Training a Nation Part II

On the ground with Anthony Charles, MD, MPH, and the Malawian Surgical Initiative.

Training a Nation Part II click to enlarge Anthony Charles, leads a team in the operating room at Kamuzu Central Hospital (Photo by Jon Gardiner/UNC)

By Jamie Williams, jamie.williams@unchealth.unc.edu

Read a previous profile of Dr. Charles and the Malawian Surgical Initiative, "Training a Nation," here.

LILONGWE, MALAWI, JUNE 5 2017 – It’s just after 6 p.m. in Lilongwe and the Chipiku Plus grocery store is crowded with people doing after work shopping. We are here to gather basics: tea, cereal, juice, a large case of bottled water. Despite the crowd, the lines at the counter are moving efficiently. Suddenly the lights go out. No one scurries out. No one does anything out of the ordinary. By the light of several raised cell phones, the clerk continues trying to scan items. She’s unsuccessful but never breaks rhythm.

A minute or two pass. The lights flash back on.

“Welcome to Africa,” Anthony Charles says, slapping me on the back.

Home for the week is a simple house behind a brick wall and a metal gate. There’s a guard at the gate and a big dog named Zsa Zsa. Zsa Zsa is the more skeptical of the two. The guard is warm and friendly, ready to talk. He tells me he likes country and western music, Don Williams especially. He asks me how often I’ve traveled to New York. He proudly shows me around the grounds, pointing out the fruit trees. Oranges still green on the tree. Peach and mango trees that, now bare, will be dropping sweet fruit in December once summer arrives.

Home and settled, it’s time to work.

Tough Questions

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Chifundo Kajombo and Carlos Varela at the morning surgery meeting (Jon Gardiner/UNC)
The Department of Surgery at Kamuzu Central Hospital starts its morning report meeting at 7:30 a.m. Anthony Charles, MD, MPH, turns on the lights in the sparse hospital conference room. It has been a few months since his last trip to Malawi. But, it’s as if he’s here every day. He exchanges greetings with a few faculty and residents, but there’s no big introduction. He sits down, things get going, and as the surgeons present their cases from the previous day, he begins peppering them with questions.

“Why did you do that?”

“Did you consider trying this?”

In one instance, the presenting physician explains that he chose to delay an operation because the patient had a full stomach. This was unacceptable, Charles replied, the patient’s case should have been deemed an emergency. It warranted immediate surgery.

“If you got shot on your way here this morning, would you tell the surgeon, ‘no, don’t operate, doctor, I’ve just had breakfast?’”

It goes on like this for the full hour of the meeting.

“If you make a decision with a patient’s life in the balance, you’d better be able to defend it,” Charles explains afterward.

It’s winter in Lilongwe. Morning smells like smoke. Fires burn to heat homes and cook food. Those fires get out of control. Or worse, children slip and fall in. Winter is burn season.

In this city, traffic accidents have no offseason. Driving these busy roads, you squeeze your shoulders together, instinctively hoping that might help your car avoid the women walking along the shoulder, or the men biking just on the edge of your lane. At night, cyclists appear, flashing in and out of headlights, but otherwise unseen in the darkness enveloping the kilometers between the city’s residential and commercial districts.

Summer is mango season. Ambitious harvesters climb higher than they should. They fall. Bones are broken.

Trauma is constant here. Quality surgical care can’t keep up.

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Kamuzu Central Hospital (Jon Gardiner/UNC)
Walking through Kamuzu Central Hospital (KCH), there are people everywhere waiting to receive care. Obvious injuries are wrapped with fraying bandages. Men hobbling on primitive wooden crutches slowly amble down the halls. Everyone smiles and waves. In the face of such difficulty there is warmth, kindness, and pride. It’s dark. But it’s not desperate.

After morning meetings, as he does often when in Malawi, Charles scrubs in for a case. The plan was to conduct an exploratory laparotomy, looking for the source of free air in the patient’s abdomen. What Charles found was advanced stomach cancer that had spread to the patient’s liver. Without the ultrasound technology that’s standard in the United States, the cancer was undetected before incision. There was nothing that could be done surgically for this patient. Charles and the resident would just wash out the abdomen and close him up.

But there was a problem.

“They didn’t have the ideal suture that we’d use in the United States,” Charles said. “They didn’t have the next best thing. They had nylon, but the wrong size. So, I said let’s go old school and use silk, which I’d never use in the US. Every option that I gave them, they did not have.”  

“That is emblematic of the problems they have here.”

Eventually, the operating team dispatched someone to another operating room and he returned with the suture they needed.

In spite of the problems that persist, things are getting better.

For nearly 10 years, Charles has led the Malawian Surgical Initiative in partnership with Kamuzu Central Hospital and the Malawi College of Medicine which is located in Blantyre.

Carlos Varela
Carlos Varela (Jamie Williams/UNC Health Care)
Dr. Carlos Varela leads the Department of Surgery at Kamuzu Central Hospital, a post he has held since 2011. Varela is Malawian, and completed his medical training at the Malawi College of Medicine in Blantyre. Postgraduate surgical training did not exist in Malawi when he entered residency, so he went to Cape Town in South Africa. “When I left for Cape Town there was no postgraduate surgery training available in this country. When I returned after residency, the Malawian Surgical Initiative was up and running. What Prof. Charles has done has helped us to train so many surgeons here in Malawi,” Varela said.

Varela and Charles work closely, and have an easy and apparent friendship. Keeping in near constant contact about cases and trends at the hospital, staying abreast of the needs of the residents in the program, and of course, playing a little good cop/bad cop during the morning meeting.

“I tell Prof. Charles that Malawi really is his second home,” Varela said. “He may go away for other things, but he’s always back and everyone knows him around the hospital.”

Under Varela’s watch, Kamuzu Central Hospital’s surgical capacity has grown considerably. In 2011, when he returned home, there was one Malawian surgeon at the hospital. Today there are seven.

“In years past we would rely on expat surgeons to help us meet our demand. They would come and spend a month or two here and then leave,” Varela said. “They would have different skill levels, and not be used to the cases they would see here, which can be very different from what they are accustomed to seeing.”

So far the Malawian Surgical Initiative has trained 16 Malawian residents, with eight currently in various stages of the five year program.

Clinical officers make up the base of the Malawian health care system. The three year post-secondary training gets them to a level similar to a physician’s assistant in the United States. Walking through Kamuzu Central, they are everywhere, dressed in white pants and short-sleeved white shirts. The Malawi College of Medicine, offering MD medical training, was founded in 1991. When Varela entered in 1997, he says there were 20 people in his class. In the last several years classes have grown and now average around 100 students. Work as a clinical officer is steady and highly respected. Graduates of the Malawi College of Medicine who go into general practice can make a good living for themselves and their families.

Varela says this occasionally makes recruiting for postgraduate training a tough sell.

“People say I’ve just gotten out of school, I can start work and make money now, why would I go back for more studying,” Varela said. “The residents who join us, though, have seen that this program can really help them advance in their careers and improve health care in the country.”

There’s no doubt that fourth-year surgery resident Vanessa Nsosa will make an impact. Nsosa’s mother Anastasia Nsosa was Malawi’s first female chief justice. It takes a lot of smarts and a lot of confidence to ascend to such a position. Vanessa inherited all of it.

“I chose surgery because during medical school, on surgical rotations, I was very good at it,”Nsosa says. “Being a general practitioner didn’t sound like something special and I wanted to be able to reach a little higher for patients.”

Throughout her training, she has had to be a ‘jack of all trades’ facing trauma cases, as well as GI and endocrine issues. When she’s working, she often thinks back to lessons learned in the morning report meeting.

“As a surgeon you’ll face pressure, you have to think quickly and know what action to take, then you have to explain it to your colleagues and, most importantly to the patient’s loved ones,” Nsosa said.

Being prepared to act quickly and decisively is the point of clinical training.

“You have to have the confidence to know that whatever problem comes through the door you’ll be able to fix it,” Charles said. “You can’t be a good surgeon without that attitude.”

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Vanessa Nsosa (Jon Gardiner/UNC)

“Hard Knock Life”

Being able to fix those problems here in Lilongwe, though, takes creativity not required of surgeons in hospitals with more resources available.

“All the bells and whistles we have in Chapel Hill that make a challenging case a little easier aren’t available and you’re forced to improvise,” Charles said. “By the time our residents are finished here, they are pretty damn good. They have done a large number of cases, they are confident in their skills, and they are able to work under pressure in an austere environment.”

Nsosa and her fellow residents understand the challenges and have banded together in support of each other.

“It’s a hard knock life, for sure,” Nsosa said. “But, there is such a great need for surgeons here and so we are motivated knowing that we can make a great impact in our country.”

Creating an environment that fosters the long term success of young surgeons like Nsosa is the next major hurdle for KCH and the Malawian Surgical Initiative.

At the moment KCH has four operating rooms, though construction is underway on a new surgical wing to house six new operating theaters.

Upgrading and expanding facilities will help surgeons provide better care for patients and help meet the outsized demand. It is also tool for Varela and Charles who hope to ensure that Malawian Surgical Initiative graduates will remain here following their training.

KCH is a public hospital, operated under the authority of the Malawi Ministry of Health. Money is tight.

It costs $50,000 to train a resident in the Malawian Surgical Initiative. The initiative is funded through public, private and corporate philanthropy, and covers half of the expenses for students, including a stipend, books and other learning materials, and funding for travel to academic conferences.  The rest is covered by the Ministry of Health. Prior to its launch, the government was spending around $60,000 per year for surgeons to receive training in other countries, with many of them never returning.

Varela is always making the case for increased government investment, for both long term and more immediate needs.

“This year there is a major scientific conference in Mozambique. If one of our residents is invited to present, then they will need a ticket and accommodations. If they don’t get that support then the resident is missing out on knowledge that will help them down the line.”

In many instances, Charles and UNC are able to step in with material and monetary support funded through private donations.

“I’m really helping to facilitate their training: if there is a course they want to take that will be beneficial they talk to me; we got all the residents laptops and if they need a new program or something, we can get it for them; if there are books that they want, I’ll get them and take them with me the next time I travel down,” Charles said.

What’s Next?

Following the residents’ training, the Ministry of Health determines where the surgeons will practice.

In addition to Kamuzu Central in Lilongwe, there are central hospitals in Blantyre, Zomba, and Mzuzu. They also have a great need for surgeons, and so, in the interest of service provision, the ministry directs some Malawian Surgical Initiative graduates to these hospitals.

Last year, Varela said, three of the program’s six graduates were sent to these facilities. Varela is pushing the government to allow the graduates to remain at KCH for at least one more year so that they are better prepared, both as surgeons and leaders. Often, when these surgeons are sent to the hospitals away from Kamuzu Central, they are quickly placed into leadership roles.

“We train our residents for clinical excellence. We aren’t giving them any skills in hospital administration,” Charles said. “But, being a physician automatically makes you a leader whether you like it or not, and when the government assigns you a role, you really aren’t in a position to turn it down. So, since this has happened and will continue to happen, we have thought about adding management and business skills as part of our training.”

The general surgery and orthopaedics residency is accredited under the College of Surgeons of East, Central, and Southern Africa. Graduates are free to practice in any of the 10 countries covered by the college. Resource disparities across the region mean that moving, say, just across Lake Malawi into Tanzania could lead to a major increase in salary.

The surgeons are also in public service as employees of the Ministry of Health. Even going into private practice in Malawi would increase their earning potential. Charles hopes that the Malawian Surgical Initiative trainees will remain in the country, in public service, but is working on compromises that will allow them to do some private work as a way to supplement their income.

Charles also hopes the trainees will develop a passion for research. It’s an expectation of the government, but, Charles admits the incredibly clinical demands of working at KCH can make it difficult to set aside time for research. He has worked to facilitate research relationships and mentorship opportunities for the residents in the Malawian Surgical Initiative and residents and faculty in the UNC Department of Surgery.

“At UNC, we have made the commitment that there will be no research in Malawi that does not involve our trainees. It is vital that their voices are included. We will not publish anything without one of the Malawians on the paper. We are usually pairing them with residents in Chapel Hill based on mutual interest. Several have shown promise, and so the next goal is to have a Malawian Surgical Initiative research project that is resident-initiated and results in publication,” Charles said.

The training is now squarely focused on general surgery and orthopaedics. Graduates still travel outside of Malawi for subspecialty training.

There is such a tremendous need for general surgeons – there are still less than 50 surgeons in the entire country – that it would be impractical to offer such specialty training before helping to increase those numbers.

“As long as we are training surgeons in Malawi, we are happy,” Charles said.

Those surgeons are prepared to take care of their people and improve the health of their country. They will be the leaders who continue to push for improved health infrastructure.

“Our trainees will do well, I have no doubt about that,” Charles said. “My hope for them is that they stay in the public service, or they devote themselves to answering the difficult questions about providing quality care at low cost in this setting. They have the skills, they have the confidence, and as conditions continue to improve here, they will simply excel.”

On our final night in Malawi, we head for dinner with Varela, surgery resident Charles Mabedi, and KCH surgeon and Malawian Surgical Initiative graduate Chifundo Kajombo. We laugh and swap stories of the trip. Mabedi and Charles discuss some advanced training he’s hoping to pursue. Varela gives a detailed cultural history of Malawi and describes the hours long road trips he makes every few months to provide care at smaller district hospitals throughout the country.

Before the food arrives, Kajombo rises and asks Mabedi to wrap his dinner up and bring it to him later at the hospital. He’s on call and needs to check on a patient.

Back to work.

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