In autumn 2009, Edward Mains flew to Malawi for a 12-week elective with the help of an RCSEd student bursary
Having never visited sub-Saharan Africa before, I wanted to find out if the generally negative popular perception of healthcare in the region reflected the reality, whilst gaining exposure to surgical and medical presentations in a novel context.
Pictured: Edward Mains with Beit-CURE patients, L-R, Thokosani, Dominisa and Margaret
I spent four weeks at the Beit-CURE Hospital in Blantyre, a centre which predominantly provides free orthopaedic services to children, with subsidisation by private adult patients and donations. Being attached to one of the three surgical teams, I had ample clinical work, including the opportunity to be first assistant in a diverse array of procedures, of which the correction of severe talipes equinovarus, burn contracture release with grafting and chronic osteomyelitis sequestrectomy were amongst the most common.
Other presentations included the ‘mango-fracture’, a supracondylar humeral fracture with a peak in incidence corresponding to the ripening of the mango, sciatic nerve palsies secondary to misplaced quinine injections, numerous cases of cerebral palsy as well as frequent skeletal tumours, often with limited treatment options. Attending some of the clinics run around the country proved a real eye-opener, with upwards of 100 patients attending, many with late presentations and correspondingly severe deformity. Service provision for the disabled is minimal and they are often subject to stigma, including one particular boy whose neuromuscular kyphoscoliosis was attributed to having fallen from a ‘sorcery craft’.
‘With only six surgical trainees in the country, the future of service provision is far from assured in Malawi’
I spent a further five weeks at the 1250-bed Queen Elizabeth Central Hospital, one of the main public hospitals in Malawi, with time attached to the medicine department as well as the opportunity to gain exposure to general surgery. The hospital benefits from close links with the adjacent Malawi College of Medicine and I had the chance to meet fellow students, clinical officers and trainees. With only six surgical trainees in the country, the future of service provision is far from assured in Malawi. I visited the country during troubled times, a series of poor economic decisions conspiring to create a shortage of foreign currency. This translated into limitations on the provision of care, most potently illustrated by the cancelling of surgical lists due to a lack of diesel for the back-up generators, as well as the need to cancel clinics.
The complexity of presentations, in particular the diverse nature of HIV manifestation, complex HAART interactions and interplay with high rates of TB, was something for which I was unprepared. Morning hand-over meetings provided great opportunities for x-ray and CT interpretation, with the high incidence of TB and HIV-associated meningitis providing some startling images. The wards were somewhat bewildering to the uninitiated, with patients on every available surface, often with highly advanced pathology. Clerking was always a challenge in view of the shortage of interpreters and my lack of Chichewa but I learned to use all the available clues, from the patient, his health-passport and family, whilst overcoming any sensibilities about press-ganging the nearest English speaker to interpret.
I gained great experience in both surgery and medicine and met a range of inspirational people working effectively in difficult environments. Malawi is a beautiful country, faced with major challenges, and I look forward to returning at a later stage in my training. I would like to thank the College for their generous financial support.