Lilongwe meets Blantyre

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

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

It's gonna be hard to leave...

Lilongwe's just too cool!

COSECSA faculty and audience

Tree hugging!

Mousebird

Blantyre insolites... and surrounds

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Tricycles and wheelchairs Update3

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

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

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

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


With Alex and Sally (from MAP) at MAP


Girl Power


Empowered!

Blantyre Insolites... and surrounds

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Clinical Digest14

Gunshots

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

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

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

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

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

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

The uses of linea

First of all, a little definition of linea.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

10. Art nouveau/ Recycl-art!

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

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


LINEA!


Held together by linea


You name it!!!


Linea-aided display


Nothing too heavy for linea

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

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!