. However the social and economic impact of neglected orthopaedic affectations, with the incredible number of road traffic and industrial accidents, congenital abnormalities and paediatric fractures and burns, cannot and should be ignored. And indeed, I found out there are a few organisations with the sole aim of addressing these problems in Malawi: MAP- Malawi against physical disability; CBM; and of course Mannion’s own charity Feet First. In addition to these are of course the orthopaedic departments at KCH (Lilongwe’s Kamuzu Central Hospital), the 500miles prosthetic centre and the aptly-named Dae Yang (pronounced Die Young!) Luke Mission Hospital, doing their own invaluable work, albeit with limited staff and resources. Unwittingly I got myself a nice little assignment from this field trip, which is to mediate the next meeting of the Malawian Orthopaedic Association, which regroups all these partners, in September with another UK-based organisation, WOC (World Orthopaedic Concern). With all this on my plate, I think it’s time I took leave of you and set myself to some serious groundwork.