Clinical Digest9/ Public Transport3

Malawi Orthopaedic Association AGM

Where do I start this one? This giant. This landmark of my activities in Malawi, which is in part the reason behind my paucity of blogging lately. It being safely behind me, successfully closed, I feel that a chapter is now ended in my Malawian medical mission. It should be possible now to tackle the next one.

“So what!” you’ll be thinking. An AGM is an AGM... just like any other. Boring. Full of protocols. Too long usually etc., etc. But let us remind ourselves that this is Malawi and the very fact of being able to hold a non-business AGM, let alone for a medical syndicate is a little miracle of sorts. Orthopaedics, in Malawi, boasts this honour. We are the only specialty with an executive committee, a Malawian consultant as patron and an AGM, which is now in its 19th round. This is a rare feat, only made possible through the unrelenting support of some donors, which is partly sad and partly encouraging. Encouraging firstly in that the donor support has been sustained all these years, bearing testimony to the value and success of the work achieved. But sad too in that it still has to be a donor that supports us and not the government through an allocated budget. This consequently does not fare well for the longevity of this event, since our principal donor, a retired American surgeon, now well in his 80s, doesn’t yet have a replacement. But for all that, this year, we spent an amazing 3days by the Lake Malawi reviewing the progress made in Orthopaedics in the last year.

This was indeed the meeting for me. After 8months in country, 6 of which have been spent in Ntcheu, it provided the perfect platform for presenting my work and, above all, the perfect audience for making my recommendations to. The bulk of my non-clinical attention in Ntcheu so far has been on improving the system for providing care to patient. This has been a combination of 1) simple modifications such as the one to our file keeping and Xray requesting systems; 2) hardware modifications and equipment acquisition to allow us to do more; and 3) more challenging surveillance stuff like monitoring our activity through audits. The latter, in an environment where data recording is not routine and patients are extremely difficult to track down, was a conundrum that I’m yet to find a reliable solution to. Meanwhile, by placing registers on wards for the staff to fill in, but which I ultimately filled most of, we compiled enough data to formulate admission statistics for each ward and pick out general treatment issues (methods, delays, complications). This brain-racking number crunching paid off as we were finally able to quantify what we were doing, and address our deficiencies/successes better. The best part of it though was the so-called phenomenon my erudite fellow VSO Klaas wisely found the name for: the Hawthorne Effect. Once a problem is spotted, the change to solve it is almost instantaneous. It used to apply to human subjects in experiments, but its wider relevance was clearly visible in our data collecting period. Delays to treatment were getting naturally reduced, while refinements to our methods were being constantly fed in. In the end we got two studies out of one (1. admission data, 2. specific management of one type of fracture) and I think this is the first time we have such data from a district level. It put Ntcheu on Malawi’s orthopaedic map for sure. But it also highlighted one interesting realisation for me. We’re so used to hearing presentations about how to manage our cases this way and that way from visiting surgeons/lecturers who are based in central hospitals and abroad. When I came here, I always held a bit of a cynical view of flying-in-for-a-week professors professing this and that mode of (low cost or low tech) treatment for the rural settings of the 3rd world, without having ever lived there. I was somewhat surprised to find that this also applied within Malawi, where what’s practiced in a central hospital can sometimes be so far removed from the districts that teaching the district officers about it becomes completely irrelevant. Of course, if the central hospital consultants had more time to spend in the rural setting, they would gain enough insight to inform them on what is pertinent to and feasible at a district level (since none of them are Malawian-trained). Yet the only time they ever have to spend in the district is a brief clinic to see saved complicated cases and occasionally operating lists on these patients. The great bit missing, for me, is a real understanding of how the hospital’s orthopaedic department actually works on a day to day basis and more importantly maybe, of how limited resources can be- such that even a “low cost” initiative might not be practical here. In a sense, I’m in a really unique position as an orthopaedic clinician with that insider knowledge.


Among the other perks of my lakeside weekend were the joys of sitting on the judging panel for the best paper presented (safely disqualifying me!) and doubling as returning officer for the new committee member elections. Sadly swimming featured low on those perks, since the agenda was so packed there was only early dawn and early evening to indulge in that. But still I was fulfilled. I was content to have made my first big step in the orthopaedic panorama of Malawi.

Matola Joy
The rest is just the usual circus I’m getting worryingly used to now. I still had to negotiate that last issue of transport back to my base. To have secured a hospital transport to the lake had been a true blessing, bearing in mind even the music was soft and that we were only 4 in the car. Unfortunately, the driver had to be released, such that come Sunday, there was no one to pick us back up. Having lost my Ntcheu colleagues, I decided to find my own way back home, accompanied by an all-but-useless friend, who was zonked beyond recognition from the previous night’s excesses and who now resorted to sleepwalking behind me essentially! Soon I was to discover that, on Sundays, in the remote backwaters of Malawi, there are hardly any buses running and the only remaining form of public transport is the god-feared Matola! Having safely avoided it for months now, I was left with only two other options: walking home or staying over here another night. None of them held any appeal to me, so I jumped aboard, clinging on to dear life! That I did surely for some 15Km in an open back pick-up travelling at 100-120Kmph. Thank God we didn’t have to go off road at any point! Thank God also for that phone call that came just before I was about to take the next matola, from my stranded colleague who, God bless him (I mean it), had been searching for a vehicle for both himself and me. So I stayed put at my stop and eventually got picked up by another “hospital transport” as we know it all too well: a 6 person 4x4 essentially, now having to fit 9 people, and bursting at the seams with bags and bags of fish and allsorts that the passengers managed to lay their hands on while at the lake! Yum Yum! How I slept through most of the journey is a mystery. But then there was one final leg of road to tackle from the point we got dropped off as our vehicle veered off to its own destination. At that stage a 30min minibus drive was all that was left to cover. Never have I been more elated to board that minibus in my entire time in Malawi. It stops at every village and even in between and typically plays the loudest gospel that the human ear can cope with. Yet yesterday, I felt no pain anymore while immersed in it. I guess I’d become comfortably numb...
An Incredible Red Moon

Uses of a Chitenje/ Calico cloth

Definition: Piece of cloth, usually decorated, designed to be wrapped around a woman’s waist. It’s often worn around a dress, skirt or trousers which the woman is already wearing inside.

How many uses can you put to a rectangular piece of fabric, the most ubiquitous item by far in Malawi (? stroke Africa)?

1. Baby carrier - first and foremost
2. Leg hider (my favourite quote: “legs are to Malawian men what boobs are to English men”)
3. Leg warmer (in winter it’s c-c-c-old!)
4. Body warmer (worn around torso)
5. Head gear
6. Purse (corner tied in a knot with money in)
7. Cleaning cloth (for those kids’ uncontrollable secretions)
8. Bed liner (including examination beds in those busy clinics)
9. Pressure bandage/ Tourniquet (all essential casualty first aid)
10. Hanging traction weights (i.e. bricks)
11. Bench liner before sitting
12. Carrying goods (tied at the corners to make a kind of bag)
13. Securing goods (e.g. bowls full of fruit/veg carried on women’s head)
14. Head cushion (for carrying heavy water buckets/stick bundles on their heads)
15. Fashion accessory
16. Political propaganda (Presidents' faces and party logos- I even saw one of Osama Bin Laden!!!)
17. Commemoration of important events (NGOs issue many of these ones)
18. Curtains or screens
19. Mats
20. Winnow
21. Water filter
22. Tourist souvenir (guess the tourist!!)

Of course I will have left out loads of uses. The floor is now yours to add more ingenuous suggestions!

Hospital Transport

I always thought that, whenever given the chance, I would readily swap public transport for an alternative, any alternative. That was indeed until this week, when I realised the full meaning of hitching a ride along a hospital vehicle. It was a perfectly legitimate behaviour from me as well, since I was on hospital business. Just to set the scene quickly here, let me explain to you what hospital transport is actually used for. There are two types of vehicles. One is your familiar chauffeur driven car for the hospital executives, when they need to go to meetings or other official (and sometimes private) business. The same vehicle also picks them up from home in the morning and drops them back in the evening- irrespective of the walking distance: 3 minutes, if I crawl, in the case of Ntcheu. It is a status-laden priviledge that comes with an otherwise poorly rewarded job and I guess the guys don’t see why they should pass it up. The second type of vehicle is your patient transport/ hospital business one. It runs whenever there is a need to deliver or pick equipment for the hospital and when patients need to be transferred to tertiary referral centres (Lilongwe and Blantyre). The way it normally works is that a trip is scheduled for such and such official business. The word is out straight away that there’s a vehicle going that side. The transport manager checks his list for patients needing transferring ‘that side’ and contacts the ward to send the patient/s along. In reality, it takes a little more coaxing from the referring clinician (me) to make sure the vehicle doesn’t leave without the patient. As the 4x4 fills up with its destined cargo, you have a number of hospital staff tagging along for a free ride and filling up the last remaining places.

It soon became clear that by giving a wide berth to public transport in favour of hospital transport (twice) this week, I was actually jumping from the pan into the fire. The obvious appeal of avoiding the long painful wait in a bus depot for the bus to fill up is quickly overcome by a string of new inconveniences. The decibel level, for one, is on a par with the public transport counterpart. I keep asking myself: Am I the only one in this country who reacts to loud (gospel – remember Michael Bolton? He’s still alive and kicking in here, along with Celine Dion, Mariah Carey and their local equivalents who all sing the exact same tune, with slight variations in the lyrics- and rap) music being played for 3 hours on end while I’m trying to snooze/read/work during a journey? Of course, if it could be drowned by my own music through earphones, things might improve a little, but I’m talking decibels that are refractory to such remedial action! As for the waiting, there’s how it goes- apparent time saved versus real time saved (or not).

The first of my two journeys was aboard the executive type vehicle to go the capital for the collection of a shipment that had arrived at the central post office. I had ordered some orthopaedic equipment from India, through a competitive grant I had secured from my NGO. That was one of my early successes some five months back, and the fact that it only turned up now says a lot about the hurdles involved in the procurement process- dealing with London office, multiple invoice changes to meet their standards, dodgy pricing mistakes, ship freight and now customs. The arrangement was to set off early with the DMO, 7am at the hospital gate with the aim of coming back early or at least allow plenty of time in the event customs proved to be difficult. At 7.15, I saw the driver come in unhurriedly and only then set off to go and pick up the DMO. When he came back at around 7.45, the DHO and another person were also in the vehicle. They had some business in Lilongwe too. We finally set off and reached Lilongwe around 10.15. Since we had more than 1 businesses to attend to, ours was naturally left last on the list. We first went to the ministry of health building, which actually is a well hidden gem in the Lilongwe architectural landscape. It sits along with the other ministries along ‘Capital Hill’ and is one of the numerous legacies of this country’s most famous and revered politician, Hastings Kamuzu Banda. It has become almost normal for me to expect to hear his name mentioned in connection with any development I see in this country. We eventually made it to the post office at around 11.15. My dreaded interaction with customs went smoother than I could ever have imagined. We managed to convince them that hospital equipment counted among items exempt from whatever hefty duty. It’s only later on that I realised there had been some butter doused on those palms behind the counter, that obviously took place in fast and discreet Chichewa. Once we got past the official businesses, the next stage was to sort out any personal business that could only be done in Lilongwe, since we were already there and had no chance of getting back in time for work. That’s when it got tricky as everyone had business in different parts of town, which gets very congested with traffic around that time- and I’m told the reason for this is that most people get in their cars to drive home for lunch. That partly explains the 2-3hour lunch break all of a sudden: 30-60min for transport, 30-60min for cooking, 30-60min for eating! It can’t save much money considering the price of fuel here, compared with the dirt cheap cost of a (simple) meal. By the time we’d sorted the mobile phone contract of my colleague out (around 4.30pm), the vehicle had managed a tyre puncture, which further accrued the delay in departing. Just as we thought that was it then, the team decided to stop at a supermarket for some special supplies not available in Ntcheu and just as we’d done that and got ready to go, someone decided we ought to stop in another part of town to buy something else. Thankfully we all figured out that would be perfunctory since the shop would already be closed by now. Thence we made our way to Ntcheu, getting there at the grand hour of 8pm, me half deaf and completely battered, but happy nonetheless to have come back with the goods I set out to collect!

As if that were not a lesson enough, the very next day, I joined the second type of vehicle to go that other city, Blantyre, again on hospital business. What I didn’t know was that I would have to share this vehicle with no fewer than 10 patients/guardians all referred to QECH hospital. One was semi-conscious and lying on a mattress laid down in the back. People were huddled against each other until the last pocket of air was filled. In addition to that, there was their luggage and the transfusion box, which gets filled every Friday. Some people had to be left behind for pure lack of space. You’ll be pleased to hear I secured a seat in the front, squeezed only by another staff member heading south. Once in Blantyre, we unloaded the patients and I made arrangements with the driver to meet up later on so I can go and obtain some more orthopaedic supplies from the stockists there. By the time I’d finished my business in CURE, QECH and the medical stores (nothing useful in stock by the way), it was already around 5pm and my driver had acquired 2 more passengers (including my colleague, whom I had handed over the ward jobs to in the morning thinking he was around!) Again, just as I thought it was time to go, so I could return to Ntcheu in one piece, we incurred delay after delay. We first picked up a parcel from an ex-hospital staff for their relatives in Ntcheu, then went to collect the blood transfusion box, then went to pick up a staff member and all her luggage to move back to Ntcheu and... the straw that broke the camel’s back... we had more patients to pick. The ones from last week, who simply had no means of getting back to Ntcheu of their own. It’s a saddening example indeed of how often people miss out on essential medical care, for the simple reason that they cannot afford transport. The glimmer of hope that I saw in that patient’s eyes as she approached the vehicle, enquiring if we were the Ntcheu transport for her and her convalescing son was, in itself, a thesis on the hardships endured by the poor class of Malawi. I don’t know how long she’d been waiting there for and even worse, I don’t how long more her friends whom we couldn’t fit in the vehicle will have more to wait. Only after that did we manage to unequivocally set off for Ntcheu. It was sunset already and I was shattered and desperate to reach home in the shortest possible time. But as a final dent into my barely standing bodily frame, that also was notbe and the reason being that our driver happened to have some sight impairment. He was completely blinded by on-coming vehicles and would slow his vehicle down to 40Kmph or less everytime one went by. Furthermore, the front seat, despite being away from the sweaty patient crowd in the back, had 1 significant drawback which possibly made it even sweatier. It sat right atop the overworked engine which was radiating constantly like a burning stove. The 2 hour drive back thus took a solid 3 ¼ and I had by then lost all will to live. Thankfully it was Friday night and happiness was just a meal, a shower and a few beers away.
Hop on board!

Ntcheu Social Football Club

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

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

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

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

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

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

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

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

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!?