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

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

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

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.