Where do I start this one? This giant. This landmark of my activities in Malawi, which is in part the reason behind my paucity of blogging lately. It being safely behind me, successfully closed, I feel that a chapter is now ended in my Malawian medical mission. It should be possible now to tackle the next one.
“So what!” you’ll be thinking. An AGM is an AGM... just like any other. Boring. Full of protocols. Too long usually etc., etc. But let us remind ourselves that this is Malawi and the very fact of being able to hold a non-business AGM, let alone for a medical syndicate is a little miracle of sorts. Orthopaedics, in Malawi, boasts this honour. We are the only specialty with an executive committee, a Malawian consultant as patron and an AGM, which is now in its 19th round. This is a rare feat, only made possible through the unrelenting support of some donors, which is partly sad and partly encouraging. Encouraging firstly in that the donor support has been sustained all these years, bearing testimony to the value and success of the work achieved. But sad too in that it still has to be a donor that supports us and not the government through an allocated budget. This consequently does not fare well for the longevity of this event, since our principal donor, a retired American surgeon, now well in his 80s, doesn’t yet have a replacement. But for all that, this year, we spent an amazing 3days by the Lake Malawi reviewing the progress made in Orthopaedics in the last year.
This was indeed the meeting for me. After 8months in country, 6 of which have been spent in Ntcheu, it provided the perfect platform for presenting my work and, above all, the perfect audience for making my recommendations to. The bulk of my non-clinical attention in Ntcheu so far has been on improving the system for providing care to patient. This has been a combination of 1) simple modifications such as the one to our file keeping and Xray requesting systems; 2) hardware modifications and equipment acquisition to allow us to do more; and 3) more challenging surveillance stuff like monitoring our activity through audits. The latter, in an environment where data recording is not routine and patients are extremely difficult to track down, was a conundrum that I’m yet to find a reliable solution to. Meanwhile, by placing registers on wards for the staff to fill in, but which I ultimately filled most of, we compiled enough data to formulate admission statistics for each ward and pick out general treatment issues (methods, delays, complications). This brain-racking number crunching paid off as we were finally able to quantify what we were doing, and address our deficiencies/successes better. The best part of it though was the so-called phenomenon my erudite fellow VSO Klaas wisely found the name for: the Hawthorne Effect. Once a problem is spotted, the change to solve it is almost instantaneous. It used to apply to human subjects in experiments, but its wider relevance was clearly visible in our data collecting period. Delays to treatment were getting naturally reduced, while refinements to our methods were being constantly fed in. In the end we got two studies out of one (1. admission data, 2. specific management of one type of fracture) and I think this is the first time we have such data from a district level. It put Ntcheu on Malawi’s orthopaedic map for sure. But it also highlighted one interesting realisation for me. We’re so used to hearing presentations about how to manage our cases this way and that way from visiting surgeons/lecturers who are based in central hospitals and abroad. When I came here, I always held a bit of a cynical view of flying-in-for-a-week professors professing this and that mode of (low cost or low tech) treatment for the rural settings of the 3rd world, without having ever lived there. I was somewhat surprised to find that this also applied within Malawi, where what’s practiced in a central hospital can sometimes be so far removed from the districts that teaching the district officers about it becomes completely irrelevant. Of course, if the central hospital consultants had more time to spend in the rural setting, they would gain enough insight to inform them on what is pertinent to and feasible at a district level (since none of them are Malawian-trained). Yet the only time they ever have to spend in the district is a brief clinic to see saved complicated cases and occasionally operating lists on these patients. The great bit missing, for me, is a real understanding of how the hospital’s orthopaedic department actually works on a day to day basis and more importantly maybe, of how limited resources can be- such that even a “low cost” initiative might not be practical here. In a sense, I’m in a really unique position as an orthopaedic clinician with that insider knowledge.
Among the other perks of my lakeside weekend were the joys of sitting on the judging panel for the best paper presented (safely disqualifying me!) and doubling as returning officer for the new committee member elections. Sadly swimming featured low on those perks, since the agenda was so packed there was only early dawn and early evening to indulge in that. But still I was fulfilled. I was content to have made my first big step in the orthopaedic panorama of Malawi.
Matola JoyThe rest is just the usual circus I’m getting worryingly used to now. I still had to negotiate that last issue of transport back to my base. To have secured a hospital transport to the lake had been a true blessing, bearing in mind even the music was soft and that we were only 4 in the car. Unfortunately, the driver had to be released, such that come Sunday, there was no one to pick us back up. Having lost my Ntcheu colleagues, I decided to find my own way back home, accompanied by an all-but-useless friend, who was zonked beyond recognition from the previous night’s excesses and who now resorted to sleepwalking behind me essentially! Soon I was to discover that, on Sundays, in the remote backwaters of Malawi, there are hardly any buses running and the only remaining form of public transport is the god-feared Matola! Having safely avoided it for months now, I was left with only two other options: walking home or staying over here another night. None of them held any appeal to me, so I jumped aboard, clinging on to dear life! That I did surely for some 15Km in an open back pick-up travelling at 100-120Kmph. Thank God we didn’t have to go off road at any point! Thank God also for that phone call that came just before I was about to take the next matola, from my stranded colleague who, God bless him (I mean it), had been searching for a vehicle for both himself and me. So I stayed put at my stop and eventually got picked up by another “hospital transport” as we know it all too well: a 6 person 4x4 essentially, now having to fit 9 people, and bursting at the seams with bags and bags of fish and allsorts that the passengers managed to lay their hands on while at the lake! Yum Yum! How I slept through most of the journey is a mystery. But then there was one final leg of road to tackle from the point we got dropped off as our vehicle veered off to its own destination. At that stage a 30min minibus drive was all that was left to cover. Never have I been more elated to board that minibus in my entire time in Malawi. It stops at every village and even in between and typically plays the loudest gospel that the human ear can cope with. Yet yesterday, I felt no pain anymore while immersed in it. I guess I’d become comfortably numb...
An Incredible Red Moon
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