By: Corey Gill, MD
Malawi is a landlocked country in sub-Saharan Africa. It is known as the "Warm Heart of Africa" and I have certainly felt this to be the case in my 3 visits to the country since 2002. Before writing about my recent remarkable chief resident experience at an orthopedic hospital in central Malawi, I would first like to briefly mention some aspects of Malawian culture and the unique travel experiences I have participated in during my visits there. Malawi is a former British colony that gained its independence in 1964. The largest ethnic group is the Chewa, and the predominant local language is Chichewa. The primary source of food in Malawi is corn, which is milled and then cooked into a product called nsima. Nsima looks and tastes similar to the grits I grew up with in the Southern United States, and is eaten at virtually every meal. Malawi is partially bordered by the large and appropriately named Lake Malawi. The lake is home to 80% of the aquarium fish in the world (cichlids), and there are a number of beautiful towns to visit along the lake's borders. There are a number of great national parks in Malawi and neighboring countries where one can see wildlife such as elephants, hippos, and lions. Malawi is located along the Eastern Rift Valley, with mountains and dramatic elevation changes seen between the northern and southern ends of the country. This geography is great for activities such as mountain biking. I was fortunate to participate in a 70 km off-road biking day trip with one of the head orthopedic surgeons on my recent trip there.
Despite its cultural riches, Malawi is one of the poorest countries in the world, with few natural resources and a life expectancy of approximately forty. There are 6 orthopedic surgeons in the country serving a population of 15 million people. In contrast, there are approximately 1000 orthopedic surgeons in the United States serving 15 million people. For my international rotation, I travelled to the BEIT Trust CURE international pediatric orthopedic hospital in Malawi's largest city, Blantyre. This charity-run hospital is staffed by 4 pediatric orthopedic surgeons who perform over 1000 procedures each year on Malawian children with a variety of conditions including: angular limb deformities, chronic osteomyelitis, untreated clubfoot, metabolic bone diseases, burn contractures, and orthopedic tumors.
The difference in care of orthopedic conditions in children in Malawi and the United States is dramatic. Fractures, such as supracondylar humerus fractures, are rarely treated surgically for a variety of reasons. There is not enough manpower to perform the surgeries, orthopedic implants are very limited in supply, and children often don't present to the hospital for weeks to months after their injuries. For example, shortly before I returned home, I saw a 14 year old child who fell out of a mango tree one year prior to presentation and complained of pain with walking. X-rays revealed an obvious displaced femoral neck fracture, a condition that would have prompted a trip to the emergency room shorty after injury 100% of the time in almost any city in the United States. For many of the conditions that I saw during my visit, presentation to the hospital occurred much later in the disease process than in developed countries. Children with osteomyelitis often had major sequelae of their infection such as large areas of involved bone requiring resection, children with clubfeet were often untreated as infants (although this is beginning to change significantly after institution of a nationwide nonoperative treatment program using the Ponseti method), and children with orthopedic tumors often did not present to the hospital until a large soft tissue had been present for many months.
Despite the severity of conditions seen in many children, the orthopedic surgeons and nurses that I worked with were often able to cause dramatic changes in the lives of the children and families seen at the hospital. Because their conditions were often severe with significant associated morbidities, surgeries that even partially improved or corrected various orthopedic pathologies dramatically improved the quality of life of these children. In addition, there is a large amount of stigma associated with orthopedic diseases in Malawi such as angular limb deformities, polydactyly, or joint contractures secondary to infection. Children with these conditions are often seen as cursed or bewitched by other members of their community and ostracized by the villages they live in. Educating parents that their children are not cursed gives them comfort and relief, and improving their childrens' cosmetic deformities better enables them to reintegrate into their communities in addition to improving their clinical function.
I was amazed during my visit at the level of stoicism, maturity and gratitude displayed by young children treated with major surgeries. For example, we performed an above-the-knee amputation on a 10 year old girl with an osteosarcoma (malignant bone tumor) of the distal femur. Despite receiving only Tylenol for pain, she was thanking us on post-operative day #1 for taking care of her and walking around on crutches with a big smile on her face. Another child with an unknown metabolic bone disease being treated with a Taylor spatial frame for a failed attempted knee fusion sustained a fracture of his femur above one of the pis from his frame. The orthopedic surgeon who performed his most recent surgery told the patient he was sorry that he was having to go through with so much, and the patient replied by trying to comfort us. He said, "Don't worry, everything will be OK."
In addition to my time at the pediatric orthopedic hospital, I spent some time at the adult hospital across the street. Surgical orthopedic care of adults at this hospital is minimal, even when surgeries are indicated. OR time is sparse, anesthesia care is suboptimal, stores of orthopedic implants are minimal (the day before I left, one of the orthopedic surgeons had to tell a patient with a Galeazzi fracture dislocation that surgery could not be performed because there were no plates in the hospital at that time), and patient triage is difficult (patients often sit in the hospital for weeks with a fracture before an orthopedic surgeon is told about them). In the face of these multiple difficulties, the one dedicated adult orthopedic surgeon in the country does remarkable work caring for the patients he is able to, but the situation is certainly appalling. I asked one of the orthopedic surgeons I worked with what happens to people with significant orthopedic injuries like open fractures from road traffic accidents (a common problem in Malawi) that need orthopedic intervention. He replied candidly "If they are lucky, they die at the scene."
While improving orthopedic care in developing countries is faced with difficulties at multiple levels such as appropriate triage of patients, remarkably insufficient number of surgeons, and gross inadequacies in healthcare infrastructure, I do not think this provides an excuse for apathy or maintaining the status quo. While we as residents are generally not able to dramatically impact patient care during our relatively short visits to places like Malawi, Mongolia, or Nicaragua, we certainly come away from these experiences with a new perspective and appreciation for the types of care available in the United States. These experiences highlight for us the need for resources, manpower, education, and infrastructure to improve orthopedic care in developing countries and hopefully will make us more likely to participate directly in this improvement during the course of our careers. In the short-term, we can educate other orthopedic surgeons and the community as a whole to the need for awareness and monetary donations to organizations like CURE internation (www.cure.org) or SIGN (www.sign-post.org) that are actively improving the care of thousands of pediatric and adult patients in developing countries around the world.